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

Simultaneous Tyrosine and Serine Phosphorylation of STAT3 Transcription Factor Is Involved in Rho A GTPase Oncogenic Transformation

Stats (signal transducers and activators of transcription) are latent cytoplasmic transcription factors that on a specific stimulus migrate to the nucleus and exert their transcriptional activity. Here we report a novel signaling pathway whereby RhoA can efficiently modulate Stat3 transcriptional activity by inducing its simultaneous tyrosine and serine phosphorylation. Tyrosine phosphorylation is exerted via a member of the Src family of kinases (SrcFK) and JAK2, whereas the JNK pathway mediates serine phosphorylation. Furthermore, cooperation of both tyrosine as well as serine phosphorylation is necessary for full activation of Stat3. Induction of Stat3 activity depends on the effector domain of RhoA and correlates with induction of both Src Kinase-related and JNK activities. Activation of Stat3 has biological implications. Coexpression of an oncogenic version of RhoA along with the wild-type, nontransforming Stat3 gene, significantly enhances its oncogenic activity on human HEK cells, suggesting that Stat3 is an essential component of RhoA-mediated transformation. In keeping with this, dominant negative Stat3 mutants or inhibition of its tyrosine or serine phosphorylation completely abrogate RhoA oncogenic potential. Taken together, these results indicate that Stat3 is an important player in RhoA-mediated oncogenic transformation, which requires simultaneous phosphorylation at both tyrosine and serine residues by specific signaling events triggered by RhoA effectors

Gallotannin Imposes S Phase Arrest in Breast Cancer Cells and Suppresses the Growth of Triple-Negative Tumors <i>In Vivo</i>

<div><p>Triple-negative breast cancers are associated with poor clinical outcomes and new therapeutic strategies are clearly needed. Gallotannin (Gltn) has been previously demonstrated to have potent anti-tumor properties against cholangiocarcinoma in mice, but little is known regarding its capacity to suppress tumor outgrowth in breast cancer models. We tested Gltn for potential growth inhibitory properties against a variety of breast cancer cell lines <i>in vitro</i>. In particular, triple-negative breast cancer cells display higher levels of sensitivity to Gltn. The loss of proliferative capacity in Gltn exposed cells is associated with slowed cell cycle progression and S phase arrest, dependent on Chk2 phosphorylation and further characterized by changes to proliferation related genes, such as cyclin D1 (CcnD1) as determined by Nanostring technology. Importantly, Gltn administered orally or via intraperitoneal (IP) injections greatly reduced tumor outgrowth of triple-negative breast cells from mammary fat pads without signs of toxicity. In conclusion, these data strongly suggest that Gltn represents a novel approach to treat triple-negative breast carcinomas.</p></div

Gltn regulates the expression of proliferation related genes.

<p>(<b>A</b>) MDA-MB-468 cells were treated with Gltn in triplicate for three or four days as indicated. RNA from treated cells or controls were isolated and gene expression analyzed by Nanostring technology. The results represent the mean fold-change of three independent drug treatments. (<b>B</b>) qPCR validation of genes regulated in MDA-MB-468 cells by Gltn. n = />2 experiments carried out in triplicate +/- S.D. (<b>C</b>) Western blotting of cyclin expression after Gltn treatment for the indicated time periods. UV light serves as a positive control for CcnD1 degradation.</p

Gltn impairs the proliferation of triple-negative breast cancer cells <i>in vitro</i>.

<p>(<b>A</b>) Triple-negative and luminal breast cancer cells were grown with Gltn or PBS as a vehicle control for 5 days at the indicated dose. Cell numbers were determined using trypan blue exclusion and hemacytometer in n = />3 experiments +/- S.E.* denotes significant differences compared to controls with p values  = /< 0.05 (<b>B</b>) Sigmoidal dose response curves comparing Gltn sensitivity in luminal MCF-7 cells with triple-negative MDA-MB-468 cells. Horizontal bars on curves represent points of IC50. (<b>C</b>) Triple-negative cell lines were seeded and exposed to 10 μM Gltn for the indicated time periods. Cells were counted as described in A. Graphs represent n = />3 experiments carried out in triplicate triplicate +/- S.E. By six days post-treatment, all cell lines showed significant differences from control group. p  = /< 0.05 as denoted by asterisks.</p

Chk2 is activated in response to Gltn.

<p>(<b>A</b>) Western blotting of Check point kinases in response to Gltn. UV light serves as a positive control for Chk1 and Chk2 phospohorylation. Results are representative of triplicate experiments. (<b>B</b>) MDA-MB-468 cells were treated with Gltn for 72 hours prior to BrdU labeling. BrdU was quantified using FACs and results are representative of three independent experiments. (<b>C</b>) Immunofluorescent images of γH2A.X in Gltn treated cells. Cells were treated with Gltn daily for the indicated time periods and probed with an anti-Ser-129-H2A.X antibody for two hours. Doxorubicin treatment serves as a positive control for DNA damage. Results are representative of three independent experiments.</p

Gltn exposure results in S phase arrest.

<p>(<b>A</b>) MDA-MB-468 cells treated with Gltn for indicated times were synchronized in G2/M using double Thymidine/Nocodozole mediated arrest. Cell cycle progression was assessed after release using propidium iodide staining detected by fluorescence activated cell sorting (FACS). Results are representative of three independent experiments. (<b>B</b>) MDA-MB-468 cells were exposed to Gltn or vehicle for 72 hours prior to labeling with BrdU. Cells were collected at the indicated time periods post-BrdU labeling. BrdU incorporation was quantified using fluorescence activated cell sorting. Cells residing above the solid line are considered to reside in the S phase compartment. Results are representative of triplicate experiments.</p

Coordinate transcriptional and translational repression of p53 by TGF-β1 impairs the stress response.

Cellular stress results in profound changes in RNA and protein synthesis. How cells integrate this intrinsic, p53-centered program with extracellular signals is largely unknown. We demonstrate that TGF-β1 signaling interferes with the stress response through coordinate transcriptional and translational repression of p53 levels, which reduces p53-activated transcription, and apoptosis in precancerous cells. Mechanistically, E2F-4 binds constitutively to the TP53 gene and induces transcription. TGF-β1-activated Smads are recruited to a composite Smad/E2F-4 element by an E2F-4/p107 complex that switches to a Smad corepressor, which represses TP53 transcription. TGF-β1 also causes dissociation of ribosomal protein RPL26 and elongation factor eEF1A from p53 mRNA, thereby reducing p53 mRNA association with polyribosomes and p53 translation. TGF-β1 signaling is dominant over stress-induced transcription and translation of p53 and prevents stress-imposed downregulation of Smad proteins. Thus, crosstalk between the TGF-β and p53 pathways defines a major node of regulation in the cellular stress response, enhancing drug resistance

Coordinate transcriptional and translational repression of p53 by TGF-β1 impairs the stress response.

Cellular stress results in profound changes in RNA and protein synthesis. How cells integrate this intrinsic, p53-centered program with extracellular signals is largely unknown. We demonstrate that TGF-β1 signaling interferes with the stress response through coordinate transcriptional and translational repression of p53 levels, which reduces p53-activated transcription, and apoptosis in precancerous cells. Mechanistically, E2F-4 binds constitutively to the TP53 gene and induces transcription. TGF-β1-activated Smads are recruited to a composite Smad/E2F-4 element by an E2F-4/p107 complex that switches to a Smad corepressor, which represses TP53 transcription. TGF-β1 also causes dissociation of ribosomal protein RPL26 and elongation factor eEF1A from p53 mRNA, thereby reducing p53 mRNA association with polyribosomes and p53 translation. TGF-β1 signaling is dominant over stress-induced transcription and translation of p53 and prevents stress-imposed downregulation of Smad proteins. Thus, crosstalk between the TGF-β and p53 pathways defines a major node of regulation in the cellular stress response, enhancing drug resistance