Immune activation state modulates infant engram expression across development

Infantile amnesia is possibly the most ubiquitous form of memory loss in mammals. We investigated how memories are stored in the brain throughout development by integrating engram labeling technology with mouse models of infantile amnesia. Here, we found a phenomenon in which male offspring in maternal immune activation models of autism spectrum disorder do not experience infantile amnesia. Maternal immune activation altered engram ensemble size and dendritic spine plasticity. We rescued the same apparently forgotten infantile memories in neurotypical mice by optogenetically reactivating dentate gyrus engram cells labeled during complex experiences in infancy. Furthermore, we permanently reinstated lost infantile memories by artificially updating the memory engram, demonstrating that infantile amnesia is a reversible process. Our findings suggest not only that infantile amnesia is due to a reversible retrieval deficit in engram expression but also that immune activation during development modulates innate, and reversible, forgetting switches that determine whether infantile amnesia will occur.

Interleukin-17 as a key player in neuroimmunometabolism

In mammals, interleukin (IL)-17 cytokines are produced by innate and adaptive lymphocytes. However, the IL-17 family has widespread expression throughout evolution, dating as far back as cnidaria, molluscs and worms, which predate lymphocytes. The evolutionary conservation of IL-17 suggests that it is involved in innate defence strategies, but also that this cytokine family has a fundamental role beyond typical host defence. Throughout evolution, IL-17 seems to have a major function in homeostatic maintenance at barrier sites. Most recently, a pivotal role has been identified for IL-17 in regulating cellular metabolism, neuroimmunology and tissue physiology, particularly in adipose tissue. Here we review the emerging role of IL-17 signalling in regulating metabolic processes, which may shine a light on the evolutionary role of IL-17 beyond typical immune responses. We propose that IL-17 helps to coordinate the cross-talk among the nervous, endocrine and immune systems for whole-body energy homeostasis as a key player in neuroimmunometabolism.

Alignment of Fellowship Training with Practice Patterns for Molecular Pathologists: A Report of the Association for Molecular Pathology Training and Education Committee

In the two decades since Accreditation Council for Graduate Medical Education-accredited Molecular Genetic Pathology fellowships began, the field of clinical molecular pathology has evolved considerably. The American Board of Pathology gathered data from board-certified molecular genetic pathologists assessing the alignment of skills and knowledge gained during fellowship with current needs on the job. The Association of Molecular Pathology conducted a parallel survey of program directors, and included questions on how various topics were taught during fellowship, as well as ranking their importance. Both surveys showed that most training aligned well with the practice needs of former trainees. Genomic profiling of tumors by next-generation sequencing, bioinformatics, laboratory management, and regulatory issues were topics thought to require increased emphasis in training. Topics related to clinical genetics and microbiology were deemed less important by those in practice, perhaps reflecting the increasing subspecialization of molecular pathologists. Program directors still viewed these topics as important to provide foundational knowledge. Parentage, identity, and human leukocyte antigen testing were less important to both survey audiences. These data may be helpful in guiding future adjustments to the Molecular Genetic Pathology curriculum and Accreditation Council for Graduate Medical Education program requirements.

Suppressive effects of the obese tumor microenvironment on CD8 T cell infiltration and effector function

Obesity is one of the leading preventable causes of cancer; however, little is known about the effects of obesity on anti-tumor immunity. Here, we investigated the effects of obesity on CD8 T cells in mouse models and patients with endometrial cancer. Our findings revealed that CD8 T cell infiltration is suppressed in obesity, which was associated with a decrease in chemokine production. Tumor-resident CD8 T cells were also functionally suppressed in obese mice, which was associated with a suppression of amino acid metabolism. Similarly, we found that a high BMI negatively correlated with CD8 infiltration in human endometrial cancer and that weight loss was associated with a complete pathological response in six of nine patients. Moreover, immunotherapy using anti-PD-1 led to tumor rejection in lean and obese mice and partially restored CD8 metabolism and anti-tumor immunity. These findings highlight the suppressive effects of obesity on CD8 T cell anti-tumor immunity, which can partially be reversed by weight loss and/or immunotherapy.

Improving adherence to cholesterol lowering guidelines through an interactive digital tool

Background

Statins are the cornerstone of primary and secondary prevention of atheroscleoric cardiovascular disease (ASCVD). Our previous retrospective analysis of 1042 consecutive patient encounters at a large urban academic institution found that one in five patients were not prescribed an appropriate statin therapy. These patients tended to be younger, of Black race, and met statin-eligibility solely via a 10-year ASCVD risk score ≥7.5%. Only one-third of patients had follow-up cholesterol levels ordered to monitor treatment efficacy.

Purpose

To improve adherence to cholesterol guidelines at our academic institution.

Methods

We implemented multiple interventions over a four-month period to support clinical decision making of guideline directed statin therapy: a) development of an online interactive tool, b) physician education on updated cholesterol guidelines and utilization of the tool, c) display of guideline summary in the workspace, and d) a documentation reminder in the electronic health record. We randomly selected encounter dates, from which 622 consecutive patient visits were analyzed. The primary outcome measures were: prescription rates of statins, documentation of a 10-year ASCVD risk score, and follow-up cholesterol levels ordered to monitor treatment efficacy.

Results

Out of the 622 patients, 232 met statin indication. In this post-intervention group, statin prescriptions rates improved when compared to the pre-intervention group (90.5% vs 82.3%, p=0.006). Among the patients who met statin indication solely via a 10-year ASCVD risk score ≥7.5%, there was an increase in documentation of the calculated 10-year ASCVD risk score (72.3% vs 57.8%; p=0.039) and in statin prescription rate (90.8% vs 67.6%; p<0.001). In addition, there was an increase in follow-up cholesterol levels ordered in all patients included in our study who met statin indication (64.1% vs 33.3%; p<0.001).

Conclusion

Our study showed higher rates of statin prescription, 10-year ASCVD risk score documentation, and treatment monitoring after multiple interventions, including an easily accessible online interactive tool, at a large urban academic institution.

Funding Acknowledgement

Type of funding sources: None. Statin Prescription Rates

Harmonization of training, training program requirements, board certification, and the practice of cytopathology: data from the American Board of Pathology surveys

INTRODUCTION

The American Board of Pathology (ABPath) has ongoing efforts to better align certification with graduate medical education, training program requirements, and pathology practice. The present study focused on the subspecialty of cytopathology. We evaluated the current content and scope of fellowship programs, practice patterns and needs of diplomates, and program director (PD) and diplomate perceptions of the ABPath certification examination to identify gaps and provide an evidence base to guide harmonization in these areas.

METHODS

Two surveys were administered: one directed to PDs of all 93 Accreditation Council for Graduate Medical Education (ACGME) cytopathology fellowship programs and the other to cytopathology diplomates submitting continuing certification reporting to the ABPath.

RESULTS

Most (86%) cytopathology diplomates work in smaller groups. Only 11% do >50% cytopathology in practice. Diplomates' cytopathology-related practice tasks varied, as did their perception of the content of fellowship training aligning with practice needs. In fellowship training programs, the specimen types, volumes, techniques of specimen acquisition, and graduated responsibility varied significantly. We identified areas in which current training and certification requirements are challenging for some programs. Diplomates and PDs had differing perceptions of the cytopathology examination; diplomates regarded image-based and microscopic glass slide questions as the best assessment of their knowledge.

CONCLUSIONS

First, fellowship training programs could benefit from shared resources and should provide more graduated responsibility for fellows. Second, the ACGME Review Committee could consider this data in future program requirement revisions. Finally, information from these surveys will be useful as the ABPath adjusts certification examination content and delivery.

ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part II: Cardiac, surgical, perioperative, operative, and post-operative challenges and management statements

Patients with connective tissue disease (CTD) present unique surgical, perioperative, operative, and postoperative challenges related to the often underlying severe pulmonary hypertension and right ventricular dysfunction. The International Society for Heart and Lung Transplantation-supported consensus document on lung transplantation in patients with CTD standardization addresses the surgical challenges and relevant cardiac involvement in the perioperative, operative, and postoperative management in patients with CTD.

Association of Pain With Atrial Fibrillation and Delirium After Cardiac Surgery: A DECADE Sub-Study

OBJECTIVE

The authors aimed to evaluate the effects of postoperative pain on the incidence of atrial fibrillation and delirium in patients having surgery with cardiopulmonary bypass (CPB).

DESIGN

Post hoc analysis of the (An investigator-initiated, multicentre, double-blind trial (ClinicalTrials NCT02004613) (DECADE)), a randomized, placebo-controlled trial.

SETTING

Tertiary, academic hospital.

PARTICIPANTS

Six hundred five adults from the DECADE enrolled at Cleveland Clinic Main Campus, who had had surgery with CPB.

INTERVENTIONS

Dexmedetomidine versus placebo started before surgical incision and postoperatively was maintained until 24 hours.

MEASUREMENTS

Primary outcomes were atrial fibrillation, diagnosed by clinicians in the intensive care unit (ICU), presence of delirium assessed with the Confusion Assessment Method for the ICU, data on pain scores, and opioid consumption, occurring between ICU admission and the earlier of postoperative day five or hospital discharge.

RESULTS

Postoperative pain levels were similar among patients with or without atrial fibrillation. Two hundred six (34%) patients had atrial fibrillation and ninety-two (15%) had delirium before hospital discharge within the first five postoperative days. The risk of atrial fibrillation was not significantly different between groups (hazard ratio: 1.09; 97.5% confidence interval [CI]: 0.99, 1.20, p = 0.039); there were no associations between postoperative pain and the risk of postoperative delirium (hazard ratio: 0.96; 97.5% CI: 0.84-1.11; p = 0.57). Postoperative opioid consumption was neither significantly associated with postoperative atrial fibrillation nor delirium.

CONCLUSIONS

Atrial fibrillation and delirium was not associated with pain after cardiac surgery. Opioid use was not associated with atrial fibrillation and delirium. Because both atrial fibrillation and delirium have a multifactorial nature, further studies should be focused on other plausible mechanisms.

Distinct metabolic programs established in the thymus control effector functions of γδ T cell subsets in tumor microenvironments

Metabolic programming controls immune cell lineages and functions, but little is known about γδ T cell metabolism. Here, we found that γδ T cell subsets making either interferon-γ (IFN-γ) or interleukin (IL)-17 have intrinsically distinct metabolic requirements. Whereas IFN-γ+ γδ T cells were almost exclusively dependent on glycolysis, IL-17+ γδ T cells strongly engaged oxidative metabolism, with increased mitochondrial mass and activity. These distinct metabolic signatures were surprisingly imprinted early during thymic development and were stably maintained in the periphery and within tumors. Moreover, pro-tumoral IL-17+ γδ T cells selectively showed high lipid uptake and intracellular lipid storage and were expanded in obesity and in tumors of obese mice. Conversely, glucose supplementation enhanced the antitumor functions of IFN-γ+ γδ T cells and reduced tumor growth upon adoptive transfer. These findings have important implications for the differentiation of effector γδ T cells and their manipulation in cancer immunotherapy.

Ethnic variations in falls and road traffic injuries resulting in hospitalisation or death in Scotland: the Scottish Health and Ethnicity Linkage Study

Objectives

To investigate ethnic differences in falls and road traffic injuries (RTIs) in Scotland.

Study design

A retrospective cohort of 4.62 million people, linking the Scottish Census 2001, with self-reported ethnicity, to hospitalisation and death records for 2001–2013.

Methods

We selected cases with International Classification of Diseases–10 diagnostic codes for falls and RTIs. Using Poisson regression, age-adjusted risk ratios (RRs, multiplied by 100 as percentages) and 95% confidence intervals (CIs) were calculated by sex for 10 ethnic groups with the White Scottish as reference. We further adjusted for country of birth and socio-economic status (SES).

Results

During about 49 million person-years, there were 275,995 hospitalisations or deaths from fall-related injuries and 43,875 from RTIs. Compared with the White Scottish, RRs for falls were higher in most White and Mixed groups, e.g., White Irish males (RR: 131; 95% CI: 122–140) and Mixed females (126; 112–143), but lower in Pakistani males (72; 64–81) and females (72; 63–82) and African females (79; 63–99). For RTIs, RRs were higher in other White British males (161; 147–176) and females (156; 138–176) and other White males (119; 104–137) and females (143; 121–169) and lower in Pakistani females (74; 57–98). The ethnic variations differed by road user type, with few cases among non-White motorcyclists and non-White female cyclists. The RRs were minimally altered by adjustment for country of birth or SES.

Conclusion

We found important ethnic variations in injuries owing to falls and RTIs, with generally lower risks in non-White groups. Culturally related differences in behaviour offer the most plausible explanation, including variations in alcohol use. The findings do not point to the need for new interventions in Scotland at present. However, as the ethnic mix of each country is unique, other countries could benefit from similar data linkage-based research.

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Ethnic inequalities in injuries are demonstrated in Scotland based on a large sample size and a fine ethnic granularity.

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White minority ethnic groups had the highest risks of fall-related injuries in Scotland.

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Fall-related injuries were the least likely in the Pakistani population.

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Ethnic differences in road traffic injuries varied by the type of road user.

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Ethnic differences in injuries were not explained by socio-economic status or country of birth.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

Low-dose dexamethasone as a treatment for women with heavy menstrual bleeding: protocol for response-adaptive randomised placebo-controlled dose-finding parallel group trial (DexFEM)

INTRODUCTION

Heavy menstrual bleeding (HMB) diminishes individual quality-of-life and poses substantial societal burden. In HMB endometrium, inactivation of cortisol (by enzyme 11β hydroxysteroid dehydrogenase type 2 (11βHSD2)), may cause local endometrial glucocorticoid deficiency and hence increased angiogenesis and impaired vasoconstriction. We propose that 'rescue' of luteal phase endometrial glucocorticoid deficiency could reduce menstrual bleeding.

METHODS AND ANALYSIS

DexFEM is a double-blind response-adaptive parallel-group placebo-controlled trial in women with HMB (108 to be randomised), with active treatment the potent oral synthetic glucocorticoid dexamethasone, which is relatively resistant to 11βHSD2 inactivation. Participants will be aged over 18 years, with mean measured menstrual blood loss (MBL) for two screening cycles ≥50 mL. The primary outcome is reduction in MBL from screening. Secondary end points are questionnaire assessments of treatment effect and acceptability. Treatment will be for 5 days in the mid-luteal phases of three treatment menstrual cycles. Six doses of low-dose dexamethasone (ranging from 0.2 to 0.9 mg twice daily) will be compared with placebo, to ascertain optimal dose, and whether this has advantage over placebo. Statistical efficiency is maximised by allowing randomisation probabilities to 'adapt' at five points during enrolment phase, based on the response data available so far, to favour doses expected to provide greatest additional information on the dose-response. Bayesian Normal Dynamic Linear Modelling, with baseline MBL included as covariate, will determine optimal dose (re reduction in MBL). Secondary end points will be analysed using generalised dynamic linear models. For each dose for all end points, a 95% credible interval will be calculated for effect versus placebo.

ETHICS AND DISSEMINATION

Dexamethasone is widely used and hence well-characterised safety-wise. Ethical approval has been obtained from Scotland A Research Ethics Committee (12/SS/0147). Trial findings will be disseminated via open-access peer-reviewed publications, conferences, clinical networks, public lectures, and our websites.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT01769820; EudractCT 2012-003405-98.

Recent advances in perioperative anesthetic management update in the perioperative support of patients with septic shock and the effect on outcomes

Septic shock during the perioperative period imparts significant challenges for anesthetic management. There is increasing support for standardization of care using evidence-based, international consensus guidelines, such as the Surviving Sepsis Campaign. This review will highlight practices in the supportive management relevant to the perioperative care of patients with severe sepsis or septic shock and their effect on clinical outcomes. It will address the epidemiological data of sepsis, the diagnostic criteria, and the role of routine, goal-directed hemodynamic resuscitation. Furthermore, it will review other options for support, including antibiotics, intensive insulin therapy, and intensive care sedation in this high risk patient population.

Culturally adapting the prevention of diabetes and obesity in South Asians (PODOSA) trial

Type 2 diabetes is extremely common in South Asians, e.g. in men from Pakistani and Indian populations it is about three times as likely as in the general population in England, despite similarities in body mass index. Lifestyle interventions reduce the incidence of diabetes. Trials in Europe and North America have not, however, reported on the impact on South Asian populations separately or provided the details of their cross-cultural adaptation processes. Prevention of diabetes and obesity in South Asians (PODOSA) is a randomized, controlled trial in Scotland of an adapted, lifestyle intervention aimed at reducing weight and increasing physical activity to reduce type 2 diabetes in Indians and Pakistanis. The trial was adapted from the Finnish Diabetes Prevention Study. We describe, reflect on and discuss the following key issues: The core adaptations to the trial design, particularly the delivery of the intervention in homes by dietitians rather than in clinics. The use of both a multilingual panel and professional translators to help translate and/or develop materials. The processes and challenges of phonetic translation. How intervention resources were adapted, modified, newly developed and translated into Urdu and Gurmukhi (written Punjabi). The insights gained in PODOSA (including time pressures on investigators, imperfections in the adaptation process, the power of verbal rather than written information, the utilization of English and the mother-tongue languages simultaneously by participants and the costs) might help the research community, given the challenge of health promotion in multi-ethnic, urban societies.

The making of a nutrition professional: the Association for Nutrition register

OBJECTIVE

Nutritionists in the UK are at the start of an exciting time of professional development. The establishment of the Association for Nutrition in 2010 has presented an opportunity to review, revitalize and expand the UK Voluntary Register of Nutritionists. In the UK and elsewhere, there is a need for a specialist register of nutritionists with title protection as a public safeguard.

DESIGN

The new structure will base professional registration on demonstration of knowledge and application in five core competencies. Initially, there will be five specialist areas: animal; public health; nutritional scientist; food; sports and exercise. The wording and requirements linking the specialist areas to the competencies have been carefully defined by leading individuals currently on the existing register in these specialist areas. These have been evaluated by a random sample of existing registrants to check for accuracy of definitions and examples. Other work aims to establish a clear quality assurance framework in nutrition for workers in the health and social care sectors (UK Public Health Skills and Career Framework Levels 1-4) who contribute to nutrition activity, such as community food workers, nutrition assistants and pharmacists. Students, co-professional affiliates and senior fellows will also find a place in the new Association. The title 'nutritionist' is not currently legally protected in the UK and it is used freely to cover a range of unregulated practice.

CONCLUSIONS

The establishment of a professional register to protect the public and to provide a clear identity for nutritionists is a vital step forward.

Challenges in recruiting South Asians into prevention trials: health professional and community recruiters' perceptions on the PODOSA trial

BACKGROUND

Recruitment of ethnic minority groups into trials is important. This was studied from the recruiters' perspective in the Prevention of Diabetes and Obesity in South Asians (PODOSA) trial.

METHODS

Semi-quantitative questionnaire survey of all 22 health professionals and 27 community workers involved in Edinburgh and Glasgow. Numbers and proportions were tabulated, while free-text responses were grouped into themes.

RESULTS

The response rate was 40/49 (82%). In the closed questions, family responsibilities, prior general practitioner screening and low interest were the main factors reported by recruiters as hindering referrals (each 28%), followed by fear of needle pricks and finding out their diabetes status (each 23%). The importance of the prevention of diabetes (60%), explaining the trial in a South Asian language (46%), verbal dialogue (43%) and the recruiter's personal relationship with the recruitee (40%) favoured referrals. Health professionals' perceived strength was their knowledge of diabetes (66%), and community workers' strength was explaining the trial in South Asian languages (65%). Strategies to improve recruitment included stronger partnership between researchers and community organizations. The open-ended response identified seven main themes: (1) shortage of recruiters' and recruitees' time; (2) poor understanding of the trial by recruitees; (3) lack of knowledge about the disease among recruitees; (4) lack of motivation and interest among recruitees; (5) delay in receiving appointments from the PODOSA team; (6) mistrust of research; and (7) narrow entry criteria.

CONCLUSION

These insights into recruiters' perspectives should help trialists improve participation by ethnic minority populations.

Characterization of adipose tissue-derived cells isolated with the Celution system

BACKGROUND

The therapeutic potential of using stem cells is tremendous. Mesenchymal stromal cells (MSC) have now been isolated in various tissues including bone marrow (BM), muscle, skin and adipose tissue. Among them, adipose tissue could be one of the most suitable cell sources for cell therapy, because of its easy accessibility, minimal morbidity and abundance of stem cells. The large numbers of stem cells in adipose tissue means that clinically relevant stem cell numbers could be extracted from the tissue, potentially eliminating the need for in vitro expansion. To utilize these characteristics of adipose tissue fully, Cytori Therapeutics Inc. has developed a closed system called Celution to isolate and concentrate stem cells and regenerative cells automatically from adipose tissue.

METHODS

Adipose tissue-derived cells were isolated using the Celution system. The output from the Celution was characterized using multicolor FACS analysis with CD31, CD34, CD45, CD90, CD105 and CD146. The multidifferentiation potential of the cells was analyzed using adipogenic and osteogenic media.

RESULTS

Our results showed that cells from the Celution are composed of heterogeneous cell populations including adipose-derived stem cells (ASC) (CD31- CD34+ CD45- CD90+ CD105- CD146-), endothelial (progenitor) cells (CD31+ CD34+ CD45- CD90+ CD105- CD146+) and vascular smooth muscle cells (CD31- CD34+ CD45- CD90+ CD105- CD146+). We also confirmed the output contains cells able to differentiate into adipogenic and osteogenic phenotypes. Our results show that cells isolated with the Celution and manually are equivalent.

DISCUSSION

Cells from adipose tissue can be processed by Celution within the time frame of a single surgical procedure. This system could provide a 'real-time' treatment setting that is cost-effective and safe.