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Odd D, Sabir H, Jones SA, Gale C, Chakkarapani E. Risk factors for infection and outcomes in infants with neonatal encephalopathy: a cohort study. Pediatr Res 2024:10.1038/s41390-024-03157-9. [PMID: 38565915 DOI: 10.1038/s41390-024-03157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 12/21/2023] [Accepted: 03/02/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND To determine the association between early infection risk factors and short-term outcomes in infants with neonatal encephalopathy following perinatal asphyxia (NE). METHODS A retrospective population-based cohort study utilizing the National Neonatal Research Database that included infants with NE admitted to neonatal units in England and Wales, Jan 2008-Feb 2018. EXPOSURE one or more of rupture of membranes >18 h, maternal group B streptococcus colonization, chorioamnionitis, maternal pyrexia or antepartum antibiotics. PRIMARY OUTCOME death or nasogastric feeds/nil by mouth (NG/NBM) at discharge. SECONDARY OUTCOMES organ dysfunction; length of stay; intraventricular hemorrhage; antiseizure medications use. RESULTS 998 (13.7%) out of 7265 NE infants had exposure to early infection risk factors. Primary outcome (20.3% vs. 23.1%, OR 0.87 (95% CI 0.71-1.08), p = 0.22), death (12.8% vs. 14.0%, p = 0.32) and NG/NBM (17.4% vs. 19.9%. p = 0.07) did not differ between the exposed and unexposed group. Time to full sucking feeds (OR 0.81 (0.69-0.95)), duration (OR 0.82 (0.71-0.95)) and the number of antiseizure medications (OR 0.84 (0.72-0.98)) were lower in exposed than unexposed infants after adjusting for confounders. Therapeutic hypothermia did not alter the results. CONCLUSIONS Infants with NE exposed to risk factors for early-onset infection did not have worse short-term adverse outcomes. IMPACT Risk factors for early-onset neonatal infection, including rupture of membranes >18 h, maternal group B streptococcus colonization, chorioamnionitis, maternal pyrexia or antepartum antibiotics, were not associated with death or short-term morbidity after cooling for NE. Despite exposure to risk factors for early-onset neonatal infection, infants with NE reached oral feeds earlier and needed fewer anti-seizure medications for a shorter duration than infants with NE but without such risk factors. This study supports current provision of therapeutic hypothermia for infants with NE and any risk factors for early-onset neonatal infection.
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Affiliation(s)
- David Odd
- Cardiff University, The School of Medicine, Cardiff, UK
| | - Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, 53127, Bonn, Germany
| | - Simon A Jones
- Cardiff University, The School of Medicine, Cardiff, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
| | - Ela Chakkarapani
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
- St Michael's Hospital Neonatal Intensive Care Unit, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK.
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Molloy EJ, El-Dib M, Soul J, Juul S, Gunn AJ, Bender M, Gonzalez F, Bearer C, Wu Y, Robertson NJ, Cotton M, Branagan A, Hurley T, Tan S, Laptook A, Austin T, Mohammad K, Rogers E, Luyt K, Wintermark P, Bonifacio SL. Neuroprotective therapies in the NICU in preterm infants: present and future (Neonatal Neurocritical Care Series). Pediatr Res 2024; 95:1224-1236. [PMID: 38114609 PMCID: PMC11035150 DOI: 10.1038/s41390-023-02895-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/19/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
The survival of preterm infants has steadily improved thanks to advances in perinatal and neonatal intensive clinical care. The focus is now on finding ways to improve morbidities, especially neurological outcomes. Although antenatal steroids and magnesium for preterm infants have become routine therapies, studies have mainly demonstrated short-term benefits for antenatal steroid therapy but limited evidence for impact on long-term neurodevelopmental outcomes. Further advances in neuroprotective and neurorestorative therapies, improved neuromonitoring modalities to optimize recruitment in trials, and improved biomarkers to assess the response to treatment are essential. Among the most promising agents, multipotential stem cells, immunomodulation, and anti-inflammatory therapies can improve neural outcomes in preclinical studies and are the subject of considerable ongoing research. In the meantime, bundles of care protecting and nurturing the brain in the neonatal intensive care unit and beyond should be widely implemented in an effort to limit injury and promote neuroplasticity. IMPACT: With improved survival of preterm infants due to improved antenatal and neonatal care, our focus must now be to improve long-term neurological and neurodevelopmental outcomes. This review details the multifactorial pathogenesis of preterm brain injury and neuroprotective strategies in use at present, including antenatal care, seizure management and non-pharmacological NICU care. We discuss treatment strategies that are being evaluated as potential interventions to improve the neurodevelopmental outcomes of infants born prematurely.
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Affiliation(s)
- Eleanor J Molloy
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland.
- Children's Hospital Ireland (CHI) at Tallaght, Dublin, Ireland.
- Neonatology, CHI at Crumlin, Dublin, Ireland.
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland.
| | - Mohamed El-Dib
- Department of Pediatrics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sandra Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Alistair J Gunn
- Departments of Physiology and Paediatrics, School of Medical Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Manon Bender
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Fernando Gonzalez
- Department of Neurology, Division of Child Neurology, University of California, San Francisco, California, USA
| | - Cynthia Bearer
- Division of Neonatology, Department of Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Yvonne Wu
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mike Cotton
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Aoife Branagan
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland
| | - Tim Hurley
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
| | - Sidhartha Tan
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Abbot Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, Rhode Island, USA
| | - Topun Austin
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Elizabeth Rogers
- Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Karen Luyt
- Translational Health Sciences, University of Bristol, Bristol, UK
- Neonatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Pia Wintermark
- Division of Neonatology, Montreal Children's Hospital, Montreal, Quebec, Canada
- McGill University Health Centre - Research Institute, Montreal, Quebec, Canada
| | - Sonia Lomeli Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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Shevtsova Y, Starodubtseva N, Tokareva A, Goryunov K, Sadekova A, Vedikhina I, Ivanetz T, Ionov O, Frankevich V, Plotnikov E, Sukhikh G, Zorov D, Silachev D. Metabolite Biomarkers for Early Ischemic-Hypoxic Encephalopathy: An Experimental Study Using the NeoBase 2 MSMS Kit in a Rat Model. Int J Mol Sci 2024; 25:2035. [PMID: 38396712 PMCID: PMC10888647 DOI: 10.3390/ijms25042035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/01/2024] [Accepted: 02/03/2024] [Indexed: 02/25/2024] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is one of the most common causes of childhood disability. Hypothermic therapy is currently the only approved neuroprotective approach. However, early diagnosis of HIE can be challenging, especially in the first hours after birth when the decision to use hypothermic therapy is critical. Distinguishing HIE from other neonatal conditions, such as sepsis, becomes a significant problem in diagnosis. This study explored the utility of a metabolomic-based approach employing the NeoBase 2 MSMS kit to diagnose HIE using dry blood stains in a Rice-Vannucci model of HIE in rats. We evaluated the diagnostic fidelity of this approach in a range between 3 and 6 h after the onset of HIE, including in the context of systemic inflammation and concomitant hypothermic therapy. Discriminant analysis revealed several metabolite patterns associated with HIE. A logistic regression model using glycine levels achieved high diagnostic fidelity with areas under the receiver operating characteristic curve of 0.94 at 3 h and 0.96 at 6 h after the onset of HIE. In addition, orthogonal partial least squares discriminant analysis, which included five metabolites, achieved 100% sensitivity and 80% specificity within 3 h of HIE. These results highlight the significant potential of the NeoBase 2 MSMS kit for the early diagnosis of HIE and could improve patient management and outcomes in this serious illness.
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Affiliation(s)
- Yulia Shevtsova
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
| | - Natalia Starodubtseva
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
- Moscow Institute of Physics and Technology, 141700 Moscow, Russia
| | - Alisa Tokareva
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Kirill Goryunov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Alsu Sadekova
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Irina Vedikhina
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Tatiana Ivanetz
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Oleg Ionov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Vladimir Frankevich
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Egor Plotnikov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
| | - Gennady Sukhikh
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
| | - Dmitry Zorov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
| | - Denis Silachev
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (N.S.); (A.T.); (K.G.); (A.S.); (I.V.); (T.I.); (O.I.); (V.F.); (E.P.); (G.S.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
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White OR, Corry KA, Moralejo DH, Law JB, Snyder JM, Mietzsch U, Juul SE, Wood TR. Rectal temperature after hypoxia-ischemia predicts white matter and cortical pathology in the near-term ferret. Pediatr Res 2024; 95:84-92. [PMID: 37684430 DOI: 10.1038/s41390-023-02793-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Neonatal encephalopathy (NE) remains a common cause of infant morbidity and mortality. Neuropathological corollaries of NE associated with acute hypoxia-ischemia include a central injury pattern involving the basal ganglia and thalamus, which may interfere with thermoregulatory circuits. Spontaneous hypothermia (SH) occurs in both preclinical models and clinical hypoxic-ischemic NE and may provide an early biomarker of injury severity. To determine whether SH predicts the degree of injury in a ferret model of hypoxic-ischemic NE, we investigated whether rectal temperature (RT) 1 h after insult correlated with long-term outcomes. METHODS Postnatal day (P)17 ferrets were presensitized with Escherichia coli lipopolysaccharide before undergoing hypoxia-ischemia/hyperoxia (HIH): bilateral carotid artery ligation, hypoxia-hyperoxia-hypoxia, and right ligation reversal. One hour later, nesting RTs were measured. RESULTS Animals exposed to HIH were separated into normothermic (NT; ≥34.4 °C) or spontaneously hypothermic (SH; <34.4 °C) groups. At P42, cortical development, ex vivo MRI, and neuropathology were quantitated. Whole-brain volume and fractional anisotropy in SH brains were significantly decreased compared to control and NT animals. SH brains also had significantly altered gyrification, greater cortical pathology, and increased corpus callosum GFAP staining relative to NT and control brains. CONCLUSION In near-term-equivalent ferrets, nesting RT 1 h after HIH may predict long-term neuropathological outcomes. IMPACT High-throughput methods to determine injury severity prior to treatment in animal studies of neonatal brain injury are lacking. In a gyrified animal model of neonatal inflammation-sensitized hypoxic-ischemic brain injury in the ferret, rectal temperature 1 h after hypoxia predicts animals who will have increased cortical pathology and white matter changes on MRI. These changes parallel similar responses in rodents and humans but have not previously been correlated with long-term neuropathological outcomes in gyrified animal models. Endogenous thermoregulatory responses to injury may provide a translational marker of injury severity to help stratify animals to treatment groups or predict outcome in preclinical studies.
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Affiliation(s)
- Olivia R White
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Kylie A Corry
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Daniel H Moralejo
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Janessa B Law
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Jessica M Snyder
- Department of Comparative Medicine, University of Washington, Seattle, WA, USA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Center on Human Development and Disability, University of Washington, Seattle, WA, USA
| | - Thomas R Wood
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA.
- Center on Human Development and Disability, University of Washington, Seattle, WA, USA.
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Kelly SB, Tran NT, Polglase GR, Hunt RW, Nold MF, Nold-Petry CA, Olson DM, Chemtob S, Lodygensky GA, Robertson SA, Gunn AJ, Galinsky R. A systematic review of immune-based interventions for perinatal neuroprotection: closing the gap between animal studies and human trials. J Neuroinflammation 2023; 20:241. [PMID: 37864272 PMCID: PMC10588248 DOI: 10.1186/s12974-023-02911-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/28/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Perinatal infection/inflammation is associated with a high risk for neurological injury and neurodevelopmental impairment after birth. Despite a growing preclinical evidence base, anti-inflammatory interventions have not been established in clinical practice, partly because of the range of potential targets. We therefore systematically reviewed preclinical studies of immunomodulation to improve neurological outcomes in the perinatal brain and assessed their therapeutic potential. METHODS We reviewed relevant studies published from January 2012 to July 2023 using PubMed, Medline (OvidSP) and EMBASE databases. Studies were assessed for risk of bias using the SYRCLE risk of bias assessment tool (PROSPERO; registration number CRD42023395690). RESULTS Forty preclinical publications using 12 models of perinatal neuroinflammation were identified and divided into 59 individual studies. Twenty-seven anti-inflammatory agents in 19 categories were investigated. Forty-five (76%) of 59 studies reported neuroprotection, from all 19 categories of therapeutics. Notably, 10/10 (100%) studies investigating anti-interleukin (IL)-1 therapies reported improved outcome, whereas half of the studies using corticosteroids (5/10; 50%) reported no improvement or worse outcomes with treatment. Most studies (49/59, 83%) did not control core body temperature (a known potential confounder), and 25 of 59 studies (42%) did not report the sex of subjects. Many studies did not clearly state whether they controlled for potential study bias. CONCLUSION Anti-inflammatory therapies are promising candidates for treatment or even prevention of perinatal brain injury. Our analysis highlights key knowledge gaps and opportunities to improve preclinical study design that must be addressed to support clinical translation.
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Affiliation(s)
- Sharmony B Kelly
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Nhi T Tran
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Rodney W Hunt
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia
| | - Marcel F Nold
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia
| | - Claudia A Nold-Petry
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - David M Olson
- Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, Canada
| | - Sylvain Chemtob
- Department of Paediatrics, CHU Sainte Justine Research Centre, University of Montreal, Quebec, Canada
| | - Gregory A Lodygensky
- Department of Paediatrics, CHU Sainte Justine Research Centre, University of Montreal, Quebec, Canada
| | - Sarah A Robertson
- The University of Adelaide, Robinson Research Institute, North Adelaide, SA, Australia
| | - Alistair J Gunn
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia.
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia.
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Barks JD, Liu Y, Dopp IA, Silverstein FS. Azithromycin reduces inflammation-amplified hypoxic-ischemic brain injury in neonatal rats. Pediatr Res 2022; 92:415-423. [PMID: 34625655 PMCID: PMC8989723 DOI: 10.1038/s41390-021-01747-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/07/2021] [Accepted: 06/16/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Systemic inflammation amplifies neonatal hypoxic-ischemic (HI) brain injury. Azithromycin (AZ), an antibiotic with anti-inflammatory properties, improves sensorimotor function and reduces tissue damage after neonatal rat HI brain injury. The objective of this study was to determine if AZ is neuroprotective in two neonatal rat models of inflammation-amplified HI brain injury. DESIGN/METHODS Seven-day-old (P7) rats received injections of toll-like receptor agonists lipopolysaccharide (LPS) or Pam3Cys-Ser-(Lys)4 (PAM) prior to right carotid ligation followed by 50 min (LPS + HI) or 60 min (PAM + HI) in 8% oxygen. Outcomes included contralateral forelimb function (forepaw placing; grip strength), survival, %Intact right hemisphere (brain damage), and a composite score incorporating these measures. We compared postnatal day 35 outcomes in controls and groups treated with three or five AZ doses. Then, we compared P21 outcomes when the first (of five) AZ doses were administered 1, 2, or 4 h after HI. RESULTS In both LPS + HI and PAM + HI models, AZ improved sensorimotor function, survival, brain tissue preservation, and composite scores. Benefits increased with five- vs. three-dose AZ and declined with longer initiation delay. CONCLUSIONS Perinatal systemic infection is a common comorbidity of neonatal asphyxia brain injury and contributes to adverse outcomes. These data support further evaluation of AZ as a candidate treatment for neonatal neuroprotection. IMPACT AZ treatment decreases sensorimotor impairment and severity of brain injury, and improves survival, after inflammation-amplified HI brain injury, and this can be achieved even with a 2 h delay in initiation. This neuroprotective benefit is seen in models of inflammation priming by both Gram-negative and Gram-positive infections. This extends our previous findings that AZ treatment is neuroprotective after HI brain injury in neonatal rats.
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Affiliation(s)
- John D.E. Barks
- Department of Pediatrics, University of Michigan Medical School, The University of Michigan, Ann Arbor, MI
| | - Yiqing Liu
- Department of Pediatrics, University of Michigan Medical School, The University of Michigan, Ann Arbor, MI
| | - Ian A. Dopp
- Department of Pediatrics, University of Michigan Medical School, The University of Michigan, Ann Arbor, MI
| | - Faye S. Silverstein
- Department of Pediatrics, University of Michigan Medical School, The University of Michigan, Ann Arbor, MI,Department of Neurology, University of Michigan Medical School, The University of Michigan, Ann Arbor, MI
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Mascarenhas D, Goyal M, Nanavati R, Kirthana SB, Subhadarsini S. Short-term outcome and complications of therapeutic hypothermia in neonates with moderate-to-severe hypoxic ischaemic encephalopathy: a single-centre retrospective observational study in a hospital in Mumbai, India. Paediatr Int Child Health 2022; 42:117-126. [PMID: 36755411 DOI: 10.1080/20469047.2023.2171762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/08/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND Although shown to reduce death or disability in moderate-to-severe hypoxic ischaemic encephalopathy (HIE), therapeutic hypothermia (TH) has recently been associated with an increase in adverse events in low- and middle-income countries (LMIC). AIM To determine the clinical characteristics, complications and short-term outcome in neonates receiving TH in King Edward Memorial Hospital, Mumbai, India. METHODS A retrospective single-centre study of neonates with moderate-to-severe HIE who received TH from 1 January 2018 to 31 December 2021 was undertaken. TH was provided as per the unit's protocol using either a servo-controlled device or a phase-changing material (PCM). RESULTS One hundred and fifty-five neonates were included with 94.2% intramural births. Mean gestation and birthweight were 38.6 (1.5) weeks and 2776.7 (431) g, respectively. HIE staging was moderate in 87.1% and severe in 12.9%, with a mean cord pH of 6.93 (0.14) and seizures in 38.7%. Adverse events included shock (50.3%), clinically significant bleeding (16%), acute kidney injury (6.7%), culture-positive sepsis (11.6%), persistent pulmonary hypertension (9%), bradycardia (9%), food intolerance (14.9%) and premature termination (7.1%). A servo-controlled device (15.5%) or PCM (84.5%) was used, with comparable adverse events. 84.5% of the neonates were discharged, 7.1% discharged against medical advice and 8.4% died. Detailed neurological assessment at discharge/discharge against medical advice suggested neurological impairment in 128 (87.1%) neonates. CONCLUSION Adverse events during TH range from asymptomatic laboratory abnormalities to life-threatening complications, which are manageable in well equipped units. Neurological impairment at discharge in neonates who received cooling mandates strict neurological follow-up.Abbreviations: aEEG: amplitude-integrated EEG; AKI: acute kidney injury; BW: birthweight; EEG: electro-encephalogram; GA: gestational age; HELIX: hypothermia for encephalopathy in low- and middle-income countries; HIE: hypoxic ischaemic encephalopathy; IVH: intraventricular haemorrhage; LMIC: low- and middle-income countries; NICHD: National Institute of Child Health and Human Development; NICU: neonatal intensive care unit; PPHN: persistent pulmonary hypertension of newborn; PCM: phase-changing material; SGA: small-for-gestational age; TH: therapeutic hypothermia.
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Affiliation(s)
- Dwayne Mascarenhas
- Department of Neonatology, Seth GS Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Medha Goyal
- Department of Neonatology, Seth GS Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Ruchi Nanavati
- Department of Neonatology, Seth GS Medical College & King Edward Memorial Hospital, Mumbai, India
| | - S B Kirthana
- Department of Neonatology, Seth GS Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Santoshi Subhadarsini
- Department of Neonatology, Seth GS Medical College & King Edward Memorial Hospital, Mumbai, India
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8
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Ehlting A, Zweyer M, Maes E, Schleehuber Y, Doshi H, Sabir H, Bernis ME. Impact of Hypoxia-Ischemia on Neurogenesis and Structural and Functional Outcomes in a Mild-Moderate Neonatal Hypoxia-Ischemia Brain Injury Model. Life (Basel) 2022; 12:life12081164. [PMID: 36013343 PMCID: PMC9410039 DOI: 10.3390/life12081164] [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: 07/04/2022] [Revised: 07/23/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is a common type of brain injury caused by a lack of oxygen and blood flow to the brain during the perinatal period. The incidence of HIE is approximately 2−3 cases per 1000 live births in high-income settings; while in low- and middle-income countries, the incidence is 3−10-fold higher. Therapeutic hypothermia (TH) is the current standard treatment for neonates affected by moderate−severe HIE. However, more than 50% of all infants with suspected HIE have mild encephalopathy, and these infants are not treated with TH because of their lower risk of adverse outcomes. Despite this, several analyses of pooled data provide increasing evidence that infants who initially have mild encephalopathy may present signs of more significant brain injury later in life. The purpose of this study was to expand our knowledge about the effect of mild−moderate hypoxia-ischemia (HI) at the cellular, structural, and functional levels. An established rat model of mild−moderate HI was used, where postnatal day (P) 7 rats were exposed to unilateral permanent occlusion of the left carotid artery and 90 min of 8% hypoxia, followed by TH or normothermia (NT) treatment. The extent of injury was assessed using histology (P14 and P42) and MRI (P11 and P32), as well as with short-term and long-term behavioral tests. Neurogenesis was assessed by BrdU staining. We showed that mild−moderate HI leads to a progressive loss of brain tissue, pathological changes in MRI scans, as well as an impairment of long-term motor function. At P14, the median area loss assessed by histology for HI animals was 20% (p < 0.05), corresponding to mild−moderate brain injury, increasing to 55% (p < 0.05) at P42. The data assessed by MRI corroborated our results. HI led to a decrease in neurogenesis, especially in the hippocampus and the lateral ventricle at early time points, with a delayed partial recovery. TH was not neuroprotective at early time points following mild−moderate HI, but prevented the increase in brain damage over time. Additionally, rats treated with TH showed better long-term motor function. Altogether, our results bring more light to the understanding of pathophysiology following mild-moderate HI. We showed that, in the context of mild-moderate HI, TH failed to be significantly neuroprotective. However, animals treated with TH showed a significant improvement in motor, but not cognitive long-term function. These results are in line with what is observed in some cases where neonates with mild HIE are at risk of neurodevelopmental deficits in infancy or childhood. Whether TH should be used as a preventive treatment to reduce adverse outcomes in mild-HIE remains of active interest, and more research has to be carried out in order to address this question.
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Affiliation(s)
- Anne Ehlting
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Bonn, 53127 Bonn, Germany; (A.E.); (M.Z.); (E.M.); (Y.S.); (M.E.B.)
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), 53127 Bonn, Germany;
| | - Margit Zweyer
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Bonn, 53127 Bonn, Germany; (A.E.); (M.Z.); (E.M.); (Y.S.); (M.E.B.)
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), 53127 Bonn, Germany;
| | - Elke Maes
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Bonn, 53127 Bonn, Germany; (A.E.); (M.Z.); (E.M.); (Y.S.); (M.E.B.)
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), 53127 Bonn, Germany;
| | - Yvonne Schleehuber
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Bonn, 53127 Bonn, Germany; (A.E.); (M.Z.); (E.M.); (Y.S.); (M.E.B.)
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), 53127 Bonn, Germany;
| | - Hardik Doshi
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), 53127 Bonn, Germany;
| | - Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Bonn, 53127 Bonn, Germany; (A.E.); (M.Z.); (E.M.); (Y.S.); (M.E.B.)
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), 53127 Bonn, Germany;
- Correspondence:
| | - Maria Eugenia Bernis
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Bonn, 53127 Bonn, Germany; (A.E.); (M.Z.); (E.M.); (Y.S.); (M.E.B.)
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), 53127 Bonn, Germany;
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9
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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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10
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Wang H, Wang Q, Chen J, Chen C. Association Among the Gut Microbiome, the Serum Metabolomic Profile and RNA m6A Methylation in Sepsis-Associated Encephalopathy. Front Genet 2022; 13:859727. [PMID: 35432460 PMCID: PMC9006166 DOI: 10.3389/fgene.2022.859727] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/14/2022] [Indexed: 12/14/2022] Open
Abstract
Objective: To investigate the relationship among the gut microbiome, serum metabolomic profile and RNA m6A methylation in patients with sepsis-associated encephalopathy (SAE), 16S rDNA technology, metabolomics and gene expression validation were applied. Methods: Serum and feces were collected from patients with and without (SAE group and non-SAE group, respectively, n = 20). The expression of serum markers and IL-6 was detected by enzyme-linked immunosorbent assay (ELISA), and blood clinical indicators were detected using a double antibody sandwich immunochemiluminescence method. The expression of RNA m6A regulator were checked by Q-RTPCR. The gut microbiome was analyzed by 16S rDNA sequencing and the metabolite profile was revealed by liquid chromatography-mass spectrometry (LC-MS/MS). Results: In the SAE group, the IL-6, ICAM-5 and METTL3 levels were significantly more than those in the non-SAE group, while the FTO levels were significantly decreased in the SAE group. The diversity was decreased in the SAE gut microbiome, as characterized by a profound increase in commensals of the Acinetobacter, Methanobrevibacter, and Syner-01 genera, a decrease in [Eubacterium]_hallii_group, while depletion of opportunistic organisms of the Anaerofilum, Catenibacterium, and Senegalimassilia genera were observed in both groups. The abundance of Acinetobacter was positively correlated with the expression of METTL3. The changes between the intestinal flora and the metabolite profile showed a significant correlation. Sphingorhabdus was negatively correlated with 2-ketobutyric acid, 9-decenoic acid, and l-leucine, and positively correlated with Glycyl-Valine [Eubacterium]_hallii_group was positively correlated with 2-methoxy-3-methylpyazine, acetaminophen, and synephrine acetonide. Conclusion: The gut microbiota diversity was decreased. The serum metabolites and expression of RNA m6A regulators in PBMC were significantly changed in the SAE group compared to the non-SAE group. The results revealed that serum and fecal biomarkers could be used for SAE screening.
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11
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Temporal Characterization of Microglia-Associated Pro- and Anti-Inflammatory Genes in a Neonatal Inflammation-Sensitized Hypoxic-Ischemic Brain Injury Model. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:2479626. [PMID: 35281473 PMCID: PMC8906938 DOI: 10.1155/2022/2479626] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/22/2021] [Accepted: 01/27/2022] [Indexed: 02/06/2023]
Abstract
Hypoxic-ischemic encephalopathy (HIE) mainly affects preterm and term newborns, leading to a high risk of brain damage. Coexisting infection/inflammation and birth asphyxia are key factors associated with intracerebral increase of proinflammatory cytokines linked to HIE. Microglia are key mediators of inflammation during perinatal brain injury, characterized by their phenotypic plasticity, which may facilitate their participation in both the progression and resolution of injury-induced inflammation. The purpose of this study was to investigate the temporal expression of genes associated with pro- and anti-inflammatory cytokines as well as the nucleotide-binding domain, leucine-rich repeat protein (NLRP-3) inflammasome from microglia cells. For this purpose, we used our established neonatal rat model of inflammation-sensitized hypoxic-ischemic (HI) brain injury in seven-day-old rats. We assessed gene expression profiles of 11 cytokines and for NLRP-3 using real-time PCR from sorted CD11b/c microglia of brain samples at different time points (3.5 h after LPS injection and 0, 5, 24, 48, and 72 hours post HI) following different treatments: vehicle, E. coli lipopolysaccharide (LPS), vehicle/HI, and LPS/HI. Our results showed that microglia are early key mediators of the inflammatory response and exacerbate the inflammatory response following HI, polarizing into a predominant proinflammatory M1 phenotype in the early hours post HI. The brains only exposed to HI showed a delay in the expression of proinflammatory cytokines. We also demonstrated that NLRP-3 plays a role in the inflammatory resolution with a high expression after HI insult. The combination of both, a preinfection/inflammation condition and hypoxia-ischemia, resulted in a higher proinflammatory cytokine storm, highlighting the significant contribution of acute inflammation sensitizing prior to a hypoxic insult on the severity of perinatal brain damage.
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12
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Car KP, Nakwa F, Solomon F, Velaphi SC, Tann CJ, Izu A, Lala SG, Madhi SA, Dangor Z. The association between early-onset sepsis and neonatal encephalopathy. J Perinatol 2022; 42:354-358. [PMID: 35001084 DOI: 10.1038/s41372-021-01290-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/18/2021] [Accepted: 11/30/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We evaluated the association between early-onset sepsis and neonatal encephalopathy in a low-middle-income setting. METHODS We undertook a retrospective study in newborns with gestational age ≥35 weeks and/or birth weight ≥2500 grams, diagnosed with neonatal encephalopathy. Early-onset sepsis was defined as culture-confirmed sepsis or probable sepsis. RESULTS Of 10,182 hospitalised newborns, 1027 (10.1%) were diagnosed with neonatal encephalopathy, of whom 52 (5.1%) had culture-confirmed and 129 (12.5%) probable sepsis. The case fatality rate for culture-confirmed sepsis associated neonatal encephalopathy was threefold higher compared to neonatal encephalopathy without sepsis (30.8% vs. 10.5%, p < 0.001). Predictors of mortality for culture-confirmed sepsis associated neonatal encephalopathy included severe neonatal encephalopathy (aOR 6.51, 95%CI: 1.03-41.44) and seizures (aOR 10.64, 95%CI: 1.05-107.39). CONCLUSION In this setting, 5% of neonatal encephalopathy cases was associated with culture-confirmed sepsis and a high case fatality rate.
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Affiliation(s)
- Kathleen P Car
- Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Firdose Nakwa
- Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fatima Solomon
- South African Medical Research Council: Vaccines and Infectious Diseases Analytical Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithembiso C Velaphi
- Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cally J Tann
- Department of Infectious Disease Epidemiology, School of Hygiene and Tropical Medicine, London, UK
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Institute for Women's Health, University College London, London, UK
| | - Alane Izu
- South African Medical Research Council: Vaccines and Infectious Diseases Analytical Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sanjay G Lala
- Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shabir A Madhi
- South African Medical Research Council: Vaccines and Infectious Diseases Analytical Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Dangor
- Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- South African Medical Research Council: Vaccines and Infectious Diseases Analytical Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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13
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Sibbin K, Crawford TM, Stark M, Battin M. Therapeutic hypothermia for neonatal encephalopathy with sepsis: a retrospective cohort study. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001420. [PMID: 36053591 PMCID: PMC8943717 DOI: 10.1136/bmjpo-2022-001420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/05/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Neonatal encephalopathy remains a major cause of infant mortality and neurodevelopmental impairment. Infection may exacerbate brain injury and mitigate the effect of therapeutic hypothermia (TH). Additionally, infants with sepsis treated with TH may be at increased risk of adverse effects. This study aimed to review the clinical characteristics and outcomes for infants with sepsis treated with TH. DESIGN AND SETTING Retrospective cohort study of infants treated with TH within Australia and New Zealand. PATIENTS 1522 infants treated with TH, including 38 with culture-positive sepsis from 2014 to 2018. INTERVENTION Anonymised retrospective review of data from Australian and New Zealand Neonatal Network. Infants with culture-positive sepsis within 48 hours were compared with those without sepsis. MAIN OUTCOME MEASURES Key outcomes include in-hospital mortality, intensive care support requirements and length of stay. RESULTS Overall the rate of mortality was similar between the groups (13% vs 13%). Infants with sepsis received a higher rate of mechanical ventilation (89% vs 70%, p=0.01), high-frequency oscillatory ventilation (32% vs 13%, p=0.003) and inhaled nitric oxide for persistent pulmonary hypertension (38% vs 16%, p<0.001). Additionally, the sepsis group had a longer length of stay (20 vs 11 days, p<0.001). CONCLUSION Infants with sepsis treated with TH required significantly more respiratory support and had a longer length of stay. Although this may suggest a more severe illness the rate of mortality was similar. Further research is warranted to review the neurodevelopmental outcomes for these infants.
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Affiliation(s)
- Kristina Sibbin
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Tara M Crawford
- Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Robinson Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Michael Stark
- Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Robinson Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Malcolm Battin
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
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14
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Dias ML, O'Connor KM, Dempsey EM, O'Halloran KD, McDonald FB. Targeting the Toll-like receptor pathway as a therapeutic strategy for neonatal infection. Am J Physiol Regul Integr Comp Physiol 2021; 321:R879-R902. [PMID: 34612068 DOI: 10.1152/ajpregu.00307.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Toll-like receptors (TLRs) are crucial transmembrane receptors that form part of the innate immune response. They play a role in the recognition of various microorganisms and their elimination from the host. TLRs have been proposed as vital immunomodulators in the regulation of multiple neonatal stressors that extend beyond infection such as oxidative stress and pain. The immune system is immature at birth and takes some time to become fully established. As such, babies are especially vulnerable to sepsis at this early stage of life. Findings suggest a gestational age-dependent increase in TLR expression. TLRs engage with accessory and adaptor proteins to facilitate recognition of pathogens and their activation of the receptor. TLRs are generally upregulated during infection and promote the transcription and release of proinflammatory cytokines. Several studies report that TLRs are epigenetically modulated by chromatin changes and promoter methylation upon bacterial infection that have long-term influences on immune responses. TLR activation is reported to modulate cardiorespiratory responses during infection and may play a key role in driving homeostatic instability observed during sepsis. Although complex, TLR signaling and downstream pathways are potential therapeutic targets in the treatment of neonatal diseases. By reviewing the expression and function of key Toll-like receptors, we aim to provide an important framework to understand the functional role of these receptors in response to stress and infection in premature infants.
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Affiliation(s)
- Maria L Dias
- Department of Physiology, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Karen M O'Connor
- Department of Physiology, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Irish Centre for Maternal and Child Health Research, University College Cork, Cork, Ireland.,Department of Pediatrics and Child Health, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Ken D O'Halloran
- Department of Physiology, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research, University College Cork, Cork, Ireland
| | - Fiona B McDonald
- Department of Physiology, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research, University College Cork, Cork, Ireland
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15
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Wintermark P, Mohammad K, Bonifacio SL. Proposing a care practice bundle for neonatal encephalopathy during therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101303. [PMID: 34711527 DOI: 10.1016/j.siny.2021.101303] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neonates with neonatal encephalopathy (NE) often present with multi-organ dysfunction that requires multidisciplinary specialized management. Care of the neonate with NE is thus complex with interaction between the brain and various organ systems. Illness severity during the first days of birth, and not only during the initial hypoxia-ischemia event, is a significant predictor of adverse outcomes in neonates with NE treated with therapeutic hypothermia (TH). We thus propose a care practice bundle dedicated to support the injured neonatal brain that is based on the current best evidence for each organ system. The impact of using such bundle on outcomes in NE remains to be demonstrated.
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Affiliation(s)
- Pia Wintermark
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, 28 Oki Drive NW, T3B 6A8, Calgary, AB, Canada.
| | - Sonia L Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, 750 Welch Road, Suite 315, 94304, Palo Alto, CA, USA.
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- Newborn Brain Society, PO Box 200783, Roxbury Crossing, 02120, MA, USA
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16
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Sabir H, Bonifacio SL, Gunn AJ, Thoresen M, Chalak LF. Unanswered questions regarding therapeutic hypothermia for neonates with neonatal encephalopathy. Semin Fetal Neonatal Med 2021; 26:101257. [PMID: 34144931 DOI: 10.1016/j.siny.2021.101257] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Therapeutic hypothermia (TH) is now well established to improve intact survival after neonatal encephalopathy (NE). However, many questions could not be addressed by the randomized controlled trials. Should late preterm newborns with NE be cooled? Is cooling beneficial for mild NE? Is the current therapeutic time window optimal, or could it be shortened or prolonged? Will either milder or deeper hypothermia be effective? Does infection/inflammation exposure in the perinatal period in combination with NE offer potentially beneficial preconditioning or might it obviate hypothermic neuroprotection? In the present review, we dissect the evidence, for whom, when and how can TH best be delivered, and highlight areas that need further research.
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Affiliation(s)
- 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.
| | | | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.
| | - Marianne Thoresen
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Neonatal Neuroscience, Translational Medicine, University of Bristol, Bristol, United Kingdom.
| | - Lina F Chalak
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical School, Dallas, TX, USA.
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17
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Sandoval Karamian AG, Mercimek-Andrews S, Mohammad K, Molloy EJ, Chang T, Chau V, Murray DM, Wusthoff CJ. Neonatal encephalopathy: Etiologies other than hypoxic-ischemic encephalopathy. Semin Fetal Neonatal Med 2021; 26:101272. [PMID: 34417137 DOI: 10.1016/j.siny.2021.101272] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Neonatal encephalopathy (NE) describes the clinical syndrome of a newborn with abnormal brain function that may result from a variety of etiologies. HIE should be distinguished from neonatal encephalopathy due to other causes using data gathered from the history, physical and neurological exam, and further investigations. Identifying the underlying cause of encephalopathy has important treatment implications. This review outlines conditions that cause NE and may be mistaken for HIE, along with their distinguishing clinical features, pathophysiology, investigations, and treatments. NE due to brain malformations, vascular causes, neuromuscular causes, genetic conditions, neurogenetic disorders and inborn errors of metabolism, central nervous system (CNS) and systemic infections, and toxic/metabolic disturbances are discussed.
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Affiliation(s)
- A G Sandoval Karamian
- Children's Hospital of Philadelphia, Division of Neurology, 3501 Civic Center Blvd Office 1200.12, Philadelphia, PA, 19104, USA.
| | - S Mercimek-Andrews
- Biochemical Geneticist, Department of Medical Genetics, University of Alberta, 8-39 Medical Sciences Building, 8613 - 144 Street, Edmonton, T6G 2H7, Alberta, Canada.
| | - K Mohammad
- Cumming School of Medicine, University of Calgary, Alberta Children's Hospital, Room B4-286, 28 Oki drive NW, Calgary, AB, T3B 6A8, Canada.
| | - E J Molloy
- Trinity College, the University of Dublin, Trinity Translational Medicine Institute, Dublin, Ireland; Children's Health Ireland at Tallaght and Crumlin & and Coombe Women's and Infants University Hospital, Dublin, Ireland; Trinity Research in Childhood Centre (TRiCC), Trinity Academic Centre, Tallaght University Hospital, Dublin 24, Ireland.
| | - T Chang
- George Washington University School of Medicine & Health Sciences, Washington, DC, 20010, USA; Neonatal Neurology Program, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.
| | - Vann Chau
- Neurology, Neonatal Neurology Program, The Hospital for Sick Children, 555 University Avenue, Toronto ON, M5G 1X8, Canada.
| | - D M Murray
- Deptartment of Paediatric and Child Health, University College Cork, ARm 2.32, Paediatric Academic Unit, Floor 2, Seahorse Unit, Cork University Hospital, Wilton, Cork, T12 DCA4, Ireland.
| | - Courtney J Wusthoff
- Division of Child Neurology, Division of Pediatrics- Neonatal and Developmental Medicine, Stanford Children's Health, 750 Welch Road, Suite 317, Palo Alto, CA, 94304 USA.
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18
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Evaluating Neuroprotective Effects of Uridine, Erythropoietin, and Therapeutic Hypothermia in a Ferret Model of Inflammation-Sensitized Hypoxic-Ischemic Encephalopathy. Int J Mol Sci 2021; 22:ijms22189841. [PMID: 34576001 PMCID: PMC8469346 DOI: 10.3390/ijms22189841] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/04/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022] Open
Abstract
Perinatal hypoxic-ischemic (HI) brain injury, often in conjunction with an inflammatory insult, is the most common cause of death or disability in neonates. Therapeutic hypothermia (TH) is the standard of care for HI encephalopathy in term and near-term infants. However, TH may not always be available or efficacious, creating a need for novel or adjunctive neurotherapeutics. Using a near-term model of inflammation-sensitized HI brain injury in postnatal day (P) 17 ferrets, animals were randomized to either the control group (n = 43) or the HI-exposed groups: saline vehicle (Veh; n = 42), Ur (uridine monophosphate, n = 23), Epo (erythropoietin, n = 26), or TH (n = 24) to test their respective therapeutic effects. Motor development was assessed from P21 to P42 followed by analysis of cortical anatomy, ex vivo MRI, and neuropathology. HI animals took longer to complete the motor assessments compared to controls, which was exacerbated in the Ur group. Injury resulted in thinned white matter tracts and narrowed cortical sulci and gyri, which was mitigated in Epo-treated animals in addition to normalization of cortical neuropathology scores to control levels. TH and Epo treatment also resulted in region-specific improvements in diffusion parameters on ex vivo MRI; however, TH was not robustly neuroprotective in any behavioral or neuropathological outcome measures. Overall, Ur and TH did not provide meaningful neuroprotection after inflammation-sensitized HI brain injury in the ferret, and Ur appeared to worsen outcomes. By comparison, Epo appears to provide significant, though not complete, neuroprotection in this model.
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Jenkins DD, Moss HG, Brown TR, Yazdani M, Thayyil S, Montaldo P, Vento M, Kuligowski J, Wagner C, Hollis BW, Wiest DB. NAC and Vitamin D Improve CNS and Plasma Oxidative Stress in Neonatal HIE and Are Associated with Favorable Long-Term Outcomes. Antioxidants (Basel) 2021; 10:antiox10091344. [PMID: 34572976 PMCID: PMC8466838 DOI: 10.3390/antiox10091344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/11/2021] [Accepted: 08/23/2021] [Indexed: 12/15/2022] Open
Abstract
N-acetylcysteine (NAC) and vitamin D provide effective neuroprotection in animal models of severe or inflammation-sensitized hypoxic ischemic encephalopathy (HIE). To translate these FDA-approved drugs to HIE neonates, we conducted an early phase, open-label trial of 10 days of NAC (25, 40 mg/kg q12h) + 1,25(OH)2D (calcitriol 0.05 mg/kg q12h, 0.03 mg/kg q24h), (NVD), for pharmacokinetic (PK) estimates during therapeutic hypothermia and normothermia. We paired PK samples with pharmacodynamic (PD) targets of plasma isoprostanoids, CNS glutathione (GSH) and total creatine (tCr) by serial MRS in basal ganglia (BG) before and after NVD infusion at five days. Infants had moderate (n = 14) or severe HIE (n = 16), funisitis (32%), and vitamin D deficiency (75%). NVD resulted in rapid, dose-responsive increases in CNS GSH and tCr that correlated positively with plasma [NAC], inversely with plasma isofurans, and was greater in infants with lower baseline [GSH] and [tCr], suggesting increases in these PD markers were titrated by neural demand. Hypothermia and normothermia altered NAC PK estimates. NVD was well tolerated. Excluding genetic syndromes (2), prolonged ECMO (2), lost-to-follow-up (1) and SIDS death (1), 24 NVD treated HIE infants have no evidence of cerebral palsy, autism or cognitive delay at 24–48 months. These data confirm that low, safe doses of NVD in HIE neonates decreased oxidative stress in plasma and CNS, improved CNS energetics, and are associated with favorable developmental outcomes at two to four years.
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Affiliation(s)
- Dorothea D Jenkins
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, 10 McClennan Banks Drive, Charleston, SC 29425, USA; (C.W.); (B.W.H.)
- Correspondence: ; Tel.: +1-843-792-2112
| | - Hunter G Moss
- Center for Biomedical Imaging, Department of Radiology, Medical University of South Carolina, Charleston, SC 29425, USA; (H.G.M.); (T.R.B.); (M.Y.)
| | - Truman R Brown
- Center for Biomedical Imaging, Department of Radiology, Medical University of South Carolina, Charleston, SC 29425, USA; (H.G.M.); (T.R.B.); (M.Y.)
| | - Milad Yazdani
- Center for Biomedical Imaging, Department of Radiology, Medical University of South Carolina, Charleston, SC 29425, USA; (H.G.M.); (T.R.B.); (M.Y.)
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London W12 0HS, UK; (S.T.); (P.M.)
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London W12 0HS, UK; (S.T.); (P.M.)
| | - Maximo Vento
- Neonatal Research Group, Health Research Institute Hospital La Fe, 46026 Valencia, Spain; (M.V.); (J.K.)
| | - Julia Kuligowski
- Neonatal Research Group, Health Research Institute Hospital La Fe, 46026 Valencia, Spain; (M.V.); (J.K.)
| | - Carol Wagner
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, 10 McClennan Banks Drive, Charleston, SC 29425, USA; (C.W.); (B.W.H.)
| | - Bruce W Hollis
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, 10 McClennan Banks Drive, Charleston, SC 29425, USA; (C.W.); (B.W.H.)
| | - Donald B Wiest
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, Medical University of South Carolina, Charleston, SC 29425, USA;
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20
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Tetorou K, Sisa C, Iqbal A, Dhillon K, Hristova M. Current Therapies for Neonatal Hypoxic-Ischaemic and Infection-Sensitised Hypoxic-Ischaemic Brain Damage. Front Synaptic Neurosci 2021; 13:709301. [PMID: 34504417 PMCID: PMC8421799 DOI: 10.3389/fnsyn.2021.709301] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
Neonatal hypoxic-ischaemic brain damage is a leading cause of child mortality and morbidity, including cerebral palsy, epilepsy, and cognitive disabilities. The majority of neonatal hypoxic-ischaemic cases arise as a result of impaired cerebral perfusion to the foetus attributed to uterine, placental, or umbilical cord compromise prior to or during delivery. Bacterial infection is a factor contributing to the damage and is recorded in more than half of preterm births. Exposure to infection exacerbates neuronal hypoxic-ischaemic damage thus leading to a phenomenon called infection-sensitised hypoxic-ischaemic brain injury. Models of neonatal hypoxia-ischaemia (HI) have been developed in different animals. Both human and animal studies show that the developmental stage and the severity of the HI insult affect the selective regional vulnerability of the brain to damage, as well as the subsequent clinical manifestations. Therapeutic hypothermia (TH) is the only clinically approved treatment for neonatal HI. However, the number of HI infants needed to treat with TH for one to be saved from death or disability at age of 18-22 months, is approximately 6-7, which highlights the need for additional or alternative treatments to replace TH or increase its efficiency. In this review we discuss the mechanisms of HI injury to the immature brain and the new experimental treatments studied for neonatal HI and infection-sensitised neonatal HI.
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Affiliation(s)
| | | | | | | | - Mariya Hristova
- Perinatal Brain Repair Group, Department of Maternal and Fetal Medicine, UCL Institute for Women’s Health, London, United Kingdom
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21
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Adams LE, Moss HG, Lowe DW, Brown T, Wiest DB, Hollis BW, Singh I, Jenkins DD. NAC and Vitamin D Restore CNS Glutathione in Endotoxin-Sensitized Neonatal Hypoxic-Ischemic Rats. Antioxidants (Basel) 2021; 10:489. [PMID: 33804757 PMCID: PMC8003885 DOI: 10.3390/antiox10030489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 01/31/2023] Open
Abstract
Therapeutic hypothermia does not improve outcomes in neonatal hypoxia ischemia (HI) complicated by perinatal infection, due to well-described, pre-existing oxidative stress and neuroinflammation that shorten the therapeutic window. For effective neuroprotection post-injury, we must first define and then target CNS metabolomic changes immediately after endotoxin-sensitized HI (LPS-HI). We hypothesized that LPS-HI would acutely deplete reduced glutathione (GSH), indicating overwhelming oxidative stress in spite of hypothermia treatment in neonatal rats. Post-natal day 7 rats were randomized to sham ligation, or severe LPS-HI (0.5 mg/kg 4 h before right carotid artery ligation, 90 min 8% O2), followed by hypothermia alone or with N-acetylcysteine (25 mg/kg) and vitamin D (1,25(OH)2D3, 0.05 μg/kg) (NVD). We quantified in vivo CNS metabolites by serial 7T MR Spectroscopy before, immediately after LPS-HI, and after treatment, along with terminal plasma drug concentrations. GSH was significantly decreased in all LPS-HI rats compared with baseline and sham controls. Two hours of hypothermia alone did not improve GSH and allowed glutamate + glutamine (GLX) to increase. Within 1 h of administration, NVD increased GSH close to baseline and suppressed GLX. The combination of NVD with hypothermia rapidly improved cellular redox status after LPS-HI, potentially inhibiting important secondary injury cascades and allowing more time for hypothermic neuroprotection.
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Affiliation(s)
- Lauren E. Adams
- Department of Pediatrics, 10 McLellan Banks Dr, Medical University of South Carolina, Charleston, SC 29425, USA; (L.E.A.); (B.W.H.); (I.S.)
| | - Hunter G. Moss
- Center for Biomedical Imaging, Department of Radiology, Medical University of South Carolina, 68 President St. Room 205, Charleston, SC 29425, USA; (H.G.M.); (T.B.)
| | - Danielle W. Lowe
- Department of Psychiatry, Medical University of South Carolina, 67 Presidents St., MSC 861, Charleston, SC 29425, USA;
| | - Truman Brown
- Center for Biomedical Imaging, Department of Radiology, Medical University of South Carolina, 68 President St. Room 205, Charleston, SC 29425, USA; (H.G.M.); (T.B.)
| | - Donald B. Wiest
- Department of Pharmacy and Clinical Sciences, College of Pharmacy, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Bruce W. Hollis
- Department of Pediatrics, 10 McLellan Banks Dr, Medical University of South Carolina, Charleston, SC 29425, USA; (L.E.A.); (B.W.H.); (I.S.)
| | - Inderjit Singh
- Department of Pediatrics, 10 McLellan Banks Dr, Medical University of South Carolina, Charleston, SC 29425, USA; (L.E.A.); (B.W.H.); (I.S.)
| | - Dorothea D. Jenkins
- Department of Pediatrics, 10 McLellan Banks Dr, Medical University of South Carolina, Charleston, SC 29425, USA; (L.E.A.); (B.W.H.); (I.S.)
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22
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Comment on: Serial blood cytokine and chemokine mRNA and microRNA over 48 h are insult specific in a piglet model of inflammation-sensitized hypoxia-ischaemia. Pediatr Res 2021; 89:409-410. [PMID: 33203964 DOI: 10.1038/s41390-020-01238-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 11/08/2022]
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23
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Shao R, Sun D, Hu Y, Cui D. White matter injury in the neonatal hypoxic-ischemic brain and potential therapies targeting microglia. J Neurosci Res 2021; 99:991-1008. [PMID: 33416205 DOI: 10.1002/jnr.24761] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/27/2020] [Accepted: 11/01/2020] [Indexed: 12/12/2022]
Abstract
Neonatal hypoxic-ischemic (H-I) injury, which mainly causes neuronal damage and white matter injury (WMI), is among the predominant causes of infant morbidity (cerebral palsy, cognitive and persistent motor disabilities) and mortality. Disruptions to the oxygen and blood supply in the perinatal brain affect the cerebral microenvironment and may affect microglial activation, excitotoxicity, and oxidative stress. Microglia are significantly associated with axonal damage and myelinating oligodendrocytes, which are major pathological components of WMI. However, the effects of H-I injury on microglial functions and underlying transformation mechanisms remain poorly understood. The historical perception that these cells are major risk factors for ischemic stroke has been questioned due to our improved understanding of the diversity of microglial phenotypes and their alterable functions, which exacerbate or attenuate injuries in different regions in response to environmental instability. Unfortunately, although therapeutic hypothermia is an efficient treatment, death and disability remain the prognosis for a large proportion of neonates with H-I injury. Hence, novel neuroprotective therapies to treat WMI following H-I injury are urgently needed. Here, we review microglial mechanisms that might occur in the developing brain due to neonatal H-I injury and discuss whether microglia function as a double-edged sword in WMI. Then, we emphasize microglial heterogeneity, notably at the single-cell level, and sex-specific effects on the etiology of neurological diseases. Finally, we discuss current knowledge of strategies aiming to improve microglia modulation and remyelination following neonatal H-I injury. Overall, microglia-targeted therapy might provide novel and valuable insights into the treatment of neonatal H-I insult.
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Affiliation(s)
- Rongjiao Shao
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Dawei Sun
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yue Hu
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Derong Cui
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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24
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Andersen M, Pedersen MV, Andelius TCK, Kyng KJ, Henriksen TB. Neurological Outcome Following Newborn Encephalopathy With and Without Perinatal Infection: A Systematic Review. Front Pediatr 2021; 9:787804. [PMID: 34988041 PMCID: PMC8721111 DOI: 10.3389/fped.2021.787804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Studies have suggested that neurological outcome may differ in newborns with encephalopathy with and without perinatal infection. We aimed to systematically review this association. Methods: We conducted this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were obtained from four databases including Pubmed, Embase, Web of Science, and The Cochrane Database. Newborns with encephalopathy with and without markers of perinatal infection were compared with regard to neurodevelopmental assessments, neurological disorders, and early biomarkers of brain damage. Risk of bias and quality of evidence were assessed by the Newcastle-Ottawa scale and Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: We screened 4,284 studies of which eight cohort studies and one case-control study met inclusion criteria. A narrative synthesis was composed due to heterogeneity between studies. Six studies were classified as having low risk of bias, while three studies were classified as having high risk of bias. Across all outcomes, the quality of evidence was very low. The neurological outcome was similar in newborns with encephalopathy with and without markers of perinatal infection. Conclusions: Further studies of higher quality are needed to clarify whether perinatal infection may affect neurological outcome following newborn encephalopathy. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42020185717.
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Affiliation(s)
- Mads Andersen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Kasper Jacobsen Kyng
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Tine Brink Henriksen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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25
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Hamdy N, Eide S, Sun HS, Feng ZP. Animal models for neonatal brain injury induced by hypoxic ischemic conditions in rodents. Exp Neurol 2020; 334:113457. [PMID: 32889009 DOI: 10.1016/j.expneurol.2020.113457] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 08/28/2020] [Accepted: 08/30/2020] [Indexed: 02/06/2023]
Abstract
Neonatal hypoxia-ischemia and resulting encephalopathies are of significant concern. Intrapartum asphyxia is a leading cause of neonatal death globally. Among surviving infants, there remains a high incidence of hypoxic-ischemic encephalopathy due to neonatal hypoxic-ischemic brain injury, manifesting as mild conditions including attention deficit hyperactivity disorder, and debilitating disorders such as cerebral palsy. Various animal models of neonatal hypoxic brain injury have been implemented to explore cellular and molecular mechanisms, assess the potential of novel therapeutic strategies, and characterize the functional and behavioural correlates of injury. Each of the animal models has individual advantages and limitations. The present review looks at several widely-used and alternative rodent models of neonatal hypoxia and hypoxia-ischemia; it highlights their strengths and limitations, and their potential for continued and improved use.
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Affiliation(s)
- Nancy Hamdy
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Sarah Eide
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Hong-Shuo Sun
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada; Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada.
| | - Zhong-Ping Feng
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada.
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26
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Ophelders DR, Gussenhoven R, Klein L, Jellema RK, Westerlaken RJ, Hütten MC, Vermeulen J, Wassink G, Gunn AJ, Wolfs TG. Preterm Brain Injury, Antenatal Triggers, and Therapeutics: Timing Is Key. Cells 2020; 9:E1871. [PMID: 32785181 PMCID: PMC7464163 DOI: 10.3390/cells9081871] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/31/2020] [Accepted: 08/05/2020] [Indexed: 02/08/2023] Open
Abstract
With a worldwide incidence of 15 million cases, preterm birth is a major contributor to neonatal mortality and morbidity, and concomitant social and economic burden Preterm infants are predisposed to life-long neurological disorders due to the immaturity of the brain. The risks are inversely proportional to maturity at birth. In the majority of extremely preterm infants (<28 weeks' gestation), perinatal brain injury is associated with exposure to multiple inflammatory perinatal triggers that include antenatal infection (i.e., chorioamnionitis), hypoxia-ischemia, and various postnatal injurious triggers (i.e., oxidative stress, sepsis, mechanical ventilation, hemodynamic instability). These perinatal insults cause a self-perpetuating cascade of peripheral and cerebral inflammation that plays a critical role in the etiology of diffuse white and grey matter injuries that underlies a spectrum of connectivity deficits in survivors from extremely preterm birth. This review focuses on chorioamnionitis and hypoxia-ischemia, which are two important antenatal risk factors for preterm brain injury, and highlights the latest insights on its pathophysiology, potential treatment, and future perspectives to narrow the translational gap between preclinical research and clinical applications.
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Affiliation(s)
- Daan R.M.G. Ophelders
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Ruth Gussenhoven
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
| | - Luise Klein
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Reint K. Jellema
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
| | - Rob J.J. Westerlaken
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Matthias C. Hütten
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Jeroen Vermeulen
- Department of Pediatric Neurology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands;
| | - Guido Wassink
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Private bag 92019, Auckland 1023, New Zealand; (G.W.); (A.J.G.)
| | - Alistair J. Gunn
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Private bag 92019, Auckland 1023, New Zealand; (G.W.); (A.J.G.)
| | - Tim G.A.M. Wolfs
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
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27
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Xiong Y, Wintermark P. Therapeutic interventions for fetal inflammatory response syndrome (FIRS). Semin Fetal Neonatal Med 2020; 25:101112. [PMID: 32303464 DOI: 10.1016/j.siny.2020.101112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Fetal inflammatory response syndrome (FIRS) is a condition defined by systemic inflammation in the fetus, a rapid increase of pro-inflammatory cytokines into the fetal circulation (including interleukin-1 and interleukin-6), as well as a cellular response (such as increased neutrophils, monocyte/macrophages, and T cells) and the presence of funisitis. FIRS can lead to death and multisystem organ damage in the fetus and newborn. Brain injuries and subsequent risk of cerebral palsy and cognitive impairments are the most threatening long-term complications. This paper reviews the definition of FIRS, summarizes its associated complications, briefly describes the available methods to study FIRS, and discusses in more detail the potential therapeutic candidates that have been so far studied to protect the fetus/newborn from FIRS and to alleviate its associated complications and sequelae.
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Affiliation(s)
- Ying Xiong
- Zhongnan Hospital of Wuhan University, Department of Anesthesiology, Wuhan University, Wuhan, China; Research Institute of the McGill University Health Centre, Montreal, Canada.
| | - Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, Montreal, Canada; Research Institute of the McGill University Health Centre, Montreal, Canada.
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28
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Mottahedin A, Blondel S, Ek J, Leverin AL, Svedin P, Hagberg H, Mallard C, Ghersi-Egea JF, Strazielle N. N-acetylcysteine inhibits bacterial lipopeptide-mediated neutrophil transmigration through the choroid plexus in the developing brain. Acta Neuropathol Commun 2020; 8:4. [PMID: 31973769 PMCID: PMC6979079 DOI: 10.1186/s40478-019-0877-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 12/23/2019] [Indexed: 12/17/2022] Open
Abstract
The etiology of neurological impairments associated with prematurity and other perinatal complications often involves an infectious or pro-inflammatory component. The use of antioxidant molecules have proved useful to protect the neonatal brain from injury. The choroid plexuses-CSF system shapes the central nervous system response to inflammation at the adult stage, but little is known on the neuroimmune interactions that take place at the choroidal blood-CSF barrier during development. We previously described that peripheral administration to neonatal mice of the TLR2 ligand PAM3CSK4 (P3C), a prototypic Gram-positive bacterial lipopeptide, induces the migration of innate immune cells to the CSF. Here we showed in neonatal rats exposed to P3C that the migration of neutrophils into the CSF, which occurred through the choroid plexuses, is abolished following administration of the antioxidant drug N-acetylcysteine. Combining light sheet microscopy imaging of choroid plexus, a differentiated model of the blood-CSF barrier, and multiplex cytokine assays, we showed that the choroidal epithelium responds to the bacterial insult by a specific pattern of cytokine secretion, leading to a selective accumulation of neutrophils in the choroid plexus and to their trafficking into CSF. N-acetylcysteine acted by blocking neutrophil migration across both the endothelium of choroidal stromal vessels and the epithelium forming the blood-CSF barrier, without interfering with neutrophil blood count, neutrophil tropism for choroid plexus, and choroidal chemokine-driven chemotaxis. N-acetylcysteine reduced the injury induced by hypoxia-ischemia in P3C-sensitized neonatal rats. Overall, the data show that a double endothelial and epithelial check point controls the transchoroidal migration of neutrophils into the developing brain. They also point to the efficacy of N-acetylcysteine in reducing the deleterious effects of inflammation-associated perinatal injuries by a previously undescribed mechanism, i.e. the inhibition of innate immune cell migration across the choroid plexuses, without interfering with the systemic inflammatory response to infection.
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O'Dea M, Sweetman D, Bonifacio SL, El-Dib M, Austin T, Molloy EJ. Management of Multi Organ Dysfunction in Neonatal Encephalopathy. Front Pediatr 2020; 8:239. [PMID: 32500050 PMCID: PMC7243796 DOI: 10.3389/fped.2020.00239] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 04/20/2020] [Indexed: 12/16/2022] Open
Abstract
Neonatal Encephalopathy (NE) describes neonates with disturbed neurological function in the first post-natal days of life. NE is an overall term that does not specify the etiology of the encephalopathy although it often involves hypoxia-ischaemia. In NE, although neurological dysfunction is part of the injury and is most predictive of long-term outcome, these infants may also have multiorgan injury and compromise, which further contribute to neurological impairment and long-term morbidities. Therapeutic hypothermia (TH) is the standard of care for moderate to severe NE. Infants with NE may have co-existing immune, respiratory, endocrine, renal, hepatic, and cardiac dysfunction that require individualized management and can be impacted by TH. Non-neurological organ dysfunction not only has a negative effect on long term outcome but may also influence the efficacy of treatments in the acute phase. Post resuscitative care involves stabilization and decisions regarding TH and management of multi-organ dysfunction. This management includes detailed neurological assessment, cardio-respiratory stabilization, glycaemic and fluid control, sepsis evaluation and antibiotics, seizure identification, and monitoring and responding to biochemical and coagulation derangements. The emergence of new biomarkers of specific organ injury may have predictive value and improve the definition of organ injury and prognosis. Further evidence-based research is needed to optimize management of NE, prevent further organ dysfunction and reduce neurodevelopmental impairment.
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Affiliation(s)
- Mary O'Dea
- Discipline of Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland.,Paediatric Research Laboratory, Trinity Translational Institute, St. James' Hospital, Dublin, Ireland.,Neonatology, Coombe Women and Infant's University Hospital, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland
| | - Deirdre Sweetman
- National Children's Research Centre, Dublin, Ireland.,Paediatrics, National Maternity Hospital, Dublin, Ireland
| | - Sonia Lomeli Bonifacio
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Mohamed El-Dib
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Eleanor J Molloy
- Discipline of Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland.,Paediatric Research Laboratory, Trinity Translational Institute, St. James' Hospital, Dublin, Ireland.,Neonatology, Coombe Women and Infant's University Hospital, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland.,Paediatrics, National Maternity Hospital, Dublin, Ireland.,Neonatology, Children's Hospital Ireland (CHI) at Crumlin, Dublin, Ireland.,Paediatrics, CHI at Tallaght, Tallaght University Hospital, Dublin, Ireland
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Antimicrobial therapy utilization in neonates with hypoxic-ischemic encephalopathy (HIE): a report from the Children's Hospital Neonatal Database (CHND). J Perinatol 2020; 40:70-78. [PMID: 31611619 DOI: 10.1038/s41372-019-0527-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 07/19/2019] [Accepted: 08/30/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE(S) Quantify antimicrobial therapy (AMT) use in newborns with hypoxic-ischemic encephalopathy treated with therapeutic hypothermia (HIE/TH). STUDY DESIGN Newborns with HIE/TH were identified from the Children's Hospital Neonatal Database (CHND). Early infection (onset ≤7 days of life) was defined as "confirmed" (culture proven) or "suspected infection" (culture negative but treated) and compared with a "no infection" group. RESULTS 1501/1534 (97.8%) neonates received AMT. 36 (2.3%) had confirmed, 255 (16.6%) suspected, and 1243 (81.0%) had no infection. The median (IQR) AMT duration was 13 (8-21), 8 (7-10), and 3 (3-7) days for the three groups, respectively (p < 0.001). AMT duration of use varied significantly across centers, adjusted for covariates (OR 1.88, 95% CI: 1.43-2.46). CONCLUSION(S) Incidence of early confirmed infection in neonates with HIE/TH (23/1000) is significantly higher than reported rates of early onset sepsis in term and near term infants (0.5-1.0/1000 live births). Antimicrobial-stewardship opportunities exist in infants with negative cultures.
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31
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Solevåg AL, Schmölzer GM, Cheung PY. Novel interventions to reduce oxidative-stress related brain injury in neonatal asphyxia. Free Radic Biol Med 2019; 142:113-122. [PMID: 31039399 DOI: 10.1016/j.freeradbiomed.2019.04.028] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 04/15/2019] [Accepted: 04/23/2019] [Indexed: 01/10/2023]
Abstract
Perinatal asphyxia-induced brain injury may present as hypoxic-ischemic encephalopathy in the neonatal period, and disability including cerebral palsy in the long term. The brain injury is secondary to both the hypoxic-ischemic event and the reoxygenation-reperfusion following resuscitation. Early events in the cascade of brain injury can be classified as either inflammation or oxidative stress through the generation of free radicals. The objective of this paper is to present efforts that have been made to limit the oxidative stress associated with hypoxic-ischemic encephalopathy. In the acute phase of ischemia/hypoxia and reperfusion/reoxygenation, the outcomes of asphyxiated infants can be improved by optimizing the initial delivery room stabilization. Interventions include limiting oxygen exposure, and shortening the time to return of spontaneous circulation through improved methods for supporting hemodynamics and ventilation. Allopurinol, melatonin, noble gases such as xenon and argon, and magnesium administration also target the acute injury phase. Therapeutic hypothermia, N-acetylcysteine2-iminobiotin, remote ischemic postconditioning, cannabinoids and doxycycline target the subacute phase. Erythropoietin, mesenchymal stem cells, topiramate and memantine could potentially limit injury in the repair phase after asphyxia. To limit the injurious biochemical processes during the different stages of brain injury, determination of the stage of injury in any particular infant remains essential. Currently, therapeutic hypothermia is the only established treatment in the subacute phase of asphyxia-induced brain injury. The effects and side effects of oxidative stress reducing/limiting medications may however be difficult to predict in infants during therapeutic hypothermia. Future neuroprotection in asphyxiated infants may indeed include a combination of therapies. Challenges include timing, dosing and administration route for each neuroprotectant.
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Affiliation(s)
- A L Solevåg
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - G M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - P-Y Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Martinello KA, Meehan C, Avdic-Belltheus A, Lingam I, Ragab S, Hristova M, Tann CJ, Peebles D, Hagberg H, Wolfs TGAM, Klein N, Tachtsidis I, Golay X, Kramer BW, Fleiss B, Gressens P, Robertson NJ. Acute LPS sensitization and continuous infusion exacerbates hypoxic brain injury in a piglet model of neonatal encephalopathy. Sci Rep 2019; 9:10184. [PMID: 31308390 PMCID: PMC6629658 DOI: 10.1038/s41598-019-46488-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 06/29/2019] [Indexed: 12/12/2022] Open
Abstract
Co-existing infection/inflammation and birth asphyxia potentiate the risk of developing neonatal encephalopathy (NE) and adverse outcome. In a newborn piglet model we assessed the effect of E. coli lipopolysaccharide (LPS) infusion started 4 h prior to and continued for 48 h after hypoxia on brain cell death and systemic haematological changes compared to LPS and hypoxia alone. LPS sensitized hypoxia resulted in an increase in mortality and in brain cell death (TUNEL positive cells) throughout the whole brain, and in the internal capsule, periventricular white matter and sensorimotor cortex. LPS alone did not increase brain cell death at 48 h, despite evidence of neuroinflammation, including the greatest increases in microglial proliferation, reactive astrocytosis and cleavage of caspase-3. LPS exposure caused splenic hypertrophy and platelet count suppression. The combination of LPS and hypoxia resulted in the highest and most sustained systemic white cell count increase. These findings highlight the significant contribution of acute inflammation sensitization prior to an asphyxial insult on NE illness severity.
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Affiliation(s)
- Kathryn A Martinello
- Institute for Women's Health, University College London, London, United Kingdom
- Robinson Research Institute, University of Adelaide, Adelaide, Australia
| | - Christopher Meehan
- Institute for Women's Health, University College London, London, United Kingdom
| | | | - Ingran Lingam
- Institute for Women's Health, University College London, London, United Kingdom
| | - Sara Ragab
- Institute for Women's Health, University College London, London, United Kingdom
| | - Mariya Hristova
- Institute for Women's Health, University College London, London, United Kingdom
| | - Cally J Tann
- Institute for Women's Health, University College London, London, United Kingdom
- Maternal, Adolescent, Reproductive and Child Health Centre, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Donald Peebles
- Institute for Women's Health, University College London, London, United Kingdom
| | - Henrik Hagberg
- Centre of Perinatal Medicine & Health, Department of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Centre for the Developing Brain, Department of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London, United Kingdom
| | - Tim G A M Wolfs
- Department of Paediatrics, University of Maastricht, Maastricht, Netherlands
| | - Nigel Klein
- Infection, Inflammation and Rheumatology, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Ilias Tachtsidis
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Xavier Golay
- Institute of Neurology, University College London, London, United Kingdom
| | - Boris W Kramer
- Department of Paediatrics, University of Maastricht, Maastricht, Netherlands
| | - Bobbi Fleiss
- Centre for the Developing Brain, Department of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London, United Kingdom
- PROTECT, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Pierre Gressens
- Centre for the Developing Brain, Department of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London, United Kingdom
- PROTECT, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, United Kingdom.
- Division of Neonatology, Sidra Medicine, Doha, Qatar.
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Hakobyan M, Dijkman KP, Laroche S, Naulaers G, Rijken M, Steiner K, van Straaten HLM, Swarte RMC, Ter Horst HJ, Zecic A, Zonnenberg IA, Groenendaal F. Outcome of Infants with Therapeutic Hypothermia after Perinatal Asphyxia and Early-Onset Sepsis. Neonatology 2019; 115:127-133. [PMID: 30419568 DOI: 10.1159/000493358] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 08/27/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Animal models suggest that neuroprotective effects of therapeutic hypothermia (TH) after perinatal asphyxia are reduced in infants with early-onset sepsis. OBJECTIVES To assess the outcome of infants with perinatal asphyxia, neonatal encephalopathy, and TH in the presence of early-onset sepsis. METHODS In a retrospective cohort of 1,084 infants with perinatal asphyxia and TH, the outcome of 42 infants (gestational age 36.1-42.6 weeks and birth weight 2,280-5,240 g) with proven sepsis (n = 14) and probable sepsis (n = 28) was analyzed. Death, cerebral palsy, or a delayed development at 2 years was considered an adverse outcome. RESULTS Sepsis was caused mostly by group B streptococci (n = 17), other Gram-positive bacteria (n = 5), and Candida albicans (n = 1). Of the 42 infants, 9 (21.4%) died, and 5 (11.9%) showed impairments on follow-up. The outcome is comparable to the previously reported outcome of infants with TH without early-onset sepsis. CONCLUSION A good outcome was reported in the majority of infants with perinatal asphyxia, TH, and early-onset sepsis. Cooling should not be withheld from these infants.
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Affiliation(s)
- Mariam Hakobyan
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Koen P Dijkman
- Department of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Sabrina Laroche
- Department of Neonatology, University Hospital, Antwerp, Belgium
| | - Gunnar Naulaers
- Department of Neonatology, University Hospital, Leuven, Belgium
| | - Monique Rijken
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Katerina Steiner
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Science, Amalia Children's Hospital, Nijmegen, The Netherlands
| | | | - Renate M C Swarte
- Department of Neonatology, Erasmus Medical Center Sophia, Rotterdam, The Netherlands
| | - Hendrik J Ter Horst
- Department of Neonatology, Beatrix Children's Hospital, University Medical Centre Groningen, Groningen, The Netherlands
| | - Alexandra Zecic
- Department of Neonatology, University Hospital, Gent, Belgium
| | - Inge A Zonnenberg
- Department of Neonatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands,
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Lally PJ, Montaldo P, Oliveira V, Swamy RS, Soe A, Shankaran S, Thayyil S. Residual brain injury after early discontinuation of cooling therapy in mild neonatal encephalopathy. Arch Dis Child Fetal Neonatal Ed 2018; 103:F383-F387. [PMID: 28935718 DOI: 10.1136/archdischild-2017-313321] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/04/2017] [Accepted: 08/10/2017] [Indexed: 12/21/2022]
Abstract
We examined the brain injury and neurodevelopmental outcomes in a prospective cohort of 10 babies with mild encephalopathy who had early cessation of cooling therapy. All babies had MRI and spectroscopy within 2 weeks after birth and neurodevelopmental assessment at 2 years. Cooling was prematurely discontinued at a median age of 9 hours (IQR 5-13) due to rapid clinical improvement. Five (50%) had injury on MRI or spectroscopy, and two (20%) had an abnormal neurodevelopmental outcome at 2 years. Premature cessation of cooling therapy in babies with mild neonatal encephalopathy does not exclude residual brain injury and adverse long-term neurodevelopmental outcomes. This study refers to babies recruited into the MARBLE study (NCT01309711, pre-results stage).
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Affiliation(s)
- Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Vânia Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Aung Soe
- Oliver Fisher Neonatal Unit, Medway Maritime Hospital, Kent, UK
| | - Seetha Shankaran
- Department of Neonatal Perinatal Medicine, Wayne State University, Detroit, Michigan, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
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Amer AR, Oorschot DE. Xenon Combined With Hypothermia in Perinatal Hypoxic-Ischemic Encephalopathy: A Noble Gas, a Noble Mission. Pediatr Neurol 2018; 84:5-10. [PMID: 29887039 DOI: 10.1016/j.pediatrneurol.2018.02.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 02/21/2018] [Indexed: 12/14/2022]
Abstract
Perinatal hypoxia-ischemia is a major cause of neonatal morbidity. It generates primary neuronal damage of the neonatal brain and later secondary damage when reperfusion of the ischemic brain tissue causes a surge of oxygen free radicals and inflammation. This post-hypoxic-ischemic brain damage is a leading cause of motor and intellectual disabilities in survivors. Research worldwide has focused on mitigating this injury. Mild or moderate hypothermia is the standard treatment in many centers. However, its benefit is modest and the search for combinatorial effective neuroprotectants continues. This review focuses on xenon as one such agent. The use of mild to moderate hypothermia is reviewed first. Then promising results on the use of xenon to potentiate the effect of hypothermia in in vitro and in vivo animal experiments are discussed. In the first feasibility study on human neonates, researchers found a significant benefit of using 50% xenon for 18 hours in addition to 72 hours of hypothermia. Yet, this additional benefit of xenon was lacking in a larger cohort study, potentially because xenon was used beyond six hours of birth. The future of using xenon is promising, but further clinical studies are awaited to confirm the feasibility of its routine use and its optimal timing, concentration, and duration, for human neonatal hypoxia-ischemia.
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Affiliation(s)
- Ashraf R Amer
- Department of Anatomy, School of Biomedical Sciences and the Brain Health Research Center, University of Otago, Dunedin, New Zealand
| | - Dorothy E Oorschot
- Department of Anatomy, School of Biomedical Sciences and the Brain Health Research Center, University of Otago, Dunedin, New Zealand.
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Falck M, Osredkar D, Maes E, Flatebø T, Wood TR, Walløe L, Sabir H, Thoresen M. Hypothermia Is Neuroprotective after Severe Hypoxic-Ischaemic Brain Injury in Neonatal Rats Pre-Exposed to PAM3CSK4. Dev Neurosci 2018; 40:189-197. [PMID: 29860252 DOI: 10.1159/000487798] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/15/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Preclinical research on the neuroprotective effect of hypothermia (HT) after perinatal asphyxia has shown variable results, depending on comorbidities and insult severity. Exposure to inflammation increases vulnerability of the neonatal brain to hypoxic-ischaemic (HI) injury, and could be one explanation for those neonates whose injury is unexpectedly severe. Gram-negative type inflammatory exposure by lipopolysaccharide administration prior to a mild HI insult results in moderate brain injury, and hypothermic neuroprotection is negated. However, the neuroprotective effect of HT is fully maintained after gram-positive type inflammatory exposure by PAM3CSK4 (PAM) pre-administration in the same HI model. Whether HT is neuroprotective in severe brain injury with gram-positive inflammatory pre-exposure has not been investigated. METHODS 59 seven-day-old rat pups were subjected to a unilateral HI insult, with left carotid artery ligation followed by 90-min hypoxia (8% O2 at Trectal 36°C). An additional 196 pups received intraperitoneal 0.9% saline (control) or PAM1 mg/kg, 8 h before undergoing the same HI insult. After randomisation to 5 h normothermia (NT37°C) or HT32°C, pups survived 1 week before they were sacrificed by perfusion fixation. Brains were harvested for hemispheric and hippocampal area loss analyses at postnatal day 14, as well as immunostaining for neuron count in the HIP CA1 region. RESULTS Normothermic PAM animals (PAM-NT) had a comparable median area loss (hemispheric: 60% [95% CI 33-66]; hippocampal: 61% [95% CI 29-67]) to vehicle animals (Veh-NT) (hemispheric: 58% [95% CI 11-64]; hippocampal: 60% [95% CI 19-68]), which is defined as severe brain injury. Furthermore, mortality was low and similar in the two groups (Veh-NT 4.5% vs. PAM-NT 6.6%). HT reduced hemispheric and hippocampal injury in the Veh group by 13 and 28%, respectively (hemispheric: p = 0.048; hippocampal: p = 0.042). HT also provided neuroprotection in the PAM group, reducing hemispheric injury by 22% (p = 0.03) and hippocampal injury by 37% (p = 0.027). CONCLUSION In these experiments with severe brain injury, Toll-like receptor-2 triggering prior to HI injury does not have an additive injurious effect, and there is a small but significant neuroprotective effect of HT. HT appears to be neuroprotective over a continuum of injury severity in this model, and the effect size tapers off with increasing area loss. Our results indicate that gram-positive inflammatory exposure prior to HI injury does not negate the neuroprotective effect of HT in severe brain injury.
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Affiliation(s)
- Mari Falck
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Damjan Osredkar
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of Paediatric Neurology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Elke Maes
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Torun Flatebø
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Thomas Ragnar Wood
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Lars Walløe
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Hemmen Sabir
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of General Paediatrics, Neonatology and Paediatric Cardiology, University Children's Hospital, Heinrich Heine University, Düsseldorf, Germany.,Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marianne Thoresen
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Neonatal Neuroscience, Translational Medicine, University of Bristol, Bristol, United Kingdom
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Mallard C, Ek CJ, Vexler ZS. The myth of the immature barrier systems in the developing brain: role in perinatal brain injury. J Physiol 2018. [PMID: 29528501 DOI: 10.1113/jp274938] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Central nervous system homeostasis is maintained by cellular barriers that protect the brain from external environmental changes and protect the CNS from harmful molecules and pathogens in the blood. Historically, for many years these barriers were thought of as immature, with limited functions, during brain development. In this review, we will present advances in the understanding of the barrier systems during development and evidence to show that in fact the barriers serve many important neurodevelopmental functions and that fetal and newborn brains are well protected. We will also discuss how ischaemic injury or systemic inflammation may breach the integrity of the barriers in the developing brain.
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Affiliation(s)
- Carina Mallard
- Department of Physiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - C Joakim Ek
- Department of Physiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Zinaida S Vexler
- Department of Neurology, University California San Francisco, USA
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Falck M, Osredkar D, Wood TR, Maes E, Flatebø T, Sabir H, Thoresen M. Neonatal Systemic Inflammation Induces Inflammatory Reactions and Brain Apoptosis in a Pathogen-Specific Manner. Neonatology 2018; 113:212-220. [PMID: 29275405 DOI: 10.1159/000481980] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/03/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND After neonatal asphyxia, therapeutic hypothermia (HT) is the only proven treatment option. Although established as a neuroprotective therapy, benefit from HT has been questioned when infection is a comorbidity to hypoxic-ischaemic (HI) brain injury. Gram-negative and gram-positive species activate the immune system through different pathogen recognition receptors and subsequent immunological systems. In rodent models, gram-negative (lipopolysaccharide [LPS]) and gram-positive (PAM3CSK4 [PAM]) inflammation similarly increase neuronal vulnerability to HI. Interestingly, while LPS pre-sensitisation negates the neuroprotective effect of HT, HT is highly beneficial after PAM-sensitised HI brain injury. OBJECTIVE We aimed to examine whether systemic gram-positive or gram-negative inflammatory sensitisation affects juvenile rat pups per se, without an HI insult. METHODS Neonatal 7-day-old rats (n = 215) received intraperitoneal injections of vehicle (0.9% NaCl), LPS (0.1 mg/kg), or PAM (1 mg/kg). Core temperature and weight gain were monitored. Brain cytokine expression (IL-6, IL-1β, TNF-α, and IL-10, via PCR), apoptosis (cleaved caspase 3, via Western blots), and microglial activation (Iba1, via immunohistochemistry) were examined. RESULTS LPS induced an immediate drop in core temperature followed by poor weight gain, none of which were seen after PAM. Furthermore, LPS induced brain apoptosis, while PAM did not. The magnitude and temporal profile of brain cytokine expression differed between LPS- and PAM-injected animals. CONCLUSION These findings reveal sepsis-like conditions and neuroinflammation specific to the inflammatory stimulus (gram-positive vs. gram-negative) in the neonatal rat. They emphasise the importance of pre-clinical models being pathogen dependent, and should always be carefully tailored to their clinical scenario.
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Affiliation(s)
- Mari Falck
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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Tann CJ, Martinello KA, Sadoo S, Lawn JE, Seale AC, Vega-Poblete M, Russell NJ, Baker CJ, Bartlett L, Cutland C, Gravett MG, Ip M, Le Doare K, Madhi SA, Rubens CE, Saha SK, Schrag S, Sobanjo-ter Meulen A, Vekemans J, Heath PT. Neonatal Encephalopathy With Group B Streptococcal Disease Worldwide: Systematic Review, Investigator Group Datasets, and Meta-analysis. Clin Infect Dis 2017; 65:S173-S189. [PMID: 29117330 PMCID: PMC5850525 DOI: 10.1093/cid/cix662] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Neonatal encephalopathy (NE) is a leading cause of child mortality and longer-term impairment. Infection can sensitize the newborn brain to injury; however, the role of group B streptococcal (GBS) disease has not been reviewed. This paper is the ninth in an 11-article series estimating the burden of GBS disease; here we aim to assess the proportion of GBS in NE cases. METHODS We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data from investigator groups reporting GBS-associated NE. Meta-analyses estimated the proportion of GBS disease in NE and mortality risk. UK population-level data estimated the incidence of GBS-associated NE. RESULTS Four published and 25 unpublished datasets were identified from 13 countries (N = 10436). The proportion of NE associated with GBS was 0.58% (95% confidence interval [CI], 0.18%-.98%). Mortality was significantly increased in GBS-associated NE vs NE alone (risk ratio, 2.07 [95% CI, 1.47-2.91]). This equates to a UK incidence of GBS-associated NE of 0.019 per 1000 live births. CONCLUSIONS The consistent increased proportion of GBS disease in NE and significant increased risk of mortality provides evidence that GBS infection contributes to NE. Increased information regarding this and other organisms is important to inform interventions, especially in low- and middle-resource contexts.
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Affiliation(s)
- Cally J Tann
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, United Kingdom;
- Neonatal Medicine, University College London Hospitals NHS Foundation Trust, United Kingdom;
| | - Kathryn A Martinello
- Neonatal Medicine, University College London Hospitals NHS Foundation Trust, United Kingdom;
- Institute for Women’s Health, University College London, United Kingdom
| | - Samantha Sadoo
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, United Kingdom;
- Neonatal Medicine, University College London Hospitals NHS Foundation Trust, United Kingdom;
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, United Kingdom;
| | - Anna C Seale
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, United Kingdom;
- College of Health and Medical Sciences, Haramaya University, Dire Dawa, Ethiopia
| | - Maira Vega-Poblete
- Neonatal Medicine, University College London Hospitals NHS Foundation Trust, United Kingdom;
- Medical School, University College London, United Kingdom
| | - Neal J Russell
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, United Kingdom;
- King’s College London, United Kingdom
| | - Carol J Baker
- Departments of Pediatrics and Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | - Linda Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Clare Cutland
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, and Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael G Gravett
- Global Alliance to Prevent Prematurity and Stillbirth, Seattle, Washington
- Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - Margaret Ip
- Department of Microbiology, Faculty of Medicine, Chinese University of Hong Kong
| | - Kirsty Le Doare
- Centre for International Child Health, Imperial College London, United Kingdom
- Vaccine Institute, Institute for Infection and Immunity, St George’s Hospital, University of London and St George’s University Hospitals NHS Foundation Trust, United Kingdom
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, and Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Craig E Rubens
- Global Alliance to Prevent Prematurity and Stillbirth, Seattle, Washington
- Department of Global Health, University of Washington, Seattle
| | | | - Stephanie Schrag
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Paul T Heath
- Vaccine Institute, Institute for Infection and Immunity, St George’s Hospital, University of London and St George’s University Hospitals NHS Foundation Trust, United Kingdom
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Intestinal microbiota impact sepsis associated encephalopathy via the vagus nerve. Neurosci Lett 2017; 662:98-104. [PMID: 28993208 DOI: 10.1016/j.neulet.2017.10.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/04/2017] [Accepted: 10/05/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The pathogenesis of sepsis associated encephalopathy (SAE) remains poorly understood. Vagus nerve plays an important role in gut-microbiota-brain axis. This study aimed to investigate whether vague nerve is a key mediator of the impact of intestinal microbiota on SAE. METHODS Male rats were randomly divided into four groups (n=20): SHAM (SH) group, lipopolysaccharide (LPS) group, fecal microbiota transplantation (FMT) +LPS group, and vagotomy (VGX)+LPS+FMT group. The left cervical vagotomy was performed 30min before LPS administration in LPS+FMT+VGX group. LPS+ FMT and LPS+FMT+VGX groups received nasogastric infusion of feces from healthy donor three times a day. Fecal samples were collected every two days to monitor changes in microbiota composition by 16S rDNA analysis. Brain function was evaluated by behavioral tests and EEG. The levels of tumor necrosis factor alpha (TNF-α), interleukin (IL)-1β, IL-6, IL-10 in brain cortex were detected by ELISA. The expression of Iba-1 in brain cortex was assessed by immunohistochemistry and Western blot analysis. RESULTS Significant modification of microbiota composition, characterized by a profound increase of commensals in the Firmicutes phylum and depletion of opportunistic organisms in the Proteobacteria phylum, was observed in FMT groups compared to LPS group. Furthermore, we identified a reconstituted bacterial community enriched in Firmicutes and depleted of Proteobacteria. In both FMT groups the diversity of the fecal microbiota and the microbiota composition were similar to SH group. LPS mice treated with FMT demonstrated a better spatial memory and less EEG abnormalities, significantly attenuated levels of IL-1β, IL-6, TNF-α, and decreased number of Iba-1 positive microglia in the cortex, but these beneficial effects of FMT were reversed by VGX. CONCLUSIONS FMT can change intestinal microbiota in sepsis patients, and vagus nerve is a key mediator between intestinal microbiota and SAE. These findings suggest that FMT and vagus nerve are potential therapy targets for treating SAE.
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