Risk and Protective Factors of Self-harm and Suicidality in Adolescents: An Umbrella Review with Meta-Analysis

Suicide remains the second most common cause of death in young people aged 10-24 years and is a growing concern globally. The literature reports a vast number of factors that can predispose an adolescent to suicidality at an individual, relational, community, or societal level. There is limited high-level research identifying and understanding these risk and protective factors of adolescent suicidality. The present study used an umbrella review and meta-analysis to synthesize evidence from the review literature in the past 20 years on risk and protective factors of self-harm and suicidality (behavior and ideation) in adolescents. The umbrella review included 33 quantitative reviews with 1149 individual studies on suicidality and self-harm. Based on the data synthesis, it compared the public health impact of exposure on the population of the identified exposure. Bullying victimization was the most attributed environmental exposure for suicidality. The other identified significant school and individual factors were sleeping disturbance, school absenteeism, and exposure to antidepressants. Several significant vulnerable young populations were identified with significantly higher prevalence of suicidality, including lesbian, gay, bisexual, transgender, queer (or questioning) youth and those with mental health disorders, problem behaviors, previous suicidality, self-harm, and gender (female). A person-centered approach emphasizing connectedness and bully-free school environments should be a priority focus for schools, health professionals, and public health policymakers.

LMJSSP for analysis of prophylactic lubricants, spermicides and residues

DNA evidence in sexual assault cases have proven increasingly difficult to obtain and analyse due to increased condom use. With more interest in alternatives to DNA evidence, prophylactic lubricants, spermicides and residues may be interesting prospects. Current interest in the analysis of prophylactic residues focuses on the evaluation and identification of lubricants and constituents, primarily through gas chromatography or Fourier transform infrared spectroscopy. Though cost-effective methods, extensive sample preparation and destructive modes of analysis remain an area for improvement. As a result, the focus has since shifted to ambient ionization methods that offer adequate sensitivity and reduced sample preparation. The Liquid Microjunction Surface Sampling Probe (LMJSSP) is a versatile ambient ionization source that employs a probe that supports a continuously flushing droplet that extracts analytes when placed in contact with a surface. The analytes are aspirated into the mass spectrometer with a Venturi pressure. In this work we use the LMJSSP to analyse the trace transfer of condom lubricant to different types of fabric (cotton, cotton-spandex, and denim). Furthermore, we examine the sensitivity and storage conditions for the direct analysis method on different swab types (cotton, silicone, and foam). Additionally, Principal Component Analysis (PCA) and Maximally Collapsing Metric Learning (MCML) are utilized for visualization of differentiability of commercially available condom brands including Durex™ and Trojan™, and product subtypes. The results present an interesting multi-disciplinary approach of using a direct liquid extraction ambient ionization technique and machine learning to improve the overall workflow for the analysis of lubricants, swabs and fabrics. Machine learning algorithms were able to differentiate between inherent differences of Durex™ and Trojan™ condoms.

OpenApePose, a database of annotated ape photographs for pose estimation

Because of their close relationship with humans, non-human apes (chimpanzees, bonobos, gorillas, orangutans, and gibbons, including siamangs) are of great scientific interest. The goal of understanding their complex behavior would be greatly advanced by the ability to perform video-based pose tracking. Tracking, however, requires high-quality annotated datasets of ape photographs. Here we present OpenApePose, a new public dataset of 71,868 photographs, annotated with 16 body landmarks of six ape species in naturalistic contexts. We show that a standard deep net (HRNet-W48) trained on ape photos can reliably track out-of-sample ape photos better than networks trained on monkeys (specifically, the OpenMonkeyPose dataset) and on humans (COCO) can. This trained network can track apes almost as well as the other networks can track their respective taxa, and models trained without one of the six ape species can track the held-out species better than the monkey and human models can. Ultimately, the results of our analyses highlight the importance of large, specialized databases for animal tracking systems and confirm the utility of our new ape database.

Developmental changes in functional connectivity between the prefrontal cortex and amygdala following fear extinction

The amygdala and prefrontal cortex (PFC) undergo dramatic changes in structure, function, and regional connectivity in early life, ultimately stabilizing in early adulthood. Pathways between these two structures underlie many forms of emotional learning, including the extinction of conditioned fear. Here we sought to characterize changes in extinction-related medial PFC (mPFC) → amygdala functional connectivity across development that might explain adolescent impairments in extinction. The retrograde tracer Fluorogold was infused into the amygdala of postnatal day (P)22-23 (juvenile), P31-32 (adolescent), or ≥ P69 (adult) rats, which were then exposed to fear conditioning and extinction training. Brains were collected following extinction or context exposure and processed for expression of pMAPK (as a marker of learning-dependent plasticity) in prelimbic (PL) and infralimbic (IL) amygdala-projecting neurons. Consistent with previous findings, amygdala-projecting mPFC neurons were located primarily in layers (L)II/III and V of the mPFC. We noted that mPFC LII/III projected predominantly to the ipsilateral basolateral amygdala, whereas LV projected bilaterally and targeted multiple amygdalar nuclei. Extinction was not associated with changes in extinction-related plasticity in the PL-amygdala pathways in any age group. No changes were seen in LII/III of the IL, but extinction-related plasticity in LV amygdala-projecting IL neurons decreased linearly across development. These findings suggest that extinction-related functional connectivity between the IL and the amygdala undergoes fundamental changes across development that may contribute to alterations in fear suppression across development.

Zebrafish as a model for cardiac disease; Cryo-EM structure of native cardiac thin filaments from Danio Rerio

Actin, tropomyosin and troponin, the proteins that comprise the contractile apparatus of the cardiac thin filament, are highly conserved across species. We have used cryo-EM to study the three-dimensional structure of the zebrafish cardiac thin and actin filaments. With 70% of human genes having an obvious zebrafish orthologue, and conservation of 85% of disease-causing genes, zebrafish are a good animal model for the study of human disease. Our structure of the zebrafish thin filament reveals the molecular interactions between the constituent proteins, showing that the fundamental organisation of the complex is the same as that reported in the human reconstituted thin filament. A reconstruction of zebrafish cardiac F-actin demonstrates no deviations from human cardiac actin over an extended length of 14 actin subunits. Modelling zebrafish homology models into our maps enabled us to compare, in detail, the similarity with human models. The structural similarities of troponin-T in particular, a region known to contain a hypertrophic cardiomyopathy 'hotspot', confirm the suitability of zebrafish to study these disease-causing mutations.

Treatment with sofosbuvir attenuates the adverse neurodevelopmental consequences of Zika virus infection in infant rhesus macaques

Zika virus (ZIKV) infection during infancy in a rhesus macaque (RM) model negatively impacts brain development resulting in long-term behavioral alterations. The current study investigated whether postexposure prophylaxis could alleviate these negative neurodevelopmental consequences. Three RM infants received a 14-day course of sofosbuvir (SOF; 15 mg/kg p.o.) treatment starting at 3 days post-infection with a Puerto Rican strain of ZIKV (PRVABC59) and were then monitored longitudinally for one year. In contrast to ZIKV-infected infant RMs who did not receive SOF, postexposure SOF treatment mitigated the neurodevelopmental, behavioral and cognitive changes seen after postnatal ZIKV infection even while not accelerating viral clearance from the blood. These data suggest that antiviral treatment may help ameliorate some, but not all, of the neurodevelopmental abnormalities associated with early postnatal ZIKV infection.

THOR-05F biofidelity evaluation in reclined and upright seated postures subjected to frontal crash pulses

The THOR 5th percentile female dummy (THOR-05F) was evaluated for two seating postures/positions in frontal impacts using a generic automotive seat environment. The conditions included 2 crash pulses: a 15 km/h test that utilized 4.5 g acceleration and a 3-point restraint with 2 kN load limiter, and a 32 km/h test that utilized 9.5 g acceleration and a 3-point restraint with a 4.5 kN load limiter and pretensioner, and two seatback angles: 25°, a nominal upright posture, and 45°, a moderate reclined posture. The BRS scores were calculated using the NHTSA BioRank method. Overall biofidelity rating was consider excellent for both seating postures. This evaluation provides an understanding of the THOR-05F response and biofidelity evaluation of the ATD in two seating postures (nominal and reclined). This is essential in the assessment and development of safety measures in emerging ADS-equipped vehicles.

The role of puberty on physical and brain development: A longitudinal study in male Rhesus Macaques

This study examined the role of male pubertal maturation on physical growth and development of neurocircuits that regulate stress, emotional and cognitive control using a translational nonhuman primate model. We collected longitudinal data from male macaques between pre- and peri-puberty, including measures of physical growth, pubertal maturation (testicular volume, blood testosterone -T- concentrations) and brain structural and resting-state functional MRI scans to examine developmental changes in amygdala (AMY), hippocampus (HIPPO), prefrontal cortex (PFC), as well as functional connectivity (FC) between those regions. Physical growth and pubertal measures increased from pre- to peri-puberty. The indexes of pubertal maturation -testicular size and T- were correlated at peri-puberty, but not at pre-puberty (23 months). Our findings also showed ICV, AMY, HIPPO and total PFC volumetric growth, but with region-specific changes in PFC. Surprisingly, FC in these neural circuits only showed developmental changes from pre- to peri-puberty for HIPPO-orbitofrontal FC. Finally, testicular size was a better predictor of brain structural maturation than T levels -suggesting gonadal hormones-independent mechanisms-, whereas T was a strong predictor of functional connectivity development. We expect that these neural circuits will show more drastic pubertal-dependent maturation, including stronger associations with pubertal measures later, during and after male puberty.

Evidence of Antineutrinos from Distant Reactors Using Pure Water at SNO

The SNO+ Collaboration reports the first evidence of reactor antineutrinos in a Cherenkov detector. The nearest nuclear reactors are located 240 km away in Ontario, Canada. This analysis uses events with energies lower than in any previous analysis with a large water Cherenkov detector. Two analytical methods are used to distinguish reactor antineutrinos from background events in 190 days of data and yield consistent evidence for antineutrinos with a combined significance of 3.5σ.

Autonomous control for miniaturized mobile robots in unknown pipe networks

Despite recent advances in robotic technology, sewer pipe inspection is still limited to conventional approaches that use cable-tethered robots. Such commercially available tethered robots lack autonomy, and their operation must be manually controlled via their tethered cables. Consequently, they can only travel to a certain distance in pipe, cannot access small-diameter pipes, and their deployment incurs high costs for highly skilled operators. In this paper, we introduce a miniaturised mobile robot for pipe inspection. We present an autonomous control strategy for this robot that is effective, stable, and requires only low-computational resources. The robots used here can access pipes as small as 75 mm in diameter. Due to their small size, low carrying capacity, and limited battery supply, our robots can only carry simple sensors, a small processor, and miniature wheel-legs for locomotion. Yet, our control method is able to compensate for these limitations. We demonstrate fully autonomous robot mobility in a sewer pipe network, without any visual aid or power-hungry image processing. The control algorithm allows the robot to correctly recognise each local network configuration, and to make appropriate decisions accordingly. The control strategy was tested using the physical micro robot in a laboratory pipe network. In both simulation and experiment, the robot autonomously and exhaustively explored an unknown pipe network without missing any pipe section while avoiding obstacles. This is a significant advance towards fully autonomous inspection robot systems for sewer pipe networks.

Combined role for YAP-TEAD and YAP-RUNX2 signalling in substrate-stiffness regulation of cardiac fibroblast proliferation

Cardiac fibrosis is associated with increased stiffness of the myocardial extracellular matrix (ECM) in part mediated by increased cardiac fibroblast proliferation However, our understanding of the mechanisms regulating cardiac fibroblast proliferation are incomplete. Here we characterise a novel mechanism involving a combined activation of Yes-associated protein (YAP) targets RUNX Family Transcription Factor 2 (RUNX2) and TEA Domain Transcription Factor (TEAD). We demonstrate that cardiac fibroblast proliferation is enhanced by interaction with a stiff ECM compared to a soft ECM. This is associated with activation of the transcriptional co-factor, YAP. We demonstrate that this stiffness induced activation of YAP enhances the transcriptional activity of both TEAD and RUNX2 transcription factors. Inhibition of either TEAD or RUNX2, using gene silencing, expression of dominant-negative mutants or pharmacological inhibition, reduces cardiac fibroblast proliferation. Using mutants of YAP, defective in TEAD or RUNX2 activation ability, we demonstrate a dual role of YAP-mediated activation of TEAD and RUNX2 for substrate stiffness induced cardiac fibroblast proliferation. Our data highlights a previously unrecognised role of YAP mediated RUNX2 activation for cardiac fibroblast proliferation in response to increased ECM stiffness.

Texas panhandle beef production tour, a high-impact compressed course in animal science

Many animal science students have little exposure to working livestock production systems prior to college. As such, they can lack insight into day-to-day challenges and rationale behind decision making in these systems, opening the door for the adoption of misconceptions frequently promoted in the popular press. In addition, students identify a lack of first-hand knowledge and experience in the industry as a challenge to their educational success. Field trips stimulate interest and motivation, provide context for learning, and influence long-term career goals, but are underutilized in higher education. The potential impact of such experiences prompted the creation of the Texas Panhandle Beef Production Tour, a 2-credit hour compressed course. Students on this tour visited beef production sites in the Texas Panhandle ranging from cow-calf operations, to feedlots and packing plants. To cement learning through reflection, students responded to a series of questions before, during, and after visiting these sites to probe preconceptions, observations, and outcomes of the experience. We performed a retroactive qualitative evaluation of these reflections (n = 22) to determine cogent themes. Emergent themes included surprise at the intensive systems of data collection and management and the level of technology used at each site. Cattle were calmer and more comfortable than expected at the feedlots and packing plants. Students expressed new appreciation and understanding of course material and a desire to share their insights with others after completing the tour. Finally, participants gained a broader view of industry opportunities and returned with renewed motivation to pursue additional hands-on opportunities. Participation in this course provided valuable insight into the livestock production industry and motivated students to explore new career options and address their own preconceptions of the industry through independent inquiry. The creation of similar courses may be useful to address misconceptions, create personal connections with course material, and broaden career interests in animal science students.

737 Supporting Surgeons in Their Return to Training

Aim

t any one time, approximately 10% of the junior doctor workforce (∼5000 doctors) take time out of training. Following the Bawa Gaba case, and with trainees shielding during the COVID pandemic, there is greater scrutiny and demand to support trainees returning to the frontline. Supported Return to Training (SuppoRTT) is a Health Education England Program designed to improve the Return-To-Training (RTT) experience. For surgical specialties there are additional challenges of reintroducing trainees to practical skills.

Method

e designed and facilitated the first regional SuppoRTT course for Orthopaedic Specialist Registrars, which consisted of peer and consultant-led clinical updates, forum discussions and externally commissioned professional coaching. A pre-course survey established participants’ concerns and expectations about RTT and formed the basis of discussions. A post-course survey assessed value of the course and impact on participants.

Results

Eight participants (6 female) attended. Grade of training on return ranged from ST3 to ST8. Main areas of concern related to colleague perception, reduced confidence with decision-making, operative skill fade, and frustrations with organisational elements of managing work-life balance. There was an overwhelmingly positive response to the support offered on our course, particularly to the discussions around RTT concerns and returning to on-calls. All respondents strongly agreed that sharing their concerns and hearing about peer experience was valuable.

Conclusions

High numbers of trainees take approved time out of training. RTT is associated with anxiety around performance and safety. Surgical trainees can be supported with a targeted course that offers clinical update, peer support and professional coaching.

Efficacy of ethylene oxide-sterilized waterproof cases for handheld cameras as sterile barriers for intraoperative imaging and recording

OBJECTIVE

To evaluate the efficacy of ethylene oxide (EtOH) sterilization of 4 different waterproof camera cases and the ability of those sterilized cases to maintain a sterile barrier for intraoperative camera use.

SAMPLE

3 action cameras, 1 smartphone, and associated waterproof cases.

PROCEDURES

Cases were inoculated by immersion in medium containing Staphylococcus pseudintermedius, Escherichia coli, and Pseudomonas aeruginosa and then manually cleaned and subjected to EtOH sterilization. Cameras were disinfected, loaded into sterile cases, and sterilely operated for 2 hours. Samples were collected from cases after inoculation, EtOH sterilization, camera loading, and 1 and 2 hours of operation and from all cameras after 2 hours of operation. Procedures were repeated twice, followed by an additional challenge round wherein cameras were purposefully contaminated prior to loading. All samples underwent bacterial culture.

RESULTS

All cases were successfully sterilized, and loading of nonsterile cameras into sterile cases caused no contamination when cameras had been disinfected beforehand. Nonpathogenic environmental contaminants were recovered from 6 of 64 culture samples and 2 of 4 room samples. During the challenge round, only the postload sample for 1 case yielded E coli, suggesting sterile glove contamination; however, postload, 1-hour, and 2-hour samples for the GoPro case yielded E coli and S pseudintermedius, suggesting major contamination.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that the evaluated cases can be safely sterilized with EtOH and used for image acquisition by aseptically prepared surgeons when cameras are disinfected prior to loading. Except for the GoPro camera, camera use did not jeopardize sterile integrity.

Intraoperative anti-A/B immunoadsorption is associated with significantly reduced blood product utilization with similar outcomes in pediatric ABO-incompatible heart transplantation

Background

Intraoperative anti-A/B immunoadsorption (ABO-IA) was recently introduced for ABO-incompatible heart transplantation. Here we report the first case series of patients transplanted with ABO-IA, and compare outcomes with those undergoing plasma exchange facilitated ABO-incompatible heart transplantation (ABO-PE).

Methods

Data were retrospectively analysed on all ABO-incompatible heart transplants undertaken at a single centre between January 1, 2000 and June 1, 2020. Data included all routine laboratory tests, demographics and pre-operative characteristics, intraoperative details and post-operative outcomes. Primary outcome measures were volume of blood product transfusions, maximum post-transplant isohaemagglutinin titres, occurrence of rejection and graft survival. Secondary outcome measures were length of intensive care and hospital stay. Demographic and survival data were also obtained for ABO-compatible transplants during the same time period for comparison.

Results

Thirty-seven patients underwent ABO-incompatible heart transplantation, with 27 (73%) using ABO-PE and 10 (27%) using ABO-IA. ABO-IA patients were significantly older than ABO-PE patients (p < 0.001) and the total volume of blood products transfused during the hospital admission was significantly lower (164 [126-212] ml/kg vs 323 [268-379] ml/kg, p < 0.001). No significant differences were noted between methods in either pre or post-transplant maximum isohaemagglutinin titres, incidence of rejection, length of intensive care or total hospital stay. Survival comparison showed no significant difference between antibody reduction methods, or indeed ABO-compatible transplants (p = 0.6).

Conclusions

This novel technique appears to allow a significantly older population than typical to undergo ABO-incompatible heart transplantation, as well as significantly reducing blood product utilization. Furthermore, intraoperative anti-A/B immunoadsorption does not demonstrate increased early post-transplant isohaemagglutinin accumulation or rates of rejection compared to ABO-PE. Early survival is equivalent between ABO-IA, ABO-PE and ABO-compatible heart transplantation.

Ultrasound has limited diagnostic utility in children with acute lymphoblastic leukemia developing pancreatitis

PURPOSE

Acute pancreatitis (AP) due to chemotherapy-induced pancreatic injury is a common side effect of treatment for acute lymphoblastic leukemia (ALL), the most common childhood malignancy. The American College of Radiology recommends ultrasound (US) for initial imaging of AP in all populations to assess for ductal obstruction. However, US may be insensitive to diagnose and assess chemotherapy-associated AP.

METHODS AND MATERIALS

The institutional review board approved this retrospective study. Patients with ALL and AP were identified from protocol databases, using Common Terminology Criteria for Adverse Events (CTCAE) version 3. Chemotherapy dosing, amylase/lipase levels, clinical symptoms, and US/computed tomography (CT) reports within 10 days of diagnosis were recorded. All CT images were reviewed for revised Atlanta classification and CT severity index (CTSI).

RESULTS

Sixty-nine patients, aged 2-21 years, experienced 88 episodes of AP, undergoing 98 US and 44 CT. Seventy-two events (82%) occurred within 30 days of asparaginase administration. Sixty-nine episodes (78%) were initially diagnosed by the presence of abdominal pain and pancreatic enzyme elevation. Overall sensitivities for AP detection were 47% using US and 98% for CT. US sensitivity was greatest in CTCAE grade 4 (86%) and necrotizing pancreatitis (67%).

CONCLUSIONS

Most cases of AP in children with ALL can be diagnosed with clinical history and labs. US has limited sensitivity in detecting pancreatitis in this population. Imaging to diagnose AP in this patient population could be limited to clinically equivocal cases.

1155 The Association Between STOPBANG Risk and Sleep Quality in an mTBI Sample

Introduction

Although Obstructive Sleep Apnea (OSA) is prevalent in the military population, traditional scoring/clinical cut-offs of available screening tools may not be appropriate for this younger, slimmer population. We additionally have limited information regarding utility of OSA screening in those with history of mild traumatic brain injury (mTBI). The current study compared multiple STOPBANG scoring methods to determine how well they were associated with self-reported sleep measures in an mTBI sample.

Methods

Secondary analyses were conducted from a large database of evaluations from a multi-center, longitudinal study of mTBI. Participants were included if they had completed the STOPBANG and additional sleep measures. The subsequent sample (N=486) included participants with history of mTBI (n=408) and controls (n=78). The sample was predominantly male (n=421) with a mean age of 39 (IQR = 31/37/47).

Results

Sleep efficiency was not significantly associated with any STOPBANG scoring, in the total sample or when controlling for mTBI. In the total sample, sleep quality was most strongly associated with traditional STOPBANG scoring (STOPBANG ≥ 3, β=0.51). Sleep duration was most strongly associated with Snoring/Tired/Hypertension (STP = 3, β=0.79). When controlling for mTBI, duration was most strongly associated with traditional scoring (β=0.48), while sleep quality was most strongly associated with Snoring/Tired/Hypertension (β=0.78). Follow-up analyses demonstrate a significant difference in correlation between groups for STP/Sleep Quality, with a stronger correlation for those without mTBI.

Conclusion

The STOPBANG measure was significantly associated with self-reported sleep quality/duration measures, but not sleep efficiency. Although traditional clinical cut-offs for OSA predicted sleep measures in this sample, the relationship between risk scores and outcomes became more nuanced when history of mTBI was included. Future studies are needed to understand the relationship between OSA risk and subsequent diagnosis in the mTBI population.

Support

Defense and Veterans Brain Injury Center (GDHS,W91YTZ-13-C-0015), DOD(W81XWH-12-2-0095), VA(I01 CX001135)

0608 Concordance Between Current AASM And CMS Scoring Criteria for Obstructive Sleep Apnea in Hospitalized Persons with TBI: A NIDILRR and VA Model System Study

Introduction

The objective of this study was to compare OSA, demographic, and TBI characteristics across the American Academy of Sleep Medicine (AASM) and Centers for Medicare and Medicare (CMS) scoring rules in moderate to severe TBI undergoing inpatient neurorehabilitation.

Methods

This is a secondary analysis from a prospective clinical trial of sleep apnea at six TBI Model System study sites (n=248). Scoring was completed by a centralized center using both the AASM and CMS criteria for OSA. Hospitalization and injury characteristics were abstracted from the medical record and demographics obtained by interview by trained research assistants using TBI Model System standard procedures.

Results

OSA was prevalent using the AASM (66%) and CMS (41.5%) criteria with moderate to strong agreement (weighted kappa = 0.64 (95%CI = 0.58, 0.70). Significant differences were observed for participants meeting AASM and CMS criteria (Agreement Group; AG) compared to those meeting criteria for AASM but not CMS (Disagreement Group; DG). At AHI ≥ 5, the DG (n=61) had lower Emergency Department Glasgow Coma Scale Scores consistent with greater injury severity (median 5 vs. 13, p = 0.0050), younger age (median 38 vs 58, p&lt;0.0001), and lower BMI (median 24.8 vs 22.1, p = 0.0007) compared to the AG (n=103). At AHI ≥ 15, female gender and but no other differences were noted possibly due to the smaller sample size.

Conclusion

The underestimation of sleep apnea using CMS criteria is consistent with prior literature; however, this is the first study to report the impact of the criteria in persons with moderate to severe TBI during a critical stage of neural recovery. Management of comorbidities in TBI has become an increasing focus for optimizing TBI outcomes. Given the chronic morbidity after moderate to severe TBI, the impact of CMS policy for OSA diagnosis for persons with chronic disability and young age are considerable.

Support

PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

0620 Characteristics Distinguishing Special Operational Forces (SOF) Personnel from Non-SOF Peers with TBI: Retrospective Analysis From the VA TBI Model Systems

Introduction

Special Operations Forces (SOF) is an umbrella term which encompasses over a dozen specialized communities across all military branches. Little is known about potential differences in demographic and health characteristics, including sleep, between SOF vs. non-SOF service members. We leveraged existing longitudinal studies of those with history of TBI to examine differences between SOF and non-SOF in the dataset.

Methods

We conducted a retrospective analysis of data from the VA TBI Model Systems, a multi-center longitudinal study of outcomes following TBI rehabilitation. Participants were included if SOF status was known (N = 261). Differences between groups on variables of interest were then classified as “Immaterial”, “Minor,” and “Important” based on either prevalence (categorical data) or degree of difference (continuous data).

Results

Of included participants, 68 (26%) were identified as SOF and 193 (74%) as non-SOF. SOF were more highly educated and more likely to have history of mild TBI. There were multiple “important” differences in co-morbidity prevalence. SOF participants were more likely to be diagnosed with sleep apnea (36% SOF vs 12% non-SOF). They were also more likely to have been diagnosed with chronic pain, a cardiac condition, high blood cholesterol, and/or osteoarthritis.

Conclusion

SOF participants differed from non-SOF in a multiple important ways, suggesting this is a different and medically complex population. The most striking finding was that SOF personnel had a significantly greater rate of sleep apnea, relative to non-SOF. The mechanism underlying this difference is not known but may relate to training, blast exposure, weapons use, and mission demands. Further investigation regarding mechanisms, prevalence, and treatment of OSA in the SOF community is needed.

Support

This research was sponsored by VHA Central Office VA TBI Model Systems Program of Research; Subcontract from General Dynamics Information Technology (W91YTZ-13-C-0015; HT0014-19-C-0004).

0606 Comparative Effectiveness of Sleep Apnea Screening Tools During Inpatient Rehabilitation for Moderate to Severe TBI

Introduction

Recent studies highlight prevalent obstructive sleep apnea after moderate to severe TBI during a time of critical neural repair. The purpose of this study is to determine the diagnostic sensitivity, specificity and comparative effectiveness of traditional sleep apnea screening tools in TBI neurorehabilitation admissions.

Methods

This is a prospective diagnostic comparative effectiveness trial of sleep apnea screening tools (STOPBANG, Berlin, MAPI [Multi-Apnea Prediction Index]) relative Level 1 polysomnography at six TBI Model System Inpatient Rehabilitation Centers. Between 05/2017 and 02/2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248. The primary outcome was the Area Under the Curve (AUC) of screening tools relative to total apnea hypopnea index ≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (IQR 29-47).

Results

Participants were primarily young to middle age (AGE IQR 28,40,59), male (81%), white (74%), and had primarily severe TBI (IQR GCS 3,6,14). A subset (26%) had a history of military service. Results revealed that the Berlin high risk score (ROC-AUC=0.63) was inferior to the MAPI (ROC-AUC = 0.7802) (p=.0211, CI: 0.0181, 0.2233) and STOPBANG (ROCAUC = 0.7852) (p=.0006, CI: 0.0629, 0.2302); both of which had comparable AUC (p=.7245, CI: -0.0472, 0.0678). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI&gt;5. The pattern was similar across TBI severity subgroups except for delirium or post-traumatic amnesia status wherein the MAPI outperformed the Berlin and STOPBANG. Youden’s Index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples.

Conclusion

This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for moderate to severe TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome.

Support

PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

Chemogenetic Inhibition of the Amygdala Modulates Emotional Behavior Expression in Infant Rhesus Monkeys

Manipulation of neuronal activity during the early postnatal period in monkeys has been largely limited to permanent lesion studies, which can be impacted by developmental plasticity leading to reorganization and compensation from other brain structures that can interfere with the interpretations of results. Chemogenetic tools, such as DREADDs (designer receptors exclusively activated by designer drugs), can transiently and reversibly activate or inactivate brain structures, avoiding the pitfalls of permanent lesions to better address important developmental neuroscience questions. We demonstrate that inhibitory DREADDs in the amygdala can be used to manipulate socioemotional behavior in infant monkeys. Two infant rhesus monkeys (1 male, 1 female) received AAV5-hSyn-HA-hM4Di-IRES-mCitrine injections bilaterally in the amygdala at 9 months of age. DREADD activation after systemic administration of either clozapine-N-oxide or low-dose clozapine resulted in decreased freezing and anxiety on the human intruder paradigm and changed the looking patterns on a socioemotional attention eye-tracking task, compared with vehicle administration. The DREADD-induced behaviors were reminiscent of, but not identical to, those seen after permanent amygdala lesions in infant monkeys, such that neonatal lesions produce a more extensive array of behavioral changes in response to the human intruder task that were not seen with DREADD-evoked inhibition of this region. Our results may help support the notion that the more extensive behavior changes seen after early lesions are manifested from brain reorganization that occur after permanent damage. The current study provides a proof of principle that DREADDs can be used in young infant monkeys to transiently and reversibly manipulate behavior.

Artificial cell membrane binding thrombin constructs drive in situ fibrin hydrogel formation

Cell membrane re-engineering is emerging as a powerful tool for the development of next generation cell therapies, as it allows the user to augment therapeutic cells to provide additional functionalities, such as homing, adhesion or hypoxia resistance. To date, however, there are few examples where the plasma membrane is re-engineered to display active enzymes that promote extracellular matrix protein assembly. Here, we report on a self-contained matrix-forming system where the membrane of human mesenchymal stem cells is modified to display a novel thrombin construct, giving rise to spontaneous fibrin hydrogel nucleation and growth at near human plasma concentrations of fibrinogen. The cell membrane modification process is realised through the synthesis of a membrane-binding supercationic thrombin-polymer surfactant complex. Significantly, the resulting robust cellular fibrin hydrogel constructs can be differentiated down osteogenic and adipogenic lineages, giving rise to self-supporting monoliths that exhibit Young's moduli that reflect their respective extracellular matrix compositions.

Breech delivery, rupture of Batson's plexus, T8 epidural hematoma, and paraplegia

A male newborn born by an atraumatic vaginal frank breech delivery was noted to have normal limb movement at birth. However, at 24 hours the neonate developed paraplegia with no evidence of spinal cord injury on radiographic films. Ultrasound and MRI demonstrated an epidural hematoma at the level of T8 and distal cord edema which extended to the conus medullaris. Delayed onset paraplegia following an atraumatic vaginal breech delivery is unlikely to have been caused by acute traction or torsion at birth. Traction and torsion injuries would present acutely. This infant developed a T8 epidural hematoma which has not been reported in a newborn. The pathophysiology of a spontaneous spinal epidural hematoma (SSEH) in adults is frequently related to increased abdominal/thoracic pressure which results in increased pressure in the highly anastomotic network of thin walled and valve-less vertebral venous plexus (Batson's plexus). Such increase in abdominal/thoracic pressure could occur during a frank breech delivery and result in a slow onset epidural hematoma. This report highlights the importance of considering slow onset epidural hematoma in the differential diagnosis of neonates who develop slow onset paraplegia. If diagnosed quickly, an epidural hematoma represents a potentially treatable etiology by rapid surgical decompression.

Impaired Cognitive Flexibility After Neonatal Perirhinal Lesions in Rhesus Macaques

Previous research indicated that monkeys with neonatal perirhinal lesions (Neo-PRh) were impaired on working memory (WM) tasks that generated proactive interference, but performed normally on WM tasks devoid of interference (Weiss et al., 2016). This finding suggested that the early lesions disrupted cognitive processes important for resolving proactive interference, such as behavioral inhibition and cognitive flexibility. To distinguish between these possibilities, the same Neo-PRh monkeys and their controls were tested using the Intradimensional/Extradimensional attentional set-shifting task (Roberts et al., 1988; Dias et al., 1997). Neo-PRh monkeys completed the Simple and Compound Discrimination stages, the Intradimensional Shift stage, and all Reversal stages comparably to controls, but made significantly more errors on the Extradimensional Shift stage of the task. These data indicate that impaired cognitive flexibility was the likely source of increased perseverative errors made by Neo-PRh monkeys when performing WM tasks, rather than impaired behavioral inhibition, and imply that the perirhinal cortex and its interactions with the PFC may play a unique and critical role in the development of attentional set shifting abilities.

First nations people's perspectives on barriers and supports for enhancing HPV vaccination: Foundations for sustainable, community-driven strategies

OBJECTIVE

In Canada, Indigenous people have higher human papillomavirus (HPV) infection rates, lower screening rates for cervical cancer, and higher rates of invasive cancer, leading to worse cervical cancer-related outcomes than observed in non-Indigenous Canadian women. Lingering harms from European colonization drive these health inequities and create public health challenges. Policy guidance is needed to optimize HPV vaccination rates and, thereby, decrease the burden of HPV-related illness, including high-morbidity surgical procedures and chemo-radiotherapy. The Enhancing HPV Vaccination In First Nations Populations in Alberta (EHVINA) project focuses on First Nations, a diverse subset of recognized Indigenous people in Canada, and seeks to increase HPV vaccination among girls and boys living in First Nation communities.

METHODS

Developing an effective strategy requires partnership with affected communities to better understand knowledge and perceptions about cancer, healthcare, and the HPV vaccine. A 2017 community gathering was convened to engage First Nations community members, health directors, and health services researchers in dialogue around unique barriers and supports to HPV vaccination in Alberta. Voices of community Elders, parents, health directors, and cancer survivors (n=24) are presented as qualitative evidence to help inform intervention design.

RESULTS

Key findings from discussions indicate barriers to HPV vaccination include resource constraints and service infrastructure gaps, historical mistrust in healthcare systems, impacts of changing modes of communication, and community sensitivities regarding sexual health promotion. Supports were identified as strengthened inter-generational relationships in communities.

CONCLUSIONS AND FUTURE DIRECTION

Ongoing dialogue and co-development of community-based strategies to increase HPV vaccine uptake are required. The identification of possible barriers to HPV vaccination in a Canadian Indigenous population contributes to limited global literature on this subject and may inform researchers and policy makers who work with Indigenous populations in other regions.

Abstract P2-05-15: Oncotype DX Breast Recurrence Score®: Real-life utilization among node positive patients in Ontario

Aims: The 21-gene Oncotype DX (ODX) Recurrence Score (RS) has been extensively validated to predict the risk of distant recurrence and the magnitude of response to hormone and chemotherapy in patients with ER+ N0 and N+ (up to 3 positive nodes) HER2- early stage breast cancer. Outcomes data from multiple large studies further confirm the assays clinical validity and utility. The test is currently reimbursed in Ontario for N0 but not for N1 patients. In 2016, a market access program has been initiated to address lack of data in current clinical practice in Ontario among N1 patients. It collects data assessing the real-life use of the test in Ontario and its impact on treatment decision. This analysis presents the interim analysis until end of May 2017.

Methods : The program allows for prospective data collection in key breast cancer centers in Ontario. Through an online dedicated platform patient data are collected including classical pathological and clinical parameters (e.g. histology, tumor grade and size, ER, PR, and HER2 status), patients age, ODX Recurrence Score results and recommended treatment both before and after the test results have been reported.

Results: A total of 7 qualified breast cancer centers or network of centers participated in the program and collected 90 cases so far. Study results demonstrated that ODX is used among a wide variety of patients profiles: 28% G1, 58% G2 and 14% of G3, 18% pre-, 12% peri- & 69% are post-menopausal, 20% are aged 40-49, 24% are 50-59, 29% are 60-69 and 26% are 70 and older, 3% tumor are &lt;1cm, 38% are 1-&lt;2cm, 52% are 2-&lt;5cm and 7% tumor size are &gt;5cm.

RS distribution is the following: &lt;18 (67%), 18-30 (30%) and &gt;30 (3%).

In addition, pre-ODX 90% of patients had a treatment recommendation for chemo-hormonotherapy (CT-HT). Post-testing, the number of patients recommended CT-HT decreased to 36%, highlighting that the test reduces unnecessary use of CT. In fact, the ODX led to an overall 54% net reduction in chemotherapy.

Conclusions: This real-life survey confirms that ODX provides critical information beyond clinical and pathological criteria. The assay changes treatment decisions among N+ patients in Ontario, sparing CT which could result in potential savings to the healthcare system.

Citation Format: Richardson R, Macchiusi A, Bhasin A, Takizawa C. Oncotype DX Breast Recurrence Score®: Real-life utilization among node positive patients in Ontario [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-05-15.

Intact perceptual ability, but impaired familiarity judgment, after neonatal perirhinal lesions in rhesus macaques

The perirhinal cortex is known to support high-level perceptual abilities as well as familiarity judgments that may affect recognition memory. We tested whether poor perceptual abilities or a loss of familiarity judgment contributed to the recognition memory impairments reported earlier in monkeys with PRh lesions received in infancy (Neo-PRh) (Weiss and Bachevalier, 2016; Zeamer et al., 2015). Perceptual abilities were assessed using a version of the Visual Paired Comparison task with black&white (B&W) stimuli, and familiarity judgments were assessed using the Constant Negative task requiring repeated familiarization exposures. Adult monkeys with Neo-PRh lesions were able to recognize B&W stimuli after short delays, suggesting that their perceptual abilities were within the range of control animals. However, the same Neo-PRh monkeys were slower to acquire the Constant Negative task, requiring more exposures to objects before judging them as familiar compared to control animals. Taken together, the data help to account for the differential patterns of functional compensation on previously reported recognition tasks following neonatal versus adult-onset PRh lesions, and provide further support to the view that the PRh is involved in familiarity processes.

Beta-thalassemia in the paediatric cardiac surgery setting - a case report and literature review

Beta (β)-thalassemia is a blood disorder with an incidence of 1 in 100,000.1 This case report outlines a patient with β-thalassemia requiring cardiopulmonary bypass (CPB) and the measures taken to ensure an uneventful procedure.

Methods Matter: Tracking Health Disparities in Alternative High Schools

Alternative high school (AHS) students are at-risk for school dropout and engage in high levels of health-risk behaviors that should be monitored over time. They are excluded from most public health surveillance efforts (e.g., Youth Risk Behavior Survey; YRBS), hindering our ability to monitor health disparities and allocate scarce resources to the areas of greatest need. Using active parental consent, we recruited 515 students from 14 AHSs in Texas to take a modified YRBS. We calculated three different participation rates, tracked participation by age of legal consent (≥18 and <18 years), and identified other considerations for obtaining quality data. Being required to use active consent resulted in a much lower cooperation rate among students <18 years (32%) versus those who were ≥18 years and could provide their own consent (57%). Because chronic truancy is prevalent in AHS students, cooperation rates may be more accurate than participation rates based off of enrollment or attendance. Requiring active consent and not having accurate participation rates may result in surveillance data that are of disparate quality. This threatens to mask the needs of AHS students and perpetuate disparities because we are likely missing the highest-risk students within a high-risk sample and cannot generalize findings.

The role of Rho kinase (Rock) in re-epithelialization of adult zebrafish skin wounds

Complete re-epithelialization of full-thickness skin wounds in adult mammals takes days to complete and relies on numerous signaling cues and multiple overlapping cellular processes that take place both within the epidermis itself and in other participating tissues. We have previously shown that re-epithelialization of full-thickness skin wounds of adult zebrafish, however, is extremely rapid and largely independent of the other processes of wound healing allowing for the dissection of specific processes that occur in, or have a direct effect on, re-epithelializing keratinocytes. Recently, we have shown that, in addition to lamellipodial crawling at the leading edge, re-epithelialization of zebrafish partial- and full-thickness wounds requires long-range epithelial rearrangements including radial intercalations, flattening and directed elongation and that each of these processes involves Rho kinase (Rock) signaling. Our studies demonstrate how these coordinated signaling events allow for the rapid collective cell migration observed in adult zebrafish wound healing. Here we discuss the particular contribution of Rock to each of these processes.

The zebrafish eye-a paradigm for investigating human ocular genetics

Although human epidemiological and genetic studies are essential to elucidate the aetiology of normal and aberrant ocular development, animal models have provided us with an understanding of the pathogenesis of multiple developmental ocular malformations. Zebrafish eye development displays in depth molecular complexity and stringent spatiotemporal regulation that incorporates developmental contributions of the surface ectoderm, neuroectoderm and head mesenchyme, similar to that seen in humans. For this reason, and due to its genetic tractability, external fertilisation, and early optical clarity, the zebrafish has become an invaluable vertebrate system to investigate human ocular development and disease. Recently, zebrafish have been at the leading edge of preclinical therapy development, with their amenability to genetic manipulation facilitating the generation of robust ocular disease models required for large-scale genetic and drug screening programmes. This review presents an overview of human and zebrafish ocular development, genetic methodologies employed for zebrafish mutagenesis, relevant models of ocular disease, and finally therapeutic approaches, which may have translational leads in the future.

Re-epithelialization of cutaneous wounds in adult zebrafish combines mechanisms of wound closure in embryonic and adult mammals

Re-epithelialization of cutaneous wounds in adult mammals takes days to complete and relies on numerous signalling cues and multiple overlapping cellular processes that take place both within the epidermis and in other participating tissues. Re-epithelialization of partial- or full-thickness skin wounds of adult zebrafish, however, is extremely rapid and largely independent of the other processes of wound healing. Live imaging after treatment with transgene-encoded or chemical inhibitors reveals that re-epithelializing keratinocytes repopulate wounds by TGF-β- and integrin-dependent lamellipodial crawling at the leading edges of the epidermal tongue. In addition, re-epithelialization requires long-range epithelial rearrangements, involving radial intercalations, flattening and directed elongation of cells - processes that are dependent on Rho kinase, JNK and, to some extent, planar cell polarity within the epidermis. These rearrangements lead to a massive recruitment of keratinocytes from the adjacent epidermis and make re-epithelialization independent of keratinocyte proliferation and the mitogenic effect of FGF signalling, which are only required after wound closure, allowing the epidermis outside the wound to re-establish its normal thickness. Together, these results demonstrate that the adult zebrafish is a valuable in vivo model for studying and visualizing the processes involved in cutaneous wound closure, facilitating the dissection of direct from indirect and motogenic from mitogenic effects of genes and molecules affecting wound re-epithelialization.

Retrospective evaluation of the efficacy of isolating bacteria from synovial fluid in dogs with suspected septic arthritis

OBJECTIVE

To evaluate the efficacy of synovial fluid culture in obtaining the causative organism from dogs with suspected septic arthritis.

METHODS

In this retrospective evaluation, synovial fluid cytology and microbiology submissions from dogs with suspected septic arthritis from March 2007 to August 2011 were reviewed. Synovial fluid cytology consistent with joint sepsis was identified. Cultures of synovial fluid from dogs with clinical histories and abnormalities consistent with septic arthritis were used to evaluate the efficacy of bacterial isolation.

RESULTS

In total, 36 dogs met the inclusion criteria. Initial aerobic cultures of joint fluid yielded bacterial growth in 44% of these dogs. All anaerobic cultures were negative. In 19% of the dogs with positive cultures, antibiotics had been administered prior to arthrocentesis compared with 10% of dogs with negative cultures. There was no association between culture efficacy and the administration of antimicrobial treatment prior to synovial fluid culture or recent surgery involving the affected joint (P=0.637 and P=0.106, respectively).

CONCLUSION

Culture of synovial fluid from dogs with suspected septic arthritis has a low yield, necessitating a more effective means of identifying bacteria from suspected septic joints in dogs.

Comparison of synovial fluid culture and 16S rRNA PCR in dogs with suspected septic arthritis

OBJECTIVE

To prospectively compare the sensitivity and specificity of 16S rRNA PCR with culture for identifying the causative organism in synovial fluid obtained from dogs with suspected septic arthritis.

METHODS

Synovial fluid cytology, PCR analysis and aerobic, anaerobic and Mycoplasma culture of samples from the affected joints of 18 dogs presenting with suspected septic arthritis were performed. Synovial fluid samples from the corresponding contralateral joints of 7 dogs were also analysed as negative controls.

RESULTS

There was no significant difference between the sensitivity of bacterial detection via culture (63.2%) versus PCR (73.7%) of synovial fluid (P=0.728) or between culture and combined PCR and culture (89.5%) of synovial fluid (P=0.124). The specificity of PCR (42.9%) was significantly lower than culture specificity (100%) (P=0.07).

CONCLUSION

Although 16S PCR may hold potential as an ancillary diagnostic test for identifying the causative organism in dogs with septic arthritis, our study failed to demonstrate improved accuracy compared with traditional synovial fluid culture.

Interleukin-4 Receptor α Signaling in Myeloid Cells Controls Collagen Fibril Assembly in Skin Repair

Activation of the immune response during injury is a critical early event that determines whether the outcome of tissue restoration is regeneration or replacement of the damaged tissue with a scar. The mechanisms by which immune signals control these fundamentally different regenerative pathways are largely unknown. We have demonstrated that, during skin repair in mice, interleukin-4 receptor α (IL-4Rα)-dependent macrophage activation controlled collagen fibril assembly and that this process was important for effective repair while having adverse pro-fibrotic effects. We identified Relm-α as one important player in the pathway from IL-4Rα signaling in macrophages to the induction of lysyl hydroxylase 2 (LH2), an enzyme that directs persistent pro-fibrotic collagen cross-links, in fibroblasts. Notably, Relm-β induced LH2 in human fibroblasts, and expression of both factors was increased in lipodermatosclerosis, a condition of excessive human skin fibrosis. Collectively, our findings provide mechanistic insights into the link between type 2 immunity and initiation of pro-fibrotic pathways.

The lasting impact of early-life adversity on individuals and their descendants: potential mechanisms and hope for intervention

The adverse effects of early-life stress are pervasive, with well-established mental and physical health consequences for exposed individuals. The impact of early adverse experiences is also highly persistent, with documented increases in risk for mental illness across the life span that are accompanied by stable alterations in neural function and hormonal responses to stress. Here, we review some of these 'stress phenotypes', with a focus on intermediary factors that may signal risk for long-term mental health outcomes, such as altered development of the fear regulation system. Intriguingly, recent research suggests that such stress phenotypes may persist even beyond the life span of the individuals, with consequences for their offspring and grand-offspring. Phenotypic characteristics may be transmitted to future generations via either the matriline or the patriline, a phenomenon that has been demonstrated in both human and animal studies. In this review, we highlight behavioral and epigenetic factors that may contribute to this multigenerational transmission and discuss the potential of various treatment approaches that may halt the cycle of stress phenotypes.