Inpatient Protocol Research Articles

Implementation of a Standardized Protocol for Postpartum Anemia: A Prospective Cohort Study.

Implementation of standardized protocols for antepartum anemia increases intravenous iron (IVFe) use and improves predelivery hemoglobin (Hb). However, this condition is often overlooked and inadequately treated in postpartum care settings. We aimed to determine if implementation of a standardized protocol for postpartum anemia increases postpartum IVFe use and affects clinical outcomes. We performed a prospective cohort study evaluating implementation of a standardized inpatient protocol for postpartum anemia. This protocol, implemented in December 2021, recommends (1) IVFe for postpartum Hb 7.0 to 8.9 g/dL and (2) oral iron for postpartum Hb 9.0 to 9.9 g/dL. We compared all postpartum inpatients at a single site from April 2021 (preimplementation period [PRE]) to April 2022 (postimplementation period [POST]). The primary outcome was any IVFe use. Secondary outcomes included number of IVFe doses, oral iron supplementation at discharge, postpartum complications, and length of stay. A total of 805 patients were included (PRE = 401; POST = 404). Patients in the PRE and POST groups differed in ethnicity (PRE: 8.2% Hispanic vs. POST: 14.9% Hispanic, p = 0.003). IVFe use significantly increased from PRE to POST (PRE: 6.0% vs. POST: 11.1%, p = 0.009) even when controlling for differences between groups (adjusted odds ratio: 2.48, 95% confidence interval: [1.08-5.67]). Patients receiving IVFe in the POST group were more likely to receive the recommended three doses of IVFe compared with patients receiving IVFe in the PRE group (POST: 29% vs. PRE: 4%, p = 0.04). Patients in the POST group had shorter lengths of stay than in the PRE group (POST: 1.69 days vs. PRE: 1.81 days, p < 0.001). There were no significant differences in blood transfusion, oral iron supplementation, or postpartum complications. Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay. · Postpartum anemia is associated with postpartum depression, fatigue, impaired cognition, and altered maternal-infant bonding.. · IVFe is more effective and better tolerated than oral iron.. · Implementation of standardized protocols for antepartum anemia has been shown to increase IVFe use.. · Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay..

Abstract 49: Activator protein 1 (AP-1) Complex in Antigen Presenting Cells contributes to Salt-Sensitive Blood Pressure in Humans

Salt-sensitivity of blood pressure (SSBP) is an independent risk factor for cardiovascular morbidity and mortality. The exact mechanism by which salt intake increases blood pressure is complex and not fully understood. We previously found that sodium entry into antigen-presenting cells (APCs) via the epithelial sodium channel (ENaC) activates proinflammatory cytokines to activate T cells and modulate salt-sensitive hypertension. The activator protein 1 (AP-1) transcriptional factors (FOS/JUN) have been implicated in activating the pro-inflammatory pathway, but its role in SSBP is unknown. We hypothesized that high salt activates the AP-1 signaling pathway and inflammation in APCs and contributes to SSBP. Our bulk RNA-sequencing data in human monocytes, demonstrated that high salt increases the expression of the AP-1 gene family, FOS (2,378.1 ± 480.7 vs 6,494.0 ± 945.5, p= 0.0009), and JUN (7,313.9 ± 984.9 vs11,370.0 ± 1,286.3, p= 0.0015) compared to normal salt-treated monocytes. In additional experiments, we enrolled patients with hypertension and phenotype them for SSBP using an established inpatient protocol of salt-loading/depletion and performed single-cell transcriptomic analyses on peripheral blood mononuclear cells (PBMCs). We observed expression of the e FOS (r= 0.5041, p= 0.0464) and JUN (r= 0.7083, p= 0.0021) genes changes in concert with blood pressure in salt-sensitive (SS) but not in salt-resistant (SR) patients. To confirm whether genes expression translates to protein expression, we cultured total splenocytes from salt-sensitive SV/129 mice for 24 hours in either normal (150 mM) or high salt media (190 mM) and performed flow cytometry. Compared to normal salt, high salt-induced a significant increase in the expression of FOS-JUN genes in monocytes of the spleen. We also adoptively transferred PBMCs from salt-sensitive (SS) and salt-resistant (SR) hypertensive individuals into immunodeficient NSG mice, treated with the high salt diet for three weeks and performed flow cytometry on immune cells of the kidney, aorta, and spleen. We found that immune cells from SS people demonstrated a higher propensity to infiltrate mouse tissues with increased expression of FOS-JUN genes than immune cells from SR people. These preliminary findings disclose the role of the AP-1 gene family in salt-sensitive hypertension and may provide a potential therapeutic target for the treatment and diagnosis of SSBP.

Abstract P182: Antigen Presenting Cell-specific Keap1-Nrf2 pathway Mediates Salt-Sensitive Hypertension in Humans

Background: Hypertension remains the leading cause of mortality worldwide and is a primary risk factor for cardiovascular disease. Of the 1.3 billion people globally affected by hypertension, over 50% exhibit salt-sensitivity of blood pressure (SSBP), which leads to higher rates of mortality, morbidity, and kidney damage compared to those with salt-resistant hypertension. Previously our research has shown that high salt intake activates antigen-presenting cells (APCs), causing inflammation and hypertension. This pro-inflammatory response is partly driven by the epithelial sodium channel (ENaC), which facilitates sodium ion transport into APCs. While the Keap1-Nrf2 pathway is known for its role in antioxidant defense and inflammatory responses, its contribution to salt-sensitive hypertension remains unclear. We hypothesize that ENaC-dependent sodium entry triggers inflammation and activates the Sp1-MALAT1-Keap1-Nrf2 signaling axis in APCs, thereby contributing to SSBP. Method: We utilized a well-established inpatient protocol to phenotype participants for salt sensitivity of blood pressure. Additionally, we conducted RNA sequencing (RNAseq) on human monocytes exposed to elevated sodium levels in vitro and performed Cellular Indexing of Transcriptomes and Epitopes by Sequencing (CITE-seq) analysis on peripheral blood mononuclear cells (PBMCs). Results: We found that whereas high salt did not significantly increases expression of Sp1 (5380.63 ± 359.77 vs 7414.54 ± 434.19, q=0.829), MALAT1 (86888.54 ±12200.12 vs 219429.90 ± 109994.16, q=0.717), Keap1 (1586.54 ± 132.94 vs 2203.72 ± 177.48, q=0.884), it significantly increased Nrf2 expression (5080.36 ± 416.64 vs 5443.54 ± 432.78, q=0.019) in RNAseq analysis of human high salt compared to normal salt treated monocyte. Furthermore, the results of the CITE-seq experiment indicated that changes in the expression of the Sp1 correlate with SSBP (r=0.5205, p=0.038). Conclusion: These preliminary findings reveal a physiological link between inflammation and salt-sensitive hypertension through the Sp1-MALAT1-Keap1-Nrf2 signaling axis in APCs. The activation of APCs mediated by Sp1 could potentially serve as a diagnostic marker for salt sensitivity in blood pressure.

Antigen Presenting Cell activator protein 1 (AP-1) complex contributes to Salt-sensitive Blood Pressure

Salt-sensitivity of blood pressure (SSBP) affects 50% of the hypertensive and 25% of the normotensive population and is a major independent risk factor for cardiovascular morbidity and mortality. We previously found that SSBP is associated with activation of the NLRP3 inflammasome in antigen presenting cells (APCs) via increased oxidated stress and isolevuglandin (IsoLG) formation, but the underlying mechanisms are unknown. The activator protein 1 (AP-1) (FOS/JUN) has been implicated in activation of the NLRP3 inflammasome but its role in SSBP is not known. We hypothesized that AP-1 transcription factor in APCs senses elevated sodium and contributes to SSBP. We further hypothesize that antioxidant flavonoid, diosmetin prevents AP-1 activation and SSBP. Using bulk RNA-sequencing in human monocytes, we found elevated sodium increases expression of the AP-1 gene family when compared to normal sodium concentration, including cFOS (2378.18 ± 480.7 vs 6494.09 ± 945.55, p= 0.0009), FOSB (53.63 ± 17. 55 vs 131.06 ± 10.30, p= 0.397), cJUN (7313.90 ± 984.93 vs 11370.09 ± 1286.35, p= 0.2563) JUNB (4218.4.36 ± 199.17 vs 570.45 ± 200.91, p= 0.0445) and JUND (3309. 63 ± 270.64 vs 8057.90 ± 1043.05, p= 0.00006). In additional experiments, we enrolled people with hypertension and phenotype them for SSBP using an established in-patient protocol of salt-loading/depletion and performed single-cell transcriptomic analyses in vivo on peripheral blood mononuclear cells (PBMCs). We found that expression of the FOSB and JUNB genes are more sensitive in concert with blood pressure in salt-sensitive (SS) but not salt-resistant (SR) humans. Moreover, diosmetin attenuated high salt-induced hypertension, 123.5 ± 4.1 vs 146.8 ± 2.5 mm Hg in controls, **p&lt; 0.01). In addition, diosmetin also reduced high salt-induced inflammation including APC production of IsoLG-protein adducts, IL-1β, and NLRP3 inflammasome expression. These findings reveal a role for immune cell AP-1 (FOS/JUN) signaling in salt-sensitive hypertension and diosmetin may provide a potential therapeutic target for treatment of SSBP. 1R01HL144941-01A1. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Outpatient vs Inpatient Single-Port Robotic Urologic Surgery: Perioperative Outcomes and Complications.

The da Vinci Single Port (SP) robotic surgical system has minimized the impact of surgery on patients. Hence, outpatient robotic procedures are being explored to reduce costs and improve patient experience. Here, we evaluate the perioperative outcomes and safety of same-day discharge (SDD) after surgery compared to inpatient procedures using the SP. A total of 374 patients underwent surgery with the da Vinci SP system between January 2019 and February 2023. Surgeries were performed in a single high-volume center. Patients were either managed with a standardized outpatient or inpatient protocol. SDD clinical pathway was implemented in June 2021. Patients were assessed for discharge eligibility based on specific guidelines. Detailed instructions were provided at discharge, and patients were followed postoperatively. Baseline characteristics, perioperative data, complications, time to complication, and readmissions were assessed. Two hundred eight patients underwent outpatient surgery and 166 underwent inpatient surgery (total = 374). Outpatient surgery was not associated with increased postoperative complications and readmission compared to inpatient surgery. Ninety percent and 74.6% of patients experienced no complications in the outpatient and inpatient populations, respectively (P =< .001). Time to first complication was also comparable between the 2 groups (3 days [IQR 1-8] vs 10 days [IQR 4-30] for outpatient vs inpatient; P = .3). The proportion of successful SDDs increased over time, reaching 88% in October 2022. Outpatient surgery using the da Vinci SP is safe and feasible, without increasing postoperative complications compared to standard inpatient surgery.

The role of structured inpatient lipid protocols in optimizing non-statin lipid lowering therapy: a review and single-center experience.

Dyslipidemia is a leading contributor to atherosclerotic cardiovascular disease (ASCVD). There has been a significant improvement in the treatment of dyslipidemia in the past 10 years with the development of new pharmacotherapies. The intent of this review is help enhance clinicians understanding of non-statin lipid lowering therapies in accordance with the 2022 American College of Cardiology Expert Consensus Clinical Decision Pathway on the Role of Non-statin Therapies for LDL-Cholesterol Lowering. We also present a single-center experience implementing a systematic inpatient protocol for lipid lowering therapy for secondary prevention of ASCVD.

An Inpatient Protocol for the Treatment of Methamphetamine Withdrawal in Patients With and Without Opioid Use Disorder.

Increasing rates of methamphetamine (METH) use, use disorders, and related overdoses are a growing public health problem. There are a lack of protocols addressing METH intoxication and withdrawal symptoms that manifest during acute withdrawal treatment resulting in inpatient management difficulties and premature discharges. This report presents a novel treatment protocol comprised of behavior-targeted and pharmacological components that aims to reduce the intensity and duration of METH intoxication and withdrawal related symptoms during early treatment, improve retention, and provide clinicians with a tool to meet this growing problem. The protocol was developed by a team of addiction physicians and other clinical staff. Clinical and administrative staff at a community acute stabilization unit were trained and the protocol was implemented with patients presenting with METH use. Pharmacological interventions, including ascorbic acid, antipsychotics, and other sedatives are discussed, as are behavior-based orders. A retrospective quality assurance examination was conducted on patient characteristics and outcomes as well as focus groups with nursing staff. A total of 23 patients consecutively admitted to the unit used the protocol (100% male). Most patients (67%) displayed symptoms of METH use or withdrawal. Behavior-related interventions were used in 52% of patients, while 48% received behavior-related and pharmacological measures. Patient completion of the protocol was 83%, and the protocol's utility was supported by nursing staff. This retrospective evaluation of a novel METH withdrawal treatment protocol suggests feasibility, tolerability, and preliminary evidence of effectiveness, providing clinicians with a new tool that requires further study.

Enhanced recovery and same-day discharge after brain tumor surgery under general anesthesia: initial experience with Hospital-at-Home-based postoperative follow-up.

The objective of this study was to describe the outcomes of outpatient oncological neurosurgery (OON) in a European clinical setting and to compare them with the conventional inpatient protocol. Patients who had undergone OON (either tumor removal or biopsy) at the authors' center since 2019 were analyzed. A matched cohort of patients was selected from patients undergoing tumor surgery in the same period. Collected data included patient demographics, postoperative progress, specific location of the target lesion, and the procedure performed. There were 18 patients in the case group and 59 patients in the control group. The outpatient surgeries had a same-day discharge rate of 89%, and all ambulatory patients successfully completed the Enhanced Recovery After Surgery program within 6.24 hours of the procedure. All ambulatory patients underwent Hospital-at-Home postoperative follow-up for an average of 4.12 days. Radiological complications were present in 11% of the case group and 8% of the control group. Postoperative neurological deficit occurred in 6% of the same-day discharge group and 3% of the control group. Among the patients in the control group, 3% suffered from postoperative seizures, whereas no seizures were observed in the case group. These differences were not statistically significant. General anesthesia-related complications were not observed in any of the patients. The authors' findings demonstrate that Enhanced Recovery After Surgery protocols and same-day discharge craniotomy for tumor resection and image-guided biopsy under general anesthesia, when patients are carefully selected, can be safely performed with excellent outcomes in a European clinical setting. The OON program proved to be a viable alternative to conventional hospitalization, showing comparable safety records and offering advantages in terms of patient recovery.

Time to diagnosis in rapid exome/genome sequencing in the clinical inpatient setting.

Exome and genome sequencing are clinically available, with many laboratories offering expedited testing (e.g., "rapid" and "ultra-rapid"). With the increase in uptake of expedited testing, there is a need for the development of inpatient protocols for best practices based on real-life data. A retrospective 2-year review (October 2019-November 2021) of the utilization of rapid exome and genome sequencing for inpatient cases at a tertiary care center using a utilization management tracking database with subsequent chart review was performed. Thirty-three expedited "rapid/priority" exome/genome tests were performed clinically. The average total turnaround time (TAT) was 17.88 days (5-43 days) with an average TAT of 13.97 days (3-41 days) for the performing laboratory. There were 5 positive diagnostic results (15.2%), 3 likely positive diagnostic results (9%), 2 noncontributory results (6%), and 26 nondiagnostic results (69.7%). Real-life data suggest that there is an approximately 3.91-day lag in getting samples to the performing laboratory. Although laboratories may advertise their expected TAT, a number of factors can potentially impact the actual time from test order placement to communication of the results for clinical use. Understanding the points of delay will enable the development of internal protocols and policies to improve time to diagnosis.

Entrainment to gradual vs. immediate 8-hour phase advance shifts with and without short-wavelength enriched polychromatic green light

ObjectivesFor optimal health and well-being the sleep episode and the circadian timing system should be properly aligned. We evaluated the effectiveness of different dynamic light and sleep/wake shift schedules for rapid circadian entrainment following an 8-hour advance of sleep. MethodsForty-three healthy participants completed an 8-day inpatient protocol in which the 8-hour sleep episode was advanced by 8 hours. Participants were assigned to one of five conditions: (1) dim ambient WHITE light and GRADUAL shift in which the sleep episode was incrementally advanced over 5days; (2) dim GREEN, short-wavelength (∼504 nm) polychromatic light and GRADUAL shift; (3) dim WHITE light and SLAM shift, including an abrupt 8-hour advance on day 3 following an extended 32-hour wake episode; (4) GREEN light and SLAM shift; or (5) COMBINED (higher illuminance WHITE plus GREEN) light and modified SLAM shift with 2 short naps scheduled on the day prior to the abrupt advance. Phase shifts of the plasma dim light melatonin onset and sleep measures were compared to examine effects of protocol condition. ResultsAfter 5days, the COMBINED light/modified SLAM shift condition showed larger phase advances of dim light melatonin onset (4.02 ± 1.13 hours) compared to the other 4 conditions (range 1.50 ± 0.96-2.83 ± 2.23 hours; p < .05) and resulted in increased REM sleep duration and fewer sleep disruptions. ConclusionsConsideration of the type of shift and the illuminance and wavelength of light may assist in designing lighting countermeasures to sleep and circadian disruption, which has implications for jetlag, shiftwork, and circadian rhythm sleep disorders.

Abstract 19150: DUSP1 is Associated With Map-Kinase Signaling in Antigen Presenting Cells Contributing to Salt-Sensitivity of Blood Pressure

Salt sensitivity of blood pressure, a pathological response characterized by a marked increase in blood pressure following salt intake, acts independently of hypertension as a risk factor for cardiovascular morbidities. Our recent research has elucidated a mechanism of sodium entry into antigen presenting cells through epithelial sodium channels (ENaC), which leads to the formation of neoantigen presenting isolevuglandin protein adducts via oxidative stress. Reactive oxygen species present in the cell may impact inflammation response as well as other intracellular pathways, chiefly the MAPK pathway. Previous studies have established an inhibitory connection between the protein-coding phosphatase DUSP1 and MAPKs. We hypothesize that DUSP1 acts as a negative regulator of MAPK signaling pathways involved in the immune response to salt-sensitive hypertension. To test our hypothesis, we isolated human monocytes from healthy participants (N=11) and treated them with either normal (150 mMol/L) or high (190 mMol/L) Na+ for 72 hours in vitro. Analysis of bulk RNA sequence data points to a significant upregulation of DUSP1 in the high salt environments compared to normal salt levels (4339 ± 770.1 vs 2721 ± 546.4 , p=0.0192). We also found that the high salt treatment led to increased expression of ERK1 (HS:2066 ± 184.0 NS:1560 ± 136.7 p= 0.0652), ERK2 (HS:8364 ± 669.8 NS:6256 ± 578.3 p= 0.0281), JNK (HS:1069 + 102.2 NS:792.3 ± 74.85 p= 0.0336), and p38 (HS: 4062 ± 329.0 NS:3010 ± 292.5, p= 0.0336). To study further, we enrolled 9 hypertensive participants who discontinued anti-hypertensive therapy for 2 weeks in an inpatient protocol to phenotype them through rapid salt loading and depletion. Blood pressure was recorded and blood collected at baseline, after salt loading, and after salt depletion and CITE-Seq analysis was performed on isolated PBMCs. After salt loading, we found a negative correlation between both p38 expression and pulse pressure (r= -0.7564 p= 0.0299) and p38 expression and systolic blood pressure (r= -0.8371, p=0.0095). We found a positive correlation between DUSP1 expression and systolic blood pressure after salt depletion (r= 0.7089, p=0.0490). These results suggest that DUSP1 plays an important role in salt sensitivity of blood pressure.

Circadian- and wake-dependent influences on face-name memory in healthy men and women over 3 weeks of chronic sleep restriction

ObjectivesFacial recognition is one of the key functions of the human brain, and linking a face to a name is critical in many social and occupational settings. This study assessed circadian- and wake-dependent effects on face-name recognition in healthy adults. MethodsThirteen healthy adults (20-70years; 7 F) were studied in a 39-day inpatient protocol that included 3weeks of 28 hours forced desynchrony with sleep restriction (6.5:21.5 hours sleep:wake). Starting 3 hours after scheduled wake, 6 novel face-name pairs were presented every 4 waking hours; recognition was tested 2 hours later. Performance data were averaged across ∼4 hours circadian phase or time-awake bins. ResultsFace-name recognition deteriorated with increased time awake (p < .0001) and exhibited significant circadian variation (p < .0001), with worst performance shortly after the core temperature nadir. There was a significant interaction between sex and circadian phase (p = .0177), with women performing significantly better than men at all circadian phases except 60° and 120°. Women exhibited a significantly higher amplitude than men during the third week of forced desynchrony (p < .01). ConclusionsLike many other aspects of neurobehavioral performance, recalling face-name associations is impacted by both duration of time awake and circadian phase. These results have implications for face recognition testing in medical contexts, such as in testing for dementia, because performance may be impacted by sleep deficiency and the time of testing.

Modification of an inpatient medical management protocol for pediatric Avoidant/Restrictive Food Intake Disorder: improving the standard of care

BackgroundNo guidelines currently exist that represent a standardization of care for Avoidant/Restrictive Food Intake Disorder (ARFID) on an inpatient service. Unique features of this diagnosis (e.g., sensory sensitivity contributing to involuntary emesis) suggest that established protocols that were developed for anorexia nervosa might be less effective for adolescents with ARFID. To inform improved inpatient medical stabilization and care for these patients, we first provide an overview of clinical characteristics for patients with ARFID who presented to a pediatric hospital for inpatient eating disorder care. We use these descriptives to outline the rationale for, and executions of, modifications to an inpatient protocol designed to flexibly meet the needs of this clinical population.MethodsChart review with descriptive statistics were conducted for patients who had received an ARFID diagnosis from March 2019 to March 2023 (N = 32, aged 9–23). We then present a case series (n = 3) of adolescents who either transitioned to a novel adjusted protocol from an original standard of care on the inpatient service, or who received only the standard protocol.ResultsThe sample was aged M(SD) = 15.6 (3.3) years, 53% male, and a majority (69%) presented with the ARFID presentation specific to fear of negative consequences. On average, patients had deviated from their growth curve for just over two years and presented with mean 76% of their estimated body weight. Of those requiring nasogastric tube insertion during admission (n = 8, 25%), average duration of tube placement was 15 days. From within this sample, case series data suggest that the adjusted protocol will continue to have a positive impact on care trajectory among adolescents admitted for ARFID including improved weight gain, reduction of emesis, and improved food intake.ConclusionsFindings demonstrate the likely need to tailor established medical inpatient protocols for those with ARFID given different symptom presentation and maintenance factors compared to patients with anorexia nervosa. Further research is warranted to explore the longer-term impact of protocol changes and to inform standardization of care for this high priority clinical population across care sites.

Autonomic dysreflexia: Current pharmacologic management.

Autonomic dysreflexia (AD) is a frequent complication of spinal cord injury (SCI), though current clinical practice patterns for medication management of this condition are unknown. Correspondingly, it is unclear if national differences in practice patterns exist. To determine trends in current pharmacologic management of AD throughout the Americas. International survey of current physician practice patterns. Academic medical center. Sixty physicians managing patients with SCI and prescribing medications to manage AD. Not applicable. Presence of a formal pharmacologic AD management protocol, first- and second-line medications, patient characteristics influencing pharmacologic management. The majority of physicians (69%) had a formal AD management protocol for inpatient care, with nitroglycerin ointment (82%) being the most common first-line medication. Strong national differences existed regarding the use of nitroglycerin ointment, with 98% of U.S.-based physicians using this as first-line medication and 0% of physicians in Canada or Latin America using this due to recent lack of medication availability. Only 67% of physicians had a preferred second-line medication, with preferences split between hydralazine (48%) and nifedipine (28%). A systolic blood pressure threshold for pharmacologic management was used by 56% of physicians, wheres 26% considered neurological level of injury in decisions to use medications for AD. Heart rate was used by only 5% of physicians in their decision to manage AD with medications. As of 2023, U.S.-based physicians caring for individuals with SCI largely have formal inpatient protocols in place for medication management of AD, with nearly all relying on nitroglycerin ointment as their first-line medication. In areas outside of the United States where nitroglycerin ointment is unavailable, pharmacologic practice patterns significantly differ.

Abstract 126: Nlrp3 Chromatin Availability And Isolg-adducted Histones In Salt-sensitivity Of Blood Pressure

Salt-sensitivity of blood pressure puts both normotensive and hypertensive individuals at a higher risk for cardiovascular morbidity and mortality. Isolevuglandins (IsoLGs) are increased in multiple oxidative-stress associated diseases, including salt sensitive hypertension. Scavenging of IsoLGs using 2-HOBA in a mouse model of salt-sensitive hypertension blocked NLRP3 inflammasome in dendritic cells (DCs) and abolished salt-induced hypertensive response. IsoLGs adduct to histones, specifically H4. We tested the hypothesis that elevated sodium in antigen-presenting cells leads to IsoLG-adducted H4 histones and increased chromatin availability to NLRP3 inflammasome components contributing to salt-sensitive hypertension. In vivo studies were performed on 19 hypertensive subjects enrolled in an acute inpatient protocol to assess response to salt loading (460 mmoL/24 hrs) and salt depletion (10 mmoL/24 hrs, and furosemide 40 mg x 3). Isolated PBMCs from salt sensitive subject (δ;SBP SD-SL = -12.9) and a salt resistant subject (δ;SBP SD-SL = 0.35) were analyzed by ATACseq. In vitro studies were performed on isolated CD11c+ dendritic cells treated with either normal salt (150mM) or high salt (190mM) and histone protein extraction isolated for western blot and blotted for D11, an ScFv specific to IsoLG-adducted proteins. Additional in vitro studies were performed on isolated monocytes from 11 individuals treated with either normal or high salt and submitted for RNA sequencing. RNAseq data of isolated monocytes demonstrated an overall upregulation in differentially expressed histone modification genes after high salt visualized in a heatmap and PCA plot, specifically, upregulation of gene HIST4H4 encoding the Histone H4 (25.4 ± 4.6 vs 65.5 ± 6.5, [n=11, q=1.5 x 10 -3 ]). Changes in chromatin availability inflammasome component NLRP3 were more salt responsive in DCs of the salt-sensitive subject versus the salt-resistant subject after salt depletion. Additionally, high salt increased IsoLG-histone adduction in CD11c+ DCs. Our results suggest the high sodium environment increase in IsoLG-adducts may epigenetically regulate NLRP3 inflammasome components in SSBP.

Abstract P418: Antigen-presenting Cell-specific MAP-kinase Signaling Contributes To Inflammation And Salt-sensitivity Of Blood Pressure In Humans

Salt-sensitivity of blood pressure (SSBP) is defined by the changes in blood pressure in concert with salt intake/depletion. SSBP affects 50 percent of hypertensive and 25 percent of normotensive individuals and is an independent risk for stroke and cardiovascular death in both groups. We recently found that phosphorylation of STAT3 and SMAD3 in antigen-presenting cells plays an important role in developing SSBP. We hypothesized that mitogen-activated protein kinases (MAPKs) signaling plays an important role in activating/phosphorylating JAK-STAT-SMAD and contributes to salt-sensitivity of blood pressure. We isolated monocytes from eleven healthy individuals and treated them with either normal salt (NS) or high salt (HS) and performed bulk-RNA-sequencing. The bulk-RNA transcriptomic data analysis suggested that out of 21 members of the MAPK family, eighteen were upregulated (1.7-fold) in monocytes exposed to high salt. Among these, MAPK7 (NS:818.18±54.96; HS:1473.18±151.50) and MAPKAPK2 (NS:3977.81±286.67; HS:6222.63±440.32) were significantly upregulated. In additional experiments, we enrolled eleven hypertensive patients and phenotyped them for salt-sensitivity using a rapid salt-load and depletion inpatient protocol. Blood was collected at baseline, after salt loading, and depletion, and CITE-Seq was performed on isolated PBMCs. The data analysis showed that MAPK7 and MAPKAPK2 expressions mirror the blood pressure changes following salt loading and depletion in salt-sensitive but not in salt-resistant patients. Moreover, we found a positive correlation between MAPKAPK2 expression and the pulse pressure ((PP) r=0.52, p=0.033) after salt-load. Epoxyeicosatrienoic acid (EET) has been shown to activate MAPKs resulting in inhibiting ENAC activity. The data showed a strong positive correlation between MAPK7 expression and levels of EETs in plasma (r=0.70, p=0.036), and urine (r=0.68, p=0.045) after salt-load. These results from bulk-RNA and single-cell CITE-Seq data indicate that MAPKs play an important role in human SSBP.

Abstract P109: Antigen Presenting Cell Activator Protein 1 Mediates Salt-sensitive Hypertension In Humans

Salt-sensitivity of blood pressure (SSBP) is defined by the changes in blood pressure according to dietary sodium loading/depletion and is a major independent risk factor for morbidity and mortality due to cardiovascular disease, even in normotensive individuals. We previously found that SSBP is associated with activation of antigen presenting cells (APCs), but the underlying mechanisms are unknown. The activator protein 1 (AP-1) (Fos/Jun) has been implicated in mediating inflammation but its role in SSBP is not known. We hypothesized that AP-1 in APCs senses elevated sodium and contributes to SSBP. Using bulk RNA-sequencing in human monocytes, we found elevated sodium increases expression of the AP-1 gene family when compared to normal sodium concentration, including FOS (2378.18 ± 480.7 vs 6494.09 ± 945.55, p= 0.0009), FOSB (47.63 ± 17. 55 vs 56.06 ± 10.30, p= 0.5320), JUN (7313.90 ± 984.93 vs 11370.09 ± 1286.35, p= 0.2563) JUNB (4745.36 ± 599. 17 vs 5955.45 ± 600.91, p= 0.7620) and JUND (3309. 63 ± 270.64 vs 8057.90 ± 1043.05, p= 0.00006). In additional experiments, we enrolled people with hypertension and phenotype them for SSBP using an established in-patient protocol of salt-loading/depletion and performed single-cell transcriptomic analyses in vivo on PBMCs. We found that expression of the FOS and JUN genes change in concert with blood pressure after salt-loading and depletion in salt-sensitive but not salt-resistant humans. Our findings reveal a role for immune cell AP-1 signaling in salt-sensitive hypertension and may provide a potential target for treatment and diagnosis. Keywords: Activator protein 1 (AP-1), FOS, JUN, Salt-sensitive hypertension, Humans

Recovery Sleep After Sleep Restriction Is Insufficient to Return Elevated Daytime Heart Rate and Systolic Blood Pressure to Baseline Levels.

Sleep restriction alters daytime cardiac activity, including elevating heart rate (HR) and blood pressure (BP). There is minimal research on the cumulative effects of sleep loss and the response after subsequent recovery sleep on HR and BP. This study examined patterns of HR and BP across baseline, sleep restriction, and recovery conditions using multiple daytime cardiac measurements. Participants (15 healthy men, mean [standard deviation] = 22.3 [2.8] years) completed an 11-day inpatient protocol with three nights of 10 hours/night baseline sleep opportunity, five sleep restriction nights (5-hour/night sleep opportunity), and two recovery nights (10-hour/night sleep opportunity). Resting HR and BP were measured every 2 hours during wake. Multilevel models with random effects for individuals examined daytime HR and BP across study conditions and days into the study. Mean daytime HR was 1.2 (0.5) beats/min lower during sleep restriction compared with baseline ( p < .001). During recovery, HR was 5.5 (1.0) beats/min higher ( p < .001), and systolic BP (SBP) was 2.9 (1.1) mm Hg higher ( p = .009). When accounting for days into the study (irrespective of condition) and measurement timing across the day, HR increased by 7.6 beats/min and SBP increased by 3.4 mm Hg across the study period ( p < .001). Our findings suggest that daytime HR and SBP increase after successive nights of sleep restriction, even after accounting for measurement time of day. HR and SBP did not recover to baseline levels after two recovery nights of sleep, suggesting that longer recovery sleep may be necessary to recover from multiple, consecutive nights of moderate sleep restriction.

An innovative inpatient protocol for alcohol withdrawal prevention in a 16-year-old adolescent: a case report

BackgroundAlcohol cessation in youth with daily drinking poses a risk of severe and life-threatening alcohol withdrawal. If unsupervised, alcohol withdrawal in heavy users can cause severe complications, such as seizures, delirium tremens, and death. We present the case of a teenager admitted at our pediatric center for the prevention of alcohol withdrawal using an innovative protocol, including a fixed-dosage benzodiazepine regimen.Case descriptionA 16-year-old Caucasian male, known to have anxiety and an attention deficit disorder, was electively admitted for medical stabilization and surveillance of alcohol withdrawal. He had been previously diagnosed with alcohol use disorder and had a past history of withdrawal symptoms. He was prescribed a course of thiamine, folic acid, as well as a fixed-dosage benzodiazepine taper over 5 days. His withdrawal symptoms were evaluated using a standardized Clinical Institute Withdrawal Assessment for Alcohol scale. During his stay, he reported minimal symptoms, as well as a score on the Clinical Institute Withdrawal Assessment for Alcohol scale consistently lower than 5. His mood, motivation, eating habits and sleeping patterns significantly improved during his stay. He developed no medical complications and demonstrated pride in his successes. He was successfully transferred to a long-term rehabilitation center.ConclusionsA withdrawal prevention protocol was developed on the basis of existing literature. It included a soothing environment, basic laboratory work evaluating the medical complications of alcohol use, as well as medication aiming to prevent and reduce potential withdrawal symptoms. The patient responded well to the fixed-dosage taper with minimal symptoms and discomfort. Although alcohol use in adolescents is frequent, alcohol withdrawal in this population is rarely seen in a pediatric hospital setting. Nonetheless, given the lack of existing guidelines regarding alcohol withdrawal in adolescents, standardized protocols could be greatly beneficial for the prevention of this condition in this population.

Development of an artificial intelligence system to identify hypoglycaemia via ECG in adults with type 1 diabetes: protocol for data collection under controlled and free-living conditions

IntroductionHypoglycaemia is a harmful potential complication in people with type 1 diabetes mellitus (T1DM) and can be exacerbated in patients receiving treatment, such as insulin therapies, by the very interventions...