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Laptook AR, Shankaran S, Faix RG. Hypothermia for Hypoxic-ischemic Encephalopathy: Second-generation Trials to Address Gaps in Knowledge. Clin Perinatol 2024; 51:587-603. [PMID: 39095098 PMCID: PMC11298012 DOI: 10.1016/j.clp.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Multiple randomized controlled trials of hypothermia for moderate or severe neonatal hypoxic-ischemic encephalopathy (HIE) have uniformly demonstrated a reduction in death or disability at early childhood evaluation. These initial trials along with other smaller studies established hypothermia as a standard of care in the neonatal community for moderate or severe HIE. The results of the initial trials have identified gaps in knowledge. This article describes 3 randomized controlled trials of hypothermia (second-generation trials) to address refinement of hypothermia therapy (longer and/or deeper cooling), late initiation of hypothermia (after 6 hours following birth), and use of hypothermia in preterm newborns.
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Affiliation(s)
- Abbot R Laptook
- Department of Pediatrics, Warren Alpert School of Medicine, Women and Infants Hospital of Rhode Island, 101 Dudley Street, Providence, RI 02905, USA.
| | - Seetha Shankaran
- Department of Pediatrics, University of Texas at Austin and Dell Medical School, Wayne State University, 15601 Madriena Way, Austin, TX 78738, USA
| | - Roger G Faix
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, USA
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2
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Gonzalez FF, Voldal E, Comstock BA, Mayock DE, Goodman AM, Cornet MC, Wu TW, Redline RW, Heagerty P, Juul SE, Wu YW. Placental Histologic Abnormalities and 2-Year Outcomes in Neonatal Hypoxic-Ischemic Encephalopathy. Neonatology 2023; 120:760-767. [PMID: 37742617 PMCID: PMC10711751 DOI: 10.1159/000533652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/12/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE We aimed to examine the association between placental abnormalities and neurodevelopmental outcomes in a multicenter cohort of newborn infants with hypoxic-ischemic encephalopathy (HIE) that underwent therapeutic hypothermia. We hypothesized that subjects with acute placental abnormalities would have reduced risk of death or neurodevelopmental impairment (NDI) at 2 years of age after undergoing therapeutic hypothermia compared to subjects without acute placental changes. STUDY DESIGN Among 500 subjects born at ≥36 weeks gestation with moderate or severe HIE enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) Trial, a placental pathologist blinded to clinical information reviewed clinical pathology reports to determine the presence of acute only, chronic only, or both acute and chronic histologic abnormalities. We calculated adjusted relative risks (aRRs) for associations between placental pathologic abnormalities and death or NDI at age 2 years, adjusting for HIE severity, treatment assignment, and site. RESULT 321/500 subjects (64%) had available placental pathology reports. Placental abnormalities were characterized as acute only (20%), chronic only (21%), both acute and chronic (43%), and none (15%). The risk of death or NDI was not statistically different between subjects with and without an acute placental abnormality (46 vs. 53%, aRR 1.1, 95% confidence interval (CI): 0.9, 1.4). Subjects with two or more chronic lesions were more likely to have an adverse outcome than subjects with no chronic abnormalities, though this did not reach statistical significance (55 vs. 45%, aRR 1.24, 95% CI: 0.99, 1.56). CONCLUSION Placental pathologic findings were not independently associated with risk of death or NDI in subjects with HIE. The relationship between multiple chronic placental lesions and HIE outcomes deserves further study.
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Affiliation(s)
- Fernando F. Gonzalez
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Emily Voldal
- Department Biostatistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Bryan A. Comstock
- Department Biostatistics, University of Washington, Seattle, WA, USA
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Amy M. Goodman
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA
| | - Marie-Coralie Cornet
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Tai-Wei Wu
- Division of Neonatology, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Raymond W. Redline
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Patrick Heagerty
- Department Biostatistics, University of Washington, Seattle, WA, USA
| | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Yvonne W. Wu
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA
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Girolamo F, Lim YP, Virgintino D, Stonestreet BS, Chen XF. Inter-Alpha Inhibitor Proteins Modify the Microvasculature after Exposure to Hypoxia-Ischemia and Hypoxia in Neonatal Rats. Int J Mol Sci 2023; 24:6743. [PMID: 37047713 PMCID: PMC10094872 DOI: 10.3390/ijms24076743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/21/2023] [Accepted: 03/29/2023] [Indexed: 04/08/2023] Open
Abstract
Microvasculature develops during early brain development. Hypoxia-ischemia (HI) and hypoxia (H) predispose to brain injury in neonates. Inter-alpha inhibitor proteins (IAIPs) attenuate injury to the neonatal brain after exposure to HI. However, the effects of IAIPs on the brain microvasculature after exposure to HI have not been examined in neonates. Postnatal day-7 rats were exposed to sham treatment or right carotid artery ligation and 8% oxygen for 90 min. HI comprises hypoxia (H) and ischemia to the right hemisphere (HI-right) and hypoxia to the whole body, including the left hemisphere (H-left). Human IAIPs (hIAIPs, 30 mg/kg) or placebo were injected immediately, 24 and 48 h after HI/H. The brains were analyzed 72 h after HI/H to determine the effects of hIAIPs on the microvasculature by laminin immunohistochemistry and calculation of (1) the percentage area stained by laminin, (2) cumulative microvessel length, and (3) density of tunneling nanotubes (TNTs), which are sensitive indicators of the earliest phases of neo-vascularization/collateralization. hIAIPs mainly affected the percent of the laminin-stained area after HI/H, cumulative vessel length after H but not HI, and TNT density in females but not males. hIAIPs modify the effects of HI/H on the microvasculature after brain injury in neonatal rats and exhibit sex-related differential effects. Our findings suggest that treatment with hIAIPs after exposure to H and HI in neonatal rats affects the laminin content of the vessel basal lamina and angiogenic responses in a sex-related fashion.
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Affiliation(s)
- Francesco Girolamo
- Department of Translational Biomedicines and Neuroscience (DiBraiN), University of Bari School of Medicine, 70124 Bari, Italy
| | - Yow-Pin Lim
- ProThera Biologics, Inc., Providence, RI 02905, USA
- Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, Providence, RI 02905, USA
| | - Daniela Virgintino
- Department of Translational Biomedicines and Neuroscience (DiBraiN), University of Bari School of Medicine, 70124 Bari, Italy
| | - Barbara S. Stonestreet
- Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI 02905, USA
| | - Xiaodi F. Chen
- Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI 02905, USA
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Bäcke P, Bruschettini M, Blomqvist YT, Sibrecht G, Olsson E. Interventions for the Management of Pain and Sedation in Newborns Undergoing Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy: A Systematic Review. Paediatr Drugs 2023; 25:27-41. [PMID: 36481984 PMCID: PMC9810674 DOI: 10.1007/s40272-022-00546-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Newborn infants undergoing therapeutic hypothermia (TH) are exposed to multiple painful and stressful procedures. The aim of this systematic review was to assess benefits and harms of pharmacological and non-pharmacological interventions for the management of pain and sedation in newborn infants undergoing TH for hypoxic-ischemic encephalopathy. METHODS We included randomized and observational studies reporting any intervention (either drugs or non-pharmacological interventions) to manage pain and sedation in newborn infants (> 33 weeks' gestational age) undergoing TH. We included any dose, duration and route of administration. We also included any type and duration of non-pharmacological interventions. Our prespecified primary outcomes were analgesia and sedation assessed using validated pain scales in the neonatal population; circulatory instability; mortality to discharge; and neurodevelopmental disability. A systematic literature search was conducted in the PubMed, Embase, CINAHL, Cochrane CENTRAL, Scopus, and Web of Science databases, with no language restrictions. Included studies underwent risk-of-bias assessment (Cochrane risk-of-bias tool and ROBINS-I) and data extraction performed by two authors independently. The plan had been to use effect measures such as mean difference for continuous outcomes and risk ratio for dichotomous outcomes, however the included studies are presented in a narrative synthesis due to their paucity and heterogeneity. RESULTS Ten studies involving 3551 infants were included-one trial and nine observational studies. Most studies examined the use of phenobarbital or other antiepileptic drugs with primary outcomes related to seizure activity. The single trial that was included compared pentoxifylline with placebo. Among the primary outcomes, six studies reported circulatory instability and five reported mortality to discharge without relevant differences; two studies reported on neurodevelopmental disability and one study reported on pain scale. Three studies were ongoing. CONCLUSIONS We found limited evidence to establish the benefits and harms of the interventions for the management of pain and sedation in newborn infants undergoing TH. Long-term outcomes were not reported. Given the very low certainty of evidence-due to imprecision of the estimates, inconsistency and limitations in study design (all nine observational studies with overall serious risk of bias)-for all outcomes, clinical trials are required to determine the most effective interventions in this population. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42020205755.
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Affiliation(s)
- Pyrola Bäcke
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Matteo Bruschettini
- Department of Pediatrics, Lund University, Lund, Sweden
- Cochrane Sweden; Research and Education, Skåne University Hospital, Lund, Sweden
| | - Ylva Thernström Blomqvist
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Greta Sibrecht
- Newborns' Infectious Diseases Department, Poznan University of Medical Sciences, Poznan, Poland
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, S-701 82, Örebro, Sweden.
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Chen X, Malaeb SN, Pan J, Wang L, Scafidi J. Editorial: Perinatal hypoxic-ischemic brain injury: Mechanisms, pathogenesis, and potential therapeutic strategies. Front Cell Neurosci 2022; 16:1086692. [PMID: 36582212 PMCID: PMC9793000 DOI: 10.3389/fncel.2022.1086692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/16/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Xiaodi Chen
- Women and Infants Hospital of RI, Alpert Medical School of Brown University, Providence, RI, United States
| | | | - Jonathan Pan
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
| | - Laishuan Wang
- Children's Hospital, Fudan University, Shanghai, China
| | - Joseph Scafidi
- Department of Neurology and Pediatrics, Kennedy Krieger Institute, Johns Hopkins School of Medicine, Baltimore, MD, United States
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6
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Bäcke P, Bruschettini M, Blomqvist YT, Olsson E. Interventions for the management of Pain and Sedation in Newborns undergoing Therapeutic hypothermia for hypoxic-ischemic encephalopathy (IPSNUT): protocol of a systematic review. Syst Rev 2022; 11:101. [PMID: 35606836 PMCID: PMC9128112 DOI: 10.1186/s13643-022-01982-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical research has shown that therapeutic hypothermia after neonatal hypoxic-ischemic injury improves survival without disability. There is no consensus regarding pain relief or sedation during therapeutic hypothermia in newborns; however, therapeutic hypothermia seems to be associated with pain and stress, and adequate analgesia and sedation are central to maximize the effect of therapeutic hypothermia. Pain needs to be adequately managed in all patients, especially the newborn infant due to the potential short- and long-term negative effects of inadequately treated pain in this population. METHODS We will perform a systematic review of pharmacological and non-pharmacological interventions for the management of pain and sedation in newborn infants undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy. We will include randomized, quasi-randomized controlled trials and observational studies. The use of pharmacological or non-pharmacological interventions will be compared to other pharmacological and or non-pharmacological interventions or no intervention/placebo. The primary outcomes for this review will be analgesia and sedation assessed with validated pain scales, circulatory instability, mortality to discharge, and moderate-to-severe neurodevelopmental disability. We will search the following databases: CINAHL, ClinicalTrials.gov , Cochrane Library, Embase, PubMed, Scopus, and Web of Science. Two independent researchers will screen the records for inclusion, extract data using a data extraction form, and assess the risk of bias in the included trials. DISCUSSION The result of this review will summarize the knowledge regarding the management of pain and sedation in infants treated with therapeutic hypothermia and potentially provide clinicians with guidance on the effective and safe methods. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020205755.
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Affiliation(s)
- Pyrola Bäcke
- University Hospital, Neonatal Intensive Care Unit, Uppsala, Sweden.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Matteo Bruschettini
- Department of Pediatrics, Lund University, Lund, Sweden.,Cochrane Sweden, Research and Development, Skåne University Hospital, Lund, Sweden
| | - Ylva Thernström Blomqvist
- University Hospital, Neonatal Intensive Care Unit, Uppsala, Sweden.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden. .,Faculty of Medicine and Health, School of Health Sciences, Örebro University, 701 82, Örebro, Sweden.
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7
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Chalak L. New Horizons in Mild Hypoxic-ischemic Encephalopathy: A Standardized Algorithm to Move past Conundrum of Care. Clin Perinatol 2022; 49:279-294. [PMID: 35210007 DOI: 10.1016/j.clp.2021.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hypoxic-ischemic encephalopathy (HIE) presents clinically with a neonatal encephalopathy (NE) whereby the mild spectrum is difficult to classify immediately after birth. For decades trials have focused exclusively on infants with moderate-severe HIE s, as these infants were easier to identify after birth and had the highest risk of adverse outcomes. Twenty years after those trials, the PRIME study finally solved the first part of the conundrum by providing a definition of mild HIE in the first 6 hours. There is strong biological plausibility and preclinical evidence supporting the efficacy of therapeutic hypothermia (TH) but there is a lack of comparative clinical data to establish the risk-benefit in mild HIE. The fundamental question of how best to manage mild HIE remains unanswered. This review will summarize (1) the evidence that neonates with mild HIE are at significant risk for adverse outcomes, (2) the gaps/controversies in management, and (3) an algorithm of care is proposed to ensure standardized management of mild HIE and the direction of future trials.
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Affiliation(s)
- Lina Chalak
- Neonatal-Perinatal Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA.
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8
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Chen X, Zhang J, Wu Y, Tucker R, Baird GL, Domonoske R, Barrios-Anderson A, Lim YP, Bath K, Walsh EG, Stonestreet BS. Inter-alpha Inhibitor Proteins Ameliorate Brain Injury and Improve Behavioral Outcomes in a Sex-Dependent Manner After Exposure to Neonatal Hypoxia Ischemia in Newborn and Young Adult Rats. Neurotherapeutics 2022; 19:528-549. [PMID: 35290609 PMCID: PMC9226254 DOI: 10.1007/s13311-022-01217-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 12/16/2022] Open
Abstract
Hypoxic-ischemic (HI) brain injury is a major contributor to neurodevelopmental morbidities. Inter-alpha inhibitor proteins (IAIPs) have neuroprotective effects on HI-related brain injury in neonatal rats. However, the effects of treatment with IAIPs on sequential behavioral, MRI, and histopathological abnormalities in the young adult brain after treatment with IAIPs in neonates remain to be determined. The objective of this study was to examine the neuroprotective effects of IAIPs at different neurodevelopmental stages from newborn to young adults after exposure of neonates to HI injury. IAIPs were given as 11-sequential 30-mg/kg doses to postnatal (P) day 7-21 rats after right common carotid artery ligation and exposure to 90 min of 8% oxygen. The resulting brain edema and injury were examined by T2-weighted magnetic resonance imaging (MRI) and cresyl violet staining, respectively. The mean T2 values of the ipsilateral hemisphere from MRI slices 6 to 10 were reduced in IAIP-treated HI males + females on P8, P9, and P10 and females on P8, P9, P10, and P14. IAIP treatment reduced hemispheric volume atrophy by 44.5 ± 29.7% in adult male + female P42 rats and improved general locomotor abilities measured by the righting reflex over time at P7.5, P8, and P9 in males + females and males and muscle strength/endurance measured by wire hang on P16 in males + females and females. IAIPs provided beneficial effects during the learning phase of the Morris water maze with females exhibiting beneficial effects. IAIPs confer neuroprotection from HI-related brain injury in neonates and even in adult rats and beneficial MRI and behavioral benefits in a sex-dependent manner.
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Affiliation(s)
- Xiaodi Chen
- Department of Pediatrics, Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Women &101 Dudley Street, Providence, RI, 02905-2499, USA
| | - Jiyong Zhang
- Department of Pediatrics, Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Women &101 Dudley Street, Providence, RI, 02905-2499, USA
| | - Yuqi Wu
- Department of Pediatrics, Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Women &101 Dudley Street, Providence, RI, 02905-2499, USA
| | - Richard Tucker
- Department of Pediatrics, Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Women &101 Dudley Street, Providence, RI, 02905-2499, USA
| | - Grayson L Baird
- Department of Diagnostic Imaging, Biostatistics Core Lifespan Hospital System, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Rose Domonoske
- Department of Pediatrics, Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Women &101 Dudley Street, Providence, RI, 02905-2499, USA
| | - Adriel Barrios-Anderson
- Department of Pediatrics, Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Women &101 Dudley Street, Providence, RI, 02905-2499, USA
| | - Yow-Pin Lim
- ProThera Biologics, Inc, Providence, RI, USA
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Kevin Bath
- Division of Developmental Neuroscience, New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University Irving Medical College, New York, NY, USA
| | - Edward G Walsh
- Department of Neuroscience, Brown University, Providence, RI, USA
| | - Barbara S Stonestreet
- Department of Pediatrics, Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Women &101 Dudley Street, Providence, RI, 02905-2499, USA.
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9
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Chalak LF, Pappas A, Tan S, Das A, Sánchez PJ, Laptook AR, Van Meurs KP, Shankaran S, Bell EF, Davis AS, Heyne RJ, Pedroza C, Poindexter BB, Schibler K, Tyson JE, Ball MB, Bara R, Grisby C, Sokol GM, D’Angio CT, Hamrick SEG, Dysart KC, Cotten CM, Truog WE, Watterberg KL, Timan CJ, Garg M, Carlo WA, Higgins RD. Association Between Increased Seizures During Rewarming After Hypothermia for Neonatal Hypoxic Ischemic Encephalopathy and Abnormal Neurodevelopmental Outcomes at 2-Year Follow-up: A Nested Multisite Cohort Study. JAMA Neurol 2021; 78:1484-1493. [PMID: 34882200 PMCID: PMC8524352 DOI: 10.1001/jamaneurol.2021.3723] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/17/2021] [Indexed: 01/19/2023]
Abstract
Importance Compared with normothermia, hypothermia has been shown to reduce death or disability in neonatal hypoxic ischemic encephalopathy but data on seizures during rewarming and associated outcomes are scarce. Objective To determine whether electrographic seizures are more likely to occur during rewarming compared with the preceding period and whether they are associated with abnormal outcomes in asphyxiated neonates receiving hypothermia therapy. Design, Setting, and Participants This prespecified nested cohort study of infants enrolled in the Optimizing Cooling (OC) multicenter Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network trial from December 2011 to December 2013 with 2 years' follow-up randomized infants to either 72 hours of cooling (group A) or 120 hours (group B). The main trial included 364 infants. Of these, 194 were screened, 10 declined consent, and 120 met all predefined inclusion criteria. A total of 112 (90%) had complete data for death or disability. Data were analyzed from January 2018 to January 2020. Interventions Serial amplitude electroencephalography recordings were compared in the 12 hours prior and 12 hours during rewarming for evidence of electrographic seizure activity by 2 central amplitude-integrated electroencephalography readers blinded to treatment arm and rewarming epoch. Odds ratios and 95% CIs were evaluated following adjustment for center, prior seizures, depth of cooling, and encephalopathy severity. Main Outcomes and Measures The primary outcome was the occurrence of electrographic seizures during rewarming initiated at 72 or 120 hours compared with the preceding 12-hour epoch. Secondary outcomes included death or moderate or severe disability at age 18 to 22 months. The hypothesis was that seizures during rewarming were associated with higher odds of abnormal neurodevelopmental outcomes. Results A total of 120 newborns (70 male [58%]) were enrolled (66 in group A and 54 in group B). The mean (SD) gestational age was 39 (1) weeks. There was excellent interrater agreement (κ, 0.99) in detection of seizures. More infants had electrographic seizures during the rewarming epoch compared with the preceding epoch (group A, 27% vs 14%; P = .001; group B, 21% vs 10%; P = .03). Adjusted odd ratios (95% CIs) for seizure frequency during rewarming were 2.7 (1.0-7.5) for group A and 3.2 (0.9-11.6) for group B. The composite death or moderate to severe disability outcome at 2 years was significantly higher in infants with electrographic seizures during rewarming (relative risk [95% CI], 1.7 [1.25-2.37]) after adjusting for baseline clinical encephalopathy and seizures as well as center. Conclusions and Relevance Findings that higher odds of electrographic seizures during rewarming are associated with death or disability at 2 years highlight the necessity of electroencephalography monitoring during rewarming in infants at risk. Trial Registration ClinicalTrials.gov Identifier: NCT01192776.
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Affiliation(s)
- Lina F. Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Sylvia Tan
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Pablo J. Sánchez
- Department of Pediatrics, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | | | - Alexis S. Davis
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Roy J. Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Claudia Pedroza
- Department of Pediatrics, University of Texas Medical School at Houston, Houston
| | - Brenda B. Poindexter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
- Emory University Hospital Midtown, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Kurt Schibler
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jon E. Tyson
- Department of Pediatrics, University of Texas Medical School at Houston, Houston
| | - M. Bethany Ball
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Rebecca Bara
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Cathy Grisby
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Carl T. D’Angio
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Shannon E. G. Hamrick
- Emory University Hospital Midtown, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Kevin C. Dysart
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | | | - William E. Truog
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | | | - Christopher J. Timan
- Department of Pediatrics, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus
| | - Meena Garg
- Department of Pediatrics, University of California, Los Angeles
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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10
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Chalak L, Redline RW, Goodman AM, Juul SE, Chang T, Yanowitz TD, Maitre N, Mayock DE, Lampland AL, Bendel-Stenzel E, Riley D, Mathur AM, Rao R, Van Meurs KP, Wu TW, Gonzalez FF, Flibotte J, Mietzsch U, Sokol GM, Ahmad KA, Baserga M, Weitkamp JH, Poindexter BB, Comstock BA, Wu YW. Acute and Chronic Placental Abnormalities in a Multicenter Cohort of Newborn Infants with Hypoxic-Ischemic Encephalopathy. J Pediatr 2021; 237:190-196. [PMID: 34144032 DOI: 10.1016/j.jpeds.2021.06.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/28/2021] [Accepted: 06/14/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To examine the frequency of placental abnormalities in a multicenter cohort of newborn infants with hypoxic-ischemic encephalopathy (HIE) and to determine the association between acuity of placental abnormalities and clinical characteristics of HIE. STUDY DESIGN Infants born at ≥36 weeks of gestation (n = 500) with moderate or severe HIE were enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy Trial. A placental pathologist blinded to clinical information reviewed clinical pathology reports to determine the presence of acute and chronic placental abnormalities using a standard classification system. RESULTS Complete placental pathologic examination was available for 321 of 500 (64%) trial participants. Placental abnormalities were identified in 273 of 321 (85%) and were more common in infants ≥40 weeks of gestation (93% vs 81%, P = .01). A combination of acute and chronic placental abnormalities (43%) was more common than either acute (20%) or chronic (21%) abnormalities alone. Acute abnormalities included meconium staining of the placenta (41%) and histologic chorioamnionitis (39%). Chronic abnormalities included maternal vascular malperfusion (25%), villitis of unknown etiology (8%), and fetal vascular malperfusion (6%). Infants with chronic placental abnormalities exhibited a greater mean base deficit at birth (-15.9 vs -14.3, P = .049) than those without such abnormalities. Patients with HIE and acute placental lesions had older mean gestational ages (39.1 vs 38.0, P < .001) and greater rates of clinically diagnosed chorioamnionitis (25% vs 2%, P < .001) than those without acute abnormalities. CONCLUSIONS Combined acute and chronic placental abnormalities were common in this cohort of infants with HIE, underscoring the complex causal pathways of HIE. TRIAL REGISTRATION ClinicalTrials.gov: NCT02811263.
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Affiliation(s)
- Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Raymond W Redline
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Amy M Goodman
- Department of Neurology, University of California San Francisco, San Francisco, CA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington School of Medicine, Washington, DC
| | - Toby D Yanowitz
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC and Magee Womens Hospital of UPMC, Pittsburgh, PA
| | - Nathalie Maitre
- Department of Pediatrics and Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | | | - Ellen Bendel-Stenzel
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - David Riley
- Department of Pediatrics, Cook Children's Medical Center, Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, TX
| | - Amit M Mathur
- Department of Pediatrics/Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St Louis, MO
| | - Rakesh Rao
- Division of Newborn-Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, MO
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Tai-Wei Wu
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Fernando F Gonzalez
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Gregory M Sokol
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Brenda B Poindexter
- Division of Neonatology, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, CA
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11
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Kota S, Jasti K, Liu Y, Liu H, Zhang R, Chalak L. EEG Spectral Power: A Proposed Physiological Biomarker to Classify the Hypoxic-Ischemic Encephalopathy Severity in Real Time. Pediatr Neurol 2021; 122:7-14. [PMID: 34243047 DOI: 10.1016/j.pediatrneurol.2021.06.001] [Citation(s) in RCA: 3] [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] [Received: 12/04/2020] [Revised: 04/16/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mild hypoxic-ischemic encephalopathy (HIE) constitutes a large unstudied population with considerable debate on how to define and treat due to the dynamic evolution of the clinical signs of encephalopathy. We propose to address this gap with quantitative physiological biomarkers to aid in stratification of the disease severity. The objectives of this prospective cohort study were to measure the electroencephalographic (EEG) power as an objective biomarker of the evolution of the clinical encephalopathy in newborns with mild to severe HIE. METHODS EEG was collected in infants with HIE using four bipolar electrodes analyzed for the first three hours of the recording. Delta power (DP, 0.5 to 4 Hz) and total power (TP, 0.5 to 20 Hz) were compared between groups with different HIE severity using a univariate ordinal logistic regression model and receiver operating characteristic curves. RESULTS A total of 44 term-born infants with mild to severe HIE were identified within six hours of birth. The DP and TP values were significantly higher for the mild group than for the moderate group for all bipolar electrodes. A one-unit increase in DP was associated with significantly lower odds of encephalopathy. DP best distinguished mild from higher encephalopathy grades by area under the curve. CONCLUSIONS We conclude that DP and TP are sensitive real-time biomarkers for monitoring the dynamic evolution of the encephalopathy severity in the first day of life. The quantitative EEG power may lead to timely recognition of the worsening of the encephalopathy and guide future therapeutic interventions targeting mild HIE.
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Affiliation(s)
- Srinivas Kota
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kaushik Jasti
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yulun Liu
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hanli Liu
- Department of Bioengineering, University of Texas at Arlington, Arlington, Texas
| | - Rong Zhang
- Departments of Neurology and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.
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12
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Blood biomarkers for neonatal hypoxic-ischemic encephalopathy in the presence and absence of sentinel events. J Perinatol 2021; 41:1322-1330. [PMID: 33024259 PMCID: PMC8021592 DOI: 10.1038/s41372-020-00850-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/01/2020] [Accepted: 09/24/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine if neonatal serum biomarkers representing different pathways of injury differ for cases of HIE of unknown cause to gain insight into timing and mechanism of injury. STUDY DESIGN In this cohort of all neonates with HIE admitted to our NICU, newborns with sentinel events were compared to those without during the 1st 3 days of life. Discard neonatal blood during the 1st 3 days of life was used for analysis. RESULTS Of 277 babies with HIE treated with whole-body hypothermia, 190 (68.6%) had blood available for biomarker analysis. In total, 71 (37.4%) were born within our system, and 119 (62.6%) were transferred in from outside hospitals. Of these babies, 77 (40.5%) had a sentinel event and 113 (59.6%) had no sentinel event. Although the degree of metabolic acidosis was similar, repeated measures analysis showed that during the initial 3 days of life neonates born with HIE in the absence of sentinel events had 41.4% decreased VEGF (p = 0.027) and 62.5% increased IL-10 serum concentrations (p = 0.005). CONCLUSION These changes indicate that neonatal HIE in the absence of sentinel events is not related to an unrecognized acute intrapartum event and is possibly related to chronic hypoxia of lower severity or recovery from a remote event.
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Koehn LM, Chen X, Logsdon AF, Lim YP, Stonestreet BS. Novel Neuroprotective Agents to Treat Neonatal Hypoxic-Ischemic Encephalopathy: Inter-Alpha Inhibitor Proteins. Int J Mol Sci 2020; 21:E9193. [PMID: 33276548 PMCID: PMC7731124 DOI: 10.3390/ijms21239193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 02/02/2023] Open
Abstract
Perinatal hypoxia-ischemia (HI) is a major cause of brain injury and mortality in neonates. Hypoxic-ischemic encephalopathy (HIE) predisposes infants to long-term cognitive deficits that influence their quality of life and place a large burden on society. The only approved treatment to protect the brain after HI is therapeutic hypothermia, which has limited effectiveness, a narrow therapeutic time window, and is not considered safe for treatment of premature infants. Alternative or adjunctive therapies are needed to improve outcomes of full-term and premature infants after exposure to HI. Inter-alpha inhibitor proteins (IAIPs) are immunomodulatory molecules that are proposed to limit the progression of neonatal inflammatory conditions, such as sepsis. Inflammation exacerbates neonatal HIE and suggests that IAIPs could attenuate HI-related brain injury and improve cognitive outcomes associated with HIE. Recent studies have shown that intraperitoneal treatment with IAIPs can decrease neuronal and non-neuronal cell death, attenuate glial responses and leukocyte invasion, and provide long-term behavioral benefits in neonatal rat models of HI-related brain injury. The present review summarizes these findings and outlines the remaining experimental analyses necessary to determine the clinical applicability of this promising neuroprotective treatment for neonatal HI-related brain injury.
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Affiliation(s)
- Liam M. Koehn
- Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, RI 02905, USA; (L.M.K.); (X.C.)
| | - Xiaodi Chen
- Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, RI 02905, USA; (L.M.K.); (X.C.)
| | - Aric F. Logsdon
- Geriatrics Research Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA;
- Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Yow-Pin Lim
- ProThera Biologics, Inc., Providence, RI 02903, USA;
- Department of Pathology and Laboratory Medicine, The Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Barbara S. Stonestreet
- Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, RI 02905, USA; (L.M.K.); (X.C.)
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14
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Fang JL, Mara KC, Weaver AL, Clark RH, Carey WA. Outcomes of outborn extremely preterm neonates admitted to a NICU with respiratory distress. Arch Dis Child Fetal Neonatal Ed 2020; 105:33-40. [PMID: 31079068 DOI: 10.1136/archdischild-2018-316244] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 04/04/2019] [Accepted: 04/07/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the risk of mortality and morbidity between outborn and propensity score-matched inborn extremely preterm neonates. SETTING Multiple neonatal intensive care units (NICU) across the USA. PATIENTS Singleton neonates born at 22-29 weeks' gestation with no major anomalies who were admitted to a NICU and discharged between 2000 and 2014. Outborn neonates were restricted to those who transferred into a NICU on the day of birth. METHODS The association between inborn-outborn status and the time-to-event outcomes of in-hospital mortality and necrotising enterocolitis (NEC) were assessed using Cox proportional hazards regression. Logistic regression was used to assess the remaining secondary outcomes: retinopathy of prematurity requiring treatment (tROP), chronic lung disease (CLD), periventricular leucomalacia (PVL) and severe intraventricular haemorrhage (IVH). Since outborn status was not random, we used 1:1 propensity score matching to reduce the imbalance in illness severity. RESULTS There were 59 942 neonates (7991 outborn) included in the study. Outborn neonates had poorer survival than inborns and higher rates of NEC, severe IVH, tROP and PVL. Inborn-outborn disparities in mortality were reduced over the study period. When analysing the matched cohort (6524 matched pairs), outborns were less likely to die in-hospital compared with inborns (HR 0.84, 95% CI 0.77 to 0.91). However, outborns experienced higher rates of NEC (HR 1.14, 95% CI 1.04 to 1.25), severe IVH (OR 1.52, 95% CI 1.38 to 1.68), tROP (OR 1.45, 95% CI 1.25 to 1.69) and CLD (OR 1.12, 95% CI 1.01 to 1.24). CONCLUSION Additional research is needed to understand the contributors to increased morbidity for outborn extremely preterm neonates and identify interventions that mitigate this risk.
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Affiliation(s)
- Jennifer L Fang
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Reese H Clark
- CREQS, Pediatrix Medical Group, Sunrise, Florida, USA
| | - William A Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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15
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O'Neill R, Dempsey EM, Garvey AA, Schwarz CE. Non-invasive Cardiac Output Monitoring in Neonates. Front Pediatr 2020; 8:614585. [PMID: 33585366 PMCID: PMC7880199 DOI: 10.3389/fped.2020.614585] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022] Open
Abstract
Circulatory monitoring is currently limited to heart rate and blood pressure assessment in the majority of neonatal units globally. Non-invasive cardiac output monitoring (NiCO) in term and preterm neonates is increasing, where it has the potential to enhance our understanding and management of overall circulatory status. In this narrative review, we summarized 33 studies including almost 2,000 term and preterm neonates. The majority of studies evaluated interchangeability with echocardiography. Studies were performed in various clinical settings including the delivery room, patent ductus arteriosus assessment, patient positioning, red blood cell transfusion, and therapeutic hypothermia for hypoxic ischemic encephalopathy. This review presents an overview of NiCO in neonatal care, focusing on technical and practical aspects as well as current available evidence. We discuss potential goals for future research.
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Affiliation(s)
- Roisin O'Neill
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Aisling A Garvey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Christoph E Schwarz
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland.,Department of Neonatology, University Children's Hospital, Tübingen, Germany
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16
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Eroğlu O, Deniz T, Kisa Ü, Atasoy P, Aydinuraz K. Effect of hypothermia on apoptosis in traumatic brain injury and hemorrhagic shock model. Injury 2017; 48:2675-2682. [PMID: 29061477 DOI: 10.1016/j.injury.2017.09.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 09/28/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The neuroprotective mechanisms of therapeutic hypothermia against trauma-related injury have not been fully understood yet. In this study, we aimed to investigate the effects of therapeutic hypothermia on biochemical and histopathological markers of apoptosis using Traumatic brain injury (TBI) and hemorrhagic shock (HS) model. METHODS A total of 50 male albino-wistar rats were divided into five groups: Group isolated TBI, Group NT (HT+HS+normothermia), Group MH (HT+HS+mild hypothermia), Group MoH (HT+HS+moderate hypothermia) and Group C (control). Neurological deficit scores were assessed at baseline and at 24h. The rats were, then, sacrificed to collect serum and brain tissue samples. Levels of Caspase-3,6,8, proteoglycan-4 (PG-4), malondialdehyde (MDA), and nitric oxide (NO) were measured in serum and brain tissue samples. Histopathological examination was performed in brain tissue. RESULTS There were significant differences in the serum levels of Caspase-3 between Group NT and Group C (p=0.018). The serum levels of Caspase-6 in Group NT (0.70±0.58) were lower than Group MH (1.39±0.28), although the difference was not statistically significant (p=0.068). There were significant differences in the brain tissue samples for Caspase-3 levels between Group NT and Group C (p=0.049). A significant difference in the Caspase-8 brain tissue levels was also observed between Group NT and Group C (p=0.022). Group NT had significantly higher scores of all the pathological variables (for edema p<0.017; for gliosis p<0.001; for congestion p<0.003, for hemorrhage p<0.011) than Group C. CONCLUSION Our study results suggest that hypothermia may exert its neuroprotective effects by reducing markers of apoptotic pathway, particularly Caspase-3 on TBI and HS.
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Affiliation(s)
- Oğuz Eroğlu
- Kırıkkale University, Faculty of Medicine, Department of Emergency Medicine, Kırıkkale, Turkey.
| | - Turgut Deniz
- Kırıkkale University, Faculty of Medicine, Department of Emergency Medicine, Kırıkkale, Turkey.
| | - Üçler Kisa
- Kırıkkale University, Faculty of Medicine, Medical Biochemistry, Kırıkkale, Turkey.
| | - Pınar Atasoy
- Kırıkkale University, Faculty of Medicine, Pathology, Kırıkkale, Turkey.
| | - Kuzey Aydinuraz
- Kırıkkale University, Faculty of Medicine, Department of General Surgery, Kırıkkale, Turkey.
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17
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Abstract
Birth asphyxia, also termed perinatal hypoxia-ischemia, is a modifiable condition as evidenced by improved outcomes of infants ≥36 weeks' gestation provided hypothermia treatment in randomized trials. Preterm animal models of asphyxia in utero demonstrate that hypothermia can provide short-term neuroprotection for the developing brain, supporting the interest in extending therapeutic hypothermia to preterm infants. This review focuses on the challenge of identifying preterm infants with perinatal asphyxia; the neuropathology of hypoxic-ischemic brain injury across extreme, moderate, and late preterm infants; and patterns of brain injury, use of therapeutic hypothermia, and approach to patient selection for neuroprotective treatments among preterm infants.
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Affiliation(s)
- Abbot R Laptook
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, 101 Dudley Street, Providence, RI 02905, USA.
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18
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Abstract
Antepartum, intrapartum, and neonatal events can result in a spectrum of long-term neurological sequelae, including cerebral palsy, cognitive delay, schizophrenia, and autism spectrum disorders [1]. Advances in obstetrical and neonatal care have led to survival at earlier gestational ages and consequently increasing numbers of periviable infants who are at significant risk for long-term neurological deficits. Therefore, efforts to decrease and prevent cerebral insults attempt not only to decrease preterm delivery but also to improve neurological outcomes in infants delivered preterm. We recently published a comprehensive review addressing the impacts of magnesium sulfate, therapeutic hypothermia, delayed cord clamping, infections, and prevention of preterm delivery on the modification of neurological risk [2]. In this review, we will briefly provide updates to the aforementioned topics as well as an expansion on avoidance of toxin and infections, specifically the Zika virus.
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Affiliation(s)
- Angie C. Jelin
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kirsten Salmeen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Dawn Gano
- Departments of Neurology & Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Irina Burd
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mari-Paule Thiet
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
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Naiman M, Shanley P, Garrett F, Kulstad E. Evaluation of advanced cooling therapy’s esophageal cooling device for core temperature control. Expert Rev Med Devices 2016; 13:423-33. [DOI: 10.1080/17434440.2016.1174573] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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20
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Foglia EE, DeMauro SB, Dysart K, Kirpalani H. When has enough evidence accumulated to change neonatal practice? Semin Fetal Neonatal Med 2015; 20:424-30. [PMID: 26441032 DOI: 10.1016/j.siny.2015.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Randomized clinical trials are the best method to assess the safety and efficacy of therapeutic interventions. However, it is not always clear how much evidence from randomized trials is required to change clinical practice. Throughout the history of neonatal medicine, some therapies were subject to excessive and unnecessary testing through replication of clinical trials. Other therapies were adopted into clinical practice with insufficient evidence. In only a few cases was the right amount of evidence accumulated to drive a change in practice. Here we present a case history for each of these three scenarios. Arising from these, we suggest principles to identify when enough evidence exists for a therapy to become standard practice.
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Affiliation(s)
- Elizabeth E Foglia
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sara B DeMauro
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kevin Dysart
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Haresh Kirpalani
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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21
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El-Mazary AAM, Abdel-Aziz RA, Mahmoud RA, El-Said MA, Mohammed NR. Correlations between maternal and neonatal serum selenium levels in full term neonates with hypoxic ischemic encephalopathy. Ital J Pediatr 2015; 41:83. [PMID: 26511525 PMCID: PMC4625852 DOI: 10.1186/s13052-015-0185-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/05/2015] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED Perinatal hypoxic-ischemic encephalopathy (HIE) is an important cause of brain injury in the newborn and can result devastating consequences. The principle mechanisms underlying neurological damage in HIE resulting from hypoxemia and/or ischemia is deprivation of glucose and oxygen supply which energy failure. A consequent reperfusion injury often deteriorates the brain metabolism by increasing the oxidative stress damage. Selenium is a constituent of the antioxidant enzyme Glutathione peroxidase and is vital to antioxidant defense. This study aimed to measure the serum selenium levels in full term neonates with HIE and their mothers and to correlate between them and the severity of HIE. METHODS The study included 60 full term neonates with HIE admitted to NICU of Minia university hospital during the period from January 2014 to February 2015. Twenty apparently healthy full term neonates selected as a control group. After history taking and careful clinical examination; all neonates were subjected to: Complete blood count, renal and liver function tests and serum electrolytes. Serum selenium was measured for all neonates and their mothers within 48 h of life using atomic flame spectrophotometer method. RESULTS Neonates with HIE had significant lower serum selenium levels than normal healthy neonates (p = 0.001**) with the lowest levels in neonates with severe HIE but there were no significant differences between patients and controls as regards the maternal serum selenium levels. Significant negative correlations between serum selenium levels and the severity of HIE and base excess were present, while positive significant correlations were present with Apgar score and pH. There were no correlations between serum selenium levels and maternal serum selenium levels urea or creatinine levels. CONCLUSIONS Neonates with HIE had lower serum selenium level than normal healthy neonates which is not dependent on the maternal serum selenium levels and was negatively correlated with the severity of HIE.
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Affiliation(s)
| | - Reem A Abdel-Aziz
- Department of Pediatrics, Faculty of Medicine, Minia University, Minia, Egypt.
| | - Ramadan A Mahmoud
- Department of Pediatrics, Faculty of Medicine, Sohag University, Sohag, Egypt.
| | - Mostafa A El-Said
- Department of Clinical Pathology, Faculty of Medicine, Minia University, Minia, Egypt.
| | - Nashwa R Mohammed
- Department of Pediatrics, Faculty of Medicine, Minia University, Minia, Egypt.
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Maze M. Preclinical neuroprotective actions of xenon and possible implications for human therapeutics: a narrative review. Can J Anaesth 2015; 63:212-26. [PMID: 26507536 DOI: 10.1007/s12630-015-0507-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/30/2015] [Accepted: 10/02/2015] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The purpose of this report is to facilitate an understanding of the possible application of xenon for neuroprotection in critical care settings. This narrative review appraises the literature assessing the efficacy and safety of xenon in preclinical models of acute ongoing neurologic injury. SOURCE Databases of the published literature (MEDLINE® and EMBASE™) were appraised for peer-reviewed manuscripts addressing the use of xenon in both preclinical models and disease states of acute ongoing neurologic injury. For randomized clinical trials not yet reported, the investigators' declarations in the National Institutes of Health clinical trials website were considered. PRINCIPAL FINDINGS While not a primary focus of this review, to date, xenon cannot be distinguished as superior for surgical anesthesia over existing alternatives in adults. Nevertheless, studies in a variety of preclinical disease models from multiple laboratories have consistently shown xenon's neuroprotective properties. These properties are enhanced in settings where xenon is combined with hypothermia. Small randomized clinical trials are underway to explore xenon's efficacy and safety in clinical settings of acute neurologic injury where hypothermia is the current standard of care. CONCLUSION According to the evidence to date, the neuroprotective efficacy of xenon in preclinical models and its safety in clinical anesthesia set the stage for the launch of randomized clinical trials to determine whether these encouraging neuroprotective findings can be translated into clinical utility.
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Affiliation(s)
- Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 1001 Potrero Avenue, Box 1363, San Francisco, CA, 94110, USA.
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Youn YA, Kim JH, Yum SK, Moon CJ, Lee IG, Sung IK. The hospital outcomes compared between the early and late hypothermia-treated groups in neonates. J Matern Fetal Neonatal Med 2015; 29:2288-92. [PMID: 26364841 DOI: 10.3109/14767058.2015.1083548] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND OBJECTIVE The incidence of hypoxic ischemic encephalopathy (HIE) in developed countries is estimated to be 1.5 per 1000 live births. The primary aim of this study was to analyze whether earlier hypothermia (≤1 h) improves hospital outcomes in survivors who underwent therapeutic hypothermia (TH) when compared with late TH (>1 h). METHOD Forty-nine (70%) newborns received TH for 72 h, within 6 h of birth; the remaining 21 received standard care. We divided the TH-treated newborns into early and late groups; early cooling was considered when TH was started ≤1 h after birth; late cooling was considered when started >1 h. RESULTS The early TH group consisted of 20 of 49 (41%) infants; the late TH group consisted of 29 (59%) infants. Apgar score at 1 min and the initial calcium level was significantly lower in the early (≤1 h) TH infants; there were significantly more inborns in the early TH group (p = 0.008). Infants in the late TH group manifested more clinical seizures followed by more abnormal EEG findings, longer ventilator care and longer hospitalization (p = 0.001). TH-related complications and mortality were not significantly different between the two groups. CONCLUSIONS Early TH (≤1 h) had lower Apgar score at 1 min and initial calcium level, but had decreased incidence of clinico-electrical seizures among HIE infants. Also, ventilator support and hospitalization period were longer in the late TH group.
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Affiliation(s)
- Young-Ah Youn
- a Department of Pediatrics , College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital , Seoul , Korea
| | - Ji Hoon Kim
- a Department of Pediatrics , College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital , Seoul , Korea
| | - Sook-Kyung Yum
- a Department of Pediatrics , College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital , Seoul , Korea
| | - Cheong-Jun Moon
- a Department of Pediatrics , College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital , Seoul , Korea
| | - In-Goo Lee
- a Department of Pediatrics , College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital , Seoul , Korea
| | - In Kyung Sung
- a Department of Pediatrics , College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital , Seoul , Korea
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Al Yazidi G, Boudes E, Tan X, Saint-Martin C, Shevell M, Wintermark P. Intraventricular hemorrhage in asphyxiated newborns treated with hypothermia: a look into incidence, timing and risk factors. BMC Pediatr 2015; 15:106. [PMID: 26315402 PMCID: PMC4551518 DOI: 10.1186/s12887-015-0415-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 08/13/2015] [Indexed: 11/24/2022] Open
Abstract
Background Intraventricular hemorrhage (IVH) is uncommon in term newborns. Asphyxia and hypothermia have been mentioned separately as possible risk factors of IVH, since they might cause fluctuations of cerebral blood flow. The aim of this study was to assess the incidence, the timing, and the risk factors of intraventricular hemorrhage (IVH) in term asphyxiated newborns treated with hypothermia. Methods We conducted a prospective cohort study of all term asphyxiated newborns treated with hypothermia from August 2008 to June 2013. The presence or not of IVH was assessed using brain magnetic resonance imaging (MRI) performed after the hypothermia treatment was completed or using head ultrasound during the hypothermia treatment. For these newborns, to determine the timing of IVH, we retrospectively reviewed if they had other brain imaging studies performed during their neonatal hospitalization stay. In addition, we compared their general characteristics with those not developing IVH. Results One hundred and sixty asphyxiated newborns met the criteria for hypothermia. Fifteen of these newborns developed IVH, leading to an estimate of 9 % (95 % CI: 5.3-15.0 %) of IVH in this population of newborns. Fifty-three percent had hemorrhage limited to the choroid plexus or IVH without ventricular dilatation; 47 % had IVH with ventricular dilatation or parenchymal hemorrhage. Sixty-seven percent had an initial normal brain imaging; the diagnostic brain imaging that demonstrated the IVH was obtained either during cooling (in 30 %), within 24 h of the rewarming (in 30 %), or 24 h after the rewarming (in 40 %). Recurrent seizures were the presenting symptom of IVH during the rewarming in 20 % of the newborns. Coagulopathy was more frequent in the asphyxiated newborns developing IVH (p < 0.001). The asphyxiated newborns developing IVH also presented more frequently with persistent pulmonary hypertension, hypotension, thrombocytopenia and coagulopathy (p = 0.03). Conclusions The asphyxiated newborns treated with hypothermia appear to be at an increased risk of IVH, especially those with significant hemodynamic instability. IVH seems to develop during late hypothermia and rewarming. Efforts should be directed towards maintaining hemodynamic stability in these patients, even during the rewarming.
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Affiliation(s)
- Ghalia Al Yazidi
- Division of Pediatric Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Elodie Boudes
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, 1001 Boul. Decarie, Site Glen, Block E, EM0.3244, Montreal, H4A 3J1, QC, Canada
| | - Xianming Tan
- Biostatistics Core Facility, Research Institute, McGill University Health Centre, Montreal, Canada
| | - Christine Saint-Martin
- Department of Radiology, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Michael Shevell
- Division of Pediatric Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, 1001 Boul. Decarie, Site Glen, Block E, EM0.3244, Montreal, H4A 3J1, QC, Canada.
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Boudes E, Tan X, Saint-Martin C, Shevell M, Wintermark P. MRI obtained during versus after hypothermia in asphyxiated newborns. Arch Dis Child Fetal Neonatal Ed 2015; 100:F238-42. [PMID: 25605620 DOI: 10.1136/archdischild-2014-306550] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 12/22/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess whether the brain MRI results obtained during hypothermia identify the later brain injury observed in asphyxiated newborns after therapy is completed. PATIENTS AND METHODS Asphyxiated newborns treated with hypothermia were prospectively enrolled in this study if they had at least one MRI performed during hypothermia treatment and then another MRI performed around day 10 of life. RESULTS A total of 129 MRI scans were obtained from 43 asphyxiated newborns treated with hypothermia. Sixty per cent developed brain injury; all the brain injuries observed on the late scans were already present on day 2-3 of life during hypothermia, and the extent of injury was similar between the early and late scans. The brain MRI on day 2-3 of life had a sensitivity of 100% (95% CI 84% to 100%) and a specificity of 100% (95% CI 77% to 100%) to identify the presence and extent of later brain injury. CONCLUSIONS The brain MRIs performed during hypothermia already permit an accurate definition of the presence and extent of brain injury that later develop in asphyxiated newborns despite treatment. These results may have research and clinical implications for the care of these newborns.
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Affiliation(s)
- Elodie Boudes
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Xianming Tan
- Centre for Innovative Medicine, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
| | - Christine Saint-Martin
- Division of Pediatric Radiology, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Michael Shevell
- Division of Pediatric Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada Division of Newborn Medicine, Children's Hospital Boston, Boston, USA
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Lachapelle J, Chen M, Oskoui M, Ali N, Brown R, Wintermark P. Placental pathology in asphyxiated newborns treated with therapeutic hypothermia. J Neonatal Perinatal Med 2015; 8:8183532261G534U4. [PMID: 25766201 DOI: 10.3233/npm-15814068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To describe the placental findings in asphyxiated newborns treated with hypothermia and to determine their association with the presence and severity of later brain injury. METHODS Prospective cohort study of the placentas of asphyxiated newborns treated with hypothermia, in whom later brain injury was defined by brain imaging and/or autopsy results. RESULTS Of the 142 asphyxiated newborns meeting the criteria for hypothermia, 73% had placenta and brain MRI/autopsy available for analysis. Fifty-one percent of these newborns developed brain injury. Sixty-five percent had microscopic placental findings involving the fetal vascular supply, which were comparable in asphyxiated newborns developing or not developing brain injury. Among the asphyxiated newborns with normal placental growth, the placental microscopic findings tended to be more common in those developing brain injury compared to those who did not: chorionic plate meconium in 50% compared to 36%, chorioamnionitis in 75% compared to 44%, and villitis of unknown etiology in 67% compared to 33%, but this did not reach statistical significance. CONCLUSIONS Antenatal placental processes are common in term asphyxiated newborns treated with hypothermia. The placenta of each asphyxiated term newborn treated with hypothermia should be carefully examined to better understand its role in the progression from perinatal depression to brain injury.
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Affiliation(s)
- J Lachapelle
- Department of Pathology, McGill University, Montreal, Canada
| | - M Chen
- Department of Pathology, McGill University, Montreal, Canada Department of Gynecology and Obstetrics, McGill University, Montreal, Canada
| | - M Oskoui
- Department of Neurology and Neurosurgery, McGill University, Montreal, Canada Department of Pediatrics, McGill University, Montreal, Canada
| | - N Ali
- Department of Pediatrics, McGill University, Montreal, Canada
| | - R Brown
- Department of Gynecology and Obstetrics, McGill University, Montreal, Canada
| | - P Wintermark
- Department of Pediatrics, McGill University, Montreal, Canada
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Kulstad EB, Naiman M, Shanley P, Garrett F, Haryu T, Waller D, Azarafrooz F, Courtney DM. Temperature modulation with an esophageal heat transfer device - a pediatric swine model study. BMC Anesthesiol 2015; 15:16. [PMID: 25685058 PMCID: PMC4327961 DOI: 10.1186/1471-2253-15-16] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 01/15/2015] [Indexed: 12/18/2022] Open
Abstract
Background An increasing number of conditions appear to benefit from control and modulation of temperature, but available techniques to control temperature often have limitations, particularly in smaller patients with high surface to mass ratios. We aimed to evaluate a new method of temperature modulation with an esophageal heat transfer device in a pediatric swine model, hypothesizing that clinically significant modulation in temperature (both increases and decreases of more than 1°C) would be possible. Methods Three female Yorkshire swine averaging 23 kg were anesthetized with inhalational isoflurane prior to placement of the esophageal device, which was powered by a commercially available heat exchanger. Swine temperature was measured rectally and cooling and warming were performed by selecting the appropriate external heat exchanger mode. Temperature was recorded over time in order to calculate rates of temperature change. Histopathology of esophageal tissue was performed after study completion. Results Average swine baseline temperature was 38.3°C. Swine #1 exhibited a cooling rate of 3.5°C/hr; however, passive cooling may have contributed to this rate. External warming blankets maintained thermal equilibrium in swine #2 and #3, demonstrating maximum temperature decrease of 1.7°C/hr. Warming rates averaged 0.29°C/hr. Histopathologic analysis of esophageal tissue showed no adverse effects. Conclusions An esophageal heat transfer device successfully modulated the temperature in a pediatric swine model. This approach to temperature modulation may offer a useful new modality to control temperature in conditions warranting temperature management (such as maintenance of normothermia, induction of hypothermia, fever control, or malignant hyperthermia).
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Affiliation(s)
- Erik B Kulstad
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL 60453 USA ; Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL 60612 USA
| | - Melissa Naiman
- Center for Advanced Design, Research, and Exploration (CADRE), University of Illinois at Chicago, 1737 W. Polk Street, Suite B14, Chicago, IL 60612 USA
| | - Patrick Shanley
- Advanced Cooling Therapy, 3440 S. Dearborn Street, #215-S, Chicago, IL 60616 USA
| | - Frank Garrett
- Garrett Technologies, 1955 Techny Road, Suite #1, Northbrook, IL 60062 USA
| | - Todd Haryu
- PreLabs, LLC, 33 Chicago Avenue, Oak Park, IL 60302 USA
| | - Donald Waller
- PreLabs, LLC, 33 Chicago Avenue, Oak Park, IL 60302 USA
| | - Farshid Azarafrooz
- Department of Comparative Medicine, Loyola University Medical Center, Maywood, IL 60153 USA
| | - Daniel Mark Courtney
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, 211 E. Ontario suite 200, Chicago, IL 60611 USA
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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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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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30
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Kracer B, Hintz SR, Van Meurs KP, Lee HC. Hypothermia therapy for neonatal hypoxic ischemic encephalopathy in the state of California. J Pediatr 2014; 165:267-73. [PMID: 24929331 PMCID: PMC4111956 DOI: 10.1016/j.jpeds.2014.04.052] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 03/18/2014] [Accepted: 04/29/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To characterize the implementation of hypothermia for neonatal hypoxic ischemic encephalopathy (HIE) in a population-based cohort. STUDY DESIGN Using the California Perinatal Quality Care Collaborative and California Perinatal Transport System linked 2010-2012 datasets, we categorized infants≥36 weeks' gestation with HIE as receiving hypothermia or normothermia. Sociodemographic and clinical factors were compared, and multivariable logistic regression was used to determine factors associated with hypothermia therapy. RESULTS There were 238 reported encephalopathy cases in 2010, 280 in 2011, and 311 in 2012. Hypothermia therapy use in newborns with HIE increased from 59% to 73% across the study period, mainly occurring in newborns with mild or moderate encephalopathy. A total of 36 centers provided hypothermia and cared for 94% of infants, with the remaining 6% being cared for at one of 25 other centers. Of the centers providing hypothermia, 12 centers performed hypothermia therapy to more than 20 patients during the 3-year study period, and 24 centers cared for <20 patients receiving hypothermia. In-hospital mortality was 13%, which primarily was associated with the severity of encephalopathy. CONCLUSIONS Our findings highlight an opportunity to explore practice-site variation and to develop quality improvement interventions to assure consistent evidence-based care of term infants with HIE and appropriate application of hypothermia therapy for eligible newborns.
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Affiliation(s)
- Bernardo Kracer
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA.
| | | | | | - Henry C. Lee
- Stanford University School of Medicine, Stanford, CA,California Perinatal Quality Care Collaborative, Stanford, CA
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Threlkeld SW, Gaudet CM, La Rue ME, Dugas E, Hill CA, Lim YP, Stonestreet BS. Effects of inter-alpha inhibitor proteins on neonatal brain injury: Age, task and treatment dependent neurobehavioral outcomes. Exp Neurol 2014; 261:424-33. [PMID: 25084519 DOI: 10.1016/j.expneurol.2014.07.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/10/2014] [Accepted: 07/20/2014] [Indexed: 12/18/2022]
Abstract
Hypoxic-ischemic (HI) brain injury is frequently associated with premature and/or full term birth related complications. HI injury often results in learning and processing deficits that reflect widespread damage to an extensive range of cortical and sub-cortical brain structures. Further, inflammation has been implicated in the long-term progression and severity of HI injury. Recently, inter-alpha inhibitor proteins (IAIPs) have been shown to attenuate inflammation in models of systemic infection. Importantly, preclinical studies of neonatal HI injury and neuroprotection often focus on single time windows of assessment or single behavioral domains. This approach limits translational validity, given evidence for a diverse spectrum of neurobehavioral deficits that may change across developmental windows following neonatal brain injury. Therefore, the aims of this research were to assess the effects of human IAIPs on early neocortical cell death (72h post-insult), adult regional brain volume measurements (cerebral cortex, hippocampus, striatum, corpus callosum) and long-term behavioral outcomes in juvenile (P38-50) and adult (P80+) periods across two independent learning domains (spatial and non-spatial learning), after postnatal day 7 HI injury in rats. Here, for the first time, we show that IAIPs reduce acute neocortical neuronal cell death and improve brain weight outcome 72h following HI injury in the neonatal rat. Further, these longitudinal studies are the first to show age, task and treatment dependent improvements in behavioral outcome for both spatial and non-spatial learning following systemic administration of IAIPs in neonatal HI injured rats. Finally, results also show sparing of brain regions critical for spatial and non-spatial learning in adult animals treated with IAIPs at the time of injury onset. These data support the proposal that inter-alpha inhibitor proteins may serve as novel therapeutics for brain injury associated with premature birth and/or neonatal brain injury and highlight the importance of assessing multiple ages, brain regions and behavioral domains when investigating experimental treatment efficacy.
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Affiliation(s)
- Steven W Threlkeld
- Department of Psychology, Rhode Island College, 600 Mount Pleasant Ave., Providence, RI 02904, USA.
| | - Cynthia M Gaudet
- Department of Psychology, Rhode Island College, 600 Mount Pleasant Ave., Providence, RI 02904, USA
| | - Molly E La Rue
- Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, 101 Dudley Street, Providence, RI 02905, USA
| | - Ethan Dugas
- Department of Psychology, Rhode Island College, 600 Mount Pleasant Ave., Providence, RI 02904, USA
| | - Courtney A Hill
- Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, 101 Dudley Street, Providence, RI 02905, USA
| | - Yow-Pin Lim
- ProThera Biologics, Inc., East Providence, RI 02914, USA
| | - Barbara S Stonestreet
- Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, 101 Dudley Street, Providence, RI 02905, USA
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32
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Papile LA, Baley JE, Benitz W, Cummings J, Carlo WA, Eichenwald E, Kumar P, Polin RA, Tan RC, Wang KS. Hypothermia and neonatal encephalopathy. Pediatrics 2014; 133:1146-50. [PMID: 24864176 DOI: 10.1542/peds.2014-0899] [Citation(s) in RCA: 216] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Data from large randomized clinical trials indicate that therapeutic hypothermia, using either selective head cooling or systemic cooling, is an effective therapy for neonatal encephalopathy. Infants selected for cooling must meet the criteria outlined in published clinical trials. The implementation of cooling needs to be performed at centers that have the capability to manage medically complex infants. Because the majority of infants who have neonatal encephalopathy are born at community hospitals, centers that perform cooling should work with their referring hospitals to implement education programs focused on increasing the awareness and identification of infants at risk for encephalopathy, and the initial clinical management of affected infants.
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MESH Headings
- Asphyxia Neonatorum/diagnosis
- Asphyxia Neonatorum/mortality
- Asphyxia Neonatorum/therapy
- Cooperative Behavior
- Follow-Up Studies
- Hospitals, Community
- Humans
- Hypothermia, Induced/methods
- Hypoxia-Ischemia, Brain/congenital
- Hypoxia-Ischemia, Brain/diagnosis
- Hypoxia-Ischemia, Brain/mortality
- Hypoxia-Ischemia, Brain/therapy
- Infant, Newborn
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/therapy
- Interdisciplinary Communication
- Randomized Controlled Trials as Topic
- Referral and Consultation
- Risk Assessment
- Survival Rate
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Biomarkers for severity of neonatal hypoxic-ischemic encephalopathy and outcomes in newborns receiving hypothermia therapy. J Pediatr 2014; 164:468-74.e1. [PMID: 24332821 PMCID: PMC4006934 DOI: 10.1016/j.jpeds.2013.10.067] [Citation(s) in RCA: 154] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 08/26/2013] [Accepted: 10/23/2013] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To evaluate serum neuronal and inflammatory biomarkers to determine whether measurements of umbilical cords at birth can stratify severity of hypoxic-ischemic encephalopathy (HIE), whether serial measurements differ with hypothermia-rewarming, and whether biomarkers correlate with neurological outcomes. STUDY DESIGN This is a prospective cohort of inborn term newborns with varying degrees of HIE by neurological assessment. Neuronal glial fibrillary acidic protein (GFAP), ubiquitin carboxyl-terminal hydrolase L1, and inflammatory cytokines were measured in serum from umbilical artery at 6-24, 48, 72, and 78 hours of age. Neurodevelopmental outcomes (Bayley Scales of Infant and Toddler Development-III scales) were performed at 15-18 months. RESULTS Twenty neonates had moderate (n = 17) or severe (n = 3) HIE and received hypothermia; 7 had mild HIE and were not cooled. At birth, serum GFAP and ubiquitin carboxyl-terminal hydrolase L1 increased with the severity of HIE (P < .001), and serial GFAP remained elevated in neonates with moderate to severe HIE. Interleukin (IL)-6, IL-8, and vascular endothelial growth factor were greater at 6-24 hours in moderate to severe vs mild HIE (P < .05). The serial values were unaffected by hypothermia-rewarming. Elevated GFAP, IL-1, IL-6, IL-8, tumor necrosis factor, interferon, and vascular endothelial growth factor at 6-24 hours were associated with abnormal neurological outcomes. CONCLUSIONS The severity of the hypoxic-ischemic injury can be stratified at birth because elevated neuronal biomarkers in cord serum correlated with severity of HIE and outcomes.
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Cotten CM, Shankaran S. Hypothermia for hypoxic-ischemic encephalopathy. ACTA ACUST UNITED AC 2014; 5:227-239. [PMID: 20625441 DOI: 10.1586/eog.10.7] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Moderate to severe hypoxic-ischemic injury in newborn infants, manifested as encephalopathy immediately or within hours after birth, is associated with a high risk of either death or a lifetime with disability. In recent multicenter clinical trials, hypothermia initiated within the first 6 postnatal hours has emerged as a therapy that reduces the risk of death or impairment among infants with hypoxic-ischemic encephalopathy. Prior to hypothermia, no therapies directly targeting neonatal encephalopathy secondary to hypoxic-ischemic injury had convincing evidence of efficacy. Hypothermia therapy is now becoming increasingly available at tertiary centers. Despite the deserved enthusiasm for hypothermia, obstetric and neonatology caregivers, as well as society at large, must be reminded that in the clinical trials more than 40% of cooled infants died or survived with impairment. Although hypothermia is an evidence-based therapy, additional discoveries are needed to further improve outcome after HIE. In this article, we briefly present the epidemiology of neonatal encephalopathy due to hypoxic-ischemic injury, describe the rationale for the use of hypothermia therapy for hypoxic-ischemic encephalopathy, and present results of the clinical trials that have demonstrated the efficacy of hypothermia. We also present findings noted during and after these trials that will guide care and direct research for this devastating problem.
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Affiliation(s)
- C Michael Cotten
- Associate Professor of Pediatrics, Duke University Medical Center, Box 2739 DUMC, Durham, NC 27710, USA, Tel.: +1 919 681 4844, ,
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Cerebral oxygen metabolism in neonatal hypoxic ischemic encephalopathy during and after therapeutic hypothermia. J Cereb Blood Flow Metab 2014; 34:87-94. [PMID: 24064492 PMCID: PMC3887346 DOI: 10.1038/jcbfm.2013.165] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 08/15/2013] [Accepted: 08/26/2013] [Indexed: 11/09/2022]
Abstract
Pathophysiologic mechanisms involved in neonatal hypoxic ischemic encephalopathy (HIE) are associated with complex changes of blood flow and metabolism. Therapeutic hypothermia (TH) is effective in reducing the extent of brain injury, but it remains uncertain how TH affects cerebral blood flow (CBF) and metabolism. Ten neonates undergoing TH for HIE and seventeen healthy controls were recruited from the NICU and the well baby nursery, respectively. A combination of frequency domain near infrared spectroscopy (FDNIRS) and diffuse correlation spectroscopy (DCS) systems was used to non-invasively measure cerebral hemodynamic and metabolic variables at the bedside. Results showed that cerebral oxygen metabolism (CMRO2i) and CBF indices (CBFi) in neonates with HIE during TH were significantly lower than post-TH and age-matched control values. Also, cerebral blood volume (CBV) and hemoglobin oxygen saturation (SO2) were significantly higher in neonates with HIE during TH compared with age-matched control neonates. Post-TH CBV was significantly decreased compared with values during TH whereas SO2 remained unchanged after the therapy. Thus, FDNIRS-DCS can provide information complimentary to SO2 and can assess individual cerebral metabolic responses to TH. Combined FDNIRS-DCS parameters improve the understanding of the underlying physiology and have the potential to serve as bedside biomarkers of treatment response and optimization.
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Gregersen M, Lee DH, Gabatto P, Bickler PE. Limitations of Mild, Moderate, and Profound Hypothermia in Protecting Developing Hippocampal Neurons After Simulated Ischemia. Ther Hypothermia Temp Manag 2013; 3:178-188. [PMID: 24380031 PMCID: PMC3868300 DOI: 10.1089/ther.2013.0017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Mild hypothermia (33°C-34°C) after cerebral ischemia in intact animals or ischemia-like conditions in vitro reduces neuron death. However, it is now clear that more profound hypothermia or delayed hypothermia may not provide significant protection. To further define the limitations of hypothermia after cerebral ischemia, we used hippocampal slice cultures to examine the effects of various degrees, durations, and delays of hypothermia on neuron death after an ischemia-like insult. Organotypic cultures of the hippocampus from 7- to 8 day-old rat pups were cooled to 32°C, 23°C, 17°C, or 4°C immediately or after a 2-4 hour delay from an injurious insult of oxygen and glucose deprivation (OGD). Cell death in CA1, CA3 and dentate regions of the cultures was assessed 24 hours later with SYTOX® or propidium iodide, both of which are fluorescent markers labeling damaged cells. OGD caused extensive cell death in CA1, CA3, and dentate regions of the hippocampal cultures. Hypothermia (32°C, 23°C and 17°C) for 4-6 hours immediately after OGD was protective at 24 hours, but when hypothermia was applied for longer periods or delayed after OGD, no protection or increased death was seen. Ultra-profound hypothermia (4°C) increased cell death in all cell areas of the hippocampus even when after a milder insult of only hypoxia. In an in vitro model of recovery after an ischemia-like insult, mild to profound hypothermia is protective only when applied without delay and for limited periods of time (6-8 hours). Longer durations of hypothermia, or delayed application of the hypothermia can increase neuron death. These findings may have implications for clinical uses of therapeutic hypothermia after hypoxic or ischemic insults, and suggest that further work is needed to elucidate the limitations of hypothermia as a protective treatment after ischemic stress.
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Affiliation(s)
- Maren Gregersen
- Severinghaus-Radiometer Research Laboratories, Department of Anesthesia and Perioperative Care, University of California at San Francisco , San Francisco, California
| | - Deok Hee Lee
- Severinghaus-Radiometer Research Laboratories, Department of Anesthesia and Perioperative Care, University of California at San Francisco , San Francisco, California
| | - Pablo Gabatto
- Severinghaus-Radiometer Research Laboratories, Department of Anesthesia and Perioperative Care, University of California at San Francisco , San Francisco, California
| | - Philip E Bickler
- Severinghaus-Radiometer Research Laboratories, Department of Anesthesia and Perioperative Care, University of California at San Francisco , San Francisco, California
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Lichter-Konecki U, Nadkarni V, Moudgil A, Cook N, Poeschl J, Meyer MT, Dimmock D, Baumgart S. Feasibility of adjunct therapeutic hypothermia treatment for hyperammonemia and encephalopathy due to urea cycle disorders and organic acidemias. Mol Genet Metab 2013; 109:354-9. [PMID: 23791307 DOI: 10.1016/j.ymgme.2013.05.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 05/20/2013] [Accepted: 05/20/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND Children with urea cycle disorders (UCDs) or organic acidemias (OAs) and acute hyperammonemia and encephalopathy are at great risk for neurological injury, developmental delay, intellectual disability, and death. Nutritional support, intravenous alternative pathway therapy, and dialysis are used to treat severe hyperammonemia associated with UCDs and nutritional support and dialysis are used to treat severe hyperammonemia in OAs. Brain protective treatment while therapy is initiated may improve neurological and cognitive function for the lifetime of the child. Animal experiments and small clinical trials in hepatic encephalopathy caused by acute liver failure suggest that therapeutic hypothermia provides neuroprotection in hyperammonemia associated encephalopathy. We report results of an ongoing pilot study that assesses if whole body cooling during rescue treatment of neonates with acute hyperammonemia and encephalopathy is feasible and can be conducted safely. METHODS Adjunct whole body therapeutic hypothermia was conducted in addition to standard treatment in acutely encephalopathic, hyperammonemic neonates with UCDs and OAs requiring dialysis. Therapeutic hypothermia was initiated using cooling blankets as preparations for dialysis were underway. Similar to standard therapeutic hypothermia treatment for neonatal hypoxic ischemic encephalopathy, patients were maintained at 33.5°C±1°C for 72h, they were then slowly rewarmed by 0.5°C every 3h over 18h. In addition data of age-matched historic controls were collected for comparison. RESULTS Seven patients were cooled using the pilot study protocol and data of seven historic controls were reviewed. All seven patients survived the initial rescue and cooling treatment, 6 patients were discharged home 2-4weeks after hospitalization, five of them feeding orally. The main complication observed in a majority of patients was hypotension. CONCLUSION Adjunct therapeutic hypothermia for neonates with UCDs and OAs receiving standard treatment was feasible and could be conducted safely in pediatric and neonatal intensive care units experienced in the application of therapeutic hypothermia in critically ill neonates. However, including adjunct therapeutic hypothermia in the already involved treatment regimen of critically ill patients with hyperammonemia and encephalopathy adds to the complexity of care and should not be done unless it is proven efficacious in a randomized clinical trial.
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MESH Headings
- Adolescent
- Child
- Child, Preschool
- Developmental Disabilities/complications
- Developmental Disabilities/pathology
- Developmental Disabilities/therapy
- Humans
- Hyperammonemia/pathology
- Hyperammonemia/therapy
- Hypothermia, Induced
- Hypoxia-Ischemia, Brain/complications
- Hypoxia-Ischemia, Brain/drug therapy
- Hypoxia-Ischemia, Brain/pathology
- Infant
- Infant, Newborn
- Pilot Projects
- Urea/metabolism
- Urea Cycle Disorders, Inborn/complications
- Urea Cycle Disorders, Inborn/genetics
- Urea Cycle Disorders, Inborn/pathology
- Urea Cycle Disorders, Inborn/therapy
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Affiliation(s)
- Uta Lichter-Konecki
- Division Genetics & Metabolism, Children's National Medical Center, Dept. of Pediatrics, George Washington University MC, Washington, DC 20010, USA.
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Wintermark P, Hansen A, Warfield SK, Dukhovny D, Soul JS. Near-infrared spectroscopy versus magnetic resonance imaging to study brain perfusion in newborns with hypoxic-ischemic encephalopathy treated with hypothermia. Neuroimage 2013; 85 Pt 1:287-93. [PMID: 23631990 DOI: 10.1016/j.neuroimage.2013.04.072] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/17/2013] [Accepted: 04/18/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The measurement of brain perfusion may provide valuable information for assessment and treatment of newborns with hypoxic-ischemic encephalopathy (HIE). While arterial spin labeled perfusion (ASL) magnetic resonance imaging (MRI) provides noninvasive and direct measurements of regional cerebral blood flow (CBF) values, it is logistically challenging to obtain. Near-infrared spectroscopy (NIRS) might be an alternative, as it permits noninvasive and continuous monitoring of cerebral hemodynamics and oxygenation at the bedside. OBJECTIVE The purpose of this study is to determine the correlation between measurements of brain perfusion by NIRS and by MRI in term newborns with HIE treated with hypothermia. DESIGN/METHODS In this prospective cohort study, ASL-MRI and NIRS performed during hypothermia were used to assess brain perfusion in these newborns. Regional cerebral blood flow (CBF) values, measured from 1-2 MRI scans for each patient, were compared to mixed venous saturation values (SctO2) recorded by NIRS just before and after each MRI. Analysis included groupings into moderate versus severe HIE based on their initial background pattern of amplitude-integrated electroencephalogram. RESULTS Twelve concomitant recordings were obtained of seven neonates. Strong correlation was found between SctO2 and CBF in asphyxiated newborns with severe HIE (r=0.88; p value=0.0085). Moreover, newborns with severe HIE had lower CBF (likely lower oxygen supply) and extracted less oxygen (likely lower oxygen demand or utilization) when comparing SctO2 and CBF to those with moderate HIE. CONCLUSIONS NIRS is an effective bedside tool to monitor and understand brain perfusion changes in term asphyxiated newborns, which in conjunction with precise measurements of CBF obtained by MRI at particular times, may help tailor neuroprotective strategies in term newborns with HIE.
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Affiliation(s)
- P Wintermark
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, 2300 Tupper Street, Montreal, QC H3H 1P3, Canada; Division of Newborn Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Peliowski-Davidovich A. Hypothermia for newborns with hypoxic ischemic encephalopathy. Paediatr Child Health 2013; 17:41-6. [PMID: 23277757 DOI: 10.1093/pch/17.1.41] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Hypoxic ischemic encephalopathy (HIE) remains a significant cause of mortality and long-term disability in late preterm and term infants. Mild therapeutic hypothermia to a rectal temperature of 34±0.5°C initiated as soon as possible within the first 6 h of life decreases mortality and severe long-term neurodevelopmental disabilities in infants with moderate HIE who are ≥36 weeks' gestational age. There are minimal side effects, and the incidence of disability in survivors is not increased. Infants with severe encephalopathy are less likely to benefit from treatment. Cooling may be achieved by either total body or selective head cooling. As cooling is now considered a standard of care, infants ≥36 weeks' gestational age who are depressed at birth should be assessed to determine whether they meet the criteria for cooling. There is currently no evidence that therapeutic hypothermia offers any benefit to infants <36 weeks' gestational age.
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Mulkey SB, Yap VL, Swearingen CJ, Riggins MS, Kaiser JR, Schaefer GB. Quantitative cranial magnetic resonance imaging in neonatal hypoxic-ischemic encephalopathy. Pediatr Neurol 2012; 47:101-8. [PMID: 22759685 PMCID: PMC3683989 DOI: 10.1016/j.pediatrneurol.2012.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 05/17/2012] [Indexed: 11/28/2022]
Abstract
The volume of acute injury detected by diffusion-weighted imaging and quantitative brain growth on serial cranial magnetic resonance imaging was not previously used to predict neurodevelopmental outcomes in infants with neonatal hypoxic-ischemic encephalopathy treated with head cooling. Our longitudinal study involved 16 head-cooled term infants with hypoxic-ischemic encephalopathy who underwent early and follow-up cranial magnetic resonance imaging and follow-up neurologic evaluations, out of 105 infants who received therapeutic hypothermia. The volume of acute injury was measured on initial cranial magnetic resonance imaging, using diffusion-weighted images. Total brain volumes were measured in both early and follow-up magnetic resonance imaging studies. Acute injury volume in the corpus callosum >0.5 cm(3) was associated with developing epilepsy (odds ratio, 20; 95% confidence interval, 1.01-1059.6; P = 0.013). Follow-up whole brain volume was reduced in those with unfavorable outcomes (i.e., epilepsy, cerebral palsy, and delayed developmental milestones), compared with infants without all three outcomes. Although acute brain injury volume and brain growth measurements may be useful predictors of outcomes in neonatal hypoxic-ischemic encephalopathy, the evolution of brain injury in these infants has yet to be fully understood and should be studied prospectively.
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Affiliation(s)
- Sarah B. Mulkey
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas,Communications should be addressed to: Dr. Mulkey; Section of Pediatric Neurology; Department of Pediatrics; University of Arkansas for Medical Sciences; Arkansas Children's Hospital; 1 Children's Way, Slot 512-15; Little Rock, AR 72202
| | - Vivien L. Yap
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas
| | - Christopher J. Swearingen
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas
| | - Melissa S. Riggins
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey R. Kaiser
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas,Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - G. Bradley Schaefer
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas
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Pfister RH, Bingham P, Edwards EM, Horbar JD, Kenny MJ, Inder T, Nelson KB, Raju T, Soll RF. The Vermont Oxford Neonatal Encephalopathy Registry: rationale, methods, and initial results. BMC Pediatr 2012; 12:84. [PMID: 22726296 PMCID: PMC3502438 DOI: 10.1186/1471-2431-12-84] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 06/04/2012] [Indexed: 12/16/2022] Open
Abstract
Background In 2006, the Vermont Oxford Network (VON) established the Neonatal Encephalopathy Registry (NER) to characterize infants born with neonatal encephalopathy, describe evaluations and medical treatments, monitor hypothermic therapy (HT) dissemination, define clinical research questions, and identify opportunities for improved care. Methods Eligible infants were ≥ 36 weeks with seizures, altered consciousness (stupor, coma) during the first 72 hours of life, a 5 minute Apgar score of ≤ 3, or receiving HT. Infants with central nervous system birth defects were excluded. Results From 2006–2010, 95 centers registered 4232 infants. Of those, 59% suffered a seizure, 50% had a 5 minute Apgar score of ≤ 3, 38% received HT, and 18% had stupor/coma documented on neurologic exam. Some infants experienced more than one eligibility criterion. Only 53% had a cord gas obtained and only 63% had a blood gas obtained within 24 hours of birth, important components for determining HT eligibility. Sixty-four percent received ventilator support, 65% received anticonvulsants, 66% had a head MRI, 23% had a cranial CT, 67% had a full channel encephalogram (EEG) and 33% amplitude integrated EEG. Of all infants, 87% survived. Conclusions The VON NER describes the heterogeneous population of infants with NE, the subset that received HT, their patterns of care, and outcomes. The optimal routine care of infants with neonatal encephalopathy is unknown. The registry method is well suited to identify opportunities for improvement in the care of infants affected by NE and study interventions such as HT as they are implemented in clinical practice.
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Abstract
Baby M was born limp, blue, and without respiratory effort at 38 weeks gestation to a 38-year-old, gravida 5, para 1, woman. Delivery was vaginal after a rapid progression of labor leaving no opportunity for a cesarean section. No other complications were noted during labor but a large surge at delivery, later diagnosed as uterine rupture, initially raised concerns about placental abruption. Apgar scores were 1, 2, and 4 at one, five, and ten minutes, respectively. She was resuscitated in the delivery room, intubated, and transferred in critical condition to the neonatal intensive care unit (NICU) at the birth hospital. Her initial cord pH was 6.7 and was slightly improved at 7.17 on arterial blood gas after resuscitation. Our NICU team was consulted because of her severe neurologic depression. The birth hospital was within walking distance of our tertiary care center and our neurologists went to evaluate her for the hypothermia protocol. Her neurologic exam was notable for dilated and unresponsive pupils, no spontaneous movements, and diminished reflexes and tone, consistent with moderate-to-severe encephalopathy. Seizure activity began at one hour of age and consisted of lip smacking, which was later confirmed by electroencephalogram (EEG). Enrollment criteria were met based on respiratory depression at birth requiring intubation and continued need for ventilation, concern for placental abruption, cord pH less than 7, and encephalopathy on exam and EEG. After stabilizing her airway and achieving central access to treat acidosis and seizures, the team prepared her for transfer to our NICU. At this point, the primary concern became her neurologic status.
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Merrill L. Therapeutic hypothermia to treat hypoxic ischemic encephalopathy in newborns: implications for nurses. Nurs Womens Health 2012; 16:126-134. [PMID: 22900770 DOI: 10.1111/j.1751-486x.2012.01718.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Hypoxic ischemic encephalopathy (HIE) in newborns is caused by an injury to the brain following a hypoxic or an ischemic event during the peripartum, intrapartum or postpartum period. HIE may result in death or cause serious impairment in survivors, and remains a significant cause of morbidity and mortality among neonates. Mild hypothermia as a treatment for HIE is commonly used to treat moderate to severe HIE, with promising results. Nurses play an integral role in identifying newborns at risk of developing HIE.
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Guenther MA, Bruder ED, Raff H. Effects of body temperature maintenance on glucose, insulin, and corticosterone responses to acute hypoxia in the neonatal rat. Am J Physiol Regul Integr Comp Physiol 2012; 302:R627-33. [DOI: 10.1152/ajpregu.00503.2011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
One of the biggest challenges of premature birth is acute hypoxia. Hypothermia during acute hypoxic periods may be beneficial. We hypothesized that prevention of hypothermia during neonatal hypoxia disrupts glucose homeostasis and places additional metabolic challenges on the neonate. Pups at PD2 and PD8 were exposed to 8% O2 for 3 h, during which they were allowed to either spontaneously cool or were kept isothermic. There was also a time control group that was subjected to normoxia and kept isothermic. Plasma glucose, insulin, C-peptide, corticosterone, and catecholamines were measured from samples collected at baseline, 1 h, 2 h, and 3 h. In postnatal day 2 (PD2) rats, hypoxia alone resulted in no change in plasma glucose by 1 h, an increase by 2 h, and a subsequent decrease below baseline values by 3 h. Hypoxia with isothermia in PD2 rats elicited a large increase in plasma insulin at 1 h. In PD8 rats, hypoxia with isothermia resulted in an initial increase in plasma glucose, but by 3 h, glucose had decreased significantly to below baseline levels. Hypoxia with and without isothermia elicited an increase in plasma corticosterone at both ages and an increase in plasma epinephrine in PD8 rats. We conclude that the insulin response to hypoxia in PD8 rats is associated with an increase in glucose similar to an adult; however, insulin responses to hypoxia in PD2 rats were driven by something other than glucose. Prevention of hypothermia during hypoxia further disrupts glucose homeostasis and increases metabolic challenges.
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Affiliation(s)
| | - Eric D. Bruder
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, and
| | - Hershel Raff
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, and
- Departments of Medicine, Surgery, and Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Abstract
INTRODUCTION We sought to determine whether 18- to 22-mo neurodevelopmental outcomes predicted functional outcomes at 7-8 y for survivors of the CoolCap study of therapeutic hypothermia for neonates with hypoxic-ischemic encephalopathy. RESULTS WeeFIM ratings were completed at 7-8 y of age on 62 (32 cooled; 30 standard care) of 135 surviving children who had had neurodevelopmental assessment at 18 mo. There was 1 refusal, 58 lost to follow-up, and 14 children whose centers declined to participate. Disability status at 18 mo was strongly associated with WeeFIM ratings (P < 0.001); there was no significant effect of treatment (P = 0.83). DISCUSSION Functional outcome at 7-8 y of survivors of neonatal encephalopathy is associated with 18-mo neurodevelopmental assessment, supporting the long-term predictive value of a favorable outcome at 18 mo assessed by published trials of therapeutic hypothermia. METHODS All surviving children who participated in the CoolCap study and were assessed at 18 mo were eligible for reassessment using the WeeFIM instrument that qualitatively measures self-care, mobility, and cognitive function. Center investigators obtained consent from the families for a certified researcher to administer the WeeFIM instrument by phone.
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Peliowski-Davidovich A. L’hypothermie chez les nouveau-nés présentant une encéphalopathie hypoxique-ischémique. Paediatr Child Health 2012. [DOI: 10.1093/pch/17.1.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Wintermark P, Hansen A, Gregas MC, Soul J, Labrecque M, Robertson RL, Warfield SK. Brain perfusion in asphyxiated newborns treated with therapeutic hypothermia. AJNR Am J Neuroradiol 2011; 32:2023-9. [PMID: 21979494 DOI: 10.3174/ajnr.a2708] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Induced hypothermia is thought to work partly by mitigating reperfusion injury in asphyxiated term neonates. The purpose of this study was to assess brain perfusion in the first week of life in these neonates. MATERIALS AND METHODS In this prospective cohort study, MR imaging and ASL-PI were used to assess brain perfusion in these neonates. We measured regional CBF values on 1-2 MR images obtained during the first week of life and compared these with values obtained in control term neonates. The same or later MR imaging scans were obtained to define the extent of brain injury. RESULTS Eighteen asphyxiated and 4 control term neonates were enrolled; 11 asphyxiated neonates were treated with hypothermia. Those developing brain injury despite being treated with induced hypothermia usually displayed hypoperfusion on DOL 1 and then hyperperfusion on DOL 2-3 in brain areas subsequently exhibiting injury. Asphyxiated neonates not treated with hypothermia who developed brain injury also displayed hyperperfusion on DOL 1-6 in brain areas displaying injury. CONCLUSIONS Our data show that ASL-PI may be useful for identifying asphyxiated neonates at risk of developing brain injury, whether or not hypothermia is administered. Because hypothermia for 72 hours may not prevent brain injury when hyperperfusion is found early in the course of neonatal hypoxic-ischemic encephalopathy, such neonates may be candidates for adjustments in their hypothermia therapy or for adjunctive neuroprotective therapies.
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Affiliation(s)
- P Wintermark
- Department of Radiology, Children’s Hospital Boston, Boston, MA, USA.
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Fleiss B, Parkington HC, Coleman HA, Dickinson H, Yawno T, Castillo-Melendez M, Hirst JJ, Walker DW. Effect of maternal administration of allopregnanolone before birth asphyxia on neonatal hippocampal function in the spiny mouse. Brain Res 2011; 1433:9-19. [PMID: 22169500 DOI: 10.1016/j.brainres.2011.11.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/30/2011] [Accepted: 11/12/2011] [Indexed: 10/15/2022]
Abstract
Clinically, treatment options where fetal distress is anticipated or identified are limited. Allopregnanolone is an endogenous steroid, that positively modulates the GABA(A) receptor, and that has anti-apoptotic and anti-excitotoxic actions, reducing brain damage in adult animal models of brain injury. We sought to determine if prophylactic treatment of the pregnant female with a single dose of this steroid could reduce birth asphyxia-induced losses in hippocampal function at 5 days of age (P5) in spiny mouse neonates (Acomys cahirinus). At 37 days gestation (term=39 days) and 1h before inducing birth asphyxia, spiny mice dams were injected subcutaneously (0.2 ml) with either 3mg/kg allopregnanolone or 20% w/v β-cyclodextrin vehicle. One hour later, fetuses were either delivered immediately by caesarean section (control group) or exposed to 7.5 min of in utero asphyxia, causing acidosis and hypoxia. At P5, ex vivo hippocampal plasticity was assessed, or brains collected to determine cell proliferation (proliferating cell nuclear antigen; PCNA) or calcium channel expression (inositol trisphosphate receptor type 1; IP(3)R1) using immunohistochemistry. Allopregnanolone partially prevented the decrease in long term potentiation at P5, and the asphyxia-induced increase in IP(3)R1 expression in CA1 pyramidal neurons. There was no effect of allopregnanolone on the asphyxia induced impairment of the input/output (I/O) curve and paired-pulse facilitation (PPF). In control birth pups, maternal allopregnanolone treatment caused significant changes in short term post-synaptic plasticity and also reduced hippocampal proliferation at P5. These findings show that allopregnanolone can modulate hippocampal development and synaptic function in a normoxic or hypoxic environment, possibly by modifying calcium metabolism. Best practice for treatment dose and timing of treatment will need to be carefully considered.
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Affiliation(s)
- Bobbi Fleiss
- Department of Physiology, Monash University, Clayton, Victoria 3800, Australia.
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Current controversies in newer therapies to treat birth asphyxia. Int J Pediatr 2011; 2011:848413. [PMID: 22164181 PMCID: PMC3228371 DOI: 10.1155/2011/848413] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 09/28/2011] [Indexed: 11/28/2022] Open
Abstract
Despite major advances in monitoring technology and knowledge of fetal and neonatal pathophysiology, neonatal hypoxic-ischemic encephalopathy (HIE) remains one of the main causes of severe adverse neurological outcome in children. Until recently, there were no therapies other than supportive measures. Over the past several years, mild hypothermia has been proven to be safe to treat HIE. Unfortunately, this neuroprotective strategy seems efficient in preventing brain injury in some asphyxiated newborns, but not in all of them. Thus, there is increasing interest to rapidly understand how to refine hypothermia therapy and add neuroprotective or neurorestorative strategies. Several promising newer treatments to treat birth asphyxia and prevent its devastating neurological consequences are currently being tested. In this paper, the physiopathology behind HIE, the currently available treatment, the potential alternatives, and the next steps before implementation of these other treatments are reviewed.
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Blanco D. Presente y futuro de la neuroprotección con hipotermia. An Pediatr (Barc) 2011; 75:295-7. [DOI: 10.1016/j.anpedi.2011.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 07/18/2011] [Accepted: 07/18/2011] [Indexed: 11/28/2022] Open
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