Ignite Creation Date:
2024-10-26 @ 3:38 PM
Last Modification Date:
2024-10-26 @ 3:38 PM
Study NCT ID:
NCT06559670
Status:
NOT_YET_RECRUITING
Last Update Posted:
None
First Post:
2024-08-02
Brief Title:
Prevention of Chronic Lung Disease CLD - Prevention Study
Sponsor:
None
Organization:
None
Study Overview
Official Title:
Prevention of Chronic Lung Disease New High Risk Profile for Early Detection and Management Starting From Perinatal Life CLD - Prevention Study
Status:
NOT_YET_RECRUITING
Status Verified Date:
2024-08
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
No
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
None
Brief Summary:
Primary endpoint
- prospectively identify potential biomarkers able to predict the severe course of pulmonary funcion in the first 12 months of life and realize a new profile to early identify hugh risk newborns
Secondary endpoints
detect genetic variance causation model by MiSeq Illumina platform correlating with severe pulmonary dysfunction and asthma development
detect MIcroRNAs as well as anti- and pro-inflammatory cytokine variations MIP-1α MCP-1 IL-8 TNF-α IFN-ɣ IL-10 correlating with the severity of pulmonary dysfunction in the first 12 months of life and the risk of asthma development
Population preterm infants with gestational age 32 weeks who have suffered from acute respiratory insufficiency at birth
Intervention
Assessment of prenatal risk factors
Collection of the following biological specimens 1 a vaginal swab from the mothers of enrolled infants 2 a placenta sample 3 an arterial or venous cord blood sample at birth 4 peripheral blood samples from enrolled infants the first within 48 hours of life the subsequent ones at 7 and 28 days of life and at 6 and 12 months of age 5 bronchoalveolar lavage BALF samples exclusively in infants intubated for clinical reasons within the first 24 hours of life at 7 and 28 days of life 6 first meconium sample issued and subsequent stool samples at 7 and 28 days of life and at 6 and 12 months of age of enrolled infants
Respiratory Functionality Testing at 6 and 12 months of age
- prospectively identify potential biomarkers able to predict the severe course of pulmonary funcion in the first 12 months of life and realize a new profile to early identify hugh risk newborns
Secondary endpoints
detect genetic variance causation model by MiSeq Illumina platform correlating with severe pulmonary dysfunction and asthma development
detect MIcroRNAs as well as anti- and pro-inflammatory cytokine variations MIP-1α MCP-1 IL-8 TNF-α IFN-ɣ IL-10 correlating with the severity of pulmonary dysfunction in the first 12 months of life and the risk of asthma development
Population preterm infants with gestational age 32 weeks who have suffered from acute respiratory insufficiency at birth
Intervention
Assessment of prenatal risk factors
Collection of the following biological specimens 1 a vaginal swab from the mothers of enrolled infants 2 a placenta sample 3 an arterial or venous cord blood sample at birth 4 peripheral blood samples from enrolled infants the first within 48 hours of life the subsequent ones at 7 and 28 days of life and at 6 and 12 months of age 5 bronchoalveolar lavage BALF samples exclusively in infants intubated for clinical reasons within the first 24 hours of life at 7 and 28 days of life 6 first meconium sample issued and subsequent stool samples at 7 and 28 days of life and at 6 and 12 months of age of enrolled infants
Respiratory Functionality Testing at 6 and 12 months of age
Detailed Description:
Background Chronic Lung Disease CLD is one of the most common complications of perinatal lung injury which represents a systemic condition with long term sequelae such as persistent pulmonary dysfunction asthma-like symptoms and BPCO CLD recognizes many prenatal risk factors including maternal smoking chorioamnionitis and intrauterine growth restriction IUGR besides postnatal risk factors such as hyperoxia parenteral nutrition inflammation and mechanical ventilation Exposure to inflammation in utero alters neonatal immune development and predisposes the fetal lung to a dysregulated prolonged response to invasive mechanical ventilation and supraphysiological oxygen Responses to injurious and protective influences early in life are modulated by genetic and epigenetic mechanisms that could result in permanent structural changes with significant consequences in adulthood IUGR pregnancies are characterized by increased oxidative stress and IUGR infants are at high risk of cardiovascular disease metabolic syndrome lung dysfunction and chronic kidney and respiratory diseases in adulthood Despite the constant increase in knowledge of the mechanisms leading to the progression of lung damage so far no effective management has been developed that would lead to CLD prevention
Aims
1 prospectively identify potential biomarkers able to predict the severe course of pulmonary function in the first 12 months of life and realize a new profile to early identify high risk newborns
2 detect genetic variance causation model by MiSeq Illumina platform correlating with severe pulmonary dysfunction and asthma development
3 detect MicroRNAs as well as anti- and pro-inflammatory cytokine variations MIP-1a MCP-1 IL-8 TNF-a IFN-g IL-10 correlating with the severity of pulmonary dysfunction in the first 12 months of life and the risk of asthma development
Experimental design This is a multicenter longitudinal study whose primary aim is to identify a new high-risk neonatal profile for Chronic Lung Disease CLD development starting from perinatal life In order to reach this objective all participant Units will perform vaginal swab to the enrolled mothers will collect placenta and cord blood at birth and peripheral blood bronchoalveolar lavage fluid BALF meconium and feces samples of all enrolled newborn infants The study will begin with the evaluation of prenatal risk factors
After delivery the placentas will be fixed in 10 buffered formalin Subsequently macroscopic and microscopic analyses will be performed according to the Amsterdam placental workshop group consensus statement A vaginal swab will be collected at the time of delivery for all the enrolled women Three ml of cord blood artery andor vein will be performed for analysis of miRNA genetic variance and cytokines In intubated infants only BALF sample will be obtained by instilling 1 mlkg of 09 sodium chloride in the endotracheal tube and suctioning the fluid into a sterile mucus trap The first BALF sample will be collected within the first 24 h of life whereas further BALF samples will be collected at 7 and 28 days of life in newborns who will be still intubated First meconium sample after birth and additional feces samples will be collected at 7 28 days of life 6 and 12 months of life Vaginal swabs placenta BALF meconium and feces samples will be stored at -80C until further processing For each sample bacterial DNA extraction will be performed in a strictly controlled level-2 biological safety workplace using DANAGENE MICROBIOME DNA kits Danagen-Bioted according to manufacturers instructions
In cord serum at birth artery and at 48 hours of life 8-10 candidate miRNAs in particular miR-451 miR-29b and miR-16 will be studied as it has been shown that they have an inhibitory effect on angiogenesis through vascular endothelial growth factor VEGF suppression and miR is associated to genetic susceptibility to CLD The genetic variance causation model will be performed in all enrolled newborns at 48 hours of life at least 500 μL of whole blood using a MiSeq Illumina platform allowing application of Next Generation Sequencing technologies
To detect anti- and pro-inflammatory cytokine variations correlating with the severity of disease over time cord blood and peripheral blood samples 2 ml into an EDTA tube will be obtained from the included infants at the admission within 48 hours of life at 7 and 28 days of life at 6 and 12 months Both anti- INF-y and pro-inflammatory IL-6 and NGF cytokines levels will be investigated All samples will be stored at -80 C until testing Cytokines will be measured with a commercially available ELISA kit according to manufacturers instructions
The investigators will also try to explore the association between mother and placenta data with newborns analysis during the first days of life Upon newborn admission to Neonatal Intensive Care Unit considerable attention will be paid to ascertaining the degree and variations in hemo-oxygenation as well as the presence of infection that is at the origin of Oxidative Stress OS and OS- related diseases The following specimens will be collected 1 ml of peripheral blood within 48 hours of life Additional peripheral blood samples will be collected at 7 and 28 days of life at 6 and 12 months of life
Oxidative stress OS and lipid mediators involved in OS will be evaluated both by biomarkers of oxidative protein damage Advanced Oxidation Protein Products AOPP and lipid peroxidation Isoprostanes IsoPs A further evaluation of oxidative stress profile will be performed by measuring non-enzymatic antioxidant molecules vitamin E glutathione GSH and ascorbic acid AA and enzymatic antioxidant molecules superoxide dismutase SOD catalase CAT and glutathione peroxidase GPx To this end high-performance liquid chromatography HPLC and gas chromatography interfaced mass spectrometry GC-MS will be employed HPLC to detect vitamin E glutathione GSH and AA
The final step will be prospectively identify a new profile of high risk newborns for severe pulmonary dysfunction in the first 12 months of life at higher risk of developing asthma and COPD in later age A long term outcome of all enrolled babies will be performed to unravel the relationships between placenta analysis miRNA expression inflammation and microbiota - as part of the in utero exposome chorioamnionitis or fetal growth restriction and oxidative stress with inflammation - as part of postnatal factors invasive respiratory support Patent Ductus Arteriosus pneumonia sepsis - with the pulmonary outcome in terms of abnormal pulmonary function at 6 and 12 months of age
At 6 and 12 months of age the infants will receive clinical and pulmonary evaluation Pulmonary function test PFT will be performed in all enrolled infants and will include Tidal breathing analysis and Nitrogen Washout test The infants will be placed in the supine position during quiet natural sleep according to American Thoracic SocietyEuropean Respiratory Society recommendations with measurement of lung volumes flow functional residual capacity Lung Clearence Index 5 LCI 5 Lung Clearence Index 25 LCI 25 time to peak tidal expiratory flowexpiratory time ratio tPTEFtE Lung ultrasound will be performed to rule out lung abnormalities After allowing adaptation to the mask tidal breathing flow volume loops for 2 minutes or 20 artifact free breaths will be recorded PFT will be made in order to relate the functional respiratory data with those of generated biochemical profile Any possible relationships among pulmonary function biochemical markers just before birth and in the infants at 6-12 months of age and anthropometric measurements will be studied Pulmonary development and function during extrauterine life will be related with prenatal measurements Data in appropriate for gestational age AGA infants small for gestational age SGA infants and large for gestational age LGA infants will be compared
Methods of data collection Several types of data will be collected including quantitative qualitative generated from imaging tissue and blood samples Clinical data for Aim 1 2 and 3 will be collected and managed using REDCap electronic data capture tools hosted at UO1- Fondazione Policlinico Universitario A Gemelli-IRCCS httpsredcap-irccspoliclinicogemelliit
A dedicated electronic case report form eCRF will be developed Pseudo-anonimyzed data will be collected from the units involved The Investigator will be responsible to ensure that the eCRF is properly and completely filled in Sources of clinical information include the physicians patient record hospital notes original laboratory records pharmacy records results of ultrasound examination etc
Statistic plan Primary endpoint of the study is to identify whether clinical demographic laboratory and other parameters are able to predict the development of chronic lung disease at 36 weeks of PMA andor of abnormal pulmonary function at 12 months of age Assuming an acceptable accuracy level with an Area Under the ROC Curve of at least 075 015 a sample size of 42 patients is required
Statistical analysis The sample will be described in its clinical and demographic characteristics using the appropriate descriptive statistics indices In depth qualitative data will be expressed as absolute and relative percentage frequency while quantitative variables as either mean and standard deviation SD or median and interquartile range IQR depending on the case To verify the Gaussian distribution of quantitative variables the Shapiro-Wilk test will be applied Differences between groups at baseline will be evaluated with regard to qualitative data by either the Chi-Squared test or the Fisher-Freeman-Haltons exact test as appropriate Quantitative data will instead be compared using Students t test for independent samples or Mann Withneys nonparametric U test depending on the data distribution Violin plots will be used to graphically represent significant or clinically relevant differences The evaluation of the difference in terms of primary outcome at 12 months will be evaluated by Kaplan-Meier survival analysis In particular the log-rank test will be applied and appropriate cumulative incidence curves will be drawn In order to assess potential predictors of the primary outcome at 12 months uni- and multivariable Cox regression models will be fitted In depth the potential predictors of the outcome will be evaluated by means of ordinary proportional hazard Cox regression models and the Hazard Ratios HR and the 95 confidence intervals CIs will be consequently reported The proportionality of the hazard functions will be evaluated by visual inspection of the hazards and Schoenfeld residual plots In case of doubtful proportionality Cox weighted regression models will be fitted Predictors to be included in the multivariable model will be selected based on the univariable analysis p005 or suggestive ie 005 p 010 and expert opinion consistent with the rule of at least 10 events by outcome variable and TRIPOD recommendations The performance of the model will be evaluated by several indices such as Cindex Somers Dxy-rank correlation Nagelkerkes R2 value calibration intercept and slop The C-index can be interpreted as an AUC ie a measure of the accuracy of the model Statistical significance is set for values of p005 Suggestive p values 005 p 010 will also be reported Statistical analyses will be conducted using STATA StataCorp USA and R httpswwwr-projectorg
Aims
1 prospectively identify potential biomarkers able to predict the severe course of pulmonary function in the first 12 months of life and realize a new profile to early identify high risk newborns
2 detect genetic variance causation model by MiSeq Illumina platform correlating with severe pulmonary dysfunction and asthma development
3 detect MicroRNAs as well as anti- and pro-inflammatory cytokine variations MIP-1a MCP-1 IL-8 TNF-a IFN-g IL-10 correlating with the severity of pulmonary dysfunction in the first 12 months of life and the risk of asthma development
Experimental design This is a multicenter longitudinal study whose primary aim is to identify a new high-risk neonatal profile for Chronic Lung Disease CLD development starting from perinatal life In order to reach this objective all participant Units will perform vaginal swab to the enrolled mothers will collect placenta and cord blood at birth and peripheral blood bronchoalveolar lavage fluid BALF meconium and feces samples of all enrolled newborn infants The study will begin with the evaluation of prenatal risk factors
After delivery the placentas will be fixed in 10 buffered formalin Subsequently macroscopic and microscopic analyses will be performed according to the Amsterdam placental workshop group consensus statement A vaginal swab will be collected at the time of delivery for all the enrolled women Three ml of cord blood artery andor vein will be performed for analysis of miRNA genetic variance and cytokines In intubated infants only BALF sample will be obtained by instilling 1 mlkg of 09 sodium chloride in the endotracheal tube and suctioning the fluid into a sterile mucus trap The first BALF sample will be collected within the first 24 h of life whereas further BALF samples will be collected at 7 and 28 days of life in newborns who will be still intubated First meconium sample after birth and additional feces samples will be collected at 7 28 days of life 6 and 12 months of life Vaginal swabs placenta BALF meconium and feces samples will be stored at -80C until further processing For each sample bacterial DNA extraction will be performed in a strictly controlled level-2 biological safety workplace using DANAGENE MICROBIOME DNA kits Danagen-Bioted according to manufacturers instructions
In cord serum at birth artery and at 48 hours of life 8-10 candidate miRNAs in particular miR-451 miR-29b and miR-16 will be studied as it has been shown that they have an inhibitory effect on angiogenesis through vascular endothelial growth factor VEGF suppression and miR is associated to genetic susceptibility to CLD The genetic variance causation model will be performed in all enrolled newborns at 48 hours of life at least 500 μL of whole blood using a MiSeq Illumina platform allowing application of Next Generation Sequencing technologies
To detect anti- and pro-inflammatory cytokine variations correlating with the severity of disease over time cord blood and peripheral blood samples 2 ml into an EDTA tube will be obtained from the included infants at the admission within 48 hours of life at 7 and 28 days of life at 6 and 12 months Both anti- INF-y and pro-inflammatory IL-6 and NGF cytokines levels will be investigated All samples will be stored at -80 C until testing Cytokines will be measured with a commercially available ELISA kit according to manufacturers instructions
The investigators will also try to explore the association between mother and placenta data with newborns analysis during the first days of life Upon newborn admission to Neonatal Intensive Care Unit considerable attention will be paid to ascertaining the degree and variations in hemo-oxygenation as well as the presence of infection that is at the origin of Oxidative Stress OS and OS- related diseases The following specimens will be collected 1 ml of peripheral blood within 48 hours of life Additional peripheral blood samples will be collected at 7 and 28 days of life at 6 and 12 months of life
Oxidative stress OS and lipid mediators involved in OS will be evaluated both by biomarkers of oxidative protein damage Advanced Oxidation Protein Products AOPP and lipid peroxidation Isoprostanes IsoPs A further evaluation of oxidative stress profile will be performed by measuring non-enzymatic antioxidant molecules vitamin E glutathione GSH and ascorbic acid AA and enzymatic antioxidant molecules superoxide dismutase SOD catalase CAT and glutathione peroxidase GPx To this end high-performance liquid chromatography HPLC and gas chromatography interfaced mass spectrometry GC-MS will be employed HPLC to detect vitamin E glutathione GSH and AA
The final step will be prospectively identify a new profile of high risk newborns for severe pulmonary dysfunction in the first 12 months of life at higher risk of developing asthma and COPD in later age A long term outcome of all enrolled babies will be performed to unravel the relationships between placenta analysis miRNA expression inflammation and microbiota - as part of the in utero exposome chorioamnionitis or fetal growth restriction and oxidative stress with inflammation - as part of postnatal factors invasive respiratory support Patent Ductus Arteriosus pneumonia sepsis - with the pulmonary outcome in terms of abnormal pulmonary function at 6 and 12 months of age
At 6 and 12 months of age the infants will receive clinical and pulmonary evaluation Pulmonary function test PFT will be performed in all enrolled infants and will include Tidal breathing analysis and Nitrogen Washout test The infants will be placed in the supine position during quiet natural sleep according to American Thoracic SocietyEuropean Respiratory Society recommendations with measurement of lung volumes flow functional residual capacity Lung Clearence Index 5 LCI 5 Lung Clearence Index 25 LCI 25 time to peak tidal expiratory flowexpiratory time ratio tPTEFtE Lung ultrasound will be performed to rule out lung abnormalities After allowing adaptation to the mask tidal breathing flow volume loops for 2 minutes or 20 artifact free breaths will be recorded PFT will be made in order to relate the functional respiratory data with those of generated biochemical profile Any possible relationships among pulmonary function biochemical markers just before birth and in the infants at 6-12 months of age and anthropometric measurements will be studied Pulmonary development and function during extrauterine life will be related with prenatal measurements Data in appropriate for gestational age AGA infants small for gestational age SGA infants and large for gestational age LGA infants will be compared
Methods of data collection Several types of data will be collected including quantitative qualitative generated from imaging tissue and blood samples Clinical data for Aim 1 2 and 3 will be collected and managed using REDCap electronic data capture tools hosted at UO1- Fondazione Policlinico Universitario A Gemelli-IRCCS httpsredcap-irccspoliclinicogemelliit
A dedicated electronic case report form eCRF will be developed Pseudo-anonimyzed data will be collected from the units involved The Investigator will be responsible to ensure that the eCRF is properly and completely filled in Sources of clinical information include the physicians patient record hospital notes original laboratory records pharmacy records results of ultrasound examination etc
Statistic plan Primary endpoint of the study is to identify whether clinical demographic laboratory and other parameters are able to predict the development of chronic lung disease at 36 weeks of PMA andor of abnormal pulmonary function at 12 months of age Assuming an acceptable accuracy level with an Area Under the ROC Curve of at least 075 015 a sample size of 42 patients is required
Statistical analysis The sample will be described in its clinical and demographic characteristics using the appropriate descriptive statistics indices In depth qualitative data will be expressed as absolute and relative percentage frequency while quantitative variables as either mean and standard deviation SD or median and interquartile range IQR depending on the case To verify the Gaussian distribution of quantitative variables the Shapiro-Wilk test will be applied Differences between groups at baseline will be evaluated with regard to qualitative data by either the Chi-Squared test or the Fisher-Freeman-Haltons exact test as appropriate Quantitative data will instead be compared using Students t test for independent samples or Mann Withneys nonparametric U test depending on the data distribution Violin plots will be used to graphically represent significant or clinically relevant differences The evaluation of the difference in terms of primary outcome at 12 months will be evaluated by Kaplan-Meier survival analysis In particular the log-rank test will be applied and appropriate cumulative incidence curves will be drawn In order to assess potential predictors of the primary outcome at 12 months uni- and multivariable Cox regression models will be fitted In depth the potential predictors of the outcome will be evaluated by means of ordinary proportional hazard Cox regression models and the Hazard Ratios HR and the 95 confidence intervals CIs will be consequently reported The proportionality of the hazard functions will be evaluated by visual inspection of the hazards and Schoenfeld residual plots In case of doubtful proportionality Cox weighted regression models will be fitted Predictors to be included in the multivariable model will be selected based on the univariable analysis p005 or suggestive ie 005 p 010 and expert opinion consistent with the rule of at least 10 events by outcome variable and TRIPOD recommendations The performance of the model will be evaluated by several indices such as Cindex Somers Dxy-rank correlation Nagelkerkes R2 value calibration intercept and slop The C-index can be interpreted as an AUC ie a measure of the accuracy of the model Statistical significance is set for values of p005 Suggestive p values 005 p 010 will also be reported Statistical analyses will be conducted using STATA StataCorp USA and R httpswwwr-projectorg
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
None
Is a FDA Regulated Device?:
None
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None