The Relationship Between Parental Stress and Postpartum Depression Among Adolescent Mothers Enrolled in a Randomized Controlled Prevention Trial

Given the high co-occurrence of depression and parental stress among adolescent mothers, we evaluated the relationship between parental stress and postpartum depression among primiparous adolescent mothers. We conducted an observational analysis among a cohort of 106 adolescent mothers at 289 postpartum visits who were enrolled in a randomized controlled trial to prevent postpartum depression. Parental stress was measured using the Parenting Stress Index, short form. The Structured Clinical Interview for DSM-IV Childhood Diagnoses was administered to assess for postpartum depression; subthreshold depression was assessed using the Children’s Depression Rating Scale, revised version. Generalized estimating equations were utilized to assess the relationship of parental stress on postpartum depression during the first 6 months postpartum. We present adjusted odds ratios (AOR) controlling for study arm, age, born in the United States, prior history of depression, and number of study visits. The median age was 16 years, 53 % were Latina, and 16 % reported a past history of depression. Nineteen adolescents (19 %) were diagnosed with postpartum depression and 25 % experienced high levels of parental stress through 6 months postpartum. Adolescent mothers who reported higher levels of parental stress were at significantly increased risk for postpartum depression [AOR 1.06 (95 % CI 1.04–1.09); p < 0.0001]. High levels of parental stress predicted subsequent postpartum depression when assessing parental stress at visits prior to a depression diagnosis to determine whether we could establish a temporal association [AOR 1.06 (95 % CI 1.02–1.09); p < 0.01]. Parental stress was also a risk factor for subthreshold depression [AOR 1.04 (95 % CI 1.01–1.07); p < 0.01]. Parental stress was a significant risk factor for developing both postpartum depression as well as subthreshold depression among adolescent mothers. Interventions that target a reduction in parental stress may lead to less depression severity among primiparous adolescent mothers.     

Risk of comorbidities and outcomes in patients with lower gastrointestinal bleeding-a nationwide study

Background

The impact of comorbidities on outcomes of patients with lower gastrointestinal bleeding (LGIB) remains unknown.

Objective

Investigate the prevalence of comorbidities and impact on outcomes of patients with LGIB.

Methods

The Nationwide Inpatient Sample 2010 was used to identify patients who had a primary discharge diagnosis of LGIB based on International Classification of Diseases, the 9th revision, clinical modification codes. The presence of comorbid illness was assessed using the Elixhauser index. Logistic regression models were used to assess the contributions of the individual Elixhauser comorbidities to predict in-hospital mortality.

Results

A total of 58,296 discharges with LGIB were identified. The overall mortality was 2.3 %. Among the patients who underwent colonoscopy, 17.3 % of patients had therapeutic intervention. As the number of comorbidities increased (i.e., 0, 1, 2, or >3), mortality increased (1.7, 2.0, 2.4, and 2.4 %, respectively). The mortality rate was highest in patients >65 years of age (2.7 %). Patients >65 years of age with two or more comorbidities had a mortality rate of 5 % as compared to 2.6 % in those with less than two comorbidities. Congestive heart failure (odds ratio, 1.67 [95 % confidence interval, 1.48–1.95]), liver disease (2.64 [1.83–3.80]), renal failure (1.99 [1.70–2.33]), and weight loss (2.66 [2.27–3.12]) were associated with a significant increase in mortality rate. Comorbidities increased hospital stay and costs.

Conclusions

Comorbidities were associated with increased the risk of mortality and health care utilization in patients with LGIB. Identification of comorbidities and development of risk-adjustment tools may improve the outcome of patients with LGIB.     

Correction: A clinical and computational study on anti-obesity effects of hydroxycitric acid

Correction for ‘A clinical and computational study on anti-obesity effects of hydroxycitric acid’ by Manu Tomar et al., RSC Adv., 2019, 9, 18578–18588.

The authors regret that the name of one of the authors (Raghavendra Pralhada Rao) was shown incorrectly in the original article. The corrected author list is as shown above.The Royal Society of Chemistry apologises for these errors and any consequent inconvenience to authors and readers.     

Review of radiographic findings in COVID-19

The purpose of this study is to review the published literature for the range of radiographic findings present in patients suffering from coronavirus disease 2019 infection. This novel corona virus is currently the cause of a worldwide pandemic. Pulmonary symptoms and signs dominate the clinical picture and radiologists are called upon to evaluate chest radiographs (CXR) and computed tomography (CT) images to assess for infiltrates and to define their extent, distribution and progression. Multiple studies attempt to characterize the disease course by looking at the timing of imaging relative to the onset of symptoms. In general, plain CXR show bilateral disease with a tendency toward the lung periphery and have an appearance most consistent with viral pneumonia. Chest CT images are most notable for showing bilateral and peripheral ground glass and consolidated opacities and are marked by an absence of concomitant pulmonary nodules, cavitation, adenopathy and pleural effusions. Published literature mentioning organ systems aside from pulmonary manifestations are relatively less common, yet present and are addressed in this review. Similarly, publications focusing on imaging modalities aside from CXR and chest CT are sparse in this evolving crisis and are likewise addressed in this review. The role of imaging is examined as it is currently being debated in the medical community, which is not at all surprising considering the highly infectious nature of Severe Acute Respiratory Syndrome coronavirus 2.     

Evaluation of Vertical Bone Gain Following Alveolar Distraction Osteogenesis in the Anterior Edentulous Mandible: A Clinical Study

Aim and Objectives

To calculate the gain in bony height and volume of the distracted upper segment using an extraosseous unidirectional device to improve the retention of the future prosthesis.

Materials and Methods

Ten cases with completely or partially edentulous but severely or considerably resorbed anterior mandibles were managed by vertical alveolar distraction osteogenesis. All the patients were evaluated preoperatively, intraoperatively and post-operatively for various parameters clinically and radiographically i.e. on OPG, lateral cephalogram and on CT scan, at different time intervals. In all cases there was increase in vertical bone height.

Results

The study showed mean vertical bone gain (VBG) on OPG as 8.2 mm. The mean VBG on lateral cephalogram was 8.1 mm. The mean VBG on CT scan at right canine was 8.35 mm, at left canine was 8.2 mm and at midline was 8.27 mm.

Conclusion

Alveolar distraction osteogenesis is a predictable method for restoring alveolar ridges prior to implant placement or prosthesis. Distraction osteogenesis is ideally suited for recreating missing tissue in the anterior esthetic zone by increasing vertical bone height as well as good width and soft tissue growth.     

A clinical and computational study on anti-obesity effects of hydroxycitric acid

Hydroxycitric acid (HCA), a major active ingredient of Garcinia cambogia extracts, is known to suppress body weight gain and fat synthesis in animals and humans. But the underlying mechanism of HCA action is not fully understood. Clinical study on 100 obese individuals for a period of 3 months was performed followed by a computational study aimed to investigate the effects of HCA treatment on human subjects at anthropometric and plasma lipid profile levels. A detailed hepatic metabolic model was used to incorporate the effect of HCA at the metabolic pathway level. Perturbation analysis of ATP citrate lyase activity in the metabolic pathway was performed to simulate the net effect of HCA. Significant reductions in body weight, triceps, subscapular, and mid axillary measurements as well as in serum triglyceride, cholesterol, HDL and LDL levels were observed following HCA dosage. During the study, half of the subjects experienced a decline in body weight and the remainder experienced an increase in body weight. However, analysis of fat mass with the help of empirical correlations clearly showed significant reduction in the mean values due to HCA dosage in both cases. An extra increase in fat free mass was responsible for offsetting the decrease in fat mass for the subjects who experienced an increase in body weight during the trials. Perturbation analysis showed a net reduction in fatty acid, triglyceride and cholesterol synthesis along with urea cycle fluxes under lipogenetic conditions. Moreover, protein synthesis fluxes increased under these conditions. These results indicate that HCA treatment can reduce body weight gain and fat accumulation in obese subjects along with improving their anthropometric parameters and metabolic state.

Hydroxycitric acid (HCA), a major active ingredient of Garcinia cambogia extracts, is known to suppress body weight gain and fat synthesis in animals and humans.     

Soluble TREM2 inhibits secondary nucleation of Aβ fibrillization and enhances cellular uptake of fibrillar Aβ

Triggering receptor expressed on myeloid cells 2 (TREM2) is a single-pass transmembrane receptor of the immunoglobulin superfamily that is secreted in a soluble (sTREM2) form. Mutations in TREM2 have been linked to increased risk of Alzheimer’s disease (AD). A prominent neuropathological component of AD is deposition of the amyloid-β (Aβ) into plaques, particularly Aβ40 and Aβ42. While the membrane-bound form of TREM2 is known to facilitate uptake of Aβ fibrils and the polarization of microglial processes toward amyloid plaques, the role of its soluble ectodomain, particularly in interactions with monomeric or fibrillar Aβ, has been less clear. Our results demonstrate that sTREM2 does not bind to monomeric Aβ40 and Aβ42, even at a high micromolar concentration, while it does bind to fibrillar Aβ42 and Aβ40 with equal affinities (2.6 ± 0.3 µM and 2.3 ± 0.4 µM). Kinetic analysis shows that sTREM2 inhibits the secondary nucleation step in the fibrillization of Aβ, while having little effect on the primary nucleation pathway. Furthermore, binding of sTREM2 to fibrils markedly enhanced uptake of fibrils into human microglial and neuroglioma derived cell lines. The disease-associated sTREM2 mutant, R47H, displayed little to no effect on fibril nucleation and binding, but it decreased uptake and functional responses markedly. We also probed the structure of the WT sTREM2–Aβ fibril complex using integrative molecular modeling based primarily on the cross-linking mass spectrometry data. The model shows that sTREM2 binds fibrils along one face of the structure, leaving a second, mutation-sensitive site free to mediate cellular binding and uptake.

Alzheimer’s disease (AD) is the most common form of dementia and features the neuropathological hallmarks of extracellular Aβ plaques and intraneuronal tau neurofibrillary tangles (1, 2). Human genetic studies on heritable mutations in APP and PSEN causing early-onset familial AD (3) argue that pathogenic Aβ drives tau neurofibrillary tangle formation; in contrast, mutations in MAPT do not lead to Aβ pathology nor cause AD, but rather a rare genetic form of early-onset primary tauopathy (4). In support of the molecular genetics, a recent cross-sectional study in postmortem human AD brain samples demonstrated the presence and correlation of robust prion bioactivity for Aβ and tau proteins in nearly all cases (5), suggesting that even at death, Aβ in prion conformations are active in the late stages of disease. Together, these data establish the importance of pathogenic Aβ throughout AD progression and highlight the urgent need to better understand the cellular and molecular mechanisms that mitigate Aβ’s role in pathogenesis.Microglia are the innate immune effector cell in the brain with myriad functions in healthy aging and neurological diseases. Recent human genetic studies have discovered mutations in several genes encoding microglia-specific proteins that increase risk for AD, thus supporting the notion that microglia are central to AD pathogenesis. Genetic variants of triggering receptor expressed on myeloid cells 2 (TREM2), a cell-surface receptor expressed on myeloid cells and microglia, increase the risk of AD by threefold, implicating microglia and the innate immune system as important determinants in AD pathogenesis (6). TREM2 consists of an extracellular Ig-like domain, a transmembrane domain, and a cytoplasmic tail. Proteolytic cleavage of TREM2 at His157 releases soluble TREM2 (sTREM2) that can be detected in the cerebrospinal fluid (7). While the function of sTREM2 is uncertain, it is believed to promote microglia survival, proliferation, and phagocytosis, making it important for cell viability and innate immune functions in the brain (6, 8, 9). Full-length membrane-bound TREM2 binds to its adaptor protein, DAP12, on the surface of microglia to transmit downstream signaling in response to clustering induced by multivalent ligands (10). Most of the studied mutations are in the Ig-like domain of TREM2. Misfolding, retention, and aberrant shedding are postulated to be caused by some mutations, while other variants have altered ability to interact with their binding partners (8, 11, 12).The R47H mutation in TREM2 constitutes one of the strongest single allele genetic risk factors for AD. The R62H, D87N, and T96K mutations in TREM2 were also linked to AD after extensive analyses of TREM2 polymorphisms (13–16). Several in vivo studies show that TREM2 regulates polarization of microglial processes toward Aβ deposits, leading to plaque compaction and pacification in human AD brain samples and mouse models (17–19). Genetic deletion of TREM2 expression in transgenic mice injected with exogenous Aβ fibrils leads to accelerated amyloid plaque seeding (20). The prominent phenotype in plaque-associated microglia suggests that the effects of AD-risk mutations or genetic deletions are driven by loss of full-length TREM2 signaling. However, a recent in vivo study using exogenously injected recombinant sTREM2 showed reduced amyloid burden and behavioral rescue in mice (21). New clues for the potential importance of sTREM2 in AD have been revealed in clinical studies on living AD patients. sTREM2 can be measured in the cerebrospinal fluid (CSF) and it increases during early stages of AD symptomology (22, 23), suggesting that sTREM2 may be a biomarker for microglia activation. Recent studies indicate that AD patients with relatively high levels of sTREM2 in the CSF have slower rates of amyloid accumulation and reduced cognitive decline (24, 25). These human data support the hypothesis that microglia and sTREM2 play a protective role in early stages of AD progression.While most risk variants of TREM2 exist in the ligand-binding Ig-like domain, the AD-associated point mutation H157Y falls within the stalk region and is known to increase the shedding of full-length TREM2, which possibly results in higher titers of sTREM2 (6). Elevated ectodomain shedding reduces cell-surface full-length TREM2 available for TREM2-mediated phagocytosis and plaque compaction as well as down-stream signal transduction. Although more work is needed, such data begin to suggest there is a delicate balance between the functions of membrane-bound and secreted TREM2, and hence opposing cellular effects of TREM2 variants can emerge (i.e., reduced versus enhanced shedding, which result in similar phenotypic outcomes by reducing cell-surface TREM2) (6, 26).sTREM2 binds to diverse ligands, including phospholipids, apolipoproteins, DNA, and Aβ. Although the full physiological and pathological roles of these interactions remain to be revealed (11, 12, 27, 28), there is general agreement that the extracellular domain of TREM2 (sTREM2) binds to oligomeric forms of Aβ42. However, the observed apparent affinities vary over many orders-of-magnitude (7, 29–31). Most studies were conducted with dimeric Fc fusion proteins, tetrameric constructs, or biotinylated protein bound to the tetrameric streptavidin, which might artificially increase the avidity of the protein for oligomeric forms of Aβ peptides (7, 29–31). Moreover, the studies that report the highest affinities relied on biolayer interferometry or surface plasmon resonance, in which oligomeric protein constructs were immobilized on a surface and Aβ peptides were allowed to diffuse over the surface. Aβ oligomers were found to bind, but they either did not dissociate at all, or they dissociated slowly, leading to affinity estimates in the picomolar to nanomolar range (7, 30, 31). However, the extent of binding of Aβ to the surface did not saturate at concentrations that were orders-of-magnitude greater than the reported dissociation constants, suggesting that the slow off-rate was instead due to precipitation of insoluble Aβ on the bilayer surface (7). In another study, Aβ was fused to the dimeric protein glutathione S-transferase (29). Furthermore, there is inconsistency in the studies involving monomeric Aβ42, with some studies finding nanomolar to low micromolar dissociation constants for the interaction of monomeric Aβ42 and TREM2 ectodomain (29, 30), in contrast to two other studies that reported weak or no interaction (7, 31).To help elucidate the role of sTREM2 and its interaction with Aβ, we evaluated the binding of sTREM2, without any nonnative oligomerization domains added to the studied construct, to specific forms of Aβ40 and Aβ42. We used NMR to show that sTREM2 does not bind to monomeric Aβ, even at high micromolar concentrations. Next, we examined the binding of sTREM2 to fibrils, formed under well-defined conditions to provide a relatively homogenous structure, as assessed by solid-state NMR (32). Additionally, because oligomeric forms of Aβ are heterogeneous and kinetically labile, we opted to determine how sTREM2 affects the formation of intermediates in the fibrillization of Aβ and show that it has a profound effect on the secondary nucleation step of the process. We find that the R47H variant binds to Aβ40 and Aβ42 fibrils with a similar affinity and inhibits their fibrilization just as the WT sTREM2 does. Finally, we show that WT sTREM2, but not the mutant R47H, strongly enhances the uptake of Aβ fibrils in human neural and microglial cells.A second goal of this report was to define the structural underpinnings of the interaction between sTREM2 and Aβ fibrils. Although individual structures of sTREM2 and Aβ40 fibrils have been reported (8, 33), the structures of the complex are not available. The molecular surface of sTREM2 is particularly interesting with regards to its function (8, 29). The crystal structure of the ectodomain of TREM2 (TREM2_ECD) revealed an immunoglobulin fold motif with a highly asymmetric distribution of charged and hydrophobic residues. The surface of the hydrophobic and aromatic protrusion at the top of the structure (Fig. 1, red dotted area) has a highly positive electrostatic potential adjacent to it is a relatively flat surface of positively charged residues (Fig. 1, black dotted area, surface 1). Surface 1 appears suited for binding to acidic moieties (like in Protein Data Bank [PDB] ID code 6B8O) (8). R47 lies near the basic patch, consistent with the R47H mutation disrupting the conformation of the CD loop (8), which comprises a large portion of surface 1. Molecular dynamics simulations suggest that disease-promoting mutations disrupt the apolar character and electrostatic surface of this region of the protein (34). The R47H mutation is also known to disrupt sTREM2’s ability to bind to and signal in response to acidic phospholipids (29). Thus, the data indicate that this surface is important for binding or signaling in response to anionic lipids. In contrast, the determinants of binding to Aβ peptides are uncertain, with different studies coming to differing conclusions concerning the effect of AD mutants on binding or uptake of Aβ fibrils (7, 29–31). Recently, it was suggested that different surfaces might be involved in binding different TREM2 ligands (29). Indeed, sTREM2 has a second unusual, variegated electrostatic surface (surface 2 in Fig. 1), with an extended band of positively charged residues flanked by acidic patches near the top and bottom of the structure, which might interact with different binding partners. Here, we use integrative structural modeling guided by chemical cross-linking mass spectrometry (XL-MS) to map the structure of the fibrillar Aβ–sTREM2 complex, and how it is affected by the R47H substitution. The resulting model suggests that the patch of hydrophobic and basic residues on sTREM2 that contains R47 does not directly interact with Aβ40 fibrils. Instead, sTREM2 is predicted to interact with Aβ primarily via surface 2, while projecting surface 1 away from the amyloid fibrils, with implications for both cellular uptake and signaling.Open in a separate windowFig. 1.Crystal structure of sTREM2 (PDB ID code 5UD7) (8), showing electrostatic potential map of the ectodomain. The white, red, and blue colors in the map correspond to the neutral, acidic, and basic residues, respectively. The map was generated using CHIMERA v1.14 (69). The hydrophobic and aromatic protrusion in sTREM2 is highlighted with a red dashed curve (hydrophobic tip). The flat surface of basic residues adjacent to the hydrophobic tip is shown with black dashed curve (surface 1). Another patch of basic residues, opposite to surface 1, is highlighted with a yellow dashed curve (surface 2). Key residues in these three regions are indicated.     

Selfie fundus imaging for diabetic retinopathy screening

BackgroundRegular screening for retinopathy and timely intervention reduces blindness from diabetes by 90%. Screening is currently dependent on the interpretation of images captured by trained technicians. Inherent barriers of accessibility and affordability with this approach impede widespread success of retinopathy screening programs. Herein, we report our observations on the potential of a novel approach, Selfie Fundus Imaging (SFI), to enhance diabetic retinopathy screening.MethodsThe study was undertaken over a two-month period during COVID 19 lockdown. 60 diabetic patients participated in the study. Retinal images were captured using three different approaches, handheld smartphone-based photographs captured by patients themselves after a short video-assisted training session (SFI group), and smartphone-based photographs captured by a trained technician and photographs taken on desktop conventional digital fundus camera (Gold standard). Sensitivity and kappa statistics was determined for retinopathy and macular oedema grading.FindingsMean age of the study participants was 52.4 years ± 9.8 years and 78% were men. Of 120 images captured using SFI, 90% were centred-gradable, 8% were decentred-gradable and 2% were ungradable. 82% patients captured the image within a minute (majority by 31–45 s). The sensitivity of SFI to detect diabetic retinopathy was 88.39%. Agreement between SFI grading and standard fundus photograph grading was 85.86% with substantial kappa (0.77). For the detection of diabetic macular oedema, the agreement between SFI images and standard images was 93.67, with almost perfect kappa (0.91).ConclusionFundus images were captured by patients using SFI without major difficulty and were comparable to images taken by trained specialist. With greater penetrance, advances, and availability of mobile photographic technology, we believe that SFI would positively impact the success of diabetic retinopathy screening programs by breaking the barriers of availability, accessibility, and affordability. SFI could ensure continuation of screening schedules for diabetic retinopathy, even in the face a highly contagious pandemic.Subject terms: Outcomes research, Retinal diseases, Physical examination     

Neuroprotection in glaucoma

Neuroprotective therapies in glaucoma may play a role in preventing ischemia and oxidative damage that results in apoptosis of retinal ganglion cells and optic nerve damage. Although intraocular pressure (IOP) is the only known modifiable risk factor for glaucoma, disease progression commonly occurs despite IOP control, suggesting that factors other than IOP play a role in its pathogenesis and can potentially act as targets for neuroprotection. Factors including mediators of apoptosis, ischemic changes, poor ocular blood flow and neurotoxins have been hypothesized to play a role in glaucoma progression. Neuroprotective targets include glutamate-induced neurotoxicity, nitric oxidase synthetase, neurotropins, calcium channel receptors, free radicals, vascular insufficiency, the rho-kinase pathway, and more. Drugs related to these factors are being evaluated for their role in neuroprotection, although this area of investigation faces several challenges including limited evidence for these agents’ efficacy in clinical studies. Additionally, while IOP-lowering therapies are considered neuroprotective as they generally slow the progress of glaucoma progression, they are limited by the extent of their effect beyond IOP control. The aim of this article is to review the current treatment options available for neuroprotection and to explore the drugs in the pipeline.