LC3-associated phagocytosis in myeloid cells, a fireman that restrains inflammation and liver fibrosis, via immunoreceptor inhibitory signaling

Control of systemic and hepatic inflammation, in particular originating from monocytes/macrophages, is crucial to prevent liver fibrosis and its progression to end-stage cirrhosis. LC3-associated phagocytosis (LAP) is a non-canonical form of autophagy that shifts the monocyte/macrophage phenotype to an anti-inflammatory phenotype. In a recent study, we uncovered LAP as a protective mechanism against inflammation-driven liver fibrosis and systemic inflammation in the context of cirrhosis. We observed that LAP is enhanced in blood and liver monocytes from patients with liver fibrosis or those who progress to cirrhosis. Combining studies in which LAP was pharmacologically or genetically inactivated, we found that LAP limits inflammation in monocytes from cirrhotic patients, and the hepatic inflammatory profile in mice with chronic liver injury, resulting in anti-fibrogenic effects. Mechanistically, LAP-induced anti-inflammatory and antifibrogenic signaling results from enhanced expression of the Fc immunoreceptor FCGR2A/FcγRIIA and activation of an FCGR2A-mediated PTPN6/SHP-1 anti-inflammatory pathway, leading to increased engulfment of IgG into LC3 ⁺ phagosomes. In patients with cirrhosis progressing to multi-organ failure (acute-on chronic liver failure), LAP is lost in monocytes, and can be restored by targeting FCGR2A-mediated PTPN6/SHP-1 signaling. These data suggest that sustaining LAP may open novel therapeutic perspectives for patients with end-stage liver disease.

[Assessment of a newly-implemented blended teaching of intensive care and emergency medicine at Paris-Diderot University]

INTRODUCTION

Blended-learning methods could be a response to student nonattendance. Non-compulsory teaching combining e-learning/interactive face-to-face sessions has been implemented at Paris-Diderot Medical School for the teaching of intensive care and emergency medicine during the 2018/2019 university period. The aim of the study was to assess this newly-implemented blended teaching.

METHODS

Questionnaire submitted to the 388 DFASM3 medical students present at the faculty exam of intensive care/emergency medicine. Attendance at a teaching modality was defined by the follow-up of more than half of this teaching modality. Correlations between attendance at e-learning and/or interactive face-to-face sessions, and grade were performed.

RESULTS

A total of 358/388 (92%) students participated in this survey. A quarter of the students (88/321 - 25%) reported they usually attended at traditional lectures. Regarding blended-learning, 210/317 (67%) students reported having attended at e-learning courses and 84/321 (27%) attended at interactive face-to-face sessions. The distribution of students according to their attendance at e-learning and/or interactive face-to-face sessions was significantly different (P<0.01). There was a significant correlation (P<0.001) between attendance at e-learning and grade obtained at the faculty exam. Nevertheless, this correlation was also found for these students in another course taught traditionally. Overall, 309/315 (98%) students were satisfied with the blended teaching, 297/318 (93%) wanted its extent to the whole medical school's curriculum.

CONCLUSION

The use of combined learning methods reached more students than traditional teachings and allowed the University to focus on its role of knowledge transfer.

Optimizing the Design and Analysis of Clinical Trials for Antibacterials Against Multidrug-resistant Organisms: A White Paper From COMBACTE's STAT-Net

Innovations are urgently required for clinical development of antibacterials against multidrug-resistant organisms. Therefore, a European, public-private working group (STAT-Net; part of Combatting Bacterial Resistance in Europe [COMBACTE]), has reviewed and tested several innovative trials designs and analytical methods for randomized clinical trials, which has resulted in 8 recommendations. The first 3 focus on pharmacokinetic and pharmacodynamic modeling, emphasizing the pertinence of population-based pharmacokinetic models, regulatory procedures for the reassessment of old antibiotics, and rigorous quality improvement. Recommendations 4 and 5 address the need for more sensitive primary end points through the use of rank-based or time-dependent composite end points. Recommendation 6 relates to the applicability of hierarchical nested-trial designs, and the last 2 recommendations propose the incorporation of historical or concomitant trial data through Bayesian methods and/or platform trials. Although not all of these recommendations are directly applicable, they provide a solid, evidence-based approach to develop new, and established, antibacterials and address this public health challenge.

Cognitive Test Differences Between our Bronx English and Spanish Speaking Patients: Lessons Learned Through the Expansion of Neuropsychological Services

Objective

To demonstrate the differences between the English-speaking and Spanish-speaking patients evaluated at a Memory Disorders Clinic.

Participants and Method

Through a foundation grant to reduce barriers to appropriate neurological care, we established a bilingual/bicultural neuropsychology post-doctoral fellowship. In the initial 2 years, 405 new patients were seen at our multidisciplinary memory disorders clinics for neuropsychological and neurological evaluations. These patients were 63% female (n = 256), and had a mean age of 73.09 (SD = 10.63, range 52-98). Fifty-eight percent of our population identified as Hispanic/Latino (primarily Puerto Rican and Dominican) and 42% were evaluated in Spanish.

Results

Patients evaluated in Spanish had less education (p &lt; .001) and were younger (p = .03) than those evaluated in English (including our Hispanic/Latino English speaking patients). Individuals evaluated in Spanish performed worse on a mental status exam (Blessed) than those evaluated in English (p = .001) even after controlling for age and education (p = .048). However, those evaluated in Spanish were more likely to do better on memory tasks than those evaluated in English, compared to their respective normative peers. Higher levels of anxiety and depression were evident in Hispanics/Latinos compared to non-Hispanics with highest levels in Hispanics evaluated in English.

Conclusions

Through a grant to expand services to the previously underserved Spanish-only speaking population of the Bronx, we were able to validate the need for appropriate language and cultural resources in our robust medical community. We demonstrated that our Spanish speaking population is diverse and requires different resources from their English-speaking counterparts. Our data supports the establishment of additional studies (including improved cultural and language specific normative data) and further education of providers working with our diverse populations.

Complex liver resection under hepatic vascular exclusion and hypothermic perfusion with versus without veno-venous bypass: a comparative study

BACKGROUND

While hypothermic liver perfusion has been shown to improve parenchymal tolerance to complex resections in patients requiring prolonged hepatic vascular exclusion (HVE), the benefit of associated veno-venous bypass (VVB) in this setting remains poorly evaluated.

METHODS

All patients undergoing liver resection requiring HVE and hypothermic liver perfusion for at least 55 min between 2006 and 2017 were retrospectively reviewed. Perioperative outcomes were compared between patients with (VVB+) or without VVB (VVB-).

RESULTS

Twenty-seven patients were analyzed, including 13 VVB+ and 14 VVB-. Median HVE duration was similar in VVB+ and VVB- patients (96 vs. 75 min, respectively). VVB+patients had longer operative time (460 vs. 375 min, p = 0.023) but less blood loss (p = 0.010). Five (19%) patients died postoperatively from liver failure or sepsis, without difference between groups. Postoperative major morbidity rate was similar between VVB+ and VVB- patients (30% vs. 50%, respectively) such as rates of liver failure, haemorrhage, renal insufficiency and sepsis, but VVB- patients experienced more respiratory complications (64% vs. 15%, p = 0.012).

CONCLUSION

During liver resection under HVE and hypothermic liver perfusion, use of VVB allows for reducing blood loss and postoperative respiratory complications. VVB should be recommended in case of liver resection with prolonged HVE.

AGR - 1 The Use of Repeat Neuropsychological Assessment to Guide Treatment of Possible Normal Pressure Hydrocephalus in a Complex Case

Objective

Normal Pressure Hydrocephalus (NPH) is a condition that is characterized by the buildup of cerebrospinal fluid (CSF) in the brain that can cause urinary incontinence, gait disturbance, and cognitive impairment. NPH can be progressive but may be managed or reversed with shunt placement. External Lumbar Drainage (ELD) trials in determining if shunt placement is appropriate are common, but the role of repeat neuropsychological assessments during ELD procedures is not well documented in the literature. Repeat, pre, peri and post- ELD trial, assessment in a complex case of possible NPH is presented.

Method

33-year-old Hispanic English-Speaking female with cognitive/memory complaints following intraventricular hemorrhage (IVH) secondary to vasculopathy was initially seen for post IVH outpatient neuropsychological evaluation. MRI showed enlarged ventricles/communicating hydrocephalus and workup for NPH was initiated. Repeat inpatient evaluations were completed during the ELD trial, with annual outpatient neuropsychological follow-up.

Results

Gait evaluation was inconclusive. Inpatient testing demonstrated minor improvement immediately following ELD opening, but performances were variable across the 4 days of re-evaluation. Shunt placement was rejected due to neuropsychological findings. Outpatient follow-up of patient over several years has demonstrated mild improvement and not evidence of cognitive decline since ELD trial.

Conclusions

Assessment of cognitive functioning in outpatient and inpatient settings before, during, and for several years following ELD testing was beneficial to ascertain the decision not to place a shunt. Repeat neuropsychological assessment in inpatient and outpatient settings provided crucial information for guiding treatment decisions.

A-58 Rare Case of Klinefelter Syndrome with 13/14 Balanced Translocation and Absence Epilepsy: Impact of Combined Genotypes on Cognitive Neuropsychological Phenotype

Objective

Klinefelter syndrome (KS) and Robertsonian translocation of 13/14 [rob t(13;14)] are the most common sex-chromosome disorder and chromosome rearrangement, respectively (Engels et al., 2008; Skakkebæk, Wallentin, & Gravholt, 2015). Both are associated with increased risk of cognitive/intellectual disability (ID). A case of KS and de novo (i.e., unbalanced) rob t(13;14) was previously reported (Gül & Şayli, 1994). A case of KS with balanced rob t(13;14) and well-controlled generalized absence epilepsy will be presented with consideration for pediatric neuropsychological practice.

Method

Neuropsychological evaluation of a 12-year-old, right-handed boy diagnosed with comorbid KS, rob t(13;14), and generalized absence epilepsy. Particular attention was given to language given his KS diagnosis. The patient is in a 12:1:1 self-contained classroom with speech-language therapy and social skills groups in place. The patient’s mother is confirmed to have rob t(13;14), whereas paternal contribution is unknown.

Results

Adolescent with a history of language difficulties, especially comprehension. Recent school-based WISC-V FSIQ was in the extremely low range (SS = 53), with weaker verbal comprehension and working memory. Academic achievement was globally very low. Expressive and receptive language, visual perception and motor coordination were extremely low to low average. Verbal list learning and visual attention were near average to average.

Conclusions

This case contributes to the very limited body of pediatric neuropsychological data on the combined genotype of KS with rob t(13;14) and absence epilepsy. Both the KS and rob t(13;14) cognitive phenotypes have been characterized as highly variable, with the comorbidity a likely increased risk for ID.

B-32 The Use of Repeat Neuropsychological Assessment to Guide Treatment of Possible Normal Pressure Hydrocephalus in a Complex Case

Objective

Normal Pressure Hydrocephalus (NPH) is a condition that is characterized by the buildup of cerebrospinal fluid (CSF) in the brain that can cause urinary incontinence, gait disturbance, and cognitive impairment. NPH can be progressive but may be managed or reversed with shunt placement. External Lumbar Drainage (ELD) trials in determining if shunt placement is appropriate are common, but the role of repeat neuropsychological assessments during ELD procedures is not well documented in the literature. Repeat, pre-, peri and post- ELD trial, assessment in a complex case of possible NPH is presented.

Method

33-year-old Hispanic English-Speaking female with cognitive/memory complaints following intraventricular hemorrhage (IVH) secondary to vasculopathy was initially seen for post IVH outpatient neuropsychological evaluation. MRI showed enlarged ventricles/communicating hydrocephalus and workup for NPH was initiated. Repeat inpatient evaluations were completed during the ELD trial, with annual outpatient neuropsychological follow-up.

Results

Gait evaluation was inconclusive. Inpatient testing demonstrated minor improvement immediately following ELD opening, but performances were variable across the 4 days of re-evaluation. Shunt placement was rejected due to neuropsychological findings. Outpatient follow-up of patient over several years has demonstrated mild improvement and not evidence of cognitive decline since ELD trial.

Conclusions

Assessment of cognitive functioning in outpatient and inpatient settings before, during, and for several years following ELD testing was beneficial to ascertain the decision not to place a shunt. Repeat neuropsychological assessment in inpatient and outpatient settings provided crucial information for guiding treatment decisions.

A-34 An Atypical Case of Primary Progressive Aphasia: Implications for Differentiating the Semantic Variant

Objective

Primary progressive aphasia is a neurodegenerative condition consisting of three primary variants. The semantic variant (svPPA) is typically associated with anomia and word-finding issues paired with fluent speech, although other symptoms can arise over time including non-verbal deficits and behavioral changes. A complex case of svPPA with evidence of robust impairment across multiple domains in the presence of notable psychosocial and medical factors is presented.

Method

Sixty-year-old woman with complaints of worsening memory and language changes in the context of marked behavioral disinhibition, deterioration of daily functioning, and indication of delusions was seen for outpatient neuropsychological evaluation. Medical history includes severe depression, anxiety, hypertension, and rheumatic heart disease. CT scan was significant for frontal and temporal atrophy and chronic right cerebellar infarct.

Results

Neuropsychological evaluation revealed uniformly extremely low scores. Presentation was notable for inappropriate behaviors, and expressive and receptive language difficulties. Significant confusion and functional impairment were evident. Her time awareness varied and she at some moments spoke about events from 20-30 years ago as if they were recent. Global language impairment was evident on formal testing and clearly moderated all other performances, including tasks of memory which were impaired. Notable weakness in visual-spatial processing and executive function were also present.

Conclusions

Complex medical and psychosocial history, and atypical decline patterns complicated the diagnosis of a patient with profound progressive expressive language impairment. SvPPA is offered as the diagnosis.

A-83 The Applicability of the Word Accentuation Test (WAT) in a Diverse Spanish Speaking Population: A Pilot Study

Objective

A valid estimate of premorbid ability (PA) is important when attempting to identify cognitive decline. Measures of PA in English have been widely validated, but there is a lack of PA instruments for Spanish speakers. The findings of a pilot study assessing the feasibility of using the Word Accentuation Test (WAT) as a PA measure in a diverse, traditionally underserved, Spanish speaking population are described.

Method

The WAT was administered as part of comprehensive neuropsychological evaluations and neurobehavioral status exams (NBSE) completed with Spanish speaking patients at Montefiore Medical Center (MMC) in a 6-month period. Sixty-one patients completed the WAT- 12 as part of comprehensive testing (mean age 60 (SD 11.05) range 43-80, 67% female) and 49 during NBSEs within the context of multidisciplinary memory disorders clinics (mean age 74.35 (SD 8.60) range 51-93, 80% female). T-tests and correlations with WAT performances were completed.

Results

Overall, our population correctly read an average of 19.67 (SD 7.61) words. There was no statistical difference by gender or age, but years of education predicted WAT performance (p = .004). For those individuals who had comprehensive cognitive evaluations, WAT scores were correlated with performance on the vocabulary subtest of the EIWA-III (p = .003). All patients without severe dementia were able to complete the task.

Conclusions

Analysis of pilot data from our diverse Spanish population demonstrated that the WAT is an PA appropriate task that appears to have good correlation with years of education and vocabulary performance. Additional research is necessary to validate the measure in this cohort and other cohorts.

Inhibition of monoacylglycerol lipase, an anti-inflammatory and antifibrogenic strategy in the liver

OBJECTIVE

Sustained inflammation originating from macrophages is a driving force of fibrosis progression and resolution. Monoacylglycerol lipase (MAGL) is the rate-limiting enzyme in the degradation of monoacylglycerols. It is a proinflammatory enzyme that metabolises 2-arachidonoylglycerol, an endocannabinoid receptor ligand, into arachidonic acid. Here, we investigated the impact of MAGL on inflammation and fibrosis during chronic liver injury.

DESIGN

C57BL/6J mice and mice with global invalidation of MAGL (MAGL ^-/- ), or myeloid-specific deletion of either MAGL (MAGL^Mye-/-), ATG5 (ATG^Mye-/-) or CB2 (CB2^Mye-/-), were used. Fibrosis was induced by repeated carbon tetrachloride (CCl₄) injections or bile duct ligation (BDL). Studies were performed on peritoneal or bone marrow-derived macrophages and Kupffer cells.

RESULTS

MAGL ^-/- or MAGL^Mye-/- mice exposed to CCl₄ or subjected to BDL were more resistant to inflammation and fibrosis than wild-type counterparts. Therapeutic intervention with MJN110, an MAGL inhibitor, reduced hepatic macrophage number and inflammatory gene expression and slowed down fibrosis progression. MAGL inhibitors also accelerated fibrosis regression and increased Ly-6C^low macrophage number. Antifibrogenic effects exclusively relied on MAGL inhibition in macrophages, since MJN110 treatment of MAGL^Mye-/- BDL mice did not further decrease liver fibrosis. Cultured macrophages exposed to MJN110 or from MAGL^Mye-/- mice displayed reduced cytokine secretion. These effects were independent of the cannabinoid receptor 2, as they were preserved in CB2^Mye-/- mice. They relied on macrophage autophagy, since anti-inflammatory and antifibrogenic effects of MJN110 were lost in ATG5^Mye-/- BDL mice, and were associated with increased autophagic flux and autophagosome biosynthesis in macrophages when MAGL was pharmacologically or genetically inhibited.

CONCLUSION

MAGL is an immunometabolic target in the liver. MAGL inhibitors may show promising antifibrogenic effects during chronic liver injury.

Rationalizing antimicrobial therapy in the ICU: a narrative review

The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.

Adeno-associated viral overexpression of neuroligin 2 in the mouse hippocampus enhances GABAergic synapses and impairs hippocampal-dependent behaviors

The cell adhesion molecule neuroligin2 (NLGN2) regulates GABAergic synapse development, but its role in neural circuit function in the adult hippocampus is unclear. We investigated GABAergic synapses and hippocampus-dependent behaviors following viral-vector-mediated overexpression of NLGN2. Transducing hippocampal neurons with AAV-NLGN2 increased neuronal expression of NLGN2 and membrane localization of GABAergic postsynaptic proteins gephyrin and GABA_ARγ2, and presynaptic vesicular GABA transporter protein (VGAT) suggesting trans-synaptic enhancement of GABAergic synapses. In contrast, glutamatergic postsynaptic density protein-95 (PSD-95) and presynaptic vesicular glutamate transporter (VGLUT) protein were unaltered. Moreover, AAV-NLGN2 significantly increased parvalbumin immunoreactive (PV⁺) synaptic boutons co-localized with postsynaptic gephyrin⁺ puncta. Furthermore, these changes were demonstrated to lead to cognitive impairments as shown in a battery of hippocampal-dependent mnemonic tasks and social behaviors.

Shock Etiologies and Fluid Management in Liver Failure

Liver failure can occur in patients with or without underlying chronic liver disease (mainly cirrhosis) and is, respectively, termed acute on chronic liver failure or acute liver failure (ALF). In both cases, it is associated with marked systemic inflammation and profound hemodynamic disturbances, that is, increased cardiac output, peripheral vasodilation, and decreased systemic vascular resistance, on top of several superimposed etiologies of shock. In patients with cirrhosis, sepsis is the main cause of intensive care unit admission but portal hypertension-related gastrointestinal hemorrhage is also common. Septic shock is also particularly frequent in patients with ALF and can complicate the initial hypovolemic shock related to poor oral intake, vomiting, and encephalopathy prior to admission. Given the susceptibility of the liver to hypoxia and also the potential deleterious effects of fluid on liver function, the assessment of hemodynamic status and volume responsiveness is especially important in these patients. However, one should keep in mind that the hyperdynamic state and low systemic vascular resistance in liver failure may bias the accuracy of some hemodynamic monitoring devices. Fluid therapy should use crystalloids, and balanced salt solutions may limit the risk of hyperchloremic acidosis and subsequent adverse kidney events. Nevertheless, the beneficial effects of albumin resuscitation have been demonstrated in patients with cirrhosis and may reflect more than mere volume expansion.