Lung ultrasound score as a tool to predict severity of bronchopulmonary dysplasia in neonates born ≤25 weeks of gestational age.

OBJECTIVE: The primary aim was to evaluate whether the addition of the posterior lung aided in diagnostic accuracy of predicting bronchopulmonary dysplasia (BPD) vs moderate-severe BPD (msBPD); the secondary aim was to explore the diagnostic accuracy of two protocols for BPD vs msBPD. STUDY DESIGN: This was a single-center prospective observational study. Preterm infants with a gestational age ≤ 25 weeks were included. Two LUS score protocols were evaluated on the 14th day of life (DOL): (A) evaluating the anterolateral (LUS score-al) lung and (B) the anterolateral combined with posterior (LUS score-alp) lung. The LUS score range for the two protocols was 0-32 and 0-48, respectively. RESULTS: A total of eighty-nine infants were enrolled. Both the LUS score-al and LUS score-alp were higher in neonates developing BPD and msBPD than in the rest of the cohort (LUS score-al 24 (23,26) vs 22 (20,23); LUS score-alp 36 (34,39) vs 28 (25,32)) (LUS score-al 25 (24,26) vs 23 (21,24); LUS score-alp 40 (39,40) vs 34 (28,36)). The LUS score-al on the 14th DOL showed a moderate diagnostic accuracy to predict BPD and msBPD (AUC 95% CI: 0.797 [0.697-0.896]; 0.811[0.713-0.909]), while the LUS score-alp significantly improved diagnostic accuracy of BPD and msBPD (AUC 95% CI: 0.902 [0.834-0.970]; 0.922 [0.848-0.996]). A cutoff of 25 points in the LUS score-al provided a sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 76.9%, 79.4%, 3.7, and 0.3 respectively to predict msBPD. Meanwhile, that of 39 points in the LUS score-alp provided a sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 81%, 98.4%, 50.5 and 0.19 to predict msBPD, respectively. CONCLUSIONS: The LUS score on the 14th DOL can predict BPD and msBPD with moderate diagnostic accuracy. Apart from that, scanning posterior enhanced diagnostic accuracy.

The Predictive Value of Lung Ultrasound Score on Hemodynamically Significant Patent Ductus Arteriosus among Neonates ≤25 Weeks.

Lung ultrasound (LU) is increasingly used to diagnose and monitor neonatal pulmonary disorders; however, its role in hemodynamically significant patent ductus arteriosus (hsPDA) has not been elucidated. This prospective study investigated the predictive value of the LU score (LUS) for hsPDA in preterm infants with gestational age (GA) ≤ 25 weeks. Preterm infants with GA ≤ 25 weeks were enrolled in this study. LU was conducted on the fourth day of life (DOL). Six lung regions in every lung were scanned, with each region rated as 0-4 points. The performance of the LUS in predicting hsPDA among infants aged ≤25 weeks was analyzed by plotting the receiver operating characteristic (ROC) curve. A total of 81 infants were included in this study. GA, birth weight (BW), gender, Apgar score, delivery mode, antenatal steroids, meconium-stained amniotic fluid, premature rapture of membrane, and early-onset sepsis were not significantly different, but infants in the hsPDA group had increased LUS (38.2 ± 2.8 vs. 30.3 ± 4.3, p < 0.001) compared with non-hsPDA group. The area under the ROC curve (AUC) value of the LUS on the fourth DOL was 0.94 (95% CI: 0.93-0.99) in predicting hsPDA. The LUS threshold at 33 achieved 89% sensitivity and 83% specificity, with the positive and negative predictive values (PPV and NPV) being 87 and 86%, respectively. The LUS can predict hsPDA in extremely preterm infants at an early stage.

Lung ultrasound score predicts patent ductus arteriosus ligation among neonates ≤25 weeks.

BACKGROUND: This prospective study aimed to investigate whether lung ultrasound score (LUSs) can predict the patent ductus arteriosus (PDA) ligation. METHODS: Preterm infants ≤25 weeks of gestational age (GA) were enrolled. A lung ultrasound was performed on the 14th day of life. Each lung zone was given a score between 0 and 4. A receiver-operating characteristic (ROC) curve was constructed to evaluate the ability of the LUSs for predicting ligation. RESULTS: A total of 81 infants were eligible with a median GA and birth weight (BW) of 25 weeks (24.1-25.2) and 710 g (645-770), respectively. The median time from birth to ligation was 35 days (32-51). Those who underwent ligation had a longer time of mechanical ventilation (34 [26-39] vs. 19 [12-30], p < 0.001), shorter time of noninvasive respiratory support (39 [32-51] vs. 50 [41.5-57], p < 0.01), higher incidence of the bronchopulmonary dysplasia (BPD) (p < 0.01), and severe BPD (p < 0.001). The LUSs had an area under the ROC of 0.96 (95% confidence interval: 0.93-0.99) for the prediction of ligation. A LUSs cutoff of 36 has a sensitivity and specificity of 96% and 86% and positive and negative predictive values of 82% and 98%, respectively. CONCLUSIONS: LUSs at an early stage of life can predict PDA ligation in extremely preterm infants. It would be helpful to reduce morbidity by reducing the duration and magnitude of respiratory support.

The Value of Lung Ultrasound Score in Neonatology.

Point-of-care lung ultrasound (LUS) is increasingly applied in the neonatal intensive care unit (NICU). Diagnostic applications for LUS in the NICU contain the diagnosis of many common neonatal pulmonary diseases (such as Respiratory distress syndrome, Transient tachypnea of the newborn, Meconium aspiration syndrome, Pneumonia, Pneumothorax, and Pleural effusion) which have been validated. In addition to being employed as a diagnostic tool in the classical sense of the term, recent studies have shown that the number and type of artifacts are associated with lung aeration. Based on this theory, over the last few years, LUS has also been used as a semi-quantitative method or as a "functional" tool. Scores have been proposed to monitor the progress of neonatal lung diseases and to decide whether or not to perform a specific treatment. The semi-quantitative LUS scores (LUSs) have been developed to predict the demand for surfactant therapy, the need of respiratory support and the progress of bronchopulmonary dysplasia. Given their ease of use, accuracy and lack of invasiveness, the use of LUSs is increasing in clinical practice. Therefore, this manuscript will review the application of LUSs in neonatal lung diseases.

Randomized trial of electrodynamic microneedling combined with 5% minoxidil topical solution for treating androgenetic alopecia in Chinese males and molecular mechanistic study of the involvement of the Wnt/ß-catenin signaling pathway.

BACKGROUND: Treatment of androgenetic alopecia (AGA) with concurrent electrodynamic microneedling and 5% minoxidil may further stimulate hair growth. OBJECTIVES: To evaluate the efficacy of microneedling combined with 5% minoxidil in Chinese male AGA patients and to explore the underlying mechanisms. METHODS: Seventy-one male volunteers with AGA completed the entire trial and follow-up. The first group (n = 23) received only 5% minoxidil twice daily for 24 weeks; the second group (n = 23) received only microneedle therapy every 3 weeks for eight treatments; and the third group (n = 25) received the combination treatment for a total of 24 weeks. Changes in hair density and diameter were evaluated before and after treatment every 3 weeks, and patients were followed up at 6 months after the final treatment. In the combination group, a PCR array was used to detect the expression of molecules in the Wnt/ß-catenin pathway within the hair loss sites on top of the head before and after treatment and within the scalp tissues from non-hair loss sites on top of the head. The tissues were obtained by punches in the most severe area of hair loss on top of the head and in the adjacent normal hair area without hair loss. Real-time quantitative PCR and western blotting were used to further examine changes in the differentially expressed molecules identified by PCR array (FZD3) and in molecules in the Wnt/ß-catenin signaling pathway closely related to hair growth (ß-catenin and LEF-1). RESULTS: Compared to single minoxidil or single microneedle treatment, the combination therapy showed superior therapeutic effects clinically, with further upregulation of FZD3, ß-catenin, and LEF-1 expression levels at both mRNA and protein levels in the treated areas. CONCLUSIONS: Microneedling combined with 5% minoxidil can improve AGA, and the underlying mechanism may involve activation of the Wnt/ß-catenin signaling pathway.

Influence of Alveolar Fluid on Aquaporins and Na+/K+-ATPase and Its Possible Theoretical or Clinical Significance.

OBJECTIVE: Pulmonary edema is the most common pathophysiological change in pulmonary disease. Aquaporins (AQPs) and Na+/K+-ATPase play pivotal roles in alveolar fluid clearance. This study aimed to explore the influence of increased alveolar fluid on the absorption of lung fluid. STUDY DESIGN: Eighty New Zealand rabbits were randomly divided into eight groups (n = 10 in each group), and models of different alveolar fluid contents were established by the infusion of different volumes of normal saline (NS) via the endotracheal tube. Five animals in each group were sacrificed immediately after infusion to determine the wet/dry ratio, while the remaining animals in each group were killed 4 hours later to determine the wet/dry ratio at 4 hours. Additionally, lung specimens were collected from each group, and quantitative real-time PCR (qRT-PCR), western blot, and immunohistochemical (IHC) analyses of AQPs and Na+/K+-ATPase were performed. RESULTS: The qRT-PCR analysis and western blot studies showed markedly decreased mRNA and protein levels of AQP1 and Na+/K+-ATPase when the alveolar fluid volume was ≥6 mL/kg, and the mRNA level of AQP5 was significantly reduced when the alveolar fluid volume was ≥4 mL/kg. In addition, IHC analysis showed the same results. At 4 hours, the lung wet/dry ratio was significantly increased when the alveolar fluid volume was ≥6 mL/kg; however, compared with 0 hours after NS infusion, there was still a significant absorption of alveolar fluid for a period of 4 hours. CONCLUSION: The results of this study suggest that increased alveolar fluid may induce the downregulation of the mRNA and protein expression of AQPs and Na+/K+-ATPase, which appear to affect alveolar fluid clearance in rabbit lungs. Early intervention is required to avoid excessive alveolar fluid accumulation. KEY POINTS: · The expression levels of AQPs and Na+/K+--ATPase were significantly decreased as alveolar fluid increased.. · At 4 hours, wet/dry ratio was significantly increased when infusion volume was ≥ 6 mL/kg.. · Early intervention is required to avoid excessive alveolar fluid accumulation..

Lung ultrasound to quantitatively evaluate extravascular lung water content and its clinical significance.

BACKGROUND: As we all know, pulmonary edema can be diagnosed by lung ultrasound (LUS), but how to accurately and quantitatively evaluate lung water content by ultrasound is a difficult problem that needs to be solved urgently. B-line assessment with LUS has recently been proposed as a reliable, noninvasive semiquantitative tool for evaluating extravascular lung water (EVLW). To date, however, there has been no easy quantitative method to evaluate EVLW by LUS. OBJECTIVE: (1) To explore the feasibility of establishing a rabbit model with increased EVLW by injecting warm normal saline (NS) into the lungs via the endotracheal tube. (2) To establish a simple, accurate and clinically operable method for quantitative assessment of EVLW using LUS. (3) To develop LUS into a resource for guiding the clinical treatment of patients with increased EVLW. METHODS: Forty-five New Zealand rabbits were randomized into nine groups (n = 5). After anesthesia, each group of rabbits was injected with different amounts of warm sterile NS (0 ml/kg, 2 ml/kg, 4 ml/kg, 6 ml/kg, 8 ml/kg, 10 ml/kg, 15 ml/kg, 20 ml/kg, 30 ml/kg) via the endotracheal tube. Each rabbit was examined by LUS before and after NS injection. At the same time, the spontaneous respiratory rate (RR, breaths per minute), heart rate (HR, bpm) and arterial blood gas (ABG) of the rabbits were recorded. Then, both lungs were dissected to obtain the wet and dry weight and conduct a complete histological examination. RESULTS: Injecting NS into the lungs through a tracheal tube can successfully establish a rabbit model with increased EVLW. The extent of EVLW increase is related to the volume of NS injected into the lungs. As the EVLW increases, three different types of B-lines can be seen in the LUS. When the NS injection volume is 2-6 ml/kg, comet-tail artifacts and B-lines are the main patterns found on LUS; as additional NS is injected into the lungs, the rabbits' RR gradually increases, while their HR gradually decreases, ABG remains normal or shows mild metabolic acidosis (MA). Confluent B-lines grow gradually but significantly, reaching a dominant position when the NS injection volume reaches 6-8 ml/kg and predominating almost entirely when the NS injection volume is 8-15 ml/kg; at that time, rabbits' RRs and HRs decrease sharply, and the ABG indicated type I respiratory failure (RF).Compact B-lines occur and predominate almost entirely when the NS injection volume reaches 10 ml/kg and 15-20 ml/kg, respectively. At that time, rabbits begin to enter cardiac and respiratory arrest, and ABG shows type II RF and MA. CONCLUSION: In this study, the establishment of an animal model with increased EVLW confirmed that different lung water content had corresponding manifestations in ultrasound and was associated with different degrees of clinical symptoms, and the study results can be used to guide clinical practice.

Specification and guideline for technical aspects and scanning parameter settings of neonatal lung ultrasound examination.

Lung ultrasound (LUS) is now widely used in the diagnosis and monitor of neonatal lung diseases. Nevertheless, in the published literatures, the LUS images may display a significant variation in technical execution, while scanning parameters may influence diagnostic accuracy. The inter- and intra-observer reliabilities of ultrasound exam have been extensively studied in general and in LUS. As expected, the reliability declines in the hands of novices when they perform the point-of-care ultrasound (POC US). Consequently, having appropriate guidelines regarding to technical aspects of neonatal LUS exam is very important especially because diagnosis is mainly based on interpretation of artifacts produced by the pleural line and the lungs. The present work aimed to create an instrument operation specification and parameter setting guidelines for neonatal LUS. Technical aspects and scanning parameter settings that allow for standardization in obtaining LUS images include (1) select a high-end equipment with high-frequency linear array transducer (12-14 MHz). (2) Choose preset suitable for lung examination or small organs. (3) Keep the probe perpendicular to the ribs or parallel to the intercostal space. (4) Set the scanning depth at 4-5 cm. (5) Set 1-2 focal zones and adjust them close to the pleural line. (6) Use fundamental frequency with speckle reduction 2-3 or similar techniques. (7) Turn off spatial compounding imaging. (8) Adjust the time-gain compensation to get uniform image from the near-to far-field.

Toll-like receptor 4-mediated necroptosis in the development of necrotizing enterocolitis.

BACKGROUND: Dramatic intestinal epithelial cell death leading to barrier dysfunction is one of the mechanism of neonatal necrotizing enterocolitis (NEC), in which Toll-like receptor 4 (TLR4) plays a pivotal role. This study explored the role of necroptosis, a drastic way of cell death in NEC. METHODS: The expression of necroptotic proteins was tested in NEC intestinal tissue and compared with controls. NEC was induced in neonatal wild-type mice and a necroptosis inhibitor was given to investigate whether NEC could be relieved. The general condition, macroscopic scoring, and histological evaluations were performed. The expression of tight junction proteins, inflammatory cytokines, and necroptosis-related proteins was measured, and barrier function was examined. Then, NEC was induced in TLR4-knockout pups to confirm the role of TLR4 in necroptosis. RESULTS: Necroptotic proteins were significantly upregulated in both NEC patient and animal models, together with the expression of TLR4. NEC could be relieved and inflammatory infiltration was decreased by necrostatin-1s. TLR4-knockout mice showed milder tissue degradation and less necroptosis after NEC induction. CONCLUSIONS: Necroptosis is an essential pathological process of NEC. TLR4 may be one stimulator of necroptosis in NEC. Inhibiting the intestinal cell necroptosis might be a useful strategy in the treatment of NEC. IMPACT: Necroptosis is a key pathological process in NEC, which appears to involve TLR4. Anti-necroptosis treatment is a promising strategy that could significantly relieve the symptoms of NEC.

Wet lung leading to RDS: the lung ultrasound findings and possible mechanisms - a pilot study from an animal mode.

BACKGROUND: Clinically, the lung ultrasound (LUS) showed wet lung could cause respiratory distress syndrome (RDS) in newborns. This work aimed to investigate LUS changes over time and its potential mechanism as alveolar fluid increase in a rabbit model. METHODS: A total of 35 New Zealand Rabbits were randomly assigned to seven groups. Models of various alveolar fluid levels were induced by infusion of different volumes of normal saline (NS) via the endotracheal tube. LUS was performed before NS infusion, immediately after NS infusion and 4 h after NS infusion. To appraise LUS changes and its potential mechanism as alveolar fluid increase, histopathological examination, the mRNA and protein expression of surfactant protein (SP), and immunohistochemistry (IHC) were performed. The expression levels of SP-B and SP-C proteins were detected using western blotting, and the relative expression levels of SP-B and SP-C mRNA were detected using qRT-PCR. RESULTS: The results showed that LUS changed from B-line to lung consolidations accompanied by air-bronchograms in some locations of lungs at 4 h when the injection volume ≥ 6 ml/kg. Histopathological examination showed alveoli collapse, inflammatory cell infiltration and alveolar wall thickened. SP-B and SP-C mRNA and protein expression were statistically significantly reduced when the injection volume ≥6 ml/kg (p < .05). IHC staining displayed the same findings. CONCLUSIONS: As alveolar fluid increase, LUS changed from wet lung to RDS after 4 h. The possible mechanism was that the SP protein expression was significantly reduced. LUS can be used to guide the administration of exogenous surfactant in this situation.

Using lung ultrasound to quantitatively evaluate pulmonary water content.

BACKGROUND: Increases in extravascular lung water (EVLW) can lead to respiratory failure. This study aimed to investigate whether the B-line score (BLS) was correlated with the EVLW content determined by the lung wet/dry ratio in a rabbit model. METHODS: A total of 45 New Zealand rabbits were randomly assigned to nine groups. Among the animals, models of various lung water content levels were induced by the infusion of different volumes of warm sterile normal saline (NS) via the endotracheal tube. The arterial blood gas, spontaneous respiratory rate, and PaO2 /FiO2 ratio were detected before and after infusion. In addition, the B-lines were determined before and immediately after infusion in each group. Finally, both lungs were resected to determine the wet/dry ratio. In addition, all lung specimens were analyzed histologically, and EVLW was quantified using the BLS based on the number and confluence of B-lines in the intercostal space. RESULTS: The BLS increased with increasing infusion volume. The BLS was statistically correlated with the wet/dry ratio (r2 = .946) and with the PaO2 /FiO2 ratio (r2 = .916). Furthermore, a repeatability study was performed for the lung ultrasound (LUS) technology (Bland-Altman plots), and the results suggest that LUS had favorable intraobserver and interobserver reproducibility. CONCLUSIONS: This study is the first to suggest that the BLS can serve as a sensitive, quantitative, noninvasive, and real-time indicator of EVLW in a rabbit model of lung water accumulation. Notably, the BLS displayed an obvious correlation with the experimental gravimetry results and could also be used to predict the pulmonary oxygenation status.

Randomized trial of electrodynamic microneedle combined with 5% minoxidil topical solution for the treatment of Chinese male Androgenetic alopecia.

Background: In treating androgenetic alopecia, 5% minoxidil is a commonly used topical drug. By using electrodynamic microneedle at the same time may increase absorption of minoxidil and further stimulate hair growth.Objective: A 24-week, randomized, evaluator blinded, comparative study was performed to evaluate the efficacy of treating Chinese male androgenetic alopecia using microneedle combined with 5% minoxidil topical solution. Methods: Randomized subjects received topical 5% minoxidil (group 1, n = 20), local electrodynamic microneedle treatments (group 2, n = 20), or local electrodynamic microneedle treatments plus topical 5% minoxidil (group 3, n = 20). A total of 12 microneedle treatments were performed every 2 weeks with 2ml 5% minoxidil delivery in group three during each microneedle treatment. Patient receiving topical 5% minoxidil applied 1 ml of the solution twice daily over the course of the study. A total of 60 Chinese male subjects with Norwood-Hamilton type III-VI androgenetic alopecia were treated.Results: The mean improvement in total hair density from baseline to 24 weeks was 18.8/cm2 in group 1, 23.4/cm2 in group 2, and 38.3/cm2 in group 3. The hair growth in the three groups was significantly different (P = 0.002), but there were no significant differences in toxicity found between the three groups.Conclusions: Treatment with microneedle plus topical 5% minoxidil was associated with the best hair growth.

Decreased Warburg effect induced by ATP citrate lyase suppression inhibits tumor growth in pancreatic cancer.

ATP citrate lyase (ACLY) is responsible for the conversion of cytosolic citrate into acetyl-CoA and oxaloacetate, and the first rate-limiting enzyme involved in de novo lipogenesis. Recent studies have demonstrated that inhibition of elevated ACLY results in growth arrest and apoptosis in a subset of cancers; however, the expression pattern and underlying biological function of ACLY in pancreatic ductal adenocarcinoma (PDAC) remains unclear. In the current study, overexpressed ACLY was more commonly observed in PDAC compared to normal pancreatic tissues. Kaplan-Meier survival analysis showed that high expression level of ACLY resulted in a poor prognosis of PDAC patients. Silencing of endogenous ACLY expression by siRNA in PANC-1 cells led to reduced cell viability and increased cell apoptosis. Furthermore, significant decrease in glucose uptake and lactate production was observed after ACLY was knocked down, and this effect was blocked by 2-deoxy-D-glucose, indicating that ACLY functions in the Warburg effect affect PDAC cell growth. Collectively, this study reveals that suppression of ACLY plays an anti-tumor role through decreased Warburg effect, and ACLY-related inhibitors might be potential therapeutic approaches for PDAC.