Child physical abuse screening in a pediatric ED; Does TRAIN(ing) Help?

BACKGROUND: Child maltreatment is distressingly prevalent yet remains under-recognized by healthcare providers. In 2015 the Ohio Children's Hospital Association developed the Timely Recognition of Abusive INjuries (TRAIN) collaborative in an effort to promote child physical abuse (CPA) screening. Our institution implemented the TRAIN initiative in 2019. The objective of this study was to examine the effects of the TRAIN initiative at this institution. METHODS: In this retrospective chart review we recorded the incidence of sentinel injuries (SIS) in children presenting to the Emergency Department (ED) of an independent level 2 pediatric trauma center. SIS were defined and identified by a diagnosis of ecchymosis, contusion, fracture, head injury, intracranial hemorrhage, abdominal trauma, open wound, laceration, abrasion, oropharyngeal injury, genital injury, intoxication, or burn in a child < 6.01 months of age. Patients were stratified into pre-TRAIN (PRE), 1/2017-9/2018, or post-TRAIN (POST), 10/2019-7/2020, periods. Repeat injury was defined as a subsequent visit for any of the previously mentioned diagnoses within 12 months of the initial visit. Demographics/visit characteristics were analyzed using Chi square analysis, Fischer's exact test, and student's paired t-test. RESULTS: In the PRE period, 12,812 ED visits were made by children < 6.01 months old; 2.8% of these visits were made by patients with SIS. In the POST period there were 5,372 ED visits, 2.6% involved SIS (p = .4). The rate of skeletal surveys performed on patients with SIS increased from 17.1% in the PRE period to 27.2% in the POST period (p = .01). The positivity rate of skeletal surveys in the PRE versus POST period was 18.9% and 26.3% respectively (p = .45). Repeat injury rates did not differ significantly in patients with SIS pre- versus post-TRAIN (p = .44). CONCLUSION: Implementation of TRAIN at this institution appears to be associated with increased skeletal survey rates.

Electron microscopic demonstration and evaluation of irreversible electroporation-induced nanopores on hepatocyte membranes.

PURPOSE: To demonstrate, evaluate, and verify the existence of irreversible electroporation (IRE)-ablation induced nanopores on the plasma membrane of hepatocytes. MATERIALS AND METHODS: On animal research committee approval, four New Zealand rabbits and two Yorkshire swine underwent IRE ablation of the liver (90 pulses, 100 µs per pulse at 2,500 V), and selected ablated liver tissues were harvested, fixed, and air-dried according to the electron microscopy (EM) protocol. A scanning electron microscope (SEM; Nova 230 NanoSEM [FEI, Hillsboro, Oregon] with 80 picoamperes and 10-kV acceleration) was used to visualize and verify IRE-created nanopores. Using NIH image (Bethesda, Maryland) and ImageScope (Aperio Inc., Vista, California), 21 ablated tissues (16 rabbit, 5 swine) were evaluated. Corresponding hematoxylin and eosin (H&E) evaluation was performed to verify IRE-induced cell death. RESULTS: In all 21 IRE-ablated tissues, the SEM was able to show numerous, well-circumscribed, round, and concave-shaped pore defects disturbing the hepatocyte plasma membranes. These pores were not seen in normal liver. The size of the nanopores ranged from 80-490 nm with the greatest frequency of pores in bimodal distribution. The highest frequency of pore size was noted at the size range 340-360 nm. CONCLUSIONS: IRE induces nanopores on hepatocyte membranes, as shown by SEM. The pore diameters are larger than nanopores created by reversible electroporation (RE), which may have implications for irreversibility or permanency.

Irreversible electroporation in eradication of rabbit VX2 liver tumor.

PURPOSE: To show the effectiveness and safety of irreversible electroporation (IRE) in treating large tumor models. MATERIALS AND METHODS: VX2 liver tumor implantation was performed in 35 New Zealand White Rabbits. The rabbits were divided into three groups 1 week after implantation. The control group included 15 rabbits; the remaining 20 rabbits were divided into two IRE treatment groups. For the treatment groups, 10 rabbits underwent ablation with a single IRE application (IRE-S group), and 10 rabbits underwent ablation with multiple IRE applications (IRE-M group). Treatments and outcomes were analyzed using ultrasound, contrast-enhanced computed tomography (CT), and immunohistologic staining (hematoxylin and eosin [H&E], P-53, Ki-67, CD30, and vascular endothelial growth factor receptor [VEGFR] staining, and terminal deoxynucleotidyl-transferase-mediated 2'-deoxyuridine 5'-triphosphate [dUTP]-biotin nick-end labeling [TUNEL] assay). RESULTS: Multiple IRE ablations consistently produced complete cell death in all the animals in the IRE-M group (n = 10, IRE ablation time 2.45 minutes ± 0.3). The results were validated with ultrasound, CT, H&E, Ki-67, P53, and TUNEL assay. A high level of CD30-positive cells were identified in the IRE groups. A sharply demarcated ablation zone with no damage to surrounding vital structures was observed in all IRE-treated tissues. No complications during or after ablation were observed in any of the animals. CONCLUSIONS: The effects of IRE were shown in a large tumor model with single and multiple IRE ablations (IRE-S and IRE-M treatment groups); complete ablation of the tumor was seen in the IRE-M group. These findings successfully show the beneficial effects and safety of IRE in the treatment of tumors and validate its potential as a clinically translatable treatment.

COVID-19: Differences in sentinel injury and child abuse reporting during a pandemic.

BACKGROUND AND OBJECTIVES: There is widespread concern that the COVID-19 pandemic has increased the incidence of child maltreatment. However, reports in the scientific literature documenting rates of child maltreatment during this period are scarce. This study was designed to explore whether the incidence of child maltreatment among patients presenting to a pediatric emergency department has increased during the COVID-19 pandemic. METHODS: We conducted a retrospective review of patients of all ages presenting to a pediatric Emergency Department trauma center, who also had a child abuse report filing or a sentinel injury diagnosis related to their index visit. All such patients who presented to this institution from March through July of 2017 through 2020 were included in the study. RESULTS: Analysis demonstrated an increase in the incidence of child maltreatment in May and June of 2020 and that there was an overall shift in distribution of types of child maltreatment during the COVID-19 pandemic. There was a significant increase in the proportion of emotional/psychological abuse (2.52 % before the pandemic to 7.00 % during the pandemic, p ≤ 0.0001) and non-medical neglect (31.5%-40.0%, p ≤ 0.0001). CONCLUSIONS: We observed an increase in specific types of child maltreatment during the COVID-19 pandemic. These findings highlight the need for increased attention to children at risk for child abuse and neglect.

Repeat expansion and methylation-sensitive triplet-primed polymerase chain reaction for fragile X mental retardation 1 gene screening in institutionalised intellectually disabled individuals.

INTRODUCTION: Fragile X syndrome (FXS) is the most prevalent X-linked intellectual disability (ID) and a leading genetic cause of autism, characterised by cognitive and behavioural impairments. The hyperexpansion of a CGG repeat in the fragile X mental retardation 1 (FMR1) gene leads to abnormal hypermethylation, resulting in the lack or absence of its protein. Tools for establishing the diagnosis of FXS have been extensively developed, including assays based on triplet-primed polymerase chain reaction (TP-PCR) for detection and quantification of the CGG trinucleotide repeat expansion, as well as determination of the methylation status of the alleles. This study aimed to utilise a simple, quick and affordable method for high sensitivity and specificity screening and diagnosis of FXS in institutionalised individuals with ID. METHODS: A total of 109 institutionalised individuals at the Center for Social Rehabilitation of Intellectual Disability Kartini, Temanggung, Central Java, Indonesia, were screened in a three-step process using FastFrax™ Identification, Sizing and Methylation Status Kits. RESULTS: Two samples that were classified as indeterminate with respect to the 41-repeat control at the identification step were subsequently determined to be non-expanded by both sizing and methylation status analyses. Two samples classified as expanded at the identification step were determined to carry full mutation expansions > 200 repeats that were fully methylated using sizing and methylation status analyses, respectively, yielding a disease prevalence of 1.83%. CONCLUSION: Repeat expansion and methylation-specific TP-PCR is practical, effective and inexpensive for the diagnosis of FXS, especially in high-risk populations of individuals with ID of undetermined aetiology.

Robust and accurate detection and sizing of repeats within the DMPK gene using a novel TP-PCR test.

Myotonic dystrophy type 1 is a multisystem disorder caused by the expansion of a trinucleotide repeat in the DMPK gene. In this study we evaluated the performance of the FastDM1TM DMPK sizing kit in myotonic dystrophy type 1 testing. This commercially available triplet repeat-primed PCR based kit was validated using reference and clinical samples. Based on testing with 19 reference samples, the assay yielded repeat sizes within three repeats from the consensus reference length, demonstrating an accuracy of 100%. Additionally, the assay generated consistent repeat size information with a concentration range of template-DNA, and upon repetition and reproduction (CV 0.36% to 0.41%). Clinical performance was established with 235 archived prenatal and postnatal clinical samples, yielding results of 100% sensitivity (95% CI, 97.29% to 100%) and 100% specificity (95% CI, 96.19% to 100%) in classifying the samples into the respective genotype groups of 5-35 (normal), 36-50 (non-pathogenic pre-expansion), 51-150 (unstable intermediate-sized pathogenic) or >150 (unstable pathogenic) CTG repeats, respectively. Furthermore, the assay identified interrupted repeat expansions in all samples known to have interruptions, and also identified interruptions in a subset of the clinical samples.

Regulation of the NRF2 transcription factor by andrographolide and organic extracts from plant endophytes.

The transcription factor NF-E2 Related Factor-2 (NRF2) is an important drug target. Activation of NRF2 has chemopreventive effects in cancer and exerts beneficial effects in a number of diseases, including neurodegenerative diseases, inflammatory diseases, hepatosteatosis, obesity and insulin resistance. Hence, there have been great efforts to discover and characterize novel NRF2 activators. One reported NRF2 activator is the labdane diterpenoid andrographolide. In this study, we identified the mechanism through which andrographolide activates NRF2. We showed that andrographolide inhibits the function of KEAP1, a protein that together with CUL3 and RBX1 forms an E3 ubiquitin ligase that polyubiquitinates NRF2. Andrographolide partially inhibits the interaction of KEAP1 with CUL3 in a manner dependent on Cys151 in KEAP1. This suggests that andrographolide forms Michael acceptor dependent adducts with Cys151 in KEAP1 in vivo, leading to inhibition of NRF2 ubiquitination and consequently accumulation of the transcription factor. Interestingly, we also showed that at higher concentrations andrographolide increases NRF2 protein expression in a Cys151 independent, but likely KEAP1 dependent manner, possibly through modification of other Cys residues in KEAP1. In this study we also screened secondary metabolites produced by endophytes isolated from non-flowering plants for NRF2-inducing properties. One of the extracts, ORX 41, increased both NRF2 protein expression and transcriptional activity markedly. These results suggest that endophytes isolated from non-flowering or other plants may be a good source of novel NRF2 inducing compounds.

Açaí (Euterpe oleraceae Mart.) berry extract exerts neuroprotective effects against ß-amyloid exposure in vitro.

The native South American palm açaí berry (Euterpe oleraceae Mart.) has high polyphenolic and antioxidant levels. This study examined whether açaí berry extract afforded protection against ß-amyloid (Aß)-mediated loss of cell viability and oxidative stress associated with anti-fibrillar effects. PC12 cells were exposed to either Aß1-42, Aß25-35 or tert butyl hydroperoxide (t-BHP), alone or in the presence of açaí extract (0.5-50µg/ml). Thioflavin T (ThT) binding assay and transmission electron microscopy were used to determine effects of açaí extract on Aß1-42 fibril morphology and compared to açaí phenolics gallic acid, cyanidin rutinoside and cyanidin glucoside. Exposure to Aß1-42, Aß25-35 or t-BHP decreased PC12 cell viability. Pretreatment with açaí extract significantly improved cell viability following Aß1-42 exposure, however Aß25-35 or t-BHP-mediated viability loss was unaltered. Açaí extract inhibited ThT fluorescence and disrupted Aß1-42 fibril and aggregate morphology. In comparison with other phenolics, açaí was most effective at inhibiting Aß1-42 aggregation. Inhibition of ß-amyloid aggregation may underlie a neuroprotective effect of açaí.

A multi-institutional medical educational collaborative: advocacy training in California pediatric residency programs.

Educational collaboratives offer a promising approach to disseminate educational resources and provide faculty development to advance residents' training, especially in areas of novel curricular content; however, their impact has not been clearly described. Advocacy training is a recently mandated requirement of the Accreditation Council for Graduate Medical Education that many programs struggle to meet.The authors describe the formation (in 2007) and impact (from 2008 to 2010) of 13 California pediatric residency programs working in an educational collaboration ("the Collaborative") to improve advocacy training. The Collaborative defined an overarching mission, assessed the needs of the programs, and mapped their strengths. The infrastructure required to build the collaboration among programs included a social networking site, frequent conference calls, and face-to-face semiannual meetings. An evaluation of the Collaborative's activities showed that programs demonstrated increased uptake of curricular components and an increase in advocacy activities. The themes extracted from semistructured interviews of lead faculty at each program revealed that the Collaborative (1) reduced faculty isolation, increased motivation, and strengthened faculty academic development, (2) enhanced identification of curricular areas of weakness and provided curricular development from new resources, (3) helped to address barriers of limited resident time and program resources, and (4) sustained the Collaborative's impact even after formal funding of the program had ceased through curricular enhancement, the need for further resources, and a shared desire to expand the collaborative network.

Heteroaromatic 4-arylquinols are novel inducers of nuclear factor-erythroid 2-related factor 2 (Nrf2).

The induction of phase 2 and antioxidant enzymes via the transcription factor Nuclear factor-erythroid 2-related factor 2 (Nrf2) is an important chemopreventive strategy in cancer and neurodegenerative diseases. Nrf2 is mainly regulated at the level of its protein stability by the cytosolic protein Keap1, which functions as a substrate recruiting subunit of a Cullin3 E3 ubiquitin ligase to target Nrf2 for ubiquitination and subsequent degradation. Phase 2 inducing agents usually covalently modify cysteine residues in Keap1, leading to inhibition of Nrf2 ubiquitination. Quinols, which due to their Michael acceptor moiety react readily with cysteine residues in selective cellular proteins, are good candidates for potential Nrf2 inducing chemopreventive agents. Indeed, we found that similar to the known phase II inducer sulforaphane, the heteroaromatic 4-arylquinols PMX290 and PMX464 increase both Nrf2 protein concentrations and transcriptional activity. Interestingly, PMX290 had a much stronger effect on the Nrf2 protein concentration, but a weaker effect on Nrf2 transcriptional activity compared to PMX464. Given the marked effect of PMX290 on the Nrf2 protein concentration, we examined its effect on the interaction of Keap1 with its binding partners. While sulforaphane was found to decrease binding of Cullin3 to Keap1, PMX290 markedly increased the interaction between these two proteins in intact cells. PMX464, which increased Nrf2 protein only weakly, also had a much smaller effect on the binding between Keap1 and Cullin3. In conclusion, PMX290 is a novel phase 2 inducing agent which increases the interaction between Keap1 and Cullin3 and may inhibit Nrf2 ubiquitination via a novel mechanism.