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Puzone S, Diplomatico M, Galderisi A, Montaldo P. Continuous glucose monitoring in neonates: challenges and opportunities. J Perinatol 2024; 44:1382-1383. [PMID: 38942928 DOI: 10.1038/s41372-024-02041-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/14/2024] [Accepted: 06/21/2024] [Indexed: 06/30/2024]
Affiliation(s)
- Simona Puzone
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli,", Naples, Italy
| | - Mario Diplomatico
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli,", Naples, Italy
- Department of Neonatal Intensive Care, AORN San Giuseppe Moscati, Avellino, Italy
| | - Alfonso Galderisi
- Department of Pediatrics, Pediatric Endocrinology, Yale University, New Haven, CT, USA
| | - Paolo Montaldo
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli,", Naples, Italy.
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.
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Ali MAM, Farghaly MAA, El-Dib I, Karnati S, Aly H, Acun C. Glucose instability and outcomes of neonates with hypoxic ischemic encephalopathy undergoing therapeutic hypothermia. Brain Dev 2024; 46:262-267. [PMID: 38782623 DOI: 10.1016/j.braindev.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 05/16/2024] [Accepted: 05/18/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND To investigate the prevalence and associated outcomes of glucose abnormalities in infants with hypoxic ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). METHODS Glucose values were reviewed in all HIE infants. Pearson's correlation was used to assess the association of hypo- and hyperglycemic episodes with neonatal brain MRI and neurodevelopmental outcomes (NDO) at 12 & 24 months. RESULTS Of 153 infants included, 31, 56 and 43 had episodes of hypo-, hyperglycemia and combined, respectively. Hyperglycemia and combined hypo/hyper had higher mortality (p = 0.035), seizures (p = 0.009), and longer hospitalization (p = 0.023). Hypo- and hyperglycemia were associated with parenchymal hemorrhages (p = 0.028 & p = 0.027, respectively). Hypoglycemia was associated with restricted diffusion (p = 0.014), while hyperglycemia was associated with cortical injuries (p = 0.045). Each hour of hyper- or hypoglycemia was associated with 5.2-5.8 times unfavorable outcomes (p < 0.001). CONCLUSION Blood glucose aberrations were detrimental in HIE infants treated with TH. Optimizing glucose management is crucial in this setting.
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Affiliation(s)
- Mahmoud A M Ali
- West Virginia University School of Medicine, Department of Pediatrics, Morgantown, WV 26505, USA; MetroHealth Medical Center, Case Western Reserve University, Department of Pediatrics, Division of Neonatology, Cleveland, OH 44109, USA.
| | - Mohsen A A Farghaly
- Cleveland Clinic Children's Hospital, Department of Neonatology, Cleveland, OH 44106, USA
| | - Injy El-Dib
- Biomedical Engineering Student, School of Engineering, Brown University, Providence, RI, USA
| | - Sreenivas Karnati
- Cleveland Clinic Children's Hospital, Department of Neonatology, Cleveland, OH 44106, USA
| | - Hany Aly
- Cleveland Clinic Children's Hospital, Department of Neonatology, Cleveland, OH 44106, USA
| | - Ceyda Acun
- Cleveland Clinic Children's Hospital, Department of Neonatology, Cleveland, OH 44106, USA
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Lagacé M, Tam EWY. Neonatal dysglycemia: a review of dysglycemia in relation to brain health and neurodevelopmental outcomes. Pediatr Res 2024:10.1038/s41390-024-03411-0. [PMID: 38972961 DOI: 10.1038/s41390-024-03411-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/27/2024] [Accepted: 06/29/2024] [Indexed: 07/09/2024]
Abstract
Neonatal dysglycemia has been a longstanding interest of research in neonatology. Adverse outcomes from hypoglycemia were recognized early but are still being characterized. Premature infants additionally introduced and led the reflection on the importance of neonatal hyperglycemia. Cohorts of infants following neonatal encephalopathy provided further information about the impacts of hypoglycemia and, more recently, highlighted hyperglycemia as a central concern for this population. Innovative studies exposed the challenges of management of neonatal glycemic levels with a "u-shape" relationship between dysglycemia and adverse neurological outcomes. Lately, glycemic lability has been recognized as a key factor in adverse neurodevelopmental outcomes. Research and new technologies, such as MRI and continuous glucose monitoring, offered novel insight into neonatal dysglycemia. Combining clinical, physiological, and epidemiological data allowed the foundation of safe operational definitions, including initiation of treatment, to delineate neonatal hypoglycemia as ≤47 mg/dL, and >150-180 mg/dL for neonatal hyperglycemia. However, questions remain about the appropriate management of neonatal dysglycemia to optimize neurodevelopmental outcomes. Research collaborations and clinical trials with long-term follow-up and advanced use of evolving technologies will be necessary to continue to progress the fascinating world of neonatal dysglycemia and neurodevelopment outcomes. IMPACT STATEMENT: Safe operational definitions guide the initiation of treatment of neonatal hypoglycemia and hyperglycemia. Innovative studies exposed the challenges of neonatal glycemia management with a "u-shaped" relationship between dysglycemia and adverse neurological outcomes. The importance of glycemic lability is also being recognized. However, questions remain about the optimal management of neonatal dysglycemia to optimize neurodevelopmental outcomes. Research collaborations and clinical trials with long-term follow-up and advanced use of evolving technologies will be necessary to progress the fascinating world of neonatal dysglycemia and neurodevelopment outcomes.
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Affiliation(s)
- Micheline Lagacé
- Faculty of Medicine, Clinician Investigator Program, University of British Columbia, Vancouver, BC, Canada
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Emily W Y Tam
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada.
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Damien J, Vannasing P, Tremblay J, Petitpas L, Marandyuk B, Balasingam T, El Jalbout R, Paquette N, Donofrio G, Birca A, Gallagher A, Pinchefsky EF. Relationship between EEG spectral power and dysglycemia with neurodevelopmental outcomes after neonatal encephalopathy. Clin Neurophysiol 2024; 163:160-173. [PMID: 38754181 DOI: 10.1016/j.clinph.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/28/2024] [Accepted: 03/23/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE We investigated how electroencephalography (EEG) quantitative measures and dysglycemia relate to neurodevelopmental outcomes following neonatal encephalopathy (NE). METHODS This retrospective study included 90 neonates with encephalopathy who received therapeutic hypothermia. EEG absolute spectral power was calculated during post-rewarming and 2-month follow-up. Measures of dysglycemia (hypoglycemia, hyperglycemia, and glycemic lability) and glucose variability were computed for the first 48 h of life. We evaluated the ability of EEG and glucose measures to predict neurodevelopmental outcomes at ≥ 18 months, using logistic regressions (with area under the receiver operating characteristic [AUROC] curves). RESULTS The post-rewarming global delta power (average all electrodes), hyperglycemia and glycemic lability predicted moderate/severe neurodevelopmental outcome separately (AUROC = 0.8, 95%CI [0.7,0.9], p < .001) and even more so when combined (AUROC = 0.9, 95%CI [0.8,0.9], p < .001). After adjusting for NE severity and magnetic resonance imaging (MRI) brain injury, only global delta power remained significantly associated with moderate/severe neurodevelopmental outcome (odds ratio [OR] = 0.9, 95%CI [0.8,1.0], p = .04), gross motor delay (OR = 0.9, 95%CI [0.8,1.0], p = .04), global developmental delay (OR = 0.9, 95%CI [0.8,1.0], p = .04), and auditory deficits (OR = 0.9, 95%CI [0.8,1.0], p = .03). CONCLUSIONS In NE, global delta power post-rewarming was predictive of outcomes at ≥ 18 months. SIGNIFICANCE EEG markers post-rewarming can aid prediction of neurodevelopmental outcomes following NE.
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Affiliation(s)
- Janie Damien
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Phetsamone Vannasing
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Julie Tremblay
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Laurence Petitpas
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Bohdana Marandyuk
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Thameya Balasingam
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Ramy El Jalbout
- Department of Radiology, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Natacha Paquette
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Gianluca Donofrio
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy; Service of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
| | - Ala Birca
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Service of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada
| | - Anne Gallagher
- Neurodevelopmental Optical Imaging Laboratory (LION Lab), Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Department of Psychology, University of Montreal, Montreal, QC, Canada.
| | - Elana F Pinchefsky
- Research Centre, Sainte-Justine University Hospital Centre, Montreal, QC, Canada; Service of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC, Canada.
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Laval N, Paquette M, Talsmat H, Marandyuk B, Wintermark P, Birca A, Pinchefsky EF, Tremblay S. Exposure to Maternal Diabetes during Pregnancy Is Associated with Aggravated Short-Term Neonatal and Neurological Outcomes following Perinatal Hypoxic-Ischemic Encephalopathy. Am J Perinatol 2024; 41:e1581-e1590. [PMID: 36918161 DOI: 10.1055/a-2053-7904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
OBJECTIVE Infants of diabetic mothers (IDM) are at higher risk of perinatal morbidities and glycemic instability, but the impact of maternal diabetes on neonatal and neurological short-term outcomes of neonates with hypoxic-ischemic encephalopathy (HIE) remains poorly described. Our objective was to determine the impact of maternal diabetes on neonatal and neurological short-term outcomes following neonatal HIE. STUDY DESIGN This was a retrospective single-center study including 102 term neonates with HIE who received therapeutic hypothermia (TH) treatment between 2013 and 2020. Multiple regression analysis was used to assess the relationship between the presence of maternal diabetes and short-term outcomes. RESULTS Neonates with HIE and maternal diabetes exposure had a significantly lower gestational age at birth (38.6 vs. 39.7 weeks of gestation, p = 0.005) and a significantly higher mean birth weight (3,588 ± 752 vs. 3,214 ± 514 g, p = 0.012). IDM with HIE were ventilated for longer duration (8 vs. 4 days, p = 0.0047) and had a longer neonatal intensive care unit (NICU) stay (18 vs. 11 days, p = 0.0483) as well as took longer time to reach full oral feed (15 vs. 7 days, p = 0.0432) compared with neonates of nondiabetic mother. Maternal diabetes was also associated with an increased risk of death or abnormal neurological examination at discharge in neonates with HIE (odds ratio: 6.41 [1.54-26.32]). CONCLUSION In neonates with HIE, maternal diabetes is associated with an increased risk of death or short-term neonatal morbidities, such as longer duration of ventilation, prolonged neonatal stay, greater need for tube feeding, and being discharged with an abnormal neurological examination. Strategies to prevent, reduce, or better control maternal diabetes during pregnancy should be prioritized to minimize complications after perinatal asphyxia. KEY POINTS · Maternal DB is associated with unfavorable outcomes.. · IDM have longer ventilatory support and tube feeding.. · IDM have higher risk of abnormal neurological examination..
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Affiliation(s)
- Nancy Laval
- CHU Ste-Justine Research Center, Montréal, QC, Canada
- Department of Neonatology, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Mariane Paquette
- CHU Ste-Justine Research Center, Montréal, QC, Canada
- Department of Neonatology, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Hamza Talsmat
- CHU Ste-Justine Research Center, Montréal, QC, Canada
| | | | - Pia Wintermark
- Department of Pediatrics, Montréal Children's Hospital, Montréal, QC, Canada
| | - Ala Birca
- CHU Ste-Justine Research Center, Montréal, QC, Canada
- Division of Neurology, Department of Neurosciences and Paediatrics, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Elana F Pinchefsky
- CHU Ste-Justine Research Center, Montréal, QC, Canada
- Division of Neurology, Department of Neurosciences and Paediatrics, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Sophie Tremblay
- CHU Ste-Justine Research Center, Montréal, QC, Canada
- Department of Neonatology, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
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J A, S S, P W, S W, P B, K M. Quality improvement and outcomes for neonates with hypoxic-ischemic encephalopathy: obstetrics and neonatal perspectives. Semin Perinatol 2024; 48:151904. [PMID: 38688744 DOI: 10.1053/j.semperi.2024.151904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Despite significant improvement in perinatal care and research, hypoxic ischemic encephalopathy (HIE) remains a global healthcare challenge. From both published research and reports of QI initiatives, we have identified a number of distinct opportunities that can serve as targets of quality improvement (QI) initiatives focused on reducing HIE. Specifically, (i) implementation of perinatal interventions to anticipate and timely manage high-risk deliveries; (ii) enhancement of team training and communication; (iii) optimization of early HIE diagnosis and management in referring centers and during transport; (iv) standardization of the approach when managing neonates with HIE during therapeutic hypothermia; (v) and establishment of protocols for family integration and follow-up, have been identified as important in successful QI initiatives. We also provide a framework and examples of tools that can be used to support QI work and discuss some of the perceived challenges and future opportunities for QI targeting HIE.
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Affiliation(s)
- Afifi J
- Department of Pediatrics, Neonatal-Perinatal Medicine, Dalhousie University, 5980 University Avenue, Halifax B3K6R8, Nova Scotia, Canada.
| | - Shivananda S
- Department of Pediatrics, Neonatal-Perinatal Medicine, University of British Columbia, Canada
| | - Wintermark P
- Department of Pediatrics, Neonatal-Perinatal Medicine, McGill University, Canada
| | - Wood S
- Department of Obstetrics and Gynecology, University of Calgary, Canada
| | - Brain P
- Department of Obstetrics and Gynecology, University of Calgary, Canada
| | - Mohammad K
- Department of Pediatrics, Section of Newborn Intensive Care, University of Calgary, Canada
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Puzone S, Diplomatico M, Caredda E, Maietta A, Miraglia Del Giudice E, Montaldo P. Hypoglycaemia and hyperglycaemia in neonatal encephalopathy: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2023; 109:18-25. [PMID: 37316160 DOI: 10.1136/archdischild-2023-325592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/30/2023] [Indexed: 06/16/2023]
Abstract
IMPORTANCE Although hypoglycaemia and hyperglycaemia represent the most common metabolic problem in neonates, there is still uncertainty regarding the effects of glucose homoeostasis on the neurological outcomes of infants with neonatal encephalopathy (NE). OBJECTIVE To systematically investigate the association between neonatal hypoglycaemia and hyperglycaemia with adverse outcome in children who suffered from NE. STUDY SELECTION We searched Pubmed, Embase and Web of Science databases to identify studies which reported prespecified outcomes and compared infants with NE who had been exposed to neonatal hypoglycaemia or hyperglycaemia with infants not exposed. DATA ANALYSIS We assessed the risk of bias (ROBINS-I), quality of evidence (Grading of Recommendations, Assessment, Development and Evaluation (GRADE)) for each of the studies. RevMan was used for meta-analysis (inverse variance, fixed effects). MAIN OUTCOME Death or neurodevelopmental outcomes at 18 months of age or later. RESULTS 82 studies were screened, 28 reviewed in full and 12 included. Children who were exposed to neonatal hypoglycaemia had higher odds of neurodevelopmental impairment or death (6 studies, 685 infants; 40.6% vs 25.4%; OR=2.17, 95% CI 1.46 to 3.25; p=0.0001). Neonatal exposure to hyperglycaemia was associated with death or neurodisability at 18 months or later (7 studies, 807 infants; 46.1% vs 28.0%; OR=3.07, 95% CI 2.17 to 4.35; p<0.00001). These findings were confirmed in the subgroup analysis, which included only the infants who underwent therapeutic hypothermia. CONCLUSIONS These data suggest that neonatal hypoglycaemia and hyperglycaemia may be associated with the neurodevelopmental outcome later on in infants with NE. Further studies with long-term follow-up are needed to optimise the metabolic management of these high-risk infants. PROSPERO REGISTRATION NUMBER CRD42022368870.
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Affiliation(s)
- Simona Puzone
- Department of Neonatal Intensive Care, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Mario Diplomatico
- Department of Neonatal Intensive Care, AORN San Giuseppe Moscati, Avellino, Italy
| | - Elisabetta Caredda
- Department of Neonatal Intensive Care, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Anna Maietta
- Department of Neonatal Intensive Care, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Paolo Montaldo
- Imperial Neonatal Service, Centre for Perinatal Neuroscience, Department of Paediatrics, Imperial College London, London, UK
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Wang J, Liu N, Zheng S, Wang X, Zhang P, Lu C, Wang L, Zhou W, Cheng G, Hu L. Association between continuous glucose profile during therapeutic hypothermia and unfavorable outcome in neonates with hypoxic-ischemic encephalopathy209 23-32. Early Hum Dev 2023; 187:105878. [PMID: 37944263 DOI: 10.1016/j.earlhumdev.2023.105878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/06/2023] [Accepted: 10/15/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The detection and management of blood glucose abnormalities in high-risk neonates are crucial for clinical care. The objective of the study was to investigate the continuous glucose profile of hypoxic-ischemic encephalopathy (HIE) patients in the whole-process of therapeutic hypothermia (TH) and its association with clinical and neurological outcomes. METHOD In this single-center retrospective study, HIE patients who received both TH and continuous glucose monitoring (CGM) were recruited from March 2016 to September 2021. RESULTS Of 47 neonates recruited, 24 had unfavorable outcome. Dysglycemia was most prevalent in the first 24 h of TH, among which hyperglycemia occurred more frequently. CGM showed that the duration, episodes and area under curve (AUC) of hypoglycemia were statistically different in neonates with different outcomes. The occurrence, longer duration, greater AUC of hypoglycemia and an early high coefficient of variation (CV%, CV = SD/mean) were associated with unfavorable outcomes (aOR 26.55 [2.02-348.5], aOR 2.11 [1.08-4.14], aOR 1.80 [1.11-2.91] and aOR respectively), while hyperglycemia was not. CONCLUSION During the whole process of TH, hypoglycemia and early unstable glycemic variability were strongly associated with unfavorable outcomes. CGM can instantly detect dysglycemia and facilitate precise glucose management in HIE neonates.
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Affiliation(s)
- Jing Wang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Ning Liu
- Department of Neonatology, General Hospital of Northern Theater Command, Shenyang, China
| | - Shiyi Zheng
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Xintong Wang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Peng Zhang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Chunmei Lu
- Department of Nursing, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Laishuan Wang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Wenhao Zhou
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China; Center for Molecular Medicine, Children's Hospital of Fudan University, Institutes of Biomedical Sciences, Fudan University, Shanghai 201102, China
| | - Guoqiang Cheng
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China.
| | - Liyuan Hu
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China.
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Improda N, Capalbo D, Poloniato A, Garbetta G, Dituri F, Penta L, Aversa T, Sessa L, Vierucci F, Cozzolino M, Vigone MC, Tronconi GM, del Pistoia M, Lucaccioni L, Tuli G, Munarin J, Tessaris D, de Sanctis L, Salerno M. Perinatal asphyxia and hypothermic treatment from the endocrine perspective. Front Endocrinol (Lausanne) 2023; 14:1249700. [PMID: 37929024 PMCID: PMC10623321 DOI: 10.3389/fendo.2023.1249700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Perinatal asphyxia is one of the three most important causes of neonatal mortality and morbidity. Therapeutic hypothermia represents the standard treatment for infants with moderate-severe perinatal asphyxia, resulting in reduction in the mortality and major neurodevelopmental disability. So far, data in the literature focusing on the endocrine aspects of both asphyxia and hypothermia treatment at birth are scanty, and many aspects are still debated. Aim of this narrative review is to summarize the current knowledge regarding the short- and long-term effects of perinatal asphyxia and of hypothermia treatment on the endocrine system, thus providing suggestions for improving the management of asphyxiated children. Results Involvement of the endocrine system (especially glucose and electrolyte disturbances, adrenal hemorrhage, non-thyroidal illness syndrome) can occur in a variable percentage of subjects with perinatal asphyxia, potentially affecting mortality as well as neurological outcome. Hypothermia may also affect endocrine homeostasis, leading to a decreased incidence of hypocalcemia and an increased risk of dilutional hyponatremia and hypercalcemia. Conclusions Metabolic abnormalities in the context of perinatal asphyxia are important modifiable factors that may be associated with a worse outcome. Therefore, clinicians should be aware of the possible occurrence of endocrine complication, in order to establish appropriate screening protocols and allow timely treatment.
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Affiliation(s)
- Nicola Improda
- Department of Translational Medical Sciences, Paediatric Endocrinology Unit, University “Federico II”, Naples, Italy
- Department of Emergency, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Donatella Capalbo
- Department of Mother and Child, Paediatric Endocrinology Unit, University Hospital “Federico II”, Naples, Italy
| | - Antonella Poloniato
- Neonatal Intensive Care Unit, San Raffaele University Hospital, Milan, Italy
| | - Gisella Garbetta
- Neonatal Intensive Care Unit, San Raffaele University Hospital, Milan, Italy
| | - Francesco Dituri
- Pediatric and Neonatal Unit, San Paolo Hospital, Civitavecchia, Italy
| | - Laura Penta
- Department of Pediatrics, University of Perugia, Perugia, Italy
| | - Tommaso Aversa
- Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy
| | - Linda Sessa
- Maternal and Child Department, Neonatal Intensive Care Unit (NICU) of University Hospital San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy
| | | | | | - Maria Cristina Vigone
- Endocrine Unit, Department of Pediatrics, University Hospital San Raffaele, Milan, Italy
| | | | - Marta del Pistoia
- Division of Neonatology and Neonatal Intensive Care Unit (NICU), Department of Clinical and Experimental Medicine, Santa Chiara University Hospital, Pisa, Italy
| | - Laura Lucaccioni
- Pediatric Unit, Department of Medical and Surgical Sciences of the Mother, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Gerdi Tuli
- Pediatric Endocrinology Unit, Regina Margherita Children’s Hospital, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Jessica Munarin
- Pediatric Endocrinology Unit, Regina Margherita Children’s Hospital, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Daniele Tessaris
- Pediatric Endocrinology Unit, Regina Margherita Children’s Hospital, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Luisa de Sanctis
- Pediatric Endocrinology Unit, Regina Margherita Children’s Hospital, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Mariacarolina Salerno
- Department of Translational Medical Sciences, Paediatric Endocrinology Unit, University “Federico II”, Naples, Italy
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Tetarbe M, Wisnowski JL, Geyer E, Tamrazi B, Wood T, Mietzsch U, Blüml S, Wu TW. Cerebral Glucose Concentration in Neonatal Hypoxic-Ischemic Encephalopathy during Therapeutic Hypothermia. J Pediatr 2023; 261:113560. [PMID: 37321289 DOI: 10.1016/j.jpeds.2023.113560] [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: 03/10/2023] [Revised: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To determine cerebral glucose concentration and its relationship with glucose infusion rate (GIR) and blood glucose concentration in neonatal encephalopathy during therapeutic hypothermia (TH). METHODS This was an observational study in which cerebral glucose during TH was quantified by magnetic resonance (MR) spectroscopy and compared with mean blood glucose at the time of scan. Clinical data (gestational age, birth weight, GIR, sedative use) that could affect glucose use were collected. The severity and pattern of brain injury on MR imaging were scored by a neuroradiologist. Student t test, Pearson correlation, repeated measures ANOVA, and multiple regression analysis were performed. RESULTS Three-hundred-sixty blood glucose values and 402 MR spectra from 54 infants (30 female infants; mean gestational age 38.6 ± 1.9 weeks) were analyzed. In total, 41 infants had normal-mild and 13 had moderate-severe injury. Median GIR and blood glucose during TH were 6.0 mg/kg/min (IQR 5-7) and 90 mg/dL (IQR 80-102), respectively. GIR did not correlate with blood or cerebral glucose. Cerebral glucose was significantly greater during than after TH (65.9 ± 22.9 vs 60.0 ± 25.2 mg/dL, P < .01), and there was a significant correlation between blood glucose and cerebral glucose during TH (basal ganglia: r = 0.42, thalamus: r = 0.42, cortical gray matter: r = 0.39, white matter: r = 0.39, all P < .01). There was no significant difference in cerebral glucose concentration in relation to injury severity or pattern. CONCLUSIONS During TH, cerebral glucose concentration is partly dependent on blood glucose concentration. Further studies to understand brain glucose use and optimal glucose concentrations during hypothermic neuroprotection are needed.
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Affiliation(s)
- Manas Tetarbe
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine of USC, Los Angeles, CA
| | - Jessica L Wisnowski
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA; Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Eduardo Geyer
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - Benita Tamrazi
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Thomas Wood
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - Stefan Blüml
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Tai-Wei Wu
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA.
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11
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Mietzsch U, Wood TR, Wu TW, Natarajan N, Glass HC, Gonzalez FF, Mayock DE, Comstock BA, Heagerty PJ, Juul SE, Wu YW. Early Glycemic State and Outcomes of Neonates With Hypoxic-Ischemic Encephalopathy. Pediatrics 2023; 152:e2022060965. [PMID: 37655394 PMCID: PMC10522925 DOI: 10.1542/peds.2022-060965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 09/02/2023] Open
Abstract
OBJECTIVES In infants with hypoxic-ischemic encephalopathy (HIE), conflicting information on the association between early glucose homeostasis and outcome exists. We characterized glycemic profiles in the first 12 hours after birth and their association with death and neurodevelopmental impairment (NDI) in neonates with moderate or severe HIE undergoing therapeutic hypothermia. METHODS This post hoc analysis of the High-dose Erythropoietin for Asphyxia and Encephalopathy trial included n = 491 neonates who had blood glucose (BG) values recorded within 12 hours of birth. Newborns were categorized based on their most extreme BG value. BG >200 mg/dL was defined as hyperglycemia, BG <50 mg/dL as hypoglycemia, and 50 to 200 mg/dL as euglycemia. Primary outcome was defined as death or any NDI at 22 to 36 months. We calculated odds ratios for death or NDI adjusted for factors influencing glycemic state (aOR). RESULTS Euglycemia was more common in neonates with moderate compared with severe HIE (63.6% vs 36.6%; P < .001). Although hypoglycemia occurred at similar rates in severe and moderate HIE (21.4% vs 19.5%; P = .67), hyperglycemia was more common in severe HIE (42.3% vs 16.9%; P < .001). Compared with euglycemic neonates, both, hypo- and hyperglycemic neonates had an increased aOR (95% confidence interval) for death or NDI (2.62; 1.47-4.67 and 1.77; 1.03-3.03) compared to those with euglycemia. Hypoglycemic neonates had an increased aOR for both death (2.85; 1.09-7.43) and NDI (2.50; 1.09-7.43), whereas hyperglycemic neonates had increased aOR of 2.52 (1.10-5.77) for death, but not NDI. CONCLUSIONS Glycemic profile differs between neonates with moderate and severe HIE, and initial glycemic state is associated death or NDI at 22 to 36 months.
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Affiliation(s)
- Ulrike Mietzsch
- Department of Pediatrics, Division of Neonatology, University of Washintgon School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Thomas R. Wood
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington
| | - Tai-Wei Wu
- Department of Pediatrics, Division of Neonatology, University of Southern California, Keck School of Medicine, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Niranjana Natarajan
- Department of Neurology, Division of Child Neurology, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington
| | - Hannah C. Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, California
- Department of Pediatrics, UCSF Benioff Children’s Hospital, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California; and
| | - Fernando F. Gonzalez
- Department of Pediatrics, UCSF Benioff Children’s Hospital, San Francisco, California
| | - Dennis E. Mayock
- Department of Pediatrics, Division of Neonatology, University of Washintgon School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Bryan A. Comstock
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Sunny E. Juul
- Department of Pediatrics, Division of Neonatology, University of Washintgon School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Yvonne W. Wu
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, California
- Department of Pediatrics, UCSF Benioff Children’s Hospital, San Francisco, California
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Giordano L, Perri A, Tiberi E, Sbordone A, Patti ML, D’Andrea V, Vento G. The Utility and Safety of a Continuous Glucose Monitoring System (CGMS) in Asphyxiated Neonates during Therapeutic Hypothermia. Diagnostics (Basel) 2023; 13:3018. [PMID: 37761385 PMCID: PMC10530216 DOI: 10.3390/diagnostics13183018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/26/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The present study was designed to assess the feasibility and reliability of a Continuous Glucose Monitoring System (CGMS) in a population of asphyxiated neonates during therapeutic hypothermia. METHODS This non-randomized feasibility study was conducted in the Neonatal Intensive Care Unit (NICU) facilities of Fondazione Policlinico A. Gemelli IRCSS. Infants matching the criteria for hypothermic treatment were included in this study and were connected to the CGMS (Medtronic, Northridge, CA, USA) within the first 12 h of life. Hypoglycemia was defined as a glucose value ≤ 47 mg/dL, and hyperglycemia was defined as a glucose value ≥ 180 mg/dL. Data obtained via the CGMS were compared with those obtained via a point-of-care blood glucometer (GTX). RESULTS The two measuring techniques were compared using the Modified Clarke Error Grid (MCEG). Sixteen infants were enrolled. The sensor had an average (standard deviation) duration of 93 (38) h. We collected 119 pairs of glycemia values (CGMVs) from the CGMS vs. GTX measurements. The CGMS detected twenty-five episodes of hypoglycemia and three episodes of hyperglycemia. All the CGMVs indicating hyperglycemia matched with the blood sample taken via the point-of-care glucometer. CONCLUSIONS The use of a CGMS would be useful as it could detect more episodes of disglycemia than standard care. Our data show poor results in terms of the accuracy of the CGMS in this particular setting.
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Affiliation(s)
- Lucia Giordano
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
- Department of Woman and Child Health and Public Health, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Alessandro Perri
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
| | - Eloisa Tiberi
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
| | - Annamaria Sbordone
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
| | - Maria Letizia Patti
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
| | - Vito D’Andrea
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
| | - Giovanni Vento
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
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Myrhaug HT, Kaasen A, Pay ASD, Henriksen L, Smedslund G, Saugstad OD, Blix E. Umbilical cord blood acid-base analysis at birth and long-term neurodevelopmental outcomes in children: a systematic review and meta-analysis. BJOG 2023. [PMID: 37041099 DOI: 10.1111/1471-0528.17480] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 12/07/2022] [Accepted: 01/23/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Umbilical cord blood acid-base sampling is routinely performed at many hospitals. Recent studies have questioned this practice and the association of acidosis with cerebral palsy. OBJECTIVE To investigate the associations between the results of umbilical cord blood acid-base analysis at birth and long-term neurodevelopmental outcomes and mortality in children. SEARCH STRATEGY We searched six databases using the search strategy: umbilical cord AND outcomes. SELECTION CRITERIA Randomised controlled trials, cohorts and case-control studies from high-income countries that investigated the association between umbilical cord blood analysis and neurodevelopmental outcomes and mortality from 1 year after birth in children born at term. DATA COLLECTION AND ANALYSIS We critically assessed the included studies, extracted data and conducted meta-analyses comparing adverse outcomes between children with and without acidosis, and the mean proportions of adverse outcomes. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. MAIN RESULTS We have very low confidence in the following findings: acidosis was associated with higher cognitive development scores compared with non-acidosis (mean difference 5.18, 95% CI 0.84-9.52; n = two studies). Children with acidosis also showed a tendency towards higher risk of death (relative risk [RR] 5.72, 95% CI 0.90-36.27; n = four studies) and CP (RR 3.40, 95% CI 0.86-13.39; n = four studies), although this was not statistically significant. The proportion of children with CP was 2.39/1000 across the studies, assessed as high certainty evidence. CONCLUSION Due to low certainty of evidence, the associations between umbilical cord blood gas analysis at delivery and long-term neurodevelopmental outcomes in children remains unclear.
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Affiliation(s)
- H T Myrhaug
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - A Kaasen
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - A S D Pay
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- Department of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - L Henriksen
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - G Smedslund
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - O D Saugstad
- Department of Paediatric Research, University of Oslo, Nydalen, Norway
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - E Blix
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
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Kamino D, Widjaja E, Brant R, Ly LG, Mamak E, Chau V, Moore AM, Williams T, Tam EW. Severity and duration of dysglycemia and brain injury among patients with neonatal encephalopathy. EClinicalMedicine 2023; 58:101914. [PMID: 37181414 PMCID: PMC10166778 DOI: 10.1016/j.eclinm.2023.101914] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 05/16/2023] Open
Abstract
Background Evidence is needed to inform thresholds for glycemic management in neonatal encephalopathy (NE). We investigated how severity and duration of dysglycemia relate to brain injury after NE. Methods A prospective cohort of 108 neonates ≥36 weeks gestational age with NE were enrolled between August 2014 and November 2019 at the Hospital for Sick Children, in Toronto, Canada. Participants underwent continuous glucose monitoring for 72 h, MRI at day 4 of life, and follow-up at 18 months. Receiver operating characteristic curves were used to assess the predictive value of glucose measures (minimum and maximum glucose, sequential 1 mmol/L glucose thresholds) during the first 72 h of life (HOL) for each brain injury pattern (basal ganglia, watershed, focal infarct, posterior-predominant). Linear and logistic regression analyses were used to assess the relationship between abnormal glycemia and 18-month outcomes (Bayley-III composite scores, Child Behavior Checklist [CBCL] T-scores, neuromotor score, cerebral palsy [CP], death), adjusting for brain injury severity. Findings Of 108 neonates enrolled, 102 (94%) had an MRI. Maximum glucose during the first 48 HOL best predicted basal ganglia (AUC = 0.811) and watershed (AUC = 0.858) injury. Minimum glucose was not predictive of brain injury (AUC <0.509). Ninety-one (89%) infants underwent follow-up assessments at 19.0 ± 1.7 months. A glucose threshold of >10.1 mmol/L during the first 48 HOL was associated with 5.8-point higher CBCL Internalizing Composite T-score (P = 0.029), 0.3-point worse neuromotor score (P = 0.035), 8.6-fold higher odds for CP diagnosis (P = 0.014). While the glucose threshold of >10.1 mmol/L during the first 48 HOL was associated with higher odds of the composite outcome of severe disability or death (OR 3.0, 95% CI 1.0-8.4, P = 0.042), it was not associated with the composite outcome of moderate-to-severe disability or death (OR 0.9, 95% CI 0.4-2.2, P = 0.801). All associations with outcome lost significance after adjusting for brain injury severity. Interpretation Maximum glucose concentration in the first 48 HOL is predictive of brain injury after NE. Further trials are needed to assess if protocols to control maximum glucose concentrations improve outcomes after NE. Funding Canadian Institutes for Health Research, National Institutes of Health, and SickKids Foundation.
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Affiliation(s)
- Daphne Kamino
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, M5G 0A4, Canada
| | - Elysa Widjaja
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, M5G 0A4, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Rollin Brant
- BC Children's Hospital Research Institute, Vancouver, BC, V5Z 4H4, Canada
- Department of Statistics, The University of British Columbia, Vancouver, BC, V6T 1Z4, Canada
| | - Linh G. Ly
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Eva Mamak
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Vann Chau
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, M5G 0A4, Canada
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Aideen M. Moore
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Tricia Williams
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Emily W.Y. Tam
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, M5G 0A4, Canada
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, M5G 1X8, Canada
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15
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Cannavò L, Perrone S, Gitto E. Brain-Oriented Strategies for Neuroprotection of Asphyxiated Newborns in the First Hours of Life. Pediatr Neurol 2023; 143:44-49. [PMID: 36996760 DOI: 10.1016/j.pediatrneurol.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 01/31/2023] [Accepted: 02/24/2023] [Indexed: 04/01/2023]
Abstract
Perinatal asphyxia represents the first cause of severe neurological disabilities and the second cause of neonatal death in term-born babies. Currently, no treatment can prevent immediate cell death from necrosis, but some therapeutic interventions, such as therapeutic hypothermia (TH), can reduce delayed cell death from apoptosis. TH significantly improves the combined outcome of mortality or major neurodevelopmental disability, but the number of patients to be treated is 7 to get 1 child with no adverse neurological outcome. The aim of this educational review is to analyze the other care strategies to be implemented to improve the neurological outcome of children with hypoxic ischemic encephalopathy (HIE). Hypocapnia, hypoglycemia, pain control, and functional brain monitoring are recognized as appropriate approaches to improve outcome in critically ill infants with HIE. Pharmacologic neuroprotective adjuncts are currently under investigation. New drugs such as allopurinol and melatonin seem to provide positive effects although more randomized controlled trials are required to establish the effective therapeutic scheme. In the meantime, sustaining the respiratory, metabolic, and cardiovascular system during TH can be a valuable aid in managing and treating the patient with HIE in an optimal way.
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Affiliation(s)
- Laura Cannavò
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Messina, Italy
| | - Serafina Perrone
- Neonatal Unit, University of Parma, Azienda Ospedaliero Universitaria di Parma, Parma, Italy.
| | - Eloisa Gitto
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Messina, Italy
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16
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Glycemia and Neonatal Encephalopathy: Outcomes in the LyTONEPAL (Long-Term Outcome of Neonatal Hypoxic EncePhALopathy in the Era of Neuroprotective Treatment With Hypothermia) Cohort. J Pediatr 2023:S0022-3476(23)00109-9. [PMID: 36828343 DOI: 10.1016/j.jpeds.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/05/2022] [Accepted: 02/12/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVES To assess in newborns with neonatal encephalopathy (NE), presumptively related to a peripartum hypoxic-ischemic event, the frequency of dysglycemia and its association with neonatal adverse outcomes. STUDY DESIGN We conducted a secondary analysis of LyTONEPAL (Long-Term Outcome of Neonatal hypoxic EncePhALopathy in the era of neuroprotective treatment with hypothermia), a population-based cohort study including 545 patients with moderate-to-severe NE. Newborns were categorized by the glycemia values assessed by routine clinical care during the first 3 days of life: normoglycemic (all glycemia measurements ranged from 2.2 to 8.3 mmol/L), hyperglycemic (at least 1 measurement >8.3 mmol/L), hypoglycemic (at least 1 measurement <2.2 mmol/L), or with glycemic lability (measurements included at least 1 episode of hypoglycemia and 1 episode of hyperglycemia). The primary adverse outcome was a composite outcome defined by death and/or brain lesions on magnetic resonance imaging, regardless of severity or location. RESULTS In total, 199 newborns were categorized as normoglycemic (36.5%), 74 hypoglycemic (13.6%), 213 hyperglycemic (39.1%), and 59 (10.8%) with glycemic lability, based on the 2593 glycemia measurements collected. The primary adverse outcome was observed in 77 (45.8%) normoglycemic newborns, 37 (59.7%) with hypoglycemia, 137 (67.5%) with hyperglycemia, and 40 (70.2%) with glycemic lability (P < .01). With the normoglycemic group as the reference, the aORs and 95% 95% CIs for the adverse outcome were significantly greater for the group with hyperglycemia (aOR 1.81; 95% CI 1.06-3.11). CONCLUSIONS Dysglycemia affects nearly two-thirds of newborns with NE and is independently associated with a greater risk of mortality and/or brain lesions on magnetic resonance imaging. TRIAL REGISTRATION NCT02676063.
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Kalogeropoulou MS, Iglesias-Platas I, Beardsall K. Should continuous glucose monitoring be used to manage neonates at risk of hypoglycaemia? Front Pediatr 2023; 11:1115228. [PMID: 37025284 PMCID: PMC10070986 DOI: 10.3389/fped.2023.1115228] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 02/28/2023] [Indexed: 04/08/2023] Open
Abstract
The National Institute for Clinical Excellence (NICE) now recommends that continuous glucose monitoring (CGM) be offered to adults and children with diabetes who are at risk from hypoglycaemia. Hypoglycaemia is common in the neonatal period, and is a preventable cause of poor neurodevelopmental outcome, but is CGM helpful in the management of neonates at risk of hypoglycaemia? Neonatal studies have shown that CGM can detect clinically silent hypoglycaemia, which has been associated with reduced executive and visual function in early childhood. Intervention trials have further shown CGM can support the targeting of glucose levels in high-risk extremely preterm neonates. In spite of significant advances in technology, including smaller sensors, better accuracy and factory calibration, further progress and adoption into clinical practice has been limited as current devices are not designed nor have regulatory approval for the specific needs of the newborn. The use of CGM has the potential to support clinical management, and prevention of hypoglycaemia but must be set within its current limitations. The data CGM provides however also provides an important opportunity to improve our understanding of potential risks of hypoglycaemia and the impact of clinical interventions to prevent it.
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Affiliation(s)
| | - Isabel Iglesias-Platas
- Department of Paediatrics, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Kathryn Beardsall
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
- Neonatal Intensive Care Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Correspondence: Kathryn Beardsall
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18
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Kalogeropoulou MS, Thomson L, Beardsall K. Continuous glucose monitoring during therapeutic hypothermia for hypoxic ischaemic encephalopathy: a feasibility study. Arch Dis Child Fetal Neonatal Ed 2022; 108:309-315. [PMID: 36600516 DOI: 10.1136/archdischild-2022-324593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Glucose dysregulation is common in infants with hypoxic ischaemic encephalopathy (HIE) and is likely to exacerbate cerebral injury. Infrequent measurement of glucose concentrations makes both identification and prevention of this risk challenging. Continuous glucose monitoring (CGM) has the potential to address both these challenges, but has not been explored in these infants. We aimed to evaluate the feasibility and potential impact of real-time CGM in term infants with HIE being treated with therapeutic hypothermia (TH). DESIGN Feasibility study. SETTING Tertiary-level neonatal unit, UK. PATIENTS Term infants with HIE undergoing TH. INTERVENTION A CGM sensor was inserted within 48 hours of birth and kept in situ for the first week of life. Clinical staff were blinded to the CGM recordings and clinical decisions were based on blood glucose assays. MAIN OUTCOME MEASURES (1) Accuracy of CGM values during and post TH, (2) Per cent of time spent outside the clinical range (2.6-10 mmol/L), (3) Episodes of hypoglycaemia and hyperglycaemia, (4) Adverse effects. RESULTS The accuracy of CGM values during TH were comparable to those when infants were normothermic. There was wide variation in per cent time outside the target range (2.6-10 mmol/L) between infants (median 5%, range 0%-34%). CGM identified 44% of infants with ≥1 episode of hypoglycaemia (<2.6 mmol/L) and 50% with ≥1 episode of hyperglycaemia (>10 mmol/L). No adverse events were observed. CONCLUSIONS This study demonstrates that CGM could be a useful adjunct for glucose monitoring in babies undergoing TH who are at risk of both hypoglycaemia and hyperglycaemia.
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Affiliation(s)
| | - Lynn Thomson
- Paediatrics, Cambridge University, Cambridge, UK
| | - Kathryn Beardsall
- School of Clinical Medicine, University of Cambridge, Cambridge, UK .,Paediatrics, Cambridge University, Cambridge, UK.,Neonatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Risk factors for unfavorable outcome at discharge of newborns with hypoxic-ischemic encephalopathy in the era of hypothermia. Pediatr Res 2022:10.1038/s41390-022-02352-w. [PMID: 36272997 DOI: 10.1038/s41390-022-02352-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/19/2022] [Accepted: 09/25/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To re-visit short-term outcomes and associated risk factors of newborns with hypoxic-ischemic encephalopathy (HIE) in an era where hypothermia treatment (HT) is widespread. METHODS This is a prospective population-based cohort in French neonatal intensive care units (NICU). Neonates born at or after 34 weeks of gestational age with HIE were included; main outcomes were in-hospital death and discharge with abnormal or normal MRI. Associations of early perinatal risk factors, present at birth or at admission to NICU, with these outcomes were studied. RESULTS A total of 794 newborns were included and HT was administered to 670 (84.4%); 18.3% died and 28.5% and 53.2% survived with abnormal and normal MRI, respectively. Severe neurological status, Apgar score at 5 mn ≤5, lactate at birth ≥11 mMoles/l, and glycemia ≥100 mg/dL at admission were associated with an increased risk of death (relative risk ratios (aRRR) (95% CI) 19.93 (10.00-39.70), 2.89 (1.22-1.62), 3.06 (1.60-5.83), and 2.55 (1.38-4.71), respectively). Neurological status only was associated with survival with abnormal MRI (aRRR (95% CI) 1.76 (1.15-2.68)). CONCLUSION Despite high use of HT in this cohort, 46.8% died or presented brain lesions. Early neurological and biological examinations were associated with unfavorable outcomes and these criteria could be used to target children who warrant further neuroprotective treatment. TRIAL REGISTRATION Clinical trial registry, NCT02676063, ClinicalTrials.gov. IMPACT In this population-based cohort of newborns with HIE where 84% received hypothermia, 46.8% still had an unfavorable evolution (death or survival with abnormal MRI). Risk factors for death were high lactate, low Apgar score, severe early neurological examination, and high glycaemia. While studies have established risk factors for HIE, few have focused on early perinatal factors associated with short-term prognosis. This French population-based cohort updates knowledge about early risk factors for adverse outcomes in the era of widespread cooling. In the future, criteria associated with an unfavorable evolution could be used to target children who would benefit from another neuroprotective strategy with hypothermia.
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Targeting Persistent Neuroinflammation after Hypoxic-Ischemic Encephalopathy-Is Exendin-4 the Answer? Int J Mol Sci 2022; 23:ijms231710191. [PMID: 36077587 PMCID: PMC9456443 DOI: 10.3390/ijms231710191] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/26/2022] [Accepted: 08/30/2022] [Indexed: 11/17/2022] Open
Abstract
Hypoxic-ischemic encephalopathy is brain injury resulting from the loss of oxygen and blood supply around the time of birth. It is associated with a high risk of death or disability. The only approved treatment is therapeutic hypothermia. Therapeutic hypothermia has consistently been shown to significantly reduce the risk of death and disability in infants with hypoxic-ischemic encephalopathy. However, approximately 29% of infants treated with therapeutic hypothermia still develop disability. Recent preclinical and clinical studies have shown that there is still persistent neuroinflammation even after treating with therapeutic hypothermia, which may contribute to the deficits seen in infants despite treatment. This suggests that potentially targeting this persistent neuroinflammation would have an additive benefit in addition to therapeutic hypothermia. A potential additive treatment is Exendin-4, which is a glucagon-like peptide 1 receptor agonist. Preclinical data from various in vitro and in vivo disease models have shown that Exendin-4 has anti-inflammatory, mitochondrial protective, anti-apoptotic, anti-oxidative and neurotrophic effects. Although preclinical studies of the effect of Exendin-4 in perinatal hypoxic-ischemic brain injury are limited, a seminal study in neonatal mice showed that Exendin-4 had promising neuroprotective effects. Further studies on Exendin-4 neuroprotection for perinatal hypoxic-ischemic brain injury, including in large animal translational models are warranted to better understand its safety, window of opportunity and effectiveness as an adjunct with therapeutic hypothermia.
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21
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Parmentier CEJ, de Vries LS, van der Aa NE, Eijsermans MJC, Harteman JC, Lequin MH, Swanenburg de Veye HFN, Koopman-Esseboom C, Groenendaal F. Hypoglycemia in Infants with Hypoxic-Ischemic Encephalopathy Is Associated with Additional Brain Injury and Worse Neurodevelopmental Outcome. J Pediatr 2022; 245:30-38.e1. [PMID: 35120986 DOI: 10.1016/j.jpeds.2022.01.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/04/2022] [Accepted: 01/26/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine the incidence of hypoglycemia among infants with hypoxic-ischemic encephalopathy (HIE) who received therapeutic hypothermia, and to assess whether infants with hypoglycemia had more brain injury on magnetic resonance imaging (MRI) or differences in neurodevelopmental outcome. STUDY DESIGN Single-center, retrospective cohort study including infants cooled for HIE. Hypoglycemia (blood glucose <36.0 mg/dL <2 hours and <46.8 mg/dL ≥2 hours after birth) was analyzed in the period before brain MRI. Brain injury was graded using a validated score. Motor and neurocognitive outcomes were assessed at 2 years for all survivors, and 5.5 years for a subset who had reached this age. RESULTS Of 223 infants analyzed, 79 (35.4%) had hypoglycemia. MRI was performed in 187 infants. Infants with hypoglycemia (n = 65) had higher brain injury scores (P = .018). After adjustment for HIE severity, hypoglycemia remained associated with higher injury scores (3.6 points higher; 95% CI, 0.8-6.4). Hyperglycemia did not affect MRI scores. In survivors at 2 years (n = 154) and 5.5 years (n = 102), a univariable analysis showed lower 2-year motor scores and lower motor and cognitive scores at preschool age in infants with hypoglycemia. After adjustment for HIE severity, infants with hypoglycemia had 9 points lower IQs (P = .023) and higher odds of adverse outcomes at preschool age (3.6; 95% CI, 1.4-9.0). CONCLUSIONS More than one-third of infants cooled for HIE had hypoglycemia. These infants had a higher degree of brain injury on MRI and lower cognitive function at preschool age. Strategies to avoid hypoglycemia should be optimized in this setting.
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Affiliation(s)
- Corline E J Parmentier
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Niek E van der Aa
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Maria J C Eijsermans
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Johanneke C Harteman
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Maarten H Lequin
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Henriette F N Swanenburg de Veye
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Corine Koopman-Esseboom
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands.
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22
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Baştuğ O, İnan DB, Özdemir A, Çelik B, Baştuğ F, Karakükcü Ç. Tubular calcium, magnesium, and phosphate excretion during therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy: A prospective study. Arch Pediatr 2021; 28:647-651. [PMID: 34688511 DOI: 10.1016/j.arcped.2021.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/30/2021] [Accepted: 09/26/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Hypocalcemia, hypomagnesemia, and hyperphosphatemia are common electrolyte disturbances in perinatal asphyxia (PA). Different reasons have been proposed for these electrolyte disturbances. This study investigated the effect of the urinary excretion of calcium (Ca), magnesium (Mg), and phosphorus (P) on the serum levels of these substances in babies who were treated using therapeutic hypothermia for hypoxic ischemic encephalopathy (HIE) caused by PA. This study sheds light on the pathophysiology that may cause changes in the serum values of these electrolytes. METHODS This study included 21 healthy newborns (control group) and 38 patients (HIE group) who had undergone therapeutic hypothermia due to HIE. Only infants with a gestational age of 36 weeks and above and a birth weight of 2000 g and above were evaluated. The urine and serum Ca, Mg, P, and creatinine levels of all infants were evaluated at 24, 48, and 72 h. RESULTS The lower serum Ca value and the higher serum P value of the HIE group were found to be statistically significant compared to the control group (p<0.05). There was no significant difference in serum Mg values between the groups. However, hypomagnesemia was detected in five patients from the HIE group. The urine excretion of FeCa and FeMg at 24 h, and FeP excretion at 48 and 72 h were found to be significantly higher in the HIE group compared to the control group. CONCLUSIONS This study determined that the urinary excretion of Ca, Mg, and P has an effect on the serum Ca, Mg, and P levels of infants with HIE.
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Affiliation(s)
- Osman Baştuğ
- Neonatal Unit, Health Sciences University, Kayseri City Hospital, Kayseri, Turkey.
| | - Doğan Bahadır İnan
- Department of Pediatrics, Health Sciences University, Kayseri City Hospital, Kayseri, Turkey
| | - Ahmet Özdemir
- Neonatal Unit, Health Sciences University, Kayseri City Hospital, Kayseri, Turkey
| | - Binnaz Çelik
- Department of Pediatrics, Health Sciences University, Kayseri City Hospital, Kayseri, Turkey
| | - Funda Baştuğ
- Department of Pediatric Nephrology, Health Sciences University, Kayseri City Hospital, Kayseri, Turkey
| | - Çiğdem Karakükcü
- Department of Biochemistry, Health Sciences University, Kayseri City Hospital, Kayseri, Turkey
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23
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Wintermark P, Mohammad K, Bonifacio SL. Proposing a care practice bundle for neonatal encephalopathy during therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101303. [PMID: 34711527 DOI: 10.1016/j.siny.2021.101303] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neonates with neonatal encephalopathy (NE) often present with multi-organ dysfunction that requires multidisciplinary specialized management. Care of the neonate with NE is thus complex with interaction between the brain and various organ systems. Illness severity during the first days of birth, and not only during the initial hypoxia-ischemia event, is a significant predictor of adverse outcomes in neonates with NE treated with therapeutic hypothermia (TH). We thus propose a care practice bundle dedicated to support the injured neonatal brain that is based on the current best evidence for each organ system. The impact of using such bundle on outcomes in NE remains to be demonstrated.
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Affiliation(s)
- Pia Wintermark
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, 28 Oki Drive NW, T3B 6A8, Calgary, AB, Canada.
| | - Sonia L Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, 750 Welch Road, Suite 315, 94304, Palo Alto, CA, USA.
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- Newborn Brain Society, PO Box 200783, Roxbury Crossing, 02120, MA, USA
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24
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Krishnan V, Kumar V, Variane GFT, Carlo WA, Bhutta ZA, Sizonenko S, Hansen A, Shankaran S, Thayyil S. Need for more evidence in the prevention and management of perinatal asphyxia and neonatal encephalopathy in low and middle-income countries: A call for action. Semin Fetal Neonatal Med 2021; 26:101271. [PMID: 34330679 PMCID: PMC8650826 DOI: 10.1016/j.siny.2021.101271] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although low- and middle-income countries (LMICs) shoulder 90 % of the neonatal encephalopathy (NE) burden, there is very little evidence base for prevention or management of this condition in these settings. A variety of antenatal factors including socio-economic deprivation, undernutrition and sub optimal antenatal and intrapartum care increase the risk of NE, although little is known about the underlying mechanisms. Implementing interventions based on the evidence from high-income countries to LMICs, may cause more harm than benefit as shown by the increased mortality and lack of neuroprotection with cooling therapy in the hypothermia for moderate or severe NE in low and middle-income countries (HELIX) trial. Pooled data from pilot trials suggest that erythropoietin monotherapy reduces death and disability in LMICs, but this needs further evaluation in clinical trials. Careful attention to supportive care, including avoiding hyperoxia, hypocarbia, hypoglycemia, and hyperthermia, are likely to improve outcomes until specific neuroprotective or neurorestorative therapies available.
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Affiliation(s)
- Vaisakh Krishnan
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK.
| | - Vijay Kumar
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK.
| | | | - Waldemar A Carlo
- Division of Neonatology, University of Alabama at Birmingham and Children's Hospital of Alabama, Birmingham, USA.
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | | | - Anne Hansen
- Division of Newborn Medicine, Boston Children's Hospital, Boston, USA.
| | | | - Sudhin Thayyil
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK.
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25
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Tam EWY, Kamino D, Shatil AS, Chau V, Moore AM, Brant R, Widjaja E. Hyperglycemia associated with acute brain injury in neonatal encephalopathy. Neuroimage Clin 2021; 32:102835. [PMID: 34601311 PMCID: PMC8496301 DOI: 10.1016/j.nicl.2021.102835] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To identify how alterations in glucose levels are associated with regional brain injury in neonatal encephalopathy. METHODS This was a prospective cohort study of 102 newborns with neonatal encephalopathy, with continuous glucose monitoring for 72 h. 97 (95%) completed 72 h of therapeutic hypothermia. Brain imaging around day 5 of life included diffusion tensor imaging and MR spectroscopy. Regions of interest were placed for both DTI and MR spectroscopy, and tractography of the optic radiation and corticospinal tract were evaluated. Linear regression models related each MR metric with minimum and maximum glucose values during each day of life, adjusting for 5-minute Apgar scores and umbilical artery pH. RESULTS Higher maximum glucose levels on the first day of life were associated with widespread changes in mean diffusivity in the anterior and posterior white matter, splenium of the corpus callosum, lentiform nucleus, pulvinar nucleus of the thalamus, posterior limb of the internal capsule, and optic radiations, thus including regions traditionally associated with hypoxia-ischemia or hypoglycemia. No associations were found between lower minimum glucose levels and DTI changes in any regions tested, or between glucose levels and MR spectroscopy. CONCLUSIONS In this cohort of neonatal encephalopathy with therapeutic hypothermia, higher maximal glucose on the first day of life was associated with widespread microstructural changes, but lower minimum glucose levels were not associated with changes in any of the regions tested. Long-term follow-up will determine if imaging findings translate to long-term outcomes.
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Affiliation(s)
- Emily W Y Tam
- Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada; Neurosciences and Mental Health Program, Hospital for Sick Children Research Institute, Toronto, ON, Canada.
| | - Daphne Kamino
- Neurosciences and Mental Health Program, Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Anwar S Shatil
- Neurosciences and Mental Health Program, Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Vann Chau
- Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada
| | - Aideen M Moore
- Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada
| | - Rollin Brant
- Department of Statistics, The University of British Columbia, Vancouver, BC, Canada
| | - Elysa Widjaja
- Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada; Neurosciences and Mental Health Program, Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Radiology, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada
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26
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Pinchefsky EF, Schneider J, Basu S, Tam EWY, Gale C. Nutrition and management of glycemia in neonates with neonatal encephalopathy treated with hypothermia. Semin Fetal Neonatal Med 2021; 26:101268. [PMID: 34301501 DOI: 10.1016/j.siny.2021.101268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Adequate nutrition and glycemic homeostasis are increasingly recognized as potentially neuroprotective for the developing brain. In the context of hypoxia-ischemia, evidence is scarce regarding optimal nutritional support and administration route, as well as the short- and long-term consequences of such interventions. In this review, we summarize current knowledge on disturbances of brain metabolism of glucose and substrates by hypoxia-ischemia, and compound effects of these mechanisms on brain injury characterized by specific patterns on EEG and MRI. Risks and benefits of nutrition delivery via parenteral or enteral routes are examined. Nutrition could mitigate adverse neurodevelopmental outcomes, and the impact of nutritional strategies and specific nutritional interventions are reviewed. Limited literature highlights the need for further studies to understand the changes in energy metabolism during and after hypoxic-ischemic injury, to optimize nutritional regimens and glucose management, and to inform the neuroprotective role of nutrition.
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Affiliation(s)
- E F Pinchefsky
- Division of Neurology, Department of Paediatrics, CHU Sainte-Justine, University of Montréal, CHU Sainte-Justine Research Center, Department of Neurosciences, Montreal, QC, Canada.
| | - J Schneider
- Department of Woman-Mother-Child, Clinic of Neonatology, University Hospital Center and University of Lausanne, Lausanne, Switzerland.
| | - S Basu
- Department of Paediatrics, The George Washington University. Division of Neonatology, Children's National Hospital, Washington, DC, USA.
| | - E W Y Tam
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Program in Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada.
| | - C Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK.
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27
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Ottolini KM, Basu SK, Herrera N, Govindan V, Mashat S, Vezina G, Ridore M, Bost J, Chang T, Massaro AN. Positive fluid balance is associated with death and severity of brain injury in neonates with hypoxic-ischemic encephalopathy. J Perinatol 2021; 41:1331-1338. [PMID: 33649446 PMCID: PMC10363283 DOI: 10.1038/s41372-021-00988-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 01/15/2021] [Accepted: 02/03/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To investigate the association between fluid balance during therapeutic hypothermia (TH) and severity of brain injury on magnetic resonance imaging (MRI) in neonates with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN This is a secondary analysis of data from a prospective observational study in neonates with HIE. Daily net positive fluid balance during TH was investigated for association with the adverse primary outcome of death or moderate-to-severe brain injury on MRI using multivariable logistic regression. RESULTS Of the 150 neonates included, 50 suffered adverse outcome and had significantly higher net positive fluid balance (53 vs. 19 ml/kg/day, p < 0.01) during first 24 hours of TH. Neonates with a net positive fluid balance (>25 ml/kg/day) at 24 hours of TH had 3.4 (95% CI 1.3-9) times higher odds of adverse outcome. CONCLUSIONS Positive fluid balance during TH in neonates with HIE is independently associated with death or moderate-to-severe brain injury on MRI.
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Affiliation(s)
- Katherine M Ottolini
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
- Department of Neonatology, 18th Healthcare Operations Squadron, Kadena AB, Okinawa, Japan
- Department of Pediatrics, Division of Neonatology, Uniformed Services University, Bethesda, MD, USA
| | - Sudeepta K Basu
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
| | - Nicole Herrera
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, USA
| | - Vedavalli Govindan
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA
| | - Suleiman Mashat
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
| | - Gilbert Vezina
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, DC, USA
| | - Michelande Ridore
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
| | - James Bost
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, USA
| | - Taeun Chang
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Epilepsy, Neurophysiology & Critical Care, Children's National Hospital, Washington, DC, USA
| | - An N Massaro
- Division of Neonatology, Children's National Hospital, Washington, DC, USA.
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA.
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28
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Lear CA, Davidson JO, Dhillon SK, King VJ, Lear BA, Magawa S, Maeda Y, Ikeda T, Gunn AJ, Bennet L. Effects of antenatal dexamethasone and hyperglycemia on cardiovascular adaptation to asphyxia in preterm fetal sheep. Am J Physiol Regul Integr Comp Physiol 2020; 319:R653-R665. [PMID: 33074015 DOI: 10.1152/ajpregu.00216.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Antenatal glucocorticoids improve outcomes among premature infants but are associated with hyperglycemia, which can exacerbate hypoxic-ischemic injury. It is still unclear how antenatal glucocorticoids or hyperglycemia modulate fetal cardiovascular adaptations to severe asphyxia. In this study, preterm fetal sheep received either saline or 12 mg im maternal dexamethasone, followed 4 h later by complete umbilical cord occlusion (UCO) for 25 min. An additional cohort of fetuses received titrated glucose infusions followed 4 h later by UCO to control for the possibility that hyperglycemia contributed to the cardiovascular effects of dexamethasone. Fetuses were studied for 7 days after UCO. Maternal dexamethasone was associated with fetal hyperglycemia (P < 0.001), increased arterial pressure (P < 0.001), and reduced femoral (P < 0.005) and carotid (P < 0.05) vascular conductance before UCO. UCO was associated with bradycardia, femoral vasoconstriction, and transient hypertension. For the first 5 min of UCO, fetal blood pressure in the dexamethasone-asphyxia group was greater than saline-asphyxia (P < 0.001). However, the relative increase in arterial pressure was not different from saline-asphyxia. Fetal heart rate and femoral vascular conductance fell to similar nadirs in both saline and dexamethasone-asphyxia groups. Dexamethasone did not affect the progressive decline in femoral vascular tone or arterial pressure during continuing UCO. By contrast, there were no effects of glucose infusions on the response to UCO. In summary, maternal dexamethasone but not fetal hyperglycemia increased fetal arterial pressure before and for the first 5 min of prolonged UCO but did not augment the cardiovascular adaptations to acute asphyxia.
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Affiliation(s)
- Christopher A Lear
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Simerdeep K Dhillon
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Victoria J King
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Benjamin A Lear
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Shoichi Magawa
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Yoshiki Maeda
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.,Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Mie, Japan
| | - Alistair J Gunn
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- The Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
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29
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Iafusco D, Zanfardino A, Bonfanti R, Rabbone I, Tinto N, Iafusco F, Meola S, Gicchino MF, Ozen G, Casaburo F, Piscopo A, Miraglia Del Giudice E, Barbetti F. Congenital diabetes mellitus. Minerva Pediatr 2020; 72:240-249. [PMID: 32274916 DOI: 10.23736/s0026-4946.20.05838-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Congenital diabetes mellitus is a rare disorder characterized by hyperglycemia that occurs shortly after birth. We define "Diabetes of Infancy" if hyperglycemia onset before 6 months of life. From the clinical point of view, we distinguish two main types of diabetes of infancy: transient (TNDM), which remits spontaneously, and permanent (PNDM), which requires lifelong treatment. TNDM may relapse later in life. About 50% of cases are transient (TNDM) and 50% permanent. Clinical manifestations include severe intrauterine growth retardation, hyperglycemia and dehydration. A wide range of different associated clinical signs including facial dysmorphism, deafness and neurological, cardiac, kidney or urinary tract anomalies are reported. Developmental delay and learning difficulties may also be observed. In this paper we review all the causes of congenital diabetes and all genes and syndromes involved in this pathology. The discovery of the pathogenesis of most forms of congenital diabetes has made it possible to adapt the therapy to the diagnosis and in the forms of alteration of the potassium channels of the pancreatic Beta cells the switch from insulin to glibenclamide per os has greatly improved the quality of life. Congenital diabetes, although it is a very rare form, has been at the must of research in recent years especially for pathogenesis and pharmacogenetics. The most striking difference compared to the more frequent autoimmune diabetes in children (type 1 diabetes) is the possibility of treatment with hypoglycemic agents and the apparent lower frequency of chronic complications.
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Affiliation(s)
- Dario Iafusco
- Department of Pediatrics, University of Campania "Luigi Vanvitelli", Naples, Italy -
| | - Angela Zanfardino
- Department of Pediatrics, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Riccardo Bonfanti
- Unit of Pediatric Diabetology, Department of Pediatrics, Diabetes Research Institute, San Raffaele Scientific Institute, Milan, Italy
| | - Ivana Rabbone
- Hub Regional Center of Pediatric Diabetology, Department of Science of Health, Maggiore della Carità University Hospital, University of Eastern Piedmont, Novara, Italy
| | - Nadia Tinto
- CEINGE Advanced Biotechnologies, Department of Molecular Medicine and Medical Biotechnology, Federico II University of Naples, Naples, Italy
| | - Fernanda Iafusco
- CEINGE Advanced Biotechnologies, Department of Molecular Medicine and Medical Biotechnology, Federico II University of Naples, Naples, Italy
| | - Serena Meola
- CEINGE Advanced Biotechnologies, Department of Molecular Medicine and Medical Biotechnology, Federico II University of Naples, Naples, Italy
| | - Maria F Gicchino
- Department of Pediatrics, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Gulsum Ozen
- Department of Pediatrics, University of Health Science, Ankara Training and Research Hospital, Ankara, Turkey
| | - Francesca Casaburo
- Department of Pediatrics, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alessia Piscopo
- Department of Pediatrics, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Fabrizio Barbetti
- Department of Experimental Medicine, Tor Vergata University, Rome, Italy
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