Silver Spring Research Articles

Sickle Cell Hemoglobin Induces Autophagy in Human Macrophages

BACKGROUND: Autophagy plays an important role in multiple cell processes including elimination of misfolded proteins and damaged organelles, clearance of intracellular microbes and regulation of innate immunity. Autophagic activity is significantly up regulated in diseases characterized by proteins aggregation such as Alzheimer's, Huntington's, and Parkinson's diseases. Sickle cell anemia (SCA) is associated with E6V mutation in beta-globin gene that induces hemoglobin (Hb) polymerization under low oxygen or acidic conditions. SCA is characterized by chronic presence of low-level plasma Hb (3-10 µM). Hb is cleared from circulation by macrophage's endocytosis, resulting in degradation of Hb in lysosomes. Acidic lysosome environment may induce Hb polymerization, lysosome dysregulation and autophagy activation.HYPOTHESIS: We hypothesize that endocytosis of HbS induces autophagy in human macrophages.METHODS: The study was approved by Howard University review board (IRB) and all subjects provided written inform consent prior the sample collection. Whole blood samples were obtained from three SCA patients and healthy individuals. Human THP-1 promonocytic cells were differentiated into macrophages with 25 nM PMA for 72 hrs and treated with either purified HbS or HbA (5 µM, Sigma-Aldrich). Total RNA was depleted of cytoplasmic and mitochondrial ribosomal RNA, and strand-specific libraries were constructed using the Illumina ® TruSeq Stranded Total RNA Gold kit. Libraries were sequenced on an Illumina ® NextSeq 500 using 75 bp paired-end sequencing on two v2.5 150 cycle High-Output kits, generating 40-50 million paired-end reads per sample. The sequencing data were mapped to human reference genome using Dragen RNA v.3.8.4 software (Illumina). Comparisons were conducted using Dragen differential expression software v. 3.6.3 software (Illumina). Transmission electron microscopy (TEM) imaging was performed at Talos 200X transmission electron microscope (Thermo Fisher Scientific). CYTO-ID Autophagy detection kit (Enzo Life Science) was used for detection of autophagy in live cells by fluorescence microscopy, and fluorescent microplate assay.RESULTS: In THP-1-derived macrophages treated with HbS compared to HbA, 28362 genes were detected including 322 differentially expressed genes (1.1%, 1.5-fold difference, 187 down and 135 up) at 5% FDR. In THP-1-differentiated macrophages treated with SCD RBC lysate compared to control RBC lysate, 30840 genes were detected including 256 differentially expressed genes (0.83%, 1.5-fold difference, 117 down and 139 up) at 5% FDR.We focused our analysis on 33 autophagy-related genes. Among these 33 genes, 30 genes were up-regulated (1.2-1.7-fold) and only 3 genes were down-regulated in macrophages treated with HbS compared to HbA (Fig.1). These changes were statistically significant for 20 genes (p<0.01). No significant differences were found in expression of autophagy-related genes in macrophages treated either with HbS or SCD RBC lysate.Autophagy activation was validated by CYTO-ID Autophagy detection kit, demonstrating significant autophagy activation in HbS treated macrophages compared to HbA treatment (1.2-fold, p=0.0019). Transmission electron microscopy demonstrated accumulation of autophagosomes in the cells treated with HbS compared to non-treated cells and cells treated with HbA.CONCLUSION: Treatment of macrophages with sickle cell hemoglobin or lysate of red blood cells collected from SCD patients up-regulates expression of autophagy-related genes and increased autophagosome formation.ACKNOWLEDGMENTS: We thank Drs. Castle Raley and Keith Crandall, George Washington University SPH Genomics Core, for sequencing and guidance in data analysis; Dr. Christine Brantner, GW Nanofabrication and Imaging Center, for TEM imaging; and students Kavita Pandya, Gretchen Whitney High School, Cerritos, CA, and Tharindi Jayatilake, Montgomery Blair High School, Silver Spring, MD, for help in analysis of autophagy-related gene expression. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Looking Into Perioperative Nurses’ Other Roles

Looking Into Perioperative Nurses’ Other Roles

Variations in the median sacral crest and angulation of the first sacral spinous process associated with sacrocaudal fusion in greyhounds

The current study aimed to investigate the association between the morphology of the median sacral crest, variation in the angle of the spinous process of the first sacral vertebra, and the occurrence of sacrocaudal fusion in greyhounds. In this study, 167 sacra from cadavers of greyhounds (previously euthanized for reasons unrelated to this study) were collected, classified into standard and fuses sacra (based on the number of fused vertebrae and type of fusion), and then classified based on the morphology of the median sacral crest into three different types: type F (full crest), type N (when the median sacral crest is incomplete, and type R (when the median sacral crest is present but it was short or reduced). Among the 167 sacra, 91 sacra were used to measure the angle of the spinous process of the first sacral vertebrae (1st SPA). Each of the sacra was digitally photographed using a Nikon D3100 digital camera (Tokyo, Japan) in which the camera was positioned laterally with the lens parallel to the central part of the lateral aspect of the sacrum and on a flat surface of the laboratory bench. Image-Pro Express Version 5.0 imaging software (Media Cybernetics, Silver Spring, Maryland) was used to draw and measure the angles. The angle of the 1st SPA was defined as the angle formed dorsally at the intersection of two lines. The first line was drawn to represent the cranial ridge of the spinous process of the 1st SPA, and the second line was drawn across the most dorsal surface points of the spinous processes of the 1st (S1) and 3rd (S3) sacral vertebrae. Significant (p < 0.001) morphological differences (F, R, N) were found in the median sacral crest, and the prevalence of median sacral crest type R in standard sacra was 35.1% compared to 10% in fused sacra, type F was 41.2% in standard sacra and 10% in fused sacra, and type N was 23.7% in standard sacra and 80% in fused sacra. The angle 1st SPA with median sacral type N was statistically significantly less (more upright) than those in sacra with median sacral type F (P < 0.042). Differences have been found in the median sacral crest and angulation of the spinous process of S1 vertebra in sacra with different types of median sacral crest.

2018 Survey of factors associated with antimicrobial drug use and stewardship practices in adult cows on conventional California dairies: immediate post-Senate Bill 27 impact.

BackgroundAntimicrobial drugs (AMD) are critical for the treatment, control, and prevention of diseases in humans and food-animals. Good AMD stewardship practices and judicious use of AMD are beneficial to the preservation of animal and human health from antimicrobial resistance threat. This study reports on changes in AMD use and stewardship practices on California (CA) dairies, following the implementation of CA Senate Bill 27 (SB 27; codified as Food and Agricultural Code, FAC 14400–14408; here onward referred to as SB 27), by modeling the associations between management practices on CA conventional dairies and seven outcome variables relating to AMD use and stewardship practices following SB 27.MethodsA survey questionnaire was mailed to 1,282 grade A licensed dairies in CA in spring of 2018. Responses from 132 conventional dairies from 16 counties were included for analyses. Multivariate logistic regression models were specified to explore the associations between survey factors and six outcome variables: producers’ familiarity with the Food and Drug Administration’s (FDA), Silver Spring, WA, USA medically important antimicrobial drugs (MIAD) term; change in over-the-counter (OTC) AMD use; initiation or increased use of alternatives to AMD; changes to prevent disease outbreaks; changes in AMD costs; and better animal health post SB 27. We employed machine learning classification models to determine which of the survey factors were the most important predictors of good-excellent AMD stewardship practices of CA conventional dairy producers.ResultsHaving a valid veterinary-client-patient-relationship, involving a veterinarian in training employees on treatment protocols and decisions on AMDs used to treat sick cows, tracking milk and/or meat withdrawal intervals for treated cows, and participating in dairy quality assurance programs were positively associated with producers’ familiarity with MIADs. Use or increased use of alternatives to AMDs since 2018 was associated with decreased use of AMDs that were previously available OTC prior to SB 27. Important variables associated with good-excellent AMD stewardship knowledge by CA conventional dairy producers included having written or computerized animal health protocols, keeping a drug inventory log, awareness that use of MIADs required a prescription following implementation of SB 27, involving a veterinarian in AMD treatment duration determination, and using selective dry cow treatment.ConclusionsOur study identified management factors associated with reported AMD use and antimicrobial stewardship practices on conventional dairies in CA within a year from implementation of SB 27. Producers will benefit from extension outreach efforts that incorporate the findings of this survey by further highlighting the significance of these management practices and encouraging those that are associated with judicious AMD use and stewardship practices on CA conventional dairies.

Traditional weight loss and dukan diets as to nutritional and laboratory results

Traditional weight loss and dukan diets as to nutritional and laboratory results

Leveraging Machine Perfusion to Ameliorate Geographic Disparities in Organ Allocation

Leveraging Machine Perfusion to Ameliorate Geographic Disparities in Organ Allocation

The Influence of Extrinsic Variation in Gunshot Wounds in a U.S. Civil War Skeletal Sample

Most gunshot studies focus on the propagation of fractures on the cranium or the midshaft of a long bone. However, bone closer to the joint is structurally different from the shaft. Here, I analyzed the morphology of fracture patterns from gunshot wounds to the distal femora of U.S. Civil War soldiers. The individual sample (n=34) of distal femora was obtained from the Civil War Skeletal Collection at the National Museum of Health and Medicine (Silver Spring, MD). Variables collected included fracture counts, average fracture lengths, combined fracture lengths, location on the femur, registered age of the soldier, and their epiphyseal fusion status. The value in a U.S. Civil War skeletal sample is that the individuals it contains are relatively homogenous in terms of age, sex, ancestry, diet, and lifestyle. The projectiles involved were most commonly “minni balls;” many of which are preserved with the associated skeletal remains. Most of the variation in injury pattern is primarily related to extrinsic variables, such as distance from shooter, interruptions in projectile trajectory, and size, shape, or velocity of the impacting projectile at the time of contact. Intrinsic variables may still play a role, such as the amount of soft tissue present and impact location (indirect or direct contact). All measured individuals were male, with an average age of 24.18±6.84yrs. There was no correlation between age and combined fracture length. The average number of bone fragments and fractures counted were 3.59±2.89 and 7.26±3.94, respectively. The average fracture length was 44.80±19.95mm, with an average combined fracture length of 339.68±207.36mm. A limitation here is that these samples were collected via limb amputation, so some of the fractures extending proximally are incomplete. Interestingly, 7 individuals had an epiphyseal fusion score of 1 or 2 (with 4 being completely fused), with 2 instances in individuals aged 23 and 24yrs. In instances of unfused epiphyses, fractures that initiated in the epiphysis did not propagate into the diaphysis. The results of this study contribute to the understanding of how extrinsically introduced variation may affect what we see and interpret in gunshot wounds as more and longer fractures are usually associated with “higher velocity projectiles.” This study also noted the importance of epiphyseal fusion on ballistic analysis to long bones, but continued research is needed in this area to fully understand this phenomenon.

Are there sex-related differences in therapeutic CPAP levels in adults undergoing in-laboratory titration?

The first-choice therapy for adults with moderate/severe obstructive sleep apnea is continuous positive airway pressure (CPAP). However, studies evaluating whether the therapeutic CPAP level obtained from a titration is affected by sex are surprisingly scarce. Our main objective was to verify if sex influenced the optimal CPAP measurement obtained during a titration. This cross-sectional study was conducted in adults diagnosed with moderate/severe obstructive sleep apnea [baseline apnea-hypopnea index (AHI) ≥ 15.0 events/h] who underwent auto-adjusting CPAP titration (S9 or S10 AutoSet ResMed) in a sleep laboratory setting. All participants used a nasal mask during the titration. The optimal pressure, leak, and residual AHI values were registered. Multiple linear regression was used to evaluate if clinical and polysomnographic data influenced the therapeutic CPAP level setting (95th percentile pressure). A total of 1,006 adults were enrolled: 354 women and 652 men. There were no statistically significant sex-related differences in the CPAP requirements and leak values delineated during the titration; all P-values > .005. However, the median residual AHI was significantly higher in males vs females: 2.7 events/h vs 2.2 events/h (P = .008). Body mass index (β: 0.292, P < .001), baseline AHI (β: 0.167, P < .001), and age (β: 0.065, P = .035) were independent predictors of the therapeutic CPAP level settings. Sex does not significantly influence the therapeutic CPAP settings. However, age, BMI, and baseline AHI emerge as independent predictors of the 95thpercentile CPAP requirement during an auto-adjusting CPAP titration. Duarte RLM, Magalhães-da-Silveira FJ, Gozal D. Are there sex-related differences in therapeutic CPAP levels in adults undergoing in-laboratory titration? JClin Sleep Med. 2021;17(9):1815-1820.

ELLEN G. WHITE PERSPECTIVE ON POLITICS AMONG SEVENTH DAY ADVENTIST LEADERS

ELLEN G. WHITE PERSPECTIVE ON POLITICS AMONG SEVENTH DAY ADVENTIST LEADERS

Pacemaker Pocket Stabilization Utilizing a Novel Envelope and a Three-Point Anchoring Technique

A 65-year-old man presented with chronic pain due to frequent movement of a dual chamber pacemaker (PPM) within the device pocket despite being secured to the underlying muscle. Due to chronic pain and possible indolent infection, the PPM was removed and a new device was implanted on the contralateral side via a persistent left superior vena cava. To prevent device movement, it was placed within a CanGaroo® envelope (Aziyo Biologics Inc., Silver Spring, MD, USA), which was secured to the underlying muscle with a silk suture along three of its corners. The envelope, which becomes incorporated into the surrounding tissue forming a vascularized tissue pocket, should further reinforce device stability over time. The patient’s left-sided symptoms abated immediately and he remains free of symptoms on the right side over a six-week follow-up period.

Antibiotic-Eluting Envelopes to Prevent Cardiac-Implantable Electronic Device Infection: Past, Present, and Future.

Objective: Cardiac-implantable electronic device (CIED) infections are associated with significant morbidity and mortality. In this review, we describe the risk factors and pathogenesis of CIED infections and review the rationale and the evidence for the use of antibiotic-eluting envelopes (ABEs) in patients at increased risk for CIED infections.Findings: The majority of CIED infections are caused by staphylococci that involve generator pocket and occur due to contamination of the device or the pocket tissues at the time of implantation. Clinical trials have shown that extending the duration of post-operative systemic antibacterial therapy is not beneficial in reducing CIED infection rate. However, ABEs that reduce device migration after implantation and provide sustained local delivery of prophylactic antibiotics at the pocket site, may provide benefit in reducing infection. Currently, there are two types of commercially available CIED envelope devices in the United States. The first ABE device (TYRX™, Medtronic Inc., Monmouth Junction, NJ) is composed of a synthetic absorbable mesh envelope that elutes minocycline and rifampin and has been shown to reduce CIED pocket infections in a large multi-center randomized clinical trial. The second ABE device (CanGaroo-G™, Aziyo Biologics, Silver Spring, MD) is composed of decellularized extracellular matrix (ECM) and was originally designed to stabilize the device within the pocket, limiting risk for migration or erosion, and providing a substrate for tissue ingrowth in a preclinical study. This device has shown promising results in a preclinical study with local delivery of gentamicin. Compared with artificial materials, such as synthetic surgical mesh, biologic ECM has been shown to foster greater tissue integration and vascular ingrowth, a reduced inflammatory response, and more rapid clearance of bacteria.Conclusions and Relevance: ABE devices provide sustained local delivery of antibiotics at the generator pocket site and appear beneficial in reducing CIED pocket infections. Given the continued increase in the use of CIED therapy and resultant infectious complications, innovative approaches to infection prevention are critical.

Patient Profiles in the Utilization of the CanGaroo® Envelope.

BackgroundThe CanGaroo® Envelope (Aziyo Biologics, Silver Spring, MD) is intended to securely hold a cardiovascular implantable electronic device (CIED) to create a stable environment when implanted in the body. Data on the utilization of this newly available product are limited.ObjectiveIn this study, our objective was to describe the specific profiles of patients who may benefit from the use of the CanGaroo® Envelope at the time of CIED implantation.Methods The utilization of the CanGaroo® Envelope was assessed from January 2019 to October 2019 among a series of patients who were either undergoing de-novo CIED implantation or replacement.ResultsAmong a total of 50 patients, the CanGaroo® Envelope was utilized in 15 (30%). Three distinct patient profiles were identified: profile 1: elderly patients with poor tissue turgor at risk of wound dehiscence or erosion; profile 2: patients with a history of previous device infection; and profile 3: patients at high risk of device infection having one or more of the following risk factors - chronic kidney disease, immunocompromised state, or diabetes mellitus. At a mean follow-up of 18 ±3 months, no CIED pocket erosion, dehiscence, or infection was noted.ConclusionsThree distinct profiles of patients who could potentially benefit from the use of the CanGaroo® Envelope were identified by the implanting physicians. Long-term follow-up data, including infection and wound dehiscence rates, are necessary to further analyze the optimal utilization of the device.

Liposomal Bupivacaine.

Liposomal Bupivacaine.

Abstract 17488: What Are the Gaps? A Qualitative Study on Patient and Family Decision Making Regarding Implantable Cardioverter Defibrillator and Cardiac Resynchronization Therapy

Background: Implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT-D) reduce mortality and improve functional status in selected patients with heart failure (HF). However, there are potential procedural risks and psychosocial concerns associated with device implant. This qualitative study aims to explore patients’ and families’ understanding of ICD/CRT-D, heart failure and arrhythmia in the process of decision making regarding device implant. Methods: We conducted 14 focus groups or interviews in Salt Lake City UT and Silver Spring MD. This study included 23 patients, who had either an ICD or CRT-D implant for primary prevention, and 14 family members. Grounded theory analysis was performed to reach a conceptual understanding of patients’ and families’ perceptions and needs. Results: Patients and families largely made decision of ICD/CRT implant based on physicians’ recommendations, e.g. “I really try to do what they tell me to do” (icdpt 1). Patients perceived ICD as lifesaving and CRT being helpful to improve functional status. Many patients described ICD as lifesaving by “restarting a heart if it stops”, while did not understand HF or ventricular arrhythmia. Patients perceived an urgency to consider ICD implant from their physicians, but no such urgency was perceived when they discussed about CRT-D implant. Few participants were concerned with costs, or had knowledge of potential lead malfunction, device removal and associated risks. Many emphasized the importance of information about life expectancies, what HF is, options of different devices, complications and precautions, and what to expect regarding lifestyle changes. Conclusion: Patients and families largely relied on the information provided by physicians and followed physicians’ guidance. They had limited understanding of their prognosis, HF and arrhythmia, and they were motivated to learn. Discussion about devices should include prognosis and healthy life style changes.

FDA public workshop: Orthopaedic sensing, measuring, and advanced reporting technology (SMART) devices.

Traditional orthopaedic devices do not communicate with physicians or patients post-operatively. After implantation, follow-up of traditional orthopaedic devices is generally limited to episodic monitoring. However, the orthopaedic community may be shifting towards incorporation of smart technology. Smart technology in orthopaedics is a term that encompasses a wide range of potential applications. Smart orthopaedic implants offer the possibility of gathering data and exchanging it with an external reader. They incorporate technology that enables automated sensing, measuring, processing, and reporting of patient or device parameters at or near the implant. While including advanced technology in orthopaedic devices has the potential to benefit patients, physicians, and the scientific community, it may also increase the patient risks associated with the implants. Understanding the benefit-risk profile of new smart orthopaedic devices is critical to ensuring their safety and effectiveness. The 2018 FDA public workshop on orthopaedic sensing, measuring, and advanced reporting technology (SMART) devices was held on April 30, 2018, at the FDA White Oak Campus in Silver Spring, MD with the goal of fostering a collaborative dialogue amongst the orthopaedic community. Workshop attendees discussed four key areas related to smart orthopaedic devices: engineering and technology considerations, clinical and patient perspectives, cybersecurity, and regulatory considerations. The workshop presentations and associated discussions highlighted the need for the orthopaedic community to collectively craft a responsible path for incorporating smart technology in musculoskeletal disease care.

Defining Endpoints and Biomarkers in Inflammatory Bowel Disease: Moving the Needle Through Clinical Trial Design

Defining Endpoints and Biomarkers in Inflammatory Bowel Disease: Moving the Needle Through Clinical Trial Design

Potential influences of obstructive sleep apnea and obesity on COVID-19 severity.

Citation:McSharry D, Malhotra A. Potential influences of obstructive sleep apnea and obesity on COVID-19 severity. J Clin Sleep Med. 2020;16(9):1645.

Evaluating the performance of BAM-based blanket filter on nitrate reduction in a karst spring

Understanding the effects of best management practices (BMPs) on nitrate reduction in karst aquifers is critical for spring restoration. In this study, Conduit Flow Process (CFPv2) and Conduit Mass Three-Dimensional (CMT3D) models were applied to evaluate nitrate removal for Silver Springs in Florida using blanket filters composed of biosorption-activated media (BAM). As the inputs of the model, the spatial and temporal variability of nitrate-N concentration in groundwater recharge was estimated as a function of population and land use, reflecting both point and non-point sources of nitrate. Additionally, the spatial heterogeneity of nitrate removal efficiency in the soil was considered in the evaluation. The model estimates that conduit flow accounts for 48% of spring discharge and 47% of nitrate-N mass transport on average, and the contributions of conduit to flow and nitrate mass transport are higher during wet years. The net effect of nitrate reduction in spring discharge was evaluated for two BMP scenarios, i.e., implementing BAM-based blanket filters in 26 stormwater retention basins and 50% of the urban area. The net effect of the BMP on nitrate reduction for Scenario 1 is limited; whereas, for Scenario 2, the nitrate-N concentration will be reduced to 1.08 mg/L in 2026 for a nitrate removal efficiency of 74% (i.e., a 4.9% reduction relative to the baseline condition). This study suggests that the BAM-based blanket filters benefit is likely to scale with penetration (i.e. greater water quality benefits can be expected with greater BMP implementation). Further, this study shows that whether BAM-based blanket filters leads to net water quality improvements or degradation depends on whether BAM removes more or less nutrients from stormwater than the unaltered soil profile. The simulated effects of the BMP on nitrate reduction may serve as an additional guidance for water resources managers to make decisions on investments in nutrient reduction technologies for spring restorations in karst systems.

Impact of Obesity on Outcomes of Patients With Coronavirus Disease 2019 in the United States: A Multicenter Electronic Health Records Network Study

Impact of Obesity on Outcomes of Patients With Coronavirus Disease 2019 in the United States: A Multicenter Electronic Health Records Network Study

Mortality Attributed to COVID-19 in High-Altitude Populations

Woolcott, Orison O., and Richard N. Bergman. Mortality attributed to COVID-19 in high-altitude populations. High Alt Med Biol. 21:409-416, 2020. Background: Since partial oxygen pressure decreases as altitude increases, environmental hypoxia could worsen Coronavirus Disease 2019 (COVID-19) patient's hypoxemia. We compared COVID-19 mortality at different altitudes. Methods: Retrospective analysis of population-level data on COVID-19 deaths was conducted in the United States (1,016 counties) and Mexico (567 municipalities). Mixed-model Poisson regression analysis of the association between altitude and COVID-19 mortality was conducted using individual-level data from 40,168 Mexican subjects with COVID-19, adjusting for multiple covariates. Results: Between January 20 and April 13, 2020, mortality rates were higher in U.S. counties located at ≥2,000 m elevation versus those located <1,500 m (12.3 vs. 3.2 per 100,000; p < 0.001). In Mexico, between March 13 and May 13, 2020, mortality rates were higher in municipalities located at ≥2,000 m versus those located <1,500 m (5.3 vs. 3.9 per 100,000; p < 0.001). Among Mexican subjects younger than 65 years, the risk of death was 36% higher in those living at ≥2,000 m versus those living at <1,500 m (adjusted incidence rate ratio [IRR]: 1.36; confidence interval [95% CI], 1.05-1.78; p = 0.022). Among Mexican men, the risk of death was 31% higher at ≥2,000 m versus that at <1,500 m (adjusted IRR: 1.31; 95% CI, 1.03-1.66; p = 0.025). No association between altitude and COVID-19 mortality was found among Mexican women or among Mexican subjects 65 years of age and older. Conclusions: Altitude is associated with COVID-19 mortality in men younger than 65 years.