Background Standard venous thromboembolism (VTE) prophylaxis with enoxaparin results in inadequate protection in certain patients, with sub-therapeutic plasma anti-Xa levels associated with elevated VTE rates. We hypothesized that many trauma patients would be sub-therapeutic on the standard prophylactic dose of enoxaparin. Our goal was to adjust the enoxaparin dose to achieve target anti-Xa levels to take advantage of the drug based on its pharmacologic properties. Methods Patients admitted to the trauma service were included if they received at least 3 doses of prophylactic enoxaparin and underwent at least 2 screening venous duplex. Peak plasma anti-Xa levels ≤ 0.2 IU/ml were considered low and the dose was increased by 10mg bid until adequate anti-Xa levels were obtained. A strict screening venous duplex protocol was followed. Patients were excluded if they were diagnosed with a DVT prior to beginning enoxaparin or did not have correctly timed anti-Xa levels. Results Sixty-one trauma patients met inclusion criteria. There were 3 patients diagnosed with VTE (4.9%). Patients had a mean age of 45.9 years and were predominantly male (70.5%). Of the 61 patients, 18 (29.5%) had therapeutic anti-Xa levels on standard enoxaparin 30mg bid. Compared to patients who had therapeutic anti-Xa levels on enoxaparin 30mg bid, the 43 patients (70.5%) who were sub-therapeutic were more likely to be male, have larger body weight, and larger body surface area. There were no significant bleeding events in the group that received an enoxaparin dose adjustment. Conclusions A majority of patients had sub-therapeutic anti-Xa levels while on enoxaparin 30mg bid suggesting inadequate VTE prophylaxis. The need for routine use of a higher dose of prophylactic enoxaparin in trauma patients and the effects of routinely dose adjusting enoxaparin on VTE rates should be the study of future prospective, randomized trials.

People are exposed to phthalates through their wide use as plasticizers and in personal care products. Many phthalates are endocrine disruptors and have been associated with adverse health outcomes. However, knowledge gaps exist in understanding the molecular mechanisms associated with the effects of exposure in early and late pregnancy. In this study, we examined the relationship of eleven urinary phthalate metabolites with isoprostane, an established marker of oxidative stress, among pregnant Mexican-American women from an agricultural cohort. Isoprostane levels were on average 20% higher at 26 weeks than at 13 weeks of pregnancy. Urinary phthalate metabolite concentrations suggested relatively consistent phthalate exposures over pregnancy. The relationship between phthalate metabolite concentrations and isoprostane levels was significant for the sum of di-2-ethylhexyl phthalate and the sum of high molecular weight metabolites with the exception of monobenzyl phthalate, which was not associated with oxidative stress at either time point. In contrast, low molecular weight metabolite concentrations were not associated with isoprostane at 13 weeks, but this relationship became stronger later in pregnancy (p-value = 0.009 for the sum of low molecular weight metabolites). Our findings suggest that prenatal exposure to phthalates may influence oxidative stress, which is consistent with their relationship with obesity and other adverse health outcomes.

SUMMARY Development of effective prevention and treatment strategies for pre-eclampsia is limited by the lack of accurate methods for identification of at-risk pregnancies. We performed small RNA sequencing (RNA-seq) of maternal serum extracellular RNAs (exRNAs) to discover and verify microRNAs (miRNAs) differentially expressed in patients who later developed pre-eclampsia. Sera collected from 73 pre-eclampsia cases and 139 controls between 17 and 28 weeks gestational age (GA), divided into separate discovery and verification cohorts, are analyzed by small RNA-seq. Discovery and verification of univariate and bivariate miRNA biomarkers reveal that bivariate biomarkers verify at a markedly higher rate than univariate biomarkers. The majority of verified biomarkers contain miR-155–5p, which has been reported to mediate the pre-eclampsia-associated repression of endothelial nitric oxide synthase (eNOS) by tumor necrosis factor alpha (TNF-α). Deconvolution analysis reveals that several verified miRNA biomarkers come from the placenta and are likely carried by placenta-specific extracellular vesicles.

Phthalates are known endocrine disruptors and found in almost all people with several associated adverse health outcomes reported in humans and animal models. Limited data are available on the relationship between exposure to endocrine disrupting chemicals and the human metabolome. We examined the relationship of metabolomic profiles in plasma and urine of 115 pregnant women with eleven urine phthalate metabolites measured at 26 weeks of gestation to identify potential biomarkers and relevant pathways. Targeted metabolomics was performed by selected reaction monitoring liquid chromatography and triple quadrupole mass spectrometry to measure 415 metabolites in plasma and 151 metabolites in urine samples. We have chosen metabolites with the best defined peaks for more detailed analysis (138 in plasma and 40 in urine). Relationship between urine phthalate metabolites and concurrent metabolomic markers in plasma and urine suggested potential involvement of diverse pathways including lipid, steroid, and nucleic acid metabolism and enhanced inflammatory response. Most of the correlations were positive for both urine and plasma, and further confirmed by regression and PCA analysis. However, after the FDR adjustment for multiple comparisons, only 9 urine associations remained statistically significant (q-values 0.0001–0.0451), including Nicotinamide mononucleotide, Cysteine T2, Cystine, and L-Aspartic acid. Additionally, we found negative associations of maternal pre-pregnancy body mass index (BMI) with more than 20 metabolomic markers related to lipid and amino-acid metabolism and inflammation pathways in plasma (p = 0.01–0.0004), while Mevalonic acid was positively associated (p = 0.009). Nicotinic acid, the only significant metabolite in urine, had a positive association with maternal BMI (p = 0.002). In summary, when evaluated in the context of metabolic pathways, the findings suggest enhanced lipid biogenesis, inflammation and altered nucleic acid metabolism in association with higher phthalate levels. These results provide new insights into the relationship between phthalates, common in most human populations, and metabolomics, a novel approach to exposure and health biomonitoring.

Oxidative stress has been linked to many obesity-related conditions among children including cardiovascular disease, diabetes mellitus and hypertension. Exposure to environmental chemicals such as phthalates, ubiquitously found in humans, may also generate reactive oxygen species (ROS) and subsequent oxidative stress. We examined longitudinal changes of 8-isoprostane urinary concentrations, a validated biomarker of oxidative stress, and associations with maternal prenatal urinary concentrations of phthalate metabolites for 258 children at 5-, 9- and 14-years of age participating in a birth cohort residing in an agricultural area in California. Phthalates are endocrine disruptors, and in utero exposure has been also linked to altered lipid metabolism, as well as adverse birth and neurodevelopmental outcomes. We found that median creatinine-corrected 8-isoprostane concentrations remained constant across all age groups and did not differ by sex. Total cholesterol, systolic and diastolic blood pressure were positively associated with 8-isoprostane in 14-year old children. No associations were observed between 8-isoprostane and BMI, BMI Z-score or waist circumference at any age. Concentrations of three metabolites of high molecular weight phthalates measured at 13 weeks gestation [monobenzyl, monocarboxyoctyl and monocarboxynonyl phthalates] were negatively associated with 8-isoprostane concentrations among 9 year olds. However, at 14 years of age, isoprostane concentrations were positively associated with two other metabolites (mono(2-ethylhexyl) and mono(2-ethyl-5-carboxypentyl) phthalates) measured in early pregnancy. Longitudinal data on 8-isoprostane in this pediatric population with a high prevalence of obesity provides new insight on certain potential cardiometabolic risks of prenatal exposure to phthalates.

Three-dimensional chromatin organization varies across different cell types and is essential for gene regulation. Functional genomic elements that reside kilobases to megabases away can be brought into spatial proximity by chromatin folding. In fixed cells, DNA fluorescence in situ hybridization and super-resolution microscopy can measure the distances between loci at ~10-100nm resolution, while chromosome conformation capture followed by next-generation sequencing (Hi-C) is able to profile genome-wide chromatin organization at kilobase-pair level resolution by measuring contact probabilities between pairs of loci. These methods provide a static snapshot of genome compaction and organization in different cellular states. However, assessing in vivo genome-wide chromatin organization changes non-invasively and longitudinally in patients is challenging due to the limitations of current technologies. Recently, circulating cell-free DNA (cfDNA) in blood has been shown as a promising biomarker to capture the genetic and local epigenetic changes within patients. Here, we inferred in vivo chromatin organization in blood cells from co-fragmentation patterns of cfDNA by using fragment lengths estimated from paired-end whole genome sequencing (WGS). We performed cfDNA WGS on 100 healthy, 34 colorectal cancer, 48 lung cancer, and 19 melanoma patients. The inferred chromatin organization is highly concordant with Hi-C performed on white blood cells and not explained by technical biases, sequence composition, or other epigenetic factors. Further, we developed methods to identify the tissue-of-origin of cfDNA based on its co-fragmentation pattern and Hi-C signal in reference cell types, which confirmed that most cfDNA in healthy individuals is derived from hematopoietic cells. In cancer patients, we observed an increased contribution to cfDNA from cancer cells that was quantitatively correlated with estimated tumor fraction in cfDNA and qualitatively matched tumor type. We also verified the results using publicly available cfDNA WGS data from different healthy and cancer patients. These results are consistent with previous studies that directly measured DNA methylation or that inferred nucleosome positions from WGS on cfDNA. However, our method has distinct advantages including using only low-coverage WGS, not requiring bisulfite treatment, and providing a more robust and quantitative estimation of cell type contributions. Collectively, our results demonstrate the potential of using cfDNA WGS to non-invasively assess the in vivo three-dimensional chromatin organization and determine tissue-of-origin in different physiological and pathological conditions, which may be useful for detecting, monitoring and treating different diseases. Citation Format: Yaping Liu, Tzu-Yu Liu, David Weinberg, Chris J. De La Torre, Catherine L. Tan, Anthony D. Schmitt, Siddarth Selvaraj, Vy Tran, Louise C. Laurent, François-Clément Bidard, Imran S. Haque. Spatial co-fragmentation pattern of cell-free DNA recapitulates in vivo chromatin organization and identifies tissue-of-origin [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5177.

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at delivery. Secondary outcomes included administration of betamethasone, FGR and neonatal outcomes. RESULTS: Of 527 women meeting study criteria, 42 had oligohydramnios that resolved prior to delivery, while 485 had persistent oligohydramnios. There were no significant differences in patient demographics or medical comorbidities between groups. The gestational age at diagnosis was significantly lower for patients with resolved versus persistent oligohydramnios (median 33 (interquartile range (IQR) 29.1-35.9) vs. 38.0 (IQR 36.4-39.3); p <0.001). There was no difference in neonatal resuscitation (41% vs. 32%, p¼0.31). Patients with resolved oligohydramnios were more likely to develop FGR than those with persistent oligohydramnios (55% vs. 36% p<0.02). There were no significant differences for rates of betamethasone administration, gestational age at delivery, birth weight, or NICU admission. CONCLUSION: Patients whose oligohydramnios resolved were diagnosed at early gestational ages and had similar rates of neonatal resuscitation but higher rates of FGR than those who had persistent oligohydramnios. These findings suggest that women with oligohydramnios diagnosed early in the third trimester should be monitored closely for FGR.