Outcomes of Trauma "Walk-Ins" in the American College of Surgeons Trauma Quality Program Database

BACKGROUND

Outcomes of trauma "walk-in" patients (using private vehicles or on foot) are understudied. We compared outcomes of ground ambulance vs walk-ins, hypothesizing that delayed resuscitation and uncoordinated care may worsen walk-in outcomes.

METHODS

A retrospective analysis 2020 American College of Surgeons Trauma Quality Programs (ACS-TQP) databases compared outcomes between ambulance vs "walk-ins." The primary outcome was in-hospital mortality, excluding external facility transfers and air transports. Data was analyzed with descriptive statistics, bivariate, multivariable logistic regression, including an Inverse Probability Weighted Regression Adjustment with adjustments for injury severity and vital signs. The primary outcome for the 2019 (pre-COVID-19 pandemic) data was similarly analyzed.

RESULTS

In 2020, 707,899 patients were analyzed, 556,361 (78.59%) used ambulance, and 151,538 (21.41%) were walk-ins. We observed differences in demographics, hospital attributes, medical comorbidities, and injury mechanism. Ambulance patients had more chronic conditions and severe injuries. Walk-ins had lower in-hospital mortality (850 (.56%) vs 23,131 (4.16%)) and arrived with better vital signs. Multivariable logistic regression models (inverse probability weighting for regression adjustment), adjusting for injury severity, demographics, injury mechanism, and vital signs, confirmed that walk-in status had lower odds of mortality. For the 2019 (pre-COVID-19 pandemic) database, walk-ins also had lower in-hospital mortality.

DISCUSSION

Our results demonstrate better survival rates for walk-ins before and during COVID-19 pandemic. Despite limitations of patient selection bias, this study highlights the need for further research into transportation modes, geographic and socioeconomic factors affecting patient transport, and tailoring management strategies based on their mode of arrival.

Is There a Role for Imaging Youth at Risk of Atherosclerosis?

PURPOSE OF REVIEW

Cardiovascular (CV) risk factors such as dyslipidemia, hypertension, diabetes, and obesity are associated with an increased risk for CV events in adults. Noninvasive measures of vascular health are associated with these CV events and can potentially help risk stratify children with CV risk factors. The purpose of this review is to summarize recent literature regarding vascular health in children with cardiovascular risk factors.

RECENT FINDINGS

Adverse changes in pulse wave velocity, pulse wave analysis, arterial distensibility, and carotid intima-media thickness are seen in children with CV risk factors supporting potential utility in risk stratification. Assessing vascular health in children can be challenging due to growth-related changes in vasculature, multiple assessment modalities, and differences in normative data. Vascular health assessment in children with cardiovascular risk factors can be a valuable tool for risk stratification and help identify opportunities for early intervention. Future areas of research include increasing normative data, improving conversion of data between different modalities, and increasing longitudinal studies in children linking childhood risk factors to adult CV outcomes.

Pediatric Primary Hypertension: An Underrecognized Condition: A Scientific Statement From the American Heart Association

The overall prevalence of hypertension in childhood is 2% to 5%, and the leading type of childhood hypertension is primary hypertension, especially in adolescence. As in adults, the leading risk factors for children with primary hypertension are excess adiposity and suboptimal lifestyles; however, environmental stress, low birth weight, and genetic factors may also be important. Hypertensive children are highly likely to become hypertensive adults and to have measurable target organ injury, particularly left ventricular hypertrophy and vascular stiffening. Ambulatory and home blood pressure monitoring may facilitate diagnosis. Primordial prevention of hypertension through public health implementation of healthier diet and increased physical activity will reduce the prevalence of primary hypertension, and evidence-based treatment guidelines should be implemented when hypertension is diagnosed. Further research to optimize recognition and diagnosis and clinical trials to better define outcomes of treatment are needed.

Association of Blood Pressure-Related Increase in Vascular Stiffness on Other Measures of Target Organ Damage in Youth

BACKGROUND

Hypertension-related increased arterial stiffness predicts development of target organ damage (TOD) and cardiovascular disease. We hypothesized that blood pressure (BP)-related increased arterial stiffness is present in youth with elevated BP and is associated with TOD.

METHODS

Participants were stratified by systolic BP into low- (systolic BP <75th percentile, n=155), mid- (systolic BP ≥80th and <90th percentile, n=88), and high-risk BP categories (≥90th percentile, n=139), based on age-, sex- and height-specific pediatric BP cut points. Clinic BP, 24-hour ambulatory BP monitoring, anthropometrics, and laboratory data were obtained. Arterial stiffness measures included carotid-femoral pulse wave velocity and aortic stiffness. Left ventricular mass index, left ventricular systolic and diastolic function, and urine albumin/creatinine were collected. ANOVA with Bonferroni correction was used to evaluate differences in cardiovascular risk factors, pulse wave velocity, and cardiac function across groups. General linear models were used to examine factors associated with arterial stiffness and to determine whether arterial stiffness is associated with TOD after accounting for BP.

RESULTS

Pulse wave velocity increased across groups. Aortic distensibility, distensibility coefficient, and compliance were greater in low than in the mid or high group. Significant determinants of arterial stiffness were sex, age, adiposity, BP, and LDL (low-density lipoprotein) cholesterol. Pulse wave velocity and aortic compliance were significantly associated with TOD (systolic and diastolic cardiac function and urine albumin/creatinine ratio) after controlling for BP.

CONCLUSIONS

Higher arterial stiffness is associated with elevated BP and TOD in youth emphasizing the need for primary prevention of cardiovascular disease.

Hypertriglyceridemia-induced acute pancreatitis in children: A mini-review

Severe hypertriglyceridemia (HTG) is a known metabolic cause of acute pancreatitis (AP) in pediatric patients. The incidence of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is less well established in pediatric compared to adult patients. Studies in adults suggest that higher risk of AP occurs when triglyceride levels (TG) are >1,000 mg/dL. Most common etiologies for severe HTG in pediatric patients are either from primary hypertriglyceridemia, underlying genetic disorders of lipid and TG metabolism, or secondary hypertriglyceridemia, separate disease or exposure which affects TG metabolism. Most common theories for the pathophysiology of HTG-AP include hydrolysis of TG by pancreatic lipase to free fatty acids leading to endothelial and acinar cell damage and ischemia, as well as hyperviscosity related to increased chylomicrons. Though there are varying reports of HTG-AP severity compared to other causes of AP, a steadily growing body of evidence suggests that HTG-AP can be associated with more severe course and complications. Therapeutic interventions for HTG-AP typically involve inpatient management with dietary restriction, intravenous fluids, and insulin; select patients may require plasmapheresis. Long term interventions generally include dietary modification, weight management, control of secondary causes, and/or antihyperlipidemic medications. Though some therapeutic approaches and algorithms exist for adult patients, evidence-based management guidelines have not been well established for pediatric patients.

Obese and Type 2 Diabetic Youth Have Increased Forward and Backward Wave Reflections

OBJECTIVE

Pulse wave analysis estimates arterial wave reflections relating to left ventricular dysfunction and cardiovascular event risk in adults. Forward and backward waves (Pf and Pb) may improve risk stratification for cardiovascular events. Data in youth are lacking. We hypothesized that a significant difference in wave reflections would be identified in young subjects with adverse cardiovascular risk factors. Approach and Results: Vital signs and labs were obtained in 551 patients aged 10 to 24 years who were lean (L=199), obese (O=173), or had type 2 diabetes (T=179). Wave separation was performed. Differences in cardiovascular risk factors and wave reflections were assessed using ANOVA. General linear models were constructed to elucidate independent predictors of wave reflections. O and T subjects had an adverse cardiovascular risk profile versus L. O and T subjects had higher Pf and Pb versus L (P≤0.05). When adjusted for adiposity and other cardiovascular risk factors, reflection magnitude increased from L to O to T with higher T versus L values (P≤0.05) and near-significant O versus L values (P=0.06). Adiposity and blood pressure were major determinants of wave reflections. Pb influenced log left ventricular mass index, log E/e', and log composite carotid intima-media thickness.

CONCLUSIONS

Adolescents and young adults with obesity and type 2 diabetes have altered forward and backward wave reflections versus lean controls related to adiposity, BP, and insulin levels. These parameters may help risk stratify patients with adverse cardiovascular risk factors.

Obesity across the lifespan in congenital heart disease survivors: Prevalence and correlates

BACKGROUND

Congenital heart disease (CHD) survivors are at risk for cardiovascular comorbidities exacerbated by obesity.

OBJECTIVES

Determine relationships between overweight/obesity and medical factors across the lifespan of CHD.

METHODS

Lesion severity, weight, blood pressure, cardiac and other comorbidities, and cardiac medications were abstracted from the medical records of 3790 CHD patients, aged ≥6 years, who attended CHD care in the Midwestern U.S.

RESULTS

The proportion of patients with overweight/obesity increased across the lifespan, with 73% of adults affected by overweight/obesity. Obesity was more prevalent among patients with moderate lesions (29%). Overweight/obesity was associated with elevated blood pressure across age and lesion severity. Young adults with obesity and simple or moderate lesions had more comorbidities (simple: IRR = 3.1, moderate: IRR = 2.3) and cardiac medications (simple: IRR = 2.2, moderate: IRR = 1.7).

CONCLUSIONS

Obesity and its cardiovascular correlates are present across the lifespan for CHD survivors, highlighting the need for early prevention and intervention.

Rationale and Best Practices for Pediatric Cardiology Prevention Programs

Atherosclerotic cardiovascular diseases are the most common cause of death in North America, and a significant number of children have conditions such as inherited dyslipidemias, overweight/obesity, and hypertension, placing them at increased risk for future cardiovascular events and other comorbidities. Training in cardiovascular prevention is an important tool to help pediatric cardiologists address these issues in children. We describe a model for training pediatric cardiologists in primary and secondary prevention strategies. A multidisciplinary team approach is needed for robust training in dyslipidemias, hypertension, insulin resistance and type 2 diabetes mellitus, and other obesity-related comorbidities. Research is a significant component of training and necessary for translating science into practice. Ongoing education is also necessary, and certification is available through associations such as the National Lipid Association, the American Diabetes Association, The Obesity Society, and the American Hypertension Specialist Certification Program. Knowledge of primordial, primary, and secondary cardiovascular prevention strategies is essential for pediatric cardiologists to accomplish the goal of helping children lead healthier lives long into adulthood.

Subclinical Systolic and Diastolic Dysfunction Is Evident in Youth With Elevated Blood Pressure

Hypertension is associated with cardiovascular events in adults. Subclinical changes to left ventricular strain and diastolic function have been found before development of decreased left ventricular ejection fraction and cardiovascular events. Our objective was to study effects of blood pressure (BP) on ventricular function in youth across the BP spectrum. Vital signs and labs were obtained in 346 participants aged 11 to 19 years who had BP categorized as low-risk (N=144; systolic BP <75th percentile), mid-risk (N=83; systolic BP ≥80th and <90th percentile), and high-risk (N=119; systolic BP ≥90th percentile). Echocardiography was performed to assess left ventricular strain and diastolic function. Differences between groups were analyzed by ANOVA. General linear models were constructed to determine independent predictors of systolic and diastolic function. Mid-risk and high-risk participants had greater adiposity and more adverse metabolic labs (lower HDL [high-density lipoprotein], higher glucose, and higher insulin) than the low-risk group. Mid-risk and high-risk participants had significantly lower left ventricular ejection fraction and peak global longitudinal strain than the low-risk group (both P≤0.05). The E/e' ratio was higher in the high-risk group versus the low-risk and mid-risk groups, and the e'/a' ratio was lower in the high-risk versus the low-risk group (both P≤0.05). BP and adiposity were statistically significant determinants of left ventricular systolic and diastolic function. Subclinical changes in left ventricular systolic and diastolic function can be detected even at BP levels below the hypertensive range as currently defined.

Human Neural Stem Cell Transplantation Rescues Functional Deficits in R6/2 and Q140 Huntington's Disease Mice

Huntington's disease (HD) is an inherited neurodegenerative disorder with no disease-modifying treatment. Expansion of the glutamine-encoding repeat in the Huntingtin (HTT) gene causes broad effects that are a challenge for single treatment strategies. Strategies based on human stem cells offer a promising option. We evaluated efficacy of transplanting a good manufacturing practice (GMP)-grade human embryonic stem cell-derived neural stem cell (hNSC) line into striatum of HD modeled mice. In HD fragment model R6/2 mice, transplants improve motor deficits, rescue synaptic alterations, and are contacted by nerve terminals from mouse cells. Furthermore, implanted hNSCs are electrophysiologically active. hNSCs also improved motor and late-stage cognitive impairment in a second HD model, Q140 knockin mice. Disease-modifying activity is suggested by the reduction of aberrant accumulation of mutant HTT protein and expression of brain-derived neurotrophic factor (BDNF) in both models. These findings hold promise for future development of stem cell-based therapies.

Abstract P4-04-02: Bromodomain and extra-terminal proteins regulate the epithelial-mesenchymal transition in breast cancer

BACKGROUND. The epithelial-mesenchymal transition (EMT) is a developmental program that cancer cells often activate to acquire a highly plastic phenotype that promotes invasion, metastasis, but also chemoresistance and cancer stem cell generation. As readers of epigenetic marks, bromodomain and extra-terminal (BET) proteins BRD2, BRD3 and BRD4 participate in the regulation of multiple transcriptional programs implicated in cancer progression. We sought to unravel the roles of BET proteins in EMT in breast cancer.

METHODS. Cell line models of the different subtypes of breast cancer were used in this study (luminal A: MCF-7, T47D, basal-like: MDA-MB-231, SUM149PT). BET expression was modulated by using RNA interference or plasmid-mediated overexpression. Small molecule JQ1 was used to inhibit BET proteins. The expression of 84 key EMT genes was monitored by PCR using a Qiagen kit. We also monitored EMT by measuring the expression of epithelial and mesenchymal markers by immunoblot and immunofluorescence staining.

RESULTS. Despite their homology, we report that BET proteins differentially regulate EMT. Based on an EMT PCR array, we identified a BRD2-specific transcriptional profile that promotes EMT, whereas BRD3 and BRD4 signatures repress this program. These individual signatures are unidentifiable upon pan-BET inhibition using JQ1, reinforcing the necessity to target each BET member separately to better understand their functions. Upon BRD2 depletion, basal-like breast cancer cells, which present a mesenchymal phenotype, exhibit a reduced expression of mesenchymal markers (N-cadherin, vimentin) and re-express epithelial markers (E-cadherin, cytokeratins). Moreover, a large panel of EMT master transcription factors is downregulated in BRD2-depleted cells, including the Snail and ZEB families or Twist. Interestingly, we found that BRD3 or BRD4 depletion leads to the opposite phenotype: an increase of mesenchymal marker expression and repression of the epithelial markers. In luminal A breast cancer cells which present an epithelial phenotype, BRD2 overexpression leads to the expression of mesenchymal markers. Similar results were obtained by depleting BRD3 or BRD4 in these cells, confirming the differential roles of BET proteins in EMT regulation.

CONCLUSION. Taken together, our results establish that BRD2 positively regulates EMT, whereas BRD3 and BRD4 repress this program. BET proteins possess separate and opposite biological functions, reinforcing the relevance of an individual targeting instead of a pan-BET inhibition using JQ1. We hypothesize that BET proteins modulate EMT through the regulation of its master transcription factors. We propose that the balance of BET proteins present at the promoters of the EMT genes is a novel mechanism of regulation of this program in breast cancer cells.BACKGROUND. The epithelial-mesenchymal transition (EMT) is a developmental program that cancer cells often activate to acquire a highly plastic phenotype that promotes invasion, metastasis, but also chemoresistance and cancer stem cell generation. As readers of epigenetic marks, bromodomain and extra-terminal (BET) proteins BRD2, BRD3 and BRD4 participate in the regulation of multiple transcriptional programs implicated in cancer progression. We sought to unravel the roles of BET proteins in EMT in breast cancer.

METHODS. Cell line models of the different subtypes of breast cancer were used in this study (luminal A: MCF-7, T47D, basal-like: MDA-MB-231, SUM149PT). BET expression was modulated by using RNA interference or plasmid-mediated overexpression. Small molecule JQ1 was used to inhibit BET proteins. The expression of 84 key EMT genes was monitored by PCR using a Qiagen kit. We also monitored EMT by measuring the expression of epithelial and mesenchymal markers by immunoblot and immunofluorescence staining.

RESULTS. Despite their homology, we report that BET proteins differentially regulate EMT. Based on an EMT PCR array, we identified a BRD2-specific transcriptional profile that promotes EMT, whereas BRD3 and BRD4 signatures repress this program. These individual signatures are unidentifiable upon pan-BET inhibition using JQ1, reinforcing the necessity to target each BET member separately to better understand their functions. Upon BRD2 depletion, basal-like breast cancer cells, which present a mesenchymal phenotype, exhibit a reduced expression of mesenchymal markers (N-cadherin, vimentin) and re-express epithelial markers (E-cadherin, cytokeratins). Moreover, a large panel of EMT master transcription factors is downregulated in BRD2-depleted cells, including the Snail and ZEB families or Twist. Interestingly, we found that BRD3 or BRD4 depletion leads to the opposite phenotype: an increase of mesenchymal marker expression and repression of the epithelial markers. In luminal A breast cancer cells which present an epithelial phenotype, BRD2 overexpression leads to the expression of mesenchymal markers. Similar results were obtained by depleting BRD3 or BRD4 in these cells, confirming the differential roles of BET proteins in EMT regulation.

CONCLUSION. Taken together, our results establish that BRD2 positively regulates EMT, whereas BRD3 and BRD4 repress this program. BET proteins possess separate and opposite biological functions, reinforcing the relevance of an individual targeting instead of a pan-BET inhibition using JQ1. We hypothesize that BET proteins modulate EMT through the regulation of its master transcription factors. We propose that the balance of BET proteins present at the promoters of the EMT genes is a novel mechanism of regulation of this program in breast cancer cells.

Citation Format: Andrieu G, Tran AH, Denis GV. Bromodomain and extra-terminal proteins regulate the epithelial-mesenchymal transition in breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-04-02.

2,3,7,8-Tetrachlorodibenzo-p-dioxin in breast milk increases autistic traits of 3-year-old children in Vietnam

Dioxin levels in the breast milk of mothers residing near a contaminated former airbase in Vietnam remain much higher than in unsprayed areas, suggesting high perinatal dioxin exposure for their infants. The present study investigated the association of perinatal dioxin exposure with autistic traits in 153 3-year-old children living in a contaminated area in Vietnam. The children were followed up from birth using the neurodevelopmental battery Bayley-III. The high-2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) exposed groups (⩾3.5 pg per g fat) showed significantly higher Autism Spectrum Rating Scale (ASRS) scores for both boys and girls than the mild-TCDD exposed groups, without differences in neurodevelopmental scores. In contrast, the high total dioxin-exposed group, indicated by polychlorinated dibenzo-p-dioxins/furans (PCDDs/Fs)--the toxic equivalents (TEQ) levels⩾17.9 pg-TEQ per g fat, had significantly lower neurodevelopmental scores than the mild-exposed group in boys, but there was no difference in the ASRS scores. The present study demonstrates a specific impact of perinatal TCDD on autistic traits in childhood, which is different from the neurotoxicity of total dioxins (PCDDs/Fs).

Neonatal immune-tolerance in mice does not prevent xenograft rejection

Assessing the efficacy of human stem cell transplantation in rodent models is complicated by the significant immune rejection that occurs. Two recent reports have shown conflicting results using neonatal tolerance to xenografts in rats. Here we extend this approach to mice and assess whether neonatal tolerance can prevent the rapid rejection of xenografts. In three strains of neonatal immune-intact mice, using two different brain transplant regimes and three independent stem cell types, we conclusively show that there is rapid rejection of the implanted cells. We also address specific challenges associated with the generation of humanized mouse models of disease.

Contribution of hippocampal place cell activity to learning and formation of goal-directed navigation in rats

Although extensive behavioral studies have demonstrated that hippocampal lesions impair navigation toward specific places, the role of hippocampal neuronal activity in the development of efficient navigation during place learning remains unknown. The aim of the present study was to investigate how hippocampal neuronal activity changes as rats learn to navigate efficiently to acquire rewards in an open field. Rats were pre-trained in a random reward task where intracranial self-stimulation rewards were provided at random locations. Then, the rats were trained in a novel place task where they were rewarded at two specific locations as they repeatedly shuttled between them. Hippocampal neuronal activity was recorded during the course of learning of the place task. The rats learned reward sites within several sessions, and gradually developed efficient navigation strategies throughout the learning sessions. Some hippocampal neurons gradually changed spatial firing as the learning proceeded, and discharged robustly near the reward sites when efficient navigation was established. Over the learning sessions, the neuronal activity was highly correlated to formation of efficient shuttling trajectories between the reward sites. At the end of the experiment, spatial firing patterns of the hippocampal neurons were re-examined in the random reward task. The specific spatial firing patterns of the neurons were preserved if the rats navigated, as if they expected to find rewards at the previously valid locations. However, those specific spatial firing patterns were not observed in rats pursuing random trajectories. These results suggest that hippocampal neurons have a crucial role in formation of an efficient navigation.

Localization of cell division protein FtsK to the Escherichia coli septum and identification of a potential N-terminal targeting domain

Escherichia coli cell division protein FtsK is a homolog of Bacillus subtilis SpoIIIE and appears to act late in the septation process. To determine whether FtsK localizes to the septum, we fused three N-terminal segments of FtsK to green fluorescent protein (GFP) and expressed them in E. coli cells. All three segments were sufficient to target GFP to the septum, suggesting that as little as the first 15% of the protein is a septum-targeting domain. Localized fluorescence was detectable only in cells containing a visible midcell constriction, suggesting that FtsK targeting normally occurs only at a late stage of septation. The largest two FtsK-GFP fusions were able at least partially to complement the ftsK44 mutation in trans, suggesting that the N- and C-terminal domains are functionally separable. However, overproduction of FtsK-GFP resulted in a late-septation phenotype similar to that of ftsK44, with fluorescent dots localized at the blocked septa, suggesting that high levels of the N-terminal domain may still localize but also inhibit FtsK activity. Interestingly, under these conditions fluorescence was also sometimes localized as bands at potential division sites, suggesting that FtsK-GFP is capable of targeting very early. In addition, FtsK-GFP localized to potential division sites in cephalexin-induced and ftsI mutant filaments, further supporting the idea that FtsK-GFP can target early, perhaps by recognizing FtsZ directly. This hypothesis was supported by the failure of FtsK-GFP to localize in ftsZ mutant filaments. In ftsK44 mutant filaments, FtsA and FtsZ were usually localized to potential division sites between the blocked septa. When the ftsK44 mutation was incorporated into the FtsK-GFP fusions, localization to midcell ranged between very weak and undetectable, suggesting that the FtsK44 mutant protein is defective in targeting the septum.

Interleukin-1 production in tumor cells of human melanoma surgical specimens

To determine whether IL-1 alpha and/or IL-1 beta protein is expressed by human melanoma tumor in vivo, we first analyzed nine human melanoma cell lines and optimized the in situ detection of these proteins. Three of the melanoma cell lines stained positively for both IL-1 alpha and IL-1 beta using immunohistochemistry (IHC). THe specificity of IHC was confirmed by the ability of purified recombinant IL-1 alpha and IL-1 beta protein to abolish the staining after being adsorbed by their respective antibodies before use in IHC. The three positively staining cell lines were also the only lines to demonstrate IL-1 production by western blot analysis as well as IL-1 secretion by ELISA. Next we examined 29 surgically obtained melanoma tumor specimens (6 primary and 23 metastases) that had been formalin fixed and paraffin embedded. Using the same anti-IL-1 antibodies, 5 of 23 metastatic tumors stained positively. None of the 6 primary lesions stained for either IL-1 alpha or IL-1 beta. Comparison of staining pattern performed on serially sectioned tissue using preimmune serum and antibodies against S-100 protein, melanoma-associated antigen (HMB-45), and CD68 (kappa P1), which recognizes monocyte-macrophage cell lineage, demonstrates for the first time that IL-1 protein is produced by human melanoma tumor cells in vivo. These findings provide the basis for examination of what may be a previously unrecognized biologically distinct subset of patients.