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Selby JV, Maas CCHM, Fireman BH, Kent DM. Impact of the PATH Statement on Analysis and Reporting of Heterogeneity of Treatment Effect in Clinical Trials: A Scoping Review. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.06.24306774. [PMID: 38766150 PMCID: PMC11100853 DOI: 10.1101/2024.05.06.24306774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Background The Predictive Approaches to Treatment Effect Heterogeneity (PATH) Statement provides guidance for using predictive modeling to identify differences (i.e., heterogeneity) in treatment effects (benefits and harms) among participants in randomized clinical trials (RCTs). It distinguished risk modeling, which uses a multivariable model to predict risk of trial outcome(s) and then examines treatment effects within strata of predicted risk, from effect modeling, which predicts trial outcomes using models that include treatment, individual participant characteristics and interactions of treatment with selected characteristics. Purpose To describe studies of heterogeneous treatment effects (HTE) that use predictive modeling in RCT data and cite the PATH Statement. Data Sources The Cited By functions in PubMed, Google Scholar, Web of Science and SCOPUS databases (Jan 7, 2020 - June 5, 2023). Study Selection 42 reports presenting 45 predictive models. Data Extraction Double review with adjudication to identify risk and effect modeling and examine consistency with Statement consensus statements. Credibility of HTE findings was assessed using criteria adapted from the Instrument to assess Credibility of Effect Modification Analyses (ICEMAN). Clinical importance of credible HTE findings was also assessed. Data Synthesis The numbers of reports, especially risk modeling reports, increased year-on-year. Consistency with consensus statements was high, except for two: only 15 of 32 studies with positive overall findings included a risk model; and most effect models explored many candidate covariates with little prior evidence for effect modification. Risk modeling was more likely than effect modeling to identify both credible HTE (14/19 vs 5/26) and clinically important HTE (10/19 vs 4/26). Limitations Risk of reviewer bias: reviewers assessing credibility and clinical importance were not blinded to adherence to PATH recommendations. Conclusions The PATH Statement appears to be influencing research practice. Risk modeling often uncovered clinically important HTE; effect modeling was more often exploratory.
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Affiliation(s)
- Joe V Selby
- Division of Research, Kaiser Permanente Northern California, Oakland, CA (emeritus)
| | - Carolien C H M Maas
- Tufts Predictive Analytics and Comparative Effectiveness Center, Tufts University School of Medicine, Boston MA
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bruce H Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - David M Kent
- Tufts Predictive Analytics and Comparative Effectiveness Center, Tufts University School of Medicine, Boston MA
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Rakshasbhuvankar A, Pillow JJ. Vitamin A and bronchopulmonary dysplasia: the next steps. THE LANCET. RESPIRATORY MEDICINE 2024:S2213-2600(24)00108-5. [PMID: 38643781 DOI: 10.1016/s2213-2600(24)00108-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/23/2024]
Affiliation(s)
- Abhijeet Rakshasbhuvankar
- Neonatal Clinical Care Unit, Child and Adolescent Health Service, Subiaco, WA, Australia; Medical School, The University of Western Australia, Crawley, WA, Australia
| | - J Jane Pillow
- Wal-yan Respiratory Centre, Telethon Kids Institute, Nedlands, WA, Australia; School of Human Sciences, The University of Western Australia, Crawley, WA 6009, Australia.
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Meyer S, Bay J, Franz AR, Erhardt H, Klein L, Petzinger J, Binder C, Kirschenhofer S, Stein A, Hüning B, Heep A, Cloppenburg E, Muyimbwa J, Ott T, Sandkötter J, Teig N, Wiegand S, Schroth M, Kick A, Wurm D, Gebauer C, Linnemann K, Kittel J, Wieg C, Kiechl-Kohlendorfer U, Schmidt S, Böttger R, Thomas W, Brevis Nunez F, Stockmann A, Kriebel T, Müller A, Klotz D, Morhart P, Nohr D, Biesalski HK, Giannopoulou EZ, Hilt S, Poryo M, Wagenpfeil S, Haiden N, Ruckes C, Ehrlich A, Gortner L. Early postnatal high-dose fat-soluble enteral vitamin A supplementation for moderate or severe bronchopulmonary dysplasia or death in extremely low birthweight infants (NeoVitaA): a multicentre, randomised, parallel-group, double-blind, placebo-controlled, investigator-initiated phase 3 trial. THE LANCET. RESPIRATORY MEDICINE 2024:S2213-2600(24)00073-0. [PMID: 38643780 DOI: 10.1016/s2213-2600(24)00073-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Vitamin A plays a key role in lung development, but there is no consensus regarding the optimal vitamin A dose and administration route in extremely low birthweight (ELBW) infants. We aimed to assess whether early postnatal additional high-dose fat-soluble enteral vitamin A supplementation versus placebo would lower the rate of moderate or severe bronchopulmonary dysplasia or death in ELBW infants receiving recommended basic enteral vitamin A supplementation. METHODS This prospective, multicentre, randomised, parallel-group, double-blind, placebo-controlled, investigator-initiated phase 3 trial conducted at 29 neonatal intensive care units in Austria and Germany assessed early high-dose enteral vitamin A supplementation (5000 international units [IU]/kg per day) or placebo (peanut oil) for 28 days in ELBW infants. Eligible infants had a birthweight of more than 400 g and less than 1000 g; gestational age at birth of 32+0 weeks postmenstrual age or younger; and the need for mechanical ventilation, non-invasive respiratory support, or supplemental oxygen within the first 72 h of postnatal age after admission to the neonatal intensive care unit. Participants were randomly assigned by block randomisation with variable block sizes (two and four). All participants received basic vitamin A supplementation (1000 IU/kg per day). The composite primary endpoint was moderate or severe bronchopulmonary dysplasia or death at 36 weeks postmenstrual age, analysed in the intention-to-treat population. This trial was registered with EudraCT, 2013-001998-24. FINDINGS Between March 2, 2015, and Feb 27, 2022, 3066 infants were screened for eligibility at the participating centres. 915 infants were included and randomly assigned to the high-dose vitamin A group (n=449) or the control group (n=466). Mean gestational age was 26·5 weeks (SD 2·0) and mean birthweight was 765 g (162). Moderate or severe bronchopulmonary dysplasia or death occurred in 171 (38%) of 449 infants in the high-dose vitamin A group versus 178 (38%) of 466 infants in the control group (adjusted odds ratio 0·99, 95% CI 0·73-1·55). The number of participants with at least one adverse event was similar between groups (256 [57%] of 449 in the high-dose vitamin A group and 281 [60%] of 466 in the control group). Serum retinol concentrations at baseline, at the end of intervention, and at 36 weeks postmenstrual age were similar in the two groups. INTERPRETATION Early postnatal high-dose fat-soluble enteral vitamin A supplementation in ELBW infants was safe, but did not change the rate of moderate or severe bronchopulmonary dysplasia or death and did not substantially increase serum retinol concentrations. FUNDING Deutsche Forschungsgemeinschaft and European Clinical Research Infrastructures Network (ECRIN).
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Affiliation(s)
- Sascha Meyer
- Clinical Centre Karlsruhe, Franz-Lust Clinic for Paediatrics, Karlsruhe, Germany.
| | - Johannes Bay
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
| | - Axel R Franz
- University Hospital Tübingen, Neonatology and Center for Paediatric Clinical Studies, Department for Paediatrics, Tübingen, Germany
| | - Harald Erhardt
- Department of Paediatrics and Adolescent Medicine, Division of Neonatology and Pediatric Intensive Care Medicine, University Medical Center Ulm, Ulm, Germany
| | - Lars Klein
- Department of General Paediatrics and Neonatology, Justus-Liebig-Universität, Giessen, Germany
| | - Jutta Petzinger
- Department of General Paediatrics and Neonatology, Justus-Liebig-Universität, Giessen, Germany
| | - Christoph Binder
- Medical University Wien, Center of Paediatrics, Department of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Vienna, Austria
| | - Susanne Kirschenhofer
- Medical University Wien, Center of Paediatrics, Department of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Vienna, Austria
| | - Anja Stein
- University Hospital Essen, Clinic for Paediatrics I, Department for Neonatology, Essen, Germany
| | - Britta Hüning
- University Hospital Essen, Clinic for Paediatrics I, Department for Neonatology, Essen, Germany
| | - Axel Heep
- Clinical Centre Oldenburg, Clinic for Neonatology, Paediatric Intensive Care, Paediatric Cardiology, Paediatric Pneumonology and Allergology, Oldenburg, Germany
| | - Eva Cloppenburg
- Clinical Centre Oldenburg, Clinic for Neonatology, Paediatric Intensive Care, Paediatric Cardiology, Paediatric Pneumonology and Allergology, Oldenburg, Germany
| | - Julia Muyimbwa
- Clinical Centre Oldenburg, Clinic for Neonatology, Paediatric Intensive Care, Paediatric Cardiology, Paediatric Pneumonology and Allergology, Oldenburg, Germany
| | - Torsten Ott
- University Hospital Münster, Clinic for Paediatrics, Department for Neonatology, Münster, Germany
| | - Julia Sandkötter
- University Hospital Münster, Clinic for Paediatrics, Department for Neonatology, Münster, Germany
| | - Norbert Teig
- University Hospital Bochum, Children's Hospital-St Josef-Hospital, Department for Neonatology and Paediatric Intensive Care, Bochum, Germany
| | - Susanne Wiegand
- University Hospital Bochum, Children's Hospital-St Josef-Hospital, Department for Neonatology and Paediatric Intensive Care, Bochum, Germany
| | - Michael Schroth
- Cnopf'sche Kinderklinik, Clinic for Neonatology and Paediatric Intensive Care, Nürnberg, Germany
| | - Andrea Kick
- Cnopf'sche Kinderklinik, Clinic for Neonatology and Paediatric Intensive Care, Nürnberg, Germany
| | - Donald Wurm
- Clinical Centre Saarbrücken, Clinic for Paediatrics, Saarbrücken, Germany
| | - Corinna Gebauer
- University Hospital Leipzig, Center of Paediatrics, Department for Neonatology, Leipzig, Germany
| | - Knud Linnemann
- University Hospital Greifswald, Center for Paediatrics, Department for Neonatology and Paediatric Intensive Care, Greifswald, Germany
| | - Jochen Kittel
- Barmherzige Brüder Hospital Regensburg, Clinic St Hedwig, Clinic for Paediatrics, Regensburg, Germany
| | - Christian Wieg
- Clinical Centre Aschaffenburg-Alzenau, Clinic for Paediatrics, Department for Neonatology and Paediatric Intensive Care, Aschaffenburg, Germany
| | | | - Susanne Schmidt
- LMU Clinic for Paediatrics, Haunersches Kinderspital, Munich, Germany
| | - Ralf Böttger
- University Hospital Magdeburg, Clinic for Paediatrics, Magdeburg, Germany
| | - Wolfgang Thomas
- Hospital Mutterhaus der Borromäerinnen, Clinic for Paediatrics, Trier, Germany
| | - Francisco Brevis Nunez
- Sana Hospital Duisburg, Clinic for Paediatrics, Department of Paediatric Intensive Care, Duisburg, Germany
| | - Antje Stockmann
- Evangelical Hospital Oberhausen, Center of Paediatrics, Department of Neonatology, Oberhausen, Germany
| | - Thomas Kriebel
- Westpfalz-Klinikum Kaiserslautern, Department of Paediatrics, Kaiserslautern, Germany
| | - Andreas Müller
- University Hospital Bonn, Eltern-Kind-Zentrum (ELKI), Neonatology/Paediatric Intensive Care, Bonn, Germany
| | - Daniel Klotz
- University Hospital Freiburg, Centre for Paediatrics, Department for Neonatology and Paediatric Intensive Care, Freiburg, Germany
| | - Patrick Morhart
- Center of Paediatrics, Department for Neonatology and Paediatric Intensive Care, Erlangen, Germany
| | | | | | - Eleni Z Giannopoulou
- University Hospital Ulm, Clinic for Paediatrics, Paediatric Endocrinology and Diabetology, Ulm, Germany
| | - Susanne Hilt
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
| | - Martin Poryo
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatric Cardiology, Homburg, Germany
| | - Stefan Wagenpfeil
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
| | - Nadja Haiden
- Medical University Wien, Center of Paediatrics, Department of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Vienna, Austria
| | - Christian Ruckes
- Interdisziplinäres Zentrum Klinische Studien (IZKS), Universitätsmedizin Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Anne Ehrlich
- Interdisziplinäres Zentrum Klinische Studien (IZKS), Universitätsmedizin Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Ludwig Gortner
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
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Baud O, Lehert P. The beneficial effect of prophylactic hydrocortisone treatment in extremely preterm infants improves upon adjustment of the baseline characteristics. Pediatr Res 2024; 95:251-256. [PMID: 37653218 PMCID: PMC10798883 DOI: 10.1038/s41390-023-02785-x] [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] [Received: 06/12/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Prophylactic low-dose hydrocortisone (HC) was found to improve survival without bronchopulmonary dysplasia (BPD) in extremely preterm infants. However, appropriately adjusting for baseline risks of BPD or death might substantially increase the precision of the HC effect size. METHODS We conducted a secondary analysis of the PREMILOC trial. The treatment effect was evaluated on the primary endpoint through a covariance analysis ANCOVA, adjusting for the baseline covariates using a mixed linear model. Several sensitivity analyses were conducted to assess the potential heterogeneity of the treatment effect across centers and subpopulations. RESULTS The interaction between treatment group and baseline risk for BPD or death was not statistically significant (p = 0.498). After adjusting for the patient's probability of BPD-free survival using baseline predictors alone, the HC treatment exhibited a highly significant effect (OR [95% CI] = 2.053 [1.602-2.501], p = 0.002), with a number needed to treat NNT [95% CI] = 5.8 [4.1-23.0]. Despite a weak interaction with sex, we found a lack of heterogeneity in the treatment effect across specific subpopulations. CONCLUSIONS In the PREMILOC trial, the beneficial effect of prophylactic HC versus placebo on BPD-free survival in extremely preterm neonates was found to be greater when adjusted to baseline risks of BPD or death. REGISTRATION NUMBERS EudraCT number 2007-002041-20, ClinicalTrial.gov number NCT00623740. IMPACT Prophylactic low-dose hydrocortisone (HC) provided past evidence of a beneficial effect in improving survival without BPD in infants born extremely preterm. Adjustment for baseline risks of BPD or death might substantially increase the precision of the HC effect size. The beneficial effect of prophylactic HC vs placebo on BPD-free survival in extremely preterm neonates was found to be greater when adjusted to baseline risks of BPD or death. We evidenced a lack of heterogeneity in the treatment effect in specific subpopulations despite some weak interaction with sex.
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Affiliation(s)
- Olivier Baud
- Division of Neonatology and Pediatric Intensive Care, Children's University Hospital of Geneva and University of Geneva, Geneva, Switzerland.
| | - Philippe Lehert
- Faculty of Medicine, University of Melbourne, Melbourne, Australia
- Faculty of Economics, University of Louvain, Louvain, Belgium
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Gentle SJ, Rysavy MA, Li L, Laughon MM, Patel RM, Jensen EA, Hintz S, Ambalavanan N, Carlo WA, Watterberg K. Heterogeneity of Treatment Effects of Hydrocortisone by Risk of Bronchopulmonary Dysplasia or Death Among Extremely Preterm Infants in the National Institute of Child Health and Human Development Neonatal Research Network Trial: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2315315. [PMID: 37256621 PMCID: PMC10233424 DOI: 10.1001/jamanetworkopen.2023.15315] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 04/11/2023] [Indexed: 06/01/2023] Open
Abstract
Importance Extremely preterm infants who develop bronchopulmonary dysplasia (BPD) are at a higher risk for adverse pulmonary and neurodevelopmental outcomes. In the National Institute of Child Health and Human Development Neonatal Research Network (NICHD NRN) Hydrocortisone Trial, hydrocortisone neither reduced rates of BPD or death nor increased rates of neurodevelopmental impairment (NDI) or death. Objective To determine whether estimated risk for grades 2 to 3 BPD or death is associated with the effect of hydrocortisone on the composite outcomes of (1) grades 2 to 3 BPD or death and (2) moderate or severe NDI or death. Design, Setting, and Participants This secondary post hoc analysis used data from the NICHD NRN Hydrocortisone Trial, which was a double-masked, placebo-controlled, randomized clinical trial conducted in 19 US academic centers. The NICHD HRN Hydrocortisone Trial enrolled infants born at a gestational age of less than 30 weeks who received mechanical ventilation for at least 7 days, including at the time of enrollment, and who were aged 14 to 28 postnatal days. Infants were enrolled between August 22, 2011, and February 4, 2018, with follow-up between 22 and 26 months of corrected age completed on March 29, 2020. Data were analyzed from September 13, 2021, to March 25, 2023. Intervention Infants were randomized to 10 days of hydrocortisone or placebo treatment. Main Outcomes and Measures Infants' baseline risk of grades 2 to 3 BPD or death was estimated using the NICHD Neonatal BPD Outcome Estimator. Differences in absolute and relative treatment effects by baseline risk were evaluated using interaction terms in models fitted to the efficacy outcome of grades 2 to 3 BPD or death and the safety outcome of moderate or severe NDI or death by follow-up. Results Among the 799 infants included in the analysis (421 boys [52.7%]), the mean (SD) gestational age was 24.9 (1.5) weeks, and the mean (SD) birth weight was 715 (167) g. The mean estimated baseline risk for grades 2 to 3 BPD or death was 54% (range, 18%-84%) in the study population. The interaction between treatment group and baseline risk was not statistically significant on a relative or absolute scale for grades 2 to 3 BPD or death; the size of the effect ranged from a relative risk of 1.13 (95% CI, 0.82-1.55) in quartile 1 to 0.94 (95% CI, 0.81-1.09) in quartile 4. Similarly, the interaction between treatment group and baseline risk was not significant on a relative or absolute scale for moderate or severe NDI or death; the size of the effect ranged from a relative risk of 1.04 (95% CI, 0.80-1.36) in quartile 1 to 0.99 (95% CI, 0.80-1.22) in quartile 4. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, the effect of hydrocortisone vs placebo was not appreciably modified by baseline risk for grades 2 to 3 BPD or death. Trial Registration ClinicalTrials.gov Identifier: NCT01353313.
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Affiliation(s)
| | - Matthew A. Rysavy
- Department of Pediatrics, University of Texas Health Science Center at Houston
| | - Lei Li
- Statistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | | | - Ravi M. Patel
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Erik A. Jensen
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan Hintz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | | | | | - Kristi Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque
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Rekkas A, Rijnbeek PR, Kent DM, Steyerberg EW, van Klaveren D. Estimating individualized treatment effects from randomized controlled trials: a simulation study to compare risk-based approaches. BMC Med Res Methodol 2023; 23:74. [PMID: 36977990 PMCID: PMC10045909 DOI: 10.1186/s12874-023-01889-6] [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: 05/17/2022] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Baseline outcome risk can be an important determinant of absolute treatment benefit and has been used in guidelines for "personalizing" medical decisions. We compared easily applicable risk-based methods for optimal prediction of individualized treatment effects. METHODS We simulated RCT data using diverse assumptions for the average treatment effect, a baseline prognostic index of risk, the shape of its interaction with treatment (none, linear, quadratic or non-monotonic), and the magnitude of treatment-related harms (none or constant independent of the prognostic index). We predicted absolute benefit using: models with a constant relative treatment effect; stratification in quarters of the prognostic index; models including a linear interaction of treatment with the prognostic index; models including an interaction of treatment with a restricted cubic spline transformation of the prognostic index; an adaptive approach using Akaike's Information Criterion. We evaluated predictive performance using root mean squared error and measures of discrimination and calibration for benefit. RESULTS The linear-interaction model displayed optimal or close-to-optimal performance across many simulation scenarios with moderate sample size (N = 4,250; ~ 785 events). The restricted cubic splines model was optimal for strong non-linear deviations from a constant treatment effect, particularly when sample size was larger (N = 17,000). The adaptive approach also required larger sample sizes. These findings were illustrated in the GUSTO-I trial. CONCLUSIONS An interaction between baseline risk and treatment assignment should be considered to improve treatment effect predictions.
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Affiliation(s)
- Alexandros Rekkas
- Department of Medical Informatics, Erasmus Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Peter R Rijnbeek
- Department of Medical Informatics, Erasmus Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - David van Klaveren
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
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Bronchopulmonary dysplasia prediction models: a systematic review and meta-analysis with validation. Pediatr Res 2023:10.1038/s41390-022-02451-8. [PMID: 36624282 DOI: 10.1038/s41390-022-02451-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/06/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023]
Abstract
Prediction models could identify infants at the greatest risk of bronchopulmonary dysplasia (BPD) and allow targeted preventative strategies. We performed a systematic review and meta-analysis with external validation of identified models. Studies using predictors available before day 14 of life to predict BPD in very preterm infants were included. Two reviewers assessed 7628 studies for eligibility. Meta-analysis of externally validated models was followed by validation using 62,864 very preterm infants in England and Wales. A total of 64 studies using 53 prediction models were included totalling 274,407 infants (range 32-156,587/study). In all, 35 (55%) studies predated 2010; 39 (61%) were single-centre studies. A total of 97% of studies had a high risk of bias, especially in the analysis domain. Following meta-analysis of 22 BPD and 11 BPD/death composite externally validated models, Laughon's day one model was the most promising in predicting BPD and death (C-statistic 0.76 (95% CI 0.70-0.81) and good calibration). Six models were externally validated in our cohort with C-statistics between 0.70 and 0.90 but with poor calibration. Few BPD prediction models were developed with contemporary populations, underwent external validation, or had calibration and impact analyses. Contemporary, validated, and dynamic prediction models are needed for targeted preventative strategies. IMPACT: This review aims to provide a comprehensive assessment of all BPD prediction models developed to address the uncertainty of which model is sufficiently valid and generalisable for use in clinical practice and research. Published BPD prediction models are mostly outdated, single centre and lack external validation. Laughon's 2011 model is the most promising but more robust models, using contemporary data with external validation are needed to support better treatments.
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Aristizabal N, Holder MP, Durham L, Ashraf AP, Taylor S, Salas AA. Safety and Efficacy of Early Vitamin D Supplementation in Critically Ill Extremely Preterm Infants: An Ancillary Study of a Randomized Trial. J Acad Nutr Diet 2023; 123:87-94. [PMID: 35728797 DOI: 10.1016/j.jand.2022.06.012] [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: 01/31/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite substantial evidence that vitamin D deficiency is highly prevalent among infants born extremely preterm (≤28 weeks' of gestation), several consensus statements do not recommend vitamin D doses >400 IU/day for these infants. Safety remains a concern. OBJECTIVE The study aim was to determine safety and efficacy profiles of enteral vitamin D in Black and White infants randomized to three different vitamin D doses soon after birth. DESIGN Ancillary study of a masked randomized clinical trial. PARTICIPANTS/SETTING Seventy-three infants born extremely preterm between 2012 and 2015 at a southern US academic neonatal unit (33' latitude) who had >90% compliance with the assigned intervention were included. INTERVENTION Infants were randomized to receive placebo (placebo group), 200 IU/day vitamin D (200 IU group), or 800 IU/day vitamin D (800 IU group) during the first 28 days after birth. MAIN OUTCOME MEASURES Safety outcomes included serum 25-hydroxy vitamin D (25[OH]D) and calcium concentrations. Efficacy outcomes included the predictive risk of bronchopulmonary dysplasia. STATISTICAL ANALYSIS Per-protocol analysis using unadjusted, repeated-measures mixed models. RESULTS Mean birth weight was 815 ± 199 g. Half were male and 56% were Black. Of 58 infants with 25(OH)D measurements at birth, 40 (69%) had vitamin D deficiency (<20 ng/mL). The mean difference in 25(OH)D in nanograms per milliliter between Postnatal Day 28 and Postnatal Day 1 was +9 in the placebo group, +23 in the 200 IU group, and +62 in the 800 IU group (P < 0.0001). The increase observed in 25(OH)D was more significant among Black infants. The predictive risk of severe bronchopulmonary dysplasia in the 200 IU and 800 IU groups was lower, but this difference did not reach statistical significance. No vitamin D or calcium toxicity was observed. CONCLUSIONS A vitamin D dose of 800 IU/day safely corrected vitamin D deficiency by Postnatal Day 14.
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Affiliation(s)
- Natalia Aristizabal
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mary Pat Holder
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Leandra Durham
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ambika P Ashraf
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sarah Taylor
- Department of Pediatrics, Yale University, New Haven, Connecticut
| | - Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
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9
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Jensen EA, Laughon MM, DeMauro SB, Cotten CM, Do B, Carlo WA, Watterberg KL. Contributions of the NICHD neonatal research network to the diagnosis, prevention, and treatment of bronchopulmonary dysplasia. Semin Perinatol 2022; 46:151638. [PMID: 36085059 PMCID: PMC11075436 DOI: 10.1016/j.semperi.2022.151638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite improvements in the care and outcomes of infants born extremely preterm, bronchopulmonary dysplasia (BPD) remains a common and frustrating complication of prematurity. This review summarizes the BPD-focused research conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN). To improve disease classification and outcome prediction, the NRN developed new data-driven diagnostic criteria for BPD and web-based tools that allow clinicians and investigators to reliably estimate BPD risk in preterm infants. Randomized trials of intramuscular vitamin A and prophylactic nasal continuous positive airway pressure conducted by the NRN have contributed to our current use of these therapies as evidence-based approaches to reduce BPD risk. A recent large, randomized trial of hydrocortisone administered beginning between the 2nd and 4th postnatal weeks provided strong evidence that this therapy promotes successful extubation but does not lower BPD rates. Ongoing studies within the NRN will address important, unanswered questions on the risks and benefits of intratracheal surfactant/corticosteroid combinations and treatment versus expectant management of the patent ductus arteriosus to prevent BPD.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States.
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sara B DeMauro
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Barbara Do
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC, United States
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristi L Watterberg
- University of New Mexico Health Sciences Center, Albuquerque, NM, United States
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10
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Yang X, Jiang S, Deng X, Luo Z, Chen A, Yu R. Effects of Antioxidants in Human Milk on Bronchopulmonary Dysplasia Prevention and Treatment: A Review. Front Nutr 2022; 9:924036. [PMID: 35923207 PMCID: PMC9340220 DOI: 10.3389/fnut.2022.924036] [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: 04/20/2022] [Accepted: 06/21/2022] [Indexed: 12/20/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a severe chronic lung illness that affects neonates, particularly premature infants. It has far-reaching consequences for infant health and their families due to intractable short- and long-term repercussions. Premature infant survival and long-term quality of life are severely harmed by BPD, which is characterized by alveolarization arrest and hypoplasia of pulmonary microvascular cells. BPD can be caused by various factors, with oxidative stress (OS) being the most common. Premature infants frequently require breathing support, which results in a hyperoxic environment in the developing lung and obstructs lung growth. OS can damage the lungs of infants by inducing cell death, inhibiting alveolarization, inducing inflammation, and impairing pulmonary angiogenesis. Therefore, antioxidant therapy for BPD relieves OS and lung injury in preterm newborns. Many antioxidants have been found in human milk, including superoxide dismutase, glutathione peroxidase, glutathione, vitamins, melatonin, short-chain fatty acids, and phytochemicals. Human milk oligosaccharides, milk fat globule membrane, and lactoferrin, all unique to human milk, also have antioxidant properties. Hence, human milk may help prevent OS injury and improve BPD prognosis in premature infants. In this review, we explored the role of OS in the pathophysiology of BPD and related signaling pathways. Furthermore, we examined antioxidants in human milk and how they could play a role in BPD to understand whether human milk could prevent and treat BPD.
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Affiliation(s)
- Xianpeng Yang
- Department of Neonatology, Wuxi Maternity and Child Health Care Hospital, Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Shanyu Jiang
- Department of Neonatology, Wuxi Maternity and Child Health Care Hospital, Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Xianhui Deng
- Department of Neonatology, Wuxi Maternity and Child Health Care Hospital, Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Zichen Luo
- Department of Neonatology, Wuxi Maternity and Child Health Care Hospital, Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Ailing Chen
- Translational Medicine Laboratory, Research Institute for Reproductive Health and Genetic Diseases, The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
- *Correspondence: Ailing Chen
| | - Renqiang Yu
- Department of Neonatology, Wuxi Maternity and Child Health Care Hospital, Wuxi School of Medicine, Jiangnan University, Wuxi, China
- Renqiang Yu
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11
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Ferrante G, Montante C, Notarbartolo V, Giuffrè M. Antioxidants: Role the in prevention and treatment of bronchopulmonary dysplasia. Paediatr Respir Rev 2022; 42:53-58. [PMID: 35177319 DOI: 10.1016/j.prrv.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/01/2022] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is one of the major causes of chronic respiratory diseases among infants. Both pharmacological and nonpharmacological approaches have been proposed for its management. Since oxidative stress is known to play a pivotal role in the pathogenesis of BPD, it is reasonable to consider the potential of antioxidant strategies in the prevention and treatment of this condition. Indeed, antioxidants can prevent or inhibit substrate oxidation. Some studies have evaluated the efficacy of the exogenous administration of vitamins and micronutrients in reducing the propagation of free radicals through their scavenging capacity. Nonetheless, encouraging preclinical results did not translate into effective preventive and/or therapeutic interventions. This narrative review evaluates the current evidence about the antioxidants that are potentially useful for preventing and treating BPD and explores the most relevant issues affecting their implementation in clinical practice, as well as their associated evidence gaps and research limitations.
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Affiliation(s)
- Giuliana Ferrante
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy.
| | - Claudio Montante
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Veronica Notarbartolo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy.
| | - Mario Giuffrè
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
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12
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Abstract
Preterm infants are at higher risk of mortality and morbidity compared with those born at term. Nutrition-related morbidities include poor growth, immune deficiency, nutritional deficiencies, and adverse long-term neurodevelopment. In addition to macronutrients, many nutritional supplements have been used to enhance growth and development, and decrease infections. Nutrients can enhance preterm infants' immune status, optimize the microbiome, improve growth and development, and influence the risk of necrotizing enterocolitis, sepsis, and other outcomes.
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Affiliation(s)
- Mohan Pammi
- Section of Neonatology, Department of Pediatrics Baylor College of Medicine & Texas Children's Hospital Houston, TX 77030, USA.
| | - Ravi M. Patel
- Department of Pediatrics, Emory University, Atlanta, Georgia
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13
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Gentle SJ, Sant'Anna G, Carlo WA. Using dexamethasone wisely in invasively ventilated preterm infants. Pediatr Pulmonol 2022; 57:785-786. [PMID: 34994096 DOI: 10.1002/ppul.25819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 01/02/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Samuel J Gentle
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Guilherme Sant'Anna
- Department of Pediatrics, Neonatal Division, McGill University Health Centre, Montreal, Quebec, Canada
| | - Waldemar A Carlo
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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14
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Sakaria RP, Dhanireddy R. Pharmacotherapy in Bronchopulmonary Dysplasia: What Is the Evidence? Front Pediatr 2022; 10:820259. [PMID: 35356441 PMCID: PMC8959440 DOI: 10.3389/fped.2022.820259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Bronchopulmonary Dysplasia (BPD) is a multifactorial disease affecting over 35% of extremely preterm infants born each year. Despite the advances made in understanding the pathogenesis of this disease over the last five decades, BPD remains one of the major causes of morbidity and mortality in this population, and the incidence of the disease increases with decreasing gestational age. As inflammation is one of the key drivers in the pathogenesis, it has been targeted by majority of pharmacological and non-pharmacological methods to prevent BPD. Most extremely premature infants receive a myriad of medications during their stay in the neonatal intensive care unit in an effort to prevent or manage BPD, with corticosteroids, caffeine, and diuretics being the most commonly used medications. However, there is no consensus regarding their use and benefits in this population. This review summarizes the available literature regarding these medications and aims to provide neonatologists and neonatal providers with evidence-based recommendations.
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Affiliation(s)
- Rishika P. Sakaria
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ramasubbareddy Dhanireddy
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, United States
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15
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Nair N, Patel RM. The center-effect on outcomes for infants born at less than 25 weeks. Semin Perinatol 2022; 46:151538. [PMID: 34911651 PMCID: PMC9730551 DOI: 10.1016/j.semperi.2021.151538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Marked variation exists in the care of infants born at <25 weeks' gestation. The center or location where a fetus or infant is cared for influences outcomes at very early gestational ages. Understanding this "center-effect," including characteristics associated with centers that have high survival of births at <25 weeks' gestation, may inform future studies and guide care practices to improve outcomes. This review focuses on the impact that the location or center of birth has on survival and other important outcomes for infants born at <25 weeks' gestation. We review potential sources of variation in care practices and other factors that might explain the "center-effect."
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Affiliation(s)
- Nitya Nair
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA
| | - Ravi Mangal Patel
- From the Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Dr. NE, Atlanta, GA.
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16
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Darlow BA. Vitamin A supplementation for very preterm infants back on the menu-for some or all? Am J Clin Nutr 2021; 114:1888-1889. [PMID: 34718371 DOI: 10.1093/ajcn/nqab328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Brian A Darlow
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
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17
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Huang L, Zhu D, Pang G. The effects of early vitamin A supplementation on the prevention and treatment of bronchopulmonary dysplasia in premature infants: a systematic review and meta-analysis. Transl Pediatr 2021; 10:3218-3229. [PMID: 35070836 PMCID: PMC8753470 DOI: 10.21037/tp-21-496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/12/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is a common and unique chronic disease of premature infants with a high mortality rate. A large number of studies have shown that vitamin A supplementation has a better effect on the prevention and treatment of BPD. METHODS Randomized controlled trials (RCTs) on early vitamin A supplementation for the prevention and treatment of BPD were searched in PubMed, EMBASE, and the Cochrane Library database. The search time was from the establishment of the database to July 28, 2021. Two investigators performed standard independent screening trials of the literature according to the inclusion and exclusion criteria. The methodology of the included articles was evaluated, and the data were extracted. If the opinions of the 2 investigators were not consistent, a third party could be consulted. The Cochrane systematic review manual was used to analyze the bias of the included studies, and the RevMan 5.3 software was used to perform the meta-analysis. RESULTS In the experimental group, the BPD incidence [-0.71, 95% confidential interval (CI): -0.34 to -0.00; Z=1.98; P=0.05], 28-day oxygen uptake rate (0.81, 95% CI: 0.38-1.730; Z=0.53; P=0.59), 36-week survival rate (1.08, 95% CI: 0.80-1.46; Z=0.49; P=0.62), incidence of patent ductus arteriosus (0.77, 95% CI: 0.27-2.21; Z=0.48; P=0.63), days of mechanical ventilation (0.02, 95% CI: -1.46-1.49; Z=0.02; P=0.98), and 28-day ventilator use (0.77, 95% CI: 0.31-1.92; Z=0.55; P=0.58) were lower than those in the control group, especially the incidence of BPD. DISCUSSION Early supplementation of vitamin A showed good efficacy and safety in the prevention and treatment of BPD in premature infants, and can also improve the survival rate of infants. Therefore, it is worthy of clinical application.
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Affiliation(s)
- Li Huang
- Department of Pediatrics, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Diqing Zhu
- Department of Pediatrics, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Gaofeng Pang
- Department of Pediatrics, The Third Affiliated Hospital of Soochow University, Changzhou, China
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