Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Ga(III)-Catalyzed Cycloisomerization Approach to the Icetexones and Nominine

The icetexane diterpenoids is a group of natural products isolated from various members of the Salvia genus. These compounds contain a [6-7-6] tricyclic motif and vary by the level of oxidation on the seven-membered ring and oxygenation of the arene moiety. The synthesis of these compounds has been achieved by our group through the use of a Ga(III)-catalyzed cycloisomerization of indenyl alkynes. This thesis explores the synthesis of the icetexone subclass of diterpenoids, which contain extra functionalization, using a similar cycloisomerization strategy.The synthesis of icetexone was first attempted through the use of a remote functionalization strategy to form the desired lactone. However, all attempts were unsuccessful. Therefore, a second generation approach using a pre-functionalized indenyl alkyne in the Ga(III)-cycloisomerization reaction yielded the desired tricyclic intermediate. A tandem epoxide opening, lactone formation, and reductive transposition sequence completed the formal synthesis of both icetexone and 5-epi-icetexone. Progress toward anastomosine, another member in this subclass, was also made. Another family of compounds that was targeted using the Ga(III)- catalyzed cycloisomerization is the C20 diterpenoid alkaloids. This large family of natural products is found in traditional Eastern medicines and has unique and complex structures. The hetisine type of natural products is characterized by their rigid heptacyclic core and a bicyclo[2.2.2]octane motif. We believed that our Ga(III) cycloisomerization methodology would enable access to the [6-7-6] tricyclic core of these molecules as a starting point for their successful synthesis.The synthesis of nominine was first attempted through an acid catalyzed hydroamination of a cycloheptadiene accessed from the Ga(III)-cycloisomerization. Low yields of the hydroamination as well as later transformations led us to develop a second- generation strategy that involved dihydroxylation of the cycloheptadiene and monoprotection of a resulting diol. Both routes are currently being explored to complete the synthesis of nominine

Table_1_Advances in risk predictive performance of pre-symptomatic type 1 diabetes via the multiplex Antibody-Detection-by-Agglutination-PCR assay.xlsx

IntroductionAchieving early diagnosis of pre-symptomatic type 1 diabetes is critical to reduce potentially life-threatening diabetic ketoacidosis (DKA) at symptom onset, link patients to FDA approved therapeutics that can delay disease progression and support novel interventional drugs development. The presence of two or more islet autoantibodies in pre-symptomatic type 1 diabetes patients indicates high-risk of progression to clinical manifestation.MethodHerein, we characterized the capability of multiplex ADAP assay to predict type 1 diabetes progression. We obtained retrospective coded sera from a cohort of 48 progressors and 44 non-progressors from the NIDDK DPT-1 study.ResultThe multiplex ADAP assay and radiobinding assays had positive predictive value (PPV)/negative predictive value (NPV) of 68%/92% and 67%/66% respectively. The improved NPV stemmed from 12 progressors tested positive for multiple islet autoantibodies by multiplex ADAP assay but not by RBA. Furthermore, 6 out of these 12 patients tested positive for multiple islet autoantibodies by RBA in subsequent sampling events with a median delay of 2.8 years compared to multiplex ADAP assay.DiscussionIn summary, multiplex ADAP assay could be an ideal tool for type 1 diabetes risk testing due to its sample-sparing nature (4µL), non-radioactiveness, compatibility with widely available real-time qPCR instruments and favorable risk prediction capability.</p

Multiplex agglutination-PCR (ADAP) autoantibody assays compared to radiobinding autoantibodies in type 1 diabetes and celiac disease

Multiplex Antibody-Detection by Agglutination-PCR (ADAP) assay was compared to singleplex standard radiobinding assays (RBA) to detect autoantibodies against insulin (IAA), GAD65 (GADA), islet antigen-2 (IA-2A), ZnT8 (ZnT8A) and tissue transglutaminase (TGA). Serum samples from 272 (114F/158M), 15-73 years of age healthy controls and 227 (109F/118M) newly diagnosed type 1 diabetes children, 1-11 years of age, were analyzed in both assay systems.The original WHO standard 97/550 and in-house reference standards for RBA were compared to ADAP. The ADAP and RBA generated parallel reference standards in all assays except TGA. Lower detection limits were observed in the ADAP assay for GADA,IAA and ZnT8A, markedly for TGA, but not for IA-2A. The Receiver Operating Characteristics (ROC) curve AUC analyses for pairwise comparison of ADAP with RBA showed no difference for GADA (n.s.), ADAP greater AUC for IAA (p = 0.005), RBA greater AUC for IA-2A (p = 0.0004) and ZnT8A (p < 0.0001) while ADAP TGA had a greater AUC compared to both RBA TGA-IgG (p < 0.0001) and TGA-IgA (p < 0.0001) . These data suggest that the ADAP and RBA assays are comparable with equal performance for GADA, better ADAP performance for IAA while the RBA showed better performance in both IA-2A and ZnT8A associated with greater heterogeneity in autoantibody levels. The simultaneous analysis of 5 different autoantibodies by ADAP in sample volume reduced to only 4 μL and at an increased lower detection limit in all assays except IA-2A makes the ADAP automated autoantibody assay a distinct advantage for high throughput screening

Disulfide-Trapping Identifies a New, Effective Chemical Probe for Activating the Nuclear Receptor Human LRH-1 (NR5A2)

<div><p>Conventional efforts relying on high-throughput physical and virtual screening of large compound libraries have failed to yield high-efficiency chemical probes for many of the 48 human nuclear receptors. Here, we investigated whether disulfide-trapping, an approach new to nuclear receptors, would provide effective lead compounds targeting human liver receptor homolog 1 (hLRH-1, NR5A2). Despite the fact that hLRH-1 contains a large ligand binding pocket and binds phospholipids with high affinity, existing synthetic hLRH-1 ligands are of limited utility due to poor solubility, low efficacy or significant off-target effects. Using disulfide-trapping, we identified a lead compound that conjugates with remarkably high-efficiency to a native cysteine residue (Cys³⁴⁶) lining the hydrophobic cavity in the ligand binding domain of hLRH-1. Guided by computational modeling and cellular assays, the lead compound was elaborated into ligands PME8 and PME9 that bind hLRH-1 reversibly (no cysteine reactivity) and increase hLRH-1 activity in cells. When compared with the existing hLRH-1 synthetic agonist RJW100, both PME8 and PME9 showed comparable induction of the LRH-1 dependent target gene <i>CYP24A1</i> in human HepG2 cells, beginning as early as 3 h after drug treatment. The induction is specific as siRNA-mediated knock-down of hLRH-1 renders both PME8 and PME9 ineffective. These data show that PME8 and PME9 are potent activators of hLRH-1 and suggest that with further development this lead series may yield useful chemical probes for manipulating LRH-1 activity in vivo.</p></div

Activity of PME9 Exceeds that of RJW100 in HepG2 Cells.

<p>Relative expression of <i>CYP24A1</i> transcripts in HepG2 cells following 16 h treatment with either vehicle (DMSO) or compounds (10 μM) as listed on the X-axis. For reference, activity with the existing NR5A agonist RJW100 is shown (grey bar). For these experiments levels of hLRH-1 were low, as doxycycline (-Dox) was not added to HepG2-hLRH-1 cells (Refer to <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0159316#pone.0159316.s002" target="_blank">S2 Fig</a>). Data are representative of at least three independent experiments with error bars representing SEM, <i>P</i> values = **** < 0.0001.</p

PME8 induces transcription of an hLRH-1 target gene in a both time- and dose-dependent manner with activity increasing at higher hLRH-1 levels.

<p><b>A.</b> Relative expression levels of the hLRH-1 target gene <i>CYP24A1</i> with increasing treatment times of PME8 (10 μM) compared to the DMSO control (black bar) ranging from 3–24 h. Corresponding expression levels of <i>hLRH-1</i> transcripts in each time condition are shown in right panel without (-Dox) or with (+Dox) induction of exogenous hLRH-1. <b>B.</b> Levels of <i>CYP24A1</i> with DMSO or with increasing concentrations of RJW100 and PME8 treatment for 16 h without (-Dox) or with (+Dox) induction of exogenous hLRH-1. Data are representative of at least three independent experiments with error bars representing SEM, <i>P</i> values = **** < 0.0001.</p