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Weiss EM, Gray MM, Ko LK, Duenas DM, Oslin E, Kraft SA. Development of the Better Research Interactions for Every Family (BRIEF) intervention to support recruitment for neonatal clinical trials: an intervention mapping guided approach. Trials 2024; 25:610. [PMID: 39267164 PMCID: PMC11395641 DOI: 10.1186/s13063-024-08446-6] [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: 03/27/2024] [Accepted: 09/02/2024] [Indexed: 09/14/2024] Open
Abstract
BACKGROUND Recruitment for neonatal clinical trials can be particularly challenging. Low enrollment rates bias the research population and decrease generalizability of findings. We identified a critical need for an intervention to improve how researchers recruit for neonatal clinical trials. Working within the US neonatal research context, we developed the Better Research Interactions for Every Family (BRIEF) Intervention, which had two overarching goals: to improve the recruitment experience for all parents, focusing on minoritized populations, and to increase participation, focusing on decreasing disparities in research participation. METHODS We used intervention mapping (IM) to guide all steps of intervention development. IM is a planning framework that provides a systematic process and detailed protocol for step-by-step decision-making for intervention development, implementation, and evaluation. RESULTS We performed IM's six steps. In step 1, we convened two stakeholder groups, a parent panel and an expert panel, who provided guidance through development of all BRIEF components. Through a recent systematic review, empirical data collected by our team, and consultations with the panels, we identified key determinants (barriers and facilitators) of low enrollment rates and research team members as change agents. In step 2, we iteratively refined our list of key factors to include and linked determinants of behavior changes to these performance objectives. In step 3, we chose three theories (social cognitive theory, theory of information processing, and the trans-theoretical model), methods from identified practical applications suitable for the population (research team members) and the context (busy research NICU teams). In step 4, we developed and refined the intervention components, including self-guided pre-work and a single in-person session. In step 5, we identified the Darbepoetin plus slow-release intravenous iron trial as our partner study in which to pilot BRIEF. In step 6, we developed a multi-stage evaluation plan that included five distinct levels of outcomes. CONCLUSIONS This manuscript shares our rationale and processes for the creation of a research team member-facing intervention aiming to improve recruitment processes for neonatal clinical trials. Our approach can inform those aiming to improve recruitment for neonatal clinical trials and those who may be considering use of IM within similar contexts.
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Affiliation(s)
- Elliott Mark Weiss
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, 4800 Sand Point Way NE, M/S FA.2.113 Neonatology, Seattle, WA, 98105, USA.
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
| | - Megan M Gray
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, 4800 Sand Point Way NE, M/S FA.2.113 Neonatology, Seattle, WA, 98105, USA
| | - Linda K Ko
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Devan M Duenas
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, 4800 Sand Point Way NE, M/S FA.2.113 Neonatology, Seattle, WA, 98105, USA
| | - Ellie Oslin
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, 4800 Sand Point Way NE, M/S FA.2.113 Neonatology, Seattle, WA, 98105, USA
| | - Stephanie A Kraft
- Department of Bioethics and Decision Sciences, Geisinger College of Health Sciences, Danville, PA, USA
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Babbo CCR, Mellet J, van Rensburg J, Pillay S, Horn AR, Nakwa FL, Velaphi SC, Kali GTJ, Coetzee M, Masemola MYK, Ballot DE, Pepper MS. Neonatal encephalopathy due to suspected hypoxic ischemic encephalopathy: pathophysiology, current, and emerging treatments. World J Pediatr 2024:10.1007/s12519-024-00836-9. [PMID: 39237728 DOI: 10.1007/s12519-024-00836-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 07/31/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND Neonatal encephalopathy (NE) due to suspected hypoxic-ischemic encephalopathy (HIE), referred to as NESHIE, is a clinical diagnosis in late preterm and term newborns. It occurs as a result of impaired cerebral blood flow and oxygen delivery during the peripartum period and is used until other causes of NE have been discounted and HIE is confirmed. Therapeutic hypothermia (TH) is the only evidence-based and clinically approved treatment modality for HIE. However, the limited efficacy and uncertain benefits of TH in some low- to middle-income countries (LMICs) and the associated need for intensive monitoring have prompted investigations into more accessible and effective stand-alone or additive treatment options. DATA SOURCES This review describes the rationale and current evidence for alternative treatments in the context of the pathophysiology of HIE based on literatures from Pubmed and other online sources of published data. RESULTS The underlining mechanisms of neurotoxic effect, current clinically approved treatment, various categories of emerging treatments and clinical trials for NE are summarized in this review. Melatonin, caffeine citrate, autologous cord blood stem cells, Epoetin alfa and Allopurinal are being tested as potential neuroprotective agents currently. CONCLUSION This review describes the rationale and current evidence for alternative treatments in the context of the pathophysiology of HIE. Neuroprotective agents are currently only being investigated in high- and middle-income settings. Results from these trials will need to be interpreted and validated in LMIC settings. The focus of future research should therefore be on the development of inexpensive, accessible monotherapies and should include LMICs, where the highest burden of NESHIE exists.
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Affiliation(s)
- Carina Corte-Real Babbo
- SAMRC Extramural Unit for Stem Cell Research and Therapy, Department of Immunology, Faculty of Health Sciences, Institute for Cellular and Molecular Medicine, University of Pretoria, Room 5-64, Level 5, Pathology Building, 15 Bophelo Road (Cnr. Steve Biko and Dr. Savage Streets), Prinshof Campus, Gezina, Pretoria, South Africa
| | - Juanita Mellet
- SAMRC Extramural Unit for Stem Cell Research and Therapy, Department of Immunology, Faculty of Health Sciences, Institute for Cellular and Molecular Medicine, University of Pretoria, Room 5-64, Level 5, Pathology Building, 15 Bophelo Road (Cnr. Steve Biko and Dr. Savage Streets), Prinshof Campus, Gezina, Pretoria, South Africa
| | - Jeanne van Rensburg
- SAMRC Extramural Unit for Stem Cell Research and Therapy, Department of Immunology, Faculty of Health Sciences, Institute for Cellular and Molecular Medicine, University of Pretoria, Room 5-64, Level 5, Pathology Building, 15 Bophelo Road (Cnr. Steve Biko and Dr. Savage Streets), Prinshof Campus, Gezina, Pretoria, South Africa
| | - Shakti Pillay
- Department of Paediatrics and Child Health, Division of Neonatology, Groote Schuur Hospital, University of Cape Town, Neonatal Unit, Cape Town, South Africa
| | - Alan Richard Horn
- Department of Paediatrics and Child Health, Division of Neonatology, Groote Schuur Hospital, University of Cape Town, Neonatal Unit, Cape Town, South Africa
| | - Firdose Lambey Nakwa
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithembiso Christopher Velaphi
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Melantha Coetzee
- Department of Paediatrics and Child Health, Division of Neonatology, Faculty of Health Sciences, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Mogomane Yvonne Khomotso Masemola
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Kalafong Hospital, University of Pretoria, Pretoria, South Africa
| | - Daynia Elizabeth Ballot
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael Sean Pepper
- SAMRC Extramural Unit for Stem Cell Research and Therapy, Department of Immunology, Faculty of Health Sciences, Institute for Cellular and Molecular Medicine, University of Pretoria, Room 5-64, Level 5, Pathology Building, 15 Bophelo Road (Cnr. Steve Biko and Dr. Savage Streets), Prinshof Campus, Gezina, Pretoria, South Africa.
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Lew CO, Calabrese E, Chen JV, Tang F, Chaudhari G, Lee A, Faro J, Juul S, Mathur A, McKinstry RC, Wisnowski JL, Rauschecker A, Wu YW, Li Y. Artificial Intelligence Outcome Prediction in Neonates with Encephalopathy (AI-OPiNE). Radiol Artif Intell 2024; 6:e240076. [PMID: 38984984 DOI: 10.1148/ryai.240076] [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] [Indexed: 07/11/2024]
Abstract
Purpose To develop a deep learning algorithm to predict 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy using MRI and basic clinical data. Materials and Methods In this study, MRI data of term neonates with encephalopathy in the High-dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) trial (ClinicalTrials.gov: NCT02811263), who were enrolled from 17 institutions between January 25, 2017, and October 9, 2019, were retrospectively analyzed. The harmonized MRI protocol included T1-weighted, T2-weighted, and diffusion tensor imaging. Deep learning classifiers were trained to predict the primary outcome of the HEAL trial (death or any neurodevelopmental impairment at 2 years) using multisequence MRI and basic clinical variables, including sex and gestational age at birth. Model performance was evaluated on test sets comprising 10% of cases from 15 institutions (in-distribution test set, n = 41) and 10% of cases from two institutions (out-of-distribution test set, n = 41). Model performance in predicting additional secondary outcomes, including death alone, was also assessed. Results For the 414 neonates (mean gestational age, 39 weeks ± 1.4 [SD]; 232 male, 182 female), in the study cohort, 198 (48%) died or had any neurodevelopmental impairment at 2 years. The deep learning model achieved an area under the receiver operating characteristic curve (AUC) of 0.74 (95% CI: 0.60, 0.86) and 63% accuracy in the in-distribution test set and an AUC of 0.77 (95% CI: 0.63, 0.90) and 78% accuracy in the out-of-distribution test set. Performance was similar or better for predicting secondary outcomes. Conclusion Deep learning analysis of neonatal brain MRI yielded high performance for predicting 2-year neurodevelopmental outcomes. Keywords: Convolutional Neural Network (CNN), Prognosis, Pediatrics, Brain, Brain Stem Clinical trial registration no. NCT02811263 Supplemental material is available for this article. © RSNA, 2024 See also commentary by Rafful and Reis Teixeira in this issue.
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Affiliation(s)
- Christopher O Lew
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Evan Calabrese
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Joshua V Chen
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Felicia Tang
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Gunvant Chaudhari
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Amanda Lee
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - John Faro
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Sandra Juul
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Amit Mathur
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Robert C McKinstry
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Jessica L Wisnowski
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Andreas Rauschecker
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Yvonne W Wu
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
| | - Yi Li
- From the Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710 (C.O.L., E.C, A.L., J.F.); Department of Radiology (J.V.C., F.T., G.C., A.R., Y.L.) and Weill Institute for Neurosciences (Y.W.W.), University of California San Francisco, San Francisco, Calif; Department of Pediatrics, University of Washington, Seattle, Wash (S.J.); Department of Pediatrics, Saint Louis University, St Louis, Mo (A.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); and Children's Hospital Los Angeles, University of Southern California, Los Angeles, Calif (J.L.W.)
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Gonzalez FF, Monsell SE, Cornet MC, Glass H, Wisnowski J, Mathur A, McKinstry R, Li Y, Wu TW, Mayock DE, Heagerty PJ, Juul SE, Wu YW. Perinatal arterial ischemic stroke diagnosed in infants receiving therapeutic hypothermia for hypoxic-ischemic encephalopathy. Pediatr Res 2024:10.1038/s41390-024-03531-7. [PMID: 39191951 DOI: 10.1038/s41390-024-03531-7] [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: 04/26/2024] [Revised: 08/09/2024] [Accepted: 08/12/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND Both perinatal arterial ischemic stroke (PAIS) and hypoxic-ischemic encephalopathy (HIE) can present with neonatal encephalopathy. We hypothesized that among infants undergoing therapeutic hypothermia, presence of PAIS is associated with a higher risk of seizures and a lower risk of persistent encephalopathy after rewarming. METHODS We studied 473 infants with moderate or severe HIE enrolled in the HEAL Trial who received a brain MRI. We defined PAIS as focal ischemic infarct(s) within an arterial distribution, and HIE pattern of brain injury as central gray, peripheral watershed, or global injury. We compared the risk of seizures (clinically suspected or electrographic), and of an abnormal 5-day Sarnat exam, in infants with and without PAIS. RESULTS PAIS was diagnosed in 21(4%) infants, most of whom (16/21, 76%) also had concurrent HIE pattern of brain injury. Infants with PAIS were more likely to have seizures (RR 2.4, CI 2.8-3.3) and persistent moderate or severe encephalopathy on 5-day Sarnat exam (RR 2.5, 95% CI 1.9-3.4). CONCLUSION Among infants undergoing therapeutic hypothermia, PAIS typically occurs with concurrent HIE pattern brain injury. The higher rate of encephalopathy after rewarming in infants with PAIS may be due to the frequent co-existence of PAIS and HIE patterns of injury.
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Affiliation(s)
- Fernando F Gonzalez
- Department of Pediatrics; UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.
| | - Sarah E Monsell
- Department Biostatistics, University of Washington, Seattle, WA, USA
| | - Marie-Coralie Cornet
- Department of Pediatrics; UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Hannah Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA
| | - Jessica Wisnowski
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Amit Mathur
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Robert McKinstry
- Mallinckrodt Institute of Radiology, Washington Univ School of Medicine, St. Louis, MO, USA
| | - Yi Li
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Tai-Wei Wu
- Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Dennis E Mayock
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Sandra E Juul
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, WA, USA
| | - Yvonne W Wu
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA
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Duck SA, Nazareth M, Fassinger A, Pinto C, Elmore G, Nugent M, St Pierre M, Vannucci SJ, Chavez-Valdez R. Blood glucose and β-hydroxybutyrate predict significant brain injury after hypoxia-ischemia in neonatal mice. Pediatr Res 2024:10.1038/s41390-024-03461-4. [PMID: 39181984 DOI: 10.1038/s41390-024-03461-4] [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: 03/28/2024] [Revised: 07/13/2024] [Accepted: 07/30/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND The Vannucci procedure is widely used to model cerebral hypoxic-ischemic (HI) injury in neonatal rodents. Identifying minimally invasive biomarkers linked to brain injury would improve stratification of pups to experimental treatments. We hypothesized that extreme blood glucose (BG) and β-hydroxybutyrate (bHB) levels immediately after HI will correlate with severity of brain injury in this model. METHODS C57BL6 mice of both sexes underwent the Vannucci procedure with BG and bHB measured immediately after hypoxia. GFAP and α-fodrin were measured to assess injury severity at 4h, P11, P18 and P40. Open field (OF), Y-maze (YM), and Object-location task (OLT) were tested at P40. RESULTS Clinical seizures-like stereotypies during hypoxia were associated with lower post-hypoxia BG in HI-injured mice. Low BG after HI was related to higher GFAP expression, higher α-fodrin breakdown, lower residual regional volume, and worse working memory. BG was superior to bHB in ROC analysis with BG threshold of <111 mg/dL providing 100% specificity with 72% sensitivity for hippocampal HI-injury. CONCLUSIONS Post-hypoxic BG is a minimally invasive screening tool to identify pups with significant HI brain injury in the Vannucci model modified for mice improving our ability to stratify pups to experimental treatments to assess effectiveness. IMPACT End hypoxic-ischemic blood glucose levels are a reliable and inexpensive biomarker to detect hypoxic-ischemic brain injury in mice. Screening with blood glucose levels post-hypoxia allows appropriate stratification of those mouse pups most likely to be injured to experimental treatments improving validity and translatability of the results. These findings provide biological plausibility to the clinical observation that extreme blood glucose levels relate to worse outcomes after hypoxia-ischemia.
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Affiliation(s)
- Sarah Ann Duck
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University - School of Medicine, Baltimore, MD, USA
| | - Michelle Nazareth
- Department of Neuroscience, Johns Hopkins University Krieger School of Arts and Sciences, Baltimore, MD, USA
| | - Abigail Fassinger
- Department of Neuroscience, Johns Hopkins University Krieger School of Arts and Sciences, Baltimore, MD, USA
| | - Charles Pinto
- Department of Human Biology, University of Toronto, Toronto, ON, Canada
| | - Genesis Elmore
- Department of Neuroscience, Johns Hopkins University Krieger School of Arts and Sciences, Baltimore, MD, USA
| | - Michael Nugent
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University - School of Medicine, Baltimore, MD, USA
| | - Mark St Pierre
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University - School of Medicine, Baltimore, MD, USA
| | - Susan J Vannucci
- Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - Raul Chavez-Valdez
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University - School of Medicine, Baltimore, MD, USA.
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Leavy A, Phelan J, Jimenez-Mateos EM. Contribution of microglia to the epileptiform activity that results from neonatal hypoxia. Neuropharmacology 2024; 253:109968. [PMID: 38692453 DOI: 10.1016/j.neuropharm.2024.109968] [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: 02/22/2024] [Revised: 04/13/2024] [Accepted: 04/22/2024] [Indexed: 05/03/2024]
Abstract
Microglia are described as the immune cells of the brain, their immune properties have been extensively studied since first described, however, their neural functions have only been explored over the last decade. Microglia have an important role in maintaining homeostasis in the central nervous system by surveying their surroundings to detect pathogens or damage cells. While these are the classical functions described for microglia, more recently their neural functions have been defined; they are critical to the maturation of neurons during embryonic and postnatal development, phagocytic microglia remove excess synapses during development, a process called synaptic pruning, which is important to overall neural maturation. Furthermore, microglia can respond to neuronal activity and, together with astrocytes, can regulate neural activity, contributing to the equilibrium between excitation and inhibition through a feedback loop. Hypoxia at birth is a serious neurological condition that disrupts normal brain function resulting in seizures and epilepsy later in life. Evidence has shown that microglia may contribute to this hyperexcitability after neonatal hypoxia. This review will summarize the existing data on the role of microglia in the pathogenesis of neonatal hypoxia and the plausible mechanisms that contribute to the development of hyperexcitability after hypoxia in neonates. This article is part of the Special Issue on "Microglia".
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Affiliation(s)
- Aisling Leavy
- Discipline of Physiology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Jessie Phelan
- Discipline of Physiology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Eva M Jimenez-Mateos
- Discipline of Physiology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.
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Öztürk M, Turgut FS, Akbalık D, Demirkıran ME, Kaplan İ. Serum Erythropoietin and Ischemic-Modified Albumin Levels in Adolescents with Obsessive-Compulsive Disorder. J Mol Neurosci 2024; 74:67. [PMID: 38995319 PMCID: PMC11245444 DOI: 10.1007/s12031-024-02247-x] [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: 05/23/2024] [Accepted: 07/09/2024] [Indexed: 07/13/2024]
Abstract
Erythropoietin (EPO) has neuroprotective effects by increasing oxidative stress resistance and stabilizing redox balance. Ischemic-modified albumin (IMA) is a product of protein oxidation, and recent evidence suggests that IMA can be used as an indicator of oxidative damage. This study aimed to investigate serum EPO and IMA levels in obsessive-compulsive disorder (OCD) patients and to investigate the relationship between EPO and IMA levels and clinical variables such as disease duration and disease severity. A total of 68 adolescents (11-18 years old), including 35 OCD patients (18 males/17 females) and 33 healthy controls (14 males/19 females) without comorbid disorders matched for age, gender, and BMI, were included in the study. The enzyme-amplified chemiluminescence technique determined serum EPO levels, and serum IMA levels were determined by the spectrophotometric method. Serum EPO levels were lower in OCD patients compared to healthy controls (p = 0.002; Z = - 3.123), and serum IMA levels (ABSU) were significantly higher in the OCD group (p = 0.005). A significant positive correlation was found between IMA levels and the duration of OCD symptoms (p = 0.015, r = 0.409). The study's findings contribute to the growing body of evidence implicating inflammatory and oxidative processes in the pathogenesis of OCD. The potential of EPO and IMA levels as diagnostic biomarkers for OCD aligns with the ongoing efforts to identify reliable biological markers for the disorder. The positive correlation of IMA levels with the duration of OCD shows the importance of early detection of oxidative damage.
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Affiliation(s)
- Masum Öztürk
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Dicle University, Diyarbakır, Turkey.
| | - Fatma Subaşı Turgut
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - Davut Akbalık
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - Mustafa Erhan Demirkıran
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - İbrahim Kaplan
- Department of Biochemistry, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
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Buckley LA, Kulhanek DR, Bruder A, Gisslen T, Paulsen ME. Inflammation as a Sex-Specific Mediator in the Relationship between Maternal and Offspring Obesity in C57Bl/6J Mice. BIOLOGY 2024; 13:399. [PMID: 38927279 PMCID: PMC11200566 DOI: 10.3390/biology13060399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024]
Abstract
Maternal obesity is a well-established risk factor for offspring obesity development. The relationship between maternal and offspring obesity is mediated in part by developmental programming of offspring metabolic circuitry, including hypothalamic signaling. Dysregulated hypothalamic inflammation has also been linked to development of obesity. We utilized an established C57Bl/6J mouse model of high-fat, high-sugar diet induced maternal obesity to evaluate the effect of maternal obesity on systemic and hypothalamic TNF-α, IL-6, and IL-1β levels in neonatal and adult offspring. The offspring of dams with obesity demonstrated increased adiposity and decreased activity compared to control offspring. Maternal obesity was associated with decreased plasma TNF-α, IL-6 and IL-1β in adult female offspring and decreased plasma IL-6 in neonatal male offspring. Neonatal female offspring of obese dams had decreased TNF-α gene expression in the hypothalamus compared to control females, while neonatal and adult male offspring of obese dams had decreased IL-6 gene expression in the hypothalamus compared to control males. In summary, our results highlight important sex differences in the inflammatory phenotype of offspring exposed to maternal obesity. Sex-specific immunomodulatory mechanisms should be considered in future efforts to develop therapeutic interventions for obesity prevention and treatment.
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Affiliation(s)
- Lauren A. Buckley
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN 55454, USA; (D.R.K.); (A.B.); (T.G.); (M.E.P.)
| | - Debra R. Kulhanek
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN 55454, USA; (D.R.K.); (A.B.); (T.G.); (M.E.P.)
| | - Adrienne Bruder
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN 55454, USA; (D.R.K.); (A.B.); (T.G.); (M.E.P.)
| | - Tate Gisslen
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN 55454, USA; (D.R.K.); (A.B.); (T.G.); (M.E.P.)
- Masonic Institute for the Developing Brain, University of Minnesota, Minneapolis, MN 55414, USA
| | - Megan E. Paulsen
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN 55454, USA; (D.R.K.); (A.B.); (T.G.); (M.E.P.)
- Masonic Institute for the Developing Brain, University of Minnesota, Minneapolis, MN 55414, USA
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9
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Wu TW, Schmicker R, Wood TR, Mietzsch U, Comstock B, Heagerty PJ, Rao R, Gonzalez F, Juul S, Wu YW. Esophageal Versus Rectal Temperature Monitoring During Whole-Body Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy: Association with Short- and Long-Term Outcomes. J Pediatr 2024; 268:113933. [PMID: 38309524 PMCID: PMC11045319 DOI: 10.1016/j.jpeds.2024.113933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/13/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
OBJECTIVE To compare the short- and long-term outcomes of infants with hypoxic-ischemic encephalopathy (HIE) treated with whole-body therapeutic hypothermia (TH), monitored by esophageal vs rectal temperature. STUDY DESIGN We conducted a secondary analysis of the multicenter High-Dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) trial. All infants had moderate or severe HIE and were treated with whole-body TH. The primary outcome was death or neurodevelopmental impairment (NDI) at 22-36 months of age. Secondary outcomes included seizures, evidence of brain injury on magnetic resonance imaging, and complications of hypothermia. Logistic regression was used with adjustment for disease severity and site as clustering variable because cooling modality differed by site. RESULTS Of the 500 infants who underwent TH, 294 (59%) and 206 (41%) had esophageal and rectal temperature monitoring, respectively. There were no differences in death or NDI, seizures, or evidence of injury on magnetic resonance imaging between the 2 groups. Infants treated with TH and rectal temperature monitoring had lower odds of overcooling (OR 0.52, 95% CI 0.34-0.80) and lower odds of hypotension (OR 0.57, 95% CI 0.39-0.84) compared with those with esophageal temperature monitoring. CONCLUSIONS Although infants undergoing TH with esophageal monitoring were more likely to experience overcooling and hypotension, the rate of death or NDI was similar whether esophageal monitoring or rectal temperature monitoring was used. Further studies are needed to investigate whether esophageal temperature monitoring during TH is associated with an increased risk of overcooling and hypotension.
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Affiliation(s)
- Tai-Wei Wu
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Robert Schmicker
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Thomas R Wood
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Bryan Comstock
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Rakesh Rao
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Fernando Gonzalez
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Sandra Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, California
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Morell AS, Monsell SE, Cornet MC, Wisnowski JL, McKinstry RC, Mathur AM, Li Y, Glass HC, Gonzalez FF, Mayock DE, Benninger KL, Van Meurs KP, Lampland AL, Wu TW, Riley D, Mietzsch U, Chalak L, Flibotte J, Weitkamp JH, Ahmad KA, Yanowitz TD, Baserga M, Merhar S, Rao R, Sokol GM, Comstock BA, Heagerty PJ, Juul SE, Wu YW. Genetic and Congenital Anomalies in Infants With Hypoxic-Ischemic Encephalopathy. Pediatr Neurol 2024; 154:44-50. [PMID: 38518503 DOI: 10.1016/j.pediatrneurol.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Infants with hypoxic ischemic encephalopathy (HIE) may have underlying conditions predisposing them to hypoxic-ischemic injury during labor and delivery. It is unclear how genetic and congenital anomalies impact outcomes of HIE. METHODS Infants with HIE enrolled in a phase III trial underwent genetic testing when clinically indicated. Infants with known genetic or congenital anomalies were excluded. The primary outcome, i.e., death or neurodevelopmental impairment (NDI), was determined at age two years by a standardized neurological examination, Bayley Scales of Infant Development, Third Edition (BSID-III), and the Gross Motor Function Classification Scales. Secondary outcomes included cerebral palsy and BSID-III motor, cognitive, and language scores at age two years. RESULTS Of 500 infants with HIE, 24 (5%, 95% confidence interval 3% to 7%) were diagnosed with a genetic (n = 15) or congenital (n = 14) anomaly. Infants with and without genetic or congenital anomalies had similar rates of severe encephalopathy and findings on brain magnetic resonance imaging. However, infants with genetic or congenital anomalies were more likely to have death or NDI (75% vs 50%, P = 0.02). Among survivors, those with a genetic or congenital anomaly were more likely to be diagnosed with cerebral palsy (32% vs 13%, P = 0.02), and had lower BSID-III scores in all three domains than HIE survivors without such anomalies. CONCLUSIONS Among infants with HIE, 5% were diagnosed with a genetic or congenital anomaly. Despite similar clinical markers of HIE severity, infants with HIE and a genetic or congenital anomaly had worse neurodevelopmental outcomes than infants with HIE alone.
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Affiliation(s)
- Adriana S Morell
- Department of Neurology, University of California San Francisco, San Francisco, California.
| | - Sarah E Monsell
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Marie-Coralie Cornet
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Jessica L Wisnowski
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California; Department of Radiology, Children's Hospital Los Angeles, Los Angeles, California
| | - Robert C McKinstry
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Amit M Mathur
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Yi Li
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Hannah C Glass
- Department of Neurology, University of California San Francisco, San Francisco, California; Department of Pediatrics, University of California San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Fernando F Gonzalez
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Dennis E Mayock
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | | | - Krisa P Van Meurs
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Andrea L Lampland
- Department of Neonatology, Children's Minnesota, St. Paul, Minnesota
| | - Tai-Wei Wu
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California
| | - David Riley
- Department of Pediatrics, Cook Children's Medical Center, Ft. Worth, Texas; Department of Pediatrics, Texas Christian University, Ft. Worth, Texas; Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth, Texas
| | - Ulrike Mietzsch
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lina Chalak
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - John Flibotte
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | - Kaashif A Ahmad
- Pediatrix Medical Group of San Antonio, San Antonio, Texas; Department of Pediatrics, Children's Hospital of San Antonio, San Antonio, Texas; Department of Pediatrics, Methodist Children's Hospital, San Antonio, Texas
| | - Toby D Yanowitz
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; Department of Pediatrics, Magee Women's Hospital of UPMC, Pittsburgh, Pennsylvania
| | - Mariana Baserga
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Stephanie Merhar
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rakesh Rao
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory M Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Sandra E Juul
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, California; Department of Pediatrics, University of California San Francisco, San Francisco, California
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11
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Mietzsch U, Kolnik SE, Wood TR, Natarajan N, Gonzalez FF, Glass H, Mayock DE, Bonifacio SL, Van Meurs K, Comstock BA, Heagerty PJ, Wu TW, Wu YW, Juul SE. Evolution of the Sarnat exam and association with 2-year outcomes in infants with moderate or severe hypoxic-ischaemic encephalopathy: a secondary analysis of the HEAL Trial. Arch Dis Child Fetal Neonatal Ed 2024; 109:308-316. [PMID: 38071538 PMCID: PMC11031347 DOI: 10.1136/archdischild-2023-326102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/09/2023] [Indexed: 01/17/2024]
Abstract
OBJECTIVE To study the association between the Sarnat exam (SE) performed before and after therapeutic hypothermia (TH) and outcomes at 2 years in infants with moderate or severe hypoxic-ischaemic encephalopathy (HIE). DESIGN Secondary analysis of the High-dose Erythropoietin for Asphyxia and EncephaLopathy Trial. Adjusted ORs (aORs) for death or neurodevelopmental impairment (NDI) based on SE severity category and change in category were constructed, adjusting for sedation at time of exam. Absolute SE Score and its change were compared for association with risk for death or NDI using locally estimated scatterplot smoothing curves. SETTING Randomised, double-blinded, placebo-controlled multicentre trial including 17 centres across the USA. PATIENTS 479/500 enrolled neonates who had both a qualifying SE (qSE) before TH and a SE after rewarming (rSE). INTERVENTIONS Standardised SE was used across sites before and after TH. All providers underwent standardised SE training. MAIN OUTCOME MEASURES Primary outcome was defined as the composite outcome of death or any NDI at 22-36 months. RESULTS Both qSE and rSE were associated with the primary outcome. Notably, an aOR for primary outcome of 6.2 (95% CI 3.1 to 12.6) and 50.3 (95% CI 13.3 to 190) was seen in those with moderate and severe encephalopathy on rSE, respectively. Persistent or worsened severity on rSE was associated with higher odds for primary outcome compared with those who improved, even when qSE was severe. CONCLUSION Both rSE and change between qSE and rSE were strongly associated with the odds of death/NDI at 22-36 months in infants with moderate or severe HIE.
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Affiliation(s)
- Ulrike Mietzsch
- Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, USA
- Pediatrics, Division of Neonatology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sarah E Kolnik
- Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, USA
- Pediatrics, Division of Neonatology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Thomas Ragnar Wood
- Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Niranjana Natarajan
- Child Neurology, University of Washington School of Medicine, Seattle, Washington, USA
- Neurology, Division of Child Neurology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Fernando F Gonzalez
- Pediatrics, University of California San Francisco School of Medicine, San Francisco, California, USA
- Pediatrics, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Hannah Glass
- Pediatrics, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
- Neurology, University of California San Francisco School of Medicine, San Francisco, California, USA
- Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Dennis E Mayock
- Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sonia L Bonifacio
- Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California, USA
- Pediatrics, Division of Neonatal and Developmental Medicine, Lucile Packard Children's Hospital School, Palo Alto, California, USA
| | - Krisa Van Meurs
- Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California, USA
- Pediatrics, Division of Neonatal and Developmental Medicine, Lucile Packard Children's Hospital School, Palo Alto, California, USA
| | - Bryan A Comstock
- Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
| | - Patrick J Heagerty
- Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
| | - Tai-Wei Wu
- Pediatrics, Division of Neonatology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- Pediatrics, Children's Hospital Los Angeles Division of Neonatology, Los Angeles, California, USA
| | - Yvonne W Wu
- Pediatrics, University of California San Francisco School of Medicine, San Francisco, California, USA
- Neurology, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Sandra E Juul
- Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, USA
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Weiss EM, Donohue PK, Wootton SH, Stevens E, Merhar SL, Puia-Dumitrescu M, Mercer A, Oslin E, Porter KM, Wilfond BS. Motivations for and against Participation in Neonatal Research: Insights from Interviews of Diverse Parents Approached for Neonatal Research in the United States. J Pediatr 2024; 275:113923. [PMID: 38492913 PMCID: PMC11399325 DOI: 10.1016/j.jpeds.2024.113923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE To describe parents' motivations for and against participation in neonatal research, including the views of those who declined participation. STUDY DESIGN We performed 44 semi-structured, qualitative interviews of parents approached for neonatal research. Here we describe their motivations for and against participation. RESULTS Altruism was an important reason parents chose to participate. Some hoped participation in research would benefit their infant. Burdens of participation to the family, such as transportation to follow up (distinct from risks/burdens to the infant), were often deciding factors among those who declined participation. Perceived risks to the infant were reasons against participation, but parents often did not differentiate between baseline risks and incremental risk of study participation. Concerns regarding their infant being treated like a "guinea pig" were common among those who declined. Finally, historical abuses and institutional racism were reported as important concerns by some research decliners from minoritized populations. CONCLUSIONS Within a diverse sample of parents approached to enroll their infant in neonatal research, motivations for and against participation emerged, which may be targets of future interventions. These motivations included reasons for participation which we may hope to encourage, such as altruism. They also included reasons against participation, which we may hope to, as feasible, eliminate, mitigate, or at least acknowledge. These findings can help clinical trialists, regulators, and funders attempting to improve neonatal research recruitment processes.
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Affiliation(s)
- Elliott Mark Weiss
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA.
| | - Pamela K Donohue
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD; Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan H Wootton
- McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - Emily Stevens
- McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - Stephanie L Merhar
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Amanda Mercer
- Counselor Education Department, Portland State University, Portland, OR
| | - Ellie Oslin
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, WA
| | - Kathryn M Porter
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, WA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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13
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Rao R, Comstock BA, Wu TW, Mietzsch U, Mayock DE, Gonzalez FF, Wood TR, Heagerty PJ, Juul SE, Wu YW. Time to Reaching Target Cooling Temperature and 2-year Outcomes in Infants with Hypoxic-Ischemic Encephalopathy. J Pediatr 2024; 266:113853. [PMID: 38006967 DOI: 10.1016/j.jpeds.2023.113853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/19/2023] [Accepted: 11/18/2023] [Indexed: 11/27/2023]
Abstract
OBJECTIVE To determine if time to reaching target temperature (TT) is associated with death or neurodevelopmental impairment (NDI) at 2 years of age in infants with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN Newborn infants ≥36 weeks of gestation diagnosed with moderate or severe HIE and treated with therapeutic hypothermia were stratified based on time at which TT was reached, defined as early (ie, ≤4 hours of age) or late (>4 hours of age). Primary outcomes were death or NDI. Secondary outcomes included neurodevelopmental assessment with Bayley Scales of Infant and Toddler Development, third edition (BSID-III) at age 2. RESULTS Among 500 infants, the median time to reaching TT was 4.3 hours (IWR, 3.2-5.7 hours). Infants in early TT group (n = 211 [42%]) compared with the late TT group (n = 289 [58%]) were more likely to be inborn (23% vs 13%; P < .001) and have severe HIE (28% vs 19%; P = .03). The early and late TT groups did not differ in the primary outcome of death or any NDI (adjusted RR, 1.05; 95% CI, 0.85-0.30; P = .62). Among survivors, neurodevelopmental outcomes did not differ significantly in the 2 groups (adjusted mean difference in Bayley Scales of Infant Development-III scores: cognitive, -2.8 [95% CI, -6.1 to 0.5], language -3.3 [95% CI, -7.4 to 0.8], and motor -3.5 [95% CI, -7.3 to 0.3]). CONCLUSIONS In infants with HIE, time to reach TT is not independently associated with risk of death or NDI at age 2 years. Among survivors, developmental outcomes are similar between those who reached TT at <4 and ≥4 hours of age. TRIAL REGISTRATION High-dose Erythropoietin for Asphyxia and Encephalopathy (HEAL); NCT02811263; https://beta. CLINICALTRIALS gov/study/NCT02811263.
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Affiliation(s)
- Rakesh Rao
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St Louis, St. Louis, MO.
| | - Bryan A Comstock
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | - Tai-Wei Wu
- Division of Neonatology, Department of Pediatrics, University of Southern California, Los Angeles, CA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | - Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | - Fernando F Gonzalez
- Division of Neonatology, Department of Pediatrics, University of California, San Francisco, CA
| | - Thomas R Wood
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | - Patrick J Heagerty
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | - Yvonne W Wu
- Division of Neonatology, Department of Pediatrics, University of California, San Francisco, CA
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14
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Chen JV, Li Y, Tang F, Chaudhari G, Lew C, Lee A, Rauschecker AM, Haskell-Mendoza AP, Wu YW, Calabrese E. Automated neonatal nnU-Net brain MRI extractor trained on a large multi-institutional dataset. Sci Rep 2024; 14:4583. [PMID: 38403673 PMCID: PMC10894871 DOI: 10.1038/s41598-024-54436-8] [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: 08/29/2023] [Accepted: 02/13/2024] [Indexed: 02/27/2024] Open
Abstract
Brain extraction, or skull-stripping, is an essential data preprocessing step for machine learning approaches to brain MRI analysis. Currently, there are limited extraction algorithms for the neonatal brain. We aim to adapt an established deep learning algorithm for the automatic segmentation of neonatal brains from MRI, trained on a large multi-institutional dataset for improved generalizability across image acquisition parameters. Our model, ANUBEX (automated neonatal nnU-Net brain MRI extractor), was designed using nnU-Net and was trained on a subset of participants (N = 433) enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) study. We compared the performance of our model to five publicly available models (BET, BSE, CABINET, iBEATv2, ROBEX) across conventional and machine learning methods, tested on two public datasets (NIH and dHCP). We found that our model had a significantly higher Dice score on the aggregate of both data sets and comparable or significantly higher Dice scores on the NIH (low-resolution) and dHCP (high-resolution) datasets independently. ANUBEX performs similarly when trained on sequence-agnostic or motion-degraded MRI, but slightly worse on preterm brains. In conclusion, we created an automatic deep learning-based neonatal brain extraction algorithm that demonstrates accurate performance with both high- and low-resolution MRIs with fast computation time.
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Affiliation(s)
- Joshua V Chen
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Yi Li
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Felicia Tang
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Gunvant Chaudhari
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Christopher Lew
- Division of Neuroradiology, Department of Radiology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Amanda Lee
- Division of Neuroradiology, Department of Radiology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Andreas M Rauschecker
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | | | - Yvonne W Wu
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
| | - Evan Calabrese
- Division of Neuroradiology, Department of Radiology, Duke University Medical Center, Durham, NC, 27710, USA.
- Duke Center for Artificial Intelligence in Radiology (DAIR), Durham, NC, USA.
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15
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Numis AL, Glass HC, Comstock BA, Gonzalez F, Maitre NL, Massey SL, Mayock DE, Mietzsch U, Natarajan N, Sokol GM, Bonifacio S, Van Meurs K, Thomas C, Ahmad K, Heagerty P, Juul SE, Wu YW, Wusthoff CJ. Relationship of Neonatal Seizure Burden Before Treatment and Response to Initial Antiseizure Medication. J Pediatr 2024; 268:113957. [PMID: 38360261 DOI: 10.1016/j.jpeds.2024.113957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To assess among a cohort of neonates with hypoxic-ischemic encephalopathy (HIE) the association of pretreatment maximal hourly seizure burden and total seizure duration with successful response to initial antiseizure medication (ASM). STUDY DESIGN This was a retrospective review of data collected from infants enrolled in the HEAL Trial (NCT02811263) between January 25, 2017, and October 9, 2019. We evaluated a cohort of neonates born at ≥36 weeks of gestation with moderate-to-severe HIE who underwent continuous electroencephalogram monitoring and had acute symptomatic seizures. Poisson regression analyzed associations between (1) pretreatment maximal hourly seizure burden, (2) pretreatment total seizure duration, (3) time from first seizure to initial ASM, and (4) successful response to initial ASM. RESULTS Among 39 neonates meeting inclusion criteria, greater pretreatment maximal hourly seizure burden was associated with lower chance of successful response to initial ASM (adjusted relative risk for each 5-minute increase in seizure burden 0.83, 95% CI 0.69-0.99). There was no association between pretreatment total seizure duration and chance of successful response. Shorter time-to-treatment was paradoxically associated with lower chance of successful response to treatment, although this difference was small in magnitude (relative risk 1.007, 95% CI 1.003-1.010). CONCLUSIONS Maximal seizure burden may be more important than other, more commonly used measures in predicting response to acute seizure treatments.
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Affiliation(s)
- Adam L Numis
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA; Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA.
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA; Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Fernando Gonzalez
- Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA
| | - Nathalie L Maitre
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Niranjana Natarajan
- Division of Pediatric Neurology, Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Gregory M Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Sonia Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Krisa Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kaashif Ahmad
- Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, San Antonio, TX
| | - Patrick Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Yvonne W Wu
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA; Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA
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16
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Geng J, Feng J, Ke F, Fang F, Jing X, Tang J, Fang C, Zhang B. MicroRNA-124 negatively regulates STAT3 to alleviate hypoxic-ischemic brain damage by inhibiting oxidative stress. Aging (Albany NY) 2024; 16:2828-2847. [PMID: 38319722 PMCID: PMC10911356 DOI: 10.18632/aging.205513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/29/2023] [Indexed: 02/07/2024]
Abstract
MicroRNA-124 (miR-124) is implicated in various neurological diseases; however, its significance in hypoxic-ischaemic brain damage (HIBD) remains unclear. This study aimed to elucidate the underlying pathophysiological mechanisms of miR-124 in HIBD. In our study performed on oxygen-glucose deprivation followed by reperfusion (OGD)/R-induced primary cortical neurons, a substantial reduction in miR-124 was observed. Furthermore, the upregulation of miR-124 significantly mitigated oxidative stress, apoptosis, and mitochondrial impairment. We demonstrated that miR-124 interacts with the signal transducer and activator of transcription 3 (STAT3) to exert its biological function using the dual-luciferase reporter gene assay. As the duration of OGD increased, miR-124 exhibited a negative correlation with STAT3. STAT3 overexpression notably attenuated the protective effects of miR-124 mimics, while knockdown of STAT3 reversed the adverse effects of the miR-124 inhibitor. Subsequently, we conducted an HIBD model in rats. In vivo experiments, miR-124 overexpression attenuated cerebral infarction volume, cerebral edema, apoptosis, oxidative stress, and improved neurological function recovery in HIBD rats. In summary, the neuroprotective effects of the miR-124/STAT3 axis were confirmed in the HIBD model. MiR-124 may serve as a potential biomarker with significant therapeutic implications for HIBD.
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Affiliation(s)
- Jiaqing Geng
- Departments of Neonatology, Renmin Hospital of Wuhan University, Wuhan 430062, China
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan 430062, China
| | - Jiangpeng Feng
- State Key Laboratory of Virology, Modern Virology Research Center, College of Life Sciences, Wuhan University, Wuhan 430062, China
| | - Fangzi Ke
- Departments of Neonatology, Renmin Hospital of Wuhan University, Wuhan 430062, China
| | - Fang Fang
- Departments of Neonatology, Renmin Hospital of Wuhan University, Wuhan 430062, China
| | - Xiaoqi Jing
- Departments of Neonatology, Renmin Hospital of Wuhan University, Wuhan 430062, China
| | - Jiaxin Tang
- Departments of Neonatology, Renmin Hospital of Wuhan University, Wuhan 430062, China
| | - Chengzhi Fang
- Departments of Neonatology, Renmin Hospital of Wuhan University, Wuhan 430062, China
| | - Binghong Zhang
- Departments of Neonatology, Renmin Hospital of Wuhan University, Wuhan 430062, China
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17
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Lu H, Shen H, Mao L, Mussap M, Song L. A ferroptosis-related ceRNA network for investigating the molecular mechanisms and the treatment of neonatal hypoxic-ischemic encephalopathy. Transl Pediatr 2024; 13:119-136. [PMID: 38323182 PMCID: PMC10839276 DOI: 10.21037/tp-23-596] [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: 12/11/2023] [Accepted: 01/16/2024] [Indexed: 02/08/2024] Open
Abstract
Background Neonatal hypoxic-ischemic brain damage (HIBD) is a clinical syndrome causing brain injury in newborns with obscure etiology. Increasing evidence suggests that ferroptosis plays a role in HIBD. This study aimed to clarify the key ferroptosis-related genes (FRGs) of HIBD, construct a long non-coding RNA-microRNA-messenger RNA (lncRNA-miRNA-mRNA) network, and further investigate the pathogenesis of HIBD. Methods Gene expression data were downloaded from the Gene Expression Omnibus and FerrDb databases. The differentially expressed lncRNAs and FRGs were screened, and the related miRNAs and mRNAs were predicted. The obtained mRNA was intersected with the differentially expressed FRGs (DE-FRGs) to identify the key DE-FRGs. Cell-type Identification by Estimating Relative Subsets of RNA Transcripts method was applied to analyze the immune cell infiltration level and the relationship between key genes and immune cells. Results Gene differential expression analysis revealed that 1,178 lncRNAs, 207 miRNAs, and 647 mRNAs were differentially expressed in the blood of HIBD patients in comparison to healthy controls. The correlations of the lncRNAs, miRNAs, and mRNAs lead to the establishment of a competing endogenous RNA (ceRNA) network associated with ferroptosis in HIBD. Further validation using an external dataset and quantitative real-time polymerase chain reaction (PCR) analysis of brain tissues from hypoxic-ischemic encephalopathy rats confirmed the expression patterns of three key genes, including HMOX1, MYCN, and QSOX1. Meanwhile, the three key genes were closely correlated with the infiltration of multiple immune cells and might affect the function of HIBD regulatory genes such as CPT2 and GCK. In addition, drug prediction suggested that four drugs, including cephaeline, emetine, mestranol, and sulmazole, might alleviate HIBD. Conclusions Our study established a ceRNA network, identified three key genes, and predicted four drugs that are associated with ferroptosis in HIBD, which provides new ideas for the investigation of the disease mechanisms and might facilitate the diagnosis and treatment of the disease.
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Affiliation(s)
- Hongyi Lu
- Department of Pediatrics, Nantong First People’s Hospital (The Second Affiliated Hospital of Nantong University), Nantong, China
| | - Haiyan Shen
- Department of Pediatrics, Nantong First People’s Hospital (The Second Affiliated Hospital of Nantong University), Nantong, China
| | - Liming Mao
- Department of Immunology, School of Medicine, Nantong University, Nantong, China
- Basic Medical Research Center, School of Medicine, Nantong University, Nantong, China
| | - Michele Mussap
- Laboratory Unit, Department of Surgical Sciences, University of Cagliari, Monserrato, Italy
| | - Lei Song
- Department of Pediatrics, Nantong First People’s Hospital (The Second Affiliated Hospital of Nantong University), Nantong, China
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18
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Glass HC, Numis AL, Comstock BA, Gonzalez FF, Mietzsch U, Bonifacio SL, Massey S, Thomas C, Natarajan N, Mayock DE, Sokol GM, Van Meurs KP, Ahmad KA, Maitre N, Heagerty PJ, Juul SE, Wu YW, Wusthoff CJ. Association of EEG Background and Neurodevelopmental Outcome in Neonates With Hypoxic-Ischemic Encephalopathy Receiving Hypothermia. Neurology 2023; 101:e2223-e2233. [PMID: 37816642 PMCID: PMC10727206 DOI: 10.1212/wnl.0000000000207744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/20/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Predicting neurodevelopmental outcome for neonates with hypoxic-ischemic encephalopathy (HIE) is important for clinical decision-making, care planning, and parent communication. We examined the relationship between EEG background and neurodevelopmental outcome among children enrolled in a trial of erythropoietin or placebo for neonates with HIE treated with therapeutic hypothermia. METHODS Participants had EEG recorded throughout hypothermia. EEG background was classified as normal, discontinuous, or severely abnormal (defined as burst suppression, low voltage suppressed, or status epilepticus) at 5 1-hour epochs: onset of recording, 24, 36, 48, and 72 hours after birth. The predominant background pattern during the entire continuous video EEG monitoring recording was calculated using the arithmetic mean of the 5 EEG background ratings (normal = 0; discontinuous = 1; severely abnormal = 2) as follows: "predominantly normal" (mean = 0), "normal/discontinuous" (0 < mean<1), "predominantly discontinuous" (mean = 1), "discontinuous/severely abnormal" (1 < mean<2), or "predominantly severely abnormal" (mean = 2). Primary outcome was death or neurodevelopmental impairment (NDI) defined as cerebral palsy, Gross Motor Function Classification Score ≥1, or cognitive score <90 on Bayley Scales of Infant Toddler Development, third edition at age 2 years. Neurodevelopment was also categorized into a 5-level ordinal measure: no, mild, moderate, severe NDI, or death for secondary analysis. We used generalized linear regression models with robust standard errors to assess the relative risk of death or NDI by EEG background in both unadjusted and adjusted analyses controlling for the effects of treatment group, sex, HIE severity, and study recruitment site. RESULTS Among 142 neonates, the predominant background EEG pattern was predominantly normal in 35 (25%), normal/discontinuous in 68 (48%), predominantly discontinuous in 11 (7.7%), discontinuous/severely abnormal in 16 (11%), and predominantly severely abnormal in 12 (8.5%). Increasing severity of background across monitoring epochs was associated with increasingly worse clinical outcomes. Children with severe EEG background abnormality at any time point (n = 36, 25%) were significantly more likely to die or have severe NDI at 2 years (adjusted relative risk: 7.95, 95% CI 3.49-18.12). DISCUSSION EEG background is strongly associated with NDI at age 2 years. These results can be used to assist health care providers to plan follow-up care and counsel families for decision-making related to goals of care.
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Affiliation(s)
- Hannah C Glass
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA.
| | - Adam L Numis
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Bryan A Comstock
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Fernando F Gonzalez
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Ulrike Mietzsch
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Sonia Lomeli Bonifacio
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Shavonne Massey
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Cameron Thomas
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Niranjana Natarajan
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Dennis E Mayock
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Gregory M Sokol
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Krisa P Van Meurs
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Kaashif A Ahmad
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Nathalie Maitre
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Patrick J Heagerty
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Sandra E Juul
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Yvonne W Wu
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
| | - Courtney J Wusthoff
- Departments of Neurology and Weill Institute for Neuroscience (H.C.G., A.L.N., Y.W.W.); Pediatrics (H.C.G., A.L.N., Y.W.W.), UCSF Benioff Children's Hospital; Epidemiology & Biostatistics (H.C.G.), University of California San Francisco, CA; Department Biostatistics (B.A.C., P.J.H.), University of Washington, Seattle; Department of Pediatrics (U.M., S.E.J.), Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital; Department of Pediatrics (K.P.V.M., S.L.B.), Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA; Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine (S.L.M.), University of Pennsylvania, Philadelphia; Department of Pediatrics (C.T.), University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, OH; Department of Neurology (N.N.), University of Washington School of Medicine, Seattle; Department of Pediatrics (G.S.), Indiana University School of Medicine, Indianapolis, IN; Pediatrix Neonatology of San Antonio (K.A.A.), TX; Department of Pediatrics, and Emory + Children's Pediatric Institute (N.M.), Emory University, Atlanta, GA; Department of Neurology (C.J.W.), Stanford University, Palo Alto, CA
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19
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Zhou J, Gao T, Tang W, Qian T, Wang Z, Xu P, Wang L. Progress in the treatment of neonatal hypoxic-ischemic encephalopathy with umbilical cord blood mononuclear cells. Brain Dev 2023; 45:533-546. [PMID: 37806836 DOI: 10.1016/j.braindev.2023.09.001] [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: 05/25/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023]
Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) is a common disease among newborns, which is a leading cause of neonatal death and permanent neurological sequelae. Therapeutic hypothermia (TH) is the only method for the treatment of HIE that has been recognized effective clinically at home and abroad, but the efficacy is limited. Recent research suggests that the cord blood-derived mononuclear cells (CB-MNCs), which the refer to blood cells containing one nucleus in the cord blood, exert anti-oxidative, anti-inflammatory, anti-apoptotic effects and play a neuroprotective role in HIE. This review focuses on safety and efficacy, the route of administration, dose, timing and combination treatment of CB-MNCs in HIE.
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Affiliation(s)
- Jiayu Zhou
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, China
| | - Ting Gao
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, China
| | - Wan Tang
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, China
| | - Tianyang Qian
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, China
| | - Ziming Wang
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, China
| | - Pu Xu
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, China
| | - Laishuan Wang
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, China.
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20
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Zhu K, Zhu X, Yu J, Chen L, Liu S, Yan M, Yang W, Sun Y, Zhang Z, Li J, Shen T, Hei M. Effects of HMGB1/RAGE/cathespin B inhibitors on alleviating hippocampal injury by regulating microglial pyroptosis and caspase activation in neonatal hypoxic-ischemic brain damage. J Neurochem 2023; 167:410-426. [PMID: 37753942 DOI: 10.1111/jnc.15965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 09/28/2023]
Abstract
Microglia play a crucial role in regulating neuroinflammation in the pathogenesis of neonatal hypoxic-ischemic brain damage (HIBD). Pyroptosis, an inflammatory form of programmed cell death, has been implicated in HIBD; however, its underlying mechanism remains unclear. We previously demonstrated that high-mobility group box 1 protein (HMGB1) mediates neuroinflammation and microglial damage in HIBD. In this study, we aimed to investigate the association between HMGB1 and microglial pyroptosis and elucidate the mechanism involved in rats with HIBD (both sexes were included) and in BV2 microglia subjected to oxygen-glucose deprivation. Our results showed that HMGB1 inhibition by glycyrrhizin (20 mg/kg) reduced the expression of microglial pyroptosis-related proteins, including caspase-1, the N-terminus fragment of gasdermin D (N-GSDMD), and pyroptosis-related inflammatory factors, such as interleukin (IL) -1β and IL-18. Moreover, HMGB1 inhibition resulted in reduced neuronal damage in the hippocampus 72 h after HIBD and ultimately improved neurobehavior during adulthood, as evidenced by reduced escape latency and path length, as well as increased time and distance spent in the target quadrant during the Morris water maze test. These results revealed that HIBD-induced pyroptosis is mediated by HMGB1/receptor for advanced glycation end products (RAGE) signaling (inhibition by FPS-ZM1, 1 mg/kg) and the activation of cathespin B (cat B). Notably, cat B inhibition by CA074-Me (5 mg/kg) also reduced hippocampal neuronal damage by suppressing microglial pyroptosis, thereby ameliorating learning and memory impairments caused by HIBD. Lastly, we demonstrated that microglial pyroptosis may contribute to neuronal damage through the HMGB1/RAGE/cat B signaling pathway in vitro. In conclusion, these results suggest that HMGB1/RAGE/cat B inhibitors can alleviate hippocampal injury by regulating microglial pyroptosis and caspase activation in HIBD, thereby reducing the release of proinflammatory mediators that destroy hippocampal neurons and induce spatial memory impairments.
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Affiliation(s)
- Kaiyi Zhu
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xing Zhu
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jie Yu
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lu Chen
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shiqi Liu
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Mingjing Yan
- The MOH Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Wei Yang
- Department of Neurosurgery, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yanyan Sun
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Zhe Zhang
- Department of Pulmonary and Critical Care Medicine, The First Hospital of Shanxi Medical University, Shanxi Medical University, Taiyuan, China
| | - Jian Li
- The MOH Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Tao Shen
- The MOH Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Mingyan Hei
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
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21
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Wisnowski JL, Monsell SE, Bluml S, Goodman AM, Li Y, Comstock B, Heagerty P, Juul SE, Wu YW, McKinstry RC, Mathur A. Brain Injury Outcomes after Adjuvant Erythropoietin Neuroprotection for Moderate or Severe Neonatal Hypoxic-Ischemic Encephalopathy: A Report from the HEAL Trial. Dev Neurosci 2023:000534618. [PMID: 37906983 PMCID: PMC11249061 DOI: 10.1159/000534618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 10/10/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION Erythropoietin (Epo) is a putative neuroprotective therapy that did not improve overall outcomes in a phase 3 randomized controlled trial for neonates with moderate or severe hypoxic-ischemic encephalopathy (HIE). However, HIE is a heterogeneous disorder, and it remains to be determined whether Epo had beneficial effects on a subset of perinatal brain injuries. METHODS This study was a secondary analysis of neuroimaging data from the High-dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) Trial, which was conducted from 2016 - 2021 at 17 sites involving 23 US academic medical centers. Participants were neonates >36 weeks' gestation undergoing therapeutic hypothermia for moderate or severe HIE who received 5 doses of study drug (Epoetin alpha 1000 U/kg/dose) or placebo in the first week of life. Treatment assignment was stratified by trial site and severity of encephalopathy. The primary outcome was the locus, pattern and acuity of brain injury as determined by three independent readers using a validated HIE Magnetic Resonance Imaging (MRI) scoring system. RESULTS Of the 500 infants enrolled in HEAL, 470 (94%) had high quality MRI data obtained at a median of 4.9 days of age (IQR 4.5 - 5.8). The incidence of injury to the deep grey nuclei, cortex, white matter, brainstem and cerebellum was similar between Epo and placebo groups. Likewise, the distribution of injury patterns was similar between groups. Among infants imaged at less than 8 days (n=414), 94 (23%) evidenced only acute, 93 (22%) only subacute and 89 (21%) both acute and subacute injuries, with similar distribution across treatment groups. CONCLUSION Adjuvant erythropoietin did not reduce the incidence of regional brain injury. Subacute brain injury was more common than previously reported, which has key implications for the development of adjuvant neuroprotective therapies for this population.
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22
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Mietzsch U, Wood TR, Wu TW, Natarajan N, Glass HC, Gonzalez FF, Mayock DE, Comstock BA, Heagerty PJ, Juul SE, Wu YW. Early Glycemic State and Outcomes of Neonates With Hypoxic-Ischemic Encephalopathy. Pediatrics 2023; 152:e2022060965. [PMID: 37655394 PMCID: PMC10522925 DOI: 10.1542/peds.2022-060965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 09/02/2023] Open
Abstract
OBJECTIVES In infants with hypoxic-ischemic encephalopathy (HIE), conflicting information on the association between early glucose homeostasis and outcome exists. We characterized glycemic profiles in the first 12 hours after birth and their association with death and neurodevelopmental impairment (NDI) in neonates with moderate or severe HIE undergoing therapeutic hypothermia. METHODS This post hoc analysis of the High-dose Erythropoietin for Asphyxia and Encephalopathy trial included n = 491 neonates who had blood glucose (BG) values recorded within 12 hours of birth. Newborns were categorized based on their most extreme BG value. BG >200 mg/dL was defined as hyperglycemia, BG <50 mg/dL as hypoglycemia, and 50 to 200 mg/dL as euglycemia. Primary outcome was defined as death or any NDI at 22 to 36 months. We calculated odds ratios for death or NDI adjusted for factors influencing glycemic state (aOR). RESULTS Euglycemia was more common in neonates with moderate compared with severe HIE (63.6% vs 36.6%; P < .001). Although hypoglycemia occurred at similar rates in severe and moderate HIE (21.4% vs 19.5%; P = .67), hyperglycemia was more common in severe HIE (42.3% vs 16.9%; P < .001). Compared with euglycemic neonates, both, hypo- and hyperglycemic neonates had an increased aOR (95% confidence interval) for death or NDI (2.62; 1.47-4.67 and 1.77; 1.03-3.03) compared to those with euglycemia. Hypoglycemic neonates had an increased aOR for both death (2.85; 1.09-7.43) and NDI (2.50; 1.09-7.43), whereas hyperglycemic neonates had increased aOR of 2.52 (1.10-5.77) for death, but not NDI. CONCLUSIONS Glycemic profile differs between neonates with moderate and severe HIE, and initial glycemic state is associated death or NDI at 22 to 36 months.
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Affiliation(s)
- Ulrike Mietzsch
- Department of Pediatrics, Division of Neonatology, University of Washintgon School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Thomas R. Wood
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington
| | - Tai-Wei Wu
- Department of Pediatrics, Division of Neonatology, University of Southern California, Keck School of Medicine, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Niranjana Natarajan
- Department of Neurology, Division of Child Neurology, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington
| | - Hannah C. Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, California
- Department of Pediatrics, UCSF Benioff Children’s Hospital, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California; and
| | - Fernando F. Gonzalez
- Department of Pediatrics, UCSF Benioff Children’s Hospital, San Francisco, California
| | - Dennis E. Mayock
- Department of Pediatrics, Division of Neonatology, University of Washintgon School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Bryan A. Comstock
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Sunny E. Juul
- Department of Pediatrics, Division of Neonatology, University of Washintgon School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Yvonne W. Wu
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, California
- Department of Pediatrics, UCSF Benioff Children’s Hospital, San Francisco, California
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23
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Chavez-Valdez R, Aziz K, Burton VJ, Northington FJ. Worse Outcomes From HIE Treatment Associated With Extreme Glycemic States. Pediatrics 2023; 152:e2023062521. [PMID: 37655403 PMCID: PMC10522924 DOI: 10.1542/peds.2023-062521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 09/02/2023] Open
Affiliation(s)
- Raul Chavez-Valdez
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics
- Neuroscience Intensive Care Nursery Program, Department of Pediatrics
| | - Khyzer Aziz
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics
- Neuroscience Intensive Care Nursery Program, Department of Pediatrics
- Division of Biomedical Informatics and Data Science, Department of Medicine
| | - Vera Joanna Burton
- Neuroscience Intensive Care Nursery Program, Department of Pediatrics
- Department of Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland
| | - Frances J. Northington
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics
- Neuroscience Intensive Care Nursery Program, Department of Pediatrics
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24
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Gonzalez FF, Voldal E, Comstock BA, Mayock DE, Goodman AM, Cornet MC, Wu TW, Redline RW, Heagerty P, Juul SE, Wu YW. Placental Histologic Abnormalities and 2-Year Outcomes in Neonatal Hypoxic-Ischemic Encephalopathy. Neonatology 2023; 120:760-767. [PMID: 37742617 PMCID: PMC10711751 DOI: 10.1159/000533652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/12/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE We aimed to examine the association between placental abnormalities and neurodevelopmental outcomes in a multicenter cohort of newborn infants with hypoxic-ischemic encephalopathy (HIE) that underwent therapeutic hypothermia. We hypothesized that subjects with acute placental abnormalities would have reduced risk of death or neurodevelopmental impairment (NDI) at 2 years of age after undergoing therapeutic hypothermia compared to subjects without acute placental changes. STUDY DESIGN Among 500 subjects born at ≥36 weeks gestation with moderate or severe HIE enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) Trial, a placental pathologist blinded to clinical information reviewed clinical pathology reports to determine the presence of acute only, chronic only, or both acute and chronic histologic abnormalities. We calculated adjusted relative risks (aRRs) for associations between placental pathologic abnormalities and death or NDI at age 2 years, adjusting for HIE severity, treatment assignment, and site. RESULT 321/500 subjects (64%) had available placental pathology reports. Placental abnormalities were characterized as acute only (20%), chronic only (21%), both acute and chronic (43%), and none (15%). The risk of death or NDI was not statistically different between subjects with and without an acute placental abnormality (46 vs. 53%, aRR 1.1, 95% confidence interval (CI): 0.9, 1.4). Subjects with two or more chronic lesions were more likely to have an adverse outcome than subjects with no chronic abnormalities, though this did not reach statistical significance (55 vs. 45%, aRR 1.24, 95% CI: 0.99, 1.56). CONCLUSION Placental pathologic findings were not independently associated with risk of death or NDI in subjects with HIE. The relationship between multiple chronic placental lesions and HIE outcomes deserves further study.
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Affiliation(s)
- Fernando F. Gonzalez
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Emily Voldal
- Department Biostatistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Bryan A. Comstock
- Department Biostatistics, University of Washington, Seattle, WA, USA
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Amy M. Goodman
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA
| | - Marie-Coralie Cornet
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Tai-Wei Wu
- Division of Neonatology, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Raymond W. Redline
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Patrick Heagerty
- Department Biostatistics, University of Washington, Seattle, WA, USA
| | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Yvonne W. Wu
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA
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25
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Wu YW, Monsell SE, Glass HC, Wisnowski JL, Mathur AM, McKinstry RC, Bluml S, Gonzalez FF, Comstock BA, Heagerty PJ, Juul SE. How well does neonatal neuroimaging correlate with neurodevelopmental outcomes in infants with hypoxic-ischemic encephalopathy? Pediatr Res 2023; 94:1018-1025. [PMID: 36859442 PMCID: PMC10444609 DOI: 10.1038/s41390-023-02510-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND In newborns with hypoxic-ischemic encephalopathy (HIE), the correlation between neonatal neuroimaging and the degree of neurodevelopmental impairment (NDI) is unclear. METHODS Infants with HIE enrolled in a randomized controlled trial underwent neonatal MRI/MR spectroscopy (MRS) using a harmonized protocol at 4-6 days of age. The severity of brain injury was measured with a validated scoring system. Using proportional odds regression, we calculated adjusted odds ratios (aOR) for the associations between MRI/MRS measures of injury and primary ordinal outcome (i.e., normal, mild NDI, moderate NDI, severe NDI, or death) at age 2 years. RESULTS Of 451 infants with MRI/MRS at a median age of 5 days (IQR 4.5-5.8), outcomes were normal (51%); mild (12%), moderate (14%), severe NDI (13%); or death (9%). MRI injury score (aOR 1.06, 95% CI 1.05, 1.07), severe brain injury (aOR 39.6, 95% CI 16.4, 95.6), and MRS lactate/n-acetylaspartate (NAA) ratio (aOR 1.6, 95% CI 1.4,1.8) were associated with worse primary outcomes. Infants with mild/moderate MRI brain injury had similar BSID-III cognitive, language, and motor scores as infants with no injury. CONCLUSION In the absence of severe injury, brain MRI/MRS does not accurately discriminate the degree of NDI. Given diagnostic uncertainty, families need to be counseled regarding a range of possible neurodevelopmental outcomes. IMPACT Half of all infants with hypoxic-ischemic encephalopathy (HIE) enrolled in a large clinical trial either died or had neurodevelopmental impairment at age 2 years despite receiving therapeutic hypothermia. Severe brain injury and a global pattern of brain injury on MRI were both strongly associated with death or neurodevelopmental impairment. Infants with mild or moderate brain injury had similar mean BSID-III cognitive, language, and motor scores as infants with no brain injury on MRI. Given the prognostic uncertainty of brain MRI among infants with less severe degrees of brain injury, families should be counseled regarding a range of possible neurodevelopmental outcomes.
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Affiliation(s)
- Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
| | - Sarah E Monsell
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Hannah C Glass
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
- Department of Epidemiology, University of California San Francisco, San Francisco, CA, USA
| | - Jessica L Wisnowski
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Amit M Mathur
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Robert C McKinstry
- Mallinckrodt Institute of Radiology, Washington Univ School of Medicine, St. Louis, MO, USA
| | - Stefan Bluml
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Radiology, University of Southern CA Keck School of Medicine, Los Angeles, CA, USA
| | - Fernando F Gonzalez
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Sandra E Juul
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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Calabrese E, Wu Y, Scheffler AW, Wisnowski JL, McKinstry RC, Mathur A, Glass HC, Comstock BA, Heagerty PJ, Gillon S, Juul SE, Hess CP, Li Y. Correlating Quantitative MRI-based Apparent Diffusion Coefficient Metrics with 24-month Neurodevelopmental Outcomes in Neonates from the HEAL Trial. Radiology 2023; 308:e223262. [PMID: 37698478 PMCID: PMC10546287 DOI: 10.1148/radiol.223262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 07/10/2023] [Accepted: 07/18/2023] [Indexed: 09/13/2023]
Abstract
Background Multiple qualitative scoring systems have been created to capture the imaging severity of hypoxic ischemic brain injury. Purpose To evaluate quantitative volumes of acute brain injury at MRI in neonates with hypoxic ischemic brain injury and correlate these findings with 24-month neurodevelopmental outcomes and qualitative brain injury scoring by radiologists. Materials and Methods In this secondary analysis, brain diffusion-weighted MRI data from neonates in the High-dose Erythropoietin for Asphyxia and Encephalopathy trial, which recruited participants between January 2017 and October 2019, were analyzed. Volume of acute brain injury, defined as brain with apparent diffusion coefficient (ADC) less than 800 × 10-6 mm2/sec, was automatically computed across the whole brain and within the thalami and white matter. Outcomes of death and neurodevelopmental impairment (NDI) were recorded at 24-month follow-up. Associations between the presence and volume (in milliliters) of acute brain injury with 24-month outcomes were evaluated using multiple logistic regression. The correlation between quantitative acute brain injury volume and qualitative MRI scores was assessed using the Kendall tau-b test. Results A total of 416 neonates had available MRI data (mean gestational age, 39.1 weeks ± 1.4 [SD]; 235 male) and 113 (27%) showed evidence of acute brain injury at MRI. Of the 387 participants with 24-month follow-up data, 185 (48%) died or had any NDI. Volume of acute injury greater than 1 mL (odds ratio [OR], 13.9 [95% CI: 5.93, 32.45]; P < .001) and presence of any acute injury in the brain (OR, 4.5 [95% CI: 2.6, 7.8]; P < .001) were associated with increased odds of death or any NDI. Quantitative whole-brain acute injury volume was strongly associated with radiologists' qualitative scoring of diffusion-weighted images (Kendall tau-b = 0.56; P < .001). Conclusion Automated quantitative volume of brain injury is associated with death, moderate to severe NDI, and cerebral palsy in neonates with hypoxic ischemic encephalopathy and correlated well with qualitative MRI scoring of acute brain injury. Clinical trial registration no. NCT02811263 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Huisman in this issue.
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Affiliation(s)
- Evan Calabrese
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Yvonne Wu
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Aaron Wolfe Scheffler
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Jessica L. Wisnowski
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Robert C. McKinstry
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Amit Mathur
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Hannah C. Glass
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Bryan A. Comstock
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Patrick J. Heagerty
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Shivani Gillon
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Sandra E. Juul
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Christopher P. Hess
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
| | - Yi Li
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.C.); Department of Neurology and Weill Institute for Neuroscience (Y.W., H.C.G.), Department of Pediatrics, UCSF Benioff Children's Hospital (Y.W., H.C.G.), Department of Epidemiology and Biostatistics (A.W.S.), School of Medicine (S.G.), and Neuroradiology Section, Department of Radiology and Biomedical Imaging (C.P.H., Y.L.), University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628; Department of Radiology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, Calif (J.L.W.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (R.C.M.); Department of Pediatrics, St Louis University, St Louis, Mo (A.M.); and Departments of Statistics (B.A.C., P.J.H.) and Pediatrics (S.E.J.), University of Washington, Seattle, Wash
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Korf JM, McCullough LD, Caretti V. A narrative review on treatment strategies for neonatal hypoxic ischemic encephalopathy. Transl Pediatr 2023; 12:1552-1571. [PMID: 37692539 PMCID: PMC10485647 DOI: 10.21037/tp-23-253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Background and Objective Hypoxic-ischemic encephalopathy (HIE) is a leading cause of death and disability worldwide. Therapeutic hypothermia (TH) represents a significant achievement in the translation of scientific research to clinical application, but it is currently the only neuroprotective treatment for HIE. This review aims to revisit the use of TH for HIE and its longitudinal impact on patient outcomes to readers new to the field of HIE. We discuss how emerging therapies address the broader pathophysiology of injury progression in the neonatal brain days to years after HIE. Methods We included full articles and book chapters published in English on PubMed with references to "hypoxic ischemic encephalopathy", "birth asphyxia", "therapeutic hypothermia", or "neonatal encephalopathy". We limited our review to outcomes on term infants and to new therapeutics that are in the second phase of clinical trials. Key Content and Findings Despite the use of TH for HIE, mortality remains high. Analysis of longitudinal studies reveals a high incidence of ongoing disability even with the implementation of TH. New therapeutics addressing the secondary phase and the less understood tertiary phase of brain injury are in clinical trials as adjunctive treatments to TH to support additional neurological repair and regeneration. Conclusions TH successfully improves outcomes after HIE, and it continues to be optimized. Larger studies are needed to understand its use in mild cases of HIE and if certain factors, such as sex, affect long term outcomes. TH primarily acts in the initial phases of injury, while new pharmaceutical therapies target additional injury pathways into the tertiary phases of injury. This may allow for more effective approaches to treatment and improvement of long-term functional outcomes after HIE.
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Affiliation(s)
- Janelle M. Korf
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Louise D. McCullough
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Viola Caretti
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
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Chalak LF, Kang S, Kota S, Liu H, Liu Y, Juul SE, Wu YW. Evaluation of neurovascular coupling during neuroprotective therapies: A single site HEAL ancillary study. Early Hum Dev 2023; 183:105815. [PMID: 37419079 PMCID: PMC10824020 DOI: 10.1016/j.earlhumdev.2023.105815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND There is a critical need for development of physiological biomarkers in infants with birth asphyxia to identify the physiologic response to therapies in real time. This is an ancillary single site study of the High-Dose Erythropoietin for Asphyxia and Encephalopathy (Wu et al., 2022 [1]) to measure neurovascular coupling (NVC) non-invasively during an ongoing blinded randomized trial. METHODS Neonates who randomized in the HEAL enrolled at a single-center Level III Neonatal Intensive Care Unit were recruited between 2017 and 2019. Neurodevelopmental impairment was blinded and defined as any of the following: cognitive score <90 on Bayley Scales of Infant Toddler Development, third edition (BSID-III), Gross Motor Function Classification Score (GMFCS) ≥1. RESULTS All twenty-seven neonates enrolled in HEAL were recruited and 3 died before complete recording. The rank-based analysis of covariance models demonstrated lack of difference in NVC between the two groups (Epo versus Placebo) that was consistent with the observed lack of effect on neurodevelopmental outcomes. CONCLUSION We demonstrate no difference in neurovascular coupling after Epo administration. These findings are consistent with overall negative trial results. Physiological biomarkers can help elucidate mechanisms of neuroprotective therapies in real time in future trials.
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Affiliation(s)
- Lina F Chalak
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States of America.
| | - Shu Kang
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX, United States of America
| | - Srinivas Kota
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Hanli Liu
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX, United States of America
| | - Yulun Liu
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States of America
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Juul SE, Voldal E, Comstock BA, Massaro AN, Bammler TK, Mayock DE, Heagerty PJ, Wu YW, Numis AL. Association of High-Dose Erythropoietin With Circulating Biomarkers and Neurodevelopmental Outcomes Among Neonates With Hypoxic Ischemic Encephalopathy: A Secondary Analysis of the HEAL Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2322131. [PMID: 37418263 PMCID: PMC10329214 DOI: 10.1001/jamanetworkopen.2023.22131] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/18/2023] [Indexed: 07/08/2023] Open
Abstract
Importance The ability to predict neurodevelopmental impairment (NDI) for infants diagnosed with hypoxic ischemic encephalopathy (HIE) is important for parental guidance and clinical treatment as well as for stratification of patients for future neurotherapeutic studies. Objectives To examine the effect of erythropoietin on plasma inflammatory mediators in infants with moderate or severe HIE and to develop a panel of circulating biomarkers that improves the projection of 2-year NDI over and above the clinical data available at the time of birth. Design, Setting, and Participants This study is a preplanned secondary analysis of prospectively collected data from infants enrolled in the High-Dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) Trial, which tested the efficacy of erythropoietin as an adjunctive neuroprotective therapy to therapeutic hypothermia. The study was conducted at 17 academic sites comprising 23 neonatal intensive care units in the United States between January 25, 2017, and October 9, 2019, with follow-up through October 2022. Overall, 500 infants born at 36 weeks' gestation or later with moderate or severe HIE were included. Intervention Erythropoietin treatment 1000 U/kg/dose on days 1, 2, 3, 4 and 7. Main Outcomes and Measures Plasma erythropoietin was measured in 444 infants (89%) within 24 hours after birth. A subset of 180 infants who had plasma samples available at baseline (day 0/1), day 2, and day 4 after birth and either died or had 2-year Bayley Scales of Infant Development III assessments completed were included in the biomarker analysis. Results The 180 infants included in this substudy had a mean (SD) gestational age of 39.1 (1.5) weeks, and 83 (46%) were female. Infants who received erythropoietin had increased concentrations of erythropoietin at day 2 and day 4 compared with baseline. Erythropoietin treatment did not alter concentrations of other measured biomarkers (eg, difference in interleukin [IL] 6 between groups on day 4: -1.3 pg/mL; 95% CI, -4.8 to 2.0 pg/mL). After adjusting for multiple comparisons, we identified 6 plasma biomarkers (C5a, interleukin [IL] 6, and neuron-specific enolase at baseline; IL-8, tau, and ubiquitin carboxy-terminal hydrolase-L1 at day 4) that significantly improved estimations of death or NDI at 2 years compared with clinical data alone. However, the improvement was only modest, increasing the AUC from 0.73 (95% CI, 0.70-0.75) to 0.79 (95% CI, 0.77-0.81; P = .01), corresponding to a 16% (95% CI, 5%-44%) increase in correct classification of participant risk of death or NDI at 2 years. Conclusions and Relevance In this study, erythropoietin treatment did not reduce biomarkers of neuroinflammation or brain injury in infants with HIE. Circulating biomarkers modestly improved estimation of 2-year outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT02811263.
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Glass HC, Wusthoff CJ, Comstock BA, Numis AL, Gonzalez FF, Maitre N, Massey SL, Mayock DE, Mietzsch U, Natarajan N, Sokol GM, Bonifacio SL, Van Meurs KP, Thomas C, Ahmad KA, Heagerty PJ, Juul SE, Wu YW. Risk of seizures in neonates with hypoxic-ischemic encephalopathy receiving hypothermia plus erythropoietin or placebo. Pediatr Res 2023; 94:252-259. [PMID: 36470964 PMCID: PMC10239788 DOI: 10.1038/s41390-022-02398-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/27/2022] [Accepted: 11/03/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND An ancillary study of the High-Dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) trial for neonates with hypoxic-ischemic encephalopathy (HIE) and treated with therapeutic hypothermia examined the hypothesis that neonates randomized to receive erythropoietin (Epo) would have a lower seizure risk and burden compared with neonates who received placebo. METHODS Electroencephalograms (EEGs) from 7/17 HEAL trial centers were reviewed. Seizure presence was compared across treatment groups using a logistic regression model adjusting for treatment, HIE severity, center, and seizure burden prior to the first dose. Among neonates with seizures, differences across treatment groups in median maximal hourly seizure burden were assessed using adjusted quantile regression models. RESULTS Forty-six of 150 (31%) neonates had EEG seizures (31% in Epo vs 30% in placebo, p = 0.96). Maximal hourly seizure burden after the study drug was not significantly different between groups (median 11.4 for Epo, IQR: 5.6, 18.1 vs median 9.7, IQR: 4.9, 21.0 min/h for placebo). CONCLUSION In neonates with HIE treated with hypothermia who were randomized to Epo or placebo, we found no meaningful between-group difference in seizure risk or burden. These findings are consistent with overall trial results, which do not support Epo use for neonates with HIE undergoing therapeutic hypothermia. IMPACT In the HEAL trial of erythropoietin (Epo) vs placebo for neonates with encephalopathy presumed due to hypoxic-ischemic encephalopathy (HIE) who were also treated with therapeutic hypothermia, electrographic seizures were detected in 31%, which is lower than most prior studies. Epo did not reduce the proportion of neonates with acute provoked seizures (31% in Epo vs 30% in placebo) or maximal hourly seizure burden after the study drug (median 11.4, IQR 5.6, 18.1 for Epo vs median 9.7, IQR 4.9, 21.0 min/h for placebo). There was no anti- or pro-convulsant effect of Epo when combined with therapeutic hypothermia for HIE.
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Affiliation(s)
- Hannah C Glass
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA.
| | - Courtney J Wusthoff
- Department of Neurology, Stanford University, Palo Alto, CA, USA
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA, USA
| | - Bryan A Comstock
- Department Biostatistics, University of Washington, Seattle, WA, USA
| | - Adam L Numis
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA
| | - Fernando F Gonzalez
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Nathalie Maitre
- Department of Pediatrics, and Emory + Children's Pediatric Institute, Emory University, Atlanta, GA, USA
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dennis E Mayock
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Ulrike Mietzsch
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Niranjana Natarajan
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Gregory M Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sonia L Bonifacio
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Sandra E Juul
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Yvonne W Wu
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA
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Juul SE, Comstock BA, Cornet MC, Gonzalez FF, Mayock DE, Glass HC, Schreiber MD, Heagerty PJ, Wu YW. Safety of High Dose Erythropoietin Used with Therapeutic Hypothermia as Treatment for Newborn Hypoxic-Ischemic Encephalopathy: Secondary Analysis of the HEAL Randomized Controlled Trial. J Pediatr 2023; 258:113400. [PMID: 37019334 PMCID: PMC10760810 DOI: 10.1016/j.jpeds.2023.113400] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/02/2023] [Accepted: 03/29/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE To assess whether high dose erythropoietin (Epo) treatment of cooled infants with neonatal hypoxic ischemic encephalopathy results in a higher risk of prespecified serious adverse events (SAEs). STUDY DESIGN Five hundred infants born at ≥36 weeks of gestation with moderate or severe hypoxic ischemic encephalopathy undergoing therapeutic hypothermia were randomized to Epo or placebo on days 1, 2, 3, 4, and 7. Pretreatment and posttreatment SAEs were compared with adjusted generalized linear models, with posttreatment models adjusted for the presence of a pretreatment SAE. Clinical risk factors and potential mechanisms for SAEs were also examined. RESULTS The rate of experiencing at least one posttreatment SAE did not significantly differ between groups (adjusted relative risk [aRR], 95% CI: 1.17, 0.92-1.49); however, posttreatment thrombosis was identified more often in the Epo group (n = 6, 2.3%) than the placebo group (n = 1, 0.4%; aRR, 95% CI: 5.09, 1.32-19.64). The rate of posttreatment intracranial hemorrhage identified at the treatment sites by either ultrasound or magnetic resonance imaging was slightly elevated in the Epo group (n = 61, 24%) but not significantly different from the placebo group (n = 46, 19%; aRR, 95% CI: 1.21, 0.85, 1.72). CONCLUSIONS A small increased risk of major thrombotic events was identified in the Epo treatment group. TRIAL REGISTRATION NCT02811263.
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Affiliation(s)
- Sandra E Juul
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA.
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Marie-Coralie Cornet
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Fernando F Gonzalez
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Dennis E Mayock
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Hannah C Glass
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA; Department of Neurology, University of California, San Francisco, San Francisco, CA
| | | | | | - Yvonne W Wu
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA; Department of Neurology, University of California, San Francisco, San Francisco, CA
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32
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Cotten CM, Fisher K, Malcolm W, Gustafson KE, Cheatham L, Marion A, Greenberg R, Kurtzberg J. A Pilot Phase I Trial of Allogeneic Umbilical Cord Tissue-Derived Mesenchymal Stromal Cells in Neonates With Hypoxic-Ischemic Encephalopathy. Stem Cells Transl Med 2023:7191802. [PMID: 37285522 DOI: 10.1093/stcltm/szad027] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/17/2023] [Indexed: 06/09/2023] Open
Abstract
Hypoxic ischemic encephalopathy (HIE) in neonates causes increased mortality and long-term morbidity in surviving babies. Hypothermia (HT) has improved outcomes, however, mortality remains high with ~half of surviving babies developing neurological impairment in their first years. We previously explored the use of autologous cord blood (CB) to determine if CB cells could lessen long-term damage to the brain. However, the feasibility of CB collection from sick neonates limited the utility of this approach. Allogeneic cord tissue mesenchymal stromal cells (hCT-MSC), cryopreserved and readily available, have been shown to ameliorate brain injury in animal models of HIE. We, therefore, conducted a pilot, phase I, clinical trial to test the safety and describe the preliminary efficacy of hCT-MSC in neonates with HIE. The study treated infants with moderate to severe HIE, treated with HT, with 1 or 2 doses of 2 million cells/kg/dose of hCT-MSC given intravenously. The babies were randomized to receive 1 or 2 doses with the first dose during HT and the second dose 2 months later. Babies were followed for survival and development with scoring of Bayley's at 12 postnatal months. Six neonates with moderate (4) or severe (2) HIE were enrolled. All received 1 dose of hCT-MSC during HT and 2 received a 2nd dose, 2 months later. hCT-MSC infusions were well tolerated although 5/6 babies developed low titer anti-HLA antibodies by 1 year of age. All babies survived, with average to low-average developmental assessment standard scores for ages between 12 and 17 postnatal months. Further study is warranted.
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Affiliation(s)
- Charles Michael Cotten
- Division of Neonatology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Kimberley Fisher
- Division of Neonatology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - William Malcolm
- Division of Neonatology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Kathryn E Gustafson
- Department of Psychiatry and Behavioral Sciences, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Lynn Cheatham
- Marcus Center for Cellular Cures, Duke University School of Medicine, Durham, NC, USA
| | - Amanda Marion
- Division of Neonatology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Rachel Greenberg
- Division of Neonatology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Joanne Kurtzberg
- Marcus Center for Cellular Cures, Duke University School of Medicine, Durham, NC, USA
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Xie Y, Yang Y, Yuan T. Brain Damage in the Preterm Infant: Clinical Aspects and Recent Progress in the Prevention and Treatment. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2023; 22:27-40. [PMID: 35209835 DOI: 10.2174/1871527321666220223092905] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/16/2022] [Accepted: 01/16/2022] [Indexed: 12/16/2022]
Abstract
Although the prevalence of brain injury and related neurodevelopmental disabilities resulting from preterm birth are major public health concerns, there are no definite neuroprotective strategies to prevent or reduce brain injury. The pattern of brain injury seen in preterm infants has evolved into more subtle lesions that are still essential to diagnose regarding neurodevelopmental outcomes. There is no specific effective method for the treatment of premature infant brain injury, and the focus of clinical treatment is still on prevention. Prevention of this injury requires insight into the pathogenesis, but many gaps exist in our understanding of how neonatal treatment procedures and medications impact cerebral hemodynamics and preterm brain injury. Many studies provide evidence about the prevention of premature infant brain injury, which is related to some drugs (such as erythropoietin, melatonin, mesenchymal stem cells, etc.). However, there are still some controversies about the quality of research and the effectiveness of therapy. This review aims to recapitulate the results of preclinical studies and provide an update on the latest developments around etiological pathways, prevention, and treatment.
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Affiliation(s)
- Yixuan Xie
- Department of Neonatology, Children\'s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, Zhejiang, P.R. China
| | - Yue Yang
- Department of Neonatology, Children\'s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, Zhejiang, P.R. China
| | - Tianming Yuan
- Department of Neonatology, Children\'s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, Zhejiang, P.R. China
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34
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Li R, Lee JK, Govindan RB, Graham EM, Everett AD, Perin J, Vezina G, Tekes A, Chen MW, Northington F, Parkinson C, O’Kane A, McGowan M, Krein C, Al-Shargabi T, Chang T, Massaro AN. Plasma Biomarkers of Evolving Encephalopathy and Brain Injury in Neonates with Hypoxic-Ischemic Encephalopathy. J Pediatr 2023; 252:146-153.e2. [PMID: 35944723 PMCID: PMC9828943 DOI: 10.1016/j.jpeds.2022.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The objective of the study was to evaluate the relationship between a panel of candidate plasma biomarkers and (1) death or severe brain injury on magnetic resonance imaging (MRI) and (2) dysfunctional cerebral pressure autoregulation as a measure of evolving encephalopathy. STUDY DESIGN Neonates with moderate-to-severe hypoxic-ischemic encephalopathy (HIE) at 2 level IV neonatal intensive care units were enrolled into this observational study. Patients were treated with therapeutic hypothermia (TH) and monitored with continuous blood pressure monitoring and near-infrared spectroscopy. Cerebral pressure autoregulation was measured by the hemoglobin volume phase (HVP) index; a higher HVP index indicates poorer autoregulation. Serial blood samples were collected during TH and assayed for Tau, glial fibrillary acidic protein, and neurogranin. MRIs were assessed using National Institutes of Child Health and Human Development scores. The relationships between the candidate biomarkers and (1) death or severe brain injury on MRI (defined as a National Institutes of Child Health and Human Development score of ≥ 2B) and (2) autoregulation were evaluated using bivariate and adjusted logistic regression models. RESULTS Sixty-two patients were included. Elevated Tau levels on days 2-3 of TH were associated with death or severe injury on MRI (aOR: 1.06, 95% CI: 1.03-1.09; aOR: 1.04, 95% CI: 1.01-1.06, respectively). Higher Tau was also associated with poorer autoregulation (higher HVP index) on the same day (P = .022). CONCLUSIONS Elevated plasma levels of Tau are associated with death or severe brain injury by MRI and dysfunctional cerebral autoregulation in neonates with HIE. Larger-scale validation of Tau as a biomarker of brain injury in neonates with HIE is warranted.
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Affiliation(s)
- Ruoying Li
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rathinaswamy B. Govindan
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Ernest M. Graham
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allen D. Everett
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jamie Perin
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gilbert Vezina
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Division of Diagnostic Imaging and Radiology, Children’s National Hospital, Washington, DC
| | - Aylin Tekes
- Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - May W. Chen
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Frances Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Charlamaine Parkinson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra O’Kane
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Meaghan McGowan
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Colleen Krein
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Tareq Al-Shargabi
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Taeun Chang
- Department of Neurology, Children’s National Hospital, Washington, DC;,Department of Pediatrics, The George Washington University School of Medicine, Washington, DC
| | - An N. Massaro
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Division of Neonatology, Children’s National Hospital, Washington, DC
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35
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Li Y, Wisnowski JL, Chalak L, Mathur AM, McKinstry RC, Licona G, Mayock DE, Chang T, Van Meurs KP, Wu TW, Ahmad KA, Cornet MC, Rao R, Scheffler A, Wu YW. Mild hypoxic-ischemic encephalopathy (HIE): timing and pattern of MRI brain injury. Pediatr Res 2022; 92:1731-1736. [PMID: 35354930 PMCID: PMC9771796 DOI: 10.1038/s41390-022-02026-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/06/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mild hypoxic-ischemic encephalopathy (HIE) is increasingly recognized as a risk factor for neonatal brain injury. We examined the timing and pattern of brain injury in mild HIE. METHODS This retrospective cohort study includes infants with mild HIE treated at 9 hospitals. Neonatal brain MRIs were scored by 2 reviewers using a validated classification system, with discrepancies resolved by consensus. Severity and timing of MRI brain injury (i.e., acute, subacute, chronic) was scored on the subset of MRIs that were performed at or before 8 days of age. RESULTS Of 142 infants with mild HIE, 87 (61%) had injury on MRI at median age 5 (IQR 4-6) days. Watershed (23%), deep gray (20%) and punctate white matter (18%) injury were most common. Among the 125 (88%) infants who received a brain MRI at ≤8 days, mild (44%) injury was more common than moderate (11%) or severe (4%) injury. Subacute (37%) lesions were more commonly observed than acute (32%) or chronic lesions (1%). CONCLUSION Subacute brain injury is common in newborn infants with mild HIE. Novel neuroprotective treatments for mild HIE will ideally target both subacute and acute injury mechanisms. IMPACT Almost two-thirds of infants with mild HIE have evidence of brain injury on MRI obtained in the early neonatal period. Subacute brain injury was seen in 37% of infants with mild HIE. Neuroprotective treatments for mild HIE will ideally target both acute and subacute injury mechanisms.
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Affiliation(s)
- Yi Li
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA.
| | - Jessica L Wisnowski
- Department of Radiology and Pediatrics, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amit M Mathur
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Robert C McKinstry
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Genesis Licona
- Division of Neonatology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington School of Medicine & Health Sciences, Washington, DC, USA
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tai-Wei Wu
- Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kaashif A Ahmad
- Pediatrix Medical Group of San Antonio, San Antonio, TX, USA
| | - Marie-Coralie Cornet
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Rakesh Rao
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Aaron Scheffler
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Yvonne W Wu
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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36
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Bang SJ, Lee J, Jeon GW, Jun YH. Erythropoietin Reduces Death and Neurodevelopmental Impairment in Neonatal Hypoxic-Ischemic Encephalopathy. NEONATAL MEDICINE 2022. [DOI: 10.5385/nm.2022.29.4.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Purpose: Erythropoietin (EPO) is a promising neuroprotective drug. We investigated whether EPO has beneficial effects on neurodevelopmental outcomes in infants with hypoxic-ischemic encephalopathy (HIE).Methods: We retrospectively reviewed the data of 56 infants with HIE born at or after 35 weeks of gestation who were admitted to Inha University Hospital between 2012 and 2021. Patients were divided into two groups based on EPO use and compared. In the EPO group, patients were administered 1,000 U/kg of EPO on days 1, 2, 3, 5, and 7, starting within 24 hours after birth. The primary outcome was death or neurodevelopmental impairment (NDI) at the age of 12 months.Results: EPO was administered to 38 infants, and 18 did not receive EPO. Only 37.5% of patients with HIE (21/56) and 60% of patients with moderate-to-severe HIE (21/35) received therapeutic hypothermia. Among all patients with HIE, death or NDI (21.1 % vs. 50.0%; odds ratio [OR], 0.09; 95% confidence interval [CI], 0.01 to 0.78; P=0.029) and brain injury on imaging (42.1% vs. 83.3%; OR, 0.16; 95% CI, 0.03 to 0.92; P=0.040) were significantly lower in the EPO group than in the control group. Among patients with moderate-to-severe HIE, brain injury on imaging (54.2% vs. 90.9%; OR, 0.04; 95% CI, 0.002 to 0.700; P=0.027) was significantly lower in the EPO group than in the control group.Conclusion: EPO administration significantly reduced mortality and NDI in infants with HIE. EPO can be considered an adjunctive therapeutic agent for neonatal HIE.
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37
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Wu YW, Comstock BA, Gonzalez FF, Mayock DE, Goodman AM, Maitre NL, Chang T, Van Meurs KP, Lampland AL, Bendel-Stenzel E, Mathur AM, Wu TW, Riley D, Mietzsch U, Chalak L, Flibotte J, Weitkamp JH, Ahmad KA, Yanowitz TD, Baserga M, Poindexter BB, Rogers EE, Lowe JR, Kuban KCK, O'Shea TM, Wisnowski JL, McKinstry RC, Bluml S, Bonifacio S, Benninger KL, Rao R, Smyser CD, Sokol GM, Merhar S, Schreiber MD, Glass HC, Heagerty PJ, Juul SE. Trial of Erythropoietin for Hypoxic-Ischemic Encephalopathy in Newborns. N Engl J Med 2022; 387:148-159. [PMID: 35830641 PMCID: PMC10542745 DOI: 10.1056/nejmoa2119660] [Citation(s) in RCA: 80] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Neonatal hypoxic-ischemic encephalopathy is an important cause of death as well as long-term disability in survivors. Erythropoietin has been hypothesized to have neuroprotective effects in infants with hypoxic-ischemic encephalopathy, but its effects on neurodevelopmental outcomes when given in conjunction with therapeutic hypothermia are unknown. METHODS In a multicenter, double-blind, randomized, placebo-controlled trial, we assigned 501 infants born at 36 weeks or more of gestation with moderate or severe hypoxic-ischemic encephalopathy to receive erythropoietin or placebo, in conjunction with standard therapeutic hypothermia. Erythropoietin (1000 U per kilogram of body weight) or saline placebo was administered intravenously within 26 hours after birth, as well as at 2, 3, 4, and 7 days of age. The primary outcome was death or neurodevelopmental impairment at 22 to 36 months of age. Neurodevelopmental impairment was defined as cerebral palsy, a Gross Motor Function Classification System level of at least 1 (on a scale of 0 [normal] to 5 [most impaired]), or a cognitive score of less than 90 (which corresponds to 0.67 SD below the mean, with higher scores indicating better performance) on the Bayley Scales of Infant and Toddler Development, third edition. RESULTS Of 500 infants in the modified intention-to-treat analysis, 257 received erythropoietin and 243 received placebo. The incidence of death or neurodevelopmental impairment was 52.5% in the erythropoietin group and 49.5% in the placebo group (relative risk, 1.03; 95% confidence interval [CI], 0.86 to 1.24; P = 0.74). The mean number of serious adverse events per child was higher in the erythropoietin group than in the placebo group (0.86 vs. 0.67; relative risk, 1.26; 95% CI, 1.01 to 1.57). CONCLUSIONS The administration of erythropoietin to newborns undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy did not result in a lower risk of death or neurodevelopmental impairment than placebo and was associated with a higher rate of serious adverse events. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT02811263.).
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Affiliation(s)
- Yvonne W Wu
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Bryan A Comstock
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Fernando F Gonzalez
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Dennis E Mayock
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Amy M Goodman
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Nathalie L Maitre
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Taeun Chang
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Krisa P Van Meurs
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Andrea L Lampland
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Ellen Bendel-Stenzel
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Amit M Mathur
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Tai-Wei Wu
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - David Riley
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Ulrike Mietzsch
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Lina Chalak
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - John Flibotte
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Joern-Hendrik Weitkamp
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Kaashif A Ahmad
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Toby D Yanowitz
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Mariana Baserga
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Brenda B Poindexter
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Elizabeth E Rogers
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Jean R Lowe
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Karl C K Kuban
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - T Michael O'Shea
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Jessica L Wisnowski
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Robert C McKinstry
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Stefan Bluml
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Sonia Bonifacio
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Kristen L Benninger
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Rakesh Rao
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Christopher D Smyser
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Gregory M Sokol
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Stephanie Merhar
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Michael D Schreiber
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Hannah C Glass
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Patrick J Heagerty
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
| | - Sandra E Juul
- From the Departments of Neurology (Y.W.W., A.M.G., H.C.G.), Pediatrics (Y.W.W., F.F.G., E.E.R., H.C.G.), and Epidemiology (H.C.G.), University of California, San Francisco, San Francisco, the Department of Pediatrics, Stanford University School of Medicine, Stanford (K.P.V.M., S. Bonifacio), and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), Children's Hospital Los Angeles, and the Departments of Pediatrics (T.-W.W., J.L.W.) and Radiology (J.L.W., S. Bluml), University of Southern California Keck School of Medicine, Los Angeles - all in California; the Department of Biostatistics, University of Washington (B.A.C., P.J.H.), and the Department of Pediatrics, University of Washington School of Medicine (D.E.M., U.M., S.E.J.) - both in Seattle; the Department of Pediatrics, Children's Healthcare of Atlanta (N.L.M.), and the Department of Pediatrics, Emory University (N.L.M., B.B.P.) - both in Atlanta; the Division of Neurology, Children's National Hospital, and the Department of Neurology, George Washington School of Medicine and Health Sciences - both in Washington, D.C. (T.C.); the Department of Neonatology, Children's Minnesota, St. Paul (A.L.L.), and the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester (E.B.-S.) - both in Minnesota; the Department of Pediatrics, Saint Louis University School of Medicine (A.M.M.), and the Departments of Radiology (R.C.M., C.D.S.), Pediatrics (R.R., C.D.S.), and Neurology (C.D.S.), Washington University in St. Louis School of Medicine - both in St. Louis; the Department of Pediatrics, Cook Children's Medical Center, the Department of Pediatrics, Texas Christian University, and the Department of Pediatrics, University of North Texas Health Science Center, Ft. Worth (D.R.), the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (L.C.), and Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, and Methodist Children's Hospital, San Antonio (K.A.A.) - all in Texas; the Department of Pediatrics, Indiana University School of Medicine, Indianapolis (U.M., G.M.S.); the Department of Pediatrics, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.F.), and the Department of Pediatrics, University of Pittsburgh School of Medicine, the Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, and the Department of Pediatrics, UPMC Magee-Womens Hospital, Pittsburgh (T.D.Y.) - all in Pennsylvania; the Department of Pediatrics, Vanderbilt University Medical Center, Nashville (J.-H.W.); the Department of Pediatrics, University of Utah, Salt Lake City (M.B.); the Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque (J.R.L.); the Department of Pediatrics, Boston University Medical Center, Boston (K.C.K.K.); the Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (T.M.O.); the Department of Pediatrics, Nationwide Children's Hospital, Columbus (K.L.B.), and the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (S.M.) - all in Ohio; and the Department of Pediatrics, University of Chicago, Chicago (M.D.S.)
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Reynolds AJ, Murray ML, Geary MP, Ater SB, Hayes BC. Uterine activity in labour and the risk of neonatal encephalopathy: a case control study. Eur J Obstet Gynecol Reprod Biol 2022; 274:73-79. [PMID: 35605517 DOI: 10.1016/j.ejogrb.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/13/2022] [Accepted: 05/12/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the relationship between intrapartum contraction frequency, rest interval duration, and cervical dilation speed and the risk of neonatal hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN This was a retrospective case-control study conducted in a maternity hospital in Dublin, Ireland. Babies born without major congenital anomalies between September 2006 and November 2017 at ≥ 35 + 0 weeks' gestational age were eligible. Cases were diagnosed with moderate-severe HIE. The controls were the first eligible baby born before and after each case with normal Apgar scores and not admitted to the neonatal unit. Intrapartum uterine activity was assessed by automated analysis of external tocography recordings. Cervical dilation was assessed by linear interpolation between vaginal examination measurements. The speed of cervical dilation was expressed as the times from 4 to 6 cm, >6 cm to the start of pushing, and from pushing to delivery. RESULTS Intrapartum tocographs results were available in 49 of 88 cases and 121 of 176 controls. The median contraction rate in cases was 7.7 (Interquartile range [IQR]: 6.6-9.0) compared to 7.0 in controls (IQR: 6.2-7.9) (p = 0.021). The median rest interval duration was 56 s (IQR: 38-76) in cases and 62 s (IQR: 50-79) in controls (p = 0.058). Cases took longer to progress from > 6 cm to the start of pushing (cases: 02:58 [01:14-04:49], controls: 01:48 [00:51-03:34], p = 0.020) and from pushing to delivery (cases: 00:34 [00:24-01:10], controls: 00:27 [00:13-00:56], p = 0.036). CONCLUSIONS Higher contraction frequencies and slower progress towards the end of labour are both independently associated with the risk of moderate-severe HIE. Inter-contraction rest interval duration as measured by external tocography does not provide additional accuracy.
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Affiliation(s)
| | | | - Michael P Geary
- Department of Obstetrics and Gynecology, Rotunda Hospital, Dublin, Ireland
| | | | - Breda C Hayes
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland
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Landucci E, Pellegrini-Giampietro DE, Facchinetti F. Experimental Models for Testing the Efficacy of Pharmacological Treatments for Neonatal Hypoxic-Ischemic Encephalopathy. Biomedicines 2022; 10:937. [PMID: 35625674 PMCID: PMC9138693 DOI: 10.3390/biomedicines10050937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 02/04/2023] Open
Abstract
Representing an important cause of long-term disability, term neonatal hypoxic-ischemic encephalopathy (HIE) urgently needs further research aimed at repurposing existing drug as well as developing new therapeutics. Since various experimental in vitro and in vivo models of HIE have been developed with distinct characteristics, it becomes important to select the appropriate preclinical screening cascade for testing the efficacy of novel pharmacological treatments. As therapeutic hypothermia is already a routine therapy for neonatal encephalopathy, it is essential that hypothermia be administered to the experimental model selected to allow translational testing of novel or repurposed drugs on top of the standard of care. Moreover, a translational approach requires that therapeutic interventions must be initiated after the induction of the insult, and the time window for intervention should be evaluated to translate to real world clinical practice. Hippocampal organotypic slice cultures, in particular, are an invaluable intermediate between simpler cell lines and in vivo models, as they largely maintain structural complexity of the original tissue and can be subjected to transient oxygen-glucose deprivation (OGD) and subsequent reoxygenation to simulate ischemic neuronal injury and reperfusion. Progressing to in vivo models, generally, rodent (mouse and rat) models could offer more flexibility and be more cost-effective for testing the efficacy of pharmacological agents with a dose-response approach. Large animal models, including piglets, sheep, and non-human primates, may be utilized as a third step for more focused and accurate translational studies, including also pharmacokinetic and safety pharmacology assessments. Thus, a preclinical proof of concept of efficacy of an emerging pharmacological treatment should be obtained firstly in vitro, including organotypic models, and, subsequently, in at least two different animal models, also in combination with hypothermia, before initiating clinical trials.
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Affiliation(s)
- Elisa Landucci
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Florence, 50139 Florence, Italy;
| | | | - Fabrizio Facchinetti
- Department of Experimental Pharmacology and Translational Science, Corporate Pre-Clinical R&D, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy;
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Victor S, Rocha-Ferreira E, Rahim A, Hagberg H, Edwards D. New possibilities for neuroprotection in neonatal hypoxic-ischemic encephalopathy. Eur J Pediatr 2022; 181:875-887. [PMID: 34820702 PMCID: PMC8897336 DOI: 10.1007/s00431-021-04320-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 12/26/2022]
Abstract
Around 0.75 million babies worldwide suffer from moderate or severe hypoxic-ischemic encephalopathy (HIE) each year resulting in around 400,000 babies with neurodevelopmental impairment. In 2010, neonatal HIE was associated with 2.4% of the total Global Burden of Disease. Therapeutic hypothermia (TH), a treatment that is now standard of care in high-income countries, provides proof of concept that strategies that aim to improve neurodevelopment are not only possible but can also be implemented to clinical practice. While TH is beneficial, neonates with moderate or severe HIE treated with TH still experience devastating complications: 48% (range: 44-53) combined death or moderate/severe disability. There is a concern that TH may not be effective in low- and middle-income countries. Therapies that further improve outcomes are desperately needed, and in high-income countries, they must be tested in conjunction with TH. We have in this review focussed on pharmacological treatment options (e.g. erythropoietin, allopurinol, melatonin, cannabidiol, exendin-4/exenatide). Erythropoietin and allopurinol show promise and are progressing towards the clinic with ongoing definitive phase 3 randomised placebo-controlled trials. However, there remain global challenges for the next decade. Conclusion: There is a need for more optimal animal models, greater industry support/sponsorship, increased use of juvenile toxicology, dose-ranging studies with pharmacokinetic-pharmacodynamic modelling, and well-designed clinical trials to avoid exposure to harmful medications or abandoning putative treatments. What is Known: • Therapeutic hypothermia is beneficial in neonatal hypoxic-ischemic encephalopathy. • Neonates with moderate or severe hypoxic-ischemic encephalopathy treated with therapeutic hypothermia still experience severe sequelae. What is New: • Erythropoietin, allopurinol, melatonin, cannabidiol, and exendin-4/exenatide show promise in conjunction with therapeutic hypothermia. • There is a need for more optimal animal models, greater industry support/sponsorship, increased use of juvenile toxicology, dose-ranging studies with pharmacokinetic-pharmacodynamic modelling, and well-designed clinical trials.
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Affiliation(s)
- Suresh Victor
- Centre for the Developing Brain, Department of Perinatal Imaging and Health, School of Biomedical Engineering and Imaging Sciences, King’s College London, 1st Floor, South Wing, St Thomas’ Hospital, Westmister Bridge Road, London, UK
| | - Eridan Rocha-Ferreira
- Centre for Perinatal Medicine and Health, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ahad Rahim
- UCL School of Pharmacy, University College London, London, UK
| | - Henrik Hagberg
- Centre for Perinatal Medicine and Health, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - David Edwards
- Centre for the Developing Brain, Department of Perinatal Imaging and Health, School of Biomedical Engineering and Imaging Sciences, King’s College London, 1st Floor, South Wing, St Thomas’ Hospital, Westmister Bridge Road, London, UK
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Song Y, Lally PJ, Yanez Lopez M, Oeltzschner G, Nebel MB, Gagoski B, Kecskemeti S, Hui SCN, Zöllner HJ, Shukla D, Arichi T, De Vita E, Yedavalli V, Thayyil S, Fallin D, Dean DC, Grant PE, Wisnowski JL, Edden RAE. Edited magnetic resonance spectroscopy in the neonatal brain. Neuroradiology 2022; 64:217-232. [PMID: 34654960 PMCID: PMC8887832 DOI: 10.1007/s00234-021-02821-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022]
Abstract
J-difference-edited spectroscopy is a valuable approach for the detection of low-concentration metabolites with magnetic resonance spectroscopy (MRS). Currently, few edited MRS studies are performed in neonates due to suboptimal signal-to-noise ratio, relatively long acquisition times, and vulnerability to motion artifacts. Nonetheless, the technique presents an exciting opportunity in pediatric imaging research to study rapid maturational changes of neurotransmitter systems and other metabolic systems in early postnatal life. Studying these metabolic processes is vital to understanding the widespread and rapid structural and functional changes that occur in the first years of life. The overarching goal of this review is to provide an introduction to edited MRS for neonates, including the current state-of-the-art in editing methods and editable metabolites, as well as to review the current literature applying edited MRS to the neonatal brain. Existing challenges and future opportunities, including the lack of age-specific reference data, are also discussed.
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Affiliation(s)
- Yulu Song
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Peter J Lally
- Department of Brain Sciences, Imperial College London, London, UK
| | - Maria Yanez Lopez
- Center for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Georg Oeltzschner
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Mary Beth Nebel
- Center for Neurodevelopmental and Imaging Research, Kennedy Krieger Institute, Baltimore, MD, 21205, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Borjan Gagoski
- Department of Radiology, Division of Neuroradiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Fetal Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA
| | | | - Steve C N Hui
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Helge J Zöllner
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Deepika Shukla
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Tomoki Arichi
- Center for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Department of Bioengineering, Imperial College London, South Kensington Campus, London, UK
| | - Enrico De Vita
- Center for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, St Thomas's Hospital, Westminster Bridge Road, Lambeth Wing, 3rd Floor, London, SE1 7EH, UK
| | - Vivek Yedavalli
- Division of Neuroradiology, Park 367G, The Johns Hopkins University School of Medicine, 600 N. Wolfe St. B-112 D, Baltimore, MD, 21287, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Daniele Fallin
- Wendy Klag Center for Autism and Developmental Disabilities, Johns Hopkins University, Baltimore, USA.,Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Douglas C Dean
- Waisman Center, University of WI-Madison, Madison, WI, 53705, USA.,Department of Pediatrics, Division of Neonatology and Newborn Nursery, University of WI-Madison, School of Medicine and Public Health, Madison, WI, 53705, USA.,Department of Medical Physics, University of WI-Madison, School of Medicine and Public Health, Madison, WI, 53705, USA
| | - P Ellen Grant
- Department of Radiology, Division of Neuroradiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Fetal Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA.,Department of Medicine, Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jessica L Wisnowski
- Children's Hospital Los Angeles, Los Angeles, CA, 90027, USA.,Department of Radiology and Fetal and Neonatal Institute, CHLA Division of Neonatology, Department of Pediatrics, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, 90033, USA
| | - Richard A E Edden
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA. .,Division of Neuroradiology, Park 367G, The Johns Hopkins University School of Medicine, 600 N. Wolfe St. B-112 D, Baltimore, MD, 21287, USA.
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Wyckoff MH, Sawyer T, Lakshminrusimha S, Collins A, Ohls RK, Leone TA. Resuscitation 2020: Proceedings From the NeoHeart 2020 International Conference. World J Pediatr Congenit Heart Surg 2021; 13:77-88. [PMID: 34919486 DOI: 10.1177/21501351211038835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Resuscitation guidelines are developed and revised by medical societies throughout the world. These guidelines are increasingly based on evidence from preclinical and clinical research. The International Liaison Committee on Resuscitation reviews evidence for each resuscitation practice and provides summary consensus statements that inform resuscitation guideline committees. A similar process is used for different populations including neonatal, pediatric, and adult resuscitation. The NeoHeart 2020 Conference brought together experts in resuscitation to discuss recent evidence and guidelines for resuscitation practices. This review summarizes the main focus of discussion from this symposium.
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Affiliation(s)
| | - Taylor Sawyer
- 12353University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | | | - Amélie Collins
- 12294Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Robin K Ohls
- 266111University of Utah, Salt Lake City, UT, USA
| | - Tina A Leone
- 12294Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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43
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Ottolenghi S, Milano G, Cas MD, Findley TO, Paroni R, Corno AF. Can Erythropoietin Reduce Hypoxemic Neurological Damages in Neonates With Congenital Heart Defects? Front Pharmacol 2021; 12:770590. [PMID: 34912224 PMCID: PMC8666450 DOI: 10.3389/fphar.2021.770590] [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: 09/04/2021] [Accepted: 11/11/2021] [Indexed: 11/21/2022] Open
Abstract
Congenital heart defects (CHD), the most common cause of birth defects with increasing birth prevalence, affect nearly 1% of live births worldwide. Cyanotic CHD are characterized by hypoxemia, with subsequent reduced oxygen delivery to the brain, especially critical during brain development, beginning in the fetus and continuing through the neonatal period. Therefore, neonates with CHD carry a high risk for neurological comorbidities, even more frequently when there are associated underlying genetic disorders. We review the currently available knowledge on potential prevention strategies to reduce brain damage induced by hypoxemia during fetal development and immediately after birth, and the role of erythropoietin (EPO) as a potential adjunctive treatment. Maternal hyper-oxygenation had been studied as a potential therapeutic to improve fetal oxygenation. Despite demonstrating some effectiveness, maternal hyper-oxygenation has proven to be impractical for extensive clinical application, thus prompting the investigation of specific pathways for pharmacological intervention. Among those, the role of antioxidant pathways and Hypoxia Inducible Factors (HIF) have been studied for their involvement in the protective response to hypoxic injury. One of the proteins induced by HIF, EPO, has properties of being anti-apoptotic, antioxidant, and protective for neurons, astrocytes, and oligodendrocytes. In human trials, EPO administration in neonates with hypoxic ischemic encephalopathy (HIE) significantly reduced the neurological hypoxemic damages in several reported studies. Currently, it is unknown if the mechanisms of pathophysiology of cyanotic CHD are like HIE. Neonates with cyanotic CHD are exposed to both chronic hypoxemia and episodes of acute ischemia-reperfusion injury when undergo cardiopulmonary bypass surgery requiring aortic cross-clamp and general anesthesia. Our review supports future trials to evaluate the potential efficiency of EPO in reducing the hypoxemic neurologic damages in neonates with CHD. Furthermore, it suggests the need to identify early biomarkers of hypoxia-induced neurological damage, which must be sensitive to the neuroprotective effects of EPO.
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Affiliation(s)
- Sara Ottolenghi
- Department of Health Science, University of Milan, Milan, Italy.,Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Giuseppina Milano
- Department Cœur-Vaisseaux, Cardiac Surgery Center, University Hospital of Lausanne, Lausanne, Switzerland
| | - Michele Dei Cas
- Department of Health Science, University of Milan, Milan, Italy
| | - Tina O Findley
- Department of Pediatrics, Children's Heart Institute, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Rita Paroni
- Department of Health Science, University of Milan, Milan, Italy
| | - Antonio F Corno
- Department of Pediatrics, Children's Heart Institute, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
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44
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Weiss EM, Guttmann KF, Olszewski AE, Magnus BE, Li S, Kim SYH, Shah AR, Juul SE, Wu YW, Ahmad KA, Bendel-Stenzel E, Isaza NA, Lampland AL, Mathur AM, Rao R, Riley D, Russell DG, Salih ZNI, Torr CB, Weitkamp JH, Anani UE, Chang T, Dudley J, Flibotte J, Havrilla EM, O’Kane AC, Perez K, Stanley BJ, Shah SK, Wilfond BS. Parental Enrollment Decision-Making for a Neonatal Clinical Trial. J Pediatr 2021; 239:143-149.e3. [PMID: 34400207 PMCID: PMC8610170 DOI: 10.1016/j.jpeds.2021.08.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/28/2021] [Accepted: 08/09/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the parental experience of recruitment and assess differences between parents who participated and those who declined to enroll in a neonatal clinical trial. STUDY DESIGN This was a survey conducted at 12 US neonatal intensive care units of parents of infants who enrolled in the High-dose Erythropoietin for Asphyxia and encephaLopathy (HEAL) trial or who were eligible but declined enrollment. Questions assessed 6 factors of the parental experience of recruitment: (1) interactions with research staff; (2) the consent experience; (3) perceptions of the study; (4) decisional conflict; (5) reasons for/against participation; and (6) timing of making the enrollment decision. RESULTS In total, 269 of 387 eligible parents, including 183 of 242 (75.6%) of those who enrolled their children in HEAL and 86 of 145 (59.3%) parents who declined to enroll their children in HEAL, were included in analysis. Parents who declined to enroll more preferred to be approached by clinical team members rather than by research team members (72.9% vs 49.2%, P = .005). Enrolled parents more frequently reported positive initial impressions (54.9% vs 10.5%, P < .001). Many parents in both groups made their decision early in the recruitment process. Considerations of reasons for/against participation differed by enrollment status. CONCLUSIONS Understanding how parents experience recruitment, and how this differs by enrollment status, may help researchers improve recruitment processes for families and increase enrollment. The parental experience of recruitment varied by enrollment status. These findings can guide future work aiming to inform optimal recruitment strategies for neonatal clinical trials.
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Affiliation(s)
- Elliott Mark Weiss
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA.
| | - Katherine F Guttmann
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aleksandra E Olszewski
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Brooke E Magnus
- Department of Psychology and Neuroscience, Boston College, Chestnut Hill, Massachusetts
| | - Sijia Li
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Scott YH Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda Maryland
| | - Anita R Shah
- Division of Neonatology, Children’s Hospital of Orange County, Orange, California
| | - Sandra E Juul
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Yvonne W Wu
- Departments of Neurology and Pediatrics, University of California San Francisco School of Medicine, San Francisco, California
| | - Kaashif A Ahmad
- Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas
| | | | - Natalia A Isaza
- Division of Neonatology, Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Andrea L Lampland
- Department of Neonatology, Children’s Minnesota Hospital, Minneapolis, Minnesota
| | - Amit M Mathur
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Rakesh Rao
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - David Riley
- Department of Pediatrics, Cook Children’s Medical Center, Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, Texas
| | - David G Russell
- Division of Neonatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Zeynep N I Salih
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Carrie B Torr
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Uchenna E Anani
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Taeun Chang
- Department of Neurology, Children’s National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Juanita Dudley
- Division of Neonatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - John Flibotte
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Erin M Havrilla
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexandra C O’Kane
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Krystle Perez
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | | | - Seema K Shah
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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45
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Suh ES. Recent studies are focus on the new treatments for hypoxicischemic encephalopathy (HIE) and long-term outcomes in later childhood and adolescence in children with a history on HIE. Clin Exp Pediatr 2021; 64:628-629. [PMID: 34592801 PMCID: PMC8650818 DOI: 10.3345/cep.2021.00822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/29/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Eun Sook Suh
- Department of Pediatrics, Soonchunhyang University Seoul Hospital, Seoul, Korea
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46
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Lee BL, Glass HC. Cognitive outcomes in late childhood and adolescence of neonatal hypoxic-ischemic encephalopathy. Clin Exp Pediatr 2021; 64:608-618. [PMID: 34044480 PMCID: PMC8650814 DOI: 10.3345/cep.2021.00164] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/18/2021] [Indexed: 12/04/2022] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is the most common cause of neonatal encephalopathy with a global incidence of approximately 1 to 8 per 1,000 live births. Neonatal encephalopathy can cause neurodevelopmental and cognitive impairments in survivors of hypoxic-ischemic insults with and without functional motor deficits. Normal neurodevelopmental outcomes in early childhood do not preclude cognitive and behavioral difficulties in late childhood and adolescence because cognitive functions are not yet fully developed at this early age. Therapeutic hypothermia has been shown to significantly reduced death and severe disabilities in term newborns with HIE. However, children treated with hypothermia therapy remain at risk for cognitive impairments and follow-up is necessary throughout late childhood and adolescence. Novel adjunctive neuroprotective therapies combined with therapeutic hypothermia may enhance the survival and neurodevelopmental outcomes of infants with HIE. The extent and severity of brain injury on magnetic resonance imaging might predict neurodevelopmental outcomes and lead to targeted interven tions in children with a history of neonatal encephalopathy. We provide a summary of the long-term cognitive outcomes in late childhood and adolescence in children with a history of HIE and the association between pattern of brain injury and neurodevelopmental outcomes.
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Affiliation(s)
- Bo Lyun Lee
- Department of Pediatrics, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA.,Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
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47
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Jeong E, Osmundson S, Gao C, Edwards DRV, Malin B, Chen Y. Learning the impact of acute and chronic diseases on forecasting neonatal encephalopathy. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 211:106397. [PMID: 34530389 PMCID: PMC8551018 DOI: 10.1016/j.cmpb.2021.106397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/30/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE There is a wide range of risk factors predisposing to the onset of neonatal encephalopathy (NE), including maternal antepartum/intrapartum comorbidities or events. However, few studies have investigated the difference in the impact of acute and chronic diseases on forecasting NE, which could assist clinicians in choosing the best course of action to prevent NE or reduce its severity and complications. In this study, we aimed to engineer features based on acute and chronic diseases and assess the differences of the impact of acute and chronic diseases on NE prediction using machine learning models. MATERIALS AND METHODS We used ten years of electronic health records of mothers from a large academic medical center to develop three types of features: chronic disease, recurrence of an acute disease, and temporal relationships between acute diseases. Two types of NE prediction models, based on acute and chronic diseases, respectively, were trained with feature selection. We further compared the prediction performance of the models with two state-of-the-art NE forecasting models. The machine learning models ranked the three types of engineered features based on their contributions to the NE prediction. RESULTS The NE model trained on acute disease features showed significantly higher AUC than the model relying on chronic disease features (AUC difference: 0.161, p-value < 0.001). The NE model trained on both acute and chronic disease features achieved the highest average AUC (0.889), with a significant improvement over the best existing model (0.854) with p = 0.0129. Recurrence of "known or suspected fetal abnormality affecting management of mother (655)" was assigned the highest weights in predicting NE. CONCLUSIONS Machine learning models based on the three types of engineered features significantly improve NE prediction. Our results specifically suggest that acute disease-associated features play a more important role in predicting NE.
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Affiliation(s)
- Eugene Jeong
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sarah Osmundson
- Department of Obstetrics and Gynecology, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Cheng Gao
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Digna R Velez Edwards
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Obstetrics and Gynecology, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Bradley Malin
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, TN, United States; Department of Computer Science, School of Engineering, Vanderbilt University, Nashville, TN, United States
| | - You Chen
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Computer Science, School of Engineering, Vanderbilt University, Nashville, TN, United States.
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48
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Chalak L, Redline RW, Goodman AM, Juul SE, Chang T, Yanowitz TD, Maitre N, Mayock DE, Lampland AL, Bendel-Stenzel E, Riley D, Mathur AM, Rao R, Van Meurs KP, Wu TW, Gonzalez FF, Flibotte J, Mietzsch U, Sokol GM, Ahmad KA, Baserga M, Weitkamp JH, Poindexter BB, Comstock BA, Wu YW. Acute and Chronic Placental Abnormalities in a Multicenter Cohort of Newborn Infants with Hypoxic-Ischemic Encephalopathy. J Pediatr 2021; 237:190-196. [PMID: 34144032 DOI: 10.1016/j.jpeds.2021.06.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/28/2021] [Accepted: 06/14/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To examine the frequency of placental abnormalities in a multicenter cohort of newborn infants with hypoxic-ischemic encephalopathy (HIE) and to determine the association between acuity of placental abnormalities and clinical characteristics of HIE. STUDY DESIGN Infants born at ≥36 weeks of gestation (n = 500) with moderate or severe HIE were enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy Trial. A placental pathologist blinded to clinical information reviewed clinical pathology reports to determine the presence of acute and chronic placental abnormalities using a standard classification system. RESULTS Complete placental pathologic examination was available for 321 of 500 (64%) trial participants. Placental abnormalities were identified in 273 of 321 (85%) and were more common in infants ≥40 weeks of gestation (93% vs 81%, P = .01). A combination of acute and chronic placental abnormalities (43%) was more common than either acute (20%) or chronic (21%) abnormalities alone. Acute abnormalities included meconium staining of the placenta (41%) and histologic chorioamnionitis (39%). Chronic abnormalities included maternal vascular malperfusion (25%), villitis of unknown etiology (8%), and fetal vascular malperfusion (6%). Infants with chronic placental abnormalities exhibited a greater mean base deficit at birth (-15.9 vs -14.3, P = .049) than those without such abnormalities. Patients with HIE and acute placental lesions had older mean gestational ages (39.1 vs 38.0, P < .001) and greater rates of clinically diagnosed chorioamnionitis (25% vs 2%, P < .001) than those without acute abnormalities. CONCLUSIONS Combined acute and chronic placental abnormalities were common in this cohort of infants with HIE, underscoring the complex causal pathways of HIE. TRIAL REGISTRATION ClinicalTrials.gov: NCT02811263.
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Affiliation(s)
- Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Raymond W Redline
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Amy M Goodman
- Department of Neurology, University of California San Francisco, San Francisco, CA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington School of Medicine, Washington, DC
| | - Toby D Yanowitz
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC and Magee Womens Hospital of UPMC, Pittsburgh, PA
| | - Nathalie Maitre
- Department of Pediatrics and Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | | | - Ellen Bendel-Stenzel
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - David Riley
- Department of Pediatrics, Cook Children's Medical Center, Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, TX
| | - Amit M Mathur
- Department of Pediatrics/Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St Louis, MO
| | - Rakesh Rao
- Division of Newborn-Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, MO
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Tai-Wei Wu
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Fernando F Gonzalez
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Gregory M Sokol
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Brenda B Poindexter
- Division of Neonatology, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, CA
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49
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Wisnowski JL, Wintermark P, Bonifacio SL, Smyser CD, Barkovich AJ, Edwards AD, de Vries LS, Inder TE, Chau V. Neuroimaging in the term newborn with neonatal encephalopathy. Semin Fetal Neonatal Med 2021; 26:101304. [PMID: 34736808 PMCID: PMC9135955 DOI: 10.1016/j.siny.2021.101304] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neuroimaging is widely used to aid in the diagnosis and clinical management of neonates with neonatal encephalopathy (NE). Yet, despite widespread use clinically, there are few published guidelines on neuroimaging for neonates with NE. This review outlines the primary patterns of brain injury associated with hypoxic-ischemic injury in neonates with NE and their frequency, associated neuropathological features, and risk factors. In addition, it provides an overview of neuroimaging methods, including the most widely used scoring systems used to characterize brain injury in these neonates and their utility as predictive biomarkers. Last, recommendations for neuroimaging in neonates with NE are presented.
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Affiliation(s)
- Jessica L. Wisnowski
- Departments of Radiology and Pediatrics (Neonatology), Children’s Hospital Los Angeles, 4650 Sunset Blvd. MS #81, Los Angeles CA 90027, USA
| | - Pia Wintermark
- Department of Pediatrics (Neonatology), McGill University/Montreal Children's Hospital, Division of Newborn Medicine, Research Institute of the McGill University Health Centre, 1001 boul. Décarie, Site Glen Block E, EM0.3244, Montréal, QC H4A 3J1, Canada.
| | - Sonia L. Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics (Neonatology), Lucile Packard Children’s Hospital, Stanford University School of Medicine, 750 Welch Road, Suite 315, Palo Alto, CA 94304, USA
| | - Christopher D. Smyser
- Departments of Neurology, Radiology, and Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8111, St Louis, MO 63110-1093, USA
| | - A. James Barkovich
- Department of Radiology, UCSF Benioff Children’s Hospital, University of California San Francisco, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA
| | - A. David Edwards
- Evelina London Children’s Hospital, Centre for Developing Brain, King’s College London, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Linda S. de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Lundlaan 6, 3584 EA, Utrecht, the Netherlands
| | - Terrie E. Inder
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Vann Chau
- Department of Pediatrics (Neurology), The Hospital for Sick Children, University of Toronto, 555 University Avenue, Room 6513, Toronto, ON M5G 1X8, Canada.
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50
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Isweisi E, Moore CM, Hurley T, Sola-Visner M, McCallion N, Ainle FN, Zareen Z, Sweetman DU, Curley AE, Molloy EJ. Haematological issues in neonates with neonatal encephalopathy treated with hypothermia. Semin Fetal Neonatal Med 2021; 26:101270. [PMID: 34330681 DOI: 10.1016/j.siny.2021.101270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Neonatal encephalopathy (NE) is associated with abnormality of neurological function and involves multiorgan dysfunction. There are long-term complications such as cerebral palsy and developmental delay. Cardiac, renal, neurological and other organ dysfunctions are well described. Haematological dysfunction is relatively common and includes anaemia, thrombocytopenia, monocyte and neutrophil activation, hypofibrinogenemia and coagulopathy. There is a lack of consensus definitions of hematological parameters and optimal levels for intervention due to the lack of interventional studies in term neonates and the lack of knowledge of the optimal values during therapeutic hypothermia. However, derangements in hematological values are also associated with neurodevelopmental outcomes. This article outlines the different hematological complications associated with NE and therapeutic hypothermia and suggests a framework for management.
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Affiliation(s)
- Eman Isweisi
- Paediatrics, Trinity College, The University of Dublin, Ireland; Trinity Translational Medicine Institute (TTMI), Trinity College Dublin & Trinity Research in Childhood Centre (TRiCC), Ireland.
| | - Carmel Maria Moore
- Department of Neonatology, National Maternity Hospital, Holles Street, Dublin 2, Dublin, Ireland
| | - Tim Hurley
- Paediatrics, Trinity College, The University of Dublin, Ireland; Trinity Translational Medicine Institute (TTMI), Trinity College Dublin & Trinity Research in Childhood Centre (TRiCC), Ireland.
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Naomi McCallion
- Department of Paediatrics, Rotunda Hospital & Department of Paediatrics, Royal College of Surgeons in Ireland, Ireland.
| | - Fionnuala Ni Ainle
- Departments of Haematology, Mater Misericordiae University Hospitals, Dublin & University College Dublin School of Medicine, Dublin, Ireland.
| | - Zunera Zareen
- Paediatrics, Trinity College, The University of Dublin, Ireland; Trinity Translational Medicine Institute (TTMI), Trinity College Dublin & Trinity Research in Childhood Centre (TRiCC), Ireland; Departments of Haematology, Mater Misericordiae University Hospitals, Dublin & University College Dublin School of Medicine, Dublin, Ireland; Paediatrics, St Michaels House, Dublin, Ireland.
| | - Deirdre U Sweetman
- Department of Neonatology, National Maternity Hospital, Holles Street, Dublin 2, Dublin, Ireland.
| | - Anna E Curley
- Department of Neonatology, National Maternity Hospital, Holles Street, Dublin 2, Dublin, Ireland.
| | - Eleanor J Molloy
- Paediatrics, Trinity College, The University of Dublin, Ireland; Trinity Translational Medicine Institute (TTMI), Trinity College Dublin & Trinity Research in Childhood Centre (TRiCC), Ireland; Neonatology, Children's Health Ireland (CHI) at Crumlin & Tallaght, Dublin, Ireland; Neonatology, Coombe Women and Infants University Hospital Dublin, Ireland.
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