#013 - Dr. Chaitra Manjunath - Navigating the role of mRNA in HIE

Hello friends 👋

In this episode of Rupa’s Fellows Friday, Chaitra discusses her research on hypoxic ischemic encephalopathy (HIE), where her primary focus has been on the potential role of microRNA profiling in predicting outcomes for affected infants, describing both the promise of this approach and the practical challenges she faced, such as patient consent and laboratory limitations. Dr. Manjunath emphasizes the critical role of mentorship and collaboration in advancing neonatal research. Beyond her scientific work, she shares a growing interest in healthcare price transparency, motivated by her own personal experiences navigating the medical system. She highlights disparities in access and cost of care and advocates for better patient awareness of healthcare options.

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Short Bio: Dr. Chaitra Manjunath is a third-year fellow at Loma Linda University Health in California, with interest in learning about neurodevelopmental outcomes in neonates and infants. Born and raised in India, she completed her medical education there and later completed her residency in Mobile, Alabama, where she worked on implementing the Cornell Delirium Scale in the PICU and conducted research on lenticulostriate vasculopathy in infants. Currently, her research focuses on the role of microRNAs in hypoxic-ischemic encephalopathy (HIE), aiming to develop biomarkers for early diagnosis and treatment. Additionally, she has developed a newfound interest in estimating the true cost of perinatal care, childbirth, and newborn specialty care using price transparency data. 

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The transcript of today's episode can be found below 👇

Srirupa (00:00.851) Hey everyone, welcome back to another fascinating episode of Rupa's Fellows Friday. I am very excited to welcome our next guest today, Dr. Chaitra Manjunath, who is a third year NICU fellow at Loma Linda University Health in California. She did her medical school in Mysore, India, and she moved to Mobile, Alabama to complete her pediatric residency. She did a lot of work on the Cornell delirium scale in the PICU and seemed to have begun that interest of neuro-NICU right there and moved to Loma Linda to do her fellowship where she currently focuses on the role of microRNA in hypoxic-ischemic encephalopathic patients, which is a very fascinating topic. And I can't wait for her to describe her project and hear more about what she's done. Hi, Chaitra. Welcome to our show. And how are you today?

Chaitra Manjunath (00:58.37) Hi Rupa, thank you for having me, I'm doing good.

Srirupa (01:01.489) All right, Chaitra, you've done some fascinating work on HIE (Hypoxic-Ischemic Encephalopathy) in your fellowship. Can you share with us a little bit more about your project and where you are right now in terms of how your project's going?

Chaitra Manjunath (01:13.544) Yes, sounds good. So as we know, hypoxic-ischemic encephalopathy or HIE accounts for 23% of all neonatal deaths worldwide. And unfortunately, one third of these babies die within the first month of their life. To begin with, I was interested to study about neurodevelopmental outcome in babies. And HIE is one of the predominant causes of it. And that's why I wanted to work on this project. And my project itself, I wanted to study about microRNA profiling in HIE infants and how we can perform correlation between the HIE read counts and known predictors of HIE like Sarnat score and MRI or MRS (Magnetic Resonance Spectroscopy) scoring system as well. And as of now, I have completed my project and we have done analysis and further analyses are upcoming, but we have enough data and we have done the first draft of our paper.

Srirupa (02:10.438) That's awesome. Share with us how you did your study and what the methodology and everything was for your study.

Chaitra Manjunath (02:16.504) Sounds good. I think microRNA is a very booming field as of now. MicroRNAs are like small 18 to 22 nucleotide hairpin looped structures, which upregulate or downregulate a gene activity or expression. So once we found out that we're going to work on this project, we went to our lab where we found that a small part of the plasma or serum stays in the lab after we have done the standard analysis for HIE patients. So we enrolled patients, we screened 59 HIE patients and we enrolled 17 patients out of them and we collected samples at 24, 48 and 72 hours, giving highest preference to 24 hour sample. And then once we got our samples, we collaborated with a lab called GenoHub. They were so amazing to perform microRNA profiling and even bioinformatic analysis for us. And then at the end by many people's input, we did perform MRI and MRS scoring on all these patients by a certified neuroradiologist. And we did correlation analysis, which was the second part of our study.

Srirupa (03:30.064) That's awesome. And share with us what you found in your study.

Chaitra Manjunath (03:34.476) Yes, so I was actually surprised that I even got the results, some results because there were so many barriers in the project that I almost gave up at different points. But fortunately, we did end up getting some useful insight. MicroRNA-499 and -208 were the two statistically significant microRNAs that we found in our project. And fortunately, both of them are very closely related to proteins which are very important in CNS (Central Nervous System) development in infants. And we did find a positive correlation between both the microRNAs with Sarnat scoring. And we did not find statistically significant correlation with the Weeke scoring, which is a newer upcoming higher sensitive scoring system in terms of MRI and MR scoring.

Srirupa (04:25.572) That's amazing. And I think it's very important to acknowledge that epigenomics is such an up and booming field. And it's something that is very fascinating. And to try and find what is the basis of all of this. Like, why are these things happening? So I think I'm very impressed that you were able to accomplish this during your three years of fellowship. Share with us your journey of how you found your mentor, how you got interested in the project, and what motivated you to keep going. Because you did mention that there were a lot of challenges. So please share with us what these challenges were and what kept you going.

Chaitra Manjunath (05:00.012) Yes, so my mentors, I think all universities do have a basic science contact person. And at that point, I was very fortunate in our fellowship program. Dr. Blood and Dr. Wilson, they were PhD professors who are basic science professors who are a part of our fellowship. So we have a meeting with them at the beginning. We also interview with them once we start our program. So they are a point of contact. And I went to Dr. Blood that I'm interested in HIE research. And he found a person that, hey, there is a person, Dr. Ma, he's already working on microRNA-210 in rat models, like go and talk to him. So he ended up becoming my primary principal investigator for my project, Dr. Ma. And then we collaborated with GenoHub laboratory. They did all the analysis for us. And then when we did have another person to look into bioinformatic analysis, he contacted Dr. Chen, who also became our mentor. And I reached out to Dr. Terrie Inder, who was remotely working on most of the HIE projects too. And she gave an input that, how about you correlate this with Weeke scoring so that we can get more information regarding both the parameters like microRNA and Weeke scores both. And I did find Dr. Kim Peggy, who's our certified neuroradiologist, who was kind enough to read all the MRI and MRS reports and do this scoring for us. So it was a lot of people who were involved. And also my program director, Dr. Namasivayam Ambalavanan and Dr. Elba Fayard were very important people who gave me the time and opportunity to work on this as well.

Srirupa (06:49.564) That's fantastic. How do you see your project moving forward, like taking shape moving forward?

Chaitra Manjunath (06:55.57) Yes, so once we actually got the patient sample, when I talked to my mentor, he had like so many fascinating ideas, but we have to cut short what I can achieve in like three years of my fellowship. So we only concentrate on like one sample for all the HIE patients that I enrolled, but we do have samples at different time points like 48 hours, 72 hours. And our next goal is to see what is the, for example, microRNA-499 level variation at 48 hours and 72 hours. And then we'll also perform whether the 24-hour samples are better or more than 24-hour samples are better. And then as time goes, we have enough sample for like next three years. And so that other fellows can also take over the project. And any project that they do for animal projects that they do, part of the NIH (National Institutes of Health) grant will be dedicated for human studies too. So they can also utilize this project for that.

Srirupa (07:59.153) That's amazing. And based on what I read in your bio, you seem to have been involved in a lot of grant writing and acquiring a lot of grants for this project. So share with us your experience as a fellow in, one, delving into this whole world of grant writing, which itself is quite fascinating, right? You have to write the exact right things to get the right amount of support that you need. So share with us about your experience in the grant writing itself.

Chaitra Manjunath (08:22.862) I think before, like, I mean, I was very terrified to write a grant because I have never done that. I didn't know it was even doable because I'm still a fellow. It is written by like, you know, PhD professors who have been doing this for a really long time. And I'm not a core basic science person to write that. So first reaching out to your basic science professor, getting a template. So what did the first paragraph say? Talk about HIE. Second paragraph, talk about the incidence. So kind of dumbing down for us to see what we need to concentrate on each and every paragraph was my way to go about it. And also, once you get the template, it's pretty easy to write whatever we want. And also, it's a very nonspecific way of writing because paper, when we write a paper, we already have the data, we know what we are doing, we have read so many papers. For grant, it's still developing, you do it beforehand. So you don't have any idea what you're getting into. And there are so many phases where you can fail and you may not even get the results that you want to get. So it's a very general way of writing it. It's just a very overview and this might happen when we do this, we need funding to do this. So it's like a story that you build. So it's a very broad way of thinking about it. And I would highly recommend all fellows to start writing a grant, even though it's like really bad, like everyone, we have to start somewhere. So, and you eventually will get better at it. So once we start, it's a really nice, I would say it is the first draft of your paper. So you already have reviewed all the research that is going on in your field. You will have a good grip to write your paper once you write a grant. And the good thing is that almost all level four NICUs who have like a fellowship program, they have a dedicated amount for the fellows in order to give them an experience of writing a grant. And there is the Marshall Klaus grant from AAP (American Academy of Pediatrics) that is given for fellows too. And that's a great experience to write the grant too. In that way, one thing is that it will make writing your papers way more easier. And the second one is that it gives you money to collaborate with people. Because I'm not a basic science person who knows the protocol for microRNA profiling in people. But the lab I collaborated with, their only job is to do microRNA profiling. So when our first analysis failed, they were like, we can optimize this. We can optimize that. And they came up with plans that they can do immediately. For me, in order to at least come up with those places where we can improve, it would take two or three years. But they had the idea that, OK, this might be the problem already. So you get an opportunity to work with the people who are already experts in this field. So you get financial support and you get technical support and you get the first draft of your paper. So it's a very good experience for all fellows to start writing grants.

Srirupa (11:21.808) No, that's fantastic. And I do agree that, you know, the fellowship is your time to explore all of these things. And whether you want to have a research career or not, it is your one chance and one attempt to like learn all of these things. So definitely good advice to give. Tell me, one of the things that struck me is being in neonatology for the last couple of years, I feel like, you know, one of the most challenging patients that you deal with are babies with HIE because you have this family that went to deliver a baby that they expect to be completely normal and then everything changes. And it's a very unexpected diagnosis. It's a very shocking diagnosis. It's a diagnosis that is just very, very difficult for them to process as well. And amongst all of this, to try and research on such a diagnosis can be challenging for consent. So share with me what your challenges were from the consent standpoint. How did you deal with that and what is your word of advice for such situations where you don't even expect families to know that their child might have this diagnosis?

Chaitra Manjunath (12:29.302) Yes, yeah, thank you for that question. Actually, before even going for this project, I decided, okay, I'm not gonna draw any blood because I had like read and heard so many people like it's hard when your baby has a very difficult diagnosis that you never expected. And some person is coming like, can I get like two mL of blood? Because whenever we talk to our basic science people, they want like pure blood samples immediately after birth that goes to minus 80. But most of the time, unfortunately, it's not really practical on a day-to-day basis. So we thought we will do the discarded sample from the patient. So it was not extra blood. If we did not have discarded samples, we would not do the project on that baby. That is how we started with. And then once I started consenting these patients, I had higher success rate when our transport managers or transport RTs, nurses, and the nurses on the unit talked about this project to the patients. I had higher success rate because they were the first point of contact with the patients and they would trust them more. And when I did chart review, I think genuinely caring for the patient does go a long way because I was following their project, actually talking to the parents irrespective of them enrolling in my project or not. I would check with them, hey, how is your baby doing? On the first day when I went to actually talk about my project, I never talked about my project at all. I would say, how is your baby doing? How did this happen? And then like actually make a personal connection with the parents so that you come off as a person who actually cares for the patients. And even after getting the consent, like go back and check, I'm really glad that your patient is going home. And I would chart check them that when they're seen in high-risk clinic, I would say, hey, I'm coming here today. Do you want to see? So it was a really nice connection with the parents. It shows you actually care for them. I thought enrolling our control patients was really hard, like, it was really harder compared to our cases population, because not many patients who are more than 35 weeks or fairly healthy, like who are not severely sick or intubated, end up being in the NICU or in the newborn nursery. And even if they do stay, they won't be getting any blood samples, like they won't be getting every day bilirubin. They'll just get a TcB and go home. So we had to broaden our control patient enrollment. So we had to take patients who were infants of diabetics and who were getting IV glucose for a while. And then also congenital syphilis who were getting antibiotics for like 10 days. Those were the patients we had to enroll. Before we were like, okay, patients who did not have any of this, completely healthy babies. That was where we started, but we couldn't get that. And the laboratory challenge was that, you know, you have to keep them immediately in the minus 80 degree, but that doesn't happen all the time. But fortunately, all our discarded samples are stored in a big minus four degree room. So that was one thing which was helpful. But if your hospital doesn't have that facility, you have to actually go to the lab and keep them in a minus four or process them within 15 minutes. So there are so many laboratory challenges too. And once we got the sample too, we found really good results with plasma EDTA. But our patients are really small and we need to get samples in a micro container. So you won't have enough sample to assess that. So we have to broaden it to plasma heparin treated samples as well.

Srirupa (16:17.614) Yeah, that's interesting. I think I agree, like connecting with the families goes a long way, especially with the consent process. And I think it's also important that you recognize that it is a hard decision for them to first of all, be in the NICU, but also to agree to enroll in a project. So I do understand that. And then kudos to you to have connected with so many families that you clearly have shown a little bit of a positive impact on their enrollment in the project as well. It's fantastic. For our listeners, one of the other things and one of the most important things that we all need to care about is price transparency. And I'd like to highlight that Chaitra has developed a newfound interest in price transparency in the NICU. And I would love for Chaitra, in her own words, to share with us what you would like to do with this project. Because I love that you are interested in something that's out of the box. And I would love for you to share with us what you're doing with your project, what your project is about, and how do you envision it to impact care.

Chaitra Manjunath (17:18.722) Yes, thank you for this question. I think it's totally out of our field to get interested in that. A very personal situation made me interested and curious in this field. So I had a knee injury and I had to get an MRI immediately. And they were suspecting medial meniscal tear. And once I went to the emergency department, they said like, hey, we'll get an MRI. You feel okay. You're able to hobble around. So we'll get an MRI, get an MRI outpatient, which will be like in a month. And then you can see an orthopedic surgeon within three months. And when this was when I was barely able to walk. So that was very surprising for me. So like I have insurance, I should be able to get the MRI sooner and I should be seen by an orthopedic surgeon immediately and be operated on within at least like in the next week. But this was very surprising for me that I wasn't even able to get an MRI within a week period or in a month. So I called a private imaging center that like, hey, I don't have insurance and I'm going to give you cash pay. And they said, okay, for $300, you'll be able to get the MRI and you're going to get it at 6 a.m. in the morning the next day itself. So even with the insurance, it would cost me $700 and I would get it within two weeks. I was very surprised that I was able to get it the next day itself and for much cheaper price. And then I was searching for like, is there any surgeon who was able to operate on me if I do end up having meniscal tear? And I came across Surgery Center of Oklahoma by Dr. Keith Smith and there are other centers like Renova, which are located in Washington and Wisconsin that with cash pay, you're able to get a total hip replacement for $20,000. So most people have high deductible plans. It means that up to like $3,000, we have to pay everything out of pocket. And the insurance negotiated rate for hip replacement is $80,000. And you have a co-insurance even after that, which is 20 to 30%. And you end up paying $20,000 to $23,000, even with insurance. And on top of that, you have to go through so many hoops of prior authorization and getting physical therapy for medial meniscal tear, which is not the right treatment. We all know that it's not the right treatment, but you have to wait for three months. And this is on top of paying high premiums every month. And I was just thinking, this is me being in healthcare and trying to get the optimal care that I know is the right and have to go through so many hoops to get the right care that I need. And think about the public who have no idea of any of these. They don't know deductible. They don't know co-insurance or they only know that they are paying some money for the insurance every month, which is also a significant amount of money, but they are not getting the care that they want. And many people don't even come to the hospital thinking that without insurance, they might have to pay more. So like vaginal delivery and C-section, we have so many populations, they deliver at home and the baby ends up having like some bad outcomes and the baby comes into the hospital and they are afraid that with every test they are getting charged more. But that is not the case right now. With cash pricing, like you can get the care immediately and for a cheaper price than with the insurance, which was very mind boggling for me that you're paying higher prices, but also getting delayed care. That's why I was interested in this project. And we also wrote a grant for this in my third year. And we collaborated with a company called CaredFor, through which we are getting cash prices for vaginal delivery, C-section, also insurance negotiated rate for all of them. And the whole importance of this project is to shed light and make people aware that you can get affordable healthcare and also very easily accessible healthcare by paying cash prices and without having to go through insurance, which is a very hard way of getting through the healthcare that you need to get. So that many people are aware of that. It was very new for me as well. So that is why I got interested in this project.

Srirupa (21:46.674) Share with us your project in the neonatology front with this interest.

Chaitra Manjunath (21:52.142) Yeah, so it was very interesting that in this way, we are able to see like what is the care for like vaginal delivery, C-section. And also when the patients, almost all the NICU patients end up going to have like higher follow-ups. So like physical therapy, occupational therapy, and the patients have like three months wait period, six months wait period. But with cash pay, they are able to get access for it immediately. And they can get whatever frequency they want to. And there are well established government physical therapy or developmental outcome clinics for every state. So meanwhile, until they get into that healthcare, they miss out on a critical period where their patients can get this care for their patient population. So through this one, until they get to that, they can get immediate care in a very easy and accessible way. And this is what I aim to do when it comes to neonatology with the price transparency.

Srirupa (22:55.906) That's a very interesting project and I see that you are graduating soon. So do you plan to carry this forward in your next steps in your career itself?

Chaitra Manjunath (23:04.96) I do. Because as of now, we were just like trying to get the data and mostly when we write papers. So when we write a paper, it can be a very short paper like in JAMA where it's very easy for readers and even common people to read. So we were planning to do that so that everybody can read and we plan to present it in like different conferences and for normal people to hear about it, not only people in medical field. So I will be able to perform that in like next three years once I'm actually graduating. So we are collecting the baseline data for this and we'll be able to get more information as we go along.

Srirupa (23:44.082) That's fantastic. It seems like you've had a very productive three years at Loma Linda and I wish you best for all your new adventures that come in your way. Share with us where you're headed towards if you'd like to share that with our listeners.

Chaitra Manjunath (23:57.334) Yeah, sure. So I did sign a contract with Children's Hospital of Orange County. And as a part of it, I am working in some underserved area like high desert area. I am very passionate about it. And it's very near and dear to my heart because I work with a patient population where they do not have access to fancy health care. And they might have language barrier. So I'm going to learn Spanish as well so that we can serve the patient population better and then I went and talked to the nurses there and like hey I'm so happy and grateful that people like you are coming to this area because before like small babies would not survive in this area because you know they did not have access to health care so I think my next job has given me that great opportunity to serve the patient with less resources and also at the same time I can do like research with the level four NICU where I can have access to a bigger data.

Srirupa (24:56.476) That's fantastic. What is one big advice you'd like to give to fellows who are interested in your line of research?

Chaitra Manjunath (25:04.28) Sure. I think collaboration is key. So always talk to people who are already working in your field and you'll learn so many important lessons from them. And when you go to conferences, my only goal is to talk to people. It's not about presenting my poster or my research. It's me trying to talk to people who have already done research in that field. So when I was in Newborn Brain Society Conference, I talked to people who are from Germany, who are from UK who are already doing projects in this field and they would take photos of my poster or my research that like, you found this microRNA was significant, we found these. So it's not about you telling about your project, it's about you learning from others' projects is very important. And then grant writing and everything might seem very challenging and very overwhelming in the beginning, but to give it a try, even though it fails, that's okay. And I would say that not many research projects lead to a successful project and they're like, I found this next Nobel Prize thing. It's not going to be like that. I was totally prepared if my project fails, that's okay. Because we got through that. The only thing that you need to concentrate is to know the steps of performing a good research. And even though you don't get any results, that's still a result. So you got through what is feasible to do, the feasibility to do microRNA profiling in HIE infants at all. So that when other people are doing, they learn very valuable lessons from your project itself.

Srirupa (26:38.845) Yeah, absolutely. Negative results are important results too. I totally agree. But this was fantastic, Chaitra. Thank you so much for sharing your passions and a lot of words of learning that you've learned through your three years of fellowship. I wish you luck with all of your endeavors and adventures coming your way. Good luck.

Chaitra Manjunath (26:56.654) Thank you so much.