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Molloy EJ, El-Dib M, Soul J, Juul S, Gunn AJ, Bender M, Gonzalez F, Bearer C, Wu Y, Robertson NJ, Cotton M, Branagan A, Hurley T, Tan S, Laptook A, Austin T, Mohammad K, Rogers E, Luyt K, Wintermark P, Bonifacio SL. Neuroprotective therapies in the NICU in preterm infants: present and future (Neonatal Neurocritical Care Series). Pediatr Res 2024; 95:1224-1236. [PMID: 38114609 PMCID: PMC11035150 DOI: 10.1038/s41390-023-02895-6] [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] [Received: 07/06/2023] [Revised: 10/19/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
The survival of preterm infants has steadily improved thanks to advances in perinatal and neonatal intensive clinical care. The focus is now on finding ways to improve morbidities, especially neurological outcomes. Although antenatal steroids and magnesium for preterm infants have become routine therapies, studies have mainly demonstrated short-term benefits for antenatal steroid therapy but limited evidence for impact on long-term neurodevelopmental outcomes. Further advances in neuroprotective and neurorestorative therapies, improved neuromonitoring modalities to optimize recruitment in trials, and improved biomarkers to assess the response to treatment are essential. Among the most promising agents, multipotential stem cells, immunomodulation, and anti-inflammatory therapies can improve neural outcomes in preclinical studies and are the subject of considerable ongoing research. In the meantime, bundles of care protecting and nurturing the brain in the neonatal intensive care unit and beyond should be widely implemented in an effort to limit injury and promote neuroplasticity. IMPACT: With improved survival of preterm infants due to improved antenatal and neonatal care, our focus must now be to improve long-term neurological and neurodevelopmental outcomes. This review details the multifactorial pathogenesis of preterm brain injury and neuroprotective strategies in use at present, including antenatal care, seizure management and non-pharmacological NICU care. We discuss treatment strategies that are being evaluated as potential interventions to improve the neurodevelopmental outcomes of infants born prematurely.
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Affiliation(s)
- Eleanor J Molloy
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland.
- Children's Hospital Ireland (CHI) at Tallaght, Dublin, Ireland.
- Neonatology, CHI at Crumlin, Dublin, Ireland.
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland.
| | - Mohamed El-Dib
- Department of Pediatrics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sandra Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Alistair J Gunn
- Departments of Physiology and Paediatrics, School of Medical Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Manon Bender
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Fernando Gonzalez
- Department of Neurology, Division of Child Neurology, University of California, San Francisco, California, USA
| | - Cynthia Bearer
- Division of Neonatology, Department of Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Yvonne Wu
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mike Cotton
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Aoife Branagan
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland
| | - Tim Hurley
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
| | - Sidhartha Tan
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Abbot Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, Rhode Island, USA
| | - Topun Austin
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Elizabeth Rogers
- Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Karen Luyt
- Translational Health Sciences, University of Bristol, Bristol, UK
- Neonatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Pia Wintermark
- Division of Neonatology, Montreal Children's Hospital, Montreal, Quebec, Canada
- McGill University Health Centre - Research Institute, Montreal, Quebec, Canada
| | - Sonia Lomeli Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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Zhu L, Yuan Q, Jing C, Sun L, Jiang L. Angiogenic responses are enhanced by recombinant human erythropoietin in a model of periventricular white matter damage of neonatal rats through EPOR-ERK1 signaling. J Neuropathol Exp Neurol 2024; 83:161-167. [PMID: 38263262 PMCID: PMC10880070 DOI: 10.1093/jnen/nlae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
Recombinant human erythropoietin (rh-EPO) has been shown to stimulate neurogenesis and angiogenesis, both of which play crucial roles in the repair of brain injuries. Previously, we observed that rh-EPO treatment effectively reduced brain damage and enhanced angiogenesis in a neonatal rat model of periventricular white matter damage (PWMD). The objective of this research is to investigate the specific mechanism through which rh-EPO regulates angiogenesis following PWMD in premature neonates. We conducted experiments utilizing a neonatal PWMD model. Following rh-EPO treatment, the levels of erythropoietin receptor (EPOR) were found to be increased in the damaged brain of rats. Although the total amount of extracellular signal-regulated kinase (ERK), a downstream protein in the EPO signaling pathway, remained unchanged, there was clear upregulation of phosphorylated ERK1 (p-ERK1) levels. The increase in levels of p-ERK1 was inhibited by an ERK kinase inhibitor, while the total amount of ERK remained unchanged. Conversely, the levels of EPOR were not affected by the inhibitor. Notably, the introduction of rh-EPO led to a significant increase in the frequency of angiogenesis-related cells and the expression levels of angiogenic factors. However, these effects were nullified when the ERK pathway was blocked. These findings indicate that rh-EPO enhances angiogenic responses through the EPOR-ERK1 pathway in a neonatal PWMD model.
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Affiliation(s)
- Lihua Zhu
- Department of Clinical Medicine, Jiangsu Health Vocational College, Nanjing 211800, China
| | - Qichao Yuan
- Department of Pediatrics, Danyang People’s Hospital Affiliate of Nantong University, Danyang 212300, China
| | - Chunping Jing
- Department of Pediatrics, Danyang People’s Hospital Affiliate of Nantong University, Danyang 212300, China
| | - Lingxian Sun
- Department of Clinical Medicine, Jiangsu Health Vocational College, Nanjing 211800, China
| | - Li Jiang
- Department of Pediatrics, Zhongda Hospital, Southeast University, Nanjing 210009, China
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Korf JM, McCullough LD, Caretti V. A narrative review on treatment strategies for neonatal hypoxic ischemic encephalopathy. Transl Pediatr 2023; 12:1552-1571. [PMID: 37692539 PMCID: PMC10485647 DOI: 10.21037/tp-23-253] [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: 04/22/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Background and Objective Hypoxic-ischemic encephalopathy (HIE) is a leading cause of death and disability worldwide. Therapeutic hypothermia (TH) represents a significant achievement in the translation of scientific research to clinical application, but it is currently the only neuroprotective treatment for HIE. This review aims to revisit the use of TH for HIE and its longitudinal impact on patient outcomes to readers new to the field of HIE. We discuss how emerging therapies address the broader pathophysiology of injury progression in the neonatal brain days to years after HIE. Methods We included full articles and book chapters published in English on PubMed with references to "hypoxic ischemic encephalopathy", "birth asphyxia", "therapeutic hypothermia", or "neonatal encephalopathy". We limited our review to outcomes on term infants and to new therapeutics that are in the second phase of clinical trials. Key Content and Findings Despite the use of TH for HIE, mortality remains high. Analysis of longitudinal studies reveals a high incidence of ongoing disability even with the implementation of TH. New therapeutics addressing the secondary phase and the less understood tertiary phase of brain injury are in clinical trials as adjunctive treatments to TH to support additional neurological repair and regeneration. Conclusions TH successfully improves outcomes after HIE, and it continues to be optimized. Larger studies are needed to understand its use in mild cases of HIE and if certain factors, such as sex, affect long term outcomes. TH primarily acts in the initial phases of injury, while new pharmaceutical therapies target additional injury pathways into the tertiary phases of injury. This may allow for more effective approaches to treatment and improvement of long-term functional outcomes after HIE.
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Affiliation(s)
- Janelle M. Korf
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Louise D. McCullough
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Viola Caretti
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
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Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) is a leading cause of death and neurodevelopmental impairment in neonates. Therapeutic hypothermia (TH) is the only established effective therapy and randomized trials affirm that TH reduces death and disability in moderate-to-severe HIE. Traditionally, infants with mild HIE were excluded from these trials due to the perceived low risk for impairment. Recently, multiple studies suggest that infants with untreated mild HIE may be at significant risk of abnormal neurodevelopmental outcomes. This review will focus on the changing landscape of TH, the spectrum of HIE presentations and their neurodevelopmental outcomes.
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Affiliation(s)
| | - Gina Milano
- University of Texas Southwestern Medical Center, 5323 Harry Hines, Dallas, Texas 75390, USA
| | - Lina F Chalak
- University of Texas Southwestern Medical Center, 5323 Harry Hines, Dallas, Texas 75390, USA.
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Peyvandi S, Rollins C. Fetal Brain Development in Congenital Heart Disease. Can J Cardiol 2023; 39:115-122. [PMID: 36174913 PMCID: PMC9905309 DOI: 10.1016/j.cjca.2022.09.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/08/2022] [Accepted: 09/18/2022] [Indexed: 02/07/2023] Open
Abstract
Neurodevelopmental impairments are the most common extracardiac morbidities among patients with complex congenital heart disease (CHD) across the lifespan. Robust clinical research in this area has revealed several cardiac, medical, and social factors that can contribute to neurodevelopmental outcome in the context of CHD. Studies using brain magnetic resonance imaging (MRI) have been instrumental in identifying quantitative and qualitative difference in brain structure and maturation in this patient population. Full-term newborns with complex CHD are known to have abnormal microstructural and metabolic brain development with patterns similar to those seen in premature infants at approximately 34 to 36 weeks' gestation. With the advent of fetal brain MRI, these brain abnormalities are now documented as they begin in utero, as early as the third trimester. Importantly, disturbed brain development in utero is now known to be independently associated with neurodevelopmental outcome in early childhood, making the prenatal period an important timeframe for potential interventions. Advances in fetal brain MRI provide a robust imaging tool to use in future neuroprotective clinical trials. The causes of abnormal fetal brain development are multifactorial and include cardiovascular physiology, genetic abnormalities, placental impairment, and other environmental and social factors. This review provides an overview of current knowledge of brain development in the context of CHD, common prenatal imaging tools to evaluate the developing fetal brain in CHD, and known risk factors contributing to brain immaturity.
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Affiliation(s)
- Shabnam Peyvandi
- University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA.
| | - Caitlin Rollins
- Boston Children's Hospital and Harvard University Departments of Neurology, Boston, Massachusetts, USA
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Yin H, Chen Z, Zhao H, Huang H, Liu W. Noble gas and neuroprotection: From bench to bedside. Front Pharmacol 2022; 13:1028688. [PMID: 36532733 PMCID: PMC9750501 DOI: 10.3389/fphar.2022.1028688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/03/2022] [Indexed: 07/26/2023] Open
Abstract
In recent years, inert gases such as helium, argon, and xenon have gained considerable attention for their medical value. Noble gases present an intriguing scientific paradox: although extremely chemically inert, they display a remarkable spectrum of clinically useful biological properties. Despite a relative paucity of knowledge about their mechanisms of action, some noble gases have been used successfully in clinical practice. The neuroprotection elicited by these noble gases has been investigated in experimental animal models of various types of brain injuries, such as traumatic brain injury, stroke, subarachnoid hemorrhage, cerebral ischemic/reperfusion injury, and neurodegenerative diseases. Collectively, these central nervous system injuries are a leading cause of morbidity and mortality every year worldwide. Treatment options are presently limited to thrombolytic drugs and clot removal for ischemic stroke, or therapeutic cooling for other brain injuries before the application of noble gas. Currently, there is increasing interest in noble gases as novel treatments for various brain injuries. In recent years, neuroprotection elicited by particular noble gases, xenon, for example, has been reported under different conditions. In this article, we have reviewed the latest in vitro and in vivo experimental and clinical studies of the actions of xenon, argon, and helium, and discuss their potential use as neuroprotective agents.
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Affiliation(s)
- Haiying Yin
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Zijun Chen
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Hailin Zhao
- Division of Anesthetics, Department of Surgery and Cancer, Pain Medicine and Intensive Care, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom
| | - Han Huang
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Wenwen Liu
- Department of Anesthesia Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Ministry of Education, Sichuan University and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Chengdu, China
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McDouall A, Wassink G, Bennet L, Gunn AJ, Davidson JO. Challenges in developing therapeutic strategies for mild neonatal encephalopathy. Neural Regen Res 2022; 17:277-282. [PMID: 34269188 PMCID: PMC8464003 DOI: 10.4103/1673-5374.317963] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
There is increasing evidence that infants with mild neonatal encephalopathy (NE) have significant risks of mortality, brain injury and adverse neurodevelopmental outcomes. In the era of therapeutic hypothermia, infants need to be diagnosed within 6 hours of birth, corresponding with the window of opportunity for treatment of moderate to severe NE, compared to the retrospective grading over 2 to 3 days, typically with imaging and formal electroencephalographic assessment in the pre-hypothermia era. This shift in diagnosis may have increased the apparent prevalence of brain damage and poor neurological outcomes seen in infants with mild NE in the era of hypothermia. Abnormal short term outcomes observed in infants with mild NE include seizures, abnormal neurologic examination at discharge, abnormal brain magnetic resonance imaging and difficulty feeding. At 2 to 3 years of age, mild NE has been associated with an increased risk of autism, language and cognitive deficits. There are no approved treatment strategies for these infants as they were not included in the initial randomized controlled trials for therapeutic hypothermia. However, there is already therapeutic creep, with many centers treating infants with mild NE despite the limited evidence for its safety and efficacy. The optimal duration of treatment and therapeutic window of opportunity for effective treatment need to be specifically established for mild NE as the evolution of injury is likely to be slower, based on preclinical data. Randomized controlled trials of therapeutic hypothermia for infants with mild NE are urgently required to establish the safety and efficacy of treatment. This review will examine the evidence for adverse outcomes after mild NE and dissect some of the challenges in developing therapeutic strategies for mild NE, before analyzing the evidence for therapeutic hypothermia and other strategies for treatment of these infants.
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Affiliation(s)
- Alice McDouall
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Guido Wassink
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, The University of Auckland, Auckland, New Zealand
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Favrais G, Saliba E, Savary L, Bodard S, Gulhan Z, Gressens P, Chalon S. Partial protective effects of melatonin on developing brain in a rat model of chorioamnionitis. Sci Rep 2021; 11:22167. [PMID: 34773065 PMCID: PMC8589852 DOI: 10.1038/s41598-021-01746-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/01/2021] [Indexed: 12/27/2022] Open
Abstract
Melatonin has shown promising neuroprotective effects due to its anti-oxidant, anti-inflammatory and anti-apoptotic properties, making it a candidate drug for translation to humans in conditions that compromise the developing brain. Our study aimed to explore the impact of prenatal melatonin in an inflammatory/infectious context on GABAergic neurons and on oligodendrocytes (OLs), key cells involved in the encephalopathy of prematurity. An inflammatory/infectious agent (LPS, 300 μg/kg) was injected intraperitoneally (i.p.) to pregnant Wistar rats at gestational day 19 and 20. Melatonin (5 mg/kg) was injected i.p. following the same schedule. Immunostainings focusing on GABAergic neurons, OL lineage and myelination were performed on pup brain sections. Melatonin succeeded in preventing the LPS-induced decrease of GABAergic neurons within the retrospenial cortex, and sustainably promoted GABAergic neurons within the dentate gyrus in the inflammatory/infectious context. However, melatonin did not effectively prevent the LPS-induced alterations on OLs and myelination. Therefore, we demonstrated that melatonin partially prevented the deleterious effects of LPS according to the cell type. The timing of exposure related to the cell maturation stage is likely to be critical to achieve an efficient action of melatonin. Furthermore, it can be speculated that melatonin exerts a modest protective effect on extremely preterm infant brains.
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Affiliation(s)
- Geraldine Favrais
- i-Brain Team- UMR INSERM U1253, UFR de Médecine, Université de Tours, Bâtiment Thérèse Planiol, 10 Bd Tonnellé, BP 3223, 37032, Tours Cedex 1, France. .,Neonatology Unit, CHRU de Tours, Tours, France.
| | - Elie Saliba
- i-Brain Team- UMR INSERM U1253, UFR de Médecine, Université de Tours, Bâtiment Thérèse Planiol, 10 Bd Tonnellé, BP 3223, 37032, Tours Cedex 1, France
| | - Léa Savary
- i-Brain Team- UMR INSERM U1253, UFR de Médecine, Université de Tours, Bâtiment Thérèse Planiol, 10 Bd Tonnellé, BP 3223, 37032, Tours Cedex 1, France
| | - Sylvie Bodard
- i-Brain Team- UMR INSERM U1253, UFR de Médecine, Université de Tours, Bâtiment Thérèse Planiol, 10 Bd Tonnellé, BP 3223, 37032, Tours Cedex 1, France
| | - Zuhal Gulhan
- i-Brain Team- UMR INSERM U1253, UFR de Médecine, Université de Tours, Bâtiment Thérèse Planiol, 10 Bd Tonnellé, BP 3223, 37032, Tours Cedex 1, France
| | | | - Sylvie Chalon
- i-Brain Team- UMR INSERM U1253, UFR de Médecine, Université de Tours, Bâtiment Thérèse Planiol, 10 Bd Tonnellé, BP 3223, 37032, Tours Cedex 1, France
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Kumar P, Hair P, Cunnion K, Krishna N, Bass T. Classical complement pathway inhibition reduces brain damage in a hypoxic ischemic encephalopathy animal model. PLoS One 2021; 16:e0257960. [PMID: 34591905 PMCID: PMC8483388 DOI: 10.1371/journal.pone.0257960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/15/2021] [Indexed: 11/19/2022] Open
Abstract
Perinatal hypoxic ischemic encephalopathy (HIE) remains a major contributor of infant death and long-term disability worldwide. The role played by the complement system in this ischemia-reperfusion injury remains poorly understood. In order to better understand the role of complement activation and other modifiable mechanisms of injury in HIE, we tested the dual-targeting anti-inflammatory peptide, RLS-0071 in an animal model of HIE. Using the well-established HIE rat pup model we measured the effects of RLS-0071 during the acute stages of the brain injury and on long-term neurocognitive outcomes. Rat pups subject to hypoxia-ischemia insult received one of 4 interventions including normothermia, hypothermia and RLS-0071 with and without hypothermia. We measured histopathological effects, brain C1q levels and neuroimaging at day 1 and 21 after the injury. A subset of animals was followed into adolescence and evaluated for neurocognitive function. On histological evaluation, RLS-0071 showed neuronal protection in combination with hypothermia (P = 0.048) in addition to reducing C1q levels in the brain at 1hr (P = 0.01) and at 8 hr in combination with hypothermia (P = 0.005). MRI neuroimaging demonstrated that RLS-0071 in combination with hypothermia reduced lesion volume at 24 hours (P<0.05) as well as decreased T2 signal at day 21 in combination with hypothermia (P<0.01). RLS-0071 alone or in combination with hypothermia improved both short-term and long-term memory. These findings suggest that modulation by RLS-0071 can potentially decrease brain damage resulting from HIE.
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Affiliation(s)
- Parvathi Kumar
- ReAlta Life Sciences, Norfolk, VA, United States of America
- Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA, United States of America
- * E-mail:
| | - Pamela Hair
- ReAlta Life Sciences, Norfolk, VA, United States of America
| | - Kenji Cunnion
- ReAlta Life Sciences, Norfolk, VA, United States of America
- Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA, United States of America
- Eastern Virginia Medical School, Norfolk, VA, United States of America
| | - Neel Krishna
- ReAlta Life Sciences, Norfolk, VA, United States of America
- Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA, United States of America
- Eastern Virginia Medical School, Norfolk, VA, United States of America
| | - Thomas Bass
- Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA, United States of America
- Eastern Virginia Medical School, Norfolk, VA, United States of America
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Davidson JO, Gonzalez F, Gressens P, Gunn AJ. Update on mechanisms of the pathophysiology of neonatal encephalopathy. Semin Fetal Neonatal Med 2021; 26:101267. [PMID: 34274259 DOI: 10.1016/j.siny.2021.101267] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Therapeutic hypothermia is now well established to significantly improve survival without disability after neonatal encephalopathy (NE). To further improve outcomes, we need to better understand the mechanisms of brain injury. The central finding, which offers the potential for neuroprotective and neurorestorative interventions, is that brain damage after perinatal hypoxia-ischemia evolves slowly over time. Although brain cells may die during profound hypoxia-ischemia, even after surprisingly severe insults many cells show transient recovery of oxidative metabolism during a "latent" phase characterized by actively suppressed neural metabolism and activity. Critically, after moderate to severe hypoxia-ischemia, this transient recovery is followed after ~6 h by a phase of secondary deterioration, with delayed seizures, failure of mitochondrial function, cytotoxic edema, and cell death over ~72 h. This is followed by a tertiary phase of remodeling and recovery. This review discusses the mechanisms of injury that occur during the primary, latent, secondary and tertiary phases of injury and potential treatments that target one or more of these phases. By analogy with therapeutic hypothermia, treatment as early as possible in the latent phase is likely to have the greatest potential to prevent injury ("neuroprotection"). In the secondary phase of injury, anticonvulsants can attenuate seizures, but show limited neuroprotection. Encouragingly, there is now increasing preclinical evidence that late, neurorestorative interventions have potential to improve long-term outcomes.
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Affiliation(s)
- Joanne O Davidson
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.
| | - Fernando Gonzalez
- Department of Pediatrics, University of California, San Francisco, CA, USA.
| | | | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.
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11
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Chakkarapani AA, Aly H, Benders M, Cotten CM, El-Dib M, Gressens P, Hagberg H, Sabir H, Wintermark P, Robertson NJ. Therapies for neonatal encephalopathy: Targeting the latent, secondary and tertiary phases of evolving brain injury. Semin Fetal Neonatal Med 2021; 26:101256. [PMID: 34154945 DOI: 10.1016/j.siny.2021.101256] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In term and near-term neonates with neonatal encephalopathy, therapeutic hypothermia protocols are well established. The current focus is on how to improve outcomes further and the challenge is to find safe and complementary therapies that confer additional protection, regeneration or repair in addition to cooling. Following hypoxia-ischemia, brain injury evolves over three main phases (latent, secondary and tertiary), each with a different brain energy, perfusion, neurochemical and inflammatory milieu. While therapeutic hypothermia has targeted the latent and secondary phase, we now need therapies that cover the continuum of brain injury that spans hours, days, weeks and months after the initial event. Most agents have several therapeutic actions but can be broadly classified under a predominant action (e.g., free radical scavenging, anti-apoptotic, anti-inflammatory, neuroregeneration, and vascular effects). Promising early/secondary phase therapies include Allopurinol, Azithromycin, Exendin-4, Magnesium, Melatonin, Noble gases and Sildenafil. Tertiary phase agents include Erythropoietin, Stem cells and others. We review a selection of promising therapeutic agents on the translational pipeline and suggest a framework for neuroprotection and neurorestoration that targets the evolving injury.
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Affiliation(s)
| | - Hany Aly
- Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
| | - Manon Benders
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Pierre Gressens
- Université de Paris, NeuroDiderot, Inserm, Paris, France; Centre for the Developing Brain, Department of Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London, SE1 7EH, United Kingdom.
| | - Henrik Hagberg
- Centre for the Developing Brain, Department of Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London, SE1 7EH, United Kingdom; Centre of Perinatal Medicine & Health, Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital University of Bonn, Bonn, Germany; German Centre for Neurodegenerative Diseases (DZNE), Bonn, Germany.
| | - Pia Wintermark
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children's Hospital, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
| | - Nicola J Robertson
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, Edinburgh BioQuarter, Edinburgh, United Kingdom; Institute for Women's Health, University College London, London, United Kingdom.
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Iqbal N, Younus J, Malik M, Fatima B, Imran A, Maqbool S, Irfan Waheed KA, Haque K. The Neuroprotective Efficacy of Postnatal Magnesium Sulfate in Term or Near-Term Infants With Moderate-to-Severe Birth Asphyxia. Cureus 2021; 13:e16826. [PMID: 34513419 PMCID: PMC8407416 DOI: 10.7759/cureus.16826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 11/05/2022] Open
Abstract
Background In Pakistan, the neonatal mortality rate is 41 per 1,000 live births and birth asphyxia is one of the leading causes of neonatal mortality and morbidity. The goal of this study was to determine whether postnatal magnesium sulfate therapy can improve short- and long-term neurological outcomes in term or near-term neonates with moderate-to-severe birth asphyxia. Methodology This prospective double-blind randomized controlled trial was conducted in the Neonatology Department of the Children's Hospital & The Institute of Child Health, Lahore. A total of 62 neonates (31 in each group) were randomized to receive either three doses of magnesium sulfate infusion at 250 mg/kg per dose, 24 hours apart (treatment group), or three doses of injection 10% distilled water infusion at 3 mL/kg, 24 hours apart (placebo group). Both groups received similar supportive care. The neurodevelopmental assessment was done at six months of age using the ShaMaq Developmental Inventory. Results Demographic data such as gestational age, mean weight, age at presentation, gender, hypoxic-ischemic encephalopathy grade, mode of delivery, and the presence of seizures at presentation were comparable between both groups. In the magnesium sulfate group, statistically significant results were seen in terms of early seizure control (p = 0.001), early initiation of feed (p = 0.002), and shorter duration of hospital stay (p = 0.003). Moreover, the magnesium sulfate group had lower mortality compared to the control group, though it was not statistically significant (p = 0.390). There was no significant difference in terms of cranial ultrasound findings between the two groups (p = 0.783) at the time of discharge. Regarding the neurodevelopmental delay, there was no significant difference between the magnesium sulfate and control groups (p = 0.535). Conclusions Postnatal magnesium sulfate treatment improves short-term neurologic outcomes at discharge in term or near-term neonates with moderate-to-severe perinatal asphyxia. However, no difference was noted in the neurodevelopmental outcome at six months.
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Affiliation(s)
- Nadeem Iqbal
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Javaria Younus
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Muneeba Malik
- Developmental and Behavioural Pediatrics, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Bushra Fatima
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Ahmed Imran
- Pediatric Radiology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Shazia Maqbool
- Developmental and Behavioural Pediatrics, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | | | - Khalid Haque
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
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Robertson NJ, Meehan C, Martinello KA, Avdic-Belltheus A, Boggini T, Mutshiya T, Lingam I, Yang Q, Sokolska M, Charalambous X, Bainbridge A, Hristova M, Kramer BW, Golay X, Weil B, Lowdell MW. Human umbilical cord mesenchymal stromal cells as an adjunct therapy with therapeutic hypothermia in a piglet model of perinatal asphyxia. Cytotherapy 2021; 23:521-535. [PMID: 33262073 PMCID: PMC8139415 DOI: 10.1016/j.jcyt.2020.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/12/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND With therapeutic hypothermia (HT) for neonatal encephalopathy, disability rates are reduced, but not all babies benefit. Pre-clinical rodent studies suggest mesenchymal stromal cells (MSCs) augment HT protection. AIMS The authors studied the efficacy of intravenous (IV) or intranasal (IN) human umbilical cord-derived MSCs (huMSCs) as adjunct therapy to HT in a piglet model. METHODS A total of 17 newborn piglets underwent transient cerebral hypoxia-ischemia (HI) and were then randomized to (i) HT at 33.5°C 1-13 h after HI (n = 7), (ii) HT+IV huMSCs (30 × 106 cells) at 24 h and 48 h after HI (n = 5) or (iii) HT+IN huMSCs (30 × 106 cells) at 24 h and 48 h after HI (n = 5). Phosphorus-31 and hydrogen-1 magnetic resonance spectroscopy (MRS) was performed at 30 h and 72 h and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL)-positive cells and oligodendrocytes quantified. In two further piglets, 30 × 106 IN PKH-labeled huMSCs were administered. RESULTS HI severity was similar between groups. Amplitude-integrated electroencephalogram (aEEG) recovery was more rapid for HT+IN huMSCs compared with HT from 25 h to 42 h and 49 h to 54 h (P ≤ 0.05). MRS phosphocreatine/inorganic phosphate was higher on day 2 in HT+IN huMSCs than HT (P = 0.035). Comparing HT+IN huMSCs with HT and HT+IV huMSCs, there were increased OLIG2 counts in hippocampus (P = 0.011 and 0.018, respectively), internal capsule (P = 0.013 and 0.037, respectively) and periventricular white matter (P = 0.15 for IN versus IV huMSCs). Reduced TUNEL-positive cells were seen in internal capsule with HT+IN huMSCs versus HT (P = 0.05). PKH-labeled huMSCs were detected in the brain 12 h after IN administration. CONCLUSIONS After global HI, compared with HT alone, the authors saw beneficial effects of HT+IN huMSCs administered at 24 h and 48 h (30 × 106 cells/kg total dose) based on more rapid aEEG recovery, improved 31P MRS brain energy metabolism and increased oligodendrocyte survival at 72 h.
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Affiliation(s)
| | | | | | | | - Tiziana Boggini
- Institute for Women's Health, University College London, London, UK
| | - Tatenda Mutshiya
- Institute for Women's Health, University College London, London, UK
| | - Ingran Lingam
- Institute for Women's Health, University College London, London, UK
| | - Qin Yang
- Institute for Women's Health, University College London, London, UK
| | | | | | - Alan Bainbridge
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Mariya Hristova
- Institute for Women's Health, University College London, London, UK
| | - Boris W Kramer
- Department of Pediatrics, University of Maastricht, Maastricht, the Netherlands
| | - Xavier Golay
- Institute for Women's Health, University College London, London, UK
| | - Ben Weil
- Royal Free London NHS Foundation Trust, London, UK
| | - Mark W Lowdell
- Institute for Women's Health, University College London, London, UK; Royal Free London NHS Foundation Trust, London, UK
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Zakharova NM, Tarahovsky YS, Komelina NP, Khrenov MO, Kovtun AL. Pharmacological torpor prolongs rat survival in lethal normobaric hypoxia. J Therm Biol 2021; 98:102906. [PMID: 34016333 DOI: 10.1016/j.jtherbio.2021.102906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 11/16/2022]
Abstract
Resistance to hypoxia is one of the most prominent features of natural hibernation and is expected to be present in the pharmacological torpor (PT) that simulates hibernation. We studied resistance to lethal hypoxia (3.5% oxygen content) in rats under PT. To initiate PT, we used the previously developed pharmacological composition (PC) which, after a single intravenous injection, can induce a daily decrease in Tb by 7 °C-8 °C at the environmental temperature of 22 °C-23 °C. Half-survival (median) time of rats in lethal hypoxia was found to increase from 5 ± 0.8 min in anesthetized control rats to 150 ± 12 min in rats injected with PC, which is a 30-fold increase. Behavioral tests after PT and hypoxia, including the traveling distance, the number of rearing and grooming episodes, revealed that animal responses are significantly restored within a week. It is assumed that the discovered unprecedented resistance of artificially torpid rats to lethal hypoxia may open up broad prospects for the therapeutic use of PT for preconditioning to various damaging factors, treatment of diseases, and extend the so-called "golden hour" for lifesaving interventions.
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Affiliation(s)
| | - Yury S Tarahovsky
- Institute of Cell Biophysics, RAS, Pushchino, Moscow Region 142290, Russia; Institute of Theoretical and Experimental Biophysics, RAS, Pushchino, Moscow Region 142290, Russia.
| | - Natalia P Komelina
- Institute of Cell Biophysics, RAS, Pushchino, Moscow Region 142290, Russia
| | - Maxim O Khrenov
- Institute of Cell Biophysics, RAS, Pushchino, Moscow Region 142290, Russia
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Ahmed J, Pullattayil S AK, Robertson NJ, More K. Melatonin for neuroprotection in neonatal encephalopathy: A systematic review & meta-analysis of clinical trials. Eur J Paediatr Neurol 2021; 31:38-45. [PMID: 33601197 DOI: 10.1016/j.ejpn.2021.02.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/11/2021] [Accepted: 02/04/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Melatonin has shown neuroprotective properties in pre-clinical studies of perinatal asphyxia through antioxidant, anti-apoptotic and anti-inflammatory actions. Studies have also demonstrated its safety and efficacy in neonatal encephalopathy (NE). However, its role in the current era of therapeutic hypothermia (HT) is unclear. The review aims to describe the currently available clinical evidence for Melatonin as a potential therapy for NE. METHODS Data Sources: We searched Medline, EMBASE, CINAHL, LILACS, and Cochrane central databases, published journals, and conference proceedings from inception to May 31, 2020. STUDY SELECTION Randomized controlled trials (RCTs) of Melatonin for NE in term or late preterm infants reporting neurodevelopmental outcomes, death, or both. The evidence quality was evaluated using the GRADE system, while the recommendations were taken according to the quality. RESULTS We included five RCTs involving 215 neonates. Long-term development outcome data is lacking in all except in one small study, reporting significantly higher composite cognition scores at 18 months. One study reported intermediate 6-month favorable development on follow-up. Meta-analysis of mortality in combined HT + Melatonin group vs HT alone (Studies = 2, participants = 54) demonstrated no significant reduction with relative risk (RR) 0.42; 95%CI, 0.99-1.12). The overall GRADE evidence quality was very low for a very small sample size. We did not meta-analyze the data for Melatonin alone therapy without HT, as the included studies were of very low quality. CONCLUSIONS Despite strong experimental data supporting the role of Melatonin as a neuroprotective agent in NE (both alone and as an adjunct with therapeutic hypothermia), the clinical data supporting the neuroprotective effects in neonates is limited. Larger well designed, adequately powered multicentre clinical trials are urgently needed to define the neuroprotective role of Melatonin in optimizing outcomes of NE.
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Affiliation(s)
- Javed Ahmed
- Division of Neonatology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar.
| | | | - Nicola J Robertson
- Institute for Women's Health, University College London, London, WC1E 6HX, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, BioQuarter, 49 Little France Crescent, Edinburgh, EH16 4SB, UK; The Roslin Institute, University of Edinburgh, Easter Bush Campus, EH25 9RG, UK.
| | - Kiran More
- Division of Neonatology, Sidra Medicine, Doha, Qatar; Weill Cornell Medicine, Doha, Qatar.
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Liang L, Yu J, Xiao L, Wang G. Sustained low-dose prophylactic early erythropoietin for improvement of neurological outcomes in preterm infants:A systematic review and meta-analysis. J Affect Disord 2021; 282:1187-1192. [PMID: 33601694 DOI: 10.1016/j.jad.2021.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/01/2021] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
Abstract
The aim of this meta-analysis was conducted to assess the effects of different doses of prophylactic rhEPO on neurodevelopmental outcomes and provide reference for rational drug use. The primary outcome was the number of infants with a Mental Developmental Index (MDI) <70 on the Bayley Scales of Infant Development. Five RCTs, comprising 2282 infants, were included in this meta-analysis. Overall, prophylactic rhEPO administration reduced the incidence of infants with an MDI <70, with an odds ratio (95% confidence interval) of 0.55 (0.38-0.79), P <0.05. The low-dose rhEPO subgroup was superior to the placebo subgroup, with an OR (95% CI) of 0.47 (0.25-0.87), P <0.05. However, high-dose rhEPO subgroup had no significant impact on MDI <70 in infants <28 weeks' gestational age. The definitions of the secondary outcome showed that there was no significant effect of rhEPO on cerebral palsy. For neonatal complications, although four studies showed that there were no differences in the pooled results of BPD and ICH events between rhEPO treatment and placebo, the ICH events were significantly lower in the low-dose rhEPO (OR 0.36; 95% CI 0.23-0.59). In addition, in the pooled results of NEC and ROP events, there were significant differences between the two groups (OR 0.63; 95% CI 0.43-0.93) (OR 0.80; 95% CI 0.65-0.98). And the NEC events were significantly lower in the low-dose rhEPO (OR 0.45; 95% CI 0.27-0.73). Sustained low-dose prophylactic early erythropoietin might be more superior than high-dose for improvement of neurological outcomes and several neonatal complications in preterm infants.
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Affiliation(s)
- Liang Liang
- Department of Psychiatry, Renmin Hospital of Wuhan University, Hubei Zhang Road (formerly Ziyang Road), Wuchang District No. 99, Jiefang Road 238, Wuhan, Hubei province, China
| | - Jia Yu
- Department of General Surgery, Renmin Hospital of Wuhan University, Hubei Zhang Road (formerly Ziyang Road), Wuchang District No. 99, Jiefang Road 238, Wuhan, Hubei province, China
| | - Ling Xiao
- Department of Psychiatry, Renmin Hospital of Wuhan University, Hubei Zhang Road (formerly Ziyang Road), Wuchang District No. 99, Jiefang Road 238, Wuhan, Hubei province, China
| | - Gaohua Wang
- Department of Psychiatry, Renmin Hospital of Wuhan University, Hubei Zhang Road (formerly Ziyang Road), Wuchang District No. 99, Jiefang Road 238, Wuhan, Hubei province, China.
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Yates N, Gunn AJ, Bennet L, Dhillon SK, Davidson JO. Preventing Brain Injury in the Preterm Infant-Current Controversies and Potential Therapies. Int J Mol Sci 2021; 22:ijms22041671. [PMID: 33562339 PMCID: PMC7915709 DOI: 10.3390/ijms22041671] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 12/12/2022] Open
Abstract
Preterm birth is associated with a high risk of morbidity and mortality including brain damage and cerebral palsy. The development of brain injury in the preterm infant may be influenced by many factors including perinatal asphyxia, infection/inflammation, chronic hypoxia and exposure to treatments such as mechanical ventilation and corticosteroids. There are currently very limited treatment options available. In clinical trials, magnesium sulfate has been associated with a small, significant reduction in the risk of cerebral palsy and gross motor dysfunction in early childhood but no effect on the combined outcome of death or disability, and longer-term follow up to date has not shown improved neurological outcomes in school-age children. Recombinant erythropoietin has shown neuroprotective potential in preclinical studies but two large randomized trials, in extremely preterm infants, of treatment started within 24 or 48 h of birth showed no effect on the risk of severe neurodevelopmental impairment or death at 2 years of age. Preclinical studies have highlighted a number of promising neuroprotective treatments, such as therapeutic hypothermia, melatonin, human amnion epithelial cells, umbilical cord blood and vitamin D supplementation, which may be useful at reducing brain damage in preterm infants. Moreover, refinements of clinical care of preterm infants have the potential to influence later neurological outcomes, including the administration of antenatal and postnatal corticosteroids and more accurate identification and targeted treatment of seizures.
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Affiliation(s)
- Nathanael Yates
- The Queensland Brain Institute, University of Queensland, St Lucia, QLD 4072, Australia;
- School of Human Sciences, University of Western Australia, Crawley, WA 6009, Australia
| | - Alistair J. Gunn
- The Department of Physiology, University of Auckland, Auckland 1023, New Zealand; (A.J.G.); (L.B.); (S.K.D.)
| | - Laura Bennet
- The Department of Physiology, University of Auckland, Auckland 1023, New Zealand; (A.J.G.); (L.B.); (S.K.D.)
| | - Simerdeep K. Dhillon
- The Department of Physiology, University of Auckland, Auckland 1023, New Zealand; (A.J.G.); (L.B.); (S.K.D.)
| | - Joanne O. Davidson
- The Department of Physiology, University of Auckland, Auckland 1023, New Zealand; (A.J.G.); (L.B.); (S.K.D.)
- Correspondence: ; Tel.: +64-9-373-7599 (ext. 89596)
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18
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Kyng KJ, Kerrn-Jespersen S, Bennedsgaard K, Skajaa T, Pedersen M, Holm IE, Henriksen TB. Short-term outcomes of remote ischemic postconditioning 1 h after perinatal hypoxia-ischemia in term piglets. Pediatr Res 2021; 89:150-156. [PMID: 32294662 DOI: 10.1038/s41390-020-0878-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/19/2020] [Accepted: 03/04/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND We aimed to assess remote ischemic postconditioning (RIPC) as a neuroprotective strategy after perinatal hypoxia-ischemia (HI) in a piglet model. METHODS Fifty-four newborn piglets were subjected to global HI for 45 min. One hour after HI, piglets were randomized to four cycles of 5 min of RIPC or supportive treatment only. The primary outcome was brain lactate/N-acetylaspartate (Lac/NAA) ratios measured by magnetic resonance spectroscopy at 72 h. Secondary outcomes included diffusion-weighted imaging and neuropathology. RESULTS RIPC was associated with a reduction in overall and basal ganglia Lac/NAA ratios at 72 h after HI, but no effect on diffusion-weighted imaging, neuropathology scores, neurological recovery, or mortality. CONCLUSIONS The selective effect of RIPC on Lac/NAA ratios may suggest that the metabolic effect is greater than the structural and functional improvement at 72 h after HI. Further studies are needed to address whether there is an add-on effect of RIPC to hypothermia, together with the optimal timing, number of cycles, and duration of RIPC. IMPACT RIPC after HI was associated with a reduction in overall and basal ganglia Lac/NAA ratios at 72 h, but had no effect on diffusion-weighted imaging, neuropathology scores, neurological recovery, or mortality. RIPC may have a selective metabolic effect, ameliorating lactate accumulation without improving other short-term outcomes assessed at 72 h after HI. We applied four cycles of 5 min RIPC, complementing existing data on other durations of RIPC. This study adds to the limited data on RIPC after perinatal HI and highlights that knowledge gaps, including timing and duration of RIPC, must be addressed together with exploring the combined effects with hypothermia.
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Affiliation(s)
- Kasper J Kyng
- Department of Paediatrics, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Sigrid Kerrn-Jespersen
- Department of Paediatrics, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kristine Bennedsgaard
- Department of Paediatrics, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Torjus Skajaa
- Department of Paediatrics, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Pedersen
- Comparative Medicine Lab, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Ida E Holm
- Department of Pathology, Randers Hospital and Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Tine B Henriksen
- Department of Paediatrics, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Pang R, Avdic-Belltheus A, Meehan C, Martinello K, Mutshiya T, Yang Q, Sokolska M, Torrealdea F, Hristova M, Bainbridge A, Golay X, Juul SE, Robertson NJ. Melatonin and/or erythropoietin combined with hypothermia in a piglet model of perinatal asphyxia. Brain Commun 2020; 3:fcaa211. [PMID: 33604569 PMCID: PMC7876304 DOI: 10.1093/braincomms/fcaa211] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 12/11/2022] Open
Abstract
As therapeutic hypothermia is only partially protective for neonatal encephalopathy, safe and effective adjunct therapies are urgently needed. Melatonin and erythropoietin show promise as safe and effective neuroprotective therapies. We hypothesized that melatonin and erythropoietin individually augment 12-h hypothermia (double therapies) and hypothermia + melatonin + erythropoietin (triple therapy) leads to optimal brain protection. Following carotid artery occlusion and hypoxia, 49 male piglets (<48 h old) were randomized to: (i) hypothermia + vehicle (n = 12), (ii) hypothermia + melatonin (20 mg/kg over 2 h) (n = 12), (iii) hypothermia + erythropoietin (3000 U/kg bolus) (n = 13) or (iv) tripletherapy (n = 12). Melatonin, erythropoietin or vehicle were given at 1, 24 and 48 h after hypoxia–ischaemia. Hypoxia–ischaemia severity was similar across groups. Therapeutic levels were achieved 3 hours after hypoxia–ischaemia for melatonin (15–30 mg/l) and within 30 min of erythropoietin administration (maximum concentration 10 000 mU/ml). Compared to hypothermia + vehicle, we observed faster amplitude-integrated EEG recovery from 25 to 30 h with hypothermia + melatonin (P = 0.02) and hypothermia + erythropoietin (P = 0.033) and from 55 to 60 h with tripletherapy (P = 0.042). Magnetic resonance spectroscopy lactate/N-acetyl aspartate peak ratio was lower at 66 h in hypothermia + melatonin (P = 0.012) and tripletherapy (P = 0.032). With hypothermia + melatonin, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labelled-positive cells were reduced in sensorimotor cortex (P = 0.017) and oligodendrocyte transcription factor 2 labelled-positive counts increased in hippocampus (P = 0.014) and periventricular white matter (P = 0.039). There was no reduction in terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labelled-positive cells with hypothermia + erythropoietin, but increased oligodendrocyte transcription factor 2 labelled-positive cells in 5 of 8 brain regions (P < 0.05). Overall, melatonin and erythropoietin were safe and effective adjunct therapies to hypothermia. Hypothermia + melatonin double therapy led to faster amplitude-integrated EEG recovery, amelioration of lactate/N-acetyl aspartate rise and reduction in terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labelled-positive cells in the sensorimotor cortex. Hypothermia + erythropoietin doubletherapy was in association with EEG recovery and was most effective in promoting oligodendrocyte survival. Tripletherapy provided no added benefit over the double therapies in this 72-h study. Melatonin and erythropoietin influenced cell death and oligodendrocyte survival differently, reflecting distinct neuroprotective mechanisms which may become more visible with longer-term studies. Staggering the administration of therapies with early melatonin and later erythropoietin (after hypothermia) may provide better protection; each therapy has complementary actions which may be time critical during the neurotoxic cascade after hypoxia–ischaemia.
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Affiliation(s)
- Raymand Pang
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Adnan Avdic-Belltheus
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Christopher Meehan
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Kathryn Martinello
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Tatenda Mutshiya
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Qin Yang
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Magdalena Sokolska
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Francisco Torrealdea
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Mariya Hristova
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
| | - Alan Bainbridge
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Xavier Golay
- Department of Brain Repair and Rehabilitation, Institute of Neurology, Queen's Square, University College London, London, UK
| | - Sandra E Juul
- Department of Pediatrics, University of Washington, Seattle, Washington, DC, USA
| | - Nicola J Robertson
- Department of Neonatology, Institute for Women's Health, University College London, London, UK
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Abstract
OBJECTIVES To investigate the effect of adding melatonin to hypothermia treatment on neurodevelopmental outcomes in asphyctic newborns. DESIGN Pilot multicenter, randomized, controlled, double-blind clinical trial. Statistical comparison of results obtained in two intervention arms: hypothermia plus placebo and hypothermia plus melatonin. SETTING Level 3 neonatal ICU. PATIENTS Twenty-five newborns were recruited. INTERVENTIONS The hypothermia plus melatonin patients received a daily dose of IV melatonin, 5 mg per kg body weight, for 3 days. General laboratory variables were measured both at neonatal ICU admission and after intervention. All infants were studied with amplitude-integrated electroencephalography and brain MRI within the first week of life. The neurodevelopmental Bayley III test, the Gross Motor Function Classification System, and the Tardieu scale were applied at the ages of 6 and 18 months. MEASUREMENTS AND MAIN RESULTS Clinical characteristics, laboratory evaluations, MRI findings, and amplitude-integrated electroencephalography background did not differ between the treatment groups. The newborns in the hypothermia plus melatonin group achieved a significantly higher composite score for the cognitive section of the Bayley III test at 18 months old, with respect to the hypothermia plus placebo group (p = 0.05). There were no differences between the groups according to the Gross Motor Function Classification System and Tardieu motor assessment scales. CONCLUSIONS The early addition of IV melatonin to asphyctic neonates is feasible and may improve long-term neurodevelopment. To our knowledge, this is the first clinical trial to analyze the administration of IV melatonin as an adjuvant therapy to therapeutic hypothermia.
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21
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Zhu Y, Mosko JJ, Chidekel A, Wolfson MR, Shaffer TH. Effects of xenon gas on human airway epithelial cells during hyperoxia and hypothermia. J Neonatal Perinatal Med 2020; 13:469-476. [PMID: 32444566 PMCID: PMC7836053 DOI: 10.3233/npm-190364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hypothermia with xenon gas has been used to reduce brain injury and disability rate after perinatal hypoxia-ischemia. We evaluated xenon gas therapy effects in an in vitro model with or without hypothermia on cultured human airway epithelial cells (Calu-3). METHODS Calu-3 monolayers were grown at an air-liquid interface and exposed to one of the following conditions: 1) 21% FiO2 at 37°C (control); 2) 45% FiO2 and 50% xenon at 37°C; 3) 21% FiO2 and 50% xenon at 32°C; 4) 45% FiO2 and 50% xenon at 32°C for 24 hours. Transepithelial resistance (TER) measurements were performed and apical surface fluids were collected and assayed for total protein, IL-6, and IL-8. Three monolayers were used for immunofluorescence localization of zonula occludens-1 (ZO-1). The data were analyzed by one-way ANOVA. RESULTS TER decreased at 24 hours in all treatment groups. Xenon with hyperoxia and hypothermia resulted in greatest decrease in TER compared with other groups. Immunofluorescence localization of ZO-1 (XY) showed reduced density of ZO-1 rings and incomplete ring-like staining in the 45% FiO2- 50% xenon group at 32°C compared with other groups. Secretion of total protein was not different among groups. Secretion of IL-6 in 21% FiO2 with xenon group at 32°C was less than that of the control group. The secretion of IL-8 in 45% FiO2 with xenon at 32°C was greater than that of other groups. CONCLUSION Hyperoxia and hypothermia result in detrimental epithelial cell function and inflammation over 24-hour exposure. Xenon gas did not affect cell function or reduce inflammation.
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Affiliation(s)
- Y Zhu
- Center for Pediatric Lung Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - J J Mosko
- Center for Pediatric Lung Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - A Chidekel
- Center for Pediatric Lung Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.,Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - M R Wolfson
- Departments of Physiology and Pediatrics, Department of Thoracic Medicine and Surgery, CENTRe: Collaborative for Environmental and Neonatal Therapeutics Research, Center for Inflammation and Translational Clinical Lung Research, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - T H Shaffer
- Center for Pediatric Lung Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.,Departments of Physiology and Pediatrics, Department of Thoracic Medicine and Surgery, CENTRe: Collaborative for Environmental and Neonatal Therapeutics Research, Center for Inflammation and Translational Clinical Lung Research, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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22
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Treatment of Neonatal Hypoxic-Ischemic Encephalopathy with Erythropoietin Alone, and Erythropoietin Combined with Hypothermia: History, Current Status, and Future Research. Int J Mol Sci 2020; 21:ijms21041487. [PMID: 32098276 PMCID: PMC7073127 DOI: 10.3390/ijms21041487] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/04/2020] [Accepted: 02/16/2020] [Indexed: 02/06/2023] Open
Abstract
Perinatal hypoxic-ischemic encephalopathy (HIE) remains a major cause of morbidity and mortality. Moderate hypothermia (33.5 °C) is currently the sole established standard treatment. However, there are a large number of infants for whom this therapy is ineffective. This inspired global research to find neuroprotectants to potentiate the effect of moderate hypothermia. Here we examine erythropoietin (EPO) as a prominent candidate. Neonatal animal studies show that immediate, as well as delayed, treatment with EPO post-injury, can be neuroprotective and/or neurorestorative. The observed improvements of EPO therapy were generally not to the level of control uninjured animals, however. This suggested that combining EPO treatment with an adjunct therapeutic strategy should be researched. Treatment with EPO plus hypothermia led to less cerebral palsy in a non-human primate model of perinatal asphyxia, leading to clinical trials. A recent Phase II clinical trial on neonatal infants with HIE reported better 12-month motor outcomes for treatment with EPO plus hypothermia compared to hypothermia alone. Hence, the effectiveness of combined treatment with moderate hypothermia and EPO for neonatal HIE currently looks promising. The outcomes of two current clinical trials on neurological outcomes at 18–24 months-of-age, and at older ages, are now required. Further research on the optimal dose, onset, and duration of treatment with EPO, and critical consideration of the effect of injury severity and of gender, are also required.
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23
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Baburamani AA, Arichi T. Complementing cooling: the ongoing search for an effective adjunct to therapeutic hypothermia. J Physiol 2020; 598:905-906. [PMID: 31994725 DOI: 10.1113/jp279518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/28/2020] [Indexed: 11/08/2022] Open
Affiliation(s)
- Ana A Baburamani
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, King's Health Partners, St Thomas' Hospital, London, SE1 7EH, UK
| | - Tomoki Arichi
- Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, King's Health Partners, St Thomas' Hospital, London, SE1 7EH, UK.,Department of Bioengineering, Imperial College London, South Kensington, London, SW7 2AZ, UK.,Children's Neurosciences, Evelina London Children's Hospital, London, UK
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24
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Krause BJ, Peñaloza E, Candia A, Cañas D, Hernández C, Arenas GA, Peralta‐Scholz MJ, Valenzuela R, García‐Herrera C, Herrera EA. Adult vascular dysfunction in foetal growth-restricted guinea-pigs is associated with a neonate-adult switching in Nos3 DNA methylation. Acta Physiol (Oxf) 2019; 227:e13328. [PMID: 31177629 DOI: 10.1111/apha.13328] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/31/2019] [Accepted: 06/04/2019] [Indexed: 12/24/2022]
Abstract
AIM Foetal growth restriction (FGR) is associated with endothelial dysfunction and cardiovascular diseases in adult subjects. Early vascular remodelling and epigenetic changes occurring on key endothelial genes might precede this altered vascular function. Further, it has been proposed that oxidative stress during development may determine some of these epigenetic modifications. To address this issue, we studied the in vivo and ex vivo vascular function and Nos3 promoter DNA methylation in arteries from eight-month-old guinea-pig born from control, FGR-treated and FGR-NAC-treated pregnancies. METHODS Femoral and carotid arteries in vivo vascular function were determined by Doppler, whilst ex vivo vascular function and biomechanical properties were assessed by wire myography. Levels of eNOS mRNA and site-specific DNA methylation in Nos3 promoter in aorta endothelial cells (AEC) were determined by qPCR and pyrosequencing respectively. RESULTS FGR adult showed an increased femoral vascular resistance (P < .05), stiffness (P < .05) and arterial remodelling (P < .01), along with an impaired NO-mediated relaxation (P < .001). These effects were prevented by maternal treatment with NAC. Endothelial-NOS mRNA levels were decreased in FGR adult compared with control and FGR-NAC (P < .05), associated with increased DNA methylation levels (P < .01). Comparison of Nos3 DNA methylation in AEC showed a differential methylation pattern between foetal and adult guinea-pigs (P < .05). CONCLUSION Altogether, these data suggest that adult vascular dysfunction in the FGR does not result from early changes in Nos3 promoter DNA methylation, but from an altered vessel structure established during foetal development.
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Affiliation(s)
- Bernardo J. Krause
- Departament of Neonatology, Division of Paediatrics, Faculty of Medicine Pontificia Universidad Católica de Chile Santiago Chile
| | - Estefanía Peñaloza
- Departament of Neonatology, Division of Paediatrics, Faculty of Medicine Pontificia Universidad Católica de Chile Santiago Chile
| | - Alejandro Candia
- Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de Medicina Universidad de Chile Santiago Chile
| | - Daniel Cañas
- Departamento de Ingeniería Mecánica, Facultad de Ingeniería Universidad de Santiago de Chile Santiago Chile
| | - Cherie Hernández
- Departament of Neonatology, Division of Paediatrics, Faculty of Medicine Pontificia Universidad Católica de Chile Santiago Chile
| | - German A. Arenas
- Departament of Neonatology, Division of Paediatrics, Faculty of Medicine Pontificia Universidad Católica de Chile Santiago Chile
| | - María José Peralta‐Scholz
- Departament of Neonatology, Division of Paediatrics, Faculty of Medicine Pontificia Universidad Católica de Chile Santiago Chile
| | - Rodrigo Valenzuela
- Departamento de Ciencias Químicas y Biológicas, Facultad de Salud Universidad Bernardo O'Higgins Santiago Chile
| | - Claudio García‐Herrera
- Departamento de Ingeniería Mecánica, Facultad de Ingeniería Universidad de Santiago de Chile Santiago Chile
| | - Emilio A. Herrera
- Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de Medicina Universidad de Chile Santiago Chile
- International Center for Andean Studies (INCAS) Universidad de Chile Putre Chile
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25
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Qin X, Cheng J, Zhong Y, Mahgoub OK, Akter F, Fan Y, Aldughaim M, Xie Q, Qin L, Gu L, Jian Z, Xiong X, Liu R. Mechanism and Treatment Related to Oxidative Stress in Neonatal Hypoxic-Ischemic Encephalopathy. Front Mol Neurosci 2019; 12:88. [PMID: 31031592 PMCID: PMC6470360 DOI: 10.3389/fnmol.2019.00088] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/21/2019] [Indexed: 12/24/2022] Open
Abstract
Hypoxic ischemic encephalopathy (HIE) is a type of neonatal brain injury, which occurs due to lack of supply and oxygen deprivation to the brain. It is associated with a high morbidity and mortality rate. There are several therapeutic strategies that can be used to improve outcomes in patients with HIE. These include cell therapies such as marrow mesenchymal stem cells (MSCs) and umbilical cord blood stem cells (UCBCs), which are being incorporated into the new protocols for the prevention of ischemic brain damage. The focus of this review is to discuss the mechanism of oxidative stress in HIE and summarize the current available treatments for HIE. We hope that a better understanding of the relationship between oxidative stress and HIE will provide new insights on the potential therapy of this devastating condition.
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Affiliation(s)
- Xingping Qin
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China.,Department of Neurosurgery, Harvard Medical School, Boston, MA, United States
| | - Jing Cheng
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yi Zhong
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Omer Kamal Mahgoub
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Farhana Akter
- Department of Neurosurgery, Harvard Medical School, Boston, MA, United States.,Department of Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Yanqin Fan
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
| | - Mohammed Aldughaim
- Department of Neurosurgery, Harvard Medical School, Boston, MA, United States
| | - Qiurong Xie
- Department of Gynecology and Obstetrics, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lingxia Qin
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lijuan Gu
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhihong Jian
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaoxing Xiong
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Renzhong Liu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
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26
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Jakab A, Ruegger C, Bucher HU, Makki M, Huppi PS, Tuura R, Hagmann C. Network based statistics reveals trophic and neuroprotective effect of early high dose erythropoetin on brain connectivity in very preterm infants. NEUROIMAGE-CLINICAL 2019; 22:101806. [PMID: 30991614 PMCID: PMC6451173 DOI: 10.1016/j.nicl.2019.101806] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 03/18/2019] [Accepted: 03/30/2019] [Indexed: 01/17/2023]
Abstract
Periventricular white matter injury is common in very preterm infants and it is associated with long term neurodevelopmental impairments. While evidence supports the protective effects of erythropoetin (EPO) in preventing injury, we currently lack the complete understanding of how EPO affects the emergence and maturation of anatomical brain connectivity and function. In this case-control study, connectomic analysis based on diffusion MRI tractography was applied to evaluate the effect of early high-dose EPO in preterm infants. A whole brain, network-level analysis revealed a sub-network of anatomical brain connections in which connectivity strengths were significantly stronger in the EPO group. This distributed network comprised connections predominantly in the frontal and temporal lobe bilaterally, and the effect of EPO was focused on peripheral and feeder connections of the core structural connectivity network. EPO resulted in a globally increased clustering coefficient, higher global and average local efficiency, while higher strength and increased clustering was found for regions in the frontal lobe and cingulate gyrus. The connectivity network most affected by the EPO treatment showed a steeper increase graph theoretical measures with age compared to the placebo group. Our results demonstrate a weak but widespread effect of EPO on the structural connectivity network and a possible trophic effect of EPO reflected by increasing network segregation, predominantly in local connections. Erythropoietin (EPO) is a potential neuroprotective agent in very preterm infants. EPO leads to increased structural brain connectivity in fronto-temporal regions. Clustering coefficient, local and global efficiency increases after EPO treatment.
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Affiliation(s)
- A Jakab
- Center for MR Research, University Children's Hospital Zurich, Zurich, Switzerland.
| | - C Ruegger
- Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - H U Bucher
- Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Malek Makki
- Center for MR Research, University Children's Hospital Zurich, Zurich, Switzerland
| | - P S Huppi
- Division of Development and Growth, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - R Tuura
- Center for MR Research, University Children's Hospital Zurich, Zurich, Switzerland
| | - C Hagmann
- Department of Neonatology, University Hospital Zurich, Zurich, Switzerland; Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
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27
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Gunn AJ, Thoresen M. Neonatal encephalopathy and hypoxic-ischemic encephalopathy. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:217-237. [PMID: 31324312 DOI: 10.1016/b978-0-444-64029-1.00010-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Acute hypoxic-ischemic encephalopathy around the time of birth remains a major cause of death and life-long disability. The key insight that led to the modern revival of studies of neuroprotection was that, after profound asphyxia, many brain cells show initial recovery from the insult during a short "latent" phase, typically lasting approximately 6h, only to die hours to days later after a "secondary" deterioration characterized by seizures, cytotoxic edema, and progressive failure of cerebral oxidative metabolism. Studies designed around this framework showed that mild hypothermia initiated as early as possible before the onset of secondary deterioration and continued for a sufficient duration to allow the secondary deterioration to resolve is associated with potent, long-lasting neuroprotection. There is now compelling evidence from randomized controlled trials that mild to moderate induced hypothermia significantly improves survival and neurodevelopmental outcomes in infancy and mid-childhood.
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Affiliation(s)
- Alistair J Gunn
- Departments of Physiology and Paediatrics, University of Auckland, Auckland, New Zealand.
| | - Marianne Thoresen
- Department of Physiology University of Oslo, Oslo, Norway; Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
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28
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Beñaldo FA, Llanos AJ, Araya-Quijada C, Rojas A, Gonzalez-Candia A, Herrera EA, Ebensperger G, Cabello G, Valenzuela GJ, Serón-Ferré M. Effects of Melatonin on the Defense to Acute Hypoxia in Newborn Lambs. Front Endocrinol (Lausanne) 2019; 10:433. [PMID: 31354619 PMCID: PMC6640618 DOI: 10.3389/fendo.2019.00433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/17/2019] [Indexed: 12/25/2022] Open
Abstract
Neonatal lambs, as other neonates, have physiologically a very low plasma melatonin concentration throughout 24 h. Previously, we found that melatonin given to neonates daily for 5 days decreased heart weight and changed plasma cortisol and gene expression in the adrenal and heart. Whether these changes could compromise the responses to life challenges is unknown. Therefore, firstly, we studied acute effects of melatonin on the defense mechanisms to acute hypoxia in the neonate. Eleven lambs, 2 weeks old, were instrumented and subjected to an episode of acute isocapnic hypoxia, consisting of four 30 min periods: normoxia (room air), normoxia after an i.v. bolus of melatonin (0.27 mg kg-1, n = 6) or vehicle (ethanol 1:10 NaCl 0.9%, n = 5), hypoxia (PaO2: 30 ± 2 mmHg), and recovery (room air). Mean pulmonary and systemic blood pressures, heart rate, and cardiac output were measured, and systemic and pulmonary vascular resistance and stroke volume were calculated. Blood samples were taken every 30 min to measure plasma norepinephrine, cortisol, glucose, triglycerides, and redox markers (8-isoprostane and FRAP). Melatonin blunted the increase of pulmonary vascular resistance triggered by hypoxia, markedly exacerbated the heart rate response, decreased heart stroke volume, and lessened the magnitude of the increase of plasmatic norepinephrine and cortisol levels induced by hypoxia. No changes were observed in pulmonary blood pressure, systemic blood pressures and resistance, cardiac output, glucose, triglyceride plasma concentrations, or redox markers. Melatonin had no effect on cardiovascular, endocrine, or metabolic variables, under normoxia. Secondly, we examined whether acute melatonin administration under normoxia could have an effect in gene expression on the adrenal, lung, and heart. Lambs received a bolus of vehicle or melatonin and were euthanized 30 min later to collect tissues. We found that melatonin affected expression of the immediate early genes egr1 in adrenal, ctgf in lung, and nr3c1, the glucocorticoid receptor, in adrenal and heart. We speculate that these early gene responses may contribute to the observed alterations of the newborn defense mechanisms to hypoxia. This could be particularly important since the use of melatonin is proposed for several diseases in the neonatal period in humans.
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Affiliation(s)
- Felipe A. Beñaldo
- Programa de Fisiopatología, ICBM, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Aníbal J. Llanos
- Programa de Fisiopatología, ICBM, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- International Center for Andean Studies (INCAS), Universidad de Chile, Santiago, Chile
| | - Claudio Araya-Quijada
- Programa de Fisiopatología, ICBM, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Auristela Rojas
- Programa de Fisiopatología, ICBM, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | | | - Emilio A. Herrera
- Programa de Fisiopatología, ICBM, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- International Center for Andean Studies (INCAS), Universidad de Chile, Santiago, Chile
| | - Germán Ebensperger
- Programa de Fisiopatología, ICBM, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Gertrudis Cabello
- Departamento de Biología, Facultad de Ciencias, Universidad de Tarapacá, Arica, Chile
| | - Guillermo J. Valenzuela
- Department of Women's Health, Arrowhead Regional Medical Center, San Bernardino, CA, United States
| | - María Serón-Ferré
- Programa de Fisiopatología, ICBM, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- *Correspondence: María Serón-Ferré
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29
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Abstract
Despite notable advances in the care and survival of preterm infants, a significant proportion of preterm neonates will have life-long cognitive, behavioral, and motor deficits, and robustly effective neuroprotective strategies are still missing. These therapies must target the pathophysiologic mechanisms observed in contemporaneous infants and rely on modern epidemiology, imaging, and experimental models and assessment techniques. Two drugs, magnesium sulfate and caffeine, are already in use in several units, and although their targets are apnea of prematurity and myometrial contractility (respectively), they do offer improved odds of positive outcomes. Nevertheless, these drugs have limited efficacy, and NICU-to-NICU administration varies greatly. As such, there is an obvious need for additional specific neurotherapeutic strategies to further enhance the outcome of this very fragile population of neonates. The chapter reviews these issues, highlights bottlenecks that need to be solved for meaningful progress in the field, and proposes future innovative avenues for intervention, including delayed interventions.
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Affiliation(s)
- Bobbi Fleiss
- NeuroDiderot, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Division of Imaging Sciences and Biomedical Engineering, Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Pierre Gressens
- NeuroDiderot, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Division of Imaging Sciences and Biomedical Engineering, Centre for the Developing Brain, King's College London, London, United Kingdom.
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30
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Bingham A, Laptook AR. Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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31
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Davidson JO, Dhillon SK, Wassink G, Zhou KQ, Bennet L, Gunn AJ. Endogenous neuroprotection after perinatal hypoxia-ischaemia: the resilient developing brain. J R Soc N Z 2018. [DOI: 10.1080/03036758.2018.1529685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Joanne O. Davidson
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Simerdeep K. Dhillon
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Guido Wassink
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Kelly Q. Zhou
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Alistair J. Gunn
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
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32
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Robertson NJ, Martinello K, Lingam I, Avdic-Belltheus A, Meehan C, Alonso-Alconada D, Ragab S, Bainbridge A, Sokolska M, Tachrount M, Middleton B, Price D, Hristova M, Golay X, Soliani Raschini A, Aquino G, Pelizzi N, Facchinetti F. Melatonin as an adjunct to therapeutic hypothermia in a piglet model of neonatal encephalopathy: A translational study. Neurobiol Dis 2018; 121:240-251. [PMID: 30300675 DOI: 10.1016/j.nbd.2018.10.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/25/2018] [Accepted: 10/04/2018] [Indexed: 02/07/2023] Open
Abstract
Therapeutic hypothermia is only partially protective for neonatal encephalopathy; there is an urgent need to develop treatments that augment cooling. Our objective was to assess safety, efficacy and pharmacokinetics of 5 and 15 mg/kg/24 h melatonin (proprietary formulation) administered at 2 h and 26 h after hypoxia-ischemia (HI) with cooling in a piglet model. Following moderate cerebral HI, 30 piglets were eligible and randomized to: i) Hypothermia (33.5 °C, 2-26 h) and vehicle (HT + V;n = 13); b) HT and 5 mg/kg melatonin over 6 h at 2 h and 26 h after HI (HT + Mel-5;n = 4); c) HT and 15 mg/kg melatonin over 6 h at 2 h and 26 h after HI (HT + Mel-15;n = 13). Intensive care was maintained for 48 h; brain MRS was acquired and cell death (TUNEL) evaluated at 48 h. Comparing HT + V with HT + Mel-5 and HT + Mel-15, there was no difference in blood pressure or inotropic support needed, brain Lactate/N Acetylaspartate at 24 h and 48 h was similar, ATP/phosphate pool was higher for HT + Mel-15 versus HT + V at 24 h (p = 0.038) but not 48 h. A localized reduction in TUNEL positive cell death was observed in the sensorimotor cortex in the 15 mg/kg melatonin group (HT + Mel-15 versus HT + V; p < 0.003) but not in the 5 mg/kg melatonin group (HT + Mel-5 versus HT + V; p = 0.808). Putative therapeutic melatonin levels were reached 8 h after HI (104 increase from baseline; ~15-30 mg/l). Mean ± SD peak plasma melatonin levels after the first infusion were 0.0014 ± 0.0012 mg/l in the HT + V group, 3.97 ± 1.53 mg/l in the HT + Mel-5 group and 16.8 ± 8.3 mg/l in the HT + Mel-15 group. Protection was dose dependent; 15 mg/kg melatonin started 2 h after HI, given over 6 h, was well tolerated and augmented hypothermic protection in sensorimotor cortex. Earlier attainment of therapeutic plasma melatonin levels may optimize protection by targeting initial events of reperfusion injury. The time window for intervention with melatonin, as adjunct therapy with cooling, is likely to be narrow and should be considered in designing future clinical studies.
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Affiliation(s)
- Nicola J Robertson
- University College London, London WC1E 6HX, UK; Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar.
| | | | | | | | | | | | - Sara Ragab
- University College London, London WC1E 6HX, UK
| | | | | | - Mohamed Tachrount
- Chronobiology Group, Faculty of Health & Medical Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - Benita Middleton
- Chronobiology Group, Faculty of Health & Medical Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - David Price
- University College London Hospitals NHS Trust, UK
| | | | - Xavier Golay
- Institute of Neurology, Queen Square, University College London, London, UK
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33
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Robinson S, Conteh FS, Oppong AY, Yellowhair TR, Newville JC, Demerdash NE, Shrock CL, Maxwell JR, Jett S, Northington FJ, Jantzie LL. Extended Combined Neonatal Treatment With Erythropoietin Plus Melatonin Prevents Posthemorrhagic Hydrocephalus of Prematurity in Rats. Front Cell Neurosci 2018; 12:322. [PMID: 30319361 PMCID: PMC6167494 DOI: 10.3389/fncel.2018.00322] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 09/06/2018] [Indexed: 12/15/2022] Open
Abstract
Posthemorrhagic hydrocephalus of prematurity (PHHP) remains a global challenge. Early preterm infants (<32 weeks gestation), particularly those exposed to chorioamnionitis (CAM), are prone to intraventricular hemorrhage (IVH) and PHHP. We established an age-appropriate, preclinical model of PHHP with progressive macrocephaly and ventriculomegaly to test whether non-surgical neonatal treatment could modulate PHHP. We combined prenatal CAM and postnatal day 1 (P1, equivalent to 30 weeks human gestation) IVH in rats, and administered systemic erythropoietin (EPO) plus melatonin (MLT), or vehicle, from P2 to P10. CAM-IVH rats developed progressive macrocephaly through P21. Macrocephaly was accompanied by ventriculomegaly at P5 (histology), and P21 (ex vivo MRI). CAM-IVH rats showed impaired performance of cliff aversion, a neonatal neurodevelopmental test. Neonatal EPO+MLT treatment prevented macrocephaly and cliff aversion impairment, and significantly reduced ventriculomegaly. EPO+MLT treatment prevented matted or missing ependymal motile cilia observed in vehicle-treated CAM-IVH rats. EPO+MLT treatment also normalized ependymal yes-associated protein (YAP) mRNA levels, and reduced ependymal GFAP-immunolabeling. Vehicle-treated CAM-IVH rats exhibited loss of microstructural integrity on diffusion tensor imaging, which was normalized in EPO+MLT-treated CAM-IVH rats. In summary, combined prenatal systemic inflammation plus early postnatal IVH caused progressive macrocephaly, ventriculomegaly and delayed development of cliff aversion reminiscent of PHHP. Neonatal systemic EPO+MLT treatment prevented multiple hallmarks of PHHP, consistent with a clinically viable, non-surgical treatment strategy.
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Affiliation(s)
- Shenandoah Robinson
- Division of Pediatric Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Fatu S Conteh
- Division of Pediatric Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Akosua Y Oppong
- Division of Pediatric Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Tracylyn R Yellowhair
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Jessie C Newville
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, United States.,Department of Neurosciences, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Nagat El Demerdash
- Division of Pediatric Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Christine L Shrock
- Division of Pediatric Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Jessie R Maxwell
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Stephen Jett
- Department of Cell Biology and Physiology, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Frances J Northington
- Division of Neonatology, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Lauren L Jantzie
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, United States.,Department of Neurosciences, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
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Nair J, Kumar VHS. Current and Emerging Therapies in the Management of Hypoxic Ischemic Encephalopathy in Neonates. CHILDREN (BASEL, SWITZERLAND) 2018; 5:E99. [PMID: 30029531 PMCID: PMC6069156 DOI: 10.3390/children5070099] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 07/09/2018] [Accepted: 07/16/2018] [Indexed: 01/01/2023]
Abstract
Neonatal hypoxic ischemic encephalopathy (HIE) presents a significant clinical burden with its high mortality and morbidity rates globally. Therapeutic hypothermia (TH) is now standard of care for infants with moderate to severe HIE, but has not definitively changed outcomes in severe HIE. In this review, we discuss newer promising markers that may help the clinician identify severity of HIE. Therapies that are beneficial and agents that hold promise for neuroprotection are described, both for use either alone or as adjuncts to TH. These include endogenous pathway modifiers such as erythropoietin and analogues, melatonin, and remote ischemic post conditioning. Stem cells have therapeutic potential in this condition, as in many other neonatal conditions. Of the agents listed, only erythropoietin and analogues are currently being evaluated in large randomized controlled trials (RCTs). Exogenous therapies such as argon and xenon, allopurinol, monosialogangliosides, and magnesium sulfate continue to be investigated. The recognition of tertiary mechanisms of brain damage has opened up new research into therapies not only to attenuate brain damage but also to promote cell repair and regeneration in a developmentally disorganized brain long after the perinatal insult. These alternative modalities may be especially important in mild HIE and in areas of the world where there is limited access to expensive hypothermia equipment and services.
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Affiliation(s)
- Jayasree Nair
- Division of Neonatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA.
| | - Vasantha H S Kumar
- Division of Neonatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA.
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Stegeman R, Lamur KD, van den Hoogen A, Breur JMPJ, Groenendaal F, Jansen NJG, Benders MJNL. Neuroprotective Drugs in Infants With Severe Congenital Heart Disease: A Systematic Review. Front Neurol 2018; 9:521. [PMID: 30018590 PMCID: PMC6037764 DOI: 10.3389/fneur.2018.00521] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 06/13/2018] [Indexed: 12/20/2022] Open
Abstract
Background: Perinatal and perioperative brain injury is a fundamental problem in infants with severe congenital heart disease undergoing neonatal cardiac surgery with cardiopulmonary bypass. An impaired neuromotor and neurocognitive development is encountered and associated with a reduction in quality of life. New neuroprotective drugs during surgery are described to reduce brain injury and improve neurodevelopmental outcome. Therefore, our aim was to provide a systematic review and best-evidence synthesis on the effects of neuroprotective drugs on brain injury and neurodevelopmental outcome in congenital heart disease infants requiring cardiac surgery with cardiopulmonary bypass. Methods: A systematic search was performed in PubMed, Embase and the Cochrane Library (PRISMA statement). Search terms were “infants,” “congenital heart disease,” “cardiac surgery,” “cardiopulmonary bypass,” and “neuroprotective drug.” Data describing the effects on brain injury and neurodevelopmental outcome were extracted. Study quality was assessed with the Cochrane Risk of Bias Tool. Two reviewers independently screened sources, extracted data and scored bias. Disagreements were resolved by involving a third researcher. Results: The search identified 293 studies of which 6 were included. In total 527 patients with various congenital heart diseases participated with an average of 88 infants (13–318) per study. Allopurinol, sodium nitroprusside, erythropoietin, ketamine, dextromethorphan and phentolamine were administered around cardiac surgery with cardiopulmonary bypass. Allopurinol showed less seizures, coma, death and cardiac events in hypoplastic left heart syndrome (HLHS) infants (OR: 0.44; 95%-CI:0.21–0.91). Sodium nitroprusside resulted in lower post cardiopulmonary bypass levels of S100ß in infants with transposition of the great arteries after 24 (p < 0.01) and 48 (p = 0.04) h of treatment. Erytropoietin, ketamine and dextromethorphan showed no neuroprotective effects. Phentolamine led to higher S100ß-levels and cerebrovascular resistance after rewarming and at the end of surgery (both p < 0.01). Risk of bias varied between studies, including low (sodium nitroprusside, phentolamine), moderate (ketamine, dextromethorphan), and high (erytropoietin, allopurinol) quality. Conclusions: Allopurinol seems promising for future trials in congenital heart disease infants to reduce brain injury given the early neuroprotective effects in hypoplastic left heart syndrome infants. Larger well-designed trials are needed to assess the neuroprotective effects of sodium nitroprusside, erytropoietin, ketamine and dextromethorphan. Future neuroprotective studies in congenital heart disease infants should not only focus on the perioperative period, however also on the perinatal period, since significant brain injury already exists before surgery.
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Affiliation(s)
- Raymond Stegeman
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Wilhelmina Children's Hospital, Utrecht, Netherlands.,Department of Pediatric Cardiology, University Medical Center Utrecht, Utrecht University, Wilhelmina Children's Hospital, Utrecht, Netherlands.,Department of Pediatric Intensive Care, University Medical Center Utrecht, Utrecht University, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Kaya D Lamur
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Wilhelmina Children's Hospital, Utrecht, Netherlands.,Department of Pediatric Cardiology, University Medical Center Utrecht, Utrecht University, Wilhelmina Children's Hospital, Utrecht, Netherlands.,Department of Pediatric Intensive Care, University Medical Center Utrecht, Utrecht University, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Agnes van den Hoogen
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Johannes M P J Breur
- Department of Pediatric Cardiology, University Medical Center Utrecht, Utrecht University, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Floris Groenendaal
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Nicolaas J G Jansen
- Department of Pediatric Intensive Care, University Medical Center Utrecht, Utrecht University, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Manon J N L Benders
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Wilhelmina Children's Hospital, Utrecht, Netherlands
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Dhillon SK, Lear CA, Galinsky R, Wassink G, Davidson JO, Juul S, Robertson NJ, Gunn AJ, Bennet L. The fetus at the tipping point: modifying the outcome of fetal asphyxia. J Physiol 2018; 596:5571-5592. [PMID: 29774532 DOI: 10.1113/jp274949] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/13/2018] [Indexed: 12/13/2022] Open
Abstract
Brain injury around birth is associated with nearly half of all cases of cerebral palsy. Although brain injury is multifactorial, particularly after preterm birth, acute hypoxia-ischaemia is a major contributor to injury. It is now well established that the severity of injury after hypoxia-ischaemia is determined by a dynamic balance between injurious and protective processes. In addition, mothers who are at risk of premature delivery have high rates of diabetes and antepartum infection/inflammation and are almost universally given treatments such as antenatal glucocorticoids and magnesium sulphate to reduce the risk of death and complications after preterm birth. We review evidence that these common factors affect responses to fetal asphyxia, often in unexpected ways. For example, glucocorticoid exposure dramatically increases delayed cell loss after acute hypoxia-ischaemia, largely through secondary hyperglycaemia. This critical new information is important to understand the effects of clinical treatments of women whose fetuses are at risk of perinatal asphyxia.
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Affiliation(s)
| | - Christopher A Lear
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Robert Galinsky
- The Department of Physiology, University of Auckland, Auckland, New Zealand.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Guido Wassink
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Sandra Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Alistair J Gunn
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- The Department of Physiology, University of Auckland, Auckland, New Zealand
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Shepherd E, Salam RA, Middleton P, Han S, Makrides M, McIntyre S, Badawi N, Crowther CA. Neonatal interventions for preventing cerebral palsy: an overview of Cochrane Systematic Reviews. Cochrane Database Syst Rev 2018; 6:CD012409. [PMID: 29926474 PMCID: PMC6513209 DOI: 10.1002/14651858.cd012409.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cerebral palsy is an umbrella term that encompasses disorders of movement and posture attributed to non-progressive disturbances occurring in the developing foetal or infant brain. As there are diverse risk factors and aetiologies, no one strategy will prevent cerebral palsy. Therefore, there is a need to systematically consider all potentially relevant interventions for prevention. OBJECTIVES PrimaryTo summarise the evidence from Cochrane Systematic Reviews regarding effects of neonatal interventions for preventing cerebral palsy (reducing cerebral palsy risk).SecondaryTo summarise the evidence from Cochrane Systematic Reviews regarding effects of neonatal interventions that may increase cerebral palsy risk. METHODS We searched the Cochrane Database of Systematic Reviews (27 November 2016) for reviews of neonatal interventions reporting on cerebral palsy. Two review authors assessed reviews for inclusion, extracted data, and assessed review quality (using AMSTAR and ROBIS) and quality of the evidence (using the GRADE approach). Reviews were organised by topic; findings were summarised in text and were tabulated. Interventions were categorised as effective (high-quality evidence of effectiveness); possibly effective (moderate-quality evidence of effectiveness); ineffective (high-quality evidence of harm); probably ineffective (moderate-quality evidence of harm or lack of effectiveness); and no conclusions possible (low- to very low-quality evidence). MAIN RESULTS Forty-three Cochrane Reviews were included. A further 102 reviews pre-specified the outcome cerebral palsy, but none of the included randomised controlled trials (RCTs) reported this outcome. Included reviews were generally of high quality and had low risk of bias, as determined by AMSTAR and ROBIS. These reviews involved 454 RCTs; data for cerebral palsy were available from 96 (21%) RCTs involving 15,885 children. Review authors considered interventions for neonates with perinatal asphyxia or with evidence of neonatal encephalopathy (3); interventions for neonates born preterm and/or at low or very low birthweight (33); and interventions for other specific groups of 'at risk' neonates (7). Quality of evidence (GRADE) ranged from very low to high.Interventions for neonates with perinatal asphyxia or with evidence of neonatal encephalopathyEffective interventions: high-quality evidence of effectivenessResearchers found a reduction in cerebral palsy following therapeutic hypothermia versus standard care for newborns with hypoxic ischaemic encephalopathy (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.54 to 0.82; seven trials; 881 children).No conclusions possible: very low-quality evidenceOne review observed no clear differences in cerebral palsy following therapeutic hypothermia versus standard care.Interventions for neonates born preterm and/or at low or very low birthweightPossibly effective interventions: moderate-quality evidence of effectivenessResearchers found a reduction in cerebral palsy with prophylactic methylxanthines (caffeine) versus placebo for endotracheal extubation in preterm infants (RR 0.54, 95% CI 0.32 to 0.92; one trial; 644 children).Probably ineffective interventions: moderate-quality evidence of harmResearchers reported an increase in cerebral palsy (RR 1.45, 95% CI 1.06 to 1.98; 12 trials; 1452 children) and cerebral palsy in assessed survivors (RR 1.50, 95% CI 1.13 to 2.00; 12 trials; 959 children) following early (at less than eight days of age) postnatal corticosteroids versus placebo or no treatment for preventing chronic lung disease in preterm infants.Probably ineffective interventions: moderate-quality evidence of lack of effectivenessTrial results showed no clear differences in cerebral palsy following ethamsylate versus placebo for prevention of morbidity and mortality in preterm or very low birthweight infants (RR 1.13, 95% CI 0.64 to 2.00; three trials, 532 children); volume expansion versus no treatment (RR 0.76, 95% CI 0.48 to 1.20; one trial; 604 children); gelatin versus fresh frozen plasma (RR 0.94, 95% CI 0.52 to 1.69; one trial, 399 children) for prevention of morbidity and mortality in very preterm infants; prophylactic indomethacin versus placebo for preventing mortality and morbidity in preterm infants (RR 1.04, 95% CI 0.77 to 1.40; four trials; 1372 children); synthetic surfactant versus placebo for respiratory distress syndrome in preterm infants (RR 0.76, 95% CI 0.55 to 1.05; five trials; 1557 children); or prophylactic phototherapy versus standard care (starting phototherapy when serum bilirubin reached a pre-specified level) for preventing jaundice in preterm or low birthweight infants (RR 0.96, 95% CI 0.50 to 1.85; two trials; 756 children).No conclusions possible: low- to very low-quality evidenceNo clear differences in cerebral palsy were observed with interventions assessed in 21 reviews.Interventions for other specific groups of 'at risk' neonatesNo conclusions possible: low- to very low-quality evidenceReview authors observed no clear differences in cerebral palsy with interventions assessed in five reviews. AUTHORS' CONCLUSIONS This overview summarises evidence from Cochrane Systematic Reviews regarding effects of neonatal interventions on cerebral palsy, and can be used by researchers, funding bodies, policy makers, clinicians, and consumers to aid decision-making and evidence translation. To formally assess other benefits and/or harms of included interventions, including impact on risk factors for cerebral palsy, review of the included Reviews is recommended.Therapeutic hypothermia versus standard care for newborns with hypoxic ischaemic encephalopathy can prevent cerebral palsy, and prophylactic methylxanthines (caffeine) versus placebo for endotracheal extubation in preterm infants may reduce cerebral palsy risk. Early (at less than eight days of age) postnatal corticosteroids versus placebo or no treatment for preventing chronic lung disease in preterm infants may increase cerebral palsy risk.Cerebral palsy is rarely identified at birth, has diverse risk factors and aetiologies, and is diagnosed in approximately one in 500 children. To date, only a small proportion of Cochrane Systematic Reviews assessing neonatal interventions have been able to report on this outcome. There is an urgent need for long-term follow-up of RCTs of such interventions addressing risk factors for cerebral palsy (through strategies such as data linkage with registries) and for consideration of the use of relatively new interim assessments (including the General Movements Assessment). Such RCTs must be rigorous in their design and must aim for consistency in cerebral palsy outcome measurement and reporting to facilitate pooling of data and thus to maximise research efforts focused on prevention.
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Affiliation(s)
- Emily Shepherd
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSouth AustraliaAustralia5006
| | - Rehana A Salam
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan74800
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Shanshan Han
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSouth AustraliaAustralia5006
| | - Maria Makrides
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Sarah McIntyre
- University of SydneyResearch Institute, Cerebral Palsy Alliance187 Allambie Road, Allambie HeightsSydneyAustralia2100
| | - Nadia Badawi
- University of SydneyResearch Institute, Cerebral Palsy Alliance187 Allambie Road, Allambie HeightsSydneyAustralia2100
- The Children's Hospital at WestmeadGrace Centre for Newborn CareSydneyAustralia
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePrivate Bag 9201985 Park RoadAucklandNew Zealand
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Netto CA, Sanches EF, Odorcyk F, Duran-Carabali LE, Sizonenko SV. Pregnancy as a valuable period for preventing hypoxia-ischemia brain damage. Int J Dev Neurosci 2018; 70:12-24. [PMID: 29920306 DOI: 10.1016/j.ijdevneu.2018.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/11/2018] [Accepted: 06/15/2018] [Indexed: 12/16/2022] Open
Abstract
Neonatal brain Hypoxia-Ischemia (HI) is one of the major causes of infant mortality and lifelong neurological disabilities. The knowledge about the physiopathological mechanisms involved in HI lesion have increased in recent years, however these findings have not been translated into clinical practice. Current therapeutic approaches remain limited; hypothermia, used only in term or near-term infants, is the golden standard. Epidemiological evidence shows a link between adverse prenatal conditions and increased risk for diseases, health problems, and psychological outcomes later in life, what makes pregnancy a relevant period for preventing future brain injury. Here, we review experimental literature regarding preventive interventions used during pregnancy, i.e., previous to the HI injury, encompassing pharmacological, nutritional and/or behavioral strategies. Literature review used PubMed database. A total of forty one studies reported protective properties of maternal treatments preventing perinatal hypoxia-ischemia injury in rodents. Pharmacological agents and dietary supplementation showed mainly anti-excitotoxicity, anti-oxidant or anti-apoptotic properties. Interestingly, maternal preconditioning, physical exercise and environmental enrichment seem to engage the same referred mechanisms in order to protect neonatal brain against injury. This construct must be challenged by further studies to clearly define the main mechanisms responsible for neuroprotection to be explored in experimental context, as well as to test their potential in clinical settings.
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Affiliation(s)
- C A Netto
- Biochemistry Department, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.
| | - E F Sanches
- Biochemistry Department, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil
| | - F Odorcyk
- Biochemistry Department, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil
| | - L E Duran-Carabali
- Biochemistry Department, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil
| | - S V Sizonenko
- Division of Child Development and Growth, Department of Pediatrics, University of Geneva, Geneva, Switzerland
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Aridas JDS, Yawno T, Sutherland AE, Nitsos I, Ditchfield M, Wong FY, Hunt RW, Fahey MC, Malhotra A, Wallace EM, Jenkin G, Miller SL. Systemic and transdermal melatonin administration prevents neuropathology in response to perinatal asphyxia in newborn lambs. J Pineal Res 2018; 64:e12479. [PMID: 29464766 PMCID: PMC5947141 DOI: 10.1111/jpi.12479] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 02/06/2018] [Indexed: 01/19/2023]
Abstract
Perinatal asphyxia remains a principal cause of infant mortality and long-term neurological morbidity, particularly in low-resource countries. No neuroprotective interventions are currently available. Melatonin (MLT), a potent antioxidant, anti-inflammatory and antiapoptotic agent, offers promise as an intravenous (IV) or transdermal therapy to protect the brain. We aimed to determine the effect of melatonin (IV or transdermal patch) on neuropathology in a lamb model of perinatal asphyxia. Asphyxia was induced in newborn lambs via umbilical cord occlusion at birth. Animals were randomly allocated to melatonin commencing 30 minutes after birth (60 mg in 24 hours; IV or transdermal patch). Brain magnetic resonance spectroscopy (MRS) was undertaken at 12 and 72 hours. Animals (control n = 9; control+MLT n = 6; asphyxia n = 16; asphyxia+MLT [IV n = 14; patch n = 4]) were euthanised at 72 hours, and cerebrospinal fluid (CSF) and brains were collected for analysis. Asphyxia resulted in severe acidosis (pH 6.9 ± 0.0; lactate 9 ± 2 mmol/L) and altered determinants of encephalopathy. MRS lactate:N-acetyl aspartate ratio was 2.5-fold higher in asphyxia lambs compared with controls at 12 hours and 3-fold higher at 72 hours (P < .05). Melatonin prevented this rise (3.5-fold reduced vs asphyxia; P = .02). Asphyxia significantly increased brain white and grey matter apoptotic cell death (activated caspase-3), lipid peroxidation (4HNE) and neuroinflammation (IBA-1). These changes were significantly mitigated by both IV and patch melatonin. Systemic or transdermal neonatal melatonin administration significantly reduces the neuropathology and encephalopathy signs associated with perinatal asphyxia. A simple melatonin patch, administered soon after birth, may improve outcome in infants affected by asphyxia, especially in low-resource settings.
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Affiliation(s)
- James D. S. Aridas
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
| | - Tamara Yawno
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVic.Australia
| | - Amy E. Sutherland
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
| | - Ilias Nitsos
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVic.Australia
| | | | - Flora Y. Wong
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Monash Children's HospitalMonash HealthClaytonVic.Australia
| | - Rod W. Hunt
- Murdoch Children's Research InstituteMelbourneVic.Australia
| | - Michael C. Fahey
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Monash Children's HospitalMonash HealthClaytonVic.Australia
| | - Atul Malhotra
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Monash Children's HospitalMonash HealthClaytonVic.Australia
| | - Euan M. Wallace
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVic.Australia
| | - Graham Jenkin
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVic.Australia
| | - Suzanne L. Miller
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVic.Australia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVic.Australia
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Wehrle FM, Held U, O'Gorman RT, Disselhoff V, Schnider B, Fauchère JC, Hüppi P, Latal B, Hagmann CF. Long-term neuroprotective effect of erythropoietin on executive functions in very preterm children (EpoKids): protocol of a prospective follow-up study. BMJ Open 2018; 8:e022157. [PMID: 29691250 PMCID: PMC5922511 DOI: 10.1136/bmjopen-2018-022157] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Premature infants are particularly vulnerable to brain injuries with associated cognitive and behavioural deficits. The worldwide first randomised interventional multicentre trial investigating the neuroprotective effects of erythropoietin (entitled 'Does erythropoietin improve outcome in very preterm infants?' (NCT00413946)) included 450 very preterm infants in Switzerland. MRI at term equivalent age showed less white matter (WM) injury in the erythropoietin group compared with the placebo group. Despite these promising imaging findings, neurodevelopmental outcome at 2 years showed no beneficial effect of early erythropoietin. One explanation could be that the assessment of more complex cognitive functions such as executive functions (EFs) is only possible at a later age. We hypothesise that due to improved WM development and fewer WM injuries, children born preterm treated with early erythropoietin will have better EF abilities at 7-12 years than those treated with placebo. METHODS AND ANALYSIS 365 children who were included into the primary analysis of the original trial (NCT00413946) will be eligible in this prospective follow-up study at the age of 7-12 years. 185 children born at term will be control children. Primary outcome measures are EF abilities and processing speed, while secondary outcomes are academic performance, IQ, fine motor abilities and global brain connectivity. A comprehensive test battery will be applied to assess EFs. MRI will be performed to assess global brain connectivity. Cognitive scores and MRI measures will be compared between both groups using the Wilcoxon test. Propensity score matching will be used to balance gender, age, socioeconomic status and other potentially unbalanced variables between the children born preterm and the healthy control children. ETHICS AND DISSEMINATION The cantonal ethical committee granted ethical approval for this study (KEK 2017-00521). Written consent will be obtained from the parents. Findings from this study will be disseminated via international and national conference presentations and publications in peer-reviewed journals.
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Affiliation(s)
- Flavia Maria Wehrle
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Ruth Tuura O'Gorman
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- MR Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Vera Disselhoff
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Barbara Schnider
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Jean-Claude Fauchère
- Department of Neonatology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Petra Hüppi
- Division of Child Development and Growth, Department of Paediatrics, Geneva University, Geneva, Switzerland
| | - Beatrice Latal
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Cornelia Franziska Hagmann
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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Jantzie LL, Oppong AY, Conteh FS, Yellowhair TR, Kim J, Fink G, Wolin AR, Northington FJ, Robinson S. Repetitive Neonatal Erythropoietin and Melatonin Combinatorial Treatment Provides Sustained Repair of Functional Deficits in a Rat Model of Cerebral Palsy. Front Neurol 2018; 9:233. [PMID: 29706928 PMCID: PMC5908903 DOI: 10.3389/fneur.2018.00233] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 03/26/2018] [Indexed: 12/21/2022] Open
Abstract
Cerebral palsy (CP) is the leading cause of motor impairment for children worldwide and results from perinatal brain injury (PBI). To test novel therapeutics to mitigate deficits from PBI, we developed a rat model of extreme preterm birth (<28 weeks of gestation) that mimics dual intrauterine injury from placental underperfusion and chorioamnionitis. We hypothesized that a sustained postnatal treatment regimen that combines the endogenous neuroreparative agents erythropoietin (EPO) and melatonin (MLT) would mitigate molecular, sensorimotor, and cognitive abnormalities in adults rats following prenatal injury. On embryonic day 18 (E18), a laparotomy was performed in pregnant Sprague–Dawley rats. Uterine artery occlusion was performed for 60 min to induce placental insufficiency via transient systemic hypoxia-ischemia, followed by intra-amniotic injections of lipopolysaccharide, and laparotomy closure. On postnatal day 1 (P1), approximately equivalent to 30 weeks of gestation, injured rats were randomized to an extended EPO + MLT treatment regimen, or vehicle (sterile saline) from P1 to P10. Behavioral assays were performed along an extended developmental time course (n = 6–29). Open field testing shows injured rats exhibit hypermobility and disinhibition and that combined neonatal EPO + MLT treatment repairs disinhibition in injured rats, while EPO alone does not. Furthermore, EPO + MLT normalizes hindlimb deficits, including reduced paw area and paw pressure at peak stance, and elevated percent shared stance after prenatal injury. Injured rats had fewer social interactions than shams, and EPO + MLT normalized social drive. Touchscreen operant chamber testing of visual discrimination and reversal shows that EPO + MLT at least partially normalizes theses complex cognitive tasks. Together, these data indicate EPO + MLT can potentially repair multiple sensorimotor, cognitive, and behavioral realms following PBI, using highly translatable and sophisticated developmental testing platforms.
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Affiliation(s)
- Lauren L Jantzie
- Department of Pediatrics, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM, United States.,Department of Neurosciences, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM, United States
| | - Akosua Y Oppong
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
| | - Fatu S Conteh
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
| | - Tracylyn R Yellowhair
- Department of Pediatrics, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM, United States
| | - Joshua Kim
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
| | - Gabrielle Fink
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
| | - Adam R Wolin
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
| | - Frances J Northington
- Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Shenandoah Robinson
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, MD, United States
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Neuroprotection of the hypoxic-ischemic mouse brain by human CD117 +CD90 +CD105 + amniotic fluid stem cells. Sci Rep 2018; 8:2425. [PMID: 29402914 PMCID: PMC5799160 DOI: 10.1038/s41598-018-20710-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/23/2018] [Indexed: 01/23/2023] Open
Abstract
Human amniotic fluid contains two morphologically-distinct sub-populations of stem cells with regenerative potential, spindle-shaped (SS-hAFSCs) and round-shaped human amniotic fluid stem cells (RS-hAFSCs). However, it is unclear whether morphological differences correlate with functionality, and this lack of knowledge limits their translational applications. Here, we show that SS-hAFSCs and RS-hAFSCs differ in their neuro-protective ability, demonstrating that a single contralateral injection of SS-hAFSCs into hypoxic-ischemic P7 mice conferred a 47% reduction in hippocampal tissue loss and 43–45% reduction in TUNEL-positive cells in the hippocampus and striatum 48 hours after the insult, decreased microglial activation and TGFβ1 levels, and prevented demyelination. On the other hand, RS-hAFSCs failed to show such neuro-protective effects. It is possible that SS-hAFSCs exert their neuroprotection via endoglin-dependent inhibition of TGFβ1 signaling in target cells. These findings identify a sub-population of CD117+CD90+CD105+ stem cells as a promising source for the neuro-protection of the developing brain.
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Zitta K, Peeters-Scholte C, Sommer L, Gruenewald M, Hummitzsch L, Parczany K, Steinfath M, Albrecht M. 2-Iminobiotin Superimposed on Hypothermia Protects Human Neuronal Cells from Hypoxia-Induced Cell Damage: An in Vitro Study. Front Pharmacol 2018; 8:971. [PMID: 29358921 PMCID: PMC5768900 DOI: 10.3389/fphar.2017.00971] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 12/20/2017] [Indexed: 12/12/2022] Open
Abstract
Perinatal asphyxia represents one of the major causes of neonatal morbidity and mortality. Hypothermia is currently the only established treatment for hypoxic-ischemic encephalopathy (HIE), but additional pharmacological strategies are being explored to further reduce the damage after perinatal asphyxia. The aim of this study was to evaluate whether 2-iminobiotin (2-IB) superimposed on hypothermia has the potential to attenuate hypoxia-induced injury of neuronal cells. In vitro hypoxia was induced for 7 h in neuronal IMR-32 cell cultures. Afterwards, all cultures were subjected to 25 h of hypothermia (33.5°C), and incubated with vehicle or 2-IB (10, 30, 50, 100, and 300 ng/ml). Cell morphology was evaluated by brightfield microscopy. Cell damage was analyzed by LDH assays. Production of reactive oxygen species (ROS) was measured using fluorometric assays. Western blotting for PARP, Caspase-3, and the phosphorylated forms of akt and erk1/2 was conducted. To evaluate early apoptotic events and signaling, cell protein was isolated 4 h post-hypoxia and human apoptosis proteome profiler arrays were performed. Twenty-five hour after the hypoxic insult, clear morphological signs of cell damage were visible and significant LDH release as well as ROS production were observed even under hypothermic conditions. Post-hypoxic application of 2-IB (10 and 30 ng/ml) reduced the hypoxia-induced LDH release but not ROS production. Phosphorylation of erk1/2 was significantly increased after hypoxia, while phosphorylation of akt, protein expression of Caspase-3 and cleavage of PARP were only slightly increased. Addition of 2-IB did not affect any of the investigated proteins. Apoptosis proteome profiler arrays performed with cellular protein obtained 4 h after hypoxia revealed that post-hypoxic application of 2-IB resulted in a ≥ 25% down regulation of 10/35 apoptosis-related proteins: Bad, Bax, Bcl-2, cleaved Caspase-3, TRAILR1, TRAILR2, PON2, p21, p27, and phospho Rad17. In summary, addition of 2-IB during hypothermia is able to attenuate hypoxia-induced neuronal cell damage in vitro. Combination treatment of hypothermia with 2-IB could be a promising strategy to reduce hypoxia-induced neuronal cell damage and should be considered in further animal and clinical studies.
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Affiliation(s)
- Karina Zitta
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | - Lena Sommer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Matthias Gruenewald
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Lars Hummitzsch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Kerstin Parczany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Markus Steinfath
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Martin Albrecht
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
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Mao J. [Patterns of brain injury in neonatal hypoxic-ischemic encephalopathy on magnetic resonance imaging: recommendations on classification]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017. [PMID: 29237520 PMCID: PMC7389802 DOI: 10.7499/j.issn.1008-8830.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Although there are unified criteria for the clinical diagnosis and grading of neonatal hypoxic-ischemic encephalopathy (HIE), clinical features and neuropathological patterns vary considerably among the neonates with HIE due to birth asphyxia in the same classification. The patterns and progression of brain injury in HIE, which is closely associated with long-term neurodevelopment outcomes, can be well shown on magnetic resonance imaging (MRI), but different sequences may lead to different MRI findings at the same time. It is suggested that diffusion-weighted imaging sequence be selected at 2-4 days after birth, and the conventional MRI sequence at 4-8 days. The major patterns of brain injury in HIE on MRI are as follows: injury of the thalamus and basal ganglia and posterior limbs of the internal capsules; watershed injury involving the cortical and subcortical white matter; focal or multifocal minimal white matter injury; extensive whole brain injury. Severe acute birth asphyxia often leads to deep grey matter injury (thalamus and basal ganglia), and the brain stem may also be involved; the pyramidal tract is the most susceptible white matter fiber tract; repetitive or intermittent hypoxic-ischemic insults, with inflammation or hypoglycemia, usually cause injuries in the watershed area and deep white matter. It is worth noting that sometimes the pattern of brain injury among those described above cannot be determined exactly, but rather a predominant one is identified; not all cases of HIE have characteristic MRI findings.
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Affiliation(s)
- Jian Mao
- Neonatologist Society, Chinese Medical Doctor Association
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45
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Luo Y, Peng M, Wei H. Melatonin Promotes Brain-Derived Neurotrophic Factor (BDNF) Expression and Anti-Apoptotic Effects in Neonatal Hemolytic Hyperbilirubinemia via a Phospholipase (PLC)-Mediated Mechanism. Med Sci Monit 2017; 23:5951-5959. [PMID: 29247156 PMCID: PMC5741953 DOI: 10.12659/msm.907592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Melatonin therapy shows positive effects on neuroprotective factor brain-derived neurotrophic factor (BDNF) expression and neuronal apoptosis in neonatal hemolytic hyperbilirubinemia. We hypothesized that melatonin promotes BDNF expression and anti-apoptotic effects in neonatal hemolytic hyperbilirubinemia through a phospholipase (PLC)-mediated mechanism. MATERIAL AND METHODS A phenylhydrazine hydrochloride (PHZ)-induced neonatal hemolytic hyperbilirubinemia model was constructed in neonatal rats. Four experimental groups - a control group (n=30), a PHZ group (n=30), a PHZ + melatonin group (n=30), and a PHZ + melatonin+U73122 (a PLC inhibitor) group (n=30) - were constructed. Trunk blood was assayed for serum hemoglobin, hematocrit, total and direct bilirubin, BDNF, S100B, and tau protein levels. Brain tissue levels of neuronal apoptosis, BDNF expression, PLC activity, IP3 content, phospho- and total Ca2+/calmodulin-dependent protein kinase type IV (CaMKIV) expression, and phospho- and total cAMP response element binding protein (CREB) expression were also assayed. RESULTS PHZ-induced hemolytic hyperbilirubinemia was validated by significantly decreased serum hemoglobin and hematocrit as well as significantly increased total and direct serum bilirubin (p<0.05). Neonatal bilirubin-induced neurotoxicity was validated by significantly decreased serum BDNF, brain BDNF, and serum S100B, along with significantly increased serum tau protein (p<0.05). PHZ-induced hemolytic hyperbilirubinemia significantly decreased serum BDNF, brain BDNF, and PLC/IP3/Ca2+ pathway activation while increasing neuronal apoptosis levels (p<0.05), all of which were partially rescued by melatonin therapy (p<0.05). Pre-treatment with the PLC inhibitor U73122 largely abolished the positive effects of melatonin on PLC/IP3/Ca2+ pathway activation, downstream BDNF levels, and neuronal apoptosis (p<0.05). CONCLUSIONS Promotion of BDNF expression and anti-apoptotic effects in neonatal hemolytic hyperbilirubinemia by melatonin largely operates via a PLC-mediated mechanism.
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Affiliation(s)
- Yong Luo
- Department of Pediatrics, Yongchuan Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Mei Peng
- Department of Infectious Diseases, Yongchuan Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Hong Wei
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China (mainland)
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46
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Martinello KA, Shepherd E, Middleton P, Crowther CA. Allopurinol for women in pregnancy for neuroprotection of the fetus. Cochrane Database Syst Rev 2017. [DOI: 10.1002/14651858.cd012881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Kathryn A Martinello
- The University of Adelaide, Women's and Children's Hospital; Department of Neonatal and Perinatal Medicine; 72 King William Road Adelaide South Australia Australia 5006
- Institute for Women's Health, University College London; Department of Neonatology; London UK
| | - Emily Shepherd
- The University of Adelaide; ARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and Gynaecology; Adelaide South Australia Australia 5006
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute; Women's and Children's Hospital 72 King William Road Adelaide South Australia Australia 5006
| | - Caroline A Crowther
- The University of Adelaide; ARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and Gynaecology; Adelaide South Australia Australia 5006
- The University of Auckland; Liggins Institute; Private Bag 92019 85 Park Road Auckland New Zealand
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47
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Yawno T, Mahen M, Li J, Fahey MC, Jenkin G, Miller SL. The Beneficial Effects of Melatonin Administration Following Hypoxia-Ischemia in Preterm Fetal Sheep. Front Cell Neurosci 2017; 11:296. [PMID: 29018332 PMCID: PMC5615225 DOI: 10.3389/fncel.2017.00296] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 09/06/2017] [Indexed: 11/24/2022] Open
Abstract
Melatonin (MLT) is an endogenous hormone that controls circadian cycle. MLT has additional important properties that make it appealing as a neuroprotective agent—it is a potent anti-oxidant, with anti-apoptotic and anti-inflammatory properties. MLT is safe for administration during pregnancy or to the newborn after birth, and can reduce white matter brain injury under conditions of chronic fetal hypoxia. Accordingly, in the current study, we examined whether an intermediate dose of MLT could restore white matter brain development when administered after an acute hypoxic ischemic (HI) insult in preterm fetal sheep. Fifteen fetal sheep at 95–98 days gestation were instrumented with femoral artery and vein catheters, and a silastic cuff placed around the umbilical cord. At 102 days gestation, the cuff was inflated, causing complete umbilical cord occlusion for 25 min in 10 fetuses, to induce acute severe HI. Five HI fetuses received intravenous MLT for 24 h beginning at 2 h after HI. The remaining five fetuses were administered saline alone. Ten days after HI, the fetal brain was collected from each animal and white and gray matter neuropathology assessed. HI caused a significant increase in apoptotic cell death (TUNEL+), activated microglia (Iba-1+), and oxidative stress (8-OHdG+) within the subventricular and subcortical white matter. HI reduced the total number of oligodendrocytes and CNPase+ myelin density. MLT administration following HI decreased apoptosis, inflammation and oxidative stress within the white matter. MLT had intermediate benefits for the developing white matter: it increased oligodendrocyte cell number within the periventricular white matter only, and improved CNPase+ myelin density within the subcortical but not the striatal white matter. MLT administration following HI was also associated with improved neuronal survival within the cortex. Neuropathology in preterm infants is complex and mediated by multiple mechanisms, including inflammation, oxidative stress and apoptotic pathways. Treatment with MLT presents a safe approach to neuroprotective therapy in preterm infants but appears to have brain region-specific benefits within the white matter.
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Affiliation(s)
- Tamara Yawno
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, ClaytonVIC, Australia
| | - Mawin Mahen
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia
| | - Jingang Li
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia
| | - Michael C Fahey
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia.,Department of Paediatrics, Monash Medical Centre, ClaytonVIC, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, ClaytonVIC, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, ClaytonVIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, ClaytonVIC, Australia
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48
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Berger HR, Nyman AKG, Morken TS, Vettukattil R, Brubakk AM, Widerøe M. Early metabolite changes after melatonin treatment in neonatal rats with hypoxic-ischemic brain injury studied by in-vivo1H MR spectroscopy. PLoS One 2017; 12:e0185202. [PMID: 28934366 PMCID: PMC5608359 DOI: 10.1371/journal.pone.0185202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 09/07/2017] [Indexed: 12/31/2022] Open
Abstract
Melatonin is a promising neuroprotective agent after perinatal hypoxic-ischemic (HI) brain injury. We used in-vivo1H magnetic resonance spectroscopy to investigate effects of melatonin treatment on brain metabolism after HI. Postnatal day 7 Sprague-Dawley rats with unilateral HI brain injury were treated with either melatonin 10 mg/kg dissolved in phosphate-buffered saline (PBS) with 5% dimethyl sulfoxide (DMSO) or vehicle (5% DMSO and/or PBS) directly and at 6 hours after HI. 1H MR spectra from the thalamus in the ipsilateral and contralateral hemisphere were acquired 1 day after HI. Our results showed that injured animals had a distinct metabolic profile in the ipsilateral thalamus compared to sham with low concentrations of total creatine, choline, N-acetyl aspartate (NAA), and high concentrations of lipids. A majority of the melatonin-treated animals had a metabolic profile characterized by higher total creatine, choline, NAA and lower lipid levels than other HI animals. When comparing absolute concentrations, melatonin treatment resulted in higher glutamine levels and lower lipid concentrations compared to DMSO treatment as well as higher macromolecule levels compared to PBS treatment day 1 after HI. DMSO treated animals had lower concentrations of glucose, creatine, phosphocholine and macromolecules compared to sham animals. In conclusion, the neuroprotective effects of melatonin were reflected in a more favorable metabolic profile including reduced lipid levels that likely represents reduced cell injury. Neuroprotective effects may also be related to the influence of melatonin on glutamate/glutamine metabolism. The modulatory effects of the solvent DMSO on cerebral energy metabolism might have masked additional beneficial effects of melatonin.
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Affiliation(s)
- Hester Rijkje Berger
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Pediatrics, St. Olavs University Hospital HF, Trondheim, Norway
- * E-mail:
| | - Axel K. G. Nyman
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tora Sund Morken
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Ophthalmology, St. Olavs University Hospital HF, Trondheim, Norway
| | - Riyas Vettukattil
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ann-Mari Brubakk
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marius Widerøe
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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Back SA. White matter injury in the preterm infant: pathology and mechanisms. Acta Neuropathol 2017; 134:331-349. [PMID: 28534077 PMCID: PMC5973818 DOI: 10.1007/s00401-017-1718-6] [Citation(s) in RCA: 259] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/27/2017] [Accepted: 04/29/2017] [Indexed: 12/22/2022]
Abstract
The human preterm brain is particularly susceptible to cerebral white matter injury (WMI) that disrupts the normal progression of developmental myelination. Advances in the care of preterm infants have resulted in a sustained reduction in the severity of WMI that has shifted from more severe focal necrotic lesions to milder diffuse WMI. Nevertheless, WMI remains a global health problem and the most common cause of chronic neurological morbidity from cerebral palsy and diverse neurobehavioral disabilities. Diffuse WMI involves maturation-dependent vulnerability of the oligodendrocyte (OL) lineage with selective degeneration of late oligodendrocyte progenitors (preOLs) triggered by oxidative stress and other insults. The magnitude and distribution of diffuse WMI are related to both the timing of appearance and regional distribution of susceptible preOLs. Diffuse WMI disrupts the normal progression of OL lineage maturation and myelination through aberrant mechanisms of regeneration and repair. PreOL degeneration is accompanied by early robust proliferation of OL progenitors that regenerate and augment the preOL pool available to generate myelinating OLs. However, newly generated preOLs fail to differentiate and initiate myelination along their normal developmental trajectory despite the presence of numerous intact-appearing axons. Disrupted preOL maturation is accompanied by diffuse gliosis and disturbances in the composition of the extracellular matrix and is mediated in part by inhibitory factors derived from reactive astrocytes. Signaling pathways implicated in disrupted myelination include those mediated by Notch, WNT-beta catenin, and hyaluronan. Hence, there exists a potentially broad but still poorly defined developmental window for interventions to promote white matter repair and myelination and potentially reverses the widespread disturbances in cerebral gray matter growth that accompanies WMI.
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Affiliation(s)
- Stephen A Back
- Division of Pediatric Neuroscience, Departments of Pediatrics and Neurology, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239-3098, USA.
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50
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A Controversial Medicolegal Issue: Timing the Onset of Perinatal Hypoxic-Ischemic Brain Injury. Mediators Inflamm 2017; 2017:6024959. [PMID: 28883688 PMCID: PMC5572618 DOI: 10.1155/2017/6024959] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/18/2017] [Indexed: 12/11/2022] Open
Abstract
Perinatal hypoxic-ischemic brain injury, as a result of chronic, subacute, and acute insults, represents the pathological consequence of fetal distress and birth or perinatal asphyxia, that is, “nonreassuring fetal status.” Hypoxic-ischemic injury (HII) is typically characterized by an early phase of damage, followed by a delayed inflammatory local response, in an apoptosis-necrosis continuum. In the early phase, the cytotoxic edema and eventual acute lysis take place; with reperfusion, additional damage should be assigned to excitotoxicity and oxidative stress. Finally, a later phase involves all the inflammatory activity and long-term neural tissue repairing and remodeling. In this model mechanism, loss of mitochondrial function is supposed to be the hallmark of secondary injury progression, and autophagy which is lysosome-mediated play a role in enhancing brain injury. Early-induced molecules driven by hypoxia, as chaperonins HSPs and ORP150, besides common markers for inflammatory responses, have predictive value in timing the onset of neonatal HII; on the other hand, clinical biomarkers for HII diagnosis, as CK-BB, LDH, S-100beta, and NSE, could be useful to predict outcomes.
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