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Pavel AM, Rennie JM, de Vries LS, Mathieson SR, Livingstone V, Finder M, Foran A, Shah DK, Pressler RM, Weeke LC, Dempsey EM, Murray DM, Boylan GB. Temporal evolution of electrographic seizures in newborn infants with hypoxic-ischaemic encephalopathy requiring therapeutic hypothermia: a secondary analysis of the ANSeR studies. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:214-224. [PMID: 38246187 PMCID: PMC10864190 DOI: 10.1016/s2352-4642(23)00296-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Despite extensive research on neonatal hypoxic-ischaemic encephalopathy, detailed information about electrographic seizures during active cooling and rewarming of therapeutic hypothermia is sparse. We aimed to describe temporal evolution of seizures and determine whether there is a correlation of seizure evolution with 2-year outcome. METHODS This secondary analysis included newborn infants recruited from eight European tertiary neonatal intensive care units for two multicentre studies (a randomised controlled trial [NCT02431780] and an observational study [NCT02160171]). Infants were born at 36+0 weeks of gestation with moderate or severe hypoxic-ischaemic encephalopathy and underwent therapeutic hypothermia with prolonged conventional video-electroencephalography (EEG) monitoring for 10 h or longer from the start of rewarming. Seizure burden characteristics were calculated based on electrographic seizures annotations: hourly seizure burden (minutes of seizures within an hour) and total seizure burden (minutes of seizures within the entire recording). We categorised infants into those with electrographic seizures during active cooling only, those with electrographic seizures during cooling and rewarming, and those without seizures. Neurodevelopmental outcomes were determined using the Bayley's Scales of Infant and Toddler Development, Third Edition (BSID-III), the Griffiths Mental Development Scales (GMDS), or neurological assessment. An abnormal outcome was defined as death or neurodisability at 2 years. Neurodisability was defined as a composite score of 85 or less on any subscales for BSID-III, a total score of 87 or less for GMDS, or a diagnosis of cerebral palsy (dyskinetic cerebral palsy, spastic quadriplegia, or mixed motor impairment) or epilepsy. FINDINGS Of 263 infants recruited between Jan 1, 2011, and Feb 7, 2017, we included 129 infants: 65 had electrographic seizures (43 during active cooling only and 22 during and after active cooling) and 64 had no seizures. Compared with infants with seizures during active cooling only, those with seizures during and after active cooling had a longer seizure period (median 12 h [IQR 3-28] vs 68 h [35-86], p<0·0001), more seizures (median 12 [IQR 5-36] vs 94 [24-134], p<0·0001), and higher total seizure burden (median 69 min [IQR 22-104] vs 167 min [54-275], p=0·0033). Hourly seizure burden peaked at about 20-24 h in both groups, and infants with seizures during and after active cooling had a secondary peak at 85 h of age. When combined, worse EEG background (major abnormalities and inactive background) at 12 h and 24 h were associated with the seizure group: compared with infants with a better EEG background (normal, mild, or moderate abnormalities), infants with a worse EEG background were more likely to have seizures after cooling at 12 h (13 [54%] of 24 vs four [14%] of 28; odds ratio 7·09 [95% CI 1·88-26·77], p=0·0039) and 24 h (14 [56%] of 25 vs seven [18%] of 38; 5·64 [1·81-17·60], p=0·0029). There was a significant relationship between EEG grade at 12 h (four categories) and seizure group (p=0·020). High total seizure burden was associated with increased odds of an abnormal outcome at 2 years of age (odds ratio 1·007 [95% CI 1·000-1·014], p=0·046), with a medium negative correlation between total seizure burden and BSID-III cognitive score (rS=-0·477, p=0·014, n=26). INTERPRETATION Overall, half of infants with hypoxic-ischaemic encephalopathy had electrographic seizures and a third of those infants had seizures beyond active cooling, with worse outcomes. These results raise the importance of prolonged EEG monitoring of newborn infants with hypoxic-ischaemic encephalopathy not only during active cooling but throughout the rewarming phase and even longer when seizures are detected. FUNDING Wellcome Trust, Science Foundation Ireland, and the Irish Health Research Board.
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Affiliation(s)
- Andreea M Pavel
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Janet M Rennie
- Institute for Women's Health, University College London, London, UK
| | - Linda S de Vries
- Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Sean R Mathieson
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Vicki Livingstone
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Mikael Finder
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden; Division of Paediatrics, Department CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Adrienne Foran
- Department of Neonatal Medicine, Rotunda Hospital, Dublin, Ireland
| | - Divyen K Shah
- Royal London Hospital, London, UK; London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ronit M Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Lauren C Weeke
- Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Eugene M Dempsey
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Deirdre M Murray
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Geraldine B Boylan
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
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Chanana V, Hackett M, Deveci N, Aycan N, Ozaydin B, Cagatay NS, Hanalioglu D, Kintner DB, Corcoran K, Yapici S, Camci F, Eickhoff J, Frick KM, Ferrazzano P, Levine JE, Cengiz P. TrkB-mediated sustained neuroprotection is sex-specific and Erα-dependent in adult mice following neonatal hypoxia ischemia. Biol Sex Differ 2024; 15:1. [PMID: 38178264 PMCID: PMC10765746 DOI: 10.1186/s13293-023-00573-0] [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: 09/04/2023] [Accepted: 12/07/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Neonatal hypoxia ischemia (HI) related brain injury is one of the major causes of life-long neurological morbidities that result in learning and memory impairments. Evidence suggests that male neonates are more susceptible to the detrimental effects of HI, yet the mechanisms mediating these sex-specific responses to neural injury in neonates remain poorly understood. We previously tested the effects of treatment with a small molecule agonist of the tyrosine kinase B receptor (TrkB), 7,8-dihydroxyflavone (DHF) following neonatal HI and determined that females, but not males exhibit increased phosphorylation of TrkB and reduced apoptosis in their hippocampi. Moreover, these female-specific effects of the TrkB agonist were found to be dependent upon the expression of Erα. These findings demonstrated that TrkB activation in the presence of Erα comprises one pathway by which neuroprotection may be conferred in a female-specific manner. The goal of this study was to determine the role of Erα-dependent TrkB-mediated neuroprotection in memory and anxiety in young adult mice exposed to HI during the neonatal period. METHODS In this study, we used a unilateral hypoxic ischemic (HI) mouse model. Erα+/+ or Erα-/- mice were subjected to HI on postnatal day (P) 9 and mice were treated with either vehicle control or the TrkB agonist, DHF, for 7 days following HI. When mice reached young adulthood, we used the novel object recognition, novel object location and open field tests to assess long-term memory and anxiety-like behavior. The brains were then assessed for tissue damage using immunohistochemistry. RESULTS Neonatal DHF treatment prevented HI-induced decrements in recognition and location memory in adulthood in females, but not in males. This protective effect was absent in female mice lacking Erα. The female-specific improved recognition and location memory outcomes in adulthood conferred by DHF therapy after neonatal HI tended to be or were Erα-dependent, respectively. Interestingly, DHF triggered anxiety-like behavior in both sexes only in the mice that lacked Erα. When we assessed the severity of injury, we found that DHF therapy did not decrease the percent tissue loss in proportion to functional recovery. We additionally observed that the presence of Erα significantly reduced overall HI-associated mortality in both sexes. CONCLUSIONS These observations provide evidence for a therapeutic role for DHF in which TrkB-mediated sustained recovery of recognition and location memories in females are Erα-associated and dependent, respectively. However, the beneficial effects of DHF therapy did not include reduction of gross tissue loss but may be derived from the enhanced functioning of residual tissues in a cell-specific manner.
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Affiliation(s)
- Vishal Chanana
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Margaret Hackett
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Nazli Deveci
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Nur Aycan
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
| | - Burak Ozaydin
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Nur Sena Cagatay
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Damla Hanalioglu
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
| | - Douglas B Kintner
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Karson Corcoran
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Sefer Yapici
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Furkan Camci
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
| | - Jens Eickhoff
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Karyn M Frick
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Peter Ferrazzano
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Jon E Levine
- Department of Neuroscience, University of Wisconsin-Madison, Madison, WI, USA
| | - Pelin Cengiz
- Department of Pediatrics, University of Wisconsin-Madison, 1500 Highland Ave-T503, Madison, WI, 53705-9345, USA.
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA.
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Joshi M, Muneer J, Mbuagbaw L, Goswami I. Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review. PLoS One 2023; 18:e0291170. [PMID: 38060481 PMCID: PMC10703341 DOI: 10.1371/journal.pone.0291170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress. OBJECTIVE This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes. METHODS We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied. RESULTS The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40-100% worldwide. TH alters most drugs' metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism. CONCLUSIONS No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.
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Affiliation(s)
- Mahima Joshi
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Javed Muneer
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ipsita Goswami
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Labusek N, Ghari P, Mouloud Y, Köster C, Diesterbeck E, Hadamitzky M, Felderhoff-Müser U, Bendix I, Giebel B, Herz J. Hypothermia combined with extracellular vesicles from clonally expanded immortalized mesenchymal stromal cells improves neurodevelopmental impairment in neonatal hypoxic-ischemic brain injury. J Neuroinflammation 2023; 20:280. [PMID: 38012640 PMCID: PMC10680187 DOI: 10.1186/s12974-023-02961-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/16/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Neonatal encephalopathy following hypoxia-ischemia (HI) is a leading cause of childhood death and morbidity. Hypothermia (HT), the only available but obligatory therapy is limited due to a short therapeutic window and limited efficacy. An adjuvant therapy overcoming limitations of HT is still missing. Mesenchymal stromal cell (MSC)-derived extracellular vesicles (EVs) have shown promising therapeutic effects in various brain injury models. Challenges associated with MSCs' heterogeneity and senescence can be mitigated by the use of EVs from clonally expanded immortalized MSCs (ciMSCs). In the present study, we hypothesized that intranasal ciMSC-EV delivery overcomes limitations of HT. METHODS Nine-day-old C57BL/6 mice were exposed to HI by occlusion of the right common carotid artery followed by 1 h hypoxia (10% oxygen). HT was initiated immediately after insult for 4 h. Control animals were kept at physiological body core temperatures. ciMSC-EVs or vehicle were administered intranasally 1, 3 and 5 days post HI/HT. Neuronal cell loss, inflammatory and regenerative responses were assessed via immunohistochemistry, western blot and real-time PCR 7 days after insult. Long-term neurodevelopmental outcome was evaluated by analyses of cognitive function, activity and anxiety-related behavior 5 weeks after HI/HT. RESULTS In contrast to HT monotherapy, the additional intranasal therapy with ciMSC-EVs prevented HI-induced cognitive deficits, hyperactivity and alterations of anxiety-related behavior at adolescence. This was preceded by reduction of striatal neuronal loss, decreased endothelial, microglia and astrocyte activation; reduced expression of pro-inflammatory and increased expression of anti-inflammatory cytokines. Furthermore, the combination of HT with intranasal ciMSC-EV delivery promoted regenerative and neurodevelopmental processes, including endothelial proliferation, neurotrophic growth factor expression and oligodendrocyte maturation, which were not altered by HT monotherapy. CONCLUSION Intranasal delivery of ciMSC-EVs represents a novel adjunct therapy, overcoming limitations of acute HT thereby offering new possibilities for improving long-term outcomes in neonates with HI-induced brain injury.
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Affiliation(s)
- Nicole Labusek
- Department of Pediatrics I, Neonatology and Experimental Perinatal Neurosciences, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Parnian Ghari
- Department of Pediatrics I, Neonatology and Experimental Perinatal Neurosciences, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Yanis Mouloud
- Institute for Transfusion Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Köster
- Department of Pediatrics I, Neonatology and Experimental Perinatal Neurosciences, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Eva Diesterbeck
- Department of Pediatrics I, Neonatology and Experimental Perinatal Neurosciences, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Martin Hadamitzky
- Institute for Medical Psychology and Behavioral Immunobiology, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, Neonatology and Experimental Perinatal Neurosciences, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ivo Bendix
- Department of Pediatrics I, Neonatology and Experimental Perinatal Neurosciences, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Bernd Giebel
- Institute for Transfusion Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Josephine Herz
- Department of Pediatrics I, Neonatology and Experimental Perinatal Neurosciences, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany.
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Brossard-Racine M, Rampakakis E, Tardif CL, Gilbert G, White A, Luu TM, Gallagher A, Pinchefsky E, Montreuil T, Simard MN, Wintermark P. Long-term consequences of neonatal encephalopathy in the hypothermia era: protocol for a follow-up cohort study at 9 years of age. BMJ Open 2023; 13:e073063. [PMID: 37055215 PMCID: PMC10106079 DOI: 10.1136/bmjopen-2023-073063] [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] [Indexed: 04/15/2023] Open
Abstract
INTRODUCTION Therapeutic hypothermia (TH) became the standard of care treatment for neonates with moderate and severe neonatal encephalopathy (NE) in most industrialized countries about 10 years ago. Although TH is effective in reducing mortality and the incidence of severe developmental disabilities, the recent literature converges in reporting frequent cognitive and behavioural difficulties at school entry in children with NE-TH. Although these challenges are deemed minor compared with cerebral palsy and intellectual disability, their impacts on a child's self-determination and family's well-being are quite significant. Therefore, the nature and extent of these difficulties need to be comprehensively described so that appropriate care can be offered. METHODS AND ANALYSIS The current study will be the largest follow-up study of neonates with NE treated with TH to characterize their developmental outcomes and associated brain structural profiles at 9 years of age. Specifically, we will compare executive function, attention, social cognition, behaviour, anxiety, self-esteem, peer problems, brain volume, cortical features, white matter microstructure and myelination between children with NE-TH and matched peers without NE. Associations of perinatal risk factors and structural brain integrity with cognitive, behavioural and psycho-emotional deficits will be evaluated to inform about the potential aggravating and protective factors associated with function. ETHICS AND DISSEMINATION This study is supported by the Canadian Institute of Health Research (202203PJT-480065-CHI-CFAC-168509), and received approval from the Pediatric Ethical Review Board of the McGill University Health Center (MP-37-2023-9320). The study findings will be disseminated in scientific journals and conferences and presented to parental associations and healthcare providers to inform best practices. TRIAL REGISTRATION NUMBER NCT05756296.
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Affiliation(s)
- Marie Brossard-Racine
- Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | | | - Angela White
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Thuy Mai Luu
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
- University of Montreal, Montreal, Quebec, Canada
| | - Anne Gallagher
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
- University of Montreal, Montreal, Quebec, Canada
| | - Elana Pinchefsky
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
- University of Montreal, Montreal, Quebec, Canada
| | - Tina Montreuil
- Department of Psychiatry, McGill University Montreal, Montreal, Quebec, Canada
- Department of Educational and Counselling Psychology, McGill University Montreal, Montreal, Quebec, Canada
| | - Marie-Noelle Simard
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
- University of Montreal, Montreal, Quebec, Canada
| | - Pia Wintermark
- Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Robertsson Grossmann K, Eriksson Westblad M, Blennow M, Lindström K. Outcome at early school age and adolescence after hypothermia-treated hypoxic-ischaemic encephalopathy: an observational, population-based study. Arch Dis Child Fetal Neonatal Ed 2022; 108:295-301. [PMID: 36600485 PMCID: PMC10176399 DOI: 10.1136/archdischild-2022-324418] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We aimed to describe long-term outcomes following hypoxic-ischaemic encephalopathy (HIE) treated with therapeutic hypothermia (TH). DESIGN Prospective, population-based observational study. SETTING Tertiary level neonatal intensive care units and neonatal outpatient clinic, Karolinska University Hospital, Stockholm, Sweden. PATIENTS Sixty-six infants treated with TH due to HIE between 2007 and 2009. INTERVENTIONS At 6-8 years and 10-12 years of age, children were assessed using a standardised neurological examination, the Movement Assessment Battery for Children, Second Edition (MABC-2) and the Wechsler Intelligence Scales for Children IV/V. Parents completed the Five-to-Fifteen (FTF) questionnaire. MAIN OUTCOME MEASURES Adverse outcome among survivors was defined as cerebral palsy (CP), epilepsy, hearing or visual impairment, full-scale IQ (FSIQ) below 85, attention deficit disorder with/without hyperactivity, autism spectrum disorder or developmental coordination disorder. RESULTS Mortality was 12%. Seventeen per cent of survivors developed CP. Mean FSIQ was normal in children without major neuromotor impairment. Assessment in early adolescence revealed emerging deficits in 26% of children with a previously favourable outcome. The proportion of children exhibiting executive difficulties increased from 7% to 19%. This was reflected also by a significantly increased proportion of children with an FTF score >90th percentile compared with norms in early adolescence. The proportion of children with an MABC-2 score ≤5th percentile was also significantly increased compared with norms. CONCLUSIONS Survivors without major neuromotor impairment have normal intelligence. The incidence of executive difficulties appears to be increased in this patient population. More subtle difficulties may go undetected at early school-age.
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Affiliation(s)
- Katarina Robertsson Grossmann
- Department of Clinical Science, Intervention and Technology, Division of Paediatrics, Karolinska Institutet, Stockholm, Sweden .,Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Mimmi Eriksson Westblad
- Department of Clinical Science, Intervention and Technology, Division of Paediatrics, Karolinska Institutet, Stockholm, Sweden.,Medical Unit of Women's Health and Allied Health Professionals Theme, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Blennow
- Department of Clinical Science, Intervention and Technology, Division of Paediatrics, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Lindström
- Department of Clinical Science, Intervention and Technology, Division of Paediatrics, Karolinska Institutet, Stockholm, Sweden.,Department of Child Neurology, Karolinska University Hospital, Stockholm, Sweden
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Klepper S, Jung S, Dittmann L, Geppert CI, Hartmann A, Beier N, Trollmann R. Further Evidence of Neuroprotective Effects of Recombinant Human Erythropoietin and Growth Hormone in Hypoxic Brain Injury in Neonatal Mice. Int J Mol Sci 2022; 23:ijms23158693. [PMID: 35955834 PMCID: PMC9368903 DOI: 10.3390/ijms23158693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 02/04/2023] Open
Abstract
Experimental in vivo data have recently shown complementary neuroprotective actions of rhEPO and growth hormone (rhGH) in a neonatal murine model of hypoxic brain injury. Here, we hypothesized that rhGH and rhEPO mediate stabilization of the blood−brain barrier (BBB) and regenerative vascular effects in hypoxic injury to the developing brain. Using an established model of neonatal hypoxia, neonatal mice (P7) were treated i.p. with rhGH (4000 µg/kg) or rhEPO (5000 IU/kg) 0/12/24 h after hypoxic exposure. After a regeneration period of 48 h or 7 d, cerebral mRNA expression of Vegf-A, its receptors and co-receptors, and selected tight junction proteins were determined using qRT-PCR and ELISA. Vessel structures were assessed by Pecam-1 and occludin (Ocln) IHC. While Vegf-A expression increased significantly with rhGH treatment (p < 0.01), expression of the Vegfr and TEK receptor tyrosine kinase (Tie-2) system remained unchanged. RhEPO increased Vegf-A (p < 0.05) and Angpt-2 (p < 0.05) expression. While hypoxia reduced the mean vessel area in the parietal cortex compared to controls (p < 0.05), rhGH and rhEPO prevented this reduction after 48 h of regeneration. Hypoxia significantly reduced the Ocln+ fraction of cortical vascular endothelial cells. Ocln signal intensity increased in the cortex in response to rhGH (p < 0.05) and in the cortex and hippocampus in response to rhEPO (p < 0.05). Our data indicate that rhGH and rhEPO have protective effects on hypoxia-induced BBB disruption and regenerative vascular effects during the post-hypoxic period in the developing brain.
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Affiliation(s)
- Simon Klepper
- Division of Pediatric Neurology, Department of Pediatrics, Friedrich-Alexander Universität Erlangen-Nürnberg, Loschgestr. 15, 91054 Erlangen, Germany
| | - Susan Jung
- Division of Pediatric Neurology, Department of Pediatrics, Friedrich-Alexander Universität Erlangen-Nürnberg, Loschgestr. 15, 91054 Erlangen, Germany
| | - Lara Dittmann
- Division of Pediatric Neurology, Department of Pediatrics, Friedrich-Alexander Universität Erlangen-Nürnberg, Loschgestr. 15, 91054 Erlangen, Germany
| | - Carol I. Geppert
- Institute of Pathology, Friedrich-Alexander Universität Erlangen-Nürnberg, Krankenhausstr. 8, 91054 Erlangen, Germany
| | - Arnd Hartmann
- Institute of Pathology, Friedrich-Alexander Universität Erlangen-Nürnberg, Krankenhausstr. 8, 91054 Erlangen, Germany
| | - Nicole Beier
- Division of Pediatric Neurology, Department of Pediatrics, Friedrich-Alexander Universität Erlangen-Nürnberg, Loschgestr. 15, 91054 Erlangen, Germany
| | - Regina Trollmann
- Division of Pediatric Neurology, Department of Pediatrics, Friedrich-Alexander Universität Erlangen-Nürnberg, Loschgestr. 15, 91054 Erlangen, Germany
- Correspondence: ; Tel.: +49-9131-8533753; Fax: +49-9131-8533389
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