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Ortiz-Seller A, Martorell P, Roselló P, Morcillo E, Ortiz JL. Comparison of Different Doses of Oral and Ocular Propranolol for Retinopathy of Prematurity: A Network Meta-Analysis. Paediatr Drugs 2024; 26:499-518. [PMID: 39112827 DOI: 10.1007/s40272-024-00647-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2024] [Indexed: 08/22/2024]
Abstract
OBJECTIVE The efficacy and safety of propranolol for retinopathy of prematurity (ROP) remain under debate. This network meta-analysis (NMA) focuses on whether a ranking may be established for different dose levels of propranolol as treatment of ROP in terms of stage progression as the primary outcome, with appearance of plus disease and need for anti-vascular endothelial growth factors (anti-VEGFs) or laser therapy as secondary endpoints. METHODS Fourteen studies (10 randomised controlled trials, three single-arm trials and one retrospective observational study) of 474 patients treated with oral or ocular propranolol were retrieved from databases up to April 2024. Meta-insight and model-based NMA were undertaken to evaluate the propranolol dose-response relationship. Studies were evaluated for model fit, risk of bias and Confidence of evidence In Network Meta-Analysis (CINeMA). Effect sizes were determined as odds ratio (OR) with 95% credible interval (CrI). RESULTS Bayesian analysis showed a trend towards improved effects for propranolol given at late stages (stages 2-3; S23) of ROP progression compared with its administration at earlier stages (stages 0-1; S01). OR values for oral propranolol 1.5 and 2 mg/kg/day given at S23 were 0.13 (95% CrI 0.04-0.37) and 0.16 (95% CrI 0.04-0.61), respectively, while given at S01 were 0.28 (95% CrI 0.02-2.96) and 0.78 (95% CrI 0.14-4.43), respectively. Similarly, OR of eye propranolol 0.2% at S23 was 0.37 (95% CrI 0.09-1.00) versus an S01 OR of 0.64 (95% CrI 0.21-2.04). Surface under the cumulative ranking curve (SUCRA) analyses confirmed best probability values for oral propranolol 1.5-2 mg/kg followed by eye propranolol 0.2%, all at S23. Model-based NMA showed nonlinearity in the dose-response for oral propranolol with a trend to greater maximal effect for its administration at late versus early stages. For secondary endpoints, lower risk values were found with oral propranolol 1.5 mg/kg/day at S23 for progression to plus disease (OR 0.14; 95% CrI 0.02-0.84) and need for anti-VEGFs (OR 0.23; 95% CrI 0.05-0.93) and laser (OR 0.16; 95% CrI 0.02-1.10) therapies also followed by eye propranolol 0.2%, and a similar profile was obtained with SUCRA analysis. Lower doses (0.5-1.0 mg/kg/day) of oral propranolol retained efficacy. Threat of adverse events was estimated as risk difference versus control with no difference for eye propranolol 0.2% and oral propranolol 0.5 mg/kg/day, modest increases of risk for oral propranolol 1.0 and 1.5 mg/kg/day and the highest risk difference for oral propranolol 2.0 mg/kg/day (0.06; 95% CI -0.01 to 0.13). CONCLUSION A diminished risk of disease progression and need for additional treatment was obtained with propranolol in ROP, but safety is a potential concern. Propranolol eye micro-drops (0.2%) can be as efficacious as oral propranolol. Nonetheless, the evidence is limited due to the paucity and quality of the available studies.
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Affiliation(s)
- Amparo Ortiz-Seller
- Unit of Pediatric Ophthalmology and Strabismus, Oftalvist Clinic, Valencia, Spain
| | - Pablo Martorell
- Department of Chemical and Nuclear Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Patricia Roselló
- Intensive Pediatric Care Unit, University Clinic Hospital of Valencia, Valencia, Spain
- Department of Pediatrics, Obstetrics and Gynecology, Faculty of Medicine, University of Valencia, Valencia, Spain
| | - Esteban Morcillo
- Health Research Institute (INCLIVA), Clinic University Hospital of Valencia, Valencia, Spain
- Department of Pharmacology, Faculty of Medicine, University of Valencia, Av. Blasco Ibáñez 15, 46010, Valencia, Spain
| | - José L Ortiz
- Health Research Institute (INCLIVA), Clinic University Hospital of Valencia, Valencia, Spain.
- Department of Pharmacology, Faculty of Medicine, University of Valencia, Av. Blasco Ibáñez 15, 46010, Valencia, Spain.
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Sotiropoulos JX, Saugstad OD, Oei JL. Aspects on Oxygenation in Preterm Infants before, Immediately after Birth, and Beyond. Neonatology 2024:1-8. [PMID: 39089224 DOI: 10.1159/000540481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 06/21/2024] [Indexed: 08/03/2024]
Abstract
BACKGROUND Oxygen is crucial for life but too little (hypoxia) or too much (hyperoxia) may be fatal or cause lifelong morbidity. SUMMARY In this review, we discuss the challenges of balancing oxygen control in preterm infants during fetal development, the first few minutes after birth, in the neonatal intensive care unit and after hospital discharge, where intensive care monitoring and response to dangerous oxygen levels is more often than not, out of reach with current technologies and services. KEY MESSAGES Appropriate oxygenation is critically important even from before birth, but at no time is the need to strike a balance more important than during the first few minutes after birth, when body physiology is changing at its most rapid pace. Preterm infants, in particular, have a poor control of oxygen balance. Underdeveloped organs, especially of the lungs, require supplemental oxygen to prevent hypoxia. However, they are also at risk of hyperoxia due to immature antioxidant defenses. Existing evidence demonstrate considerable challenges that need to be overcome before we can ensure safe treatment of preterm infants with one of the most commonly used drugs in newborn care, oxygen.
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Affiliation(s)
- James X Sotiropoulos
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Ola D Saugstad
- Department of Pediatric Research, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ju Lee Oei
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia,
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia,
- Department of Newborn Care, The Royal Hospital for Women, Randwick, New South Wales, Australia,
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Nardini P, Zizi V, Molino M, Fazi C, Calvani M, Carrozzo F, Giuseppetti G, Calosi L, Guasti D, Biagini D, Di Francesco F, Filippi L, Pini A. Protective Effects of Beta-3 Adrenoceptor Agonism on Mucosal Integrity in Hyperoxia-Induced Ileal Alterations. Antioxidants (Basel) 2024; 13:863. [PMID: 39061931 PMCID: PMC11273805 DOI: 10.3390/antiox13070863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/15/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
Organogenesis occurs in the uterus under low oxygen levels (4%). Preterm birth exposes immature newborns to a hyperoxic environment, which can induce a massive production of reactive oxygen species and potentially affect organ development, leading to diseases such as necrotizing enterocolitis. The β3-adrenoreceptor (β3-AR) has an oxygen-dependent regulatory mechanism, and its activation exerts an antioxidant effect. To test the hypothesis that β3-AR could protect postnatal ileal development from the negative impact of high oxygen levels, Sprague-Dawley rat pups were raised under normoxia (21%) or hyperoxia (85%) for the first 2 weeks after birth and treated or not with BRL37344, a selective β3-AR agonist, at 1, 3, or 6 mg/kg. Hyperoxia alters ileal mucosal morphology, leading to increased cell lipid oxidation byproducts, reduced presence of β3-AR-positive resident cells, decreased junctional protein expression, disrupted brush border, mucin over-production, and impaired vascularization. Treatment with 3 mg/kg of BRL37344 prevented these alterations, although not completely, while the lower 1 mg/kg dose was ineffective, and the higher 6 mg/kg dose was toxic. Our findings indicate the potential of β3-AR agonism as a new therapeutic approach to counteract the hyperoxia-induced ileal alterations and, more generally, the disorders of prematurity related to supra-physiologic oxygen exposure.
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Affiliation(s)
- Patrizia Nardini
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (G.G.); (L.C.); (D.G.)
- Imaging Platform, Department Experimental and Clinical Medicine & Joint Laboratory with Department Biology, University of Florence, 50139 Florence, Italy
| | - Virginia Zizi
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (G.G.); (L.C.); (D.G.)
| | - Marta Molino
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (G.G.); (L.C.); (D.G.)
| | - Camilla Fazi
- Department of Pediatric, Meyer Children’s University Hospital, 50139 Florence, Italy;
| | - Maura Calvani
- Azienda Ospedaliera Universitaria Meyer, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 50139 Florence, Italy;
| | - Francesco Carrozzo
- Department of Health Science, University of Florence, 50139 Florence, Italy;
| | - Giorgia Giuseppetti
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (G.G.); (L.C.); (D.G.)
| | - Laura Calosi
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (G.G.); (L.C.); (D.G.)
- Imaging Platform, Department Experimental and Clinical Medicine & Joint Laboratory with Department Biology, University of Florence, 50139 Florence, Italy
| | - Daniele Guasti
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (G.G.); (L.C.); (D.G.)
- Imaging Platform, Department Experimental and Clinical Medicine & Joint Laboratory with Department Biology, University of Florence, 50139 Florence, Italy
| | - Denise Biagini
- Department of Chemistry and Industrial Chemistry, University of Pisa, 56124 Pisa, Italy; (D.B.); (F.D.F.)
| | - Fabio Di Francesco
- Department of Chemistry and Industrial Chemistry, University of Pisa, 56124 Pisa, Italy; (D.B.); (F.D.F.)
| | - Luca Filippi
- Neonatology and Neonatal Intensive Care Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy
| | - Alessandro Pini
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (G.G.); (L.C.); (D.G.)
- Imaging Platform, Department Experimental and Clinical Medicine & Joint Laboratory with Department Biology, University of Florence, 50139 Florence, Italy
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Scaramuzzo RT, Crucitta S, del Re M, Cammalleri M, Bagnoli P, Dal Monte M, Pini A, Filippi L. β3-adREnoceptor Analysis in CORD Blood of Neonates (β3 RECORD): Study Protocol of a Pilot Clinical Investigation. Life (Basel) 2024; 14:776. [PMID: 38929758 PMCID: PMC11204445 DOI: 10.3390/life14060776] [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: 05/03/2024] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Background and Objective: The embryo and the fetus develop in a physiologically hypoxic environment, where vascularization is sustained by HIF-1, VEGF, and the β-adrenergic system. In animals, β3-adrenoceptors (β3-ARs), up-regulated by hypoxia, favor global fetal wellness to such an extent that most diseases related to prematurity are hypothesized to be induced or aggravated by a precocious β3-AR down-regulation, due to premature exposure to a relatively hyperoxic environment. In animals, β3-AR pharmacological agonism is currently investigated as a possible new therapeutic opportunity to counteract oxygen-induced damages. Our goal is to translate the knowledge acquired in animals to humans. Recently, we have demonstrated that fetuses become progressively more hypoxemic from mid-gestation to near-term, but starting from the 33rd-34th week, oxygenation progressively increases until birth. The present paper aims to describe a clinical research protocol, evaluating whether the expression level of HIF-1, β3-ARs, and VEGF is modulated by oxygen during intrauterine and postnatal life, in a similar way to animals. Materials and Methods: In a prospective, non-profit, single-center observational study we will enroll 100 preterm (group A) and 100 full-term newborns (group B). We will collect cord blood samples (T0) and measure the RNA expression level of HIF-1, β3-ARs, and VEGF by digital PCR. In preterms, we will also measure gene expression at 48-72h (T1), 14 days (T2), and 30 days (T3) of life and at 40 ± 3 weeks of post-menstrual age (T4), regardless of the day of life. We will compare group A (T0) vs. group B (T0) and identify any correlations between the values obtained from serial samples in group A and the clinical data of the patients. Our protocol has been approved by the Pediatric Ethical Committee for Clinical Research of the Tuscany region (number 291/2022). Expected Results: The observation that in infants, the HIF-1/β3-ARs/VEGF axis shows similar modulation to that of animals could suggest that β3-ARs also promote fetal well-being in humans.
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Affiliation(s)
| | - Stefania Crucitta
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (S.C.); (M.d.R.)
| | - Marzia del Re
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (S.C.); (M.d.R.)
| | - Maurizio Cammalleri
- Unit of General Physiology, Department of Biology, University of Pisa, 56126 Pisa, Italy; (M.C.); (P.B.); (M.D.M.)
| | - Paola Bagnoli
- Unit of General Physiology, Department of Biology, University of Pisa, 56126 Pisa, Italy; (M.C.); (P.B.); (M.D.M.)
| | - Massimo Dal Monte
- Unit of General Physiology, Department of Biology, University of Pisa, 56126 Pisa, Italy; (M.C.); (P.B.); (M.D.M.)
| | - Alessandro Pini
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy;
| | - Luca Filippi
- Neonatology Unit, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
- Neonatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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Choi HJ, Shin BS, Shin SH, Kim EK, Kim HS. Critical period of oxygen supplementation and invasive ventilation: implications for severe retinopathy of prematurity. Ital J Pediatr 2024; 50:58. [PMID: 38561824 PMCID: PMC10985977 DOI: 10.1186/s13052-024-01629-6] [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: 12/10/2023] [Accepted: 03/13/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Several studies have identified graded oxygen saturation targets to prevent retinopathy of prematurity (ROP), a serious complication in preterm infants. We aimed to analyze the critical period of oxygen supplementation and/or invasive ventilation associated with severe ROP. METHODS This retrospective case-control study included neonates with a gestational age (GA) < 29 weeks. Participants were divided into two groups: treated retinopathy and untreated/no retinopathy. Time-weighted average FiO2 (TWAFiO2) and weekly invasive ventilation were compared between groups by postnatal age (PNA) and postmenstrual age (PMA). The association of treated retinopathy with TWAFiO2 and invasive ventilation was analyzed. RESULTS Data from 287 neonates were analyzed; 98 were treated for ROP and had lower GAs (25.5 vs. 27.4 weeks, p < 0.01) and lower birthweights (747.6 vs. 1014 g, p < 0.001) than those with untreated/no ROP. TWAFiO2 was higher from PMA 26-34 weeks, except for PMA 31 weeks in treated ROP, and higher in the first nine weeks of life in treated ROP. On multiple logistic regression, TWAFiO2 and invasive ventilation were associated with ROP treatment during the first seven weeks PNA. Invasive ventilation was associated with ROP treatment from PMA 26-31 weeks; no association was found for TWAFiO2 and PMA. CONCLUSIONS Amount of oxygen supplementation and/or invasive ventilation during the first 7 weeks of life or up to 31 weeks PMA was associated with development of severe ROP. This period might be candidate timing for strict oxygen supplementation strategies in preterm infants, while concerns of mortality with low oxygen supplementation should be further explored.
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Affiliation(s)
- Ho Jung Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Baek Sup Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
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Bishnoi K, Prasad R, Upadhyay T, Mathurkar S. A Narrative Review on Managing Retinopathy of Prematurity: Insights Into Pathogenesis, Screening, and Treatment Strategies. Cureus 2024; 16:e56168. [PMID: 38618439 PMCID: PMC11015904 DOI: 10.7759/cureus.56168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/14/2024] [Indexed: 04/16/2024] Open
Abstract
Retinopathy of prematurity (ROP) is a rare proliferative ocular condition that can happen in premature babies (born preterm <36 weeks) or who weigh <1.5 kg at birth (low birth weight babies). ROP is a major cause of childhood blindness. It is a premature disease since retina vascularization is completed only by 40 weeks of life. The survivability for preterm infants has increased owing to recent improvements in neonatal care during the past decade. As a result, the prevalence of ROP has risen concurrently. The abnormal development of blood vessels in the retina is the cause of this illness. It occurs in two phases, phases 1 and 2. Most preterm infants weighing <1.5 kg need supplemental oxygen for respiratory support at birth. This leads to the initiation of phase 1 (vasoconstrictive phase). Phase 1 is characterized by loss of maternal-fetal connection and hyperoxia due to supplemental oxygen therapy. Oxygen's vasoconstrictive and obliterative action is primarily observed in developing retinal vessels. The inhibition of vascular endothelial growth factor follows from this. Phase 2 (vasoproliferative phase) shows the dilatation and tortuosity of the bigger existing vessels together with neovascularization and proliferation of new vessels into the vitreous when the baby is shifted from respiratory support to room air. Now, the retina gets hypoxic, where the retina becomes more metabolically active but is yet minimally vascularized, leading to VEGF-induced vasoproliferation, which might result in retinal detachment. Patients with ROP face the danger of loss of vision. If correct and quick treatment is not provided, they might land into permanent blindness. Yet, ROP remains one of the most preventable causes of childhood blindness worldwide. Blindness caused by ROP can only be avoided if screening programs are readily available, pertinent, and appropriate. The initial stage in the therapy of ROP is the screening of premature neonates. Timely screening and management for ROP is important to avoid this irreversible loss of vision. The treatment is based on the severity of the disease. Management may include pharmacological interventions like intravitreal and anti-vascular endothelial growth factor and non-pharmacological interventions like laser surgery, vitrectomy, and scleral buckling. We conducted a thorough literature search of studies on pathogenesis, risk factors, classification, and various treatment options for retinopathy of prematurity in infants, using a mixture of pertinent keywords. Only those studies published in peer-reviewed journals between 2010 and 2023 and written in English were included. Duplicate studies, unavailable in full-text for free, or studies unrelated to our subject matter were excluded. After thoroughly evaluating the selected studies, the results were synthesized and presented narratively. This article sheds light on the pathogenesis of ROP, particularly its relation to oxygen use, screening, and potential therapeutic management of ROP. Today advances in screening techniques have improved the outcomes for infants with ROP. Still, ongoing research is needed to optimize management strategies and reduce the burden of this condition.
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Affiliation(s)
- Kratika Bishnoi
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Roshan Prasad
- Ophthalmology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Tanisha Upadhyay
- Ophthalmology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swapneel Mathurkar
- Ophthalmology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Pascarella F, Scaramuzzo RT, Pini A, Cammalleri M, Bagnoli P, Ciantelli M, Filippi L. Propranolol: a new pharmacologic approach to counter retinopathy of prematurity progression. Front Pediatr 2024; 12:1322783. [PMID: 38292211 PMCID: PMC10824858 DOI: 10.3389/fped.2024.1322783] [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: 10/16/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
Despite the evident progress in neonatal medicine, retinopathy of prematurity (ROP) remains a serious threat to the vision of premature infants, due to a still partial understanding of the mechanisms underlying the development of this disease and the lack of drugs capable of arresting its progression. Although ROP is a multifactorial disease, retinal vascularization is strictly dependent on oxygen concentration. The exposition of the retina of a preterm newborn, still incompletely vascularized, to an atmosphere relatively hyperoxic, as the extrauterine environment, induces the downregulation of proangiogenic factors and therefore the interruption of vascularization (first ischemic phase of ROP). However, over the following weeks, the growing metabolic requirement of this ischemic retina produces a progressive hypoxia that specularly promotes the surge of proangiogenic factors, finally leading to proliferative retinopathy (second proliferative phase of ROP). The demonstration that the noradrenergic system is actively involved in the coupling between hypoxia and the induction of vasculogenesis paved the way for a pharmacologic intervention aimed at counteracting the interaction of noradrenaline with specific receptors and consequently the progression of ROP. A similar trend has been observed in infantile hemangiomas, the most common vascular lesion of childhood induced by pre-existing hypoxia, which shares similar characteristics with ROP. The fact that propranolol, an unselective antagonist of β1/2 adrenoceptors, counteracts the growth of infantile hemangiomas, suggested the idea of testing the efficacy of propranolol in infants with ROP. From preclinical studies, ongoing clinical trials demonstrated that topical administration of propranolol likely represents the optimal approach to reconcile its efficacy and maximum safety. Given the strict relationship between vessels and neurons, recovering retinal vascularization with propranolol may add further efficacy to prevent retinal dysfunction. In conclusion, the strategy of contrasting precociously the progression of the disease appears to be more advantageous than the current wait-and-see therapeutic approach, which instead is mainly focused on avoiding retinal detachment.
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Affiliation(s)
| | | | - Alessandro Pini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maurizio Cammalleri
- Unit of General Physiology, Department of Biology, University of Pisa, Pisa, Italy
| | - Paola Bagnoli
- Unit of General Physiology, Department of Biology, University of Pisa, Pisa, Italy
| | | | - Luca Filippi
- Neonatology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Filippi L, Nardini P, Zizi V, Molino M, Fazi C, Calvani M, Carrozzo F, Cavallaro G, Giuseppetti G, Calosi L, Crociani O, Pini A. β3 Adrenoceptor Agonism Prevents Hyperoxia-Induced Colonic Alterations. Biomolecules 2023; 13:1755. [PMID: 38136626 PMCID: PMC10741994 DOI: 10.3390/biom13121755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Oxygen level is a key regulator of organogenesis and its modification in postnatal life alters the maturation process of organs, including the intestine, which do not completely develop in utero. The β3-adrenoreceptor (β3-AR) is expressed in the colon and has an oxygen-dependent regulatory mechanism. This study shows the effects of the β3-AR agonist BRL37344 in a neonatal model of hyperoxia-driven colonic injury. For the first 14 days after birth, Sprague-Dawley rat pups were exposed to ambient oxygen levels (21%) or hyperoxia (85%) and treated daily with BRL37344 at 1, 3, 6 mg/kg or untreated. At the end of day 14, proximal colon samples were collected for analysis. Hyperoxia deeply influences the proximal colon development by reducing β3-AR-expressing cells (27%), colonic length (26%) and mucin production (47%), and altering the neuronal chemical coding in the myenteric plexus without changes in the neuron number. The administration of BRL37344 at 3 mg/kg, but not at 1 mg/kg, significantly prevented these alterations. Conversely, it was ineffective in preventing hyperoxia-induced body weight loss. BRL37344 at 6 mg/kg was toxic. These findings pave the way for β3-AR pharmacological targeting as a therapeutic option for diseases caused by hyperoxia-impaired development, typical prematurity disorders.
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Affiliation(s)
- Luca Filippi
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy;
| | - Patrizia Nardini
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (L.C.); (O.C.)
- Imaging Platform, Department Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy
| | - Virginia Zizi
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (L.C.); (O.C.)
| | - Marta Molino
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (L.C.); (O.C.)
| | - Camilla Fazi
- Department of Pediatric, Meyer Children’s University Hospital, 50139 Florence, Italy;
| | - Maura Calvani
- Division of Pediatric Oncology/Hematology, Meyer University Children’s Hospital, 50139 Florence, Italy; (M.C.); (F.C.)
| | - Francesco Carrozzo
- Division of Pediatric Oncology/Hematology, Meyer University Children’s Hospital, 50139 Florence, Italy; (M.C.); (F.C.)
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Giorgia Giuseppetti
- Department of Clinical and Experimental Medicine, University of Pisa, 56124 Pisa, Italy;
| | - Laura Calosi
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (L.C.); (O.C.)
| | - Olivia Crociani
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (L.C.); (O.C.)
| | - Alessandro Pini
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy; (P.N.); (V.Z.); (M.M.); (L.C.); (O.C.)
- Imaging Platform, Department Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy
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9
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Scaramuzzo RT, Bagnoli P, Dal Monte M, Cammalleri M, Pini A, Ballini S, Bendinelli A, Desideri I, Ciantelli M, Filippi L. Treating infants with 0.2% propranolol eye micro-drops drastically reduced the progression of retinopathy of prematurity. Acta Paediatr 2023; 112:1905-1906. [PMID: 37199226 DOI: 10.1111/apa.16850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 05/19/2023]
Affiliation(s)
| | - Paola Bagnoli
- Department of Biology, University of Pisa, Pisa, Italy
| | | | | | - Alessandro Pini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sandy Ballini
- Neonatology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Anna Bendinelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Ielizza Desideri
- Hospital Pharmacy, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | - Luca Filippi
- Neonatology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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10
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Sharma A, Singh NK. Long Non-Coding RNAs and Proliferative Retinal Diseases. Pharmaceutics 2023; 15:pharmaceutics15051454. [PMID: 37242701 DOI: 10.3390/pharmaceutics15051454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/21/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Retinopathy refers to disorders that affect the retina of the eye, which are frequently caused by damage to the retina's vascular system. This causes leakage, proliferation, or overgrowth of blood vessels through the retina, which can lead to retinal detachment or breakdown, resulting in vision loss and, in rare cases, blindness. In recent years, high-throughput sequencing has significantly hastened the discovery of new long non-coding RNAs (lncRNAs) and their biological functions. LncRNAs are rapidly becoming recognized as critical regulators of several key biological processes. Current breakthroughs in bioinformatics have resulted in the identification of several lncRNAs that may have a role in retinal disorders. Nevertheless, mechanistic investigations have yet to reveal the relevance of these lncRNAs in retinal disorders. Using lncRNA transcripts for diagnostic and/or therapeutic purposes may aid in the development of appropriate treatment regimens and long-term benefits for patients, as traditional medicines and antibody therapy only provide temporary benefits that must be repeated. In contrast, gene-based therapies can provide tailored, long-term treatment solutions. Here, we will discuss how different lncRNAs affect different retinopathies, including age-related macular degeneration (AMD), diabetic retinopathy (DR), central retinal vein occlusion (CRVO), proliferative vitreoretinopathy (PVR), and retinopathy of prematurity (ROP), which can cause visual impairment and blindness, and how these retinopathies can be identified and treated using lncRNAs.
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Affiliation(s)
- Anamika Sharma
- Integrative Biosciences Center, Wayne State University, Detroit, MI 48202, USA
- Department of Ophthalmology, Visual and Anatomical Sciences, Wayne State University School of Medicine, Detroit, MI 48202, USA
| | - Nikhlesh K Singh
- Integrative Biosciences Center, Wayne State University, Detroit, MI 48202, USA
- Department of Ophthalmology, Visual and Anatomical Sciences, Wayne State University School of Medicine, Detroit, MI 48202, USA
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11
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Fevereiro-Martins M, Marques-Neves C, Guimarães H, Bicho M. Retinopathy of prematurity: A review of pathophysiology and signaling pathways. Surv Ophthalmol 2023; 68:175-210. [PMID: 36427559 DOI: 10.1016/j.survophthal.2022.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022]
Abstract
Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the retina and a leading cause of visual impairment and childhood blindness worldwide. The disease is characterized by an early stage of retinal microvascular degeneration, followed by neovascularization that can lead to subsequent retinal detachment and permanent visual loss. Several factors play a key role during the different pathological stages of the disease. Oxidative and nitrosative stress and inflammatory processes are important contributors to the early stage of ROP. Nitric oxide synthase and arginase play important roles in ischemia/reperfusion-induced neurovascular degeneration. Destructive neovascularization is driven by mediators of the hypoxia-inducible factor pathway, such as vascular endothelial growth factor and metabolic factors (succinate). The extracellular matrix is involved in hypoxia-induced retinal neovascularization. Vasorepulsive molecules (semaphorin 3A) intervene preventing the revascularization of the avascular zone. This review focuses on current concepts about signaling pathways and their mediators, involved in the pathogenesis of ROP, highlighting new potentially preventive and therapeutic modalities. A better understanding of the intricate molecular mechanisms underlying the pathogenesis of ROP should allow the development of more effective and targeted therapeutic agents to reduce aberrant vasoproliferation and facilitate physiological retinal vascular development.
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Affiliation(s)
- Mariza Fevereiro-Martins
- Laboratório de Genética and Grupo Ecogenética e Saúde Humana, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Portugal; Instituto de Investigação Científica Bento da Rocha Cabral, Lisboa, Portugal; Departamento de Oftalmologia, Hospital Cuf Descobertas, Lisboa, Portugal.
| | - Carlos Marques-Neves
- Centro de Estudos das Ci.¼ncias da Visão, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal; Grupo Ecogenética e Saúde Humana, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
| | - Hercília Guimarães
- Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.
| | - Manuel Bicho
- Laboratório de Genética and Grupo Ecogenética e Saúde Humana, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Portugal; Instituto de Investigação Científica Bento da Rocha Cabral, Lisboa, Portugal.
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12
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β-Adrenoreceptors as Therapeutic Targets for Ocular Tumors and Other Eye Diseases-Historical Aspects and Nowadays Understanding. Int J Mol Sci 2023; 24:ijms24054698. [PMID: 36902129 PMCID: PMC10003534 DOI: 10.3390/ijms24054698] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/21/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
β-adrenoreceptors (ARs) are members of the superfamily of G-protein-coupled receptors (GPCRs), and are activated by catecholamines, such as epinephrine and norepinephrine. Three subtypes of β-ARs (β1, β2, and β3) have been identified with different distributions among ocular tissues. Importantly, β-ARs are an established target in the treatment of glaucoma. Moreover, β-adrenergic signaling has been associated with the development and progression of various tumor types. Hence, β-ARs are a potential therapeutic target for ocular neoplasms, such as ocular hemangioma and uveal melanoma. This review aims to discuss the expression and function of individual β-AR subtypes in ocular structures, as well as their role in the treatment of ocular diseases, including ocular tumors.
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13
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Cammalleri M, Amato R, Dal Monte M, Filippi L, Bagnoli P. The β3 adrenoceptor in proliferative retinopathies: "Cinderella" steps out of its family shadow. Pharmacol Res 2023; 190:106713. [PMID: 36863427 DOI: 10.1016/j.phrs.2023.106713] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/14/2023] [Accepted: 02/27/2023] [Indexed: 03/04/2023]
Abstract
In the retina, hypoxic condition leads to overgrowing leaky vessels resulting in altered metabolic supply that may cause impaired visual function. Hypoxia-inducible factor-1 (HIF-1) is a central regulator of the retinal response to hypoxia by activating the transcription of numerous target genes, including vascular endothelium growth factor, which acts as a major player in retinal angiogenesis. In the present review, oxygen urge by the retina and its oxygen sensing systems including HIF-1 are discussed in respect to the role of the beta-adrenergic receptors (β-ARs) and their pharmacologic manipulation in the vascular response to hypoxia. In the β-AR family, β1- and β2-AR have long been attracting attention because their pharmacology is intensely used for human health, while β3-AR, the third and last cloned receptor is no longer increasingly emerging as an attractive target for drug discovery. Here, β3-AR, a main character in several organs including the heart, the adipose tissue and the urinary bladder, but so far a supporting actor in the retina, has been thoroughly examined in respect to its function in retinal response to hypoxia. In particular, its oxygen dependence has been taken as a key indicator of β3-AR involvement in HIF-1-mediated responses to oxygen. Hence, the possibility of β3-AR transcription by HIF-1 has been discussed from early circumstantial evidence to the recent demonstration that β3-AR acts as a novel HIF-1 target gene by playing like a putative intermediary between oxygen levels and retinal vessel proliferation. Thus, targeting β3-AR may implement the therapeutic armamentarium against neovascular pathologies of the eye.
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Affiliation(s)
| | - Rosario Amato
- Department of Biology, University of Pisa, Pisa, Italy
| | | | - Luca Filippi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Paola Bagnoli
- Department of Biology, University of Pisa, Pisa, Italy.
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14
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Bujoreanu Bezman L, Tiutiuca C, Totolici G, Carneciu N, Bujoreanu FC, Ciortea DA, Niculet E, Fulga A, Alexandru AM, Stan DJ, Nechita A. Latest Trends in Retinopathy of Prematurity: Research on Risk Factors, Diagnostic Methods and Therapies. Int J Gen Med 2023; 16:937-949. [PMID: 36942030 PMCID: PMC10024537 DOI: 10.2147/ijgm.s401122] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/17/2023] [Indexed: 03/15/2023] Open
Abstract
Retinopathy of prematurity (ROP) is a vasoproliferative disorder with an imminent risk of blindness, in cases where early diagnosis and treatment are not performed. The doctors' constant motivation to give these fragile beings a chance at life with optimal visual acuity has never stopped, since Terry first described this condition. Thus, throughout time, several specific advancements have been made in the management of ROP. Apart from the most known risk factors, this narrative review brings to light the latest research about new potential risk factors, such as: proteinuria, insulin-like growth factor 1 (IGF-1) and blood transfusions. Digital imaging has revolutionized the management of retinal pathologies, and it is more and more used in identifying and staging ROP, particularly in the disadvantaged regions by the means of telescreening. Moreover, optical coherence tomography (OCT) and automated diagnostic tools based on deep learning offer new perspectives on the ROP diagnosis. The new therapeutical trend based on the use of anti-VEGF agents is increasingly used in the treatment of ROP patients, and recent research sustains the theory according to which these agents do not interfere with the neurodevelopment of premature babies.
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Affiliation(s)
- Laura Bujoreanu Bezman
- Department of Ophthalmology, “Sfantul Apostol Andrei” Emergency Clinical Hospital, Galati, Romania
- Department of Morphological and Functional Sciences, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
| | - Carmen Tiutiuca
- Department of Ophthalmology, “Sfantul Apostol Andrei” Emergency Clinical Hospital, Galati, Romania
- Clinical Surgical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
- Correspondence: Carmen Tiutiuca, Clinical Surgical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, 800008, Romania, Tel +40741330788, Email
| | - Geanina Totolici
- Department of Ophthalmology, “Sfantul Apostol Andrei” Emergency Clinical Hospital, Galati, Romania
- Clinical Surgical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
| | - Nicoleta Carneciu
- Department of Ophthalmology, “Sfantul Apostol Andrei” Emergency Clinical Hospital, Galati, Romania
- Department of Morphological and Functional Sciences, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
| | - Florin Ciprian Bujoreanu
- Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
- Florin Ciprian Bujoreanu, Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, 800008, Romania, Tel +40741395844, Email
| | - Diana Andreea Ciortea
- Department of Pediatrics, “Sfantul Ioan” Emergency Clinical Hospital for Children, Galati, Romania
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
| | - Elena Niculet
- Department of Morphological and Functional Sciences, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
- Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
| | - Ana Fulga
- Clinical Surgical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
- Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
| | - Anamaria Madalina Alexandru
- Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
- Department of Neonatology, “Sfantul Apostol Andrei” Emergency Clinical Hospital, Galati, Romania
| | - Daniela Jicman Stan
- Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
| | - Aurel Nechita
- Department of Pediatrics, “Sfantul Ioan” Emergency Clinical Hospital for Children, Galati, Romania
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Galati, Romania
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15
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Kim H, Kim J, Ryu J. Noncoding RNAs as a novel approach to target retinopathy of prematurity. Front Pharmacol 2022; 13:1033341. [PMID: 36386230 PMCID: PMC9641647 DOI: 10.3389/fphar.2022.1033341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/11/2022] [Indexed: 06/21/2024] Open
Abstract
Retinopathy of prematurity (ROP), a vascular disease characterized by abnormal vessel development in the retina, has become a primary cause of blindness in children around the world. ROP can be developed during two different phases: vessel loss and vessel proliferation. Once preterm infants with immature retinal vessel growth are exposed to high level of oxygen inside the incubator, vessel loss can occur. When infants are exposed to room air, they may experience the proliferation of vessels in the retina. Although multiple factors are reported to be involved in the pathogenesis of ROP, including vaso-endothelial growth factors (VEGFs) and hypoxia-inducible factors, the pathogenesis of ROP is not completely understood. Although laser therapy and pharmacologic agents, such as anti-VEGF agents, have been commonly used to treat ROP, the incidence of ROP is rapidly rising. Given that current therapies can be invasive and long-term effects are not fully known, the search for novel therapeutic targets with less destructive properties needs to be considered. Within the last decade, the field of noncoding RNA therapy has shown potential as next-generation therapy to treat diverse diseases. In this review, we introduce various noncoding RNAs regulating ROP and discuss their role as potential therapeutic targets in ROP.
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Affiliation(s)
- Hyunjong Kim
- Vessel-Organ Interaction Research Center, College of Pharmacy, Kyungpook National University, Daegu, South Korea
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, South Korea
| | - Jaesub Kim
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, South Korea
| | - Juhee Ryu
- Vessel-Organ Interaction Research Center, College of Pharmacy, Kyungpook National University, Daegu, South Korea
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, South Korea
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16
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Lucchesi M, Marracci S, Amato R, Filippi L, Cammalleri M, Dal Monte M. Neurosensory Alterations in Retinopathy of Prematurity: A Window to Neurological Impairments Associated to Preterm Birth. Biomedicines 2022; 10:biomedicines10071603. [PMID: 35884908 PMCID: PMC9313429 DOI: 10.3390/biomedicines10071603] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/21/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Retinopathy of prematurity (ROP) is one of the main blinding diseases affecting preterm newborns and is classically considered a vascular disorder. The premature exposure to the extrauterine environment, which is hyperoxic in respect to the intrauterine environment, triggers a cascade of events leading to retinal ischemia which, in turn, makes the retina hypoxic thus setting off angiogenic processes. However, many children with a history of ROP show persistent vision impairment, and there is evidence of an association between ROP and neurosensory disabilities. This is not surprising given the strict relationship between neuronal function and an adequate blood supply. In the present work, we revised literature data evidencing to what extent ROP can be considered a neurodegenerative disease, also taking advantage from data obtained in preclinical models of ROP. The involvement of different retinal cell populations in triggering the neuronal damage in ROP was described along with the neurological outcomes associated to ROP. The situation of ROP in Italy was assessed as well.
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Affiliation(s)
- Martina Lucchesi
- Department of Biology, University of Pisa, 56127 Pisa, Italy; (M.L.); (S.M.); (R.A.); (M.C.)
| | - Silvia Marracci
- Department of Biology, University of Pisa, 56127 Pisa, Italy; (M.L.); (S.M.); (R.A.); (M.C.)
| | - Rosario Amato
- Department of Biology, University of Pisa, 56127 Pisa, Italy; (M.L.); (S.M.); (R.A.); (M.C.)
| | - Luca Filippi
- Department of Clinical and Experimental Medicine, Division of Neonatology and NICU, University of Pisa, 56126 Pisa, Italy;
| | - Maurizio Cammalleri
- Department of Biology, University of Pisa, 56127 Pisa, Italy; (M.L.); (S.M.); (R.A.); (M.C.)
| | - Massimo Dal Monte
- Department of Biology, University of Pisa, 56127 Pisa, Italy; (M.L.); (S.M.); (R.A.); (M.C.)
- Correspondence: ; Tel.: +39-050-2211426
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