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Quirke F, Biesty L, Battin M, Bloomfield FH, Daly M, Finucane E, Healy P, Hurley T, Kirkham JJ, Molloy E, Haas DM, Meher S, Ní Bhraonáin E, Walker K, Webbe J, Devane D. Neonatal encephalopathy: a systematic review of reported treatment outcomes. BMJ Paediatr Open 2024; 8:e002510. [PMID: 39322607 PMCID: PMC11425948 DOI: 10.1136/bmjpo-2024-002510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 08/04/2024] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND Neonatal encephalopathy (NE) is a multi-organ condition potentially leading to death or long-term neurodisability. Therapeutic hypothermia is the standard treatment for NE; however, long-term impairments remain common. Studies of new treatments for NE often measure and report different outcomes. Core outcome sets (COSs), a minimum set of outcomes to be measured and reported in all studies for a condition, address this problem. This paper aimed to identify outcomes reported (primary, secondary, adverse events and other reported outcomes) in (1) randomised trials and (2) systematic reviews of randomised trials of interventions for the treatment of NE in the process of developing a COS for interventions for the treatment of NE. METHODS We completed a systematic search for outcomes used to evaluate treatments for NE using MEDLINE, Embase, Cochrane CENTRAL, the Cochrane Database of Systematic Reviews and the WHO International Clinical Trials Registry Platform. Two reviewers screened all included articles independently. Outcomes were extracted verbatim, similar outcomes were grouped and outcome domains were developed. RESULTS 386 outcomes were reported in 116 papers, from 85 studies. Outcomes were categorised into 18 domains. No outcome was reported by all studies, a single study reported 11 outcomes and it was not explicitly stated that outcomes had input from parents. DISCUSSION Heterogeneity in reported outcomes means that synthesis of studies evaluating new treatments for NE remains difficult. A COS, that includes parental/family input, is needed to ensure consistency in measuring and reporting outcomes, and to enable comparison of randomised trials.
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Affiliation(s)
- Fiona Quirke
- Neonatal Encephalopathy PhD Training Network, Health Research Board, Dublin, Ireland
- Health Research Board -Trials Methodology Research Network (HRB-TMRN), University of Galway, Galway, Ireland
| | - Linda Biesty
- School of Nursing & Midwifery, University of Galway, Galway, Ireland
- Evidence Synthesis Ireland, University of Galway, Galway, Ireland
| | | | | | - Mandy Daly
- Advocacy and Policymaking Irish Neonatal Health Alliance, Wicklow, Ireland
| | - Elaine Finucane
- Evidence Synthesis Ireland, University of Galway, Galway, Ireland
| | - Patricia Healy
- School of Nursing & Midwifery, University of Galway, Galway, Ireland
| | - Tim Hurley
- Neonatal Encephalopathy PhD Training Network, Health Research Board, Dublin, Ireland
| | - Jamie J Kirkham
- Centre for Biostatistics, Manchester Academic Health Science Centre, Manchester University, Manchester, UK
| | - Eleanor Molloy
- Paediatrics, Trinity College Dublin, Dublin, Ireland
- Paediatrics, Tallaght Hospital, Dublin, Ireland
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University, Bloomington, Indiana, USA
| | - Shireen Meher
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | - Karen Walker
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - James Webbe
- Academic Neonatal Medicine, Imperial College London, London, UK
| | - Declan Devane
- Health Research Board -Trials Methodology Research Network (HRB-TMRN), University of Galway, Galway, Ireland
- Evidence Synthesis Ireland, University of Galway, Galway, Ireland
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Lin J, Deng L, Qi A, Jiang H, Xu D, Zheng Y, Zhang Z, Guo X, Hu B, Li P. Catalpol alleviates hypoxia ischemia-induced brain damage by inhibiting ferroptosis through the PI3K/NRF2/system Xc-/GPX4 axis in neonatal rats. Eur J Pharmacol 2024; 968:176406. [PMID: 38341076 DOI: 10.1016/j.ejphar.2024.176406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 02/12/2024]
Abstract
Hypoxic-ischemic encephalopathy (HIE) is a brain damage caused by perinatal hypoxia and blood flow reduction. Severe HIE leads to death. Available treatments remain limited. Oxidative stress and nerve damage are major factors in brain injury caused by HIE. Catalpol, an iridoid glucoside found in the root of Rehmannia glutinosa, has antioxidant and neuroprotective effects. This study examined the neuroprotective effects of catalpol using a neonatal rat HIE model and found that catalpol might protect the brain through inhibiting neuronal ferroptosis and ameliorating oxidative stress. Behavior tests suggested that catalpol treatment improved functions of motor, learning, and memory abilities after hypoxic-ischemic injury. Catalpol treatment inhibited changes to several ferroptosis-related proteins, including p-PI3K, p-AKT, NRF2, GPX4, SLC7A11, SLC3A2, GCLC, and GSS in HIE neonatal rats. Catalpol also prevented changes to several ferroptosis-related proteins in PC12 cells after oxygen-glucose deprivation. The ferroptosis inducer erastin reversed the protective effects of catalpol both in vitro and in vivo. We concluded that catalpol protects against hypoxic-ischemic brain damage (HIBD) by inhibiting ferroptosis through the PI3K/NRF2/system Xc-/GPX4 axis.
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Affiliation(s)
- Jingjing Lin
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Lu Deng
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Ailin Qi
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Hong Jiang
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Di Xu
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Yuehui Zheng
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Zixuan Zhang
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Xiaoman Guo
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Beilei Hu
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China.
| | - Peijun Li
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China; Institute of Brain Science and Brain-inspired Research, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, Shandong, China.
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3
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Yimenicioglu S, Kaya TB, Yıldırım E, Arayıcı S, Bildirici Y, Ekici A. The factors affecting neurodevelopmental outcomes in HIE. Acta Neurol Belg 2023; 123:1903-1909. [PMID: 36352199 DOI: 10.1007/s13760-022-02126-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 10/23/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Hypoxic ischemic encephalopathy (HIE) has different neurological outcomes. AIM We wanted to see if there was any developmental delay in neonates with hypoxia ischemic encephalopathy who were given therapeutic hypothermia. STUDY DESIGN Retrospective cohort study. METHODS The Denver developmental screening test II (DDST-II) was performed to newborns who had been applied to therapeutic hypothermia. RESULTS There were 69 male and 36 female newborns. The mean 1-min and 5-min Apgar scores were 4.72 ± 2.51 and 7.03 ± 2.017, respectively. The mean pH and mean base excess were 6.92 ± 0.1 and -18.05 ± 5.72, respectively. The most common risk factors were meconium staining (17.1%). There were 67 patients with Stage I, 20 with Stage II, and 18 with Stage III. Diffusion restriction was seen in 13 patients. 28 patients had seizures. In aEEG, 12 patients had burst suppression. Three (2.9%) infants died during hospitalization. 19 patients missed follow-up appointments. Thirteen patients had abnormal development according to DDST-II. Seven patients had gross motor function delays and were diagnosed with cerebral palsy. Three had language skill delays, but two of them had speech disorders after two years of age. Two had delayed milestones. Two had delays in fine motor skills but did not have any sequels after two years of age. A significant difference was found between seizures and the severity of Sarnat stage, intubation in the delivery room with developmental delay. Apgar scores were significantly lower in patients with CP. CONCLUSION We should closely follow-up neonates who had low Apgar scores, seizures, a high Sarnat stage, were intubated in the delivery room.
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Affiliation(s)
- Sevgi Yimenicioglu
- Department of Pediatric Neurology, Health Ministry Eskisehir City Hospital, Eskisehir, Turkey.
| | - Tugba Barsan Kaya
- Department of Neonatal Intensive Care Unit, Eskisehir Osmangazi University Hospital, Eskisehir, Turkey
| | - Egemen Yıldırım
- Department of Neonatal Intensive Care Unit, Health Ministry Eskisehir City Hospital, Eskişehir, Turkey
| | - Sema Arayıcı
- Department of Neonatal Intensive Care Unit, Akdeniz University Hospital, Antalya, Turkey
| | - Yaşar Bildirici
- Department of Pediatrics, Health Ministry Eskisehir City Hospital, Eskisehir, Turkey
| | - Arzu Ekici
- Department of Pediatric Neurology, Health Ministry Bursa Yüksek İhtisas Eğitim Araştirma Hastahanesi, Bursa, Turkey
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4
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Ovcjak A, Pontello R, Miller SP, Sun HS, Feng ZP. Hypothermia combined with neuroprotective adjuvants shortens the duration of hospitalization in infants with hypoxic ischemic encephalopathy: Meta-analysis. Front Pharmacol 2023; 13:1037131. [PMID: 36686686 PMCID: PMC9853207 DOI: 10.3389/fphar.2022.1037131] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023] Open
Abstract
Objective: Therapeutic hypothermia (TH) is the current standard of care for neonatal hypoxic-ischemic encephalopathy (HIE), yet morbidity and mortality remain significant. Adjuvant neuroprotective agents have been suggested to augment hypothermic-mediated neuroprotection. This analysis aims to identify the classes of drugs that have been used in combination with hypothermia in the treatment of neonatal HIE and determine whether combination therapy is more efficacious than TH alone. Methods: A systematic search of PubMed, Embase and Medline from conception through December 2022 was conducted. Randomized- and quasi-randomized controlled trials, observational studies and retrospective studies evaluating HIE infants treated with combination therapy versus TH alone were selected. Primary reviewers extracted information on mortality, neurodevelopmental impairment and length of hospitalization for meta-analyses. Effect sizes were pooled using a random-effects model and measured as odds ratio (OR) or mean difference (MD) where applicable, and 95% confidence intervals (CI) were calculated. Risk of bias was assessed using the tool from the Cochrane Handbook for Systematic Reviews of Interventions. Results: The search strategy collected 519 studies, 16 of which met analysis inclusion criteria. HIE infants totaled 1,288 infants from included studies, 646 infants received some form of combination therapy, while 642 received TH alone. GABA receptor agonists, NMDA receptor antagonists, neurogenic and angiogenic agents, stem cells, glucocorticoids and antioxidants were identified as candidate adjuvants to TH that have been evaluated in clinical settings compared to TH alone. Length of hospitalization was significantly reduced in infants treated with combination therapy (MD -4.81, 95% CI [-8.42. to -1.19], p = .009) compared to those treated with TH alone. Risk of mortality and neurodevelopmental impairment did not differ between combination therapy and TH alone groups. Conclusion: Compared to the current standard of care, administration of neuroprotective adjuvants with TH reduced the duration of hospitalization but did not impact the risk of mortality or neurodevelopmental impairment in HIE infants. Meta-analysis was limited by a moderate risk of bias among included studies and small sample sizes. This analysis highlights the need for preclinical trials to conduct drug development studies in hypothermic settings to identify relevant molecular targets that may offer additive or synergistic neuroprotection to TH, and the need for larger powered clinical trials to determine the dose and timing of administration at which maximal clinical benefits are observed for adjuvant neuroprotectants.
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Affiliation(s)
- Andrea Ovcjak
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Riley Pontello
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Steve P. Miller
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Hong-Shuo Sun
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, Faculty of Medicine, The University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Zhong-Ping Feng
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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5
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Nguyen NP, Helmbrecht H, Ye Z, Adebayo T, Hashi N, Doan MA, Nance E. Brain Tissue-Derived Extracellular Vesicle Mediated Therapy in the Neonatal Ischemic Brain. Int J Mol Sci 2022; 23:620. [PMID: 35054800 PMCID: PMC8775954 DOI: 10.3390/ijms23020620] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 12/28/2021] [Indexed: 02/04/2023] Open
Abstract
Hypoxic-Ischemic Encephalopathy (HIE) in the brain is the leading cause of morbidity and mortality in neonates and can lead to irreparable tissue damage and cognition. Thus, investigating key mediators of the HI response to identify points of therapeutic intervention has significant clinical potential. Brain repair after HI requires highly coordinated injury responses mediated by cell-derived extracellular vesicles (EVs). Studies show that stem cell-derived EVs attenuate the injury response in ischemic models by releasing neuroprotective, neurogenic, and anti-inflammatory factors. In contrast to 2D cell cultures, we successfully isolated and characterized EVs from whole brain rat tissue (BEV) to study the therapeutic potential of endogenous EVs. We showed that BEVs decrease cytotoxicity in an ex vivo oxygen glucose deprivation (OGD) brain slice model of HI in a dose- and time-dependent manner. The minimum therapeutic dosage was determined to be 25 μg BEVs with a therapeutic application time window of 4-24 h post-injury. At this therapeutic dosage, BEV treatment increased anti-inflammatory cytokine expression. The morphology of microglia was also observed to shift from an amoeboid, inflammatory phenotype to a restorative, anti-inflammatory phenotype between 24-48 h of BEV exposure after OGD injury, indicating a shift in phenotype following BEV treatment. These results demonstrate the use of OWH brain slices to facilitate understanding of BEV activity and therapeutic potential in complex brain pathologies for treating neurological injury in neonates.
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Affiliation(s)
- Nam Phuong Nguyen
- Molecular Engineering & Sciences Institute, University of Washington, Seattle, WA 98195, USA;
| | - Hawley Helmbrecht
- Department of Chemical Engineering, University of Washington, Seattle, WA 98195, USA; (H.H.); (Z.Y.); (N.H.)
| | - Ziming Ye
- Department of Chemical Engineering, University of Washington, Seattle, WA 98195, USA; (H.H.); (Z.Y.); (N.H.)
- Department of Biochemistry, University of Washington, Seattle, WA 98195, USA
| | - Tolulope Adebayo
- Department of Biology, University of Washington, Seattle, WA 98195, USA;
| | - Najma Hashi
- Department of Chemical Engineering, University of Washington, Seattle, WA 98195, USA; (H.H.); (Z.Y.); (N.H.)
| | - My-Anh Doan
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA;
| | - Elizabeth Nance
- Molecular Engineering & Sciences Institute, University of Washington, Seattle, WA 98195, USA;
- Department of Chemical Engineering, University of Washington, Seattle, WA 98195, USA; (H.H.); (Z.Y.); (N.H.)
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA;
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6
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Olson L, Lothian C, Ådén U, Lagercrantz H, Robertson NJ, Setterwall F. Phase-Changing Glauber Salt Solution for Medical Applications in the 28-32 °C Interval. MATERIALS 2021; 14:ma14237106. [PMID: 34885261 PMCID: PMC8658730 DOI: 10.3390/ma14237106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022]
Abstract
(1) Background: The field of medicine requires simple cooling materials. However, there is little knowledge documented about phase change materials (PCM) covering the range of 28 to 40 degrees Celsius, as needed for medical use. Induced mild hypothermia, started within 6 h after birth, is an emerging therapy for reducing death and severe disabilities in asphyxiated infants. Currently, this hypothermia is accomplished with equipment that needs a power source and a liquid supply. Neonatal cooling is more frequent in low-resource settings, where ~1 million deaths are caused by birth-asphyxia. (2) Methods: A simple and safe cooling method suitable for medical application is needed for the 28 to 37.5 °C window. (3) Results: Using empirical experiments in which the ingredients in Glauber salt were changed, we studied the effects of temperature on material in the indicated temperature range. The examination, in a controlled manner, of different mixtures of NaCl, Na2SO4 and water resulted in a better understanding of how the different mixtures act and how to compose salt solutions that can satisfy clinical cooling specifications. (4) Conclusions: Our Glauber salt solution is a clinically suited PCM in the temperature interval needed for the cooling of infants suffering from asphyxia.
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Affiliation(s)
- Linus Olson
- Department of Women’s and Children’s Health, Karolinska Institutet, 17177 Stockholm, Sweden; (U.Å.); (H.L.)
- Department of Neonatology, Vietnam National Children’s Hospital, Hanoi, Vietnam
- Correspondence: ; Tel.: +84-0333472900 or +46-707539513
| | - Carina Lothian
- Neonatal Unit, Stockholm Söder Hospital, 11883 Stockholm, Sweden;
| | - Ulrika Ådén
- Department of Women’s and Children’s Health, Karolinska Institutet, 17177 Stockholm, Sweden; (U.Å.); (H.L.)
| | - Hugo Lagercrantz
- Department of Women’s and Children’s Health, Karolinska Institutet, 17177 Stockholm, Sweden; (U.Å.); (H.L.)
| | - Nicola J. Robertson
- Institute for Women’s Health, University College London, London WC1E 6HU, UK;
| | - Fredrik Setterwall
- Division of Energy Processes, Chemical Engineering and Technology, Royal Institute of Technology, 10044 Stockholm, Sweden;
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7
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Tveita T, Sieck GC. Physiological Impact of Hypothermia: The Good, the Bad and the Ugly. Physiology (Bethesda) 2021; 37:69-87. [PMID: 34632808 DOI: 10.1152/physiol.00025.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Hypothermia is defined as a core body temperature of < 35°C, and as body temperature is reduced the impact on physiological processes can be beneficial or detrimental. The beneficial effect of hypothermia enables circulation of cooled experimental animals to be interrupted for 1-2 h without creating harmful effects, while tolerance of circulation arrest in normothermia is between 4 and 5 min. This striking difference has attracted so many investigators, experimental as well as clinical, to this field, and this discovery was fundamental for introducing therapeutic hypothermia in modern clinical medicine in the 1950's. Together with the introduction of cardiopulmonary bypass, therapeutic hypothermia has been the cornerstone in the development of modern cardiac surgery. Therapeutic hypothermia also has an undisputed role as a protective agent in organ transplantation and as a therapeutic adjuvant for cerebral protection in neonatal encephalopathy. However, the introduction of therapeutic hypothermia for organ protection during neurosurgical procedures or as a scavenger after brain and spinal trauma has been less successful. In general, the best neuroprotection seems to be obtained by avoiding hyperthermia in injured patients. Accidental hypothermia occurs when endogenous temperature control mechanisms are incapable of maintaining core body temperature within physiologic limits and core temperature becomes dependent on ambient temperature. During hypothermia spontaneous circulation is considerably reduced and with deep and/or prolonged cooling, circulatory failure may occur, which may limit safe survival of the cooled patient. Challenges that limit safe rewarming of accidental hypothermia patients include cardiac arrhythmias, uncontrolled bleeding, and "rewarming shock".
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Affiliation(s)
- Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
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8
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Tetorou K, Sisa C, Iqbal A, Dhillon K, Hristova M. Current Therapies for Neonatal Hypoxic-Ischaemic and Infection-Sensitised Hypoxic-Ischaemic Brain Damage. Front Synaptic Neurosci 2021; 13:709301. [PMID: 34504417 PMCID: PMC8421799 DOI: 10.3389/fnsyn.2021.709301] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
Neonatal hypoxic-ischaemic brain damage is a leading cause of child mortality and morbidity, including cerebral palsy, epilepsy, and cognitive disabilities. The majority of neonatal hypoxic-ischaemic cases arise as a result of impaired cerebral perfusion to the foetus attributed to uterine, placental, or umbilical cord compromise prior to or during delivery. Bacterial infection is a factor contributing to the damage and is recorded in more than half of preterm births. Exposure to infection exacerbates neuronal hypoxic-ischaemic damage thus leading to a phenomenon called infection-sensitised hypoxic-ischaemic brain injury. Models of neonatal hypoxia-ischaemia (HI) have been developed in different animals. Both human and animal studies show that the developmental stage and the severity of the HI insult affect the selective regional vulnerability of the brain to damage, as well as the subsequent clinical manifestations. Therapeutic hypothermia (TH) is the only clinically approved treatment for neonatal HI. However, the number of HI infants needed to treat with TH for one to be saved from death or disability at age of 18-22 months, is approximately 6-7, which highlights the need for additional or alternative treatments to replace TH or increase its efficiency. In this review we discuss the mechanisms of HI injury to the immature brain and the new experimental treatments studied for neonatal HI and infection-sensitised neonatal HI.
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Affiliation(s)
| | | | | | | | - Mariya Hristova
- Perinatal Brain Repair Group, Department of Maternal and Fetal Medicine, UCL Institute for Women’s Health, London, United Kingdom
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9
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Riviello JJ, Erklauer J. Evidence-Based Protocols in Child Neurology. Neurol Clin 2021; 39:883-895. [PMID: 34215392 DOI: 10.1016/j.ncl.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Medical care has become more complex as the scientific method has expanded medical knowledge. Medicine is also now practiced across different medical systems of varying complexity, and creating standard treatment guidelines is one way of establishing uniform treatment across these systems. The creation of guidelines ensures the delivery of quality medical care and improved patient outcomes. Evidence-based medicine is the application of scientific research to produce these treatment guidelines. This article shall focus on the current treatment guidelines used for inpatient pediatric neurology.
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Affiliation(s)
- James J Riviello
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA.
| | - Jennifer Erklauer
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA; Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA
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10
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Szakmar E, Meunier H, El-Dib M, Yang E, Inder TE. Interobserver Reliability of an MR Imaging Scoring System in Infants with Hypoxic-Ischemic Encephalopathy. AJNR Am J Neuroradiol 2021; 42:969-974. [PMID: 33766829 DOI: 10.3174/ajnr.a7048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 11/23/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE MR imaging has a key role in predicting neurodevelopmental outcomes following neonatal hypoxic-ischemic encephalopathy (HIE). A novel MR imaging scoring system for hypoxic-ischemic brain injury was used in our patient population with the aim of assessing interobserver variability and developing subcategories for the severity of brain injury. MATERIALS AND METHODS We evaluated brain MR images of 252 infants who underwent hypothermia for HIE between 2014 and 2019. First, 40 infants were selected randomly to test interobserver variability. Discrepancies were identified during the assessment of the first 20 MR images. The remaining 20 MR images were scored after adjusting the scoring system. Second, we determined cutoff values for the severity of injury that were based on the percentiles of the total scores in the full cohort. RESULTS The interobserver reliability showed excellent agreement for the total score both before (intraclass correlation coefficient = 0.96; 95% CI 0.89-0.99) and after the adjustment (intraclass correlation coefficient = 0.96; 95% CI, 0.89-0.98). The average of the differences and the agreement interval between the 2 readers decreased after the adjustment. Subcategories of brain injury were the following: We considered a total score of ≤4 (≤75%) as normal, 5-10 (76%-90%) as mild, 11-15 (91%-95%) as moderate, and >15 (>95%) as severe brain injury. The agreement on the classification of brain injury improved in the second epoch (weighted κ = 0.723 versus 0.887). CONCLUSIONS The adjusted scoring system may lead to a higher degree of interrater agreement. The presented cutoff values may be used to determine the severity of brain injury in future clinical studies including infants with mild hypoxia-ischemia.
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Affiliation(s)
- E Szakmar
- From the Department of Pediatric Newborn Medicine (E.S., H.M., M.E.-D., T.E.I.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,First Department of Pediatrics (E.S.), Semmelweis University, Budapest, Hungary
| | - H Meunier
- From the Department of Pediatric Newborn Medicine (E.S., H.M., M.E.-D., T.E.I.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Neonatal Intensive Care Unit, (H.M.), Hôpital Alix de Champagne, Reims, France
| | - M El-Dib
- From the Department of Pediatric Newborn Medicine (E.S., H.M., M.E.-D., T.E.I.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - E Yang
- Department of Radiology (E.Y.), Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - T E Inder
- From the Department of Pediatric Newborn Medicine (E.S., H.M., M.E.-D., T.E.I.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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11
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Badawi N, Mcintyre S, Hunt RW. Perinatal care with a view to preventing cerebral palsy. Dev Med Child Neurol 2021; 63:156-161. [PMID: 33251607 PMCID: PMC7839537 DOI: 10.1111/dmcn.14754] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2020] [Indexed: 01/02/2023]
Abstract
Birth prevalence of cerebral palsy (CP) is declining in high-income countries, to as low as 1.4 per 1000 live births in the most recent international reports. This represents a 35% reduction in birth prevalence over a 15-year period. This reduction is underpinned by a heightened focus of attention towards all aspects of CP, including: increased awareness, better data collection, development of national networks and registries, an explosion of research in basic science, perinatal care, neonatal neurology, public health, early detection, and targeted early intervention. Quick uptake of evidence into practice has ensued and overall improvements in clinical care occurred concurrently. It is anticipated that with continued partnerships with families, ongoing research driving further clinical improvement and vice versa, birth prevalence and severity of CP will further decline and the focus will shift to prevention in low- and middle-income countries. WHAT THIS PAPER ADDS: Research in the field of perinatal care and cerebral palsy (CP) prevention has increased significantly. In high-income countries, increased awareness of CP and scientific advances have improved clinical care. Population-based registers have limitations but remain the best mechanism to quantify birth prevalence of CP and accurately track trends. There have been recent reductions in the birth prevalence of CP.
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Affiliation(s)
- Nadia Badawi
- Grace Centre for Newborn CareChildren's Hospital at Westmead Sydney Children's Hospital NetworkSydneyNSWAustralia,Cerebral Palsy Alliance Research InstituteSpecialty of Child & Adolescent HealthSydney Medical SchoolFaculty of Medicine & HealthThe University of SydneySydneyNSWAustralia
| | - Sarah Mcintyre
- Cerebral Palsy Alliance Research InstituteSpecialty of Child & Adolescent HealthSydney Medical SchoolFaculty of Medicine & HealthThe University of SydneySydneyNSWAustralia
| | - Rod W Hunt
- Department of PaediatricsMonash UniversityMelbourneVICAustralia,Neonatal ResearchClinical SciencesMurdoch Children's Research InstituteMelbourneVICAustralia,Monash NewbornMonash HealthMelbourneVICAustralia
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12
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Bruckner M, Lista G, Saugstad OD, Schmölzer GM. Delivery Room Management of Asphyxiated Term and Near-Term Infants. Neonatology 2021; 118:487-499. [PMID: 34023837 DOI: 10.1159/000516429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/09/2021] [Indexed: 11/19/2022]
Abstract
Approximately 800,000 newborns die annually due to birth asphyxia. The resuscitation of asphyxiated term newly born infants often occurs unexpected and is challenging for healthcare providers as it demands experience and knowledge in neonatal resuscitation. Current neonatal resuscitation guidelines often focus on resuscitation of extremely and/or very preterm infants; however, the recommendations for asphyxiated term newborn infants differ in some aspects to those for preterm infants (i.e., respiratory support, supplemental oxygen, and temperature management). Since the update of the neonatal resuscitation guidelines in 2015, several studies examining various resuscitation approaches to improve the outcome of asphyxiated infants have been published. In this review, we discuss current recommendations and recent findings and provide an overview of delivery room management of asphyxiated term newborn infants.
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Affiliation(s)
- Marlies Bruckner
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Gianluca Lista
- Division of Neonatology, Department of Pediatric, "V. Buzzi" Ospedale Dei Bambini, Milan, Italy
| | - Ola D Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway.,Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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13
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Min YJ, Ling EA, Li F. Immunomodulatory Mechanism and Potential Therapies for Perinatal Hypoxic-Ischemic Brain Damage. Front Pharmacol 2020; 11:580428. [PMID: 33536907 PMCID: PMC7849181 DOI: 10.3389/fphar.2020.580428] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/13/2020] [Indexed: 12/13/2022] Open
Abstract
Hypoxia-ischemia (HI) is one of the most common causes of death and disability in neonates. Currently, the only available licensed treatment for perinatal HI is hypothermia. However, it alone is not sufficient to prevent the brain injuries and/or neurological dysfunction related to HI. Perinatal HI can activate the immune system and trigger the peripheral and central responses which involve the immune cell activation, increase in production of immune mediators and release of reactive oxygen species. There is mounting evidence indicating that regulation of immune response can effectively rescue the outcomes of brain injury in experimental perinatal HI models such as Rice-Vannucci model of newborn hypoxic-ischemic brain damage (HIBD), local transient cerebral ischemia and reperfusion model, perinatal asphyxia model, and intrauterine hypoxia model. This review summarizes the many studies about immunomodulatory mechanisms and therapies for HI. It highlights the important actions of some widely documented therapeutic agents for effective intervening of HI related brain damage, namely, HIBD, such as EPO, FTY720, Minocycline, Gastrodin, Breviscapine, Milkvetch etc. In this connection, it has been reported that the ameboid microglial cells featured prominently in the perinatal brain represent the key immune cells involved in HIBD. To this end, drugs, chemical agents and herbal compounds which have the properties to suppress microglia activation have recently been extensively explored and identified as potential therapeutic agents or strategies for amelioration of neonatal HIBD.
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Affiliation(s)
- Ying-Jun Min
- Department of Pathology and Pathophysiology, School of Basic Medical Sciences, Kunming Medical University, Kunming, China
| | - Eng-Ang Ling
- Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Fan Li
- Department of Pathology and Pathophysiology, School of Basic Medical Sciences, Kunming Medical University, Kunming, China
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Zhang Z, Chen X, Liu S. Role of Sirtuin-1 in Neonatal Hypoxic-Ischemic Encephalopathy and Its Underlying Mechanism. Med Sci Monit 2020; 26:e924544. [PMID: 32826847 PMCID: PMC7461657 DOI: 10.12659/msm.924544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/21/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Neonatal hypoxic-ischemic encephalopathy (HIE) is a dreaded disease and one of the leading causes of severe neurological dysfunction in neonates. The present study explored the functions of Sirtuin-1 (SIRT1) in neonatal HIE. MATERIAL AND METHODS A HIE neonatal rat model was generated to determine SIRT1 levels in brain tissues. Cell apoptosis and cell viability were analyzed by flow cytometry and MTT assay. qRT-PCR and Western blot analysis were used to assess gene mRNA and protein levels. Subsequently, the effect of SIRT1 on HIE was investigated in vitro by constructing an oxygen-glucose deprivation (OGD) cell model. RESULTS The effective construction of the HIE rat model was confirmed by the enhanced brain cell apoptosis and the increased expression of HIE-related molecular markers, including S100 calcium-binding protein B (S100B) and neuron-specific enolase (NSE). SIRT1 expression was downregulated in HIE rat brain tissues. These findings indicated that SIRT1 was downregulated in neuronal cells subjected to OGD. In addition, enhanced cell viability and reduced cell apoptosis were observed, suggesting that SIRT1 overexpression relieved OGD-induced neuronal cell injury. Transfection with SIRT1-siRNA further increased OGD-induced neuronal cell injury, evidenced by decreased cell viability and enhanced cell apoptosis. Finally, SIRT1 overexpression significantly downregulated p-p65 protein expression. CONCLUSIONS Our findings revealed that SIRT1 may be a novel and promising therapy target for HIE treatment.
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Affiliation(s)
- Zhen Zhang
- Department of Pediatrics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, P.R, China
| | - Xin Chen
- Department of Pediatrics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, P.R, China
| | - Sichen Liu
- Department of Neonatology, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar, Heilongjiang, P.R. China
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15
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O'Dea M, Sweetman D, Bonifacio SL, El-Dib M, Austin T, Molloy EJ. Management of Multi Organ Dysfunction in Neonatal Encephalopathy. Front Pediatr 2020; 8:239. [PMID: 32500050 PMCID: PMC7243796 DOI: 10.3389/fped.2020.00239] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 04/20/2020] [Indexed: 12/16/2022] Open
Abstract
Neonatal Encephalopathy (NE) describes neonates with disturbed neurological function in the first post-natal days of life. NE is an overall term that does not specify the etiology of the encephalopathy although it often involves hypoxia-ischaemia. In NE, although neurological dysfunction is part of the injury and is most predictive of long-term outcome, these infants may also have multiorgan injury and compromise, which further contribute to neurological impairment and long-term morbidities. Therapeutic hypothermia (TH) is the standard of care for moderate to severe NE. Infants with NE may have co-existing immune, respiratory, endocrine, renal, hepatic, and cardiac dysfunction that require individualized management and can be impacted by TH. Non-neurological organ dysfunction not only has a negative effect on long term outcome but may also influence the efficacy of treatments in the acute phase. Post resuscitative care involves stabilization and decisions regarding TH and management of multi-organ dysfunction. This management includes detailed neurological assessment, cardio-respiratory stabilization, glycaemic and fluid control, sepsis evaluation and antibiotics, seizure identification, and monitoring and responding to biochemical and coagulation derangements. The emergence of new biomarkers of specific organ injury may have predictive value and improve the definition of organ injury and prognosis. Further evidence-based research is needed to optimize management of NE, prevent further organ dysfunction and reduce neurodevelopmental impairment.
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Affiliation(s)
- Mary O'Dea
- Discipline of Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland
- Paediatric Research Laboratory, Trinity Translational Institute, St. James' Hospital, Dublin, Ireland
- Neonatology, Coombe Women and Infant's University Hospital, Dublin, Ireland
- National Children's Research Centre, Dublin, Ireland
| | - Deirdre Sweetman
- National Children's Research Centre, Dublin, Ireland
- Paediatrics, National Maternity Hospital, Dublin, Ireland
| | - Sonia Lomeli Bonifacio
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Mohamed El-Dib
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Eleanor J. Molloy
- Discipline of Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland
- Paediatric Research Laboratory, Trinity Translational Institute, St. James' Hospital, Dublin, Ireland
- Neonatology, Coombe Women and Infant's University Hospital, Dublin, Ireland
- National Children's Research Centre, Dublin, Ireland
- Paediatrics, National Maternity Hospital, Dublin, Ireland
- Neonatology, Children's Hospital Ireland (CHI) at Crumlin, Dublin, Ireland
- Paediatrics, CHI at Tallaght, Tallaght University Hospital, Dublin, Ireland
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Charki S, Kalyanshettar SS, Singh S, Biradar V, Kulkarni T, Patil SV. Experience of therapeutic hypothermia in neonates with perinatal asphyxia in a tertiary care center in North Karnataka, India. J Clin Neonatol 2020. [DOI: 10.4103/jcn.jcn_85_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Idris Z, Song Yee A, Kandasamy R, Abd Manaf A, Hasyizan Bin Hassan M, Nazaruddin Wan Hassan W. Direct Brain Cooling in Treating Severe Traumatic Head Injury. TRAUMATIC BRAIN INJURY - NEUROBIOLOGY, DIAGNOSIS AND TREATMENT 2019. [DOI: 10.5772/intechopen.84685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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18
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Hwang M, Sridharan A, Darge K, Riggs B, Sehgal C, Flibotte J, Huisman TAGM. Novel Quantitative Contrast-Enhanced Ultrasound Detection of Hypoxic Ischemic Injury in Neonates and Infants: Pilot Study 1. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2025-2038. [PMID: 30560547 DOI: 10.1002/jum.14892] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 11/05/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To investigate whether quantitative contrast-enhanced ultrasound (CEUS) can accurately identify neonates and infants with hypoxic ischemic brain injury. METHODS In this prospective cohort study, 8 neonates and infants with a suspicion of hypoxic ischemic injury were evaluated with CEUS. RESULTS An interesting trend was observed in the central gray nuclei-to-cortex perfusion ratios. The ratios at the peak enhancement, wash-in area under the curve, perfusion index, and maximum wash-in slopes were lower in all of the affected cases compared to the normal group but not statistically significant given the small sample size (P = .0571). Additionally, when the central gray nuclei-to-cortex perfusion ratio was plotted for all time points along the time-intensity curve, it was observed that the affected cases showed a trend that was qualitatively different from that of the normal cases. In the affected cases, the ratio time-intensity curves either stayed below 1.0 for the entire enhancement period or reached 1.0 close to peak wash-in before falling just below 1.0 for the remaining period of enhancement. However, in the unaffected patients, there was a steep wash-in that crossed the 1.0 threshold and remained above 1.0 for most of the enhancement period. CONCLUSIONS Bedside CEUS is an easily obtainable brain-imaging modality that has the potential to effectively identify infants and neonates with evolving brain injury. A larger prospective study evaluating the correlation between CEUS findings and the reference standard of diffusion- and perfusion-weighted magnetic resonance imaging is needed to establish it as a diagnostic tool.
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Affiliation(s)
- Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kassa Darge
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Becky Riggs
- Department of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Chandra Sehgal
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Andrews PJ, Sinclair HL, Rodríguez A, Harris B, Rhodes J, Watson H, Murray G. Therapeutic hypothermia to reduce intracranial pressure after traumatic brain injury: the Eurotherm3235 RCT. Health Technol Assess 2019; 22:1-134. [PMID: 30168413 DOI: 10.3310/hta22450] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of disability and death in young adults worldwide. It results in around 1 million hospital admissions annually in the European Union (EU), causes a majority of the 50,000 deaths from road traffic accidents and leaves a further ≈10,000 people severely disabled. OBJECTIVE The Eurotherm3235 Trial was a pragmatic trial examining the effectiveness of hypothermia (32-35 °C) to reduce raised intracranial pressure (ICP) following severe TBI and reduce morbidity and mortality 6 months after TBI. DESIGN An international, multicentre, randomised controlled trial. SETTING Specialist neurological critical care units. PARTICIPANTS We included adult participants following TBI. Eligible patients had ICP monitoring in place with an ICP of > 20 mmHg despite first-line treatments. Participants were randomised to receive standard care with the addition of hypothermia (32-35 °C) or standard care alone. Online randomisation and the use of an electronic case report form (CRF) ensured concealment of random treatment allocation. It was not possible to blind local investigators to allocation as it was obvious which participants were receiving hypothermia. We collected information on how well the participant had recovered 6 months after injury. This information was provided either by the participant themself (if they were able) and/or a person close to them by completing the Glasgow Outcome Scale - Extended (GOSE) questionnaire. Telephone follow-up was carried out by a blinded independent clinician. INTERVENTIONS The primary intervention to reduce ICP in the hypothermia group after randomisation was induction of hypothermia. Core temperature was initially reduced to 35 °C and decreased incrementally to a lower limit of 32 °C if necessary to maintain ICP at < 20 mmHg. Rewarming began after 48 hours if ICP remained controlled. Participants in the standard-care group received usual care at that centre, but without hypothermia. MAIN OUTCOME MEASURES The primary outcome measure was the GOSE [range 1 (dead) to 8 (upper good recovery)] at 6 months after the injury as assessed by an independent collaborator, blind to the intervention. A priori subgroup analysis tested the relationship between minimisation factors including being aged < 45 years, having a post-resuscitation Glasgow Coma Scale (GCS) motor score of < 2 on admission, having a time from injury of < 12 hours and patient outcome. RESULTS We enrolled 387 patients from 47 centres in 18 countries. The trial was closed to recruitment following concerns raised by the Data and Safety Monitoring Committee in October 2014. On an intention-to-treat basis, 195 participants were randomised to hypothermia treatment and 192 to standard care. Regarding participant outcome, there was a higher mortality rate and poorer functional recovery at 6 months in the hypothermia group. The adjusted common odds ratio (OR) for the primary statistical analysis of the GOSE was 1.54 [95% confidence interval (CI) 1.03 to 2.31]; when the GOSE was dichotomised the OR was 1.74 (95% CI 1.09 to 2.77). Both results favoured standard care alone. In this pragmatic study, we did not collect data on adverse events. Data on serious adverse events (SAEs) were collected but were subject to reporting bias, with most SAEs being reported in the hypothermia group. CONCLUSIONS In participants following TBI and with an ICP of > 20 mmHg, titrated therapeutic hypothermia successfully reduced ICP but led to a higher mortality rate and worse functional outcome. LIMITATIONS Inability to blind treatment allocation as it was obvious which participants were randomised to the hypothermia group; there was biased recording of SAEs in the hypothermia group. We now believe that more adequately powered clinical trials of common therapies used to reduce ICP, such as hypertonic therapy, barbiturates and hyperventilation, are required to assess their potential benefits and risks to patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN34555414. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 45. See the NIHR Journals Library website for further project information. The European Society of Intensive Care Medicine supported the pilot phase of this trial.
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Affiliation(s)
- Peter Jd Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - H Louise Sinclair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Aryelly Rodríguez
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Bridget Harris
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Gordon Murray
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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20
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A shared vision of quality of life: Partnering in decision-making to understand families' realities. Paediatr Respir Rev 2019; 29:14-18. [PMID: 30366651 DOI: 10.1016/j.prrv.2018.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 09/11/2018] [Indexed: 11/22/2022]
Abstract
Quality of life (QOL) measures are increasingly used when important prognostication and treatment decisions need to be made in the care of a critically ill child. Unfortunately, health-care professionals and families experience difficulties when attempting to accurately predict and estimate QOL for a patient. Aspects such as subjectivity, complexity and adaptation to illness play an important role in how QOL is ultimately experienced. This often leads to inaccurate estimates of QOL, when performed by individuals other than the patient, such as clinicians or family members. In order to make decisions in the best interest of the patient, a partnership between families and clinicians must be fostered, based on communication, trust and mutual understanding of values. This article will attempt to describe some of the challenges that come into play when assessing QOL for a patient and will provide tools for building a clinician-family partnership in the decision-making process.
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22
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Mild Hypothermia Prevents NO-Induced Cytotoxicity in Human Neuroblastoma Cells Via Induction of COX-2. J Mol Neurosci 2018; 67:173-180. [DOI: 10.1007/s12031-018-1222-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/18/2018] [Indexed: 12/13/2022]
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23
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Skoromets AP, Schugareva LM, Shumilina MV, Gorelik YV. [The improvement of treatment efficacy in newborn full-term infants with severe birth asphyxia]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 116:83-88. [PMID: 27456726 DOI: 10.17116/jnevro20161163283-88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To investigate the efficacy of cytoflavin as add-on to moderate controlled hypothermia in the treatment of newborn full-term infants with severe birth asphyxia. MATERIAL AND METHODS Sixty full-term underweight children diagnosed with severe birth asphyxia (Apgar score 4-5) underwent moderate hypothermia for 72 hours. Depending on the regimen, the children were divided into two equal groups: the basic group received cytoflavin in dose of 2 ml/kg / day and the control group received the traditional scheme of therapy. RESULTS The inclusion of cytoflavin increases the efficacy of therapy by reducing the severity of depression of consciousness (the increase in the average total score on the modified Glasgow Coma Scale pediatric/Saint Petersburg by 47.1% in children of the basic group compared with 27.9% in the control group, p=0.04) and more rapid recovery of vital functions (early extubation by 20.3%, p=0.03, and transition to enteral feeding earlier by 16.7% compared with the control group). The use of cytoflavin in newborns with severe asphyxia reduces lactic acidosis in the blood serum and normalizes EEG parameters as compared to the control group (p=0.02). CONCLUSION Cytoflavin can be recommended as adjunctive therapy in full-term infants with severe intrapartum asphyxia.
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Affiliation(s)
- A P Skoromets
- Mechnikov North-Western State Medical University, Saint-Petersburg, Russia
| | - L M Schugareva
- Mechnikov North-Western State Medical University, Saint-Petersburg, Russia; Children's Hospital #1, Saint-Petersburg, Russia
| | - M V Shumilina
- Pavlov First Saint Petersburg State Medical University, Saint-Petersburg, Russia
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Kim TK, Park D, Ban YH, Cha Y, An ES, Choi J, Choi EK, Kim YB. Improvement by Human Oligodendrocyte Progenitor Cells of Neurobehavioral Disorders in an Experimental Model of Neonatal Periventricular Leukomalacia. Cell Transplant 2018; 27:1168-1177. [PMID: 29978719 PMCID: PMC6158554 DOI: 10.1177/0963689718781330] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The effects of human oligodendrocyte progenitor (F3.olig2) cells on improving neurobehavioral deficits were investigated in an experimental model of periventricular leukomalacia (PVL). Seven-day-old male rats were subjected to hypoxia-ischemia-lipopolysaccharide injection (HIL), and intracerebroventricularly transplanted with F3.olig2 (4 × 105 cells/rat) once at post-natal day (PND) 10 or repeatedly at PND10, 17, 27, and 37. Neurobehavioral disorders were evaluated at PND14, 20, 30, and 40 via cylinder test, locomotor activity, and rotarod performance, and cognitive function was evaluated at PND41-45 through passive avoidance and Morris water-maze performances. F3.olig2 cells recovered the rate of use of the forelimb contralateral to the injured brain, improved locomotor activity, and restored rotarod performance of PVL animals; in addition, marked improvement of learning and memory function was seen. It was confirmed that transplanted F3·olig2 cells migrated to injured areas, matured to oligodendrocytes expressing myelin basic protein (MBP), and markedly attenuated the loss of host MBP in the corpus callosum. The results indicate that the transplanted F3.olig2 cells restored neurobehavioral functions by preventing axonal demyelination, and that human oligodendrocyte progenitor cells could be a candidate for cell therapy of perinatal hypoxic-ischemic and infectious brain injuries including PVL and cerebral palsy.
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Affiliation(s)
- Tae-Kyun Kim
- 1 College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Dongsun Park
- 1 College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Young-Hwan Ban
- 1 College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Yeseul Cha
- 1 College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Eun Suk An
- 1 College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Jieun Choi
- 1 College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Ehn-Kyoung Choi
- 1 College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Yun-Bae Kim
- 1 College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
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25
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Ahn SY, Chang YS, Sung DK, Sung SI, Park WS. Hypothermia broadens the therapeutic time window of mesenchymal stem cell transplantation for severe neonatal hypoxic ischemic encephalopathy. Sci Rep 2018; 8:7665. [PMID: 29769612 PMCID: PMC5955959 DOI: 10.1038/s41598-018-25902-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/26/2018] [Indexed: 01/06/2023] Open
Abstract
Recently, we have demonstrated that concurrent hypothermia and mesenchymal stem cells (MSCs) transplantation synergistically improved severe neonatal hypoxic ischemic encephalopathy (HIE). The current study was designed to determine whether hypothermia could extend the therapeutic time window of MSC transplantation for severe neonatal HIE. To induce HIE, newborn rat pups were exposed to 8% oxygen for 2 h following unilateral carotid artery ligation on postnatal day (P) 7. After approving severe HIE involving >50% of the ipsilateral hemisphere volume, hypothermia (32 °C) for 2 days was started. MSCs were transplanted 2 days after HIE modeling. Follow-up brain MRI, sensorimotor function tests, assessment of inflammatory cytokines in the cerebrospinal fluid (CSF), and histological evaluation of peri-infarction area were performed. HIE induced progressively increasing brain infarction area over time, increased cell death, reactive gliosis and brain inflammation, and impaired sensorimotor function. All these damages observed in severe HIE showed better, robust improvement with a combination treatment of hypothermia and delayed MSC transplantation than with either stand-alone therapy. Hypothermia itself did not significantly reduce brain injury, but broadened the therapeutic time window of MSC transplantation for severe newborn HIE.
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Affiliation(s)
- So Yoon Ahn
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Stem Cell and Regenerative Medicine Institute, Samsung Medical Center, Seoul, South Korea
| | - Yun Sil Chang
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea.,Stem Cell and Regenerative Medicine Institute, Samsung Medical Center, Seoul, South Korea
| | - Dong Kyung Sung
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Stem Cell and Regenerative Medicine Institute, Samsung Medical Center, Seoul, South Korea
| | - Se In Sung
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Stem Cell and Regenerative Medicine Institute, Samsung Medical Center, Seoul, South Korea
| | - Won Soon Park
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. .,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea. .,Stem Cell and Regenerative Medicine Institute, Samsung Medical Center, Seoul, South Korea.
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Yang GS, Zhou XY, An XF, Liu XJ, Zhang YJ, Yu D. Mild hypothermia inhibits the Notch 3 and Notch 4 activation and seizure after stroke in the rat model. Pathol Res Pract 2018; 214:1008-1016. [PMID: 29754932 DOI: 10.1016/j.prp.2018.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/20/2018] [Accepted: 05/01/2018] [Indexed: 12/18/2022]
Abstract
Ischemic brain injury is an important cause for seizure. Mild hypothermia of the brain or the whole body is an effective way to remit the post-stroke seizure. Our previous study revealed an implication of Notch 1 and 2 in the post-stroke seizure. This study further investigated the involvement of Notch 3 and 4 in post-stroke seizure and the effect of mild hypothermia on these two factors. A global cerebral ischemia (GCI) model was conducted in Sprague Dawley rats. Seizure activity was evaluated by the frequency of seizure attacks, seizure severity scores, and seizure discharges. Seizures were frequently occurred in the first and the second 24 h after GCI, however active whole-body cooling (mild hypothermia) and DAPT (Notch inhibitor) injection into the hippocampus, alone or in combination, alleviated seizure activity after GCI. Immunohistochemistry and Western blot assays revealed the up-regulation of Notch intracellular domain (NICD) 3 and 4 in the cerebral cortex and hippocampus following GCI, but mild hypothermia and DAPT inhibited the up-regulation of NICD 3 and 4. NF-κB, PPARα, PPARγ, cyclin D1, Sox2 and Pax6 are associated with the pathogenesis of diverse type of seizures. GCI induced NF-κB, cyclin D1, and Pax6 activity, but suppressed PPARγ. These effects of GCI were abolished by both mild hypothermia and DAPT treatment. This indicated the implication of Notch signaling in the effects of GCI. Collectively, mild hypothermia inhibits Notch 3 and Notch 4 activation and seizure after stroke in the rat model. This study adds to the further understanding of the pathogenesis of post-stroke seizures and the protective mechanism of mild hypothermia.
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Affiliation(s)
- Guo-Shuai Yang
- Department of Neurology, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou 570208, Hainan Province, China.
| | - Xiao-Yan Zhou
- Department of Neurology, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou 570208, Hainan Province, China
| | - Xue-Fang An
- Department of Neurology, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou 570208, Hainan Province, China
| | - Xuan-Jun Liu
- Department of Neurology, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou 570208, Hainan Province, China
| | - Yan-Jun Zhang
- Department of Neurology, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou 570208, Hainan Province, China
| | - Dan Yu
- Department of Neurology, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou 570208, Hainan Province, China
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Lakshminrusimha S, Shankaran S, Laptook A, McDonald S, Keszler M, Van Meurs K, Guillet R, Chawla S, Sood BG, Bonifacio S, Das A, Higgins RD. Pulmonary Hypertension Associated with Hypoxic-Ischemic Encephalopathy-Antecedent Characteristics and Comorbidities. J Pediatr 2018; 196:45-51.e3. [PMID: 29502880 PMCID: PMC6052458 DOI: 10.1016/j.jpeds.2017.12.055] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/27/2017] [Accepted: 12/19/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the characteristics of term infants with persistent pulmonary hypertension of the newborn (PPHN) associated with moderate or severe hypoxic ischemic encephalopathy (HIE). METHODS We compared infants with and without PPHN enrolled in 2 randomized trials of therapeutic hypothermia: the induced hypothermia trial of cooling to 33.5°C for 72 hours vs normothermia, and the "usual-care" arm (33.5°C for 72 hours) of the optimizing cooling trial. RESULTS Among 303 infants with HIE from these 2 studies, 67 (22%) had PPHN and 236 (78%) did not. We compared infants with PPHN with those without PPHN. The proportion of patients treated with therapeutic hypothermia was similar in PPHN and no-PPHN groups (66% vs 65%). Medication use during resuscitation (58% vs 44%), acidosis after birth (pH: 7.0 ± 0.2 vs 7.1 ± 0.2), severe HIE (43% vs 28%), meconium aspiration syndrome (39% vs 7%), pulmonary hemorrhage (12% vs 3%), culture-positive sepsis (12% vs 3%), systemic hypotension (65% vs 28%), inhaled nitric oxide therapy (64% vs 3%), and extracorporeal membrane oxygenation (12% vs 0%) were more common in the PPHN group. Length of stay (26 ± 21 vs 16 ± 14 days) and mortality (27% vs 16%) were higher in the PPHN group. CONCLUSIONS PPHN is common among infants with moderate/severe HIE and is associated with severe encephalopathy, lung disease, sepsis, systemic hypotension, and increased mortality. The prevalence of PPHN was not different between those infants receiving therapeutic hypothermia at 33.5°C in these 2 trials (44/197 = 22%) compared with infants receiving normothermia in the induced hypothermia trial (23/106 = 22%).
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28
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Cashen K, Reeder RW, Shanti C, Dalton HJ, Dean JM, Meert KL. Is therapeutic hypothermia during neonatal extracorporeal membrane oxygenation associated with intracranial hemorrhage? Perfusion 2017; 33:354-362. [PMID: 29228894 DOI: 10.1177/0267659117747693] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The use of therapeutic hypothermia during neonatal extracorporeal membrane oxygenation (ECMO) as a neurologic protective strategy has gained interest among clinicians despite limited data. Our objective is to describe the relationship between the use of therapeutic hypothermia during neonatal ECMO and complications, mortality and functional status among survivors. METHODS Secondary analysis of data collected by the Collaborative Pediatric Critical Care Research Network between December 2012 and September 2014. Data were collected prospectively from 267 neonates (<30 days) undergoing ECMO at eight clinical sites. Twenty neonates received therapeutic hypothermia. RESULTS Neonates receiving therapeutic hypothermia were more likely to have intracranial hemorrhage during the first seven days of ECMO than were non-hypothermic neonates (40.0% vs 15.8%, p=0.012). No differences were observed between groups for hospital mortality or functional status at hospital discharge among survivors. Variables independently associated with intracranial hemorrhage in the first seven days of ECMO included therapeutic hypothermia, gestational age at birth, age at initiation of ECMO, fibrinogen concentration and mode of ECMO. CONCLUSION Therapeutic hypothermia during neonatal ECMO appears to be associated with intracranial hemorrhage.
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Affiliation(s)
- Katherine Cashen
- 1 Department of Pediatrics, Division of Critical Care, Children's Hospital of Michigan/Wayne State University, Detroit, MI, USA
| | - Ron W Reeder
- 2 Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Christina Shanti
- 3 Department of General Surgery, Children's Hospital of Michigan/Wayne State University, Detroit, MI, USA
| | - Heidi J Dalton
- 4 Department of Pediatrics, Inova Fairfax Hospital, Falls Church, VA, USA
| | - J Michael Dean
- 2 Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Kathleen L Meert
- 1 Department of Pediatrics, Division of Critical Care, Children's Hospital of Michigan/Wayne State University, Detroit, MI, USA
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29
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Yozawitz E, Stacey A, Pressler RM. Pharmacotherapy for Seizures in Neonates with Hypoxic Ischemic Encephalopathy. Paediatr Drugs 2017; 19:553-567. [PMID: 28770451 DOI: 10.1007/s40272-017-0250-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Seizures are common in neonates with moderate and severe hypoxic ischemic encephalopathy (HIE) and are associated with worse outcomes, independent of HIE severity. In contrast to adults and older children, no new drugs have been licensed for treatment of neonatal seizures over the last 50 years, because of a lack of controlled clinical trials. Hence, many antiseizure medications licensed in older children and adults are used off-label for neonatal seizure, which is associated with potential risks of adverse effects during a period when the brain is particularly vulnerable. Phenobarbital is worldwide the first-line drug and is considered standard of care, although there is a limited evidence base for its efficacy. Second-line agents include phenytoin, benzodiazepines, levetiracetam, and lidocaine. These drugs are discussed in more detail along with two emerging drugs (bumetanide and topiramate). More safety, pharmacokinetic, and efficacy data are needed from well-designed clinical trials to develop safe and effective antiseizure regimes for the treatment of neonatal seizures in HIE.
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Affiliation(s)
- Elissa Yozawitz
- Department of Neurology and Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Arthur Stacey
- UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Ronit M Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, Great Ormond Street, London, WC1N 3JH, UK. .,Clinical Neurosciences, UCL- Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
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30
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Rewell SSJ, Jeffreys AL, Sastra SA, Cox SF, Fernandez JA, Aleksoska E, van der Worp HB, Churilov L, Macleod MR, Howells DW. Hypothermia revisited: Impact of ischaemic duration and between experiment variability. J Cereb Blood Flow Metab 2017; 37:3380-3390. [PMID: 28084873 PMCID: PMC5624387 DOI: 10.1177/0271678x16688704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
To assess the true effect of novel therapies for ischaemic stroke, a positive control that can validate the experimental model and design is vital. Hypothermia may be a good candidate for such a positive control, given the convincing body of evidence from animal models of ischaemic stroke. Taking conditions under which substantial efficacy had been seen in a meta-analysis of hypothermia for focal ischaemia in animal models, we undertook three randomised and blinded studies examining the effect of hypothermia induced immediately following the onset of middle cerebral artery occlusion on infarct volume in rats (n = 15, 23, 264). Hypothermia to a depth of 33℃ and maintained for 130 min significantly reduced infarct volume compared to normothermia treatment (by 27-63%) and depended on ischaemic duration (F(3,244) = 21.242, p < 0.05). However, the protective effect varied across experiments with differences in both the size of the infarct observed in normothermic controls and the time to reach target temperature. Our results highlight the need for sample size and power calculations to take into account variations between individual experiments requiring induction of focal ischaemia.
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Affiliation(s)
- Sarah SJ Rewell
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Amy L Jeffreys
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Steven A Sastra
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Susan F Cox
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - John A Fernandez
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Elena Aleksoska
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonid Churilov
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Malcolm R Macleod
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
| | - David W Howells
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania
- David W Howells, School of Medicine, Faculty of Health, University of Tasmania, Medical Science Precinct, 17 Liverpool Street, Hobart, Tasmania, Australia.
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31
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Maoulainine FMR, Elbaz M, Elfaiq S, Boufrioua G, Elalouani FZ, Barkane M, El Idrissi Slitine N. Therapeutic Hypothermia in Asphyxiated Neonates: Experience from Neonatal Intensive Care Unit of University Hospital of Marrakech. Int J Pediatr 2017; 2017:3674140. [PMID: 28567061 PMCID: PMC5439062 DOI: 10.1155/2017/3674140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/02/2017] [Accepted: 03/16/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Therapeutic hypothermia (TH) is now recommended for the treatment neonates with hypoxic-ischemic encephalopathy (HIE). This treatment protocol is applied in our department since June 2012. The aim of this study is to report the first experience with head cooling in asphyxiated neonates in Morocco. PATIENTS AND METHODS Prospective study of newborns admitted for HIE from July 18, 2012, to May 15, 2014, in Neonatal Intensive Care Unit (NICU) of Mohamed VI University Hospital. The results were studied by comparing a newborn group who received hypothermia to a control group. RESULTS Seventy-two cases of neonates with perinatal asphyxia were admitted in the unit. According to inclusion criteria thirty-eight cases were eligible for the study. Only 19 cases have received the hypothermia protocol for different reason; the arrival beyond six hours of life was the main cause accounting for 41%. Complications of asphyxia were comparable in both groups with greater pulmonary hypertension recorded in the control group. The long-term follow-up of protocol group was normal in almost half of cases. CONCLUSION Our first experience with the controlled TH supports its beneficial effect in newborns with HIE. This treatment must be available in all the centers involved in the neonatal care in Morocco.
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Affiliation(s)
- F. M. R. Maoulainine
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
- Research Unit of Childhood Health and Development, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
| | - M. Elbaz
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
| | - S. Elfaiq
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
| | - G. Boufrioua
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
| | - F. Z. Elalouani
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
| | - M. Barkane
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
| | - Nadia El Idrissi Slitine
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
- Research Unit of Childhood Health and Development, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
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Diaz J, Abiola S, Kim N, Avaritt O, Flock D, Yu J, Northington FJ, Chavez-Valdez R. Therapeutic Hypothermia Provides Variable Protection against Behavioral Deficits after Neonatal Hypoxia-Ischemia: A Potential Role for Brain-Derived Neurotrophic Factor. Dev Neurosci 2017; 39:257-272. [PMID: 28196356 DOI: 10.1159/000454949] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 12/05/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite treatment with therapeutic hypothermia (TH), infants who survive hypoxic ischemic (HI) encephalopathy (HIE) have persistent neurological abnormalities at school age. Protection by TH against HI brain injury is variable in both humans and animal models. Our current preclinical model of hypoxia-ischemia (HI) and TH displays this variability of outcomes in neuropathological and neuroimaging end points with some sexual dimorphism. The detailed behavioral phenotype of this model is unknown. Whether there is sexual dimorphism in certain behavioral domains is also not known. Brain-derived neurotrophic factor (BDNF) supports neuronal cell survival and repair but may also be a marker of injury. Here, we characterize the behavioral deficits after HI and TH stratified by sex, as well as late changes in BDNF and its correlation with memory impairment. METHODS HI was induced in C57BL6 mice on postnatal day 10 (p10) (modified Vannucci model). Mice were randomized to TH (31°C) or normothermia (NT, 36°C) for 4 h after HI. Controls were anesthesia-exposed, age- and sex-matched littermates. Between p16 and p39, growth was followed, and behavioral testing was performed including reflexes (air righting, forelimb grasp and negative geotaxis) and sensorimotor, learning, and memory skills (open field, balance beam, adhesive removal, Y-maze tests, and object location task [OLT]). Correlations between mature BDNF levels in the forebrain and p42 memory outcomes were studied. RESULTS Both male and female HI mice had an approximately 8-12% lower growth rate (g/day) than shams (p ≤ 0.01) by p39. TH ameliorated this growth failure in females but not in males. In female mice, HI injury prolonged the time spent at the periphery (open field) at p36 (p = 0.004), regardless of treatment. TH prevented motor impairments in the balance beam and adhesive removal tests in male and female mice, respectively (p ≤ 0.05). Male and female HI mice visited the new arm of the Y-maze 12.5% (p = 0.05) and 10% (p = 0.03) less often than shams, respectively. Male HI mice also had 35% lower exploratory preference score than sham (p ≤ 0.001) in the OLT. TH did not prevent memory impairments found with Y-maze testing or OLT in either sex (p ≤ 0.01) at p26. At p42, BDNF levels in the forebrain ipsilateral to the HI insult were 1.7- to 2-fold higher than BDNF levels in the sham forebrain, and TH did not prevent this increase. Higher BDNF levels in the forebrain ipsilateral to the insult correlated with worse performance in the Y-maze in both sexes and in OLT in male mice (p = 0.01). CONCLUSIONS TH provides benefit in specific domains of behavior following neonatal HI. In general, these benefits accrued to both males and females, but not in all areas. In some domains, such as memory, no benefit of TH was found. Late differences in individual BDNF levels may explain some of these findings.
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Affiliation(s)
- Johana Diaz
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
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33
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Yang HJ, Ju F, Guo XX, Ma SP, Wang L, Cheng BF, Zhuang RJ, Zhang BB, Shi X, Feng ZW, Wang M. RNA-binding protein RBM3 prevents NO-induced apoptosis in human neuroblastoma cells by modulating p38 signaling and miR-143. Sci Rep 2017; 7:41738. [PMID: 28134320 PMCID: PMC5278414 DOI: 10.1038/srep41738] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/28/2016] [Indexed: 01/25/2023] Open
Abstract
Nitric oxide (NO)-induced apoptosis in neurons is an important cause of neurodegenerative disease in humans. The cold-inducible protein RBM3 mediates the protective effects of cooling on apoptosis induced by various insults. However, whether RBM3 protects neural cells from NO-induced apoptosis is unclear. This study aimed to investigate the neuroprotective effect of RBM3 on NO-induced apoptosis in human SH-SY5Y neuroblastoma cells. Firstly, we demonstrated that mild hypothermia (32 °C) induces RBM3 expression and confers a potent neuroprotective effect on NO-induced apoptosis, which was substantially diminished when RBM3 was silenced by siRNA. Moreover, overexpression of RBM3 exhibited a strong protective effect against NO-induced apoptosis. Signaling pathway screening demonstrated that only p38 inhibition by RBM3 provided neuroprotective effect, although RBM3 overexpression could affect the activation of p38, JNK, ERK, and AKT signaling in response to NO stimuli. Notably, RBM3 overexpression also blocked the activation of p38 signaling induced by transforming growth factor-β1. Furthermore, both RBM3 overexpression and mild hypothermia abolished the induction of miR-143 by NO, which was shown to mediate the cytotoxicity of NO in a p38-dependent way. These findings suggest that RBM3 protects neuroblastoma cells from NO-induced apoptosis by suppressing p38 signaling, which mediates apoptosis through miR-143 induction.
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Affiliation(s)
- Hai-Jie Yang
- School of Life Science and Technology, Xinxiang Medical University, Xinxiang 453003, China.,Henan Collaborative Innovation Center of Molecular Diagnosis and Laboratory Medicine, Xinxiang Medical University, Xinxiang 453003, China.,Henan Key Lab of Biological Psychiatry, Second Affiliated Hospital of Xinxiang Medical University, Xinxiang 453003, China
| | - Fei Ju
- School of Life Science and Technology, Xinxiang Medical University, Xinxiang 453003, China.,Henan Collaborative Innovation Center of Molecular Diagnosis and Laboratory Medicine, Xinxiang Medical University, Xinxiang 453003, China
| | - Xin-Xin Guo
- School of Life Science and Technology, Xinxiang Medical University, Xinxiang 453003, China.,Henan Collaborative Innovation Center of Molecular Diagnosis and Laboratory Medicine, Xinxiang Medical University, Xinxiang 453003, China
| | - Shuang-Ping Ma
- School of Life Science and Technology, Xinxiang Medical University, Xinxiang 453003, China
| | - Lei Wang
- School of Life Science and Technology, Xinxiang Medical University, Xinxiang 453003, China
| | - Bin-Feng Cheng
- School of Life Science and Technology, Xinxiang Medical University, Xinxiang 453003, China
| | - Rui-Juan Zhuang
- School of Life Science and Technology, Xinxiang Medical University, Xinxiang 453003, China
| | - Bin-Bin Zhang
- School of Life Science and Technology, Xinxiang Medical University, Xinxiang 453003, China
| | - Xiang Shi
- School of Life Science and Technology, Xinxiang Medical University, Xinxiang 453003, China
| | - Zhi-Wei Feng
- Henan Collaborative Innovation Center of Molecular Diagnosis and Laboratory Medicine, Xinxiang Medical University, Xinxiang 453003, China
| | - Mian Wang
- School of Life Science and Technology, Xinxiang Medical University, Xinxiang 453003, China.,Henan Collaborative Innovation Center of Molecular Diagnosis and Laboratory Medicine, Xinxiang Medical University, Xinxiang 453003, China
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Lee YK, Penn A, Patel M, Pandit R, Song D, Ha BY. Hypothermia-treated neonates with hypoxic-ischemic encephalopathy: Optimal timing of quantitative ADC measurement to predict disease severity. Neuroradiol J 2016; 30:28-35. [PMID: 27881816 DOI: 10.1177/1971400916678229] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
To determine the optimal time window for MR imaging with quantitative ADC measurement in neonatal HIE after hypothermia treatment, a retrospective review was performed on consecutive hypothermia-treated term neonates with HIE, with an initial and follow-up MR imaging within the first two weeks of life. Three neuroradiologists categorized each set of MR imaging as normal, mild, moderate or severe HIE based on a consensus review of the serial imaging. The lowest ADC values from the white matter, corpus callosum, and basal ganglia/thalamus were measured. The ADC values between mild-moderate and severe HIE were compared using a Student's t-test over a range of different time windows. A total of 33 MR imaging examinations were performed on 16 neonates that included three normal, four mild, five moderate, and four severe HIE. The time window of 3-10 days showed a statistically significant decrease in ADC value in severe HIE compared to mild-moderate HIE in all three locations, respectively: white matter 0.5 ± 0.22 versus 0.83 ± 0.27 ( p value 0.01), corpus callosum 0.69 ± 0.19 versus 0.91 ± 0.17 ( p value 0.01), and basal ganglia/thalamus 0.63 ± 0.16 versus 0.98 ± 0.06 ( p value <0.01). The range of 3-10 days is the optimal time window for MR imaging with quantitative ADC after hypothermia treatment.
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Affiliation(s)
- Yauk K Lee
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Alex Penn
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Mahesh Patel
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Rajul Pandit
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Dongli Song
- 2 Department of Pediatrics, Santa Clara Valley Medical Center, USA
| | - Bo Yoon Ha
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
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35
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Lakshminrusimha S, Saugstad OD. The fetal circulation, pathophysiology of hypoxemic respiratory failure and pulmonary hypertension in neonates, and the role of oxygen therapy. J Perinatol 2016; 36 Suppl 2:S3-S11. [PMID: 27225963 DOI: 10.1038/jp.2016.43] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 02/10/2016] [Accepted: 02/16/2016] [Indexed: 12/31/2022]
Abstract
Neonatal hypoxemic respiratory failure (HRF), a deficiency of oxygenation associated with insufficient ventilation, can occur due to a variety of etiologies. HRF can result when pulmonary vascular resistance (PVR) fails to decrease at birth, leading to persistent pulmonary hypertension of newborn (PPHN), or as a result of various lung disorders including congenital abnormalities such as diaphragmatic hernia, and disorders of transition such as respiratory distress syndrome, transient tachypnea of newborn and perinatal asphyxia. PVR changes throughout fetal life, evident by the dynamic changes in pulmonary blood flow at different gestational ages. Pulmonary vascular transition at birth requires an interplay between multiple vasoactive mediators such as nitric oxide, which can be potentially inactivated by superoxide anions. Superoxide anions have a key role in the pathophysiology of HRF. Oxygen (O2) therapy, used in newborns long before our knowledge of the complex nature of HRF and PPHN, has continued to evolve. Over time has come the discovery that too much O2 can be toxic. Recommendations on the optimal inspired O2 levels to initiate resuscitation in term newborns have ranged from 100% (pre 1998) to the currently recommended use of room air (21%). Questions remain about the most effective levels, particularly in preterm and low birth weight newborns. Attaining the appropriate balance between hypoxemia and hyperoxemia, and targeting treatments to the pathophysiology of HRF in each individual newborn are critical factors in the development of improved therapies to optimize outcomes.
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Affiliation(s)
| | - O D Saugstad
- Department of Pediatric Research, University of Oslo and Oslo University Hospital, Oslo, Norway
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36
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Zhang J, Klufas D, Manalo K, Adjepong K, Davidson JO, Wassink G, Bennet L, Gunn AJ, Stopa EG, Liu K, Nishibori M, Stonestreet BS. HMGB1 Translocation After Ischemia in the Ovine Fetal Brain. J Neuropathol Exp Neurol 2016; 75:527-38. [PMID: 27151753 DOI: 10.1093/jnen/nlw030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Inflammation contributes to the evolution of hypoxic-ischemic (HI) brain injury. High-mobility group box-1 (HMGB1) is a nuclear protein that is translocated from the nucleus and released after ischemia in adult rodents and thereby initiates inflammatory responses. However, there is very little information regarding the effects of HI on HMGB1 in immature brains. To investigate the effects of HI on HMGB1 in the term-equivalent fetal brain, ovine fetuses at 127 days gestation were studied after 30 minutes of carotid occlusion. Groups were sham-control and ischemia with 48 hours and ischemia with 72 hours of reperfusion. By immunohistochemistry, HMGB1 was found to be localized primarily in cell nuclei and partially in cytoplasmic compartments in the cerebral cortex of controls. Ischemia increased the area fraction of neuronal cells with cytoplasmic HMGB1 staining, and Western immunoblot revealed that cytosolic HMGB1 expression increased after ischemia (p < 0.05) and decreased in nuclei in ischemic versus the sham-control brains (p < 0.05). These data indicate that HMGB1 translocates from the nuclear to cytosolic compartments after ischemic brain injury in fetal sheep. This translocation may enable the action of HMGB1 as a proinflammatory cytokine that contributes to HI injury in the developing brain.
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Affiliation(s)
- Jiyong Zhang
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Daniel Klufas
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Karina Manalo
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Kwame Adjepong
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Joanne O Davidson
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Guido Wassink
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Laura Bennet
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Alistair J Gunn
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Edward G Stopa
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Keyue Liu
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Masahiro Nishibori
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Barbara S Stonestreet
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN).
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37
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Rumajogee P, Bregman T, Miller SP, Yager JY, Fehlings MG. Rodent Hypoxia-Ischemia Models for Cerebral Palsy Research: A Systematic Review. Front Neurol 2016; 7:57. [PMID: 27199883 PMCID: PMC4843764 DOI: 10.3389/fneur.2016.00057] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 04/03/2016] [Indexed: 12/28/2022] Open
Abstract
Cerebral palsy (CP) is a complex multifactorial disorder, affecting approximately 2.5-3/1000 live term births, and up to 22/1000 prematurely born babies. CP results from injury to the developing brain incurred before, during, or after birth. The most common form of this condition, spastic CP, is primarily associated with injury to the cerebral cortex and subcortical white matter as well as the deep gray matter. The major etiological factors of spastic CP are hypoxia/ischemia (HI), occurring during the last third of pregnancy and around birth age. In addition, inflammation has been found to be an important factor contributing to brain injury, especially in term infants. Other factors, including genetics, are gaining importance. The classic Rice-Vannucci HI model (in which 7-day-old rat pups undergo unilateral ligation of the common carotid artery followed by exposure to 8% oxygen hypoxic air) is a model of neonatal stroke that has greatly contributed to CP research. In this model, brain damage resembles that observed in severe CP cases. This model, and its numerous adaptations, allows one to finely tune the injury parameters to mimic, and therefore study, many of the pathophysiological processes and conditions observed in human patients. Investigators can recreate the HI and inflammation, which cause brain damage and subsequent motor and cognitive deficits. This model further enables the examination of potential approaches to achieve neural repair and regeneration. In the present review, we compare and discuss the advantages, limitations, and the translational value for CP research of HI models of perinatal brain injury.
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Affiliation(s)
- Prakasham Rumajogee
- Division of Genetics and Development, Krembil Research Institute, Toronto Western Hospital, University Health Network , Toronto, ON , Canada
| | - Tatiana Bregman
- Division of Genetics and Development, Krembil Research Institute, Toronto Western Hospital, University Health Network , Toronto, ON , Canada
| | - Steven P Miller
- Department of Pediatrics, Hospital for Sick Children , Toronto, ON , Canada
| | - Jerome Y Yager
- Division of Pediatric Neurosciences, Stollery Children's Hospital, University of Alberta , Edmonton, AB , Canada
| | - Michael G Fehlings
- Division of Genetics and Development, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, ON, Canada; Division of Neurosurgery, Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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McKenna MC, Scafidi S, Robertson CL. Metabolic Alterations in Developing Brain After Injury: Knowns and Unknowns. Neurochem Res 2015; 40:2527-43. [PMID: 26148530 PMCID: PMC4961252 DOI: 10.1007/s11064-015-1600-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 04/10/2015] [Accepted: 05/02/2015] [Indexed: 12/21/2022]
Abstract
Brain development is a highly orchestrated complex process. The developing brain utilizes many substrates including glucose, ketone bodies, lactate, fatty acids and amino acids for energy, cell division and the biosynthesis of nucleotides, proteins and lipids. Metabolism is crucial to provide energy for all cellular processes required for brain development and function including ATP formation, synaptogenesis, synthesis, release and uptake of neurotransmitters, maintaining ionic gradients and redox status, and myelination. The rapidly growing population of infants and children with neurodevelopmental and cognitive impairments and life-long disability resulting from developmental brain injury is a significant public health concern. Brain injury in infants and children can have devastating effects because the injury is superimposed on the high metabolic demands of the developing brain. Acute injury in the pediatric brain can derail, halt or lead to dysregulation of the complex and highly regulated normal developmental processes. This paper provides a brief review of metabolism in developing brain and alterations found clinically and in animal models of developmental brain injury. The metabolic changes observed in three major categories of injury that can result in life-long cognitive and neurological disabilities, including neonatal hypoxia-ischemia, pediatric traumatic brain injury, and brain injury secondary to prematurity are reviewed.
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Affiliation(s)
- Mary C McKenna
- Department of Pediatrics and Program in Neuroscience, University of Maryland School of Medicine, 655 W. Baltimore St., Room 13-019, Baltimore, MD, 21201, USA.
| | - Susanna Scafidi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Courtney L Robertson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Adenosine A1 receptors contribute to immune regulation after neonatal hypoxic ischemic brain injury. Purinergic Signal 2015; 12:89-101. [PMID: 26608888 DOI: 10.1007/s11302-015-9482-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/28/2015] [Indexed: 12/20/2022] Open
Abstract
Neonatal brain hypoxic ischemia (HI) often results in long-term motor and cognitive impairments. Post-ischemic inflammation greatly effects outcome and adenosine receptor signaling modulates both HI and immune cell function. Here, we investigated the influence of adenosine A1 receptor deficiency (A1R(-/-)) on key immune cell populations in a neonatal brain HI model. Ten-day-old mice were subjected to HI. Functional outcome was assessed by open locomotion and beam walking test and infarction size evaluated. Flow cytometry was performed on brain-infiltrating cells, and semi-automated analysis of flow cytometric data was applied. A1R(-/-) mice displayed larger infarctions (+33%, p < 0.05) and performed worse in beam walking tests (44% more mistakes, p < 0.05) than wild-type (WT) mice. Myeloid cell activation after injury was enhanced in A1R(-/-) versus WT brains. Activated B lymphocytes expressing IL-10 infiltrated the brain after HI in WT, but were less activated and did not increase in relative frequency in A1R(-/-). Also, A1R(-/-) B lymphocytes expressed less IL-10 than their WT counterparts, the A1R antagonist DPCPX decreased IL-10 expression whereas the A1R agonist CPA increased it. CD4(+) T lymphocytes including FoxP3(+) T regulatory cells, were unaffected by genotype, whereas CD8(+) T lymphocyte responses were smaller in A1R(-/-) mice. Using PCA to characterize the immune profile, we could discriminate the A1R(-/-) and WT genotypes as well as sham operated from HI-subjected animals. We conclude that A1R signaling modulates IL-10 expression by immune cells, influences the activation of these cells in vivo, and affects outcome after HI.
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40
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McKenna MC, Scafidi S, Robertson CL. Metabolic Alterations in Developing Brain After Injury: Knowns and Unknowns. Neurochem Res 2015. [PMID: 26148530 DOI: 10.1007/s11064‐015‐1600‐7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Brain development is a highly orchestrated complex process. The developing brain utilizes many substrates including glucose, ketone bodies, lactate, fatty acids and amino acids for energy, cell division and the biosynthesis of nucleotides, proteins and lipids. Metabolism is crucial to provide energy for all cellular processes required for brain development and function including ATP formation, synaptogenesis, synthesis, release and uptake of neurotransmitters, maintaining ionic gradients and redox status, and myelination. The rapidly growing population of infants and children with neurodevelopmental and cognitive impairments and life-long disability resulting from developmental brain injury is a significant public health concern. Brain injury in infants and children can have devastating effects because the injury is superimposed on the high metabolic demands of the developing brain. Acute injury in the pediatric brain can derail, halt or lead to dysregulation of the complex and highly regulated normal developmental processes. This paper provides a brief review of metabolism in developing brain and alterations found clinically and in animal models of developmental brain injury. The metabolic changes observed in three major categories of injury that can result in life-long cognitive and neurological disabilities, including neonatal hypoxia-ischemia, pediatric traumatic brain injury, and brain injury secondary to prematurity are reviewed.
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Affiliation(s)
- Mary C McKenna
- Department of Pediatrics and Program in Neuroscience, University of Maryland School of Medicine, 655 W. Baltimore St., Room 13-019, Baltimore, MD, 21201, USA.
| | - Susanna Scafidi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Courtney L Robertson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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41
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Park WS, Sung SI, Ahn SY, Yoo HS, Sung DK, Im GH, Choi SJ, Chang YS. Hypothermia augments neuroprotective activity of mesenchymal stem cells for neonatal hypoxic-ischemic encephalopathy. PLoS One 2015; 10:e0120893. [PMID: 25816095 PMCID: PMC4376738 DOI: 10.1371/journal.pone.0120893] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 01/27/2015] [Indexed: 01/21/2023] Open
Abstract
Though hypothermia is the only clinically available treatment for neonatal hypoxic-ischemic encephalopathy (HIE), it is not completely effective in severe cases. We hypothesized that combined treatment with hypothermia and transplantation of human umbilical cord blood (UCB)-derived mesenchymal stem cells (MSCs) would synergistically attenuate severe HIE compared to stand-alone therapy. To induce hypoxia-ischemia (HI), male Sprague-Dawley rats were subjected to 8% oxygen for 120 min after unilateral carotid artery ligation on postnatal day (P) 7. After confirmation of severe HIE involving >50% of the ipsilateral hemisphere volume as determined by diffusion-weighted brain magnetic resonance imaging (MRI) within 2 h after HI, intraventricular MSC transplantation (1 × 105 cells) and/or hypothermia with target temperature at 32°C for 24 h were administered 6 h after induction of HI. Follow-up brain MRI at P12 and P42, sensorimotor function tests at P40–42, evaluation of cytokines in the cerebrospinal fluid (CSF) at P42, and histologic analysis of peri-infarct tissues at P42 were performed. Severe HI resulted in progressively increased brain infarction over time as assessed by serial MRI, increased number of cells positive for terminal deoxynucleotidyl transferase nick-end labeling, microgliosis and astrocytosis, increased CSF cytokine levels, and impaired function in behavioral tests such as rotarod and cylinder tests. All of the abnormalities observed in severe HIE showed greater improvement after combined treatment with hypothermia and MSC transplantation than with either therapy alone. Overall, these findings suggest that combined treatment with hypothermia and human UCB-derived MSC transplantation might be a novel therapeutic modality to improve the prognosis of severe HIE, an intractable disease that currently has no effective treatment.
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Affiliation(s)
- Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Yoon Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Soo Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Kyung Sung
- Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Geun Ho Im
- Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Jin Choi
- Biomedical Research Institute, MEDIPOST Co., Ltd., Seoul, Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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42
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Lascarrou JB, Meziani F, Le Gouge A, Boulain T, Bousser J, Belliard G, Asfar P, Frat JP, Dequin PF, Gouello JP, Delahaye A, Hssain AA, Chakarian JC, Pichon N, Desachy A, Bellec F, Thevenin D, Quenot JP, Sirodot M, Labadie F, Plantefeve G, Vivier D, Girardie P, Giraudeau B, Reignier J. Therapeutic hypothermia after nonshockable cardiac arrest: the HYPERION multicenter, randomized, controlled, assessor-blinded, superiority trial. Scand J Trauma Resusc Emerg Med 2015; 23:26. [PMID: 25882712 PMCID: PMC4353458 DOI: 10.1186/s13049-015-0103-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Meta-analyses of nonrandomized studies have provided conflicting data on therapeutic hypothermia, or targeted temperature management (TTM), at 33°C in patients successfully resuscitated after nonshockable cardiac arrest. Nevertheless, the latest recommendations issued by the International Liaison Committee on Resuscitation and by the European Resuscitation Council recommend therapeutic hypothermia. New data are available on the adverse effects of therapeutic hypothermia, notably infectious complications. The risk/benefit ratio of therapeutic hypothermia after nonshockable cardiac arrest is unclear. METHODS HYPERION is a multicenter (22 French ICUs) trial with blinded outcome assessment in which 584 patients with successfully resuscitated nonshockable cardiac arrest are allocated at random to either TTM between 32.5 and 33.5°C (therapeutic hypothermia) or TTM between 36.5 and 37.5°C (therapeutic normothermia) for 24 hours. Both groups are managed with therapeutic normothermia for the next 24 hours. TTM is achieved using locally available equipment. The primary outcome is day-90 neurological status assessed by the Cerebral Performance Categories (CPC) Scale with dichotomization of the results (1 + 2 versus 3 + 4 + 5). The primary outcome is assessed by a blinded psychologist during a semi-structured telephone interview of the patient or next of kin. Secondary outcomes are day-90 mortality, hospital mortality, severe adverse events, infections, and neurocognitive performance. The planned sample size of 584 patients will enable us to detect a 9% absolute difference in day-90 neurological status with 80% power, assuming a 14% event rate in the control group and a two-sided Type 1 error rate of 4.9%. Two interim analyses will be performed, after inclusion of 200 and 400 patients, respectively. DISCUSSION The HYPERION trial is a multicenter, randomized, controlled, assessor-blinded, superiority trial that may provide an answer to an issue of everyday relevance, namely, whether TTM is beneficial in comatose patients resuscitated after nonshockable cardiac arrest. Furthermore, it will provide new data on the tolerance and adverse events (especially infectious complications) of TTM at 32.5-33.5°C. TRIAL REGISTRATION ClinicalTrials.gov: NCT01994772 .
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Affiliation(s)
| | - Ferhat Meziani
- Medical Intensive Care Unit, University Hospital Center, University of Strasbourg, Strasbourg, France.
| | - Amélie Le Gouge
- INSERM CIC1415, CHRU de Tours, Tours, France. .,Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France.
| | - Thierry Boulain
- Medical Intensive Care Unit, Regional Hospital Center, Orleans, France.
| | - Jérôme Bousser
- Medical-Surgical intensive Care Unit, General Hospital Center, Saint Brieuc, France.
| | - Guillaume Belliard
- Medical Intensive Care Unit, South Brittany General Hospital Center, Lorient, France.
| | - Pierre Asfar
- Medical Intensive Care Unit, University Hospital Center, Angers, France.
| | - Jean Pierre Frat
- Medical Intensive Care Unit, University Hospital Center, Poitiers, France.
| | | | - Jean Paul Gouello
- Medical-Surgical Intensive Care Unit, General Hospital Center, Saint Malo, France.
| | - Arnaud Delahaye
- Medical-Surgical Intensive Care Unit, General Hospital Center, Rodez, France.
| | - Ali Ait Hssain
- Medical Intensive Care Unit, University Hospital Center, Clermond-Ferrand, France.
| | | | - Nicolas Pichon
- Medical-Surgical Intensive Care Unit, University Hospital Center, Limoges, France.
| | - Arnaud Desachy
- Medical-Surgical Intensive Care Unit, General Hospital Center, Angouleme, France.
| | - Fréderic Bellec
- Medical-Surgical Intensive Care Unit, General Hospital Center, Montauban, France.
| | - Didier Thevenin
- Medical-Surgical Intensive Care Unit, General Hospital Center, Lens, France.
| | | | - Michel Sirodot
- Medical-Surgical Intensive Care Unit, General Hospital Center, Annecy, France.
| | - François Labadie
- Medical-Surgical Intensive Care Unit, General Hospital Center, Saint Nazaire, France.
| | - Gaétan Plantefeve
- Medical-Surgical Intensive Care Unit, General Hospital Center, Argenteuil, France.
| | - Dominique Vivier
- Medical-Surgical Intensive Care Unit, General Hospital Center, Le Mans, France.
| | - Patrick Girardie
- Medical Intensive Care Unit, University Hospital Center, Lille, France.
| | - Bruno Giraudeau
- INSERM CIC1415, CHRU de Tours, Tours, France. .,Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France.
| | - Jean Reignier
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France.
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Newmyer R, Mendelson J, Pang D, Fink EL. Targeted Temperature Management in Pediatric Central Nervous System Disease. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2015; 1:38-47. [PMID: 26042193 PMCID: PMC4450147 DOI: 10.1007/s40746-014-0008-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Acute central nervous system conditions due to hypoxic-ischemic encephalopathy, traumatic brain injury (TBI), status epilepticus, and central nervous system infection/inflammation, are a leading cause of death and disability in childhood. There is a critical need for effective neuroprotective therapies to improve outcome targeting distinct disease pathology. Fever, defined as patient temperature > 38°C, has been clearly shown to exacerbate brain injury. Therapeutic hypothermia (HT) is an intervention using targeted temperature management that has multiple mechanisms of action and robust evidence of efficacy in multiple experimental models of brain injury. Prospective clinical evidence for its neuroprotective efficacy exists in narrowly-defined populations with hypoxic-ischemic injury outside of the pediatric age range while trials comparing hypothermia to normothermia after TBI have failed to demonstrate a benefit on outcome but consistently demonstrate potential use in decreasing refractory intracranial pressure. Data in children from prospective, randomized controlled trials using different strategies of targeted temperature management for various outcomes are few but a large study examining HT versus controlled normothermia to improve neurological outcome in cardiac arrest is underway.
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Affiliation(s)
- Robert Newmyer
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
| | - Jenny Mendelson
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
| | - Diana Pang
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
| | - Ericka L Fink
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
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44
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Yamamoto Y, Ibara S, Tokuhisa T, Hirakawa E, Yoneda S, Kobayashi K, Kato E, Maruyama Y, Maede Y, Kuwabara T. Calcium concentration in hypoxic-ischemic encephalopathy during hypothermia. Pediatr Int 2015; 57:64-7. [PMID: 25287276 DOI: 10.1111/ped.12438] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 05/22/2014] [Accepted: 06/17/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to investigate the relationship between prognosis and the changes in serum-ionized calcium concentration in neonates with hypoxic-ischemic encephalopathy (HIE) before and during brain hypothermia (BHT). METHODS Serum samples were obtained from 16 HIE neonates who underwent BHT. All patients underwent developmental testing at 18 months of age. RESULTS Mean serum-ionized calcium concentration in the poor outcome group (developmental quotient [DQ], <80; nine infants) was significantly lower than in the good outcome group (DQ >80; seven infants), both immediately before and after 6 h of BHT. Mean serum-ionized calcium concentration significantly decreased in both groups for 6 h, and the lowest adjusted serum-ionized calcium during 6 h of BHT was <1.05 mmol/L, known as the cut-off value for poor outcome, in 57.1% of the good outcome group. CONCLUSION The influx of calcium into cells continues regardless of neurological prognosis during the early phase of BHT, but BHT might protect some high-risk patients against neurological damage at low adjusted serum-ionized calcium concentration.
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Affiliation(s)
- Yutaka Yamamoto
- Department of Neonatology, Gifu Prefectural General Medical Center, Gifu, Japan; Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan; Perinatal Medical Center, Kagoshima City Hospital, Kagoshima, Japan
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45
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Orbach SA, Bonifacio SL, Kuzniewicz M, Glass HC. Lower incidence of seizure among neonates treated with therapeutic hypothermia. J Child Neurol 2014; 29:1502-7. [PMID: 24334344 PMCID: PMC4053513 DOI: 10.1177/0883073813507978] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Animal studies suggest that hypothermia decreases seizure burden, whereas limited human data are inconclusive. This retrospective cohort study examines the relationship between therapeutic hypothermia and seizure in neonates with hypoxic-ischemic encephalopathy. Our center admitted 224 neonates from July 2004 to December 2011 who met institutional cooling criteria. Seventy-three neonates were born during the pre-cooling era, prior to November 2007, and 151 were born during the cooling era. Among neonates with moderate encephalopathy, the incidence of seizure in cooled infants was less than half the incidence in those not cooled (26% cooling, 61% pre-cooling era; risk ratio = 0.43, 95% confidence interval = 0.30-0.61). Among neonates with severe encephalopathy, there was no difference in the incidence (83% vs. 87%; risk ratio = 1.05, 95% confidence interval = 0.78-1.39). These results support animal data and suggest a mechanism by which neonates with moderate encephalopathy can benefit more from cooling than neonates with severe encephalopathy.
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Affiliation(s)
- Sharon A Orbach
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sonia L Bonifacio
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Michael Kuzniewicz
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Hannah C Glass
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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Combined treatment of xenon and hypothermia in newborn rats--additive or synergistic effect? PLoS One 2014; 9:e109845. [PMID: 25286345 PMCID: PMC4186877 DOI: 10.1371/journal.pone.0109845] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 06/23/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Breathing the inert gas Xenon (Xe) enhances hypothermic (HT) neuroprotection after hypoxia-ischemia (HI) in small and large newborn animal models. The underlying mechanism of the enhancement is not yet fully understood, but the combined effect of Xe and HT could either be synergistic (larger than the two effects added) or simply additive. A previously published study, using unilateral carotid ligation followed by hypoxia in seven day old (P7) rats, showed that the combination of mild HT (35°C) and low Xe concentration (20%), both not being neuroprotective alone, had a synergistic effect and was neuroprotective when both were started with a 4 h delay after a moderate HI insult. To examine whether another laboratory could confirm this finding, we repeated key aspects of the study. DESIGN/METHODS After the HI-insult 120 pups were exposed to different post-insult treatments: three temperatures (normothermia (NT) NT37°C, HT35°C, HT32°C) or Xe concentrations (0%, 20% or 50%) starting either immediately or with a 4 h delay. To assess the synergistic potency of Xe-HT, a second set (n = 101) of P7 pups were exposed to either HT35°C+Xe0%, NT+Xe20% or a combination of HT35°C+Xe20% starting with a 4 h delay after the insult. Brain damage was analyzed using relative hemispheric (ligated side/unligated side) brain tissue area loss after seven day survival. RESULTS Immediate HT32°C (p = 0.042), but not HT35°C significantly reduced brain injury compared to NT37°C. As previously shown, adding immediate Xe50% to HT32°C increased protection. Neither 4 h-delayed Xe20%, nor Xe50% at 37°C significantly reduced brain injury (p>0.050). In addition, neither 4 h-delayed HT35°C alone, nor HT35°C+Xe20% reduced brain injury. We found no synergistic effect of the combined treatments in this experimental model. CONCLUSIONS Combining two treatments that individually were ineffective (delayed HT35°C and delayed Xe20%) did not exert neuroprotection when combined, and therefore did not show a synergistic treatment effect.
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Boudes E, Gilbert G, Leppert IR, Tan X, Pike GB, Saint-Martin C, Wintermark P. Measurement of brain perfusion in newborns: pulsed arterial spin labeling (PASL) versus pseudo-continuous arterial spin labeling (pCASL). NEUROIMAGE-CLINICAL 2014; 6:126-33. [PMID: 25379424 PMCID: PMC4215516 DOI: 10.1016/j.nicl.2014.08.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 07/31/2014] [Accepted: 08/16/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Arterial spin labeling (ASL) perfusion-weighted imaging (PWI) by magnetic resonance imaging (MRI) has been shown to be useful for identifying asphyxiated newborns at risk of developing brain injury, whether or not therapeutic hypothermia was administered. However, this technique has been only rarely used in newborns until now, because of the challenges to obtain sufficient signal-to-noise ratio (SNR) and spatial resolution in newborns. OBJECTIVE To compare two methods of ASL-PWI (i.e., single inversion-time pulsed arterial spin labeling [single TI PASL], and pseudo-continuous arterial spin labeling [pCASL]) to assess brain perfusion in asphyxiated newborns treated with therapeutic hypothermia and in healthy newborns. DESIGN/METHODS We conducted a prospective cohort study of term asphyxiated newborns meeting the criteria for therapeutic hypothermia; four additional healthy term newborns were also included as controls. Each of the enrolled newborns was scanned at least once during the first month of life. Each MRI scan included conventional anatomical imaging, as well as PASL and pCASL PWI-MRI. Control and labeled images were registered separately to reduce the effect of motion artifacts. For each scan, the axial slice at the level of the basal ganglia was used for comparisons. Each scan was scored for its image quality. Quantification of whole-slice cerebral blood flow (CBF) was done afterwards using previously described formulas. RESULTS A total number of 61 concomitant PASL and pCASL scans were obtained in nineteen asphyxiated newborns treated with therapeutic hypothermia and four healthy newborns. After discarding the scans with very poor image quality, 75% (46/61) remained for comparison between the two ASL methods. pCASL images presented a significantly superior image quality score compared to PASL images (p < 0.0001). Strong correlation was found between the CBF measured by PASL and pCASL (r = 0.61, p < 0.0001). CONCLUSION This study demonstrates that both ASL methods are feasible to assess brain perfusion in healthy and sick newborns. However, pCASL might be a better choice over PASL in newborns, as pCASL perfusion maps had a superior image quality that allowed a more detailed identification of the different brain structures.
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Affiliation(s)
- Elodie Boudes
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | | | | | - Xianming Tan
- Center for Innovative Medicine, Research Institute, McGill University Health Centre, Montreal, Canada
| | - G Bruce Pike
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada ; Department of Radiology, University of Calgary, Calgary, Canada
| | - Christine Saint-Martin
- Department of Radiology, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
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Successful hypothermia treatment of hypoxic-ischemic encephalopathy in a neonate with epidermolysis bullosa. Indian J Pediatr 2014; 81:803-4. [PMID: 23934101 DOI: 10.1007/s12098-013-1182-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 07/10/2013] [Indexed: 10/26/2022]
Abstract
Despite advances in the neonatal care, hypoxic ischemic encephalopathy in late preterm and term infants remains an important cause of morbidity and mortality. There is lack of data on the application of therapeutic hypothermia in the existence of severe skin lesions. Epidermolysis bullosa is a rare group of inherited conditions which causes blisters in skin and mucosal membranes. In this report, the authors describe a successful whole-body hypothermia treatment of severe hypoxic ischemic encephalopathy in a term newborn with dystrophic epidermolysis bullosa. They observed that therapeutic hypothermia may also be given in newborns with dystrophic epidermolysis bullosa without any complications.
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Arango JI, Allred K, Adelson PD, Soni P, Stradleigh R, Wahnoun R, Carballo C. Hypothermia in hypoxic ischemic encephalopathy: a 5-year experience at Phoenix Children's Hospital Neuro NICU. Adv Pediatr 2014; 61:215-23. [PMID: 25037129 DOI: 10.1016/j.yapd.2014.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We found TH to be safe and effective in improving survival and neurodevelopmental outcomes following HIE in term children. Additionally, the use of a multidisciplinary team involved with these complex patients and the use of advanced monitoring techniques will likely assist in identifying second insults (ie, seizures), leading to more rapidly instituted treatments. Our study, however, had the limitation of including only retrospective data from patients in whom TH was provided. This makes it difficult to identify the specific sources for the improved outcomes and/or the presence of complications.
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Affiliation(s)
- Jorge I Arango
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - Kimberlee Allred
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - P David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - Parita Soni
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - Ryan Stradleigh
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - Remy Wahnoun
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - Cristina Carballo
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA.
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Zhang M, Wang H, Zhao J, Chen C, Leak RK, Xu Y, Vosler P, Chen J, Gao Y, Zhang F. Drug-induced hypothermia in stroke models: does it always protect? CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2014; 12:371-80. [PMID: 23469851 DOI: 10.2174/1871527311312030010] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 11/06/2012] [Accepted: 11/11/2012] [Indexed: 12/19/2022]
Abstract
Ischemic stroke is a common neurological disorder lacking a cure. Recent studies show that therapeutic hypothermia is a promising neuroprotective strategy against ischemic brain injury. Several methods to induce therapeutic hypothermia have been established; however, most of them are not clinically feasible for stroke patients. Therefore, pharmacological cooling is drawing increasing attention as a neuroprotective alternative worthy of further clinical development. We begin this review with a brief introduction to the commonly used methods for inducing hypothermia; we then focus on the hypothermic effects of eight classes of hypothermia-inducing drugs: the cannabinoids, opioid receptor activators, transient receptor potential vanilloid, neurotensins, thyroxine derivatives, dopamine receptor activators, hypothermia-inducing gases, adenosine, and adenine nucleotides. Their neuroprotective effects as well as the complications associated with their use are both considered. This article provides guidance for future clinical trials and animal studies on pharmacological cooling in the setting of acute stroke.
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Affiliation(s)
- Meijuan Zhang
- Department of Neurology, University of Pittsburgh School of Medicine, 3500 Terrace Street, Pittsburgh, PA 15213, USA
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