Differential remodeling of the electron transport chain is required to support TLR3 and TLR4 signaling and cytokine production in macrophages

Increasing evidence suggests that mitochondria play a critical role in driving innate immune responses against bacteria and viruses. However, it is unclear if differential reprogramming of mitochondrial function contributes to the fine tuning of pathogen specific immune responses. Here, we found that TLR3 and TLR4 engagement on murine bone marrow derived macrophages was associated with differential remodeling of electron transport chain complex expression. This remodeling was associated with differential accumulation of mitochondrial and cytosolic ROS, which were required to support ligand specific inflammatory and antiviral cytokine production. We also found that the magnitude of TLR3, but not TLR4, responses were modulated by glucose availability. Under conditions of low glucose, TLR3 engagement was associated with increased ETC complex III expression, increased mitochondrial and cytosolic ROS and increased inflammatory and antiviral cytokine production. This amplification was selectively reversed by targeting superoxide production from the outer Q-binding site of the ETC complex III. These results suggest that ligand specific modulation of the ETC may act as a rheostat that fine tunes innate immune responses via mitochondrial ROS production. Modulation of these processes may represent a novel mechanism to modulate the nature as well as the magnitude of antiviral vs. inflammatory immune responses.

PP31 Strategies to manage emergency ambulance telephone callers with sustained high needs – an evaluation using linked data (STRETCHED)

Background

Ambulance services across the UK have recognised a clinical and operational problem with persistent high users of the 999 service, but there is a lack of evidence about what works in this setting and how. We aim to evaluate the effectiveness, safety and efficiency of multi-agency case management approaches to the care of people who frequently call the emergency ambulance service, and gain understanding of barriers and facilitators to implementation.

Methods

We will carry out a mixed methods evaluation using anonymised linked routine data outcomes in a ‘natural experiment’ cohort design in four UK ambulance services, with one case management intervention site and one control site within each service. We will describe the epidemiology of ‘frequent calling’; assess the effects of case management on process, outcomes, safety and costs up to six months for 300 high users per service (n-1200); and examine the views of stakeholders, including patients, through qualitative methods. We will synthesise quantitative and qualitative findings, informed by a logic model describing predicted mechanisms of change.

Results

We received confirmation of NIHR grant funding for this study in 2018 so do not yet have results to report.

Conclusions

Telephone callers with sustained high needs represent a significant, high profile policy challenge to emergency ambulance services. Such callers may be indicative of gaps elsewhere in the health care system, which could be more effectively addressed by pro-active care. The STRETCHED study provides the opportunity to contribute to the currently sparse evidence base on interventions for this patient group.

Perceptions of physicians in Saudi Arabia on the use of international clinical guidelines for managing primary insomnia

INTRODUCTION

While there are no national clinical guidelines for managing primary insomnia in Saudi Arabia, there are also no published studies of physicians' perceptions of and attitudes towards using international guidelines. The objective of this study was to explore the knowledge, perceptions, and attitudes of physicians practising in Saudi Arabia about using international guidelines for managing insomnia.

METHODS

A qualitative study using in-depth, face-to-face, and semi-structured interviews with 15 physicians held in July 2017 at a tertiary care hospital in Jazan, the distal south-western province in Saudi Arabia. Interviews were audio-recorded, transcribed verbatim, coded using the qualitative software NVivo11 and analysed thematically. Data saturation was assumed as no new understandings of the broad thematic issues were produced by the last three interviews.

RESULTS

Themes identified were: Knowledge, Resistance, Barriers and Facilitators. Participants acknowledged their lack of awareness of available guidelines and their lack of training and education about Cognitive Behavioural Therapy for Insomnia (CBT-I). They highlighted a lack of education for patients about insomnia and its treatment. Beliefs about dependence on hypnotics and the inappropriateness of international guidelines for Saudi Arabia inclined many to resist using them. Inability to document diagnosis and consultations due to limited time and lack of suitable electronic systems, lack of suitably trained practitioners for referral for CBT-I, and lack of accountability for practice were identified as key barriers to following international guidelines. Development of national guidelines was the most important facilitator suggested by participants.

CONCLUSIONS

The health authorities in the government of the Kingdom of Saudi Arabia (KSA) should improve general public awareness about sleep disorders and provide focused training for specialists and technologists. Above all, KSA needs its own nationwide guidelines for treating sleep-disorders based on evidence-based clinical trials, consistent with its history, culture, socioeconomic conditions and traditions.

Central ghrelin receptor stimulation modulates sex motivation in male rats in a site dependent manner

Ghrelin, a hormone produced primarily by the stomach, has been associated with motivational processes that include reward-seeking behaviors. In male laboratory mice, elevation of ghrelin levels enhances some aspects of sexual motivation and behavior, whereas in other experiments with male mice, rats, and other species, ghrelin treatment or food deprivation decreases sexual motivation and/or behavior. The present tested the hypothesis that stimulation of ghrelin receptors in different brain regions have opposite effects on male sexual motivation and behavior. To do this we examined appetitive and consummatory sex behaviors of male rats with a truncated ghrelin receptor (FHH-GHSR^m1/Mcwi), and that of their WT (FHH) littermates. We also examined the effects of ghrelin or the ghrelin antagonist D-Lys-GHRP6 delivered into the VTA or the MPOA on appetitive and consummatory sex behaviors in male Long Evans rats. Results demonstrate that rats with a truncated ghrelin receptor, or rats that are food deprived, show deficits in anticipatory sex. Furthermore, although ghrelin does not further stimulate sex anticipation in rats when infused into the VTA, intra-VTA infusions of D-Lys-GHRP6 into the VTA further decreases in sex anticipation in food deprived rats. In contrast, ghrelin delivery into the mPOA decreased sex anticipation compared to saline or D-Lys-GHRP6 infused rats. Overall, these data suggest that ghrelin receptor signalling is important for full expression of appetitive sex behaviors. Within the VTA, ghrelin may act to enhance sex motivation, while acting on the mPOA to decrease sex motivation and promote foraging.

The impact of age on major orthopaedic trauma: an analysis of the United Kingdom Trauma Audit Research Network database

AIMS

To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries.

PATIENTS AND METHODS

The Trauma Audit Research Network database was reviewed to identify eligible patients admitted between April 2012 and June 2015. Distribution and severity of injury, interventions, comorbidity, critical care episodes and mortality were recorded. The population was divided into young (64 years or younger) and older (65 years and older) patients.

RESULTS

Of 142 765 adults sustaining major trauma, 72 942 (51.09 %) had long bone or pelvic fractures and 45.81% of these were > 65 years old. Road traffic collision was the most common mechanism in the young (40.4%) and, in older people, fall from standing height (80.4%) predominated. The 30 day mortality in older patients with fractures is greater (6.8% versus 2.5%), although critical care episodes are more common in the young (18.2% versus 9.7%). Older people are less likely to be admitted to critical care beds and are often managed in isolation by surgeons. Orthopaedic surgery is the most common admitting and operating specialty and, in older people, fracture surgery accounted for 82.1% of procedures.

CONCLUSION

Orthopaedic trauma in older people is associated with mortality that is significantly greater than for similar fractures in the young. As with the hip fracture population, major trauma in the elderly is a growing concern which highlights the need for a review of admission pathways and shared orthogeriatric care models. Cite this article: Bone Joint J 2017;99-B:1677-80.

Corticosteroids and infliximab impair the performance of interferon-γ release assays used for diagnosis of latent tuberculosis

The impact of immunosuppression on interferon-γ release assays and novel cytokine biomarkers of TB infection, mycobacteria-specific IL-2, IP-10 and TNF-α responses was investigated in an ex vivo model. Cytokine responses in standard QuantiFERON-TB Gold in-Tube (QFT-GIT) assays were compared with duplicate assays containing dexamethasone or infliximab. Dexamethasone converted QFT-GIT results from positive to negative in 30% of participants. Antigen-stimulated interferon-γ, IL-2 and TNF-α responses were markedly reduced, but IP-10 responses were preserved. Infliximab caused QFT-GIT result conversion in up to 30% of participants and substantial reductions in all cytokine responses. Therefore, corticosteroids and anti-TNF-α agents significantly impair interferon-γ release assay performance. IP-10 may be a more robust TB biomarker than interferon-γ in patients receiving corticosteroids.

Using Patient-Reported Outcome Measures for Quality Improvement in Clinical Genetics: an Exploratory Study

International advocacy of patient-centred healthcare delivery has led to emphasis on the (re)design and evaluation of healthcare processes and outcomes from a patient perspective. Patient-reported outcome measures (PROMs) have significant potential to inform such attempts. However there is limited understanding of the processes by which this can be achieved. This exploratory study followed attempts to utilise two different PROMs measures to support service quality improvement in clinical genetics. PROMs used were the Genetic Counseling Outcome Scale (GCOS-24), a well-validated clinical genetics-specific PROM and Euroqol (EQ-5D), a generic PROM favoured by the UK National Institute for Health and Excellence (NICE). Both of these PROMs enable pre/post intervention comparison. A service audit tool was also used, premised on a patient-reported experience measure. In addition, the study draws on interviews with clinical staff to identify challenges associated with the use of PROMs (response rate, data collection, analysis). Benefits are also explored and include the provision of insight into patients' needs; complementing clinical judgement; identification of needs being met, evidencing the benefit of services provided; prompting consideration of areas requiring attention; and encouraging professional development.

Measurable Supratentorial White Matter Volume Changes in Patients with Diffuse Intrinsic Pontine Glioma Treated with an Anti-Vascular Endothelial Growth Factor Agent, Steroids, and Radiation

BACKGROUND AND PURPOSE

Assessing the response to treatment in infiltrative brain tumors by using lesion volume-based response criteria is challenging. We hypothesized that in such tumors, volume measurements alone may not accurately capture changes in actual tumor burden during treatment. We longitudinally evaluated volume changes in both normal-appearing supratentorial white matter and the brain stem lesions in patients treated for diffuse intrinsic pontine glioma to determine to what extent adjuvant systemic therapies may skew the accuracy of tumor response assessments based on volumetric analysis.

MATERIALS AND METHODS

The anatomic MR imaging and diffusion tensor imaging data of 26 patients with diffuse intrinsic pontine glioma were retrospectively analyzed. Treatment included conformal radiation therapy in conjunction with vandetanib and dexamethasone. Volumetric and diffusion data were analyzed with time, and differences between time points were evaluated statistically.

RESULTS

Normalized brain stem lesion volume decreased during combined treatment (slope = -0.222, P < .001) and increased shortly after completion of radiation therapy (slope = 0.422, P < .001). Supratentorial white matter volume steadily and significantly decreased with time (slope = -0.057, P < .001).

CONCLUSIONS

Longitudinal changes in brain stem lesion volume are robust; less pronounced but measurable changes occur in the supratentorial white matter. Volume changes in nonirradiated supratentorial white matter during the disease course reflect the effects of systemic medication on the water homeostasis of normal parenchyma. Our data suggest that adjuvant nontumor-targeted therapies may have a more substantial effect on lesion volume changes than previously thought; hence, an apparent volume decrease in infiltrative tumors receiving combined therapies may lead to overestimation of the actual response and tumor control.

The early intervention message: perspectives of parents of children with autism spectrum disorder

BACKGROUND

There is strong evidence that early intervention (EI) can improve outcomes for children with autism spectrum disorder (ASD), and consequently, the importance of EI has been widely promoted to families of children with ASD. However, the perspectives of parents of children with ASD regarding the EI message have not been widely examined.

METHODS

This study used qualitative methods to explore parental perspectives on the EI message. Semi-structured interviews were undertaken with 14 participants from 12 family units to explore the perspectives of parents of children with ASD on the EI message. Thematic analysis was undertaken on the data.

RESULTS

Three central themes were constructed following data analysis: (i) parents' initial perceptions of EI following their child's diagnosis with ASD; (ii) the consequences (both positive and negative) of the EI message; and (iii) parents' perspectives on life after EI. The results of this study indicated that parents were acutely aware of the importance of EI, and although this provided parents with hope immediately post-diagnosis, it also placed pressure on parental decision-making regarding which intervention approaches to access for their children with ASD.

CONCLUSIONS

The results of this study highlight the importance of carefully considering how health messages, specifically the importance of EI, are communicated to families of children with ASD. Furthermore, the findings of this study also highlight the need for allied health professionals to communicate openly with parents about the anticipated outcomes of EI programmes.

Regionalisation of trauma care in England

AIMS

We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England.

PATIENTS AND METHODS

An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital.

RESULTS AND CONCLUSION

A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of "good recovery". In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253-61.