The patent ductus arteriosus management debate: it's not over yet.
The patent ductus arteriosus management debate: it's not over yet.
复制标题
动脉导管未闭管理争论：尚未结束。
DOI：
10.1038/s41372-021-01059-w
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发表时间：
2021
期刊：
影响因子：
--
通讯作者：
Reese,Jeff
中科院分区：
文献类型：
--
作者：
Lopata,SusanM;Slaughter,JamesC;Gillam-Krakauer,Maria;Reese,Jeff
早产儿护理的一个重大挑战是降低慢性肺病（CLD）的发病率。应对这一挑战的努力包括各种呼吸支持策略、药物干预（咖啡因、维生素A、类固醇）和积极措施，以诱导动脉导管未闭（PDA） bbb闭合。先前的研究表明PDA与CLD的发展之间存在关联[2-6]。尽管有这些观察结果，研究评估了用于导管关闭的各种药物治疗，无论是预防性的还是在有血流动力学意义的PDA发展的证据后，都没有显示CLD和其他不良后果的减少[10]。新生儿学家留下的印象是，关闭导管的策略效果有限，可能使婴儿面临不必要的治疗和相关风险。尽管非药物治疗策略越来越受欢迎，但对于PDA的保守或非治疗方法是否真的是解决问题的答案，目前还没有足够的信息。在这一期的《围产期杂志》上，Bussmann及其同事报道了PDA随机对照试验的亚分析结果，这是一项单中心双盲研究，发现在小于29周的持续PDA分流高危婴儿中，布洛芬治疗组（n= 30）与安慰剂治疗组（n= 30）相比，CLD或死亡的主要结局没有差异。在本研究中，一项事后二级分析发现，当治疗组的婴儿根据成功关闭PDA进行分层时，与未成功关闭PDA的婴儿（85%）或接受安慰剂的婴儿（60%）相比，观察到导管关闭的婴儿（29%）的复合CLD/死亡发生率显著降低。作者得出结论，早期消除分流可降低CLD bb0。考虑到研究样本量小（n= 17闭合DAs vs n= 13治疗组持续PDA），应该进行进一步的研究来验证这一结论，这限制了分析的效力及其广泛的适用性。虽然将这些新信息纳入PDA治疗的随机对照试验列表可能很有吸引力，但在干预组中对应答者/无应答者的亚分析的依赖在概念上是有问题的，失去了随机化和盲对照组的好处，引入了看不见的新混杂因素，扩大了新对照组之间的人口统计学差距，这些差距可能无法通过回归分析充分解决。这项研究的一个优势是在讨论PDA治疗对呼吸系统疾病的影响时，一个明确定义的PDA评分系统的有用性的证明。在新生儿研究和临床实践中，对具有血流动力学意义的PDA的共同定义是至关重要的，以便确定因长时间导管分流而患病风险最大的婴儿以及治疗的疗效和时机。几十年来，人们一直在努力开发临床和超声心动图标准，以区分无害的、即将关闭的PDA和真正具有血流动力学意义的、有终末器官损伤风险的PDA，这导致了复杂的评分系统b[14]，但只有少数在随机对照试验中进行了测试。值得赞扬的是，在这项研究中，El-Khuffash， McNamara和同事们很好地展示了PDA严重程度评分（PDAsc）的实施，包括妊娠不成熟和肺循环过度和左心室舒张功能指标[15]。临床决策工具如PDAsc对指导治疗和改善…
A significant challenge in the care of the premature neonate is reducing the incidence of chronic lung disease (CLD). Efforts to tackle this challenge have included various respiratory support strategies, pharmacological interventions (caffeine, vitamin A, steroids), and active measures to induce closure of a patent ductus arteriosus (PDA)[1]. Prior studies have shown an association between a PDA and the development of CLD [2–6]. Despite these observations, studies evaluating various pharmacologic therapies used for ductal closure given both prophylactically and after evidence of the development of a hemodynamically significant PDA have generally failed to show a decrease in CLD and other adverse outcomes [7]. Neonatologists are left with the impression that strategies to close the ductus have limited benefit and may expose infants to unnecessary treatments and their associated risks. Although non-pharmacologic management strategies have gained popularity [8], there is insufficient information to know whether conservative or non-treatment approaches to a PDA are really the answer. In this issue of the Journal of Perinatology, Bussmann and colleagues report the results of a sub-analysis of The PDA RCT, a single-center double-blind study that found no difference in the primary outcome of CLD or death between infants with high risk for persistent PDA shunt at a gestational age of< 29 weeks who were treated with ibuprofen (n= 30) compared to placebo (n= 30)[9]. In the present study, a post hoc secondary analysis found that when infants in the treatment arm were stratified based on successful closure of the PDA, significantly lower rates of the composite CLD/death outcome were observed in infants with a closed ductus (29%) compared to those with unsuccessful PDA closure (85%) or those who received placebo (60%). The authors conclude that early shunt elimination may reduce CLD [10]. Further research validating this conclusion should be undertaken given the small sample size of the study (n= 17 closed DAs vs. n= 13 with persistent PDA in the treatment arm) which limits the power of the analysis and its broad applicability. While it may be tempting to include this new information with curated lists of RCTs of PDA treatment [11], the reliance on subanalysis of responders/non-responders in the intervention arm is conceptually problematic, losing the benefits of randomization and blind comparison groups, introducing unseen new confounders, and widening demographic gaps between the new comparison groups that may not be adequately resolved by regression analyses [12]. A strength of this study is the demonstration of the usefulness of a welldefined PDA scoring system in the debate on effect of PDA treatment on respiratory morbidity. A shared definition of a hemodynamically significant PDA is critical in neonatology for both research and clinical practice in order to both identify infants at greatest risk of morbidity from a prolonged ductal shunt and the efficacy and timing of treatment [13]. Decades-long efforts to develop clinical and echocardiographic criteria that discriminate between the innocent, soon-to-close PDA and the truly hemodynamically significant PDA that poses risk for end-organ injury have led to complex scoring systems [14], but only a few that have been tested in RCTs. To their credit, in this study, El-Khuffash, McNamara, and colleagues nicely demonstrate implementation of a PDA Severity Score (PDAsc) incorporating gestational immaturity and indicators of pulmonary over circulation and left ventricular diastolic function [15]. Clinical decision-making tools such as the PDAsc are essential to guide treatment and improve …
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DOI：
10.1073/pnas.82.4.1089
发表时间：
1985-01-01
影响因子：
11.1
作者：
WHITE, PC;GROSSBERGER, D;STROMINGER, JL
通讯作者：
STROMINGER, JL
双色荧光同时检测两个细胞群并应用于 B 细胞决定簇的识别
影响因子：
64.8
作者：
J. J. Rood;A. Leeuwen;J. Ploem
通讯作者：
J. Ploem
DOI：
--
发表时间：
1980
影响因子：
11.1
作者：
Z. Awdeh;C. Alper
通讯作者：
C. Alper
影响因子：
64.8
作者：
CARROLL, MC;CAMPBELL, RD;PORTER, RR
通讯作者：
PORTER, RR
人类补体第四种成分的 C4A 和 C4B 同种型在几个 C1 携带细胞表面上的共价结合特性。
影响因子：
4.4
作者：
D. Isenman;J. Young
通讯作者：
J. Young