Characteristics of traumatic major haemorrhage in a tertiary trauma center

BACKGROUND

Major traumatic haemorrhage is potentially preventable with rapid haemorrhage control and improved resuscitation techniques. Although advances in prehospital trauma management, haemorrhage is still associated with high mortality. The aim of this study was to use a recent pragmatic transfusion-based definition of major bleeding to characterize patients at risk of major bleeding and associated outcomes in this cohort after trauma.

METHODS

This was a retrospective cohort study including all trauma patients (n = 7020) admitted to a tertiary trauma center from January 2015 to June 2020. The major bleeding cohort (n = 145) was defined as transfusion of 4 units of any blood components (red blood cells, plasma, or platelets) within 2 h of injury. Univariate and multivariable logistic regression analyses were performed to identify risk factors for 24-hour and 30-day mortality post trauma admission.

RESULTS

In the major bleeding cohort (n = 145; 145/7020, 2.1% of the trauma population), there were 77% men (n = 112) and 23% women (n = 33), median age 39 years [IQR 26-53] and median Injury Severity Score (ISS) was 22 [IQR 13-34]. Blunt trauma dominated over penetrating trauma (58% vs. 42%) where high-energy fall was the most common blunt mechanism and knife injury was the most common penetrating mechanism. The major bleeding cohort was younger (OR 0.99; 95% CI 0.98 to 0.998, P = 0.012), less female gender (OR 0.66; 95% CI 0.45 to 0.98, P = 0.04), and had more penetrating trauma (OR 4.54; 95% CI 3.24 to 6.36, P = 0.001) than the rest of the trauma cohort. A prehospital (OR 2.39; 95% CI 1.34 to 4.28; P = 0.003) and emergency department (ED) (OR 6.91; 95% CI 4.49 to 10.66, P = 0.001) systolic blood pressure < 90 mmHg was associated with the major bleeding cohort as well as ED blood gas base excess < -3 (OR 7.72; 95% CI 5.37 to 11.11; P < 0.001) and INR > 1.2 (OR 3.09; 95% CI 2.16 to 4.43; P = 0.001). Emergency damage control laparotomy was performed more frequently in the major bleeding cohort (21.4% [n = 31] vs. 1.5% [n = 106]; OR 3.90; 95% CI 2.50 to 6.08; P < 0.001). There was no difference in transportation time from alarm to hospital arrival between the major bleeding cohort and the rest of the trauma cohort (47 [IQR 38;59] vs. 49 [IQR 40;62] minutes; P = 0.17). However, the major bleeding cohort had a shorter time from ED to first emergency procedure (71.5 [IQR 10.0;129.0] vs. 109.00 [IQR 54.0; 259.0] minutes, P < 0.001). In the major bleeding cohort, patients with penetrating trauma, compared to blunt trauma, had a shorter alarm to hospital arrival time (44.0 [IQR 35.5;54.0] vs. 50.0 [IQR 41.5;61.0], P = 0.013). The 24-hour mortality in the major bleeding cohort was 6.9% (10/145). All fatalities were due to blunt trauma; 40% (4/10) high energy fall, 20% (2/10) motor vehicle accident, 10% (1/10) motorcycle accident, 10% (1/10) traffic pedestrian, 10% (1/10) traffic other, and 10% (1/10) struck/hit by blunt object. In the logistic regression model, prehospital cardiac arrest (OR 83.4; 95% CI 3.37 to 2063; P = 0.007) and transportation time (OR 0.95, 95% CI 0.91 to 0.99, P = 0.02) were associated with 24-hour mortality.

RESULTS

Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control. The major bleeding trauma cohort is a small part of the entire trauma population, and is characterized of being younger, male gender, higher ISS, and exposed to more penetrating trauma. Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control.

Impact of storage time prior to cryopreservation on mechanical properties of aortic homografts

Optimal time spans in homograft procurement are still debatable among tissue banks and needs to be further investigated. Cell viability decreases at longer preparation intervals, but the effect on collagen and elastic fibers has not been investigated to the same extent. These fibers are of importance to the homograft elasticity and strength. The objective of this study was to analyze the mechanical properties of homograft tissue at different time spans in the procurement process. Ten aortic homografts were collected at the Tissue Bank in Lund. Twelve samples were obtained from each homograft, cryopreserved in groups of three after 2-4 days, 7-9 days, 28-30 days, and 60-62 days in antibiotic decontamination. Mechanical testing was performed with uniaxial tensile tests, calculating elastic modulus, yield stress and energy at yield stress. Two randomly selected samples were assessed with light microscopy. Procurement generated a total of 120 samples, with 30 samples in each time group. Elastic modulus and yield stress was significantly higher in samples cryopreserved after 2-4 days (2.7 MPa (2.5-5.0) and 0.78 MPa (0.68-1.0)) compared to 7-9 days (2.2 MPa (2.0-2.6) and 0.53 MPa (0.46-0.69)), p = 0.008 and 0.011 respectively. Light microscopy did not show any difference in collagen and elastin at different time spans. There was a significant decrease in elastic modulus and yield stress after 7 days of decontamination at 4 °C compared to 2-4 days. This could indicate some deterioration of elastin and collagen at longer decontamination intervals. Clinical significance of these findings remains to be clarified.

Investigation of tryptophan to kynurenine degradation in response to interferon-γ in melanoma cell lines

Background and aim

Melanoma is a fatal form of skin cancer that carries a grave prognosis if the cancer cells spread and form metastases. The Kynurenine (Kyn) pathway is activated by the enzyme indoleamine 2,3-dioxygenase 1 (IDO-1) and has been shown to have a role in tumour progression. We have previously shown that interferon-γ (IFN-γ) acts as an inducer of tryptophan (Trp) degradation to Kyn in keratinocytes of the basal layer in a 3D epidermis model. Before extending our reconstructed human epidermis model to not only contain keratinocytes but also fibroblasts and melanocytes/melanoma cells, we have in this study set out to investigate possible differences between primary adult melanocytes and six melanoma cell lines regarding the expression of the immune checkpoint inhibitors IDO-1 and programmed death ligand 1 (PD-L1) together with Kyn production.

Methods

The melanocytes and melanoma cells were stimulated with 1-20 ng/ml of IFN-γ and the levels of Trp to Kyn degradation were monitored with high-performance liquid chromatography (HPLC). To analyze the viability of the cell types after IFN-γ treatment, an MTT assay was performed. mRNA quantity of IDO-1, PD-L1 and IFN-γ receptor (IFN-GR1) was analyzed with qPCR.

Results

After 24 h, only the metastatic cell line WM-266-4 was affected by all concentrations of IFN-γ, whereas at 48 h, the higher IFN-γ concentrations gave a more pronounced effect on the viability in all cell types. Trp was detected at various levels in the culture medium from all cell types before and after IFN-γ treatment. The degradation to Kyn was detected in primary melanocytes, Mel Juso, and Mel Ho cell lines after 24 h of treatment and low levels of IFN-γ. However, the higher concentration of IFN-γ, 20 ng/ml, induced Kyn to various degrees in all cell types after 24 h. The change in mRNA quantity of IDO-1 and PD-L1 was similar in all cell types.

Conclusion

To conclude, no significant difference in upregulation of the immune checkpoint inhibitors PD-L1 and IDO-1 was seen between primary tumour and metastatic melanoma. IFN-γ stimulation of melanocytes and different stages of melanoma cell lines resulted in an increased Kyn/Trp ratio in the more aggressive melanoma cells when a high concentration was used (20 ng/ml) but when a lower concentration of IFN-γ (5 ng/ml) was used an increased Kyn/Trp ratio were detected in media from primary melanocytes and early-stage melanoma.

Antisecretory factor in breastmilk is associated with reduced incidence of sepsis in preterm infants

BACKGROUND

Antisecretory Factor (AF) is a protein present in breastmilk that regulates inflammatory processes. We aimed to investigate the level of AF in mothers' own milk (MOM) in relation to sepsis and other neonatal morbidities in preterm infants.

METHODS

Samples of breastmilk and infant plasma were collected at 1, 4, and 12 weeks after birth from 38 mothers and their 49 infants born before 30 weeks gestation. AF-compleasome in MOM was determined by a sandwich enzyme-linked immunosorbent assay (ELISA) and inflammatory markers in infant plasma by a panel of 92 inflammatory proteins. Neonatal treatments and outcomes were recorded.

RESULTS

The level of AF in MOM week 1 was lower for infants with later sepsis compared to no sepsis (p = 0.005). Corrected for nutritional intake of MOM, higher levels of AF decreased the risk for sepsis, OR 0.24. AF in MOM week 1 was negatively correlated to inflammatory proteins in infant plasma week 4, markedly IL-8, which was also associated with infant sepsis. Overall, higher AF levels in MOM was associated with fewer major morbidities of prematurity.

CONCLUSION

Mother's milk containing high levels of antisecretory factor is associated with reduced risk for sepsis and inflammation in preterm infants.

IMPACT

High level of antisecretory factor (AF) in mothers' own milk is associated with less risk for later sepsis in preterm infants. Receiving mothers' milk with low AF levels during the first week after birth is correlated with more inflammatory proteins in infant's plasma 2-4 weeks later. Human breastmilk has anti-inflammatory properties, and antisecretory factor in mothers' own milk is a component of potential importance for infants born preterm. The findings suggest that food supplementation with AF to mothers of preterm infants to increase AF-levels in breastmilk may be a means to decrease the risk of inflammatory morbidities of prematurity.

Patient-derived scaffolds representing breast cancer microenvironments influence chemotherapy responses in adapted cancer cells consistent with clinical features

BACKGROUND

The tumor microenvironment clearly influences cancer progressing properties but less is known about how individual cancer microenvironments potentially moderate cancer treatment effects. By cultivating and treating cancer cell lines in patient-derived scaffolds (PDS), the impact of specific characteristics of individual cancer microenvironments can be incorporated in human-like growth modelling and cancer drug treatment testing.

METHODS

PDSs from 78 biobanked primary breast cancer samples with known patient outcomes, were prepared and repopulated with donor breast cancer cell lines, followed by treatment with 5-fluorouracil or doxorubicin after cellular adaption to the various microenvironments. Cancer cell responses to the treatments were monitored by RNA-analyses, highlighting changes in gene sets representative for crucial tumor biological processes such as proliferation, cancer stem cell features, differentiation and epithelial-to-mesenchymal transition.

RESULTS

The chemotherapy treatments induced distinct gene expression patterns in adapted cancer cells with clusters of similar treatment responses depending on the patient-derived cancer microenvironment used as growth substrate. The doxorubicin treatment displayed a favorable gene signature among surviving cancer cells with low proliferation (MKI67) and pluripotency features (NANOG, POU5F1), in comparison to 5-fluorouracil showing low proliferation but increased pluripotency. Specific gene changes monitored post-treatment were also significantly correlated with clinical data, including histological grade (NANOG), lymph node metastasis (SLUG) and disease-free patient survival (CD44).

CONCLUSIONS

This laboratory-based treatment study using patient-derived scaffolds repopulated with cancer cell lines, clearly illustrates that the human cancer microenvironment influences chemotherapy responses. The differences in treatment responses defined by scaffold-cultures have potential prognostic and treatment predictive values.

Access to novel cancer medicines in four countries in Central and Eastern Europe in relation to clinical benefit

BACKGROUND

Almost 100 novel cancer medicines have been approved in Europe over the last decade. Limited public health care resources in countries in Central and Eastern Europe (CEE) call for a prioritization of access to effective medicines. We investigated how both reimbursement status and waiting time to reimbursement correlate with the magnitude of clinical benefit provided by novel medicines in four selected countries (Czechia, Hungary, Poland, and Slovakia).

MATERIALS AND METHODS

A total of 124 indications of 51 cancer medicines with marketing authorization by the European Medicines Agency in 2011-2020 were included and followed up until 2022. Data on reimbursement status and waiting time to reimbursement (i.e. time from marketing authorization to national reimbursement approval) were collected for each country. Data were analyzed in relation to clinical benefit status (i.e. substantial versus nonsubstantial clinical benefit) of indications according to the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS).

RESULTS

The degree of reimbursement differed between countries with 64% of indications with reimbursement in Czechia, 40% in Hungary, 51% in Poland, and 19% in Slovakia. In all countries, a significantly greater proportion of indications with a substantial clinical benefit was reimbursed (P < 0.05). The median waiting time to reimbursement ranged from 27 months in Poland to 37 months in Hungary. No significant differences in waiting time in relation to clinical benefit were observed in any country (P = 0.25-0.84).

CONCLUSIONS

Cancer medicines with a substantial clinical benefit are more likely to be reimbursed in all four CEE countries. Waiting times to reimbursement are equally long for medicines with or without a substantial clinical benefit, indicating a lack of prioritization of fast access to medicines delivering a substantial benefit. Incorporation of the ESMO-MCBS in reimbursement assessments and decisions could aid in better utilization of limited resources to deliver more effective cancer care.

In vitro effects of undifferentiated callus extracts from Plantago major L, Rhodiola rosea L and Silybum marianum L in normal and malignant human skin cells

Background and objectives

The occurrence of non-melanoma and melanoma skin cancers is currently increasing rapidly with one in every three cancers diagnosed as a skin cancer. A useful strategy to control the progression of skin cancer could be the use of plant flavonoids that suppress pro-inflammatory cytokines involved in tumor initiation and progression. In this study, the anti-inflammatory and antioxidant activity of undifferentiated callus extracts from Plantago major L, Silybum marianum L and Rhodiola rosea L was investigated both in normal and malignant skin cells.

Methods

Antioxidant activity of the extracts was analyzed by using the Trolox Equivalent Antioxidant Capacity (TEAC) assay. High-Performance Thin-Layer Chromatography (HPTLC) was performed to demonstrate the phytochemical profile, and the total flavonoid content was analyzed with an aluminum chloride colorimetric method. The anti-inflammatory effect was investigated by cell treatments using the plant extracts. Thereafter, the possible suppression of induced IL-6 response was measured from the cultured skin cancer cell lines A2058 and A431, and normal primary keratinocytes with Enzyme-Linked Immunosorbent Assay (ELISA).

Results

The HPTLC analysis assessed that the extracts contained a complex phytochemical profile that was rich in phenolic and flavonoid compounds. Dose response assays showed that concentrations between 15 and 125 μg/mL of all three plant extracts could be used to investigate an effect on the IL-6 production. The S. marianum extract had the most pronounced anti-inflammatory effect, which significantly inhibited induced IL-6 production in both normal keratinocytes and skin cells derived from epidermal carcinoma. The extract from S. marianum also had the highest flavonoid content and showed the highest antioxidant activity of the three extracts tested.

Conclusion

All in all, we have confirmed that undifferentiated callus extracts of S. marianum possess properties such as antioxidant and anti-inflammatory activities in both normal and malignant keratinocytes, and thus could be a promising agent controlling the pro-inflammatory IL-6 production.

Cord clamping beyond 3 minutes: Neonatal short-term outcomes and maternal postpartum hemorrhage

BACKGROUND

Delaying cord clamping (CC) for 3-5 minutes reduces iron deficiency and improves neurodevelopment. Data on the effects of CC beyond 3 minutes in relation to short-term neonatal outcomes and maternal risk of postpartum hemorrhage are scarce.

METHODS

This was a prospective observational study performed in two delivery departments. Pregnant women with vaginal deliveries were included. Time to CC, estimated postpartum blood loss, and perinatal data were recorded. Spearman's correlation analysis and comparisons between newborns clamped before and after 3 minutes were performed.

RESULTS

In total, 904 dyads were included. The mean gestational age ± standard deviation was 40.1 ± 1.2 weeks. CC was performed at a median time of 6 minutes (range 0-23.5). Apgar scores at 5 and 10 minutes were positively correlated with time to CC (correlation coefficient .140, P &lt; .001 and .161, &lt; .001). There was no correlation between CC time and bilirubin level (correlation coefficient .021, P = .54). The median postpartum blood loss was 300 mL (70-2550 mL), with a negative correlation between CC time and postpartum blood loss (-0.115, P = .001). The postpartum blood loss was larger in the group clamped at ≤3 minutes (median [interquartile range] 400 mL [300-600] vs 300 mL [250-450], [P = .003]].

CONCLUSIONS

Umbilical CC times beyond 3 minutes in vaginal deliveries were not associated with negative short-term outcomes in newborns and were associated with a smaller maternal postpartum blood loss. Although CC time as long as 6 minutes could be considered as safe, further research is needed to decide the optimal timing.

Selective transfer of maternal antibodies in preterm and fullterm children

Preterm newborns are more likely to suffer from infectious diseases at birth compared to children delivered at term. Whether this is due to compromised cellular, humoral, or organ-specific development remains unclear. To begin to define whether maternal-fetal antibody transfer profiles differ across preterm (PT) and fullterm (FT) infants, the overall quantity and functional quality of an array of 24 vaccine-, endemic pathogen-, and common antigen-specific antibodies were assessed across a cohort of 11 PT and 12 term-delivered maternal:infant pairs from birth through week 12. While total IgG levels to influenza, pneumo, measles, rubella, EBV, and RSV were higher in FT newborns, selective Fc-receptor binding antibodies was noted in PT newborns. In fact, near equivalent antibody-effector functions were observed across PT and FT infants, despite significant quantitative differences in transferred antibody levels. Moreover, temporal transfer analysis revealed the selective early transfer of FcRn, FcγR2, and FcγR3 binding antibodies, pointing to differential placental sieving mechanisms across gestation. These data point to selectivity in placental transfer at distinct gestational ages, to ensure that children are endowed with the most robust humoral immunity even if born preterm.

Core competencies for a biomedical laboratory scientist - a Delphi study

BACKGROUND

After completing university education, biomedical laboratory scientists work in clinical laboratories, in biomedical research laboratories, in biotech, and in pharmaceutical companies. Laboratory diagnostics have undergone rapid development over the recent years, with the pace showing no signs of abatement. This rapid development challenges the competence of the staff and will most certainly influence the education of future staff. This study aimed to examine what was considered the necessary competencies needed to pursue a career as a biomedical laboratory scientist.

METHODS

A modified Delphi technique was used, with the panel of experts expressing their views in a series of three questionnaire. Consensus was defined as the point which 75 % or more of the panel participants agreed that a particular competency was necessary.

RESULTS

The study highlights the perceived importance of mostly generic competencies that relate to quality, quality assurance, and accuracy, as well as different aspects of safety, respect, trustworthiness (towards patients/clients and colleagues), and communication skills. The results also stress the significance of self-awareness and professionality.

CONCLUSIONS

We identified important competencies for biomedical laboratory scientists. Together with complementary information from other sources, i.e., guidelines, laws, and scientific publications, the competencies identified can be used as learning outcomes in a competency-based education to provide students with all the competencies needed to work as professional biomedical laboratory scientists.

Non-Invasive, Topical Sampling of Potential, Low-Molecular Weight, Skin Cancer Biomarkers: A Study on Healthy Volunteers

Monitoring of low-molecular weight cancer biomarkers, such as tryptophan (Trp) and its derivative kynurenine (Kyn), might be advantageous to non-invasive skin cancer detection. Thus, we assessed several approaches of topical sampling of Trp and Kyn, in relation to phenylalanine (Phe) and tyrosine (Tyr), on the volar forearm of six healthy volunteers. The sampling was performed with three hydrogels (made of agarose or/and chitosan), hydrated starch films, cotton swabs, and tape stripping. The biomarkers were successfully sampled by all approaches, but the amount of collected Kyn was low, 20 ± 10 pmol/cm². Kyn quantification was below LOQ, and thus, it was detected only in 20% of topical samples. To mitigate variability problems of absolute amounts of sampled amino acids, Tyr/Trp, Phe/Trp, and Phe/Tyr ratios were assessed, proving reduced inter-individual variation from 79 to 45% and intra-individual variation from 42 to 21%. Strong positive correlation was found between Phe and Trp, pointing to the Phe/Trp ratio (being in the 1.0-2.0 range, at 95% confidence) being least dependent on sampling materials, approaches, and sweating. This study leads to conclusion that due to the difficulty in quantifying less abundant Kyn, and thus the Trp/Kyn ratio, the Phe/Trp ratio might be a possible, alternative biomarker for detecting skin cancers.

Changes in Antisecretory Factor in Human Milk During the Postpartum and Length of Gestation

BACKGROUND

Preterm infants are more susceptible to inflammatory complications than term infants. Human milk contains numerous bioactive components protecting the newborn infant. Antisecretory factor, a protein regulating secretory and inflammatory processes by complex binding with complement factors, is present in human milk.

RESEARCH AIMS

To describe antisecretory factor (1) in mother's own milk in term and preterm infants; and (2) in donor milk before and after Holder pasteurization.

METHODS

The study was prospective, longitudinal, explorative, and descriptive. Antisecretory factor-compleasome was determined using sandwich enzyme-linked immunosorbent assay in longitudinal human milk samples over 12 weeks from mothers (N = 87) of term (n = 41) and of preterm (n = 46) infants and 20 anonymized donor human milk samples before and after Holder pasteurization.

RESULTS

Antisecretory factor-compleasome was overall higher in colostrum versus mature milk (p < .001) and no difference was found in term or preterm colostrum (p = .82). In mature milk, compleasome was higher and more variable in the preterm group (p = .01). After Holder pasteurization, compleasome levels increased (p < .001).

CONCLUSION

Antisecretory factor followed the pattern of other immunological factors with high levels in colostrum. After preterm birth, levels of antisecretory factor were higher and more variable in mature milk. Holder pasteurization did not degrade antisecretory factor, indicating preserved anti-inflammatory properties in donor human milk.

Catalase Activity in Keratinocytes, Stratum Corneum, and Defatted Algae Biomass as a Potential Skin Care Ingredient

The generation of reactive oxygen species presents a destructive challenge for the skin organ and there is a clear need to advance skin care formulations aiming at alleviating oxidative stress. The aim of this work was to characterize the activity of the antioxidative enzyme catalase in keratinocytes and in the skin barrier (i.e., the stratum corneum). Further, the goal was to compare the activity levels with the corresponding catalase activity found in defatted algae biomass, which may serve as a source of antioxidative enzymes, as well as other beneficial algae-derived molecules, to be employed in skin care products. For this, an oxygen electrode-based method was employed to determine the catalase activity and the apparent kinetic parameters for purified catalase, as well as catalase naturally present in HaCaT keratinocytes, excised stratum corneum samples collected from pig ears with various amounts of melanin, and defatted algae biomass from the diatom Phaeodactylum tricornutum. Taken together, this work illustrates the versatility of the oxygen electrode-based method for characterizing catalase function in samples with a high degree of complexity and enables the assessment of sample treatment protocols and comparisons between different biological systems related to the skin organ or algae-derived materials as a potential source of skin care ingredients for combating oxidative stress.

Oral health plays second fiddle in palliative care: an interview study with registered nurses in home healthcare

Background

Oral health is crucial to the experience of well-being, and symptoms from the mouth are common at the end of life. Palliative care aims to identify and treat symptoms early to avoid unnecessary suffering and is thus an important part of nursing in home healthcare. The aim of this study was to illustrate the professional reflections of registered nurses about oral health amongst patients in palliative care, who are being cared for in a home healthcare setting.

Results

The results showed oral health in end-of-life care, to be an area marked by responsibility and ethical considerations. This was seen in all four partly overlapping themes that emerged through the analysis: Oral health is easily overlooked in palliative care, Oral health is everybody’s but in reality nobody’s responsibility, Patient integrity can be an obstacle for oral health, and Focus on oral health is urgently needed. The mouth is often not included as part of the daily basic care routine, by the registered nurses and the home healthcare staff, until the patient is near end of life. Moreover, neither does the patient tell about symptoms from the mouth. The interpreted whole indicates that the registered nurses had a bad conscience about not doing what they are actually responsible for and ought to do.

Conclusion

The oral health of patients at the end of life risks being forgotten or falling between the cracks, due to the nurses’ scattered tasks and unclear delimitations between their, and other professionals’ responsibilities. The responsibilities of registered nurses are also ethically demanding, since their intent to respect the patient’s integrity could mean that in some cases the patients does not allow them to help with oral health. To reduce the risk that oral health is overlooked, clearer demarcation and guidelines on the division of responsibilities are required. Routines that clearly implement early and recurring oral health assessments in home healthcare as well as continuing education updates on oral health and oral care are also needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00859-3.

Periodontitis and cardiovascular outcome – a prospective follow-up of the PAROKRANK cohort

Background

There is an association between periodontitis (PD) and myocardial infarction (MI). Whether that is related to shared risk factors or it is causal is debated. The Periodontitis and Its Relation to Coronary Artery Disease (PAROKRANK) case-control study previously reported on an independent association between PD and a first MI.

Purpose

This follow-up of the PAROKRANK study tests the hypothesis that PD increases the risk for new cardiovascular (CV) events.

Methods

Between 2010–2014 805 patients (age &lt;75 years; females 19%) with a first MI and 805 controls without MI, matched for gender, age (mean 62±8 years) and living area underwent a CV and dental examination including panoramic x-ray. The PD was categorised in three grades: healthy (≥80% remaining alveolar bone height), moderate (79–66%) or severe (&lt;66%). The composite primary endpoint was the first of all-cause death, non-fatal MI or stroke, or severe heart failure until December 2018. The first of CV-death, non-fatal MI or stroke, or severe heart failure served as a secondary CV-endpoint. Data on outcomes were provided via linkage to the National Patient Registries and the Cause of Death Registry. Cumulative event rates, stratified by PD status at baseline in the combined cohort of cases and controls, were calculated using logistic regression and the Kaplan-Meier method.

Results

A total of 1587 participants with evaluated PD-status were followed for a mean of 6.2 (range 0.2–8.5) years. The total number of primary events and CV-events was 205 and 158 respectively. The number of deaths was 68. Baseline PD-status was healthy in 985 (mean age 60.4 years), moderate in 489 (mean age 65.1 years) and severe in 113 (mean age 64.3 years) participants. The figure presents the time to primary event by the three PD grades in the combined cohort (patients and controls). Time to the primary endpoint differed between the three PD grades (log-rank test 0.0148), however, significant only for patients (log-rank test patients vs. controls: 0.0382 vs. 0.608). Replacing the primary endpoint with the secondary CV-endpoint just changed the outcome slightly (log-rank 0.0976), possibly due to a low number of CV-deaths within the CV-event. Compared to participants without PD, the presence of PD at baseline was associated with the primary endpoint in the total cohort (Odds Ratio (OR): 1.49; 95% Confidence Interval (CI): 1.11–2.00) as well as the CV-endpoint (OR 1.42; 95% CI 1.02–1.98). PD was not associated with total mortality (OR 1.57; 95% CI 0.97–2.56).

Conclusion

In this up to 8-years follow up of the PAROKRANK cohort there was a graded increase in the risk for new CV-events by the presence of PD. This was in particular seen in the MI-patients. Together with the previous case-control based report from PAROKRANK, on an association between PD and a first MI, the findings during the follow-up supports the assumption that there may be a causal relationship between PD and CV-disease.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The PAROKRANK study was supported by grants from AFA Insurance, Swedish Heart-Lung Foundation, Swedish Research Council, Swedish Society of Medicine, Stockholm County Council (ALF project and Steering committee KI/SLL for odontological research), and The Baltic Child Foundation. Figure 1

Long term outcome after a first myocardial infarction

Background

Prognosis after a myocardial infarction (MI) have improved consistently over the last decades. In parallel, the incidence of cardiovascular (CV) events has been reduced and life expectancy in people free from CV disease improved.

Purpose

To explore the long-term mortality and burden of cardiovascular disease in patients after a first MI compared to matched controls in a contemporary setting.

Methods

The Swedish case-control study PAROKRANK recruited 805 patients &lt;75 years with a first MI and 805 age-, gender- and area-matched controls from 2010 to 2014. All participants were followed by means of registry-based information. The primary endpoint was the first of a composite of all-cause death, non-fatal MI, non-fatal stroke and heart failure hospitalization. Data on the outcomes were provided via linkage to the National Patient Registries and the Cause of Death Registry. Hazard Ratios (HR) for the first composite event were calculated by means of a Cox regression model, subsequently adjusted for smoking, education level and marital status at baseline. Event curves for the time-to-first event in patients and controls were computed by Kaplan-Meier curves and the two groups were compared by means of the log-rank test.

Results

Data from 804 patients and 800 controls (mean age in both groups 62 years; women 19%) were complete for an average period of 6.2 years (0.2–8.5 years). The total number of events was 211. Patients had a higher event rate than controls (log rank p&lt;0.0001). Unadjusted HR for the primary outcome was 2.08 (95% confidence interval (CI) 1.56–2.77) while the adjusted HR was 2.04 (95% CI 1.52–2.73). Mortality did not differ significantly between patients (n=38; 4.7%) and controls (n=35; 4.4%). In total, 82.5% of the patients and 91.3% of the controls were event-free during follow-up.

Conclusion

This long-term follow-up of a contemporary, nationwide case-control cohort illustrates that the likelihood for CV events is higher in patients with a first MI compared to their matched controls while mortality did not differ. The access to high quality of care and cardiac rehabilitation might explain the low rates of adverse outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): AFA Insurance, Swedish Heart-Lung Foundation, Swedish Research Council, Swedish Society of Medicine, Stockholm County Council (ALF project and Steering committee KI/SLL for odontological research), and The Baltic Child Foundation. Figure 1. Kaplan-Meier curves

Patient-derived scaffolds as a drug-testing platform for endocrine therapies in breast cancer

Three-dimensional cell culture platforms based on decellularised patient-based microenvironments provide in vivo-like growth conditions allowing cancer cells to interact with intact structures and components of the surrounding tissue. A patient-derived scaffold (PDS) model was therefore evaluated as a testing platform for the endocrine therapies (Z)-4-Hydroxytamoxifen (4OHT) and fulvestrant as well as the CDK4/6-inhibitor palbociclib, monitoring the treatment responses in breast cancer cell lines MCF7 and T47D adapted to the patient-based microenvironments. MCF7 cells growing in PDSs showed increased resistance to 4OHT and fulvestrant treatment (100- and 20-fold) compared to 2D cultures. Quantitative PCR analyses of endocrine treated cancer cells in PDSs revealed upregulation of pluripotency markers further supported by increased self-renewal capacity in sphere formation assays. When comparing different 3D growth platforms including PDS, matrigel, gelatin sponges and 3D-printed hydrogels, 3D based cultures showed slightly varying responses to fulvestrant and palbociclib whereas PDS and matrigel cultures showed more similar gene expression profiles for 4OHT treatment compared to the other platforms. The results support that the PDS technique maximized to provide a multitude of smaller functional PDS replicates from each primary breast cancer, is an up-scalable patient-derived drug-testing platform available for gene expression profiling and downstream functional assays.

Bifidobacteria-mediated immune system imprinting early in life

Immune-microbe interactions early in life influence the risk of allergies, asthma, and other inflammatory diseases. Breastfeeding guides healthier immune-microbe relationships by providing nutrients to specialized microbes that in turn benefit the host's immune system. Such bacteria have co-evolved with humans but are now increasingly rare in modern societies. Here we show that a lack of bifidobacteria, and in particular depletion of genes required for human milk oligosaccharide (HMO) utilization from the metagenome, is associated with systemic inflammation and immune dysregulation early in life. In breastfed infants given Bifidobacterium infantis EVC001, which expresses all HMO-utilization genes, intestinal T helper 2 (Th2) and Th17 cytokines were silenced and interferon β (IFNβ) was induced. Fecal water from EVC001-supplemented infants contains abundant indolelactate and B. infantis-derived indole-3-lactic acid (ILA) upregulated immunoregulatory galectin-1 in Th2 and Th17 cells during polarization, providing a functional link between beneficial microbes and immunoregulation during the first months of life.

Patient-derived scaffolds influence secretion profiles in cancer cells mirroring clinical features and breast cancer subtypes

BACKGROUND

Breast cancer is a common malignancy with varying clinical behaviors and for the more aggressive subtypes, novel and more efficient therapeutic approaches are needed. Qualities of the tumor microenvironment as well as cancer cell secretion have independently been associated with malignant clinical behaviors and a better understanding of the interplay between these two features could potentially reveal novel targetable key events linked to cancer progression.

METHODS

A newly developed human derived in vivo-like growth system, consisting of decellularized patient-derived scaffolds (PDSs) recellularized with standardized breast cancer cell lines (MCF7 and MDA-MB-231), were used to analyze how 63 individual patient specific microenvironments influenced secretion determined by proximity extension assays including 184 proteins and how these relate to clinical outcome.

RESULTS

The secretome from cancer cells in PDS cultures varied distinctly from cells grown as standard monolayers and besides a general increase in secretion from PDS cultures, several secreted proteins were only detectable in PDSs. Monolayer cells treated with conditioned media from PDS cultures, further showed increased mammosphere formation demonstrating a cancer stem cell activating function of the PDS culture induced secretion. The detailed secretomic profiles from MCF7s growing on 57 individual PDSs differed markedly but unsupervised clustering generated three separate groups having similar secretion profiles that significantly correlated to different clinical behaviors. The secretomic profile that associated with cancer relapse and high grade breast cancer showed induced secretion of the proteins IL-6, CCL2 and PAI-1, all linked to cancer stem cell activation, metastasis and priming of the pre-metastatic niche. Cancer promoting pathways such as "Suppress tumor immunity" and "Vascular and tissue remodeling" was also linked to this more malignant secretion cluster.

CONCLUSION

PDSs repopulated with cancer cells can be used to assess how cancer secretion is effected by specific and varying microenvironments. More malignant secretion patterns induced by specific patient based cancer microenvironments could further be identified pinpointing novel therapeutic opportunities targeting micro environmentally induced cancer progression via secretion of potent cytokines. Video abstract.

Femoral strength and strains in sideways fall: Validation of finite element models against bilateral strain measurements

Low impact falls to the side are the main cause of hip fractures in elderly. Finite element (FE) models of the proximal femur may help in the assessment of patients at high risk for a hip fracture. However, extensive validation is essential before these models can be used in a clinical setting. This study aims to use strain measurements from bilateral digital image correlation to validate an FE model against ex vivo experimental data of proximal femora under a sideways fall loading condition. For twelve subjects, full-field strain measurements were available on the medial and lateral side of the femoral neck. In this study, subject-specific FE models were generated based on a consolidated procedure previously validated for stance loading. The material description included strain rate dependency and separate yield and fracture strain limits in tension and compression. FE predicted fracture force and experimentally measured peak forces showed a strong correlation (R² = 0.92). The FE simulations predicted the fracture initiation within 3 mm distance of the experimental fracture line for 8/12 subjects. The predicted and measured strains correlated well on both the medial side (R² = 0.87) and the lateral side (R² = 0.74). The lower correlation on the lateral side is attributed to the irregularity of the cortex and presence of vessel holes in this region. The combined validation against bilateral full-field strain measurements and peak forces has opened the door for a more elaborate qualitative and quantitative validation of FE models of femora under sideways fall loading.

Breast cancer patient-derived scaffolds as a tool to monitor chemotherapy responses in human tumor microenvironments

Breast cancer is a heterogeneous disease where the tumor microenvironment, including extracellular components, plays a crucial role in tumor progression, potentially modulating treatment response. Different approaches have been used to develop three‐dimensional models able to recapitulate the complexity of the extracellular matrix. Here, we use cell‐free patient‐derived scaffolds (PDSs) generated from breast cancer samples that were recellularized with cancer cell lines as an in vivo‐like culture system for drug testing. We show that PDS cultured MCF7 cancer cells increased their resistance against the front‐line chemotherapy drugs 5‐fluorouracil, doxorubicin and paclitaxel in comparison to traditional two‐dimensional cell cultures. The gene expression of the environmentally adapted cancer cells was modulated in different ways depending on the drug and the concentration used. High doses of doxorubicin reduced cancer stem cell features, whereas 5‐fluorouracil increased stemness and decreased the proliferative phenotype. By using PDSs repopulated with other breast cancer cell lines, T‐47D and MDA‐MB‐231, we observed both general and cell line specific drug responses. In summary, PDSs can be used to examine the extracellular matrix influence on cancer drug responses and for testing novel compounds in in vivo‐like microenvironments.

The influence of microstructure on crack propagation in cortical bone at the mesoscale

The microstructure of cortical bone is key for the tissue's high toughness and strength and efficient toughening mechanisms have been identified at the microscale, for example when propagating cracks interact with the osteonal microstructure. Finite element models have been proposed as suitable tools for analyzing the complex link between the local tissue structure and the fracture resistance of cortical bone. However, previous models that could capture realistic crack paths in cortical bone were due to the required computational effort limited to idealized osteon geometries and small (<1 mm²) model domains. The objective of this study was therefore to bridge the gap between experimental and numerical analysis of crack propagation in cortical bone by introducing image-based models at the mesoscale. Tissue orientation maps from high-resolution micro-CT images were used to define the distribution and orientation of weak interfaces in the models. Crack propagation was simulated using the extended finite element method in combination with an interface damage model, previously developed to simulate crack propagation in microstructural osteon models. The results showed that image-based mesoscale models can be used to capture interactions between cracks and microstructure. The simulated crack paths predicted the general trends seen in experiments with more irregular patterns for cracks propagating perpendicular compared to parallel to the osteon orientation. In all, the proposed method enabled an efficient description of the tissue level microstructure, which is a necessity to predict realistic crack paths in cortical bone and is an important step towards simulating crack propagation in bone models in 3D.

Characterization of cell-free breast cancer patient-derived scaffolds using liquid chromatography-mass spectrometry/mass spectrometry data and RNA sequencing data

Patient-derived scaffolds (PDSs) generated from primary breast cancer tumors can be used to model the tumor microenvironment in vitro. Patient-derived scaffolds are generated by repeated detergent washing, removing all cells. Here, we analyzed the protein composition of 15 decellularized PDSs using liquid chromatography-mass spectrometry/mass spectrometry. One hundred forty-three proteins were detected and their relative abundance was calculated using a reference sample generated from all PDSs. We performed heatmap analysis of all the detected proteins to display their expression patterns across different PDSs together with pathway enrichment analysis to reveal which processes that were connected to PDS protein composition. This protein dataset together with clinical information is useful to investigators studying the microenvironment of breast cancers. Further, after repopulating PDSs with either MCF7 or MDA-MB-231 cells, we quantified their gene expression profiles using RNA sequencing. These data were also compared to cells cultured in conventional 2D conditions, as well as to cells cultured as xenografts in immune-deficient mice. We investigated the overlap of genes regulated between these different culture conditions and performed pathway enrichment analysis of genes regulated by both PDS and xenograft cultures compared to 2D in both cell lines to describe common processes associated with both culture conditions. Apart from our described analyses of these systems, these data are useful when comparing different experimental model systems. Downstream data analyses and interpretations can be found in the research article “Patient-derived scaffolds uncover breast cancer promoting properties of the microenvironment” [1].

The Reliability and Validity of a Novel Sport-Specific Balance Test to Differentiate Performance Levels in Elite Curling Players

Balance as a skill and task-specific capacity is considered an essential physical quality in curling, required for executing effective stone delivery. However, no testing protocols have been developed to test curling-specific balance in the delivery position. Thus, the primary aim of this study was to investigate the reliability, validity and usefulness of a newly-developed, curling-specific balance test (CSBT) which involved the delivery position. The secondary aim was to examine the differences between elite and sub-elite curlers for core strength and flexibility, which have previously been identified as important qualities in curling and determinants of balance. Twenty curling players (13 females aged 19 ± 3.1 years; 7 males aged 19.6 ± 2.3 years) from five Swedish super-league curling clubs were divided into two groups according to playing level: elite and sub-elite. Variables included body mass, body height, body mass index, age, playing experience, training frequency, plank test, sit and reach test, standing single-leg balance test (SLBT) and CSBT. The CSBT was executed on a multiaxial tilting balance plate while mimicking the curling delivery position (i.e., a deep lunge position with the front foot on the plate). The participants completed the CSBT on three separate occasions, with each test consisting of three, 20-s attempts. Both the relative and absolute reliability were good for the CSBT (ICC = 0.90; CV = 14.5%). The CSBT demonstrated good measurement usefulness, being sensitive to detect moderate changes that exceeded 0.5 times the test standard deviation. Construct validity of the CSBT was evidenced by the large discriminatory capacity to differentiate expertise level in curling players (t-test: 2.85, p < 0.01; large ES), irrespective of other physical capacities (e.g., flexibility and core strength). However, the elite and sub-elite players also differed in age, playing experience and training frequency. Content validity was confirmed by a weak correlation (r = 0.21; 95%CI: -0.26 to 0.60) between the CSBT and SLBT, which suggests that curling-specific and standing balance should be considered as independent and task-specific motor skills. In conclusion, the CSBT can be used as a reliable, valid and useful tool for the assessment of curling-specific balance performance. In addition, longer and more extensive involvement in curling training contributed to superior specific balance in elite curlers.

Abstract P1-04-01: Breast cancer patient derived scaffolds as a platform for studying cancer promoting properties of the microenvironment

Despite great efficiencies of today’s anti-cancer therapies in breast cancer medicine, recurrences and metastasis still remains a major challenge. The tumor initiating population of cancer stem cells (CSC) is believed to promote metastasis and drug resistance, suggesting that selectively targeting CSC and their niche may be a potential beneficial therapeutic strategy. However, specific driving factors in the microenvironment influencing the CSC niche remains unknown. To study the influence of specific cancer microenvironments, we have developed a novel three-dimensional cell culture platform, using cell-free patient derived scaffolds (PDS) from decellularized breast cancer tumors. We confirmed that our novel patient derived scaffold (PDS) recapitulates the native microenvironment where the cancer cells originate and, retains their biological properties. Our data demonstrate that culturing breast cancer cell lines in PDSs promotes CSC and EMT-like properties and decreases proliferation, similarly to in vivo conditions. Additionally, global gene expression profiling revealed that PDS cultures exhibit transcriptional patterns more similar to patient derived xenografts than to traditional monolayer cultures. Moreover, we analyzed the expression of cells cultured in 108 PDSs made from breast cancer tumors with clinical follow-up data, using a gene panel representative of relevant breast cancer related processes. This revealed that expression changes of several EMT markers and other CSC related genes in the PDS cultured cancer cells were correlated to clinical parameters such as grade, lymph node metastasis, patient survival and disease recurrences. Altogether, our data shows that PDS can reveal unique additional information about the malignancy-inducing properties of specific tumor microenvironments, potentially provides a complementary diagnosis tool for breast cancer tumors in vitro, and is a promising platform for drug screening of anti-cancer therapies.

Citation Format: Elena Garre, Anna Gustafsson, Maria del Carmen Leiva-Arrabal, Paul Fitzpatrick, Pernilla Gregersson, Anders Ståhlberg, Göran Landberg. Breast cancer patient derived scaffolds as a platform for studying cancer promoting properties of the microenvironment [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-04-01.

Abstract P6-06-14: Analysis of secreted proteome in an in vivo like human 3D model of breast cancer

Background: Breast cancer is the most common form of cancer amongst women and affects millions worldwide each year. The tumor micro environment plays a key role in cancer progression and disease outcome of which a highly important factor is the secreted proteome which includes cytokines, chemokines and other proteins. Cancer cells influence neighboring cells by both autocrine and paracrine secretion which affects cancer cell characteristics such as stem-like properties, proliferation and metastatic capacity. Due to the importance of cancer cell signaling and cell to cell communication, when studying the cancer cell secretome in a three-dimensional environment new signaling pathways and new possible drug targets can be investigated.

Methods: To understand the complexity of breast cancer cell secretion, the human in vivo like system patient derived scaffolds (PDS) was used as a modeling system whereby patient specific extracellular matrix mediated cellular secretion in both ERα+ and ERα- cell lines were investigated. 54 human breast cancer tumors were decellularized and the PDS were repopulated with either MCF7 or MDA-MB-231 cells. Cell lines were grown on scaffolds for 21 days. At day 16 cell media was changed and at day 21 conditioned media was collected for secretome analysis. Multiplex Proximity Extension Assay (OLINK, Uppsala Sweden) was performed on conditioned media and 184 proteins were analyzed for each sample.

Results: The secretome from cells grown in PDS culture differs distinctly from the secretome from cells cultured in standard monolayer cultures, both in numbers and amount of secreted proteins. Secreted proteins from cells grown in PDS cultures were also shown to increase the cancer stem cell population compared to secretome from cells cultivated in monolayer culture. By comparing secretomic profiles from MCF7 cells grown in 54 PDSs, three clusters were created with an unsupervised clustering method. When these three clusters were correlated to clinical information about the specific tumors in each cluster, patients in one of the clusters were found to have a significantly lower chance of relapse-free survival and a higher frequency of high-grade tumors. Further, cells grown in PDS from this cluster also showed a different genetic profile with increased expression of markers related to epithelial-mesenchymal transition.

Conclusion: Breast cancer cells grown in a three-dimensional in vivo-like model have a distinct different secretomic profile compare to monolayer cultured cells and the secretion can be related to the original characteristics of the breast tumor. This highlights the importance of the tumor microenvironment induced secretion and the possibility to target secreted proteins as a therapeutic strategy.

Citation Format: Emma Persson, Pernilla Gregersson, Paul Fitzpatrick, Anna Gustafsson, Anders Ståhlberg, Göran Landberg. Analysis of secreted proteome in an in vivo like human 3D model of breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-06-14.

Swedish national guideline for prevention and treatment of neonatal hypoglycaemia in newborn infants with gestational age ≥35 weeks

AIM

Postnatal hypoglycaemia in newborn infants remains an important clinical problem where prolonged periods of hypoglycaemia are associated with poor neurodevelopmental outcome. The aim was to develop an evidence-based national guideline with the purpose to optimise prevention, diagnosis and treatment of hypoglycaemia in newborn infants with a gestational age ≥35 + 0 weeks.

METHODS

A PubMed search-based literature review was used to find actual and applicable evidence for all incorporated recommendations. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used for grading the evidence of the recommendations.

RESULTS

Recommendations for the prevention of neonatal hypoglycaemia were extended and updated, focusing on promotion of breastfeeding as one prevention strategy. Oral dextrose gel as a novel supplemental therapy was incorporated in the treatment protocol. A new threshold-based screening and treatment protocol presented as a flow chart was developed.

CONCLUSION

An updated and evidence-based national guideline for screening and treatment of neonatal hypoglycaemia will support standardised regimes, which may prevent hypoglycaemia and the risk for hypoglycaemia-related long-term sequelae.

Patient-derived scaffolds uncover breast cancer promoting properties of the microenvironment

Tumor cells interact with the microenvironment that specifically supports and promotes tumor development. Key components in the tumor environment have been linked to various aggressive cancer features and can further influence the presence of subpopulations of cancer cells with specific functions, including cancer stem cells and migratory cells. To model and further understand the influence of specific microenvironments we have developed an experimental platform using cell-free patient-derived scaffolds (PDSs) from primary breast cancers infiltrated with standardized breast cancer cell lines. This PDS culture system induced a series of orchestrated changes in differentiation, epithelial-mesenchymal transition, stemness and proliferation of the cancer cell population, where an increased cancer stem cell pool was confirmed using functional assays. Furthermore, global gene expression profiling showed that PDS cultures were similar to xenograft cultures. Mass spectrometry analyses of cell-free PDSs identified subgroups based on their protein composition that were linked to clinical properties, including tumor grade. Finally, we observed that an induction of epithelial-mesenchymal transition-related genes in cancer cells growing on the PDSs were significantly associated with clinical disease recurrences in breast cancer patients. Patient-derived scaffolds thus mimics in vivo-like growth conditions and uncovers unique information about the malignancy-inducing properties of tumor microenvironment.

Associations among Periodontitis, Calcified Carotid Artery Atheromas, and Risk of Myocardial Infarction

Cardiovascular disease is a common cause of morbidity and premature mortality. Cardiovascular disease can be prevented when risk factors are identified early. Calcified carotid artery atheromas (CCAAs), detected in panoramic radiographs, and periodontitis have both been associated with increased risk of cardiovascular disease. This case-control study aimed to 1) investigate associations between periodontitis and CCAA detected in panoramic radiographs and 2) determine the risk of future myocardial infarctions due to CCAA combined with periodontitis. We evaluated 1,482 participants (738 cases and 744 controls) with periodontitis and CCAAs recruited from the PAROKRANK study (Periodontitis and Its Relation to Coronary Artery Disease). Participants were examined with panoramic radiographs, including the carotid regions. Associations between myocardial infarction and periodontitis combined with CCAA were evaluated in 696 cases and 696 age-, sex-, and residential area–matched controls. Periodontitis was evaluated radiographically (as degree of bone loss) and with a clinical periodontal disease index score (from clinical and radiographic assessments). We found associations between CCAA and clinical periodontal disease index score among cases (odds ratio [OR], 1.51; 95% CI, 1.09 to 2.10; P = 0.02) and controls (OR, 1.70; 95% CI, 1.22 to 2.38; P < 0.01), although not between CCAA and the degree of bone loss. In a multivariable model, myocardial infarction was associated with CCAA combined with periodontitis, as assessed by degree of bone loss (OR, 1.75; 95% CI, 1.11 to 2.74; P = 0.01). When the cohort was stratified by sex, only men showed a significant association between myocardial infarction and CCAA combined with periodontitis. Participants with clinically diagnosed periodontitis exhibited CCAA in panoramic radiographs more often than those without periodontitis, irrespective of the presence of a recent myocardial infarction. Participants with combined periodontitis and CCAA had a higher risk of having had myocardial infarction as compared with participants with either condition alone. These findings implied that patients in dental care might benefit from dentists assessing panoramic radiographs for CCAA—particularly, patients with periodontitis who have not received any preventive measures for cardiovascular disease.

Crack propagation in cortical bone is affected by the characteristics of the cement line: a parameter study using an XFEM interface damage model

Bulk properties of cortical bone have been well characterized experimentally, and potent toughening mechanisms, e.g., crack deflections, have been identified at the microscale. However, it is currently difficult to experimentally measure local damage properties and isolate their effect on the tissue fracture resistance. Instead, computer models can be used to analyze the impact of local characteristics and structures, but material parameters required in computer models are not well established. The aim of this study was therefore to identify the material parameters that are important for crack propagation in cortical bone and to elucidate what parameters need to be better defined experimentally. A comprehensive material parameter study was performed using an XFEM interface damage model in 2D to simulate crack propagation around an osteon at the microscale. The importance of 14 factors (material parameters) on four different outcome criteria (maximum force, fracture energy, crack length and crack trajectory) was evaluated using ANOVA for three different osteon orientations. The results identified factors related to the cement line to influence the crack propagation, where the interface strength was important for the ability to deflect cracks. Crack deflection was also favored by low interface stiffness. However, the cement line properties are not well determined experimentally and need to be better characterized. The matrix and osteon stiffness had no or low impact on the crack pattern. Furthermore, the results illustrated how reduced matrix toughness promoted crack penetration of the cement line. This effect is highly relevant for the understanding of the influence of aging on crack propagation and fracture resistance in cortical bone.

Hypoxia-induced secretion stimulates breast cancer stem cell regulatory signalling pathways

It is well known that tumour cells are dependent on communication with the tumour microenvironment. Previously, it has been shown that hypoxia (HX) induces pronounced, diverse and direct effects on cancer stem cell (CSC) qualities in different breast cancer subtypes. Here, we describe the mechanism by which HX-induced secretion influences the spreading of CSCs. Conditioned media (CM) from estrogen receptor (ER)-α-positive hypoxic breast cancer cell cultures increased the fraction of CSCs compared to normal growth conditions, as determined using sets of CSC assays and model systems. In contrast, media from ERα-negative hypoxic cell cultures instead decreased this key subpopulation of cancer cells. Further, there was a striking overrepresentation of JAK-STAT-associated cytokines in both the ERα-positive and ERα-negative linked hypoxic responses as determined by a protein screen of the CM. JAK-STAT inhibitors and knockdown experiments further supported the hypothesis that this pathway is critical for the CSC-activating and CSC-inactivating effects induced by hypoxic secretion. We also observed that the interleukin-6-JAK2-STAT3 axis was specifically central for the ERα-negative hypoxic behaviour. Our results underline the importance of considering breast cancer subtypes in treatments targeting JAK-STAT or HX-associated processes and indicate that HX is not only a confined tumour biological event, but also influences key tumour properties in widespread normoxic microenvironments.

Leaky gut biomarkers in depression and suicidal behavior

OBJECTIVE

Inflammation is associated with major depressive disorder (MDD) and suicidal behavior. According to the 'leaky gut hypothesis', increased intestinal permeability may contribute to this relationship via bacterial translocation across enterocytes. We measured plasma levels of gut permeability markers, in patients with a recent suicide attempt (rSA), MDD subjects with no history of a suicide attempt (nsMDD), and healthy controls (HC), and related these markers to symptom severity and inflammation.

METHOD

We enrolled rSA (n = 54), nsMDD (n = 13), and HC (n = 17). Zonulin, intestinal fatty acid binding protein (I-FABP), soluble CD14, and interleukin-6 (IL-6) were quantified in plasma. Montgomery-Åsberg Depression Rating Scale (MADRS) and Suicide Assessment Scale (SUAS) were used for symptom assessments.

RESULTS

The rSA group displayed higher I-FABP and lower zonulin levels compared with both the nsMDD and the HC groups (all P < 0.001). IL-6 correlated positively with I-FABP (r = 0.24, P < 0.05) and negatively with zonulin (r = -0.25, P < 0.05). In all subjects, I-FABP levels correlated positively with MADRS (r = 0.25, P < 0.05) and SUAS scores (r = 0.38, P < 0.001), and the latter correlation was significant also in the nsMDD group (r = 0.60, P < 0.05).

CONCLUSION

The 'leaky gut hypothesis' may improve our understanding of the link between inflammation and suicidal behavior. These findings should be considered preliminary until replicated in larger cohorts.

Invasive Dental Treatment and Risk for a First Myocardial Infarction

Invasive dental treatment is suggested to be associated with an increased risk for the development of cardiovascular events. We tested the hypothesis that the incidence of a first myocardial infarction (MI) within 4 wk after invasive dental treatments is increased. A registry-based case-control study within nationwide health care and population registries in Sweden was performed. The case patients included 51,880 individuals with a first fatal or nonfatal MI between January 2011 and December 2013. For each case, 5 control subjects, free from prior MI and matched for age, sex, and geographic area of residence, were randomly selected from the national population registry through risk set sampling with replacement, resulting in 246,978 control subjects. Information on dental treatments was obtained from the Dental Health Register, and the procedures were categorized into invasive dental treatments or other dental treatments. Conditional logistic regression was used to estimate odds ratios (ORs) for MI with corresponding 95% confidence intervals (CIs). In addition to the matching variables, adjustments were made for the following confounders: diabetes, previous cardiovascular disease (CVD), CVD drug treatment, education, and income. The mean age for case patients and controls subjects was 72.6 ± 13.0 y and 72.3 ± 13.0 y, respectively. Case patients more often had previous CVD (49% vs. 23%; P < 0.001) and diabetes (19% vs. 11%; P < 0.001) and received more treatment with CVD drugs (68% vs. 56%; P < 0.001) than control subjects. There was no association between invasive dental treatments during the 4 wk preceding the MI index date (crude OR = 0.99; 95% CI, 0.92 to 1.06; adjusted for confounders OR = 0.98; 95% CI, 0.91 to 1.06). This study did not support the hypothesis of an increased incidence of MI after recent invasive dental treatment.

Severe Periodontitis Is Associated with Myocardial Infarction in Females

The aim of the present study was to test the hypothesis that there is a sex difference in the association between periodontitis (PD) and a first myocardial infarction (MI). The analysis in the case-control study was based on 785 patients (147 females and 638 males) with a first MI and 792 matched controls (147 females and 645 males), screened for cardiovascular risk factors and subjected to a panoramic dental X-ray. Periodontal status was defined by alveolar bone loss and diagnosed as no PD (≥80% remaining alveolar bone), mild to moderate PD (66% to 79%), or severe PD (<66%). Logistic regression was used when analyzing PD as a risk factor for MI, adjusting for age, smoking, diabetes, education, and marital status. The mean age was 64 ± 7 y for females and 62 ± 8 y for males. Severe PD was more common in female patients than female controls (14 vs. 4%, P = 0.005), with an increased risk for severe PD among female patients with a first MI (odds ratio [OR] = 3.92, 95% confidence interval [CI] =1.53 to 10.00, P = 0.005), which remained (OR = 3.72, 95% CI = 1.24 to 11.16, P = 0.005) after adjustments. Male patients had more severe PD (7% vs. 4%; P = 0.005) than male controls and an increased risk for severe PD (OR = 1.88, 95% CI = 1.14 to 3.11, P = 0.005), but this association did not remain following adjustment (OR = 1.67, 95% CI = 0.97 to 2.84, NS). Severe PD was associated with MI in both females and males. After adjustments for relevant confounders, this association did, however, remain only in females. These data underline the importance of considering poor dental health when evaluating cardiovascular risk, especially in females.

Linking multiscale deformation to microstructure in cortical bone using in situ loading, digital image correlation and synchrotron X-ray scattering

The incidence of fragility fractures is expected to increase in the near future due to an aging population. Therefore, improved tools for fracture prediction are required to treat and prevent these injuries efficiently. For such tools to succeed, a better understanding of the deformation mechanisms in bone over different length scales is needed. In this study, an experimental setup including mechanical tensile testing in combination with digital image correlation (DIC) and small/wide angle X-ray scattering (SAXS/WAXS) was used to study deformation at multiple length scales in bovine cortical bone. Furthermore, micro-CT imaging provided detailed information about tissue microstructure. The combination of these techniques enabled measurements of local deformations at the tissue- and nanoscales. The orientation of the microstructure relative to the tensile loading was found to influence the strain magnitude on all length scales. Strains in the collagen fibers were 2-3 times as high as the strains found in the mineral crystals for samples with microstructure oriented parallel to the loading. The local tissue strain at fracture was found to be around 0.5%, independent of tissue orientation. However, the maximum force and the irregularity of the crack path were higher when the load was applied parallel to the tissue orientation. This study clearly shows the potential of combining these different experimental techniques concurrently with mechanical testing to gain a better understanding of bone damage and fracture over multiple length scales in cortical bone.

STATEMENT OF SIGNIFICANCE

To understand the pathophysiology of bone, it is important to improve our knowledge about the deformation and fracture mechanisms in bone. In this study, we combine several recently available experimental techniques with mechanical loading to investigate the deformation mechanisms in compact bone tissue on several length scales simultaneously. The experimental setup included mechanical tensile testing in combination with digital image correlation, microCT imaging, and small/wide angle X-ray scattering. The combination of techniques enabled measurements of local deformations at the tissue- and nanoscales. The study clearly shows the potential of combining different experimental techniques concurrently with mechanical testing to gain a better understanding of structure-property-function relationships in bone tissue.

Fluctuating potentials in GaAs:Si nanowires: critical reduction of the influence of polytypism on the electronic structure

In this work, the effects of Si doping in GaAs nanowires (NWs) grown on GaAs (111)B by molecular beam epitaxy with different Si doping levels (nominal free carrier concentrations of 1 × 10¹⁶, 8 × 10¹⁶, 1 × 10¹⁸ and 5 × 10¹⁸ cm^-3) are deeply investigated using scanning electron microscopy (SEM), transmission electron microscopy (TEM), grazing incidence X-ray diffraction (GID), photoluminescence (PL) and cathadoluminescence (CL). TEM results reveal a mixture of wurtzite (WZ) and zinc-blende (ZB) segments along the NW axis independently of the Si doping levels. GID measurements suggest a slight increase of the ZB fraction with the Si doping. Low temperature PL and CL spectra exhibit sharp lines in the energy range 1.41-1.48 eV, for the samples with lower Si doping levels. However, the emission intensity increases and is accompanied by a clear broadening of the observed lines for the samples with higher Si doping levels. The staggered type-II band alignment only determines the optical properties of the lower doping levels in GaAs:Si NWs. For the higher Si doping levels, the electronic energy level structure of the NWs is determined by electrostatic fluctuating potentials intimately related to the amphoteric behavior of the Si dopant in GaAs. For the heavily doped NWs, the estimated depth of the potential wells is ∼96-117 meV. Our results reveal that the occurrence of the fluctuating potentials is not dependent on the crystalline phase and shows that the limitation imposed by the polytypism can be overcome.

Effects of Acute Exercise on Circulating Soluble Form of the Urokinase Receptor in Patients With Major Depressive Disorder

Inflammation has been proposed to play a role in the generation of depressive symptoms. Previously, we demonstrated that patients with major depressive disorder (MDD) have increased plasma levels of the soluble form of the urokinase receptor (suPAR), a marker for low-grade inflammation. The aim of this study was to test the hypothesis that acute exercise would induce inflammatory response characterized by increased suPAR and elucidate whether patients with MDD display altered levels of suPAR in response to acute exercise. A total of 17 patients with MDD and 17 controls were subjected to an exercise challenge. Plasma suPAR (P-suPAR) was analyzed before, during, and after exercise. There was a significantly higher baseline P-suPAR in the patients with MDD, and the dynamic changes of P-suPAR during the exercise were significantly lower in the patients with MDD, compared with the controls. This study supports the hypothesis that an activation of systemic inflammatory processes, measured as elevated P-suPAR, is involved in the pathophysiology of depression. The study concludes that P-suPAR is influenced by acute exercise, most likely due to release from activated neutrophils.

Activity of inflammatory bowel disease influences the expression of cytokines in gingival tissue

This study assessed the cytokine expression in gingival and intestinal tissues from periodontitis patients with inflammatory bowel disease (IBD) and evaluated if IBD activity is a covariate to the amount of gingival cytokines. Paired gingival and intestinal tissues were collected from 21 patients and homogenised using a cell disruptor. Cytokine expression (IL-1β, IL-4, IL-6, IL-10, IL-21, IL-22, IL-23, IL-25, IL-31, IL-33, IL-17A, IL-17F, IFN-γ, sCD40L, and TNF-α) was evaluated using bead-based multiplex technology. An inflammation score was developed using the intestinal cytokines that showed good accuracy to discriminate IBD active patients from those in remission and then a similar score was applied to gingival tissue. IL-4, IL-10 and IL-21 expressions were significantly increased in gingival tissue from patients with an active disease as compared to those with a disease in remission. The inflammation score (mean value of IL-1β, IL-6, IL-21, and sCD40L) was significantly higher in gingival tissue from patients with IBD activity. There was a significant correlation between gingival and intestinal inflammation scores (rho=0.548; P=0.01). Significantly higher IL-23 and IFN-γ levels and lower IL-31 and TNF-α levels were observed in gingival tissues than in intestinal ones. Activity of inflammatory bowel disease influenced the cytokine expression in gingival tissue.

Strains caused by daily loading might be responsible for delayed healing of an incomplete atypical femoral fracture

Atypical femoral fractures are insufficiency fractures in the lateral femoral diaphysis or subtrochanteric region that mainly affect older patients on bisphosphonate therapy. Delayed healing is often seen in patients with incomplete fractures (cracks), and histology of bone biopsies shows mainly necrotic material inside the crack. We hypothesized that the magnitude of the strains produced in the soft tissue inside the crack during normal walk exceeds the limit for new bone formation, and thereby inhibit healing. A patient specific finite element model was developed, based on clinical CT images and high resolution μCT images of a biopsy from the crack site. Strain distributions in the femur and inside the crack were calculated for load cases representing normal walk. The models predicted large strains inside the crack, with strain levels above 10% in more than three quarters of the crack volume. According to two different tissue differentiation theories, bone would only form in less than 1-5% of the crack volume. This can explain the impaired healing generally seen in incomplete atypical fractures. Furthermore, the microgeometry of the crack highly influenced the strain distributions. Hence, a realistic microgeometry needs to be considered when modeling the crack. Histology of the biopsy showed signs of remodeling in the bone tissue adjacent to the fracture line, while the crack itself contained mainly necrotic material and signs of healing only in portions that seemed to have been widened by resorption. In conclusion, the poor healing capacity of incomplete atypical femoral fractures can be explained by biomechanical factors, and daily low impact activities are enough to cause strain magnitudes that prohibit bone formation.

Comparison of structural anisotropic soft tissue models for simulating Achilles tendon tensile behaviour

The incidence of tendon injury (tendinopathy) has increased over the past decades due to greater participation in sports and recreational activities. But little is known about the aetiology of tendon injuries because of our limited knowledge in the complex structure-function relationship in tendons. Computer models can capture the biomechanical behaviour of tendons and its structural components, which is essential for understanding the underlying mechanisms of tendon injuries. This study compares three structural constitutive material models for the Achilles tendon and discusses their application on different biomechanical simulations. The models have been previously used to describe cardiovascular tissue and articular cartilage, and one model is novel to this study. All three constitutive models captured the tensile behaviour of rat Achilles tendon (root mean square errors between models and experimental data are 0.50-0.64). They further showed that collagen fibres are the main load-bearing component and that the non-collagenous matrix plays a minor role in tension. By introducing anisotropic behaviour also in the non-fibrillar matrix, the new biphasic structural model was also able to capture fluid exudation during tension and high values of Poisson׳s ratio that is reported in tendon experiments.

Synthesis and Evaluation of Astatinated N-[2-(Maleimido)ethyl]-3-(trimethylstannyl)benzamide Immunoconjugates

Effective treatment of metastasis is a great challenge in the treatment of different types of cancers. Targeted alpha therapy utilizes the short tissue range (50-100 μm) of α particles, making the method suitable for treatment of disseminated occult cancers in the form of microtumors or even single cancer cells. A promising radioactive nuclide for this type of therapy is astatine-211. Astatine-211 attached to tumor-specific antibodies as carrier molecules is a system currently under investigation for use in targeted alpha therapy. In the common radiolabeling procedure, astatine is coupled to the antibody arbitrarily on lysine residues. By instead coupling astatine to disulfide bridges in the antibody structure, the immunoreactivity of the antibody conjugates could possibly be increased. Here, the disulfide-based conjugation was performed using a new coupling reagent, maleimidoethyl 3-(trimethylstannyl)benzamide (MSB), and evaluated for chemical stability in vitro. The immunoconjugates were subsequently astatinated, resulting in both high radiochemical yield and high specific activity. The MSB-conjugate was shown to be stable with a long shelf life prior to the astatination. In a comparison of the in vivo distribution of the new immunoconjugate with other tin-based immunoconjugates in tumor-bearing mice, the MSB conjugation method was found to be a viable option for successful astatine labeling of different monoclonal antibodies.

Increased Soluble Urokinase-Type Plasminogen Activator Receptor (suPAR) Levels in Plasma of Suicide Attempters

The soluble form of the urokinase receptor, suPAR, has been suggested as a novel biomarker of low-grade inflammation. Activation of the immune system has been proposed to contribute to the development of depression and suicidal behavior. In order to identify depressed and suicidal individuals who could benefit from an anti-inflammatory treatment, a reliable biomarker of low-grade inflammation is vital. This study evaluates plasma suPAR levels as a biomarker of low-grade inflammation in patients with major depressive disorder and in patients who recently attempted suicide. The plasma suPAR and an established biomarker, C reactive protein (CRP) of suicide attempters (n = 54), depressed patients (n = 19) and healthy controls (n = 19) was analyzed with enzyme-linked immunosorbent assays. The biomarker attributes of sensitivity and sensibility were evaluated using ROC curve analysis. Both the depressed patients and suicide attempters had increased plasma suPAR. The levels of suPAR discriminated better between controls and suicide attempters than did CRP. In the future, plasma suPAR might be a superior prognosticator regarding outcome of treatment applying conventional antidepressants in conjunction with anti-inflammatory drugs.