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Austin T, Connolly D, Dinwiddy K, Hart AR, Heep A, Harigopal S, Joy H, Luyt K, Malamateniou C, Merchant N, Rizava C, Rutherford MA, Spike K, Vollmer B, Boardman JP. Neonatal brain magnetic resonance imaging: clinical indications, acquisition and reporting. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326747. [PMID: 38373753 DOI: 10.1136/archdischild-2023-326747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/05/2024] [Indexed: 02/21/2024]
Affiliation(s)
- Topun Austin
- Neonatal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Daniel Connolly
- Department of Neuroradiology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Kate Dinwiddy
- British Association of Perinatal Medicine, Royal College of Paediatrics and Child Health, London, UK
| | | | - Axel Heep
- University of Bristol Medical School, Bristol, UK
| | - Sundeep Harigopal
- Neonatal Intensive Care, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Harriet Joy
- Department of Neuroradiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Karen Luyt
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | | | | | - Kelly Spike
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Brigitte Vollmer
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton, UK
- Neonatal and Paediatric Neurology, Southampton Children's Hospital, Southampton, UK
| | - James P Boardman
- Institute for Regeneration and Repair, University of Edinburgh Division of Reproductive and Developmental Sciences, Edinburgh, UK
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2
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Spielman DM, Gu M, Hurd RE, Riemer RK, Okamura K, Hanley FL. Proton magnetic resonance spectroscopy assessment of neonatal brain metabolism during cardiopulmonary bypass surgery. NMR IN BIOMEDICINE 2022; 35:e4752. [PMID: 35483967 PMCID: PMC9484292 DOI: 10.1002/nbm.4752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 06/14/2023]
Abstract
Here, we report on the development and performance of a robust 3-T single-voxel proton magnetic resonance spectroscopy (1 H MRS) experimental protocol and data analysis pipeline for quantifying brain metabolism during cardiopulmonary bypass (CPB) surgery in a neonatal porcine model, with the overall goal of elucidating primary mechanisms of brain injury associated with these procedures. The specific aims were to assess which metabolic processes can be reliably interrogated by 1 H MRS on a 3-T clinical scanner and to provide an initial assessment of brain metabolism during deep hypothermia cardiac arrest (DHCA) surgery and recovery. Fourteen neonatal pigs underwent CPB surgery while placed in a 3-T MRI scanner for 18, 28, and 37°C DHCA studies under hyperglycemic, euglycemic, and hypoglycemic conditions. Total imaging times, including baseline measurements, circulatory arrest (CA), and recovery averaged 3 h/animal, during which 30-40 single-voxel 1 H MRS spectra (sLASER pulse sequence, TR/TE = 2000/30 ms, 64 or 128 averages) were acquired from a 2.2-cc right midbrain voxel. 1 H MRS at 3 T was able to reliably quantify (1) anaerobic metabolism via depletion of brain glucose and the associated build-up of lactate during CA, (2) phosphocreatine (PCr) to creatine (Cr) conversion during CA and subsequent recovery upon reperfusion, (3) a robust increase in the glutamine-to-glutamate (Gln/Glu) ratio during the post-CA recovery period, and (4) a broadening of the water peak during CA. In vivo 1 H MRS at 3 T can reliably quantify subtle metabolic brain changes previously deemed challenging to interrogate, including brain glucose concentrations even under hypoglycemic conditions, ATP usage via the conversion of PCr to Cr, and differential changes in Glu and Gln. Observed metabolic changes during CPB surgery of a neonatal porcine model provide new insights into possible mechanisms for prevention of neuronal injury.
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Affiliation(s)
- Daniel M. Spielman
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Meng Gu
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Ralph E. Hurd
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - R. Kirk Riemer
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Kenichi Okamura
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Frank L. Hanley
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
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3
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Optical Monitoring in Neonatal Seizures. Cells 2022; 11:cells11162602. [PMID: 36010678 PMCID: PMC9407001 DOI: 10.3390/cells11162602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/30/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Neonatal seizures remain a significant cause of morbidity and mortality worldwide. The past decade has resulted in substantial progress in seizure detection and understanding the impact seizures have on the developing brain. Optical monitoring such as cerebral near-infrared spectroscopy (NIRS) and broadband NIRS can provide non-invasive continuous real-time monitoring of the changes in brain metabolism and haemodynamics. AIM To perform a systematic review of optical biomarkers to identify changes in cerebral haemodynamics and metabolism during the pre-ictal, ictal, and post-ictal phases of neonatal seizures. METHOD A systematic search was performed in eight databases. The search combined the three broad categories: (neonates) AND (NIRS) AND (seizures) using the stepwise approach following PRISMA guidance. RESULTS Fifteen papers described the haemodynamic and/or metabolic changes observed with NIRS during neonatal seizures. No randomised controlled trials were identified during the search. Studies reported various changes occurring in the pre-ictal, ictal, and post-ictal phases of seizures. CONCLUSION Clear changes in cerebral haemodynamics and metabolism were noted during the pre-ictal, ictal, and post-ictal phases of seizures in neonates. Further studies are necessary to determine whether NIRS-based methods can be used at the cot-side to provide clear pathophysiological data in real-time during neonatal seizures.
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Pang R, Mujuni BM, Martinello KA, Webb EL, Nalwoga A, Ssekyewa J, Musoke M, Kurinczuk JJ, Sewegaba M, Cowan FM, Cose S, Nakakeeto M, Elliott AM, Sebire NJ, Klein N, Robertson NJ, Tann CJ. Elevated serum IL-10 is associated with severity of neonatal encephalopathy and adverse early childhood outcomes. Pediatr Res 2022; 92:180-189. [PMID: 33674741 PMCID: PMC9411052 DOI: 10.1038/s41390-021-01438-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neonatal encephalopathy (NE) contributes substantially to child mortality and disability globally. We compared cytokine profiles in term Ugandan neonates with and without NE, with and without perinatal infection or inflammation and identified biomarkers predicting neonatal and early childhood outcomes. METHODS In this exploratory biomarker study, serum IL-1α, IL-6, IL-8, IL-10, TNFα, and VEGF (<12 h) were compared between NE and non-NE infants with and without perinatal infection/inflammation. Neonatal (severity of NE, mortality) and early childhood (death or neurodevelopmental impairment to 2.5 years) outcomes were assessed. Predictors of outcomes were explored with multivariable linear and logistic regression and receiver-operating characteristic analyses. RESULTS Cytokine assays on 159 NE and 157 non-NE infants were performed; data on early childhood outcomes were available for 150 and 129, respectively. NE infants had higher IL-10 (p < 0.001), higher IL-6 (p < 0.017), and lower VEGF (p < 0.001) levels. Moderate and severe NE was associated with higher IL-10 levels compared to non-NE infants (p < 0.001). Elevated IL-1α was associated with perinatal infection/inflammation (p = 0.013). Among NE infants, IL-10 predicted neonatal mortality (p = 0.01) and adverse early childhood outcome (adjusted OR 2.28, 95% CI 1.35-3.86, p = 0.002). CONCLUSIONS Our findings support a potential role for IL-10 as a biomarker for adverse outcomes after neonatal encephalopathy. IMPACT Neonatal encephalopathy is a common cause of child death and disability globally. Inflammatory cytokines are potential biomarkers of encephalopathy severity and outcome. In this Ugandan health facility-based cohort, neonatal encephalopathy was associated with elevated serum IL-10 and IL-6, and reduced VEGF at birth. Elevated serum IL-10 within 12 h after birth predicted severity of neonatal encephalopathy, neonatal mortality, and adverse early childhood developmental outcomes, independent of perinatal infection or inflammation, and provides evidence to the contribution of the inflammatory processes. Our findings support a role for IL-10 as a biomarker for adverse outcomes after neonatal encephalopathy in a sub-Saharan African cohort.
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Affiliation(s)
- Raymand Pang
- Institute for Women's Health, University College London, London, UK
| | - Brian M Mujuni
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | | | - Emily L Webb
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Angela Nalwoga
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Julius Ssekyewa
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Margaret Musoke
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | | | - Margaret Sewegaba
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Frances M Cowan
- Department of Pediatrics, Imperial College London, London, UK
| | - Stephen Cose
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Margaret Nakakeeto
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Alison M Elliott
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Neil J Sebire
- UCL Institute of Child Health and GOSH BRC, UCL, London, UK
| | - Nigel Klein
- UCL Institute of Child Health and GOSH BRC, UCL, London, UK
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Cally J Tann
- Institute for Women's Health, University College London, London, UK.
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda.
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
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Proton MR Spectroscopy of Pediatric Brain Disorders. Diagnostics (Basel) 2022; 12:diagnostics12061462. [PMID: 35741272 PMCID: PMC9222059 DOI: 10.3390/diagnostics12061462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 11/17/2022] Open
Abstract
In vivo MR spectroscopy is a non -invasive methodology that provides information about the biochemistry of tissues. It is available as a “push-button” application on state-of-the-art clinical MR scanners. MR spectroscopy has been used to study various brain diseases including tumors, stroke, trauma, degenerative disorders, epilepsy/seizures, inborn errors, neuropsychiatric disorders, and others. The purpose of this review is to provide an overview of MR spectroscopy findings in the pediatric population and its clinical use.
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6
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Martinello KA, Meehan C, Avdic-Belltheus A, Lingam I, Mutshiya T, Yang Q, Akin MA, Price D, Sokolska M, Bainbridge A, Hristova M, Tachtsidis I, Tann CJ, Peebles D, Hagberg H, Wolfs TGAM, Klein N, Kramer BW, Fleiss B, Gressens P, Golay X, Robertson NJ. Hypothermia is not therapeutic in a neonatal piglet model of inflammation-sensitized hypoxia-ischemia. Pediatr Res 2022; 91:1416-1427. [PMID: 34050269 PMCID: PMC8160560 DOI: 10.1038/s41390-021-01584-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/20/2021] [Accepted: 05/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Perinatal inflammation combined with hypoxia-ischemia (HI) exacerbates injury in the developing brain. Therapeutic hypothermia (HT) is standard care for neonatal encephalopathy; however, its benefit in inflammation-sensitized HI (IS-HI) is unknown. METHODS Twelve newborn piglets received a 2 µg/kg bolus and 1 µg/kg/h infusion over 52 h of Escherichia coli lipopolysaccharide (LPS). HI was induced 4 h after LPS bolus. After HI, piglets were randomized to HT (33.5 °C 1-25 h after HI, n = 6) or normothermia (NT, n = 6). Amplitude-integrated electroencephalogram (aEEG) was recorded and magnetic resonance spectroscopy (MRS) was acquired at 24 and 48 h. At 48 h, terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL)-positive brain cell death, microglial activation/proliferation, astrogliosis, and cleaved caspase-3 (CC3) were quantified. Hematology and plasma cytokines were serially measured. RESULTS Two HT piglets died. aEEG recovery, thalamic and white matter MRS lactate/N-acetylaspartate, and TUNEL-positive cell death were similar between groups. HT increased microglial activation in the caudate, but had no other effect on glial activation/proliferation. HT reduced CC3 overall. HT suppressed platelet count and attenuated leukocytosis. Cytokine profile was unchanged by HT. CONCLUSIONS We did not observe protection with HT in this piglet IS-HI model based on aEEG, MRS, and immunohistochemistry. Immunosuppressive effects of HT and countering neuroinflammation by LPS may contribute to the observed lack of HT efficacy. Other immunomodulatory strategies may be more effective in IS-HI. IMPACT Acute infection/inflammation is known to exacerbate perinatal brain injury and can worsen the outcomes in neonatal encephalopathy. Therapeutic HT is the current standard of care for all infants with NE, but the benefit in infants with coinfection/inflammation is unknown. In a piglet model of inflammation (LPS)-sensitized HI, we observed no evidence of neuroprotection with cooling for 24 h, based on our primary outcome measures: aEEG, MRS Lac/NAA, and histological brain cell death. Additional neuroprotective agents, with beneficial immunomodulatory effects, require exploration in IS-HI models.
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Affiliation(s)
- Kathryn A Martinello
- Institute for Women's Health, University College London, London, UK
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | | | | | - Ingran Lingam
- Institute for Women's Health, University College London, London, UK
| | - Tatenda Mutshiya
- Institute for Women's Health, University College London, London, UK
| | - Qin Yang
- Institute for Women's Health, University College London, London, UK
| | - Mustafa Ali Akin
- Department of Paediatrics, Ondokuz Mayıs University, Samsun, Turkey
| | - David Price
- Medical Physics and Biomedical Engineering, University College London NHS Foundation Trust, London, UK
| | - Magdalena Sokolska
- Medical Physics and Biomedical Engineering, University College London NHS Foundation Trust, London, UK
| | - Alan Bainbridge
- Medical Physics and Biomedical Engineering, University College London NHS Foundation Trust, London, UK
| | - Mariya Hristova
- Institute for Women's Health, University College London, London, UK
| | - Ilias Tachtsidis
- Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Cally J Tann
- Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Donald Peebles
- Institute for Women's Health, University College London, London, UK
| | - Henrik Hagberg
- Department of Clinical Sciences, Centre of Perinatal Medicine and Health, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Centre for the Developing Brain, Kings College London, London, UK
| | - Tim G A M Wolfs
- Department of Pediatrics, University of Maastricht, Maastricht, The Netherlands
| | - Nigel Klein
- Paediatric Infectious Diseases and Immunology, Institute of Child Health, University College London, London, UK
| | - Boris W Kramer
- Department of Pediatrics, University of Maastricht, Maastricht, The Netherlands
| | - Bobbi Fleiss
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
- Université de Paris, NeuroDiderot, Inserm, Paris, France
| | | | - Xavier Golay
- Institute of Neurology, University College London, London, UK
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK.
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
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Landucci E, Pellegrini-Giampietro DE, Facchinetti F. Experimental Models for Testing the Efficacy of Pharmacological Treatments for Neonatal Hypoxic-Ischemic Encephalopathy. Biomedicines 2022; 10:937. [PMID: 35625674 PMCID: PMC9138693 DOI: 10.3390/biomedicines10050937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 02/04/2023] Open
Abstract
Representing an important cause of long-term disability, term neonatal hypoxic-ischemic encephalopathy (HIE) urgently needs further research aimed at repurposing existing drug as well as developing new therapeutics. Since various experimental in vitro and in vivo models of HIE have been developed with distinct characteristics, it becomes important to select the appropriate preclinical screening cascade for testing the efficacy of novel pharmacological treatments. As therapeutic hypothermia is already a routine therapy for neonatal encephalopathy, it is essential that hypothermia be administered to the experimental model selected to allow translational testing of novel or repurposed drugs on top of the standard of care. Moreover, a translational approach requires that therapeutic interventions must be initiated after the induction of the insult, and the time window for intervention should be evaluated to translate to real world clinical practice. Hippocampal organotypic slice cultures, in particular, are an invaluable intermediate between simpler cell lines and in vivo models, as they largely maintain structural complexity of the original tissue and can be subjected to transient oxygen-glucose deprivation (OGD) and subsequent reoxygenation to simulate ischemic neuronal injury and reperfusion. Progressing to in vivo models, generally, rodent (mouse and rat) models could offer more flexibility and be more cost-effective for testing the efficacy of pharmacological agents with a dose-response approach. Large animal models, including piglets, sheep, and non-human primates, may be utilized as a third step for more focused and accurate translational studies, including also pharmacokinetic and safety pharmacology assessments. Thus, a preclinical proof of concept of efficacy of an emerging pharmacological treatment should be obtained firstly in vitro, including organotypic models, and, subsequently, in at least two different animal models, also in combination with hypothermia, before initiating clinical trials.
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Affiliation(s)
- Elisa Landucci
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Florence, 50139 Florence, Italy;
| | | | - Fabrizio Facchinetti
- Department of Experimental Pharmacology and Translational Science, Corporate Pre-Clinical R&D, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy;
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Campion S, Inselman A, Hayes B, Casiraghi C, Joseph D, Facchinetti F, Salomone F, Schmitt G, Hui J, Davis-Bruno K, Van Malderen K, Morford L, De Schaepdrijver L, Wiesner L, Kourula S, Seo S, Laffan S, Urmaliya V, Chen C. The benefits, limitations and opportunities of preclinical models for neonatal drug development. Dis Model Mech 2022; 15:275112. [PMID: 35466995 PMCID: PMC9066504 DOI: 10.1242/dmm.049065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Increased research to improve preclinical models to inform the development of therapeutics for neonatal diseases is an area of great need. This article reviews five common neonatal diseases – bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, perinatal hypoxic–ischemic encephalopathy and neonatal sepsis – and the available in vivo, in vitro and in silico preclinical models for studying these diseases. Better understanding of the strengths and weaknesses of specialized neonatal disease models will help to improve their utility, may add to the understanding of the mode of action and efficacy of a therapeutic, and/or may improve the understanding of the disease pathology to aid in identification of new therapeutic targets. Although the diseases covered in this article are diverse and require specific approaches, several high-level, overarching key lessons can be learned by evaluating the strengths, weaknesses and gaps in the available models. This Review is intended to help guide current and future researchers toward successful development of therapeutics in these areas of high unmet medical need. Summary: This article reviews and analyzes the available preclinical models for five common neonatal diseases to direct therapeutic development in these areas of high unmet medical need.
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Affiliation(s)
- Sarah Campion
- Pfizer Worldwide Research, Development, and Medical, Groton, CT 06340, USA
| | - Amy Inselman
- U.S. Food and Drug Administration, National Center for Toxicological Research, Division of Systems Biology, Jefferson, AR 72079, USA
| | - Belinda Hayes
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Silver Spring, MD 20993, USA
| | - Costanza Casiraghi
- Department of Experimental Pharmacology and Translational Science, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy
| | - David Joseph
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Silver Spring, MD 20993, USA
| | - Fabrizio Facchinetti
- Department of Experimental Pharmacology and Translational Science, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy
| | - Fabrizio Salomone
- Department of Experimental Pharmacology and Translational Science, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy
| | - Georg Schmitt
- Pharma Research and Early Development, Roche Innovation Center Basel, Pharmaceutical Sciences, F. Hoffmann-La Roche, 4070 Basel, Switzerland
| | - Julia Hui
- Bristol Myers Squibb, Nonclinical Research and Development, Summit, NJ 07901, USA
| | - Karen Davis-Bruno
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Silver Spring, MD 20993, USA
| | - Karen Van Malderen
- Federal Agency for Medicines and Health Products (FAMHP), Department DG PRE authorization, 1210 Brussels, Belgium
| | - LaRonda Morford
- Eli Lilly, Global Regulatory Affairs, Indianapolis, IN 46285, USA
| | | | - Lutz Wiesner
- Federal Institute for Drugs and Medical Devices, Clinical Trials, 53175 Bonn, Germany
| | - Stephanie Kourula
- Janssen R&D, Drug Metabolism & Pharmacokinetics, 2340 Beerse, Belgium
| | - Suna Seo
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Silver Spring, MD 20993, USA
| | - Susan Laffan
- GlaxoSmithKline, Non-Clinical Safety, Collegeville, PA 19406, USA
| | | | - Connie Chen
- Health and Environmental Sciences Institute, Washington, DC 20005, USA
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9
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Nanyunja C, Sadoo S, Mambule I, Mathieson SR, Nyirenda M, Webb EL, Mugalu J, Robertson NJ, Nabawanuka A, Gilbert G, Bwambale J, Martinello K, Bainbridge A, Lubowa S, Srinivasan L, Ssebombo H, Morgan C, Hagmann C, Cowan FM, Le Doare K, Wintermark P, Kawooya M, Boylan GB, Nakimuli A, Tann CJ. Protocol for the Birth Asphyxia in African Newborns (Baby BRAiN) Study: a Neonatal Encephalopathy Feasibility Cohort Study. Gates Open Res 2022; 6:10. [PMID: 35614965 PMCID: PMC9110736 DOI: 10.12688/gatesopenres.13557.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND: Neonatal encephalopathy (NE) is a leading cause of child mortality worldwide and contributes substantially to stillbirths and long-term disability. Ninety-nine percent of deaths from NE occur in low-and-middle-income countries (LMICs). Whilst therapeutic hypothermia significantly improves outcomes in high-income countries, its safety and effectiveness in diverse LMIC contexts remains debated. Important differences in the aetiology, nature and timing of neonatal brain injury likely influence the effectiveness of postnatal interventions, including therapeutic hypothermia. METHODS: This is a prospective pilot feasibility cohort study of neonates with NE conducted at Kawempe National Referral Hospital, Kampala, Uganda. Neurological investigations include continuous video electroencephalography (EEG) (days 1-4), serial cranial ultrasound imaging, and neonatal brain Magnetic Resonance Imaging and Spectroscopy (MRI/ MRS) (day 10-14). Neurodevelopmental follow-up will be continued to 18-24 months of age including Prechtl's Assessment of General Movements, Bayley Scales of Infant Development, and a formal scored neurological examination. The primary outcome will be death and moderate-severe neurodevelopmental impairment at 18-24 months. Findings will be used to inform explorative science and larger trials, aiming to develop urgently needed neuroprotective and neurorestorative interventions for NE applicable for use in diverse settings. DISCUSSION: The primary aims of the study are to assess the feasibility of establishing a facility-based cohort of children with NE in Uganda, to enhance our understanding of NE in a low-resource sub-Saharan African setting and provide infrastructure to conduct high-quality research on neuroprotective/ neurorestorative strategies to reduce death and disability from NE. Specific objectives are to establish a NE cohort, in order to 1) investigate the clinical course, aetiology, nature and timing of perinatal brain injury; 2) describe electrographic activity and quantify seizure burden and the relationship with adverse outcomes, and; 3) develop capacity for neonatal brain MRI/S and examine associations with early neurodevelopmental outcomes.
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Affiliation(s)
| | - Samantha Sadoo
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ivan Mambule
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | | | - Emily L Webb
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - J Mugalu
- Kawempe National Referral Hospital, Kampala, UK
| | - Nicola J Robertson
- University College London, London, UK
- University of Edinburgh, Edinburgh, UK
| | | | | | | | | | | | | | | | | | - Cathy Morgan
- Cerebral Palsy Alliance Research Institute, University of Sydney, Sydney, Australia
| | | | | | - Kirsty Le Doare
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- St George's, University of London, London, UK
| | | | - Michael Kawooya
- Ernest Cook Ultrasound Research and Education Institute (ECUREI), Kampala, Uganda
| | | | - Annettee Nakimuli
- Kawempe National Referral Hospital, Kampala, UK
- Makarere University, Kampala, Uganda
| | - Cally J Tann
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
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10
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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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11
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Malak R, Sikorska D, Rosołek M, Baum E, Mojs E, Daroszewski P, Matecka M, Fechner B, Samborski W. Impact of umbilical cord arterial pH, gestational age, and birth weight on neurodevelopmental outcomes for preterm neonates. PeerJ 2021; 9:e12043. [PMID: 34567841 PMCID: PMC8428260 DOI: 10.7717/peerj.12043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/02/2021] [Indexed: 11/20/2022] Open
Abstract
Background The aim of this study was to determine the impact of umbilical cord arterial pH, gestational age, and birth weight on neurodevelopmental outcomes for preterm neonates. Methods We examined 112 neonates. Inclusion criteria were: Saturations greater than 88%, and heart rates between 100–205 beats per minute. Measurements We assessed several neurodevelopmental factors as part of the Brazelton Neonatal Behavioral Assessment Scale (NBAS), 4th edition, such as asymmetric tonic neck reflex (ATNR), motor maturity, response to sensory stimuli, habituation, and state regulation. Initial assessment parameters such as APGAR score and umbilical cord arterial pH were used to assess neonates. Results We found a strong correlation between the presence of the sucking reflex and umbilical cord arterial pH (r = 0.32; p = 0.018981). Umbilical cord arterial pH was also correlated with the presence of asymmetric tonic neck reflex (r = 0.27; p = 0.047124), cost of attention (r = 0.31; p = 0.025381) and general motor maturity (r = 0.34; p = 0.011741). Conclusions We found that the sucking reflex may be affected in infants with low umbilical cord arterial pH values. Practitioners and parents can use the NBAS to help determine neurodevelopmental factors and outcomes in preterm infants, possibly leading to safer and more effective feeding practices and interventions.
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Affiliation(s)
- Roksana Malak
- Department and Clinic of Rheumatology, Rehabilitation and Internal Diseases, Poznan University of Medical Science, Poznań, Poland, Poznań, Wielkopolskie, Great Poland, Polska
| | - Dorota Sikorska
- Department and Clinic of Rheumatology, Rehabilitation and Internal Diseases, Poznan University of Medical Science, Poznan, Polska
| | - Marta Rosołek
- Department of Physiotherapy, Poznan University of Medical Science, Poznań, Poland, Poznan University of Medical Science, Poznan, Polska
| | - Ewa Baum
- Department of Social Sciences and the Humanities Poznan University of Medical Sciences, Poznan, Polska
| | - Ewa Mojs
- Department of Clinical Psychology, Poznan University of Medical Sciences, Poznań, Poland, Poznan University of Medical Science, Poznan, Polska
| | - Przemysław Daroszewski
- Department of Organization and Management in Health Care, Poznan University of Medical Sciences, Poznan, Polska
| | - Monika Matecka
- Department of Geriatrics and Gerontology, Poznan University of Medical Sciences, Poznan, Polska
| | - Brittany Fechner
- Department and Clinic of Rheumatology, Rehabilitation and Internal Diseases, Poznan University of Medical Science, Poznan, Polska
| | - Włodzimierz Samborski
- Department and Clinic of Rheumatology, Rehabilitation and Internal Diseases, Poznan University of Medical Science, Poznan, Polska
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12
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Alm PA. Stuttering: A Disorder of Energy Supply to Neurons? Front Hum Neurosci 2021; 15:662204. [PMID: 34630054 PMCID: PMC8496059 DOI: 10.3389/fnhum.2021.662204] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/10/2021] [Indexed: 11/30/2022] Open
Abstract
Stuttering is a disorder characterized by intermittent loss of volitional control of speech movements. This hypothesis and theory article focuses on the proposal that stuttering may be related to an impairment of the energy supply to neurons. Findings from electroencephalography (EEG), brain imaging, genetics, and biochemistry are reviewed: (1) Analyses of the EEG spectra at rest have repeatedly reported reduced power in the beta band, which is compatible with indications of reduced metabolism. (2) Studies of the absolute level of regional cerebral blood flow (rCBF) show conflicting findings, with two studies reporting reduced rCBF in the frontal lobe, and two studies, based on a different method, reporting no group differences. This contradiction has not yet been resolved. (3) The pattern of reduction in the studies reporting reduced rCBF corresponds to the regional pattern of the glycolytic index (GI; Vaishnavi et al., 2010). High regional GI indicates high reliance on non-oxidative metabolism, i.e., glycolysis. (4) Variants of the gene ARNT2 have been associated with stuttering. This gene is primarily expressed in the brain, with a pattern roughly corresponding to the pattern of regional GI. A central function of the ARNT2 protein is to act as one part of a sensor system indicating low levels of oxygen in brain tissue and to activate appropriate responses, including activation of glycolysis. (5) It has been established that genes related to the functions of the lysosomes are implicated in some cases of stuttering. It is possible that these gene variants result in a reduced peak rate of energy supply to neurons. (6) Lastly, there are indications of interactions between the metabolic system and the dopamine system: for example, it is known that acute hypoxia results in an elevated tonic level of dopamine in the synapses. Will mild chronic limitations of energy supply also result in elevated levels of dopamine? The indications of such interaction effects suggest that the metabolic theory of stuttering should be explored in parallel with the exploration of the dopaminergic theory.
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Affiliation(s)
- Per A. Alm
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
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13
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Koskela T, Kendall GS, Memon S, Sokolska M, Mabuza T, Huertas-Ceballos A, Mitra S, Robertson NJ, Meek J, Whitehead K. Prognostic value of neonatal EEG following therapeutic hypothermia in survivors of hypoxic-ischemic encephalopathy. Clin Neurophysiol 2021; 132:2091-2100. [PMID: 34284244 PMCID: PMC8407358 DOI: 10.1016/j.clinph.2021.05.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/10/2021] [Accepted: 05/25/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Early prediction of neurological deficits following neonatal hypoxic-ischemic encephalopathy (HIE) may help to target support. Neonatal animal models suggest that recovery following hypoxia-ischemia depends upon cortical bursting. To test whether this holds in human neonates, we correlated the magnitude of cortical bursting during recovery (≥postnatal day 3) with neurodevelopmental outcomes. METHODS We identified 41 surviving infants who received therapeutic hypothermia for HIE (classification at hospital discharge: 19 mild, 18 moderate, 4 severe) and had 9-channel electroencephalography (EEG) recordings as part of their routine care. We correlated burst power with Bayley-III cognitive, motor and language scores at median 24 months. To examine whether EEG offered additional prognostic information, we controlled for structural MRI findings. RESULTS Higher power of central and occipital cortical bursts predicted worse cognitive and language outcomes, and higher power of central cortical bursts predicted worse motor outcome, all independently of structural MRI findings. CONCLUSIONS Clinical EEG after postnatal day 3 may provide additional prognostic information by indexing persistent active mechanisms that either support recovery or exacerbate brain damage, especially in infants with less severe encephalopathy. SIGNIFICANCE These findings could allow for the effect of clinical interventions in the neonatal period to be studied instantaneously in the future.
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Affiliation(s)
- Tuomas Koskela
- Research IT Services, University College London, London WC1E 7HB, UK.
| | - Giles S Kendall
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK; Academic Neonatology, Institute for Women's Health, University College London, London WC1E 6HU, UK.
| | - Sara Memon
- Department of Neuroscience, Physiology & Pharmacology, University College London, London WC1E 6BT, UK.
| | - Magdalena Sokolska
- Department of Medical Physics and Biomedical Engineering, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK.
| | - Thalitha Mabuza
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK.
| | - Angela Huertas-Ceballos
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK.
| | - Subhabrata Mitra
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK; Academic Neonatology, Institute for Women's Health, University College London, London WC1E 6HU, UK.
| | - Nicola J Robertson
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK; Academic Neonatology, Institute for Women's Health, University College London, London WC1E 6HU, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.
| | - Judith Meek
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK.
| | - Kimberley Whitehead
- Neonatal Intensive Care Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals, London WC1E 6DB, UK; Department of Neuroscience, Physiology & Pharmacology, University College London, London WC1E 6BT, UK.
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Thermal Index for early non-invasive assessment of brain injury in newborns treated with therapeutic hypothermia: preliminary report. Sci Rep 2021; 11:12578. [PMID: 34131269 PMCID: PMC8206354 DOI: 10.1038/s41598-021-92139-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/27/2021] [Indexed: 12/02/2022] Open
Abstract
Perinatal asphyxia (PA) is the 3rd most common cause of neonatal death and one of the most common causes of severe neurological impairments in children. Current tools and measurements mainly based on the analysis of clinical evaluation and laboratory and electrophysiological tests do not give consistent data allowing to predict the severity of hypoxic-ischemic encephalopathy (HIE) until a magnetic resonance imaging (MRI) score is performed. The aim of this work is to evaluate the usefulness of the new index, called Thermal Index (TI) in the assessment of the degree of brain damage in newborns in the course of therapeutic hypothermia (TH) due to PA. This was a prospective, observational, pilot study which did not require any changes in the applicable procedures. Analysis has been applied to six newborn babies treated with TH in Neonatal/Paediatric ICU in University Hospital in Opole in 2018 due to PA. They all met criteria for TH according to the current recommendations. Brain MRI was performed after the end of TH when the children were brought back to normal temperature, with the use of a 1.5 T scanner, using T1-, T2-weighted images, fluid-attenuated inversion recovery (FLAIR), inversion recovery (IR), susceptibility-weighted imaging (SWI), and diffusion-weighted imaging (DWI). The images were assessed using MRI score according to the scoring system proposed by Weeke et al. The Thermal Index assessing endogenous heat production was calculated according to the formula proposed in this paper. A high, statistically significant positive correlation was found between MRI scores and TI values (0.98; p = 0.0003) in the 1st hour of therapy. High correlation with MRI assessment, the non-invasiveness of measurements and the availability of results within the first few hours of treatment, allow authors to propose the Thermal Index as a tool for early evaluating of the brain injury in newborns treated with TH. Further research is required to confirm the usefulness of the proposed method.
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15
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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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16
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Melatonin for Neonatal Encephalopathy: From Bench to Bedside. Int J Mol Sci 2021; 22:ijms22115481. [PMID: 34067448 PMCID: PMC8196955 DOI: 10.3390/ijms22115481] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 12/21/2022] Open
Abstract
Neonatal encephalopathy is a leading cause of morbidity and mortality worldwide. Although therapeutic hypothermia (HT) is now standard practice in most neonatal intensive care units in high resource settings, some infants still develop long-term adverse neurological sequelae. In low resource settings, HT may not be safe or efficacious. Therefore, additional neuroprotective interventions are urgently needed. Melatonin’s diverse neuroprotective properties include antioxidant, anti-inflammatory, and anti-apoptotic effects. Its strong safety profile and compelling preclinical data suggests that melatonin is a promising agent to improve the outcomes of infants with NE. Over the past decade, the safety and efficacy of melatonin to augment HT has been studied in the neonatal piglet model of perinatal asphyxia. From this model, we have observed that the neuroprotective effects of melatonin are time-critical and dose dependent. Therapeutic melatonin levels are likely to be 15–30 mg/L and for optimal effect, these need to be achieved within the first 2–3 h after birth. This review summarises the neuroprotective properties of melatonin, the key findings from the piglet and other animal studies to date, and the challenges we face to translate melatonin from bench to bedside.
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17
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Fitzgerald E, Roberts J, Tennant DA, Boardman JP, Drake AJ. Metabolic adaptations to hypoxia in the neonatal mouse forebrain can occur independently of the transporters SLC7A5 and SLC3A2. Sci Rep 2021; 11:9092. [PMID: 33907288 PMCID: PMC8079390 DOI: 10.1038/s41598-021-88757-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/16/2021] [Indexed: 02/02/2023] Open
Abstract
Neonatal encephalopathy due to hypoxia-ischemia is associated with adverse neurodevelopmental effects. The involvement of branched chain amino acids (BCAAs) in this is largely unexplored. Transport of BCAAs at the plasma membrane is facilitated by SLC7A5/SLC3A2, which increase with hypoxia. We hypothesized that hypoxia would alter BCAA transport and metabolism in the neonatal brain. We investigated this using an organotypic forebrain slice culture model with, the SLC7A5/SLC3A2 inhibitor, 2-Amino-2-norbornanecarboxylic acid (BCH) under normoxic or hypoxic conditions. We subsequently analysed the metabolome and candidate gene expression. Hypoxia was associated with increased expression of SLC7A5 and SLC3A2 and an increased tissue abundance of BCAAs. Incubation of slices with 13C-leucine confirmed that this was due to increased cellular uptake. BCH had little effect on metabolite abundance under normoxic or hypoxic conditions. This suggests hypoxia drives increased cellular uptake of BCAAs in the neonatal mouse forebrain, and membrane mediated transport through SLC7A5 and SLC3A2 is not essential for this process. This indicates mechanisms exist to generate the compounds required to maintain essential metabolism in the absence of external nutrient supply. Moreover, excess BCAAs have been associated with developmental delay, providing an unexplored mechanism of hypoxia mediated pathogenesis in the developing forebrain.
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Affiliation(s)
- Eamon Fitzgerald
- University/British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK.
| | - Jennie Roberts
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Daniel A Tennant
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James P Boardman
- MRC Centre for Reproductive Health, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Amanda J Drake
- University/British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
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18
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Wisnowski JL, Bluml S, Panigrahy A, Mathur AM, Berman J, Chen PSK, Dix J, Flynn T, Fricke S, Friedman SD, Head HW, Ho CY, Kline-Fath B, Oveson M, Patterson R, Pruthi S, Rollins N, Ramos YM, Rampton J, Rusin J, Shaw DW, Smith M, Tkach J, Vasanawala S, Vossough A, Whitehead MT, Xu D, Yeom K, Comstock B, Heagerty PJ, Juul SE, Wu YW, McKinstry RC. Integrating neuroimaging biomarkers into the multicentre, high-dose erythropoietin for asphyxia and encephalopathy (HEAL) trial: rationale, protocol and harmonisation. BMJ Open 2021; 11:e043852. [PMID: 33888528 PMCID: PMC8070884 DOI: 10.1136/bmjopen-2020-043852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION MRI and MR spectroscopy (MRS) provide early biomarkers of brain injury and treatment response in neonates with hypoxic-ischaemic encephalopathy). Still, there are challenges to incorporating neuroimaging biomarkers into multisite randomised controlled trials. In this paper, we provide the rationale for incorporating MRI and MRS biomarkers into the multisite, phase III high-dose erythropoietin for asphyxia and encephalopathy (HEAL) Trial, the MRI/S protocol and describe the strategies used for harmonisation across multiple MRI platforms. METHODS AND ANALYSIS Neonates with moderate or severe encephalopathy enrolled in the multisite HEAL trial undergo MRI and MRS between 96 and 144 hours of age using standardised neuroimaging protocols. MRI and MRS data are processed centrally and used to determine a brain injury score and quantitative measures of lactate and n-acetylaspartate. Harmonisation is achieved through standardisation-thereby reducing intrasite and intersite variance, real-time quality assurance monitoring and phantom scans. ETHICS AND DISSEMINATION IRB approval was obtained at each participating site and written consent obtained from parents prior to participation in HEAL. Additional oversight is provided by an National Institutes of Health-appointed data safety monitoring board and medical monitor. TRIAL REGISTRATION NUMBER NCT02811263; Pre-result.
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Affiliation(s)
- Jessica L Wisnowski
- Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
- Pediatrics, Children's Hospital Los Angeles Division of Neonatology, Los Angeles, California, USA
| | - Stefan Bluml
- Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Ashok Panigrahy
- Radiology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amit M Mathur
- Pediatrics, Division of Neonatal-Perinatal Medicine, SSM Health Cardinal Glennon Children's Hospital, Saint Louis, Missouri, USA
- Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University, Saint Louis, Missouri, USA
| | - Jeffrey Berman
- Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - James Dix
- Radiology, Methodist Children's Hospital, San Antonio, Texas, USA
| | - Trevor Flynn
- Radiology, University of California San Francisco, San Francisco, California, USA
| | - Stanley Fricke
- Radiology, Children's National Medical Center, Washington, District of Columbia, USA
- Radiology, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Seth D Friedman
- Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Hayden W Head
- Radiology, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Chang Y Ho
- Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Beth Kline-Fath
- Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael Oveson
- Radiology, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Richard Patterson
- Radiology, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Sumit Pruthi
- Radiology, Vanderbilt University, Nashville, Tennessee, USA
| | - Nancy Rollins
- Radiology, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Yanerys M Ramos
- Radiology, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - John Rampton
- Radiology, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Jerome Rusin
- Radiology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Dennis W Shaw
- Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Mark Smith
- Radiology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jean Tkach
- Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Arastoo Vossough
- Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew T Whitehead
- Radiology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Duan Xu
- Radiology, University of California San Francisco, San Francisco, California, USA
| | - Kristen Yeom
- Radiology, Stanford University, Stanford, California, USA
| | - Bryan Comstock
- Biostatistics, University of Washington, Seattle, Washington, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sandra E Juul
- Pediatrics, Division of Neonatology, University of Washington, Seattle, Washington, USA
| | - Yvonne W Wu
- Neurology, University of California San Francisco, San Francisco, California, USA
| | - Robert C McKinstry
- Radiology, St. Louis Children's Hospital and Washington University, Saint Louis, Missouri, USA
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Laptook AR, Shankaran S, Barnes P, Rollins N, Do BT, Parikh NA, Hamrick S, Hintz SR, Tyson JE, Bell EF, Ambalavanan N, Goldberg RN, Pappas A, Huitema C, Pedroza C, Chaudhary AS, Hensman AM, Das A, Wyckoff M, Khan A, Walsh MC, Watterberg KL, Faix R, Truog W, Guillet R, Sokol GM, Poindexter BB, Higgins RD. Limitations of Conventional Magnetic Resonance Imaging as a Predictor of Death or Disability Following Neonatal Hypoxic-Ischemic Encephalopathy in the Late Hypothermia Trial. J Pediatr 2021; 230:106-111.e6. [PMID: 33189747 PMCID: PMC7914162 DOI: 10.1016/j.jpeds.2020.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To investigate if magnetic resonance imaging (MRI) is an accurate predictor for death or moderate-severe disability at 18-22 months of age among infants with neonatal encephalopathy in a trial of cooling initiated at 6-24 hours. STUDY DESIGN Subgroup analysis of infants ≥36 weeks of gestation with moderate-severe neonatal encephalopathy randomized at 6-24 postnatal hours to hypothermia or usual care in a multicenter trial of late hypothermia. MRI scans were performed per each center's practice and interpreted by 2 central readers using the Eunice Kennedy Shriver National Institute of Child Health and Human Development injury score (6 levels, normal to hemispheric devastation). Neurodevelopmental outcomes were assessed at 18-22 months of age. RESULTS Of 168 enrollees, 128 had an interpretable MRI and were seen in follow-up (n = 119) or died (n = 9). MRI findings were predominantly acute injury and did not differ by cooling treatment. At 18-22 months, death or severe disability occurred in 20.3%. No infant had moderate disability. Agreement between central readers was moderate (weighted kappa 0.56, 95% CI 0.45-0.67). The adjusted odds of death or severe disability increased 3.7-fold (95% CI 1.8-7.9) for each increment of injury score. The area under the curve for severe MRI patterns to predict death or severe disability was 0.77 and the positive and negative predictive values were 36% and 100%, respectively. CONCLUSIONS MRI injury scores were associated with neurodevelopmental outcome at 18-22 months among infants in the Late Hypothermia Trial. However, the results suggest caution when using qualitative interpretations of MRI images to provide prognostic information to families following perinatal hypoxia-ischemia. TRIAL REGISTRATION Clinicaltrials.gov: NCT00614744.
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Affiliation(s)
- Abbot R. Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown
University, Providence, RI
| | | | - Patrick Barnes
- Department of Radiology and Pediatrics, Stanford University
School of Medicine, Palo Alto, CA
| | - Nancy Rollins
- Department of Radiology, University of Texas Southwestern
Medical Center, Dallas, TX
| | - Barbara T. Do
- Biostatistics and Epidemiology Division, RTI International,
Research Triangle Park, NC
| | - Nehal A. Parikh
- Perinatal Institute, Cincinnati Children’s Hospital
Medical Center, Cincinnati, OH
| | - Shannon Hamrick
- Emory University School of Medicine, Department of
Pediatrics, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Susan R. Hintz
- Department of Pediatrics, Division of Neonatal and
Developmental Medicine, Stanford University School of Medicine and Lucile Packard
Children’s Hospital, Palo Alto, CA
| | - Jon E. Tyson
- Department of Pediatrics, McGovern Medical School at The
University of Texas Health Science Center at Houston, Houston, TX
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City,
IA
| | | | | | - Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit,
MI
| | - Carolyn Huitema
- Social, Statistical and Environmental Sciences Unit, RTI
International, Rockville, MD
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at The
University of Texas Health Science Center at Houston, Houston, TX
| | | | - Angelita M. Hensman
- Department of Pediatrics, Women and Infants Hospital, Brown
University, Providence, RI
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI
International, Rockville, MD
| | - Myra Wyckoff
- Department of Pediatrics, University of Texas
Southwestern Medical Center, Dallas, TX
| | - Amir Khan
- Department of Pediatrics, McGovern Medical School at The
University of Texas Health Science Center at Houston, Houston, TX
| | - Michelle C. Walsh
- Department of Pediatrics, Rainbow Babies &
Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | | | - Roger Faix
- Department of Pediatrics, Division of Neonatology,
University of Utah School of Medicine, Salt Lake City, UT
| | - William Truog
- Department of Pediatrics, Children’s Mercy
Hospital and University of Missouri Kansas City School of Medicine, Kansas City,
MO
| | - Ronnie Guillet
- University of Rochester School of Medicine and Dentistry,
Rochester, NY
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN
| | - Brenda B. Poindexter
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN,Cincinnati Children’s Hospital Medical Center,
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati,
OH
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health
and Human Development, Pregnancy and Perinatology Branch,George Mason University, Fairfax, VA
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20
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Bale G, Rajaram A, Kewin M, Morrison L, Bainbridge A, Liu L, Anazodo U, Diop M, Lawrence KS, Tachtsidis I. Multimodal Measurements of Brain Tissue Metabolism and Perfusion in a Neonatal Model of Hypoxic-Ischaemic Injury. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1269:203-208. [PMID: 33966218 DOI: 10.1007/978-3-030-48238-1_32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This is the first multimodal study of cerebral tissue metabolism and perfusion post-hypoxic-ischaemic (HI) brain injury using broadband near-infrared spectroscopy (bNIRS), diffuse correlation spectroscopy (DCS), positron emission tomography (PET) and magnetic resonance spectroscopy (MRS). In seven piglet preclinical models of neonatal HI, we measured cerebral tissue saturation (StO2), cerebral blood flow (CBF), cerebral oxygen metabolism (CMRO2), changes in the mitochondrial oxidation state of cytochrome c oxidase (oxCCO), cerebral glucose metabolism (CMRglc) and tissue biochemistry (Lac+Thr/tNAA). At baseline, the parameters measured in the piglets that experience HI (not controls) were 64 ± 6% StO2, 35 ± 11 ml/100 g/min CBF and 2.0 ± 0.4 μmol/100 g/min CMRO2. After HI, the parameters measured were 68 ± 6% StO2, 35 ± 6 ml/100 g/min CBF, 1.3 ± 0.1 μmol/100 g/min CMRO2, 0.4 ± 0.2 Lac+Thr/tNAA and 9.5 ± 2.0 CMRglc. This study demonstrates the capacity of a multimodal set-up to interrogate the pathophysiology of HIE using a combination of optical methods, MRS, and PET.
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Affiliation(s)
- Gemma Bale
- Biomedical Optics Research Laboratory, University College London, London, UK.
| | - Ajay Rajaram
- Medical Biophysics, Western University, and Lawson Health Research Institute, London, ON, Canada
| | - Matthew Kewin
- Medical Biophysics, Western University, and Lawson Health Research Institute, London, ON, Canada
| | - Laura Morrison
- Medical Biophysics, Western University, and Lawson Health Research Institute, London, ON, Canada
| | - Alan Bainbridge
- Medical Physics, University College London Hospital, London, UK
| | - Linshan Liu
- Medical Biophysics, Western University, and Lawson Health Research Institute, London, ON, Canada
| | - Udunna Anazodo
- Medical Biophysics, Western University, and Lawson Health Research Institute, London, ON, Canada
| | - Mamadou Diop
- Medical Biophysics, Western University, and Lawson Health Research Institute, London, ON, Canada
| | - Keith St Lawrence
- Medical Biophysics, Western University, and Lawson Health Research Institute, London, ON, Canada
| | - Ilias Tachtsidis
- Biomedical Optics Research Laboratory, University College London, London, UK
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21
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Harvey-Jones K, Lange F, Tachtsidis I, Robertson NJ, Mitra S. Role of Optical Neuromonitoring in Neonatal Encephalopathy-Current State and Recent Advances. Front Pediatr 2021; 9:653676. [PMID: 33898363 PMCID: PMC8062863 DOI: 10.3389/fped.2021.653676] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/15/2021] [Indexed: 11/19/2022] Open
Abstract
Neonatal encephalopathy (NE) in term and near-term infants is a significant global health problem; the worldwide burden of disease remains high despite the introduction of therapeutic hypothermia. Assessment of injury severity and effective management in the neonatal intensive care unit (NICU) relies on multiple monitoring modalities from systemic to brain-specific. Current neuromonitoring tools provide information utilized for seizure management, injury stratification, and prognostication, whilst systemic monitoring ensures multi-organ dysfunction is recognized early and supported wherever needed. The neuromonitoring technologies currently used in NE however, have limitations in either their availability during the active treatment window or their reliability to prognosticate and stratify injury confidently in the early period following insult. There is therefore a real need for a neuromonitoring tool that provides cot side, early and continuous monitoring of brain health which can reliably stratify injury severity, monitor response to current and emerging treatments, and prognosticate outcome. The clinical use of near-infrared spectroscopy (NIRS) technology has increased in recent years. Research studies within this population have also increased, alongside the development of both instrumentation and signal processing techniques. Increasing use of commercially available cerebral oximeters in the NICU, and the introduction of advanced optical measurements using broadband NIRS (BNIRS), frequency domain NIRS (FDNIRS), and diffuse correlation spectroscopy (DCS) have widened the scope by allowing the direct monitoring of oxygen metabolism and cerebral blood flow, both key to understanding pathophysiological changes and predicting outcome in NE. This review discusses the role of optical neuromonitoring in NE and why this modality may provide the next significant piece of the puzzle toward understanding the real time state of the injured newborn brain.
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Affiliation(s)
- Kelly Harvey-Jones
- Neonatology, EGA Institute for Women's Health, University College London, London, United Kingdom
| | - Frederic Lange
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Ilias Tachtsidis
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Nicola J Robertson
- Neonatology, EGA Institute for Women's Health, University College London, London, United Kingdom.,Edinburgh Neuroscience & Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Subhabrata Mitra
- Neonatology, EGA Institute for Women's Health, University College London, London, United Kingdom
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22
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Russell-Buckland J, Kaynezhad P, Mitra S, Bale G, Bauer C, Lingam I, Meehan C, Avdic-Belltheus A, Martinello K, Bainbridge A, Robertson NJ, Tachtsidis I. Systems Biology Model of Cerebral Oxygen Delivery and Metabolism During Therapeutic Hypothermia: Application to the Piglet Model. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1269:31-38. [PMID: 33966191 DOI: 10.1007/978-3-030-48238-1_5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Hypoxic ischaemic encephalopathy (HIE) is a significant cause of death and disability. Therapeutic hypothermia (TH) is the only available standard of treatment, but 45-55% of cases still result in death or neurodevelopmental disability following TH. This work has focussed on developing a new brain tissue physiology and biochemistry systems biology model that includes temperature effects, as well as a Bayesian framework for analysis of model parameter estimation. Through this, we can simulate the effects of temperature on brain tissue oxygen delivery and metabolism, as well as analyse clinical and experimental data to identify mechanisms to explain differing behaviour and outcome. Presented here is an application of the model to data from two piglets treated with TH following hypoxic-ischaemic injury showing different responses and outcome following treatment. We identify the main mechanism for this difference as the Q10 temperature coefficient for metabolic reactions, with the severely injured piglet having a median posterior value of 0.133 as opposed to the mild injury value of 5.48. This work demonstrates the use of systems biology models to investigate underlying mechanisms behind the varying response to hypothermic treatment.
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Affiliation(s)
- Joshua Russell-Buckland
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
| | - P Kaynezhad
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - S Mitra
- Institute for Women's Health, University College London, London, UK
| | - G Bale
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - C Bauer
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - I Lingam
- Institute for Women's Health, University College London, London, UK
| | - C Meehan
- Institute for Women's Health, University College London, London, UK
| | | | - K Martinello
- Institute for Women's Health, University College London, London, UK
| | - A Bainbridge
- Department of Medical Physics and Biomedical Engineering, University College London Hospital, London, UK
| | - N J Robertson
- Institute for Women's Health, University College London, London, UK
| | - I Tachtsidis
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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23
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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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24
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Pang R, Martinello KA, Meehan C, Avdic-Belltheus A, Lingam I, Sokolska M, Mutshiya T, Bainbridge A, Golay X, Robertson NJ. Proton Magnetic Resonance Spectroscopy Lactate/N-Acetylaspartate Within 48 h Predicts Cell Death Following Varied Neuroprotective Interventions in a Piglet Model of Hypoxia-Ischemia With and Without Inflammation-Sensitization. Front Neurol 2020; 11:883. [PMID: 33013626 PMCID: PMC7500093 DOI: 10.3389/fneur.2020.00883] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 07/10/2020] [Indexed: 12/24/2022] Open
Abstract
Despite therapeutic hypothermia, survivors of neonatal encephalopathy have high rates of adverse outcome. Early surrogate outcome measures are needed to speed up the translation of neuroprotection trials. Thalamic lactate (Lac)/N-acetylaspartate (NAA) peak area ratio acquired with proton (1H) magnetic resonance spectroscopy (MRS) accurately predicts 2-year neurodevelopmental outcome. We assessed the relationship between MR biomarkers acquired at 24-48 h following injury with cell death and neuroinflammation in a piglet model following various neuroprotective interventions. Sixty-seven piglets with hypoxia-ischemia, hypoxia alone, or lipopolysaccharide (LPS) sensitization were included, and neuroprotective interventions were therapeutic hypothermia, melatonin, and magnesium. MRS and diffusion-weighted imaging (DWI) were acquired at 24 and 48 h. At 48 h, experiments were terminated, and immunohistochemistry was assessed. There was a correlation between Lac/NAA and overall cell death [terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL)] [mean Lac/NAA basal ganglia and thalamus (BGT) voxel r = 0.722, white matter (WM) voxel r = 0.784, p < 0.01] and microglial activation [ionized calcium-binding adapter molecule 1 (Iba1)] (BGT r = -0.786, WM r = -0.632, p < 0.01). Correlation with marker of caspase-dependent apoptosis [cleaved caspase 3 (CC3)] was lower (BGT r = -0.636, WM r = -0.495, p < 0.01). Relation between DWI and TUNEL was less robust (mean diffusivity BGT r = -0.615, fractional anisotropy BGT r = 0.523). Overall, Lac/NAA correlated best with cell death and microglial activation. These data align with clinical studies demonstrating Lac/NAA superiority as an outcome predictor in neonatal encephalopathy (NE) and support its use in preclinical and clinical neuroprotection studies.
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Affiliation(s)
- Raymand Pang
- Department of Neonatology, Institute for Women's Health, University College London, London, United Kingdom
| | - Kathryn A. Martinello
- Department of Neonatology, Institute for Women's Health, University College London, London, United Kingdom
| | - Christopher Meehan
- Department of Neonatology, Institute for Women's Health, University College London, London, United Kingdom
| | - Adnan Avdic-Belltheus
- Department of Neonatology, Institute for Women's Health, University College London, London, United Kingdom
| | - Ingran Lingam
- Department of Neonatology, Institute for Women's Health, University College London, London, United Kingdom
| | - Magda Sokolska
- Medical Physics and Engineering, University College London NHS Foundation Trust, London, United Kingdom
| | - Tatenda Mutshiya
- Department of Neonatology, Institute for Women's Health, University College London, London, United Kingdom
| | - Alan Bainbridge
- Medical Physics and Engineering, University College London NHS Foundation Trust, London, United Kingdom
| | - Xavier Golay
- Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, United Kingdom
| | - Nicola J. Robertson
- Department of Neonatology, Institute for Women's Health, University College London, London, United Kingdom
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25
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Bale G, Mitra S, Tachtsidis I. Metabolic brain measurements in the newborn: Advances in optical technologies. Physiol Rep 2020; 8:e14548. [PMID: 32889790 PMCID: PMC7507543 DOI: 10.14814/phy2.14548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 01/12/2023] Open
Abstract
Neonatal monitoring in neonatal intensive care is pushing the technological boundaries of newborn brain monitoring in order to improve patient outcome. There is an urgent need of a cot side, real time monitoring for assessment of brain injury severity and neurodevelopmental outcome, in particular for term newborn infants with hypoxic-ischemic brain injury. This topical review discusses why brain tissue metabolic monitoring is important in this group of infants and introduces the currently used neuromonitoring techniques for metabolic monitoring in the neonatal intensive care unit (NICU). New optical techniques that can monitor changes in brain metabolism together with brain hemodynamics at the cot side are presented. Early studies from these emerging technologies have demonstrated their potential to deliver continuous information regarding cerebral physiological changes in sick newborn infants in real time. The promises of these new tools as well as their potential limitations are discussed.
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Affiliation(s)
- Gemma Bale
- Medical Physics and Biomedical EngineeringUniversity College LondonLondonUK
| | - Subhabrata Mitra
- Neonatology, EGA Institute for Women's HealthUniversity College LondonLondonUK
| | - Ilias Tachtsidis
- Medical Physics and Biomedical EngineeringUniversity College LondonLondonUK
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26
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Mitra S, Bale G, Meek J, Tachtsidis I, Robertson NJ. Cerebral Near Infrared Spectroscopy Monitoring in Term Infants With Hypoxic Ischemic Encephalopathy-A Systematic Review. Front Neurol 2020; 11:393. [PMID: 32536901 PMCID: PMC7267214 DOI: 10.3389/fneur.2020.00393] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/17/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Neonatal hypoxic ischemic encephalopathy (HIE) remains a significant cause of mortality and morbidity worldwide. Cerebral near infrared spectroscopy (NIRS) can provide cot side continuous information about changes in brain hemodynamics, oxygenation and metabolism in real time. Objective: To perform a systematic review of cerebral NIRS monitoring in term and near-term infants with HIE. Search Methods: A systematic search was performed in Ovid EMBASE and Medline database from inception to November 2019. The search combined three broad categories: measurement (NIRS monitoring), disease condition [hypoxic ischemic encephalopathy (HIE)] and subject category (newborn infants) using a stepwise approach as per PRISMA guidance. Selection Criteria: Only human studies published in English were included. Data Collection and Analysis: Two authors independently selected, assessed the quality, and extracted data from the studies for this review. Results: Forty-seven studies on term and near-term infants following HIE were identified. Most studies measured multi-distance NIRS based cerebral tissue saturation using monitors that are referred to as cerebral oximeters. Thirty-nine studies were published since 2010; eight studies were published before this. Fifteen studies reviewed the neurodevelopmental outcome in relation to NIRS findings. No randomized study was identified. Conclusion: Commercial NIRS cerebral oximeters can provide important information regarding changes in cerebral oxygenation and hemodynamics following HIE and can be particularly helpful when used in combination with other neuromonitoring tools. Optical measurements of brain metabolism using broadband NIRS and cerebral blood flow using diffuse correlation spectroscopy add additional pathophysiological information. Further randomized clinical trials and large observational studies are necessary with proper study design to assess the utility of NIRS in predicting neurodevelopmental outcome and guiding therapeutic interventions.
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Affiliation(s)
- Subhabrata Mitra
- Neonatology, Institute for Women's Health, University College London, London, United Kingdom
| | - Gemma Bale
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Judith Meek
- Neonatology, Institute for Women's Health, University College London, London, United Kingdom
| | - Ilias Tachtsidis
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Nicola J Robertson
- Neonatology, Institute for Women's Health, University College London, London, United Kingdom
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27
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Montaldo P, Ivain P, Lally P, Bassett P, Pant S, Oliveira V, Mendoza J, Morales M, Swamy R, Shankaran S, Thayyil S. White matter injury after neonatal encephalopathy is associated with thalamic metabolite perturbations. EBioMedicine 2020; 52:102663. [PMID: 32062359 PMCID: PMC7016374 DOI: 10.1016/j.ebiom.2020.102663] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although thalamic magnetic resonance (MR) spectroscopy (MRS) accurately predicts adverse outcomes after neonatal encephalopathy, its utility in infants without MR visible deep brain nuclei injury is not known. We examined thalamic MRS metabolite perturbations in encephalopathic infants with white matter (WM) injury with or without cortical injury and its associations with adverse outcomes. METHODS We performed a subgroup analysis of all infants recruited to the MARBLE study with isolated WM or mixed WM/cortical injury, but no visible injury to the basal ganglia/thalamus (BGT) or posterior limb of the internal capsule (PLIC). We used binary logistic regression to examine the association of MRS biomarkers with three outcomes (i) WM injury score (1 vs. 2/3); (ii) cortical injury scores (0/1 vs. 2/3); and (iii) adverse outcomes (defined as death, moderate/severe disability) at two years (yes/no). We also assessed the accuracy of MRS for predicting adverse outcome. FINDINGS Of the 107 infants included in the analysis, five had adverse outcome. Reduced thalamic N-acetylaspartate concentration [NAA] (odds ratio 0.4 (95% CI 0.18-0.93)) and elevated thalamic Lactate/NAA peak area ratio (odds ratio 3.37 (95% CI 1.45-7.82)) were significantly associated with higher WM injury scores, but not with cortical injury. Thalamic [NAA] (≤5.6 mmol/kg/wet weight) had the best accuracy for predicting adverse outcomes (sensitivity 1.00 (95% CI 0.16-1.00); specificity 0.95 (95% CI 0.84-0.99)). INTERPRETATION Thalamic NAA is reduced in encephalopathic infants without MR visible deep brain nuclei injury and may be a useful predictor of adverse outcomes. FUNDING The National Institute for Health Research (NIHR).
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Affiliation(s)
- Paolo Montaldo
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK; Department of Neonatal Intensive Care, Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy.
| | - Phoebe Ivain
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Pete Lally
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | | | - Stuti Pant
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Vania Oliveira
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Josephine Mendoza
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Maria Morales
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Ravi Swamy
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | | | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
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Kaynezhad P, Mitra S, Bale G, Bauer C, Lingam I, Meehan C, Avdic-Belltheus A, Martinello KA, Bainbridge A, Robertson NJ, Tachtsidis I. Quantification of the severity of hypoxic-ischemic brain injury in a neonatal preclinical model using measurements of cytochrome-c-oxidase from a miniature broadband-near-infrared spectroscopy system. NEUROPHOTONICS 2019; 6:045009. [PMID: 31737744 PMCID: PMC6855218 DOI: 10.1117/1.nph.6.4.045009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/14/2019] [Indexed: 05/05/2023]
Abstract
We describe the development of a miniaturized broadband near-infrared spectroscopy system (bNIRS), which measures changes in cerebral tissue oxyhemoglobin ( [ HbO 2 ] ) and deoxyhemoglobin ([HHb]) plus tissue metabolism via changes in the oxidation state of cytochrome-c-oxidase ([oxCCO]). The system is based on a small light source and a customized mini-spectrometer. We assessed the instrument in a preclinical study in 27 newborn piglets undergoing transient cerebral hypoxia-ischemia (HI). We aimed to quantify the recovery of the HI insult and estimate the severity of the injury. The recovery in brain oxygenation ( Δ [ HbDiff ] = Δ [ HbO 2 ] - Δ [ HHb ] ), blood volume ( Δ [ HbT ] = Δ [ HbO 2 ] + Δ [ HHb ] ), and metabolism ( Δ [ oxCCO ] ) for up to 30 min after the end of HI were quantified in percentages using the recovery fraction (RF) algorithm, which quantifies the recovery of a signal with respect to baseline. The receiver operating characteristic analysis was performed on bNIRS-RF measurements compared to proton ( H 1 ) magnetic resonance spectroscopic (MRS)-derived thalamic lactate/N-acetylaspartate (Lac/NAA) measured at 24-h post HI insult; Lac/NAA peak area ratio is an accurate surrogate marker of neurodevelopmental outcome in babies with neonatal HI encephalopathy. The Δ [ oxCCO ] -RF cut-off threshold of 79% within 30 min of HI predicted injury severity based on Lac/NAA with high sensitivity (100%) and specificity (93%). A significant difference in thalamic Lac/NAA was noticed ( p < 0.0001 ) between the two groups based on this cut-off threshold of 79% Δ [ oxCCO ] -RF. The severe injury group ( n = 13 ) had ∼ 30 % smaller recovery in Δ [ HbDiff ] -RF ( p = 0.0001 ) and no significant difference was observed in Δ [ HbT ] -RF between groups. At 48 h post HI, significantly higher P 31 -MRS-measured inorganic phosphate/exchangeable phosphate pool (epp) ( p = 0.01 ) and reduced phosphocreatine/epp ( p = 0.003 ) were observed in the severe injury group indicating persistent cerebral energy depletion. Based on these results, the bNIRS measurement of the oxCCO recovery fraction offers a noninvasive real-time biomarker of brain injury severity within 30 min following HI insult.
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Affiliation(s)
- Pardis Kaynezhad
- University College London, Department of Medical Physics and Biomedical Engineering, London, United Kingdom
- Address all correspondence to Ilias Tachtsidis, E-mail:
| | - Subhabrata Mitra
- University College London, Institute for Women’s Health, London, United Kingdom
| | - Gemma Bale
- University College London, Department of Medical Physics and Biomedical Engineering, London, United Kingdom
| | - Cornelius Bauer
- University College London, Department of Medical Physics and Biomedical Engineering, London, United Kingdom
| | - Ingran Lingam
- University College London, Institute for Women’s Health, London, United Kingdom
| | - Christopher Meehan
- University College London, Institute for Women’s Health, London, United Kingdom
| | | | | | - Alan Bainbridge
- University College London Hospital, Department of Medical Physics and Biomedical Engineering, London, United Kingdom
| | - Nicola J. Robertson
- University College London, Institute for Women’s Health, London, United Kingdom
| | - Ilias Tachtsidis
- University College London, Department of Medical Physics and Biomedical Engineering, London, United Kingdom
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Azzopardi D, Chew AT, Deierl A, Huertas A, Robertson NJ, Tusor N, Edwards AD. Prospective qualification of early cerebral biomarkers in a randomised trial of treatment with xenon combined with moderate hypothermia after birth asphyxia. EBioMedicine 2019; 47:484-491. [PMID: 31451436 PMCID: PMC6796501 DOI: 10.1016/j.ebiom.2019.08.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/16/2019] [Accepted: 08/16/2019] [Indexed: 11/28/2022] Open
Abstract
Background The TOBY-Xe proof of concept randomised trial found no effect of xenon combined with hypothermia after birth asphyxia on the lactate to N-acetyl aspartate ratio (Lac/NAA) in the thalamus and fractional anisotropy (FA) in white matter tracts measured within 15 days of birth. To confirm that these biomarkers are qualified to predict long-term outcome after neural rescue therapy we assessed surviving participants at 2–3 years of age. Methods Of the 92 infants in TOBY-Xe, one was omitted from the study, 69 survived and we assessed 62 participants, 32 in the hypothermia and xenon and 30 in the hypothermia only groups. We examined the relation between Lac/NAA and FA and the scores of the Bayley Scales of Infant and Toddler Development III and calculated their predictive accuracy for moderate or severe disability or death. Results Fifteen of 62 participants (24%) developed moderate/severe disability, and 22/92 (24%) died. The Lac/NAA ratio (difference in medians 0.628, 95% CI -0.392 to 4.684) and FA (difference in means −0.055, 95% CI -0.033 to −0.077) differed significantly between participants with or without moderate or severe disability or death and were significantly related with development scores in both groups. Adverse outcomes were correctly identified in 95.65% of cases by Lac/NAA and 78.79% by FA, with adequate mean calibration of the model. Interpretation The results confirm the qualification of the cerebral magnetic resonance biomarkers employed in the TOBY-Xe study as predictors of outcome after neuroprotective therapy. Fund The Centre for the Developing Brain, King's College London, UK.
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Affiliation(s)
- Denis Azzopardi
- Centre for the Developing Brain, School of Bioengineering and Imaging Sciences, King's College London, UK.
| | - Andrew T Chew
- Centre for the Developing Brain, School of Bioengineering and Imaging Sciences, King's College London, UK
| | - Aniko Deierl
- Neonatal Department, Imperial College Healthcare NHS Trust, London, UK
| | - Angela Huertas
- Neonatal Department, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Nora Tusor
- Centre for the Developing Brain, School of Bioengineering and Imaging Sciences, King's College London, UK
| | - A David Edwards
- Centre for the Developing Brain, School of Bioengineering and Imaging Sciences, King's College London, UK
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Battin M. Better Data Enables Better Intervention. EClinicalMedicine 2018; 6:7-8. [PMID: 31193630 PMCID: PMC6537704 DOI: 10.1016/j.eclinm.2018.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/29/2018] [Indexed: 11/21/2022] Open
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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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