Karl C K Kuban

University of Massachusetts Medical School, Worcester, Massachusetts, United States

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Publications (103)599.81 Total impact

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    ABSTRACT: To assess antenatal and early postnatal antecedents of attention problems identified by the Child Behavior Checklist in extremely preterm children.
    The Journal of pediatrics. 09/2014;
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    ABSTRACT: Abstract Background: We sought to disentangle the contributions of hyperthyrotropinemia (an indicator of thyroid dysfunction) (HTT) and intermittent or sustained systemic inflammation (ISSI) to structural and functional indicators of brain damage. Methods: We measured the concentrations of thyroid-stimulating hormone (TSH) on day 14 and of 25 inflammation-related proteins in blood collected during the first 2 postnatal weeks from 786 infants born before the 28th week of gestation who were not considered to have hypothyroidism. We defined hyperthyrotropinemia (HTT) as a TSH concentration in the highest quartile for gestational age on postnatal day 14 and ISSI was defined as a concentration in the top quartile for gestational age of a specific inflammation-related protein on 2 separate days a week apart during the first 2 postnatal weeks. We first assessed the risk of brain damage indicators by comparing 1) neonates who had HTT to those without (regardless of ISSI) and 2) neonates with HTT only, ISSI only, or HTT+ISSI to those who were exposed to neither HTT nor ISSI. Results: In univariable models that compared those with HTT to those without, HTT was not significantly associated with any indicator of brain damage. In models that compared HTT only, ISSI only, and HTT+ISSI to those with neither, children with ISSI only or with HTT+ISSI were at significantly higher risk of ventriculomegaly [odds ratios (ORs) 2-6], whereas those with HTT only were at significantly reduced risk of a hypoechoic lesion (ORs 0.2-0.4). Children with HTT only had a higher risk of quadriparesis and those with ISSI alone had a higher risk of hemiparesis (ORs 1.6-2.4). Elevated risk of a very low mental development score was associated with both ISSI only and HTT+ISSI, whereas a very low motor development score and microcephaly were associated with HTT+ISSI. Conclusions: The association of HTT with increased or decreased risk of indicators of brain damage depends on the presence or absence of ISSI.
    Journal of pediatric endocrinology & metabolism: JPEM 06/2014; · 0.75 Impact Factor
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    ABSTRACT: The authors hypothesized that among extremely preterm infants, elevated concentrations of inflammation-related proteins in neonatal blood are associated with cerebral palsy at 24 months. In 939 infants born before 28 weeks gestation, the authors measured blood concentrations of 25 proteins on postnatal days 1, 7, and 14 and evaluated associations between elevated protein concentrations and cerebral palsy diagnosis. Protein elevations within 3 days of birth were not associated with cerebral palsy. Elevations of tumor necrosis factor-α, tumor necrosis factor-α-receptor-1, interleukin-8, and intercellular adhesion molecule-1 on at least 2 days were associated with diparesis. Recurrent-persistent elevations of interleukin-6, E-selectin, or insulin-like growth factor binding protein-1 were associated with hemiparesis. Diparesis and hemiparesis were more likely among infants who had at least 4 of 9 protein elevations that previously have been associated with cognitive impairment and microcephaly. Repeated elevations of inflammation-related proteins during the first 2 postnatal weeks are associated with increased risk of cerebral palsy.
    Journal of child neurology 03/2014; · 1.59 Impact Factor
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    ABSTRACT: Background:Extremely preterm birth is associated with subsequent behavioral problems. We hypothesized that perinatal systemic inflammation, a risk factor for cerebral white matter injury and cognitive impairment, is associated with behavior problems observed at 2 years.Methods:In a cohort of 600 children born before 28 weeks gestation, we measured 25 inflammation-related proteins in blood collected on postnatal days 1, 7, and 14, and identified behavior problems using parent responses to the Child Behavior Checklist for Ages 1.5-5 (CBCL/1.5-5) at two years of age. A persistent or recurrent protein elevation was defined as a concentration in the highest quartile (for gestational age and postnatal age) on at least two days approximately one week apart. Behavior problems were defined by CBCL/1.5-5 subscale scores at or above the 93(rd) percentile.Results:A single-day elevation of ICAM-3 was associated with an increased risk of an attention problem, as were persistent or recurrent elevations of MPO, IL-6, TNF-RI, IL-8, ICAM-3, VEGF-R1, and VEGF-R2. These associations persisted among infants without white matter injury and cognitive impairment.Conclusions:Among children born extremely prematurely, recurrent or persistent elevations of inflammation-related proteins in blood during in the first two postnatal weeks are associated with an attention problem at age 2 years.Pediatric Research (2014); doi:10.1038/pr.2014.41.
    Pediatric Research 03/2014; · 2.67 Impact Factor
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    ABSTRACT: Background Very little is known about the prevalence, antecedents and correlates of impaired visual fixation in former very preterm newborns. Methods In the multi-center ELGAN Study sample of 1057 infants born before the 28th week of gestation who had a developmental assessment at 2 years corrected age, we identified 73 who were unable to follow an object across the midline. We compared them to the 984 infants who could follow an object across the midline. Results In this sample of very preterm newborns, those who had impaired visual fixation were much more likely than those without impaired visual fixation to have been born after the shortest of gestations (odds ratio = 3.2; 99% confidence interval =1.4, 7.5) and exposed to maternal aspirin (OR: 5.2; 99% CI: 2.2, 12). They were also more likely than their peers to have had prethreshold ROP (OR: 4.1; 99% CI: 1.8, 9.0). At age 2 years, the children with impaired fixation were more likely than others to be unable to walk (even with assistance) (OR: 7.5; 99% CI: 2.2, 26) and have a Mental Development Index more than 3 standard deviations below the mean of a normative sample (OR:3.6; 99% CI: 1.4, 8.2). Conclusion Risk factors for brain and retinal damage, such as very low gestational age, appear to be risk factors for impaired visual fixation. This inference is further supported by the co-occurrence at age 2 years of impaired visual fixation, inability to walk, and a very low Mental Development Index
    Pediatric Neurology. 01/2014;
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    ABSTRACT: Purpose To explain why very preterm newborns who develop retinopathy of prematurity (ROP) appear to be at increased risk of abnormalities of both brain structure and function. Methods A total of 1,085 children born at <28 weeks' gestation had clinically indicated retinal examinations and had a developmental assessment at 2 years corrected age. Relationships between ROP categories and brain abnormalities were explored using logistic regression models with adjustment for potential confounders. Results The 173 children who had severe ROP, defined as prethreshold ROP (n = 146) or worse (n = 27) were somewhat more likely than their peers without ROP to have brain ultrasound lesions or cerebral palsy. They were approximately twice as likely to have very low Bayley Scales scores. After adjusting for risk factors common to both ROP and brain disorders, infants who developed severe ROP were at increased risk of low Bayley Scales only. Among children with prethreshold ROP, exposure to anesthesia was not associated with low Bayley Scales. Conclusions Some but not all of the association of ROP with brain disorders can be explained by common risk factors. Most of the increased risks of very low Bayley Scales associated with ROP are probably not a consequence of exposure to anesthetic agents.
    Journal of American Association for Pediatric Ophthalmology and Strabismus. 01/2014; 18(3):241–247.
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    ABSTRACT: The offspring of obese women are at increased risk for systemic inflammation. Blood concentrations of inflammatory proteins in preterm newborns of obese women have not been reported. To compare blood concentrations in the highest quartile for gestational age of inflammatory proteins and day of blood specimen collection on two days at least one week apart of newborns of overweight (i.e., BMI 25-29) and obese women (i.e., BMI≥30) with newborns of women with lower BMIs. Because deliveries for spontaneous indications are more likely than those for other indications to be associated with inflammation, we evaluated spontaneous indication deliveries separately from maternal or fetal indications. Prospective cohort study. We measured from 939 children born before the 28th week of gestation 25 inflammation-related proteins in blood obtained on postnatal day 1 (range 1-3), day 7 (range 5-8) and day 14 (range 12-15). Among infants delivered for spontaneous indications, maternal BMI was not related to elevated concentrations of any protein. Among infants delivered for maternal (i.e., preeclampsia) or fetal indications, those whose mother was overweight or obese were more likely than others to have elevated concentrations of inflammation proteins. Maternal pre-pregnancy overweight and obesity appear to contribute to a pro-inflammatory state in very preterm newborns delivered for maternal or fetal indications. Our failure to see a similar pattern among newborns delivered for spontaneous indications, which often have inflammatory characteristics, might reflect competing risks.
    Early human development 09/2013; · 2.12 Impact Factor
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    ABSTRACT: Isolated periventricular leukomalacia, defined as periventricular leukomalacia unaccompanied by intraventricular hemorrhage, is reportedly increased in newborns with systemic hypotension and in infants who received treatment for systemic hypotension or a patent ductus arteriosus. This study sought to determine if the risk profile of one or more hypoechoic lesions unaccompanied by intraventricular hemorrhage, our surrogate for isolated periventricular leukomalacia, differs from that of one or more hypoechoic lesions preceded or accompanied by intraventricular hemorrhage. We compared extremely preterm infants (i.e., gestation 23-27 weeks) with each of these entities to 885 extremely preterm infants who had neither an isolated hypoechoic lesion nor a hypoechoic lesion preceded or accompanied by intraventricular hemorrhage. The risk of a hypoechoic lesion with intraventricular hemorrhage (N = 61) was associated with gestation <25 weeks, high Score for Acute Neonatal Physiology, early recurrent or prolonged acidemia, analgesic exposure, and mechanical ventilation 1 week after birth. In this large, multicenter sample of extremely low gestational age newborns, the risk profile of a hypoechoic lesion unaccompanied by intraventricular hemorrhage differed from that of a hypoechoic lesion with intraventricular hemorrhage. This suggests that hypoechoic lesions accompanied or preceded by intraventricular hemorrhage (our surrogate for periventricular hemorrhagic infarction) may have a different causal pathway than hypoechoic lesions without intraventricular hemorrhage, our surrogate for periventricular leukomalacia.
    Pediatric Neurology 08/2013; 49(2):88-96. · 1.42 Impact Factor
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    ABSTRACT: Neonatal inflammation is associated with perinatal brain damage. We evaluated to what extent elevated blood levels of inflammation-related proteins supplement information about the risk of impaired early cognitive function provided by inflammation-related illnesses. From 800 infants born before the 28(th) week of gestation, we collected blood spots on days 1, 7 and 14, for analysis of 25 inflammation-related proteins, and data about culture-positive bacteremia, necrotizing enterocolitis (Bell stage IIIb), and isolated perforation of the intestine, during the first two weeks, and whether they were ventilated on postnatal day 14. We considered a protein to be persistently or recurrently elevated if its concentration was in the top quartile (for gestational age and day blood was collected) on two separate days one week apart. We assessed the children at 2 years of age with the Bayley Mental Development Index (MDI). The combinations of NEC and ventilation on day 14, and of bacteremia and ventilation on day 14 consistently provided information about elevated risk of MDI <55, regardless of whether or not a variable for an elevated protein concentration was included in the model. A variable for a persistently or recurrently elevated concentration of each of the following proteins provided additional information about an increased risk of MDI <55: CRP, SAA, IL-6, TNF-alpha, IL-8, MIP-1beta, ICAM-1, E-SEL, and IGFBP-1. We conclude that elevated blood concentrations of inflammation-related proteins provide information about the risk of impaired cognitive function at age 2 years that supplements information provided by inflammation-associated illnesses.
    Brain Behavior and Immunity 01/2013; · 5.61 Impact Factor
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    ABSTRACT: Background:We sought to disentangle the contributions of perinatal systemic inflammation and being small for gestational age (SGA) to the occurrence of low Bayley Mental Development Indices (MDIs) at the age of 2 y.Methods:We measured the concentration of 25 inflammation-related proteins in blood obtained during the first two postnatal weeks from 805 infants who were born before the 28th wk of gestation and who had MDI measurements at the age of 2 y and were able to walk independently.Results:SGA newborns who did not have systemic inflammation (a concentration of an inflammation-related protein in the top quartile for gestational age on two days a week apart) were at a greater risk of an MDI <55, but not 55-69, than their peers who had neither SGA nor systemic inflammation. SGA infants who had elevated blood concentrations of interleukin (IL)-1β, tumor necrosis factor-α, or IL-8 during the first 2 postnatal weeks were at even higher risk of an MDI <55 than their SGA peers without systemic inflammation and their non-SGA peers with systemic inflammation.Conclusion:SGA appears to place very preterm newborns at an increased risk of a very low MDI. Systemic inflammation adds considerably to the increased risk.Pediatric Research (2013); doi:10.1038/pr.2012.188.
    Pediatric Research 12/2012; · 2.67 Impact Factor
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    ABSTRACT: To see if the systemic inflammation profile of 123 infants born before the 28th week of gestation who had intraventricular hemorrhage without white matter injury differed from that of 68 peers who had both lesions, we compared both groups to 677 peers who had neither. Cranial ultrasound scans were read independently by multiple readers until concordance. The concentrations of 25 proteins were measured with multiplex arrays using an electrochemiluminescence system. Infants who had both hemorrhage and white matter injury were more likely than others to have elevated concentrations of C-reactive protein and interleukin 8 on days 1, 7, and 14, and elevated concentrations of serum amyloid A and tumor necrosis factor-α on 2 of these days. Intraventricular hemorrhage should probably be viewed as 2 entities: hemorrhage alone and hemorrhage with white matter injury. Each entity is associated with inflammation, but the combination has a stronger inflammatory signal than hemorrhage alone.
    Journal of child neurology 10/2012; · 1.59 Impact Factor
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    ABSTRACT: We sought to evaluate the association between maternal medication use during pregnancy and cerebral white matter damage and cerebral palsy (CP) among very preterm infants. This analysis of data from the Extremely Low Gestational Age Newborns (ELGAN) Study included 877 infants born <28 weeks' gestation. Mothers were interviewed, charts were reviewed, placentas were cultured and assessed histologically, and children were evaluated at 24 months corrected age. A diagnostic algorithm classified neurologic findings as quadriparetic CP, diparetic CP, hemiparetic CP, or no CP. After adjustment for the potential confounding of disorders for which medications might have been indicated, the risk of quadriparetic CP remained elevated among the infants of mothers who consumed aspirin (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.3-6.9) and nonsteroidal antiinflammatory drugs (NSAIDs) (OR, 2.4; 95% CI, 1.04-5.8). The risk of diparetic CP was also associated with maternal consumption of an NSAID, but only if the consumption was not approved by a physician (OR, 3.5; 95% CI 1.1-11.0). The possibility that aspirin and NSAID use in pregnancy could lead to perinatal brain damage cannot be excluded.
    American journal of obstetrics and gynecology 09/2012; 207(3):192.e1-9. · 3.28 Impact Factor
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    ABSTRACT: The newborn classified as growth-restricted on fetal weight curves, but not on birth weight curves, is classified prenatally as small for gestational age (SGA), but postnatally as appropriate for gestational age (AGA). To see (1) to what extent the neurodevelopmental outcomes at 24 months corrected age differed among three groups of infants (those identified as SGA based on birth weight curves (B-SGA), those identified as SGA based on fetal weight curves only (F-SGA), and the referent group of infants considered AGA, (2) if girls and boys were equally affected by growth restriction, and (3) to what extent neurosensory limitations influenced what we found. Observational cohort of births before the 28th week of gestation. Outcome measures: Mental Development Index (MDI) and Psychomotor Development Index (PDI) of the Bayley Scales of Infant Development II. B-SGA, but not F-SGA girls were at an increased risk of a PDI<70 (OR=2.8; 95% CI: 1.5, 5.3) compared to AGA girls. B-SGA and F-SGA boys were not at greater risk of low developmental indices than AGA boys. Neurosensory limitations diminished associations among girls of B-SGA with low MDI, and among boys B-SGA and F-SGA with PDI<70. Only girls with the most severe growth restriction were at increased risk of neurodevelopmental impairment at 24 months corrected age in the total sample. Neurosensory limitations appear to interfere with assessing growth restriction effects in both girls and boys born preterm.
    Early human development 06/2012; 88(9):765-71. · 2.12 Impact Factor
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    ABSTRACT: Extremely low gestational age neonates are more likely than term infants to develop cognitive impairment. Few studies have addressed antenatal risk factors of this condition. We identified antenatal antecedents of cognitive impairment determined by the Mental Development Index (MDI) portion of the Bayley Scales of Infant Development, Second Edition (BSID-II), at 24 months corrected age. We studied a multicenter cohort of 921 infants born before 28 weeks of gestation during 2002 to 2004 and assessed their placentas for histologic characteristics and microorganisms. The mother was interviewed and her medical record was reviewed. At 24 months adjusted age, children were assessed with BSID-II. Multinomial logistic models were used to estimate odds ratios. A total of 103 infants (11%) had an MDI <55, and 99 infants (11%) had an MDI between 55 and 69. No associations were identified between organisms recovered from the placenta and developmental delay. Factors most strongly associated with MDI <55 were thrombosis of fetal vessels (OR 3.1; 95% confidence interval [CI] 1.2, 7.7), maternal BMI >30 (OR 2.0; 95% CI 1.1, 3.5), maternal education ≤12 years (OR 3.4; 95% CI 1.9, 6.2), nonwhite race (OR 2.2; 95% CI 1.3, 3.8), birth weight z score < -2 (OR 2.8; 95% CI 1.1, 6.9), and male gender (OR 2.7; 95% CI 1.6, 4.5). Antenatal factors, including thrombosis of fetal vessels in the placenta, severe fetal growth restriction, and maternal obesity, convey information about the risk of cognitive impairment among extremely premature newborns.
    PEDIATRICS 03/2012; 129(3):494-502. · 4.47 Impact Factor
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    ABSTRACT: To evaluate the hypothesis that elevated levels of inflammation-related proteins in early postnatal blood predict impaired mental and motor development in extremely preterm infants. We measured concentrations of 25 inflammation-related proteins in blood collected on postnatal days 1, 7, and 14 from 939 infants born before 28 weeks gestation. An elevated level was defined as a concentration in the highest quartile for gestational age and day of blood collection. We identified impaired development at age 24 months using the Bayley Scales of Infant Development, Second Edition. The primary outcomes were scores on the Mental Scale or the Motor Scale of <55 (more than 3 SDs below the mean). For 17 of the 25 inflammation-related proteins, 1 or more statistically significant associations (P<.01) was found between an elevated blood level of the protein and a developmental impairment. Elevations on multiple days were more often associated with developmental impairment than were elevations present for only 1 day. The highest number of predictive elevations was found in day-14 blood. In extremely preterm infants, elevated levels of inflammation-related proteins in blood collected on postnatal days 7 and 14, especially when sustained, are associated with impaired mental and motor development at age 2 years.
    The Journal of pediatrics 03/2012; 160(3):395-401.e4. · 4.02 Impact Factor
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    ABSTRACT: Whether intraventricular hemorrhage increases the risk of adverse developmental outcome among premature infants is controversial. Using brain ultrasound, we identified intraventricular hemorrhage and white matter abnormalities among 1064 infants born before 28 weeks' gestation. We identified adverse developmental outcomes at 24 months of age using a standardized neurologic examination and the Bayley Scales of Infant Development Mental and Motor Scales. In logistic regression models that adjusted for gestational age, sex, and public insurance, isolated intraventricular hemorrhage was associated with visual fixation difficulty but no other adverse outcome. Infants who had a white matter lesion unaccompanied by intraventricular hemorrhage were at increased risk of cerebral palsy, low Mental and Motor Scores, and visual and hearing impairments. Except when accompanied or followed by a white matter lesion, intraventricular hemorrhage is associated with no more than a modest increase (and possibly no increase) in the risk of adverse developmental outcome during infancy.
    Journal of child neurology 01/2012; 27(1):22-9. · 1.59 Impact Factor
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    ABSTRACT: To explore the relationships between blood gas derangements and blood concentrations of inflammation-related proteins shortly after preterm birth. Observational cohort. Fourteen neonatal intensive care units. Seven hundred and forty five infants born before the 28th week of gestation who were classified by their blood gas derangements during the first three postnatal days and by the concentrations of 25 proteins in their blood on days 1, 7, and 14. We classified these newborns by whether or not they had a highest or lowest PaO2, PCO2, and lowest pH in the most extreme quartile, and by whether or not they had a protein concentration in the highest quartile. Blood gas derangements on two days were much more likely to be accompanied or followed by sustained or recurrent systemic inflammation than a derangement on only one day. This was most evident for acidemia, and slightly less so for hypercapnia. Our finding that protein concentration patterns indicative of systemic inflammation are associated with several blood gas derangements raises the possibility that organ damage attributed to these derangements might be accompanied by or involve an inflammatory response.
    Cytokine 08/2011; 56(2):392-8. · 2.52 Impact Factor
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    ABSTRACT: The Modified Checklist for Autism in Toddlers (M-CHAT) has yielded elevated rates of screening failure for children born preterm or with low birthweight. We extended these findings with a detailed examination of M-CHAT items in a large sample of children born at extremely low gestational age. The sample was grouped according to children's current limitations and degree of impairment. The aim was to better understand how disabilities might influence M-CHAT scores. Fourteen participating institutions of the Extremely Low Gestational Age Newborns (ELGAN) Study prospectively collected information about 1086 infants who were born before the 28th week of gestation and had an assessment at age 24-months. The 24-month visit included a neurological assessment, the Bayley Scales of Infant Development, Second edition (BSID-II), M-CHAT and a medical history form. Outcome measures included the distribution of failed M-CHAT items among groups classified according to cerebral palsy diagnosis, gross motor function, BSID-II scores and vision or hearing impairments. M-CHAT items were failed more frequently by children with concurrently identified impairments (motor, cognitive, vision and hearing). In addition, the frequency of item failure increased with the severity of impairment. The failed M-CHAT items were often, but not consistently, related to children's specific impairments. Importantly, four of the six M-CHAT 'critical items' were commonly affected by presence and severity of concurrent impairments. The strong association between impaired sensory or motor function and M-CHAT results among extremely low gestational age children suggests that such impairments might give rise to false positive M-CHAT screening.
    Paediatric and Perinatal Epidemiology 07/2011; 25(4):366-76. · 2.16 Impact Factor
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    ABSTRACT: To assess how well early ultrasound lesions in preterm newborns predict reduced head circumference at 2 years, the investigators followed 923 children born before the 28th week of gestation who were not microcephalic at birth. Six percent of children who had a normal ultrasound scan were microcephalic compared with 15% to 20% who had intraventricular hemorrhage, an echolucent lesion, or ventriculomegaly. The odds ratios (95% confidence intervals) for microcephaly associated with different ultrasound images were intraventricular hemorrhage, 1.5 (0.8-3.0); ventriculomegaly, 3.3 (1.8-6.0); an echodense lesion, 1.6 (0.7-3.5); and an echolucent lesion, 3.1 (1.5-6.2). Ventriculomegaly and an echolucent lesion had very similar low positive predictive values (24% and 27%, respectively) and high negative predictive values (91% and 90%, respectively) for microcephaly. Ventriculomegaly had a higher sensitivity for microcephaly than did an echolucent lesion (24% vs 16%, respectively). Focal white-matter lesion (echolucent lesion) and diffuse white-matter damage (ventriculomegaly) predict an increased risk of microcephaly.
    Journal of child neurology 02/2011; 26(2):188-94. · 1.59 Impact Factor
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    ABSTRACT: To evaluate if concentrations of inflammation-related proteins were elevated in early postnatal blood specimens of preterm newborns who two years later had a small head. We measured 25 proteins in blood collected on days 1, 7, and 14 from 839 infants born before the 28th week of gestation and whose head circumference was measured at birth and near 24-months post-term equivalent. We excluded children whose birth head circumference was at or below the third centile. A protein concentration was considered elevated if it was in the highest quartile for gestational age and the day the specimen was obtained. When proteins were evaluated individually, elevated concentrations of SAA on day 1 and five proteins on day 14, IL-6, TNF-R2, IL-8, MCP-1, and ICAM-1 were associated with significantly increased risk of microcephaly (head circumference Z-score <-2). The ten proteins whose elevated concentrations on two separate days a week apart predicted microcephaly, but did not do so when elevated on only one of these days were CRP, SAA, IL-1β, IL-6, TNF-α, IL-8, MCP-1, ICAM-1, E-SEL, IGFBP-1. Elevated protein concentrations weakly predicted a less severe reduction in head circumference (Z-score ≥ -2, < -1). Concentrations of inflammation-related proteins in the circulation shortly after preterm birth provide information about the risk of a reduced head circumference more than two years later. The ELGAN Study was supported by a cooperative agreement with the National Institute of Neurological Disorders and Stroke of the United States.
    Early human development 02/2011; 87(5):325-30. · 2.12 Impact Factor

Publication Stats

3k Citations
599.81 Total Impact Points

Institutions

  • 2014
    • University of Massachusetts Medical School
      Worcester, Massachusetts, United States
  • 2007–2014
    • Boston Medical Center
      Boston, Massachusetts, United States
  • 2013
    • VU University Amsterdam
      Amsterdamo, North Holland, Netherlands
    • University of Texas Southwestern Medical Center
      Dallas, Texas, United States
  • 2012–2013
    • Wake Forest School of Medicine
      • • Division of Neonatology
      • • Department of Pediatrics
      Winston-Salem, NC, United States
    • Michigan State University
      • Department of Epidemiology
      East Lansing, MI, United States
    • Newton-Wellesley Hospital
      Boston, Massachusetts, United States
  • 2005–2013
    • Boston University
      • Department of Pediatrics
      Boston, Massachusetts, United States
  • 2011
    • New Hanover Regional Medical Center
      Wilmington, North Carolina, United States
    • Harvard University
      • Department of Biostatistics
      Cambridge, Massachusetts, United States
  • 2010–2011
    • Beverly Hospital, Boston MA
      Beverly, Massachusetts, United States
    • Beth Israel Deaconess Medical Center
      • Department of Neonatology
      Boston, MA, United States
  • 1986–2011
    • Boston Children's Hospital
      • • Division of Newborn Medicine
      • • Department of Neurology
      Boston, MA, United States
  • 2009–2010
    • Brigham and Women's Hospital
      • • Department of Obstetrics and Gynecology
      • • Center for Brain Mind Medicine
      Boston, MA, United States
    • University of North Carolina at Chapel Hill
      • Department of Medicine
      Chapel Hill, NC, United States
    • Tufts Medical Center
      Boston, Massachusetts, United States
  • 1990–2010
    • Massachusetts General Hospital
      • • Department of Radiology
      • • Department of Neurology
      Boston, MA, United States
  • 1986–2009
    • Harvard Medical School
      • Department of Neurology
      Boston, Massachusetts, United States
  • 1998–2005
    • Tufts University
      Georgia, United States
  • 1999–2001
    • New England Baptist Hospital
      Boston, Massachusetts, United States