Citations

Background The epidemiological transition of non-communicable diseases replacing infectious diseases as the main contributors to disease burden has been well documented in global health literature. Less focus, however, has been given to the relationship between sociodemographic changes and injury. The aim of this study was to examine the association between disability-adjusted life years (DALYs) from injury for 195 countries and territories at different levels along the development spectrum between 1990 and 2017 based on the Global Burden of Disease (GBD) 2017 estimates. Methods Injury mortality was estimated using the GBD mortality database, corrections for garbage coding and CODEm—the cause of death ensemble modelling tool. Morbidity estimation was based on surveys and inpatient and outpatient data sets for 30 cause-of-injury with 47 nature-of-injury categories each. The Socio-demographic Index (SDI) is a composite indicator that includes lagged income per capita, average educational attainment over age 15 years and total fertility rate. Results For many causes of injury, age-standardised DALY rates declined with increasing SDI, although road injury, interpersonal violence and self-harm did not follow this pattern. Particularly for self-harm opposing patterns were observed in regions with similar SDI levels. For road injuries, this effect was less pronounced. Conclusions The overall global pattern is that of declining injury burden with increasing SDI. However, not all injuries follow this pattern, which suggests multiple underlying mechanisms influencing injury DALYs. There is a need for a detailed understanding of these patterns to help to inform national and global efforts to address injury-related health outcomes across the development spectrum.

We investigated the mechanisms involved in the development of airway hyperresponsiveness (AHR) following exposure of mice to halogens. Male mice (C57BL/6; 20–25 g) exposed to either bromine (Br2) or Cl2(600 or 400 ppm, respectively, for 30 min) developed AHR 24 h after exposure. Nifedipine (5 mg/kg body wt; an L-type calcium channel blocker), administered subcutaneously after Br2or Cl2exposure, produced higher AHR compared with Br2or Cl2alone. In contrast, diltiazem (5 mg/kg body wt; a nondihydropyridine L-type calcium channel blocker) decreased AHR to control (air) values. Exposure of immortalized human airway smooth muscle cells (hASMC) to Br2resulted in membrane potential depolarization ( VmAir: 62 ± 3 mV; 3 h post Br2:−45 ± 5 mV; means ± 1 SE; P < 0.001), increased intracellular [Ca2+]i, and increased expression of the calcium-sensing receptor (Ca-SR) protein. Treatment of hASMC with a siRNA against Ca-SR significantly inhibited the Br2and nifedipine-induced Vmdepolarization and [Ca2+]iincrease. Intranasal administration of an antagonist to Ca-SR in mice postexposure to Br2reversed the effects of Br2and nifedipine on AHR. Incubation of hASMC with low-molecular-weight hyaluronan (LMW-HA), generated by exposing high-molecular-weight hyaluronan (HMW-HA) to Br2, caused Vmdepolarization, [Ca2+]iincrease, and Ca-SR expression to a similar extent as exposure to Br2and Cl2. The addition of HMW-HA to cells or mice exposed to Br2, Cl2, or LMW-HA reversed these effects in vitro and improved AHR in vivo. We conclude that detrimental effects of halogen exposure on AHR are mediated via activation of the Ca-SR by LMW-HA.

LMP-1, an Epstein-Barr virus membrane protein expressed during latent infection, has oncogenic properties, as judged from its ability to transform B lymphocytes and rodent fibroblasts. LMP-1 induces the expression of bcl2, an oncogene which protects cells from apoptosis, as well as of genes encoding other proteins involved in cell regulation and growth control. The mechanisms by which LMP-1 upregulates these proteins is unknown, but it is plausible that LMP-1 modifies signal transduction pathways that result in the activation of one or more transcription factors that ultimately regulate transcription of oncogenic genes. NF-kappa B, a transcription factor controlling the expression of genes involved in cell activation and growth control, has been shown to be activated by LMP-1. The mechanism(s) regulating this activation remains unknown. Our data indicate that increased NF-kappa B DNA binding and functional activity are present in B-lymphoid cells stably or transiently expressing LMP-1. I kappa B alpha is selectively modified in LMP-1-expressing B cells. A phosphorylated form of I kappa B alpha and increased protein turnover-degradation correlate with increased NF-kappa B nuclear translocation. This results in increased transcription of NF-kappa B-dependent-genes, including those encoding p105 and I kappa B alpha (MAD3). These results indicate that LMP-1 activates NF-kappa B in B-cell lines by targeting I kappa B alpha. Identification of the pathways activated by LMP-1 to result in posttranslational modifications of I kappa B alpha will aid in determining the role of this virus-host cell protein interaction in Epstein-Barr virus-mediated oncogenesis.

ABSTRACTLeukotoxin and endotoxin derived fromPasteurella haemolyticaserotype 1 are the primary virulence factors contributing to the pathogenesis of lung injury in bovine pneumonic pasteurellosis. Activation of bovine alveolar macrophages with endotoxin or leukotoxin results in the induction of cytokine gene expression, with different kinetics (H. S. Yoo, S. K. Maheswaran, G. Lin, E. L. Townsend, and T. R. Ames, Infect. Immun. 63:381–388, 1995; H. S. Yoo, B. S. Rajagopal, S. K. Maheswaran, and T. R. Ames, Microb. Pathog. 18:237–252, 1995). Furthermore, extracellular Ca2+is required for leukotoxin-induced cytokine gene expression. However, the involvement of Ca2+in endotoxin effects and the precise signaling mechanisms in the regulation of intracellular Ca2+by leukotoxin and endotoxin are not known. In fura-2-acetoxymethyl ester-loaded alveolar macrophages, intracellular Ca2+regulation by leukotoxin and endotoxin was studied by video fluorescence microscopy. Leukotoxin induced a sustained elevation of intracellular Ca2+in a concentration-dependent fashion by influx of extracellular Ca2+through voltage-gated channels. In the presence of fetal bovine serum, endotoxin elevated intracellular Ca2+even in the absence of extracellular Ca2+. Leukotoxin-induced intracellular Ca2+elevation was inhibited by pertussis toxin, inhibitors of phospholipases A2and C, and the arachidonic acid analog 5,8,11,14-eicosatetraynoic acid. Intracellular Ca2+elevation by endotoxin was inhibited by inhibitors of phospholipase C and protein tyrosine kinase, but not by pertussis toxin, or the arachidonic acid analog. To the best of our knowledge, this is the first report of Ca2+signaling by leukotoxin through a G-protein-coupled mechanism involving activation of phospholipases A2and C and release of arachidonic acid in bovine alveolar macrophages. Ca2+signaling by endotoxin, on the other hand, involves activation of phospholipase C and requires tyrosine phosphorylation. The differences in the Ca2+signaling mechanisms may underlie the reported temporal differences in gene expression during leukotoxin and endotoxin activation.

Abstract Acute lymphoblastic leukemia (ALL) and acute myelogenous leukemia (AML) are the two most common childhood leukemias. Novel drug therapies and allogeneic hematopoietic cell transplant (alloHCT) have improved ALL and AML treatment outcomes over the past two decades. However, alloHCT may be associated with significant morbidity and mortality that results in increased healthcare utilization. To date, no multi-center comparative effectiveness studies have been performed specifically evaluating alloHCT in children with ALL or AML. This study uses a novel methodology to investigate the hypothesis that matched sibling donor (MSD) alloHCT has significantly lower healthcare utilization compared to unrelated donor (URD) and that among URD, umbilical cord blood transplants (CBT) will have higher initial utilization but lower long-term utilization. Clinical and transplant outcomes data from the Center for International Blood and Marrow Transplant Research (CIBMTR) database were merged with inpatient resource utilization and standardized cost data from the Pediatric Health Information System (PHIS) database using a probabilistic merge methodology. This merged dataset contained U.S. patients age 1-21 years who received alloHCT for ALL or AML from 2004-2013 with comprehensive CIBMTR data at a PHIS reporting hospital. The primary outcomes of overall survival (OS), leukemia free survival (LFS), and inpatient resource utilization were evaluated using Kaplan-Meier analysis, Cox proportional hazards, and unadjusted Poisson regression analysis. Cost and resource comparisons for all donor types were made through day+100 and focused on URD only comparisons up to 2-year follow-up. Donor procurement costs were not directly included in this analysis. A total of 797 patients (54% of CIBMTR eligible patients and 89% of CIBMTR patients at PHIS centers) were successfully identified in both CIBMTR and PHIS; 433 had ALL and had 364 AML. LFS for ALL at 3 years was 68% for MSD, 53% for MUD, and 53% for CBT. The LFS in ALL was significantly impacted by donor type, age, disease status, and CMV (Table). The associated total costs were significantly higher for well-matched unrelated bone marrow (MUD) vs MSD at 100d ($246,149 vs $147,547, p<0.01), but CBT costs were not significantly higher compared to MUD at 100d ($275,673 vs $246,149, p=0.09). When median total costs per day were compared across donor source, findings were similar with well- MUD was significantly higher than MSD at 100d ($3,388/d vs $2,511/d, p=0.012), and no significant difference between CBT and MUD ($3,881/d vs $3,388/d, p=0.53). The corresponding average length of stay (ALOS) was 35 days for MUD, 34 days MSD, and 53 days CBT. Among URD alloHCT, median CBT costs per day were not significantly higher compared to MUD at 2yrs ($2,472/d vs $2,294/d, p=0.49). AlloHCT for AML had a 3-yr LFS of 56% for MSD, 46% for MUD, and 41% for CBT. LFS were significantly different by disease status and performance status (Table). The associated total costs were significantly higher for MUD at 100d than MSD ($259,293 vs $143,870, p<0.001), but CBT costs were not significantly higher compared to MUD at 100d ($301,160 vs $259,293, p=0.055). Comparisons of median total costs per day were similar, MUD vs MSD at 100d was significantly higher ($3,627/d vs $2,478/d, p<0.01), but CBT costs were not significantly higher compared to MUD at 100d ($3,891/d vs $3,627/d, p=0.95). The corresponding ALOS was 38 days for MUD, 35 days MSD, and 66 days CBT. Among URD alloHCT, median CBT costs per day were not significantly higher compared to MUD at 2yrs ($3,232/d vs $3,102/d, p=0.49). This study recapitulates previously published outcomes of alloHCT for acute leukemia AND adds key findings on the impact of alloHCT on inpatient resource utilization and costs. Specifically, MSD and MUD alloHCT provide similar survival outcomes; however, MSD alloHCT has a significant advantage in cost and resource utilization for both ALL and AML. Among URD transplants, CBT does not show any substantial survival or resource utilization advantage over MUD. Ongoing research will need to be performed to determine if the difference among URD alloHCT becomes significant with a larger sample size and/or beyond the 2 years following alloHCT. Table Table. Disclosures Pulsipher: Novartis: Consultancy, Other: Study Steering Committee; Jazz Pharmaceutical: Consultancy; Medac: Other: Housing support for conference; Chimerix: Consultancy. Hahn:Novartis: Equity Ownership; NIH: Research Funding.

Abstract Introduction Immune thrombocytopenia (ITP) is an acquired disorder characterized by immune-mediated platelet destruction along with decreased platelet production. Adults with ITP are treated initially with glucocorticoids, intravenous immunoglobulin, and/or anti-D, but as many as 80% of patients (pts) will eventually relapse and become steroid-refractory. There is no universally agreed upon 2nd line therapy for ITP and consensus guidelines recommend either rituximab (R) or splenectomy (S) as acceptable, potentially curative options. Long-term responses to 2nd line S have been reported around 60%, and around 25% for R. It is unknown whether long-term outcome in the 3rd line setting is influenced by sequence of therapy. We evaluated the impact of sequence of 2nd and 3rdline therapy with R and/or S. Methods We identified all pts with ITP treated from 1990 through 2015 at the three Mayo Clinic (Arizona, Florida, and Minnesota) sites that were treated with R and/or S. Patients were excluded who were <18 years of age at the time of second-line treatment. Those with secondary ITP that received specific treatment for an infectious, autoimmune, or malignant condition causing thrombocytopenia were excluded. Patients with Evan's syndrome were included if the treatment was for thrombocytopenia, and not primarily for hemolytic anemia. For this analysis, secondary ITP was defined as ITP associated with hematologic malignancy. Hematologic malignancies did not require specific therapy at the time of treatment for ITP. Patients with uncontrolled infections or uncontrolled autoimmune disorders were excluded from analysis. We collected data from medical records regarding demographics, medical history, treatment history, response to treatment, and relapse. Medical history was captured for all concurrent diagnoses that could be considered associated with ITP including infectious and autoimmune conditions. Primary end-points were freedom from relapse after 2nd and 3rd line treatment with R or S. We used Kaplan-Meier method to estimate freedom from relapse after 2nd and 3rd line treatments. We also evaluated response to treatment, as defined by a platelet count >30,000/mm3 according to consensus guidelines. We performed three separate analyses for the entire cohort, primary ITP, and secondary ITP (separating out those with a concurrent diagnosis of malignancy). Results We identified 222 patients with a diagnosis of ITP, of which 191 had primary and 31 had secondary ITP. Treatment characteristics were similar in all groups except that pts treated initially with S were younger at diagnosis than pts treated with R (49 vs 60 years, P=0.003) and at time of 2ndline treatment (51.5 vs 61 years, P=0.018). For the overall cohort, patients treated with S as second-line therapy were more likely to achieve CR (86.6% vs 44%, P<0.0001), and had a significantly higher freedom from relapse at 5y (53.57% v. 14.96%, P<0.0001). Patients treated with S followed by R (S to R) had a trend towards higher 2y freedom from relapse than those treated with R followed by S (R to S) (69.48% v. 58.43%, P=0.3264). These data remained similar when primary ITP and secondary ITP were separated (data not shown). Conclusions These data support that S provides superior FFR at 5 years compared to R as second line treatment and suggests that, when needed, splenectomy followed by rituximab as opposed to rituximab followed by splenectomy might have a slight advantage. Disclosures No relevant conflicts of interest to declare.

Abstract Introduction: Current advances in allogeneic hematopoietic cell transplant (alloHCT) may warrant a paradigm shift in managing children with sickle cell disease (SCD). This study characterizes the clinical outcomes and health care utilization (HCU) of alloHCT for pediatric SCD. We hypothesize that early alloHCT will have improved clinical outcomes, and decreased HCU. Methods: The Center for International Blood and Marrow Transplant Research database was used to identify children 21 years or less with alloHCT for SCD in the United States. Patient data included comprehensive research forms (CRF) from 2000-13 and transplant essential data (TED) forms from 2000-11. CRFs provided clinical risk factors associated with overall survival, graft failure, grade III-IV acute GVHD, and GVHD related event free survival (GREFS) - the survival free of graft failure, chronic GVHD, or death. Risk factors included age, gender, performance status, year of alloHCT, prior SCD complications and therapy, CMV status, donor type, conditioning regimen, and GVHD prophylaxis. Due to low event rates and sample size, only univariate analysis of risk factors was performed. TED data was merged with Pediatric Health Information System (PHIS) inpatient data using a probabilistic merging algorithm to determine risk factors and clinical outcomes associated with HCU. Available PHIS adjusted cost data was used to determine the total adjusted cost for all inpatient admissions per patient per hospital day. To standardize these costs, the total adjusted cost per 30 hospital days was calculated for each patient and used as the primary HCU outcome. HCU outcomes were analyzed for the alloHCT year, day 0 to day +365. Results: CRF data for 161 patients showed an overall survival at 2 years of 90% (95% confidence intervals [CI] 85-95%): 96% (95% CI 89-100%) for related and unrelated cord blood transplant (CBT), 94% (95% CI 86-98%) matched siblings (MSD), and 74% (95% CI 54-90%) matched unrelated donors (MUD, p=0.002). All deaths occurred among children with pre-alloHCT complications of SCD, and deaths were due to organ failure (37.5%), infections (25%), GVHD (6.25%). Risk of death was significantly higher for children ≥10 years old (HR 21, p=0.003) and MUD compared to MSD (HR 5.88, p=0.005) but lower with cyclosporine A (CSA) GVHD prophylaxis versus FK506 (HR 0.33, p=0.031). 75% of deaths occurred before day +42. Cumulative acute GVHD incidence at day 100 was 14% (95% CI 9-20%)and was associated with age ≥10yrs (HR 2.63, p=0.035). Chronic GVHD incidence was 31% (95% CI 23-38%) at 2yrs, and factors associated were age ≥10yrs (HR 1.92, p=0.034), MUD vs MSD (HR 2.53, p=0.017), and CSA vs FK506 prophylaxis (HR 0.48, p=0.018). Chronic GVHD risk increased significantly after 2006 (HR 2.81, p=0.018). The 2yr GREFS was 64% (95% CI 56-71%). Age ≥10yrs (HR 2.2, p=0.005), MUD (vs MSD, HR 3.00, p=0.002) and CSA prophylaxis (vs FK506, HR 0.49, p=0.011) were significantly associated with this outcome. Among the 175 patients with combined TED and PHIS data, the median total adjusted cost was $117,393 per 30 hospital days per patient (range: $36,244-$515,640) during the alloHCT year with a median of 53 hospital days per patient (range: 16-304). Age ≥10yrs and HCU were not significantly associated (p=0.775). MSD had the lowest HCU compared to CBT and unrelated transplants (p<0.001). CBT and peripheral blood stem cells were associated with higher HCU compared to bone marrow (p=0.004). Increased HCU was associated with prior stroke (p=0.0004) and pain crises (p=0.0094) but not acute chest syndrome (p=0.2913). Overall SCD complication and severity indices correlated with increased HCU (p=0.052, p=0.0219, respectively). Conclusions: AlloHCT outcomes in children with SCD were linked to age and donor type suggesting that early alloHCT before age 10 years is preferred. Specifically, SCD severity and MUD alloHCT are associated with poorer outcomes and increased HCU. This supports the recommendation of early alloHCT, prior to onset of SCD complications, for children with SCD and an available MSD. Donor source and type had a significant impact on both outcomes and HCU. CBT outcomes were similar to MSD bone marrow; yet CBT had higher HCU suggesting additional analysis is needed to determine if the clinical benefit outweighs the cost. Further analysis is also needed to better understand and mitigate risk factors associated with poor outcomes and increased HCU following MUD alloHCT. Disclosures Arnold: Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program: Other: award. Hahn:NIH/NHLBI: Research Funding; Novartis: Equity Ownership.

Pharmacologic stimulation of a G protein–coupled receptor preferentially expressed on fibroblasts reverses experimental lung and liver fibrosis.

Altered airway smooth muscle (ASM) mass and extracellular matrix (ECM) deposition in airways are characteristic features of remodeling in asthma. Increased ECM production modulates ASM cell proliferation and leads to airway remodeling. Our previous studies showed that ASM from patients with asthma exhibited increased expression of estrogen receptor (ER)‐β, which upon activation down‐regulated ASM proliferation, implicating an important role for estrogen signaling in airway physiology. There is no current information on the effect of differential ER activation on ECM production. In this study, we evaluated the effect of ER‐α vs. ER‐β activation on ECM production, deposition, and underlying pathways. Primary human ASM cells isolated from asthmatics and nonasthmatics were treated with E 2 , an ER‐α agonist [propylpyrazoletriol (PPT)], and an ER‐β agonist [WAY‐200070 (WAY)] with TNF‐α or platelet‐derived growth factor (PDGF) followed by evaluation of ECM production and deposition. Expression of proteins and genes corresponding to ECM were measured using Western blotting and quantitative RT‐PCR with subsequent matrix metalloproteinase (MMP) activity. Molecular mechanisms of ER activation in regulating ECM were evaluated by luciferase reporter assays for activator protein 1 (AP‐1) and NF‐κB. TNF‐α or PDGF significantly ( P < 0.001) increased ECM deposition and MMP activity in human ASM cells, which was significantly reduced with WAY treatment but not with PPT. Furthermore, TNF‐α‐ or PDGF‐induced ECM gene expression in ASM cells was significantly reduced with WAY ( P < 0.001). Moreover, WAY significantly down‐regulated the activation of NF‐κB( P < 0.001) and AP‐1 ( P < 0.01, P < 0.05) in ASM cells from asthmatics and nonasthmatics. Overall, we demonstrate differential ER signaling in controlling ECM production and deposition. Activation of ER‐β diminishes ECM deposition via suppressing the NF‐κB pathway activity and might serve as a novel target to blunt airway remodeling.—Ambhore, N. S., Kalidhindi, R. S. R., Pabelick, C. M., Hawse, J. R., Prakash, Y. S., Sathish, V. Differential estrogen‐receptor activation regulates extracellular matrix deposition in human airway smooth muscle remodeling via NF‐κB pathway. FASEB J. 33, 13935‐13950 (2019). www.fasebj.org

Asthma is defined as chronic inflammation of the airways and is characterized by airway remodeling, hyperresponsiveness, and acute bronchoconstriction of airway smooth muscle (ASM) cells. Clinical findings suggest a higher incidence and severity of asthma in adult women, indicating a concrete role of sex steroids in modulating the airway tone. Estrogen, a major female sex steroid mediates its role through estrogen receptors (ER) ERα and ERβ, which are shown to be expressed in human ASM, and their expression is upregulated in lung inflammation and asthma. Previous studies suggested rapid, nongenomic signaling of estrogen via ERs reduces intracellular calcium ([Ca2+]i), thereby promoting relaxation of ASM. However, long-term ER activation on [Ca2+]iregulation in human ASM during inflammation or in asthma is still not known. In Fura-2-loaded nonasthmatic and asthmatic human ASM cells, we found that prolonged (24 h) exposure to ERα agonist (PPT) increased [Ca2+]iresponse to histamine, whereas ERβ activation (WAY) led to decreased [Ca2+] compared with vehicle. This was further confirmed by ER overexpression and knockdown studies using various bronchoconstrictor agents. Interestingly, ERβ activation was more effective than 17β-estradiol in reducing [Ca2+]iresponses in the presence of TNF-α or IL-13, while no observable changes were noticed with PPT in the presence of either cytokine. The [Ca2+]i-reducing effects of ERβ were mediated partially via L-type calcium channel inhibition and increased Ca2+sequestration by sarcoplasmic reticulum.Overall, these data highlight the differential signaling of ERα and ERβ in ASM during inflammation. Specific ERβ activation reduces [Ca2+]iin the inflamed ASM cells and is likely to play a crucial role in regulating ASM contractility, thereby relaxing airways.