Rajiv Gandhi University of Health Sciences Bengaluru, Karnataka

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BENGALURU, KARNATAKA

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

6.0) BRIEF RESUME OF THE INTENDED WORK:

6.1) NEED FOR STUDY:

Hypoxic ischemic encephalopathy (HIE) following perinatal asphyxia is an important cause of neurodevelopmental impairment in infants. Approximately 15- 20% of asphyxiated newborns with HIE die during the newborn period and 25% of the survivors exhibit permanent deficits such as mental retardation, cerebral palsy, seizures and learning disabilities.1 Given these incidence figures, paediatricians have long sought effective strategies to prevent and minimize the consequences of HIE.

The brain injury caused by hypoxic ischemic insult is an evolving process that begins with the initial insult and extends into a recovery period that begins less than 6hrs and extends up to 48hrs after resuscitation. This second period is referred as the “reperfusion phase” of injury. It is this that is potentially amenable to a variety of interventions.

Evidence suggests that this therapeutic window from 6-48hrs after a cerebral hypoxic- ischemic insult has lead to the development of novel pharmaceutical products that potentially have neuroprotective properties. Such as: free radical scavengers, glutamate receptor blockers, anti-apoptotic and anti-inflammatory agents, and growth factors.2 But none of these interventions has yet proven to limit the brain damage in newborns with HIE.

The current treatment for HIE is predominantly supportive, to maintain physiologic parameters. Multicenter trials have demonstrated that hypothermia improved outcomes for term neonates with moderate HIE if the infants underwent cooling within 6 hours.3

There is a need for effective treatment that can be implemented even 6 hours after the injurious event.

MECHANISM OF ACTION OF ERYTHROPOIETIN (EPO): The various mechanisms by which erythropoietin works is:

1.  In HIE there will be up regulation of nitric oxide (NO) synthase leading to accumulation of NO, which releases free radicals such as excitatory amino acids (glutamate) ultimately leading to neuronal apoptosis. Studies demonstrated EPO decreased the NO levels.5

2.  EPO activates phosphatidyl inositol 3 kinase (PI3-K) further activates Akt(serine threonine kinase) leading to up regulation of X linked inhibitor of apoptosis protein (XIAP) and BCL2 which inhibits caspase activity thus counteracting neuronal apoptosis.

3.  EPO receptors are expressed in embryonal germinal zone during neurogenesis as well in adult subventricular zone (SVZ). Studies have shown this SVZ contain neuronal precursor cells. After HIE, this area increased in size due to proliferation of neuronal cells brought by EPO.

6.2) REVIEW OF LITERATURE:

Zhu C, Kang W, Xu F et al did a study on term newborns using rHu Erythropoietin at 300 U/kg (n=52) or 500 U/kg (n=31), on alternate days for 2 weeks, starting <48 hours after birth. Neurodevelopmental outcomes were assessed at 18 months of age. Study concluded that repeated, low-dose; rHu erythropoietin treatment reduced the risk of disability for infants with moderate HIE, without apparent side effects.

In a study conducted by Elmahdy H, Rahman A, Mashad E et al using 45 neonates into 3

groups, normal healthy group(n=15), HIE EPO group (n = 15; infants with mild/moderate HIE received rHu erythropoietin, 2500 IU/kg, subcutaneously, daily for 5 days), and a HIE-control group (n=15; did not receive erythropoietin). At 2 weeks of age EEG findings improved significantly (p=0.1) and NO concentrations decreased (p=0.01) in the HIE-erythropoietin group compared to HIE-control group. At 6 months, HIE-EPO group had few neurologic(p=.03) and developmental(p=.03) abnormalities.

Maier RF, Obladen M, Scigalla P et al demonstrated the safety and efficacy of recombinant human erythropoietin in the prevention and treatment of anaemia of prematurity.6 This study concluded showing infants with very low birth weights needed less transfusions if given EPO during the first 6 weeks of life (250IU/kg 3times a week).

6.3) AIMS AND OBJECTIVES OF STUDY

Aim is to assess the usefulness of erythropoietin in a group of newborns with HIE.

OBJECTIVE:

- To assess neurological outcomes at the time of discharge and at 3 months of age.

7.0) MATERIALS AND METHODS:

7.1) SOURCE OF DATA:

·  Place of study- MSR HOSPITALS (NICU)

·  Study period – Nov 2010 to April 2012

·  Type of study – Randomised control trial,

INCLUSION CRITERIA:

Essential criteria: Term newborns with the evidence of moderate HIE within 48 hours of age of birth.

Along with 2 or more of the following:

•  History of fetal distress (late decelerations, decreased heart rate variability, or bradycardia (100 beats/minute);

•  5-minute Apgar score of less than 7 ;

•  Base deficit = or 12 mEq/L in cord blood or admission arterial blood sample;

•  Requirement of immediate ventilation with mask or tracheal tube after delivery.

EXCLUSION CRITERIA:

•  Twin gestation

•  Congenital malformations of CNS

•  Chromosomal abnormalities

•  Chorioamnionitis (or) congenital infections

•  Preterm, IUGR

•  Postnatal age of >48 hours.

7.2) METHODS OF COLLECTION OF DATA:

METHOD:

Written informed consent will be obtained from the parents for all patients assigned to either group. Maternal and delivery history would be reviewed thoroughly for all subjects; gestational age will be assessed by Ballard’s score. Patients will be undergoing full neurological assessment at enrolment.The severity of HIE will be graded according to staging described by Sarnat and Sarnat. And only HIE stage 2(moderate HIE) would be chosen for the study. The subjects will be randomised using block randomisation technique into study and control groups.

Study group (N=18) will receive rHu EPO, 500 U/kg/dose daily for 5 days, intravenously starting <48 hours after birth.

Neonates in control group (N=18) will only receive standard post resuscitation care,

The study will be conducted at NICU, MSR hospital during the period from Nov 2010 to April 2012 and is to be approved by the ethical committee, M.S.Ramaiah Medical College and hospital.

Sample Size: The sample size has been estimated in consultation with the biostatistician. The sample size chosen is 18. This is based on 10% alpha error and 90% power.

OUTCOME MEASURES:

Primary outcome:

a) Neurological assessment by Amiel Tison method at discharge and 3 months of age.

b) Changes in EEG at day 7 or at discharge (whichever is earlier).

Secondary outcome:

a) Need for > one anticonvulsant to control the seizures.

b) Duration of HIE STAGE 2.

c) Oral feedings (sucking) at day 7.

Statistical Analysis: Descriptive statistics comprising of mean (SD) and percentage shall be used to summarize the data. Independent t-test shall be used to compare the statistical difference in mean Ameil tison neurological score between the two groups. Level of significance shall be fixed at 90% (alpha error = 10%).

7.5) Does the study require any investigation or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.

YES. Study group (N=18) will receive rHu EPO, 500 U/kg daily for 5days, starting <48 hours after birth.

7.6) Has ethical clearance been obtained from your institution in case of 7.6-.

8.0) LIST OF REFERENCES:

1. Itoo BA, Al-Hawsawi ZM, Khan AH. HIE. Incidence and risk factors in

North Western Saudi Arabia.2003. Saudi Medical Journal;24(2): 147–53

2. Sherman MP. Interventions for perinatal hypoxic-ischemic encephalopathy.1998.

Pediatrics;102(3) Pt 1: 662

3. Gluckman PD, Wyatt JS, Azzopardi D, Ballard R,Edwads AD et al. Selective head cooling

with mild systemic hypothermia after neonatal encephalopathy: multicentre RCT.

2005 Lancet;365(9460): 663–70

4. Changlian Zhu, Wenqing Kang, Falin Xu, Xiuyong Cheng, Zhan Zhang et al. Erythropoietin

improved Neurologic Outcomes in Newborns With HIE .2009. DOI: 10.1542/peds.2008-

3553; 124;e218-e226; originally published online Jul 27, 2009; Pediatrics

5. Siren AL, Fratelli M, Brines M, Geomans C, Casagrande, et al. Erythropoietin prevents

neuronal apoptosis after cerebral ischemia and metabolic stress. 2001, Proc Natl Acad Sci

U S A;98: 4044-9

6. Maier RF, Obladen M, Scigalla P , Linderkamp O, Duc G, et al. The effect of epoetin

(recombinant human erythropoietin)on the need for transfusion in very-low-birth-weight

infants.1994. N Engl JMed;330(17): 1173–8

7. Chang YS, Mu D, Wendland M, Michael, Sheldon,et al. Erythropoietin improves

functional and histological outcome in neonatal stroke.2005.Pediat Res;58(1): 106-11

8. Amiel-Tison C, Ellison P. Birth asphyxia in the full-term newborn: early assessment and

outcome.1986. Dev Med Child Neurol; 28(5):671–82