Maternal stressors and maternal bonding among immigrant and Refugee Arab Americans resettled in the United States

Maternal bonding with the infant and child is essential for the growth and development of the child, and for establishing the relationship between them. The effect of maternal acculturative stress, trauma, and depressive symptoms on maternal bonding has been established in nonimmigrant populations, but not in immigrant and refugee populations. In this study, we aimed to (1) examine the relationships among maternal psychosocial stress (acculturative stress, posttraumatic stress), depressive symptoms, and maternal bonding, and (2) examine whether maternal depression is a mediator of the relationship between maternal psychosocial stress and maternal bonding among a sample of Arab American immigrant and refugee mothers. Using a cross-sectional design, we recruited 78 immigrant and refugee Arab American mothers. Acculturative stress was correlated with posttraumatic stress (ρ = 0.56, p < 0.001), depressive symptoms (ρ = 0.48, p < 0.001), and bonding impairment (ρ = 0.39, p < 0.001). Posttraumatic stress and depressive symptoms were also correlated with maternal bonding impairment (ρ = 0.39, and 0.52, respectively, p < 0.001 for both). The effect of maternal psychosocial stress on maternal bonding was mediated by depressive symptoms. We concluded that higher levels of acculturative stress and posttraumatic stress were associated with higher levels of depressive symptoms and impairment of maternal bonding. Additionally, maternal depressive symptoms mediated the relationship between maternal stress and bonding. Assessing the stressors and depressive symptoms of immigrant and refugee mothers is key to avoiding negative effects on child outcomes.

Practical approaches to conducting biopsychosocial research with refugee and internally displaced communities

Refugees and internally displaced people comprise one percent of the world population. Forced migration involves a multitude of ongoing stressful and traumatic experiences, often resulting in lasting psychological symptoms for people resettling as refugees. Despite these risks, the underrepresentation of refugee populations in research-particularly in biological sciences-has impeded the allocation of effective resources and the development of novel interventions for these groups. This paper identifies and addresses key methodological challenges to successfully and appropriately conducting research with refugee and internally displaced communities, many of which have served as barriers to improving research representation for these populations. Methodological challenges discussed include language and literacy barriers; political fears; differing cultural dynamics between participants and researchers; and others. We provide practical recommendations for overcoming each challenge, often sourced from our experience conducting multi-year studies and interventions in refugee mental health. Several key strategies include the recruitment of researchers and research assistants from similar cultural and linguistic backgrounds as participants; providing detailed, ongoing communication about informed consent; avoiding assumptions regarding participants' understanding of concepts that may vary based on culture or experience (e.g., "voluntary" research; confidentiality); and adopting flexible data collection procedures compatible with participants' needs and restrictions. Finally, we discuss the role of the researcher in regard to cultural competencies and partnering with the refugee community. Given the increasing global population of refugees, the strategies discussed in this paper are suggested in order to encourage future research in this underrepresented population and empower investigators to logistically carry out studies with refugees.

Antibiotic prescription in bone augmentation and dental implant procedures: a multi-center study

BACKGROUND

Adherence to antibiotic recommendations and safety aspects of restrictive use are important components when combating antibiotic resistance. The primary aim of this study was to assess the impact of national guidelines on antibiotic prescriptions for bone augmentation procedures among dentists working at three specialized clinics. The secondary aim was to assess the occurrence of postoperative infections.

METHODS

Medical charts of 400 patients treated with bone augmentation were reviewed: 200 in the years 2010-2011 and 200 in 2014-2015. The Swedish national recommendations for antibiotic prophylaxis were published in 2012.

RESULTS

There was a wide variation in antibiotic regiments prescribed throughout the study. The number of patients treated with antibiotic prophylaxis in a single dose of 2 g amoxicillin, and treated as advocated in the national recommendations, was low and decreasing between the two time periods from 25% (n = 50/200) in 2010-2011 to 18.5% (n = 37/200) in 2014-2015. The number of patients not given any antibiotics either as a prophylactic single dose or during the postoperative phase increased (P < 0.001). The administration of a 3-7-days antibiotic prescription increased significantly from 25.5% in 2010-2011 to 35% in 2014-2015. The postoperative infection rates (4.5% and 6.5%) were without difference between the studied periods. Smoking and omitted antibiotic prophylaxis significantly increased the risk of postoperative infection. Logistic regression analyses showed that patient male gender and suffering from a disease were predictive factors for the clinician to adhere to the guidelines.

CONCLUSIONS

After introduction of national recommendations for antibiotic prophylaxis before bone augmentation procedures, the patient group receiving a single preoperative dose decreased while the group not given antibiotic prophylaxis increased. There was no difference in occurrence of postoperative infections between the two time periods. The results indicate a need for educational efforts and strategies for implementation of antibiotic prudence and awareness among surgeons performing bone augmentation procedures.

Perceived adversity and psychological distress in refugee married couples resettling in the United States

BACKGROUND

Syrian and Iraqi refugees are a growing segment of the U.S. population, and although exposure to war and violence has been linked to psychological distress in individual refugees, few studies have examined the distress in married couples.

METHODS

Using a cross-sectional design, a convenience sample of 101 Syrian and Iraqi refugee couples was recruited from a community agency. The purpose of this study was to (1) examine the relationships between perceived adversity and psychological distress (PTSD, anxiety, and depressive symptoms) among individual study participants; and (2) determine whether these relationships were correlated to their spouses' perceived adversity and psychological distress.

RESULTS

The bivariate correlation analysis showed strong positive correlations between PTSD and depression/anxiety for wives (r = .79; p < .001) and for husbands (r = .74; p < .001). There were also low- to mid-range positive cross-associations between husbands' and wives' PTSD (r = .34; p = .001) and depression/anxiety (r = .43; p < .001). Finally, we found a significant positive association between husbands' and wives' perception of adversity (r = .44; p < .001). Interestingly, the husbands' perception of adversity was positively associated with their PTSD (r = .30; p = .02) and depression/ anxiety scores (r = .26; p = .04) as well as with their wives' depression/ anxiety scores (r = .23; p = .08). In contrast, the wives' perception of adversity was not associated with either their own or their spouses' psychological distress.

CONCLUSION

Our findings suggest that war, trauma, and stress of migration impact the couple as a unit, possibly due to shared experiences, and the impact of one partner's stress on the other. Addressing these perceptions and personal interpretations of the adverse experiences via cognitive therapy approaches could help reduce not only stress in the individual but also that of their partner.

Metabolic profile in first episode drug naïve patients with psychosis and its relation to cognitive functions and social cognition: a case control study

1st episode drug naïve patients with psychosis might be at higher risk for cardiometabolic disturbances which could affect the different cognitive, and executive functions and domains of social cognition. This study aimed to study the metabolic parameters in 1st episode drug naïve patients with psychosis, to evaluate the relation of these cardiometabolic domains to the cognitive, executive functions, and social cognition. Socio-demographic characteristics of 150 first episode drug naïve patients with psychosis and 120 matched healthy control groups were collected. The current study also assessed the cardiometabolic profile and cognitive functions in both groups. Social cognition was examined by Edinburgh Social Cognition Test. The study revealed a statistically significant difference in parameters of metabolic profile among the studied groups (p < 0.001*), the scores of cognitive and executive tests were statistically significantly different (p < 0.001*). In addition, the patient's group has lowered scores of domains of social cognition (p < 0.001*). Also, the mean affective theory of mind was negatively correlated with the conflict cost of the Flanker test (r = -.185* p value = .023). The total cholesterol level (r = - 0.241**, p value = .003) and level of triglycerides (r = - 0.241**, p value = 0.003) were negatively correlated with the interpersonal domain of social cognition, the total cholesterol level is positively correlated to the total score of social cognition (r = 0.202*, p value = 0.013). Patients with 1st episode drug naïve psychosis showed disturbed cardiometabolic parameters which have deleterious effects on cognitive functions and social cognition.

Psychosocial Factors and Telomere Length Among Parents and Infants of Immigrant Arab American Families

Background: Immigrant Arab American families face multiple stressors related to migration and resettlement. Telomere length (TL) is an established biomarker of aging and psychosocial stress. No published studies have concurrently examined the association between maternal and paternal psychosocial factors and infants' TL. The purpose of this study was to: (1) compare mother, father, and infant TLs; (2) explore the association of maternal and paternal psychosocial factors (acculturative stress and depressive symptoms) with maternal and paternal TL; and (3) explore the association of maternal and paternal psychosocial factors with infants' TL among Arab American immigrants. Method: Using a cross-sectional exploratory design, a sample of 52 immigrant Arab American mother-father-infant triads were recruited from community centers. Data were collected in a single home visit when the infant was 6-24 months old. Each parent completed the study questionnaires addressing their psychosocial factors (acculturative stress, and depressive symptoms), then parents and infants provided buccal cell for TL measurement. Results: Maternal TL was positively correlated to infants' TL (r = .31, p = .04) and significantly shorter (p < .001). Paternal TL was not correlated with infant TL but was significantly shorter than infant's TL (p < .001). Maternal depression was significantly correlated with mothers' TL (r = .4, p = .007). Higher levels of maternal depressive symptoms were significantly associated with shorter infant TL when controlling for background characteristics. Conclusions: Our pilot study is the first study to examine maternal and paternal psychosocial factors related to migration and infants' TL. More research is needed to advance our understanding of the effects of immigration on the intergenerational transfer of stress and trauma.

Association of maternal and paternal psychosocial stress and infant hair cortisol among Arab American immigrants: A pilot study

Acculturative stress is unique among immigrants and refers to the stress associated with maintaining cultural values and traditions in the host country. Immigrant parents confront psychosocial variables such as acculturative stress, anxiety, and depression that might result in intergenerational negative consequences on their infants. Measurement of hair cortisol concentration (HCC), an outcome of neuroendocrine dysregulation, is one relatively noninvasive approach to gauge stress in infants. No published studies have evaluated associations among parents' psychosocial variables and infants' HCC among immigrant families. Therefore, the purpose of this study was to: (1) examine the relationship between maternal and paternal psychosocial stress variables; and (2) examine the association between psychosocial variables of both parents (acculturative stress, anxiety, and depression) and infants' HCC among immigrant Arab American families. A sample of 31 immigrant Arab American triads (mother-father-infant) was recruited. During one home visit, each parent completed the study questionnaires separately when the baby was 6-24 months old and a hair sample was collected from the infant for HCC. Parents reported significant symptoms of anxiety (33% mothers; 45% fathers) and depression (33% mothers; 35.5% fathers). Paternal acculturative stress, anxiety, and depressive symptoms were significantly correlated to infants' HCC. Acculturative stress, anxiety, and depressive symptoms were significantly correlated between mother-father dyads. Future research should continue to focus on immigrant families and include both parents to better understand and improve infant health.

Antibiotic utilization in emergency dental care in Stockholm 2016: a cross sectional study

OBJECTIVES

To investigate systemic antibiotics utilization in emergency dental care and to determine the most common treatment measures performed during emergency visits in public versus private emergency care in Sweden.

MATERIAL AND METHODS

Two questionnaires were answered by dentists at one large public and one large private emergency dental clinic in Stockholm, Sweden. The first questionnaire pertained to the emergency care provided to patients (n = 1023) and the second concerned the dentists' (n = 13) own knowledge and attitudes towards antibiotic treatment and oral infections. The results of the questionnaires were tested using a Chi-square test.

RESULTS

Sixteen percent of all patients seeking emergency dental treatment received antibiotics. The most common overall reason for visiting an emergency clinic was pain (52%, n = 519). The most common diagnoses made by the participating dentists in the public clinic were tooth/filling fracture (17%, n = 91) and gingivitis (14%, n = 76), while in the private clinic they were tooth fracture (29%, n = 146) and symptomatic apical periodontitis (15%, n = 72). Although the number of patients with infection was higher in the public care clinic, there was no significant difference in total number of antibiotic prescriptions between the two clinics. The rate of patients receiving antibiotic prescription as sole treatment was 41% (n = 34) in private care and 31% (n = 18) in public care. Thirty-one percent (n = 4) of dentists prescribed antibiotics for patients with diagnoses normally not requiring antibiotics, citing reasons such as time limitation, patient request, patient travel, patient safety, and follow-up not possible.

CONCLUSION

Although antibiotic prescription frequency among the Swedish emergency care dentists participating in this study was low, areas for improvement could include providing education to improve dentists' knowledge on both antibiotic prescription in emergency dental care and treatment of acute oral infections.

Acculturative Stress and Postpartum Depressive Symptoms among Immigrant Arab American Couples

PURPOSE

The purpose of this study was to examine the relationships between acculturative stress, perceived stress, social support, and postpartum depression (PPD) symptoms among immigrant Arab American couples.

METHODS

Using a cross-sectional design, 30 Arab American immigrant couples were enrolled. During home visits, couples completed the demographic information, the Multi-Dimensional Acculturative Stress Inventory, Perceived Stress, the Multidimensional Scale of Perceived Social Support among Arab Women, and the Edinburgh Postnatal Depression Scale. Data were analyzed using bivariate linear regression and Pearson correlation.

RESULTS

In bivariate regressions, paternal and maternal acculturative stress was moderately associated with maternal PPD symptoms (r = .39, and .46, respectively; p < .05). Maternal perceived stress (r = .70, P < .01) was strongly associated with PPD and maternal perceived social support was moderately associated with PPD (r = -.42, p < .05). Maternal and paternal acculturative stress was strongly correlated (r = .61, p < .001).

CONCLUSION

Couple's acculturative stress and mother's perceived stress were positively associated with mother's PPD symptoms. Our findings suggest the need to develop a culturally appropriate procedure to assess couple's stress that may affect immigrant women at high risk for PPD.

Characteristics of Oral Manifestations in Symptomatic Non-Hospitalized COVID-19 Patients: A Cross-Sectional Study on a Sample of the Saudi Population

Purpose

Few case reports and letters to the editor have been published regarding oral signs and symptoms in COVID-19 patients. The aim of the study therefore is to investigate different types of oral manifestations in COVID-19 patients as well as their prevalence.

Patients and Methods

The study is a cross-sectional study from a single medical center. A convenience sample was taken from all patients who were COVID-19 confirmed, symptomatic, and non-hospitalized. Demographic information, medical and travel history, general symptoms, and clinical examination results of the oral cavity were collected.

Results

This study included a total of 109 patients. Loss of taste was the most common oral manifestation of COVID-19 (43.4%), followed by erythema/desquamated gingivitis and coated tongue (7.3% each) and ulcers/blisters (6.4%). Loss of taste was the only symptom persisting for 10 days. Oral manifestations appeared as a single symptom (79.3%), and dorsum of tongue was the most common oral location (72.4%).

Conclusion

Loss of taste was the most prevalent specific reported oral manifestation. Other nonspecific oral lesions/symptoms are controversial. It has been suggested that oral examinations of COVID-19 patients should be conducted as part of routine examinations to investigate any possible correlation between the disease and the oral cavity.

Psychometric Analysis of the Arabic Translation of the Multidimensional Scale of Perceived Social Support

BACKGROUND

Social support has been related to postpartum depression (PPD) among immigrant women. The Multidimensional Scale of Perceived Social Support (MSPSS) has been translated to Arabic (MSPSS-AW) but not validated among postpartum women.

PURPOSE

To further replicate and refine the already existing MSPSS-AW to determine: (a) reliability and construct validity of the MSPSS-AW in immigrant Arab American postpartum women, and (b) relationship of dimensions of social support and PPD.

METHODS

Using a cross-sectional design, 115 Arab American immigrant postpartum women completed demographic questionnaire, MSPSS-AW, and the Edinburgh Postnatal Depression Scale.

RESULTS

Confirmatory factor analysis replicated three- factor model for social support (Family, Friends, and Husband). Internal consistency reliability coefficients for the three subscales ranged from .65 to .79. The MSPSS-AW subscales were related to PPD symptoms controlling for years of education, anxiety, and depression during pregnancy.

CONCLUSION

The MSPSS-AW is reliable and valid for use with immigrant Arab American postpartum women.

COVID-19 during pregnancy should we really worry from vertical transmission or rather from fetal hypoxia and placental insufficiency? A systematic review

Background

COVID-19 is the largest outbreak to strike humanity. The wide scale of fatalities and morbidities lead to a concurrent pandemic of uncertainty in scientific evidence. Conflicting evidences are released on daily basis about the neonatal outcomes of COVID-19-positive mothers. The aim of this study was to use the relevant case reports and series to determine the percentage of newborns who test positive for COVID-19 who are born to COVID-19-positive mothers. Secondary outcomes included examining laboratory abnormalities among COVID-19-positive neonates, and any depicted placental abnormalities in COVID-19-positive mothers. For this purpose, systematic review was performed on all studies reporting primary data on fetus-mother pairs with COVID-19. Data bases were searched for studies that met our inclusion and exclusion criteria.

Results

Final screening revealed 67 studies, from which the primary data of 1787 COVID-19 mothers were identified and had their pregnancy outcome analyzed. Only 2.8% of infants born to COVID-19-positive mothers tested positive, and this finding is identical to percentages reported in former Coronaviridae outbreaks, whereas 20% manifested with intrauterine hypoxia alongside placental abnormalities suggestive of heavy placental vaso-occlusive involvement.

Conclusions

These findings suggest that while vertical transmission is unlikely, there appears to be an underlying risk of placental insufficiency due to the prothrombotic tendency observed in COVID-19 infection. Guidelines for proper prophylactic anticoagulation in COVID-positive mothers need to be established.

Recruiting Immigrant and Refugee Arab American Mother-Father-Infant Triads Resettling in the United States: A Feasibility Study

BACKGROUND

Recent Iraqi and Syrian immigrant families are exposed to stress, anxiety, and depressive symptoms due to civil war. Recruitment challenges specific to conducting research within this population include the lack of knowledge about research, stigma of mental illness, and mistrust.

PURPOSES

Among immigrant Iraqi and Syrian families: (1) evaluate the approach to recruitment and retention; and (2) evaluate the acceptability of the study procedures.

METHODS

This feasibility study was conducted based on the work of Orsmond and Cohn. It is focused on the evaluation of recruitment capability and resulting sample characteristics and evaluation of acceptability and suitability of the study procedures. Mother-father-infant triads were recruited from a community center. Parents completed questionnaires about stress and depressive symptoms. Buccal swab samples were obtained from the triads to measure telomere length, and infant hair samples were obtained to measure cortisol level. Telomere length and hair cortisol were utilized as measures of chronic stress.

RESULTS

Ten mother-father-infant triads were enrolled out of 11 approached. Challenges faced this study included inability to reach families by telephone and the effect of cultural norms where the husband's permission was needed before proceeding, resulting in a slow pace of recruitment. The study strategy and procedures appeared to be feasible as all of the families who participated completed all study protocols.

CONCLUSION

This study provides feasibility data to inform the launching of a larger study to examine the associations of family stress with infant stress and development. These findings from Iraqi and Syrian families may be generalizable to studies seeking to recruit these and other immigrant and refugee population families.

Prophylactic antibiotics for staged bone augmentation in implant dentistry

Background: The objective of the study was to assess the effect of prophylactic antibiotics on the outcome of bone augmentation and subsequent dental implant placement by combining the recommended quality assessment methods for systematic reviews and primary studies.Materials and methods: This is a complex systematic review in which systematic reviews as well as primary studies are scrutinised. A search of Medline (OVID), The Cochrane Library (Wiley) and EMBASE, PubMed and Health technology assessment (HTA) organisations as-well as a complementary hand-search was carried out. Selected primary studies were assessed using GRADE. Each study was reviewed by three authors independently.Results: Abstract screening yielded six potential systematic reviews allocated for full-text inspection. A total of ten primary studies were read in full-text. No relevant systematic reviews regarding the topic of this article were found. The quality assessment resulted in two primary studies with a moderate risk of bias. Of the two studies with a moderate risk of bias, one compared a single dose of clindamycin 600 mg preoperatively with the same preoperative dose followed by four doses of 300 mg every 6 h. The second study compared a single dose prophylaxis of two different types of antibiotic compounds.Conclusion: In conclusion, the scientific evidence regarding the use of antibiotic prophylaxis for reducing the risk of infection in conjunction with bone augmentation procedures during dental implant placement is very limited. The infection rate as compared to nonusage of prophylactic antibiotics, selection of the most suitable compound, and the optimal duration of prophylactic treatment is still unknown.

Analysis of maternal and child health policies in Malawi: The methodological perspective

The question of why most health policies do not achieve their intended results continues to receive a considerable attention in the literature. This is in the light of the recognized gap between policy as intent and policy as practice, which calls for substantial research work to understand the factors that improve policy implementation. Although there is substantial work that explains the reasons why policies achieve or fail to achieve their intended outcomes, there are limited case studies that illustrate how to analyze policies from the methodological perspective. In this article, we report and discuss how a mixed qualitative research method was applied for analyzing maternal and child health policies in Malawi. For the purposes of this article, we do not report research findings; instead we focus our dicussion on the methodology of the study and draw lessons for policy analysis research work. We base our disusssion on our experiences from a study in which we analyzed maternal and child health policies in Malawi over the period from 1964 to 2008. Noting the multifaceted nature of maternal and child health policies, we adopted a mixed qualitative research method, whereby a number of data collection methods were employed. This approach allowed for the capturing of different perspectives of maternal and child health policies in Malawi and for strengthening of the weaknesses of each method, especially in terms of data validity. This research suggested that the multidimensional nature of maternal and child health policies, like other health policies, calls for a combination of research designs as well as a variety of methods of data collection and analysis. In addition, we suggest that, as an emerging research field, health policy analysis will benefit more from case study designs because they provide rich experiences in the actual policy context.

A phase 1b study of placenta-derived mesenchymal stromal cells in patients with idiopathic pulmonary fibrosis

BACKGROUND AND OBJECTIVE

Idiopathic pulmonary fibrosis (IPF) is a degenerative disease characterized by fibrosis following failed epithelial repair. Mesenchymal stromal cells (MSC), a key component of the stem cell niche in bone marrow and possibly other organs including lung, have been shown to enhance epithelial repair and are effective in preclinical models of inflammation-induced pulmonary fibrosis, but may be profibrotic in some circumstances.

METHODS

In this single centre, non-randomized, dose escalation phase 1b trial, patients with moderately severe IPF (diffusing capacity for carbon monoxide (DLCO ) ≥ 25% and forced vital capacity (FVC) ≥ 50%) received either 1 × 10(6) (n = 4) or 2 × 10(6) (n = 4) unrelated-donor, placenta-derived MSC/kg via a peripheral vein and were followed for 6 months with lung function (FVC and DLCO ), 6-min walk distance (6MWD) and computed tomography (CT) chest.

RESULTS

Eight patients (4 female, aged 63.5 (57-75) years) with median (interquartile range) FVC 60 (52.5-74.5)% and DLCO 34.5 (29.5-40)% predicted were treated. Both dose schedules were well tolerated with only minor and transient acute adverse effects. MSC infusion was associated with a transient (1% (0-2%)) fall in SaO2 after 15 min, but no changes in haemodynamics. At 6 months FVC, DLCO , 6MWD and CT fibrosis score were unchanged compared with baseline. There was no evidence of worsening fibrosis.

CONCLUSIONS

Intravenous MSC administration is feasible and has a good short-term safety profile in patients with moderately severe IPF.

Antibiotic prescription patterns among Swedish dentists working with dental implant surgery: adherence to recommendations

OBJECTIVES

To investigate antibiotic prophylaxis prescription behaviors among Swedish dentists working with dental implant surgery and the influence of scientific reviews.

MATERIAL AND METHODS

An observational questionnaire study was conducted in 2008 and 2012. Dental clinic addresses were found through online search services of Swedish telephone directories. The questionnaires were posted to eligible dentists (120 in 2008, 161 in 2012) in the Stockholm region, Sweden. Absolute frequencies were used to describe the data. Chi-square tests were applied to assess statistically significant differences.

RESULTS

The response rate was 75% in 2008 and 88% in 2012. In 2008, 88% of the dentists routinely prescribed antibiotic prophylaxis when performing implant surgery and 74% in 2012 (P = 0.01). There was a significant reduction in the dentists prescription patterns as 65% prescribed a single dose in 2012, compared to 49% in 2008 (P = 0.04). Amoxicillin was the drug of choice for 47% of the respondents in 2012, and 21% in 2008 (P = 0.01). Dentists without postgraduate clinical training were significantly more prone to extend antibiotic administration after surgery (P < 0.009).

CONCLUSIONS

There is a wide variation in the choice of compound and prescription patterns of prophylactic antibiotic prior to implant insertion. A reduction in antibiotic prescription to a single dose was observed comparing 2008 and 2012, probably influenced by scientific reviews. Dentists with postgraduate education are more likely to limit antibiotic usage.

FLT3-ligand treatment of humanized mice results in the generation of large numbers of CD141+ and CD1c+ dendritic cells in vivo

We established a humanized mouse model incorporating FLT3-ligand (FLT3-L) administration after hematopoietic cell reconstitution to investigate expansion, phenotype, and function of human dendritic cells (DC). FLT3-L increased numbers of human CD141(+) DC, CD1c(+) DC, and, to a lesser extent, plasmacytoid DC (pDC) in the blood, spleen, and bone marrow of humanized mice. CD1c(+) DC and CD141(+) DC subsets were expanded to a similar degree in blood and spleen, with a bias toward expansion of the CD1c(+) DC subset in the bone marrow. Importantly, the human DC subsets generated after FLT3-L treatment of humanized mice are phenotypically and functionally similar to their human blood counterparts. CD141(+) DC in humanized mice express C-type lectin-like receptor 9A, XCR1, CADM1, and TLR3 but lack TLR4 and TLR9. They are major producers of IFN-λ in response to polyinosinic-polycytidylic acid but are similar to CD1c(+) DC in their capacity to produce IL-12p70. Although all DC subsets in humanized mice are efficient at presenting peptide to CD8(+) T cells, CD141(+) DC are superior in their capacity to cross-present protein Ag to CD8(+) T cells following activation with polyinosinic-polycytidylic acid. CD141(+) DC can be targeted in vivo following injection of Abs against human DEC-205 or C-type lectin-like receptor 9A. This model provides a feasible and practical approach to dissect the function of human CD141(+) and CD1c(+) DC and evaluate adjuvants and DC-targeting strategies in vivo.

Myeloma-induced alloreactive T cells arising in myeloma-infiltrated bones include double-positive CD8+CD4+ T cells: evidence from myeloma-bearing mouse model

The graft-versus-myeloma (GVM) effect represents a powerful form of immune attack exerted by alloreactive T cells against multiple myeloma cells, which leads to clinical responses in multiple myeloma transplant recipients. Whether myeloma cells are themselves able to induce alloreactive T cells capable of the GVM effect is not defined. Using adoptive transfer of T naive cells into myeloma-bearing mice (established by transplantation of human RPMI8226-TGL myeloma cells into CD122(+) cell-depleted NOD/SCID hosts), we found that myeloma cells induced alloreactive T cells that suppressed myeloma growth and prolonged survival of T cell recipients. Myeloma-induced alloreactive T cells arising in the myeloma-infiltrated bones exerted cytotoxic activity against resident myeloma cells, but limited activity against control myeloma cells obtained from myeloma-bearing mice that did not receive T naive cells. These myeloma-induced alloreactive T cells were derived through multiple CD8(+) T cell divisions and enriched in double-positive (DP) T cells coexpressing the CD8αα and CD4 coreceptors. MHC class I expression on myeloma cells and contact with T cells were required for CD8(+) T cell divisions and DP-T cell development. DP-T cells present in myeloma-infiltrated bones contained a higher proportion of cells expressing cytotoxic mediators IFN-γ and/or perforin compared with single-positive CD8(+) T cells, acquired the capacity to degranulate as measured by CD107 expression, and contributed to an elevated perforin level seen in the myeloma-infiltrated bones. These observations suggest that myeloma-induced alloreactive T cells arising in myeloma-infiltrated bones are enriched with DP-T cells equipped with cytotoxic effector functions that are likely to be involved in the GVM effect.

Compartmentalization of allogeneic T-cell responses in the bone marrow and spleen of humanized NOD/SCID mice containing activated human resident myeloid dendritic cells

OBJECTIVE

Human allogeneic (allo)-T-cell responses within recipient lymphoid tissues and the degree to which they are altered in the presence of activated tissue-resident dendritic cells (DC) remain unknown. This study examined allo-T-cell recruitment and the early allo-T-cell responses that occur in the bone marrow (BM) and spleen (SP) of humanized (hu) nonobese diabetic (NOD)/severe combined immunodeficient (SCID) recipients containing activated human tissue-resident myeloid DC (MDC).

MATERIALS AND METHODS

Human naïve allo-T cells were transferred into polyinosinic:polycytidylic acid [poly(I:C)]-treated or untreated huNOD/SCID recipients containing human tissue-resident DC derived from transplanted CD34(+) cells. Activation of human tissue-resident MDC mediated by poly(I:C) treatment, recruitment, proliferation, and effector differentiation of allo-T cells in the BM and SP of huNOD/SCID recipients were analyzed in vivo by flow cytometry.

RESULTS

Poly(I:C) treatment induced transient activation of human MDC within a maximum of 8 hours, as evidenced in the BM by an increased proportion of MDC-expressing CD86 while in the SP by MDC expressing CD86 and producing interleukin-12. Poly(I:C)-pretreated huNOD/SCID recipients showed changes in the recruitment of allo-T cells in the BM and SP and developed different allo-T cell responses within the BM and SP compartments. In the BM, allo-T cells underwent multiple divisions and increased numbers of interferon-gamma(+) and tumor necrosis factor-alpha(+) effector cells, while the majority of splenic allo-T cells underwent a single division and had fewer effector allo-T cells.

CONCLUSIONS

Our experimental transplantation model demonstrates that early allo-T-cell responses are regulated by compartmentalization in the BM and secondary lymphoid tissues; events potentially occurring after allotransplantation in human recipients.

Cord blood CD34+ cells cultured with FLT3L, stem cell factor, interleukin-6, and IL-3 produce CD11c+CD1a-/c- myeloid dendritic cells

Methods that allow expansion of myeloid dendritic cells (MDCs) from CD34(+) cells are potentially important for boosting anti-leukemic responses after cord blood (CB) hematopoietic stem cell transplantation (HSCT). We showed that the combination of early-acting cytokines FLT3-ligand (FL), stem cell factor (SCF), interleukin (IL)-3, and IL-6 supported the generation of CD11c(+)CD16() CD1a()/c() MDCs from CB CD34(+) cells or CB myeloid precursors. Early-acting cytokine-derived MDCs were maintained within the myeloid CD33(+)CD14()CD15() precursors with a mean of 4 x 10(6) cells generated from 1-4 x 10(4) CB CD34(+) cells or myeloid precursors after 2 weeks. After 8-12 days of culture the MDCs expressed higher levels of HLA-DR antigen but lower levels of CD40 and CD86 antigen, compared to adult blood MDCs. At this stage of differentiation, the early-acting cytokine-derived MDCs had acquired the ability to induce greater allogeneic T cell proliferation than monocytes or granulocytes derived from same culture. Early-acting cytokine-derived MDCs exposed to the cytokine cocktail (CC) comprising IL-1beta, IL-6, tumor necrosis factor (TNF)-alpha, and prostaglandin E (PGE)-2, upregulated the surface co-stimulatory molecules CD40 and CD86 and enhanced allogeneic T cell proliferation, as is characteristic of MDCs maturation. The reliable production of MDCs from CB CD34(+) cells provides a novel way to study their lineage commitment pathway(s) and also a potential means of enriching CB with MDCs to improve prospects for DC immunotherapy following CB HSCT.

Decreased blood dendritic cell counts in type 1 diabetic children

In this study DC numbers, phenotype and DC responses to the Toll-like receptor (TLR)-3 ligand, poly I:C, were examined in new-onset Type 1 diabetes (T1D) patients (ND) and in established T1D patients (ED). Absolute blood myeloid DC (MDC) and plasmacytoid DC (PDC) numbers were decreased in ND and ED patients compared to age-matched controls. The decrease in MDC and PDC counts was less evident in patients with a combination of T1D and coeliac disease (CD) or CD alone. The age-dependent decline in blood DC numbers, found in control children, was not evident in ND patients, such that 2-10 years old ND children had similar MDC and PDC numbers to 15-17 years old controls. In ED patients the t-score of MDC and PDC numbers related to the age of diagnosis but not to disease duration. Blood DC in T1D patients were not distinguished from those of controls by the levels of HLA-DR, CD40 and CD86 expression or the percentage of DC expressing cytokines, IL-12, IL-10, IL-6 and TNF-alpha, in responses to poly I:C. If low DC numbers are shown to contribute to the autoimmunity in T1D, interventions aimed to increase DC numbers may mitigate against beta-cell loss.

Blood monocytes, myeloid dendritic cells and the cytokines interleukin (IL)-7 and IL-15 maintain human CD4+ T memory cells with mixed helper/regulatory function

The number and function of human T cells in the periphery are regulated by homeostatic signals received from antigen-presenting cells (APCs) and the common gamma chain (gammac) cytokines interleukin (IL)-7 and IL-15. We found that, in the absence of introduced antigen, blood monocytes or myeloid dendritic cells (MDCs) in the presence of IL-7 and IL-15 (IL-7/IL-15) can regulate CD4(+) T memory (Tm) cell numbers by polyclonal cell proliferation. The dynamics of CD4(+) Tm cell proliferation, in the presence of IL-7/IL-15, was dependent on contact with MDCs and to a lesser extent on contact with monocytes. IL-7/IL-15 either alone or combined with monocytes or MDCs enhanced the proportion of CD4(+) Tm cells with activated and effector phenotype and diminished the helper function of CD4(+) Tm cells. These CD4(+) Tm cells, preconditioned with IL-7/IL-15 alone or with monocytes or MDCs and IL-7/IL-15, reduced T cell-dependent immunoglobulin M (IgM) and IgG responses. This appeared to be a contact-dependent effect involving a reduction in antibody-producing CD27(+) B memory cells, but contact-independent suppression by soluble factors also contributed to the antibody-producing capacity of CD27(+) B memory cells. These results indicate that blood monocytes, MDCs and the cytokines IL-7/IL-15 contribute to homeostasis of CD4(+) Tm cells by regulating their number, activation state and helper/suppressor (regulatory) function. In healthy individuals, this mode of regulating CD4(+) Tm cell homeostasis may provide a basis for the control of autoimmune responses.

The CMRF58 antibody recognizes a subset of CD123hi dendritic cells in allergen-challenged mucosa

CD123(hi) CD11c(-) dendritic cells (CD123(hi) DC) are a distinct subset of human DC present in bone marrow, blood, lymphoid organs, and peripheral tissues. Pathogen stimulation, cytokine, or CD40 ligation induces CD123(hi) DC maturation, involving a shift from their innate immune to cognate antigen-presenting functions. In this study, we revealed that blood CD123(hi) DC in the presence of cytokine (granulocyte macrophage-colony stimulating factor and interleukin-3) undergo progressive, step-wise maturation through an "early" stage, delineated by expression of the antigen detected by the new monoclonal antibody CMRF58 (CD123(hi)CMRF58(+)CD40(-)CD86(-)CD83(-)) to the "late" stage with costimulatory antigen expression (CD123(hi)CMRF58(+)CD40(+)CD86(+)CD83(+/-)). In this early stage, cytokine-maintained CD123(hi) DC do not display changes in their morphology, no longer produce interferon-alpha (IFN-alpha) in response to bacteria, and develop the capacity to induce proliferation and polarization of allogeneic T cells. CD123(hi)CMRF58(+) DC, phenotypically similar to in vitro cytokine-maintained CD123(hi) DC, were not detected in tonsil but are present in allergen-challenged nasal mucosa of allergic individuals. Thus, CD123(hi) DC in certain tissue environments such as allergen-challenged nasal mucosa share a common CD123(hi)CMRF58(+) phenotype with in vitro cytokine-maintained blood CD123(hi) DC characterized by lack of IFN-alpha production.

Monitoring dendritic cells in clinical practice using a new whole blood single-platform TruCOUNT assay

Dendritic cells (DC) from distinct DC subsets are essential contributors to normal human immune responses. Despite this, reliable assays that enable DC to be counted precisely have been slow to evolve. We have now developed a new single-platform flow cytometric assay based on TruCOUNT beads and the whole blood "Lyse/No-Wash" protocol that allows precise counting of the CD14(-) blood DC subsets: CD11c(+)CD16(-) DC, CD11c(+)CD16(+) DC, CD123(hi) DC, CD1c(+) DC and BDCA-3(+) DC. This assay requires 50 microl of whole blood; does not rely on a hematology blood analyser for the absolute DC counts; allows DC counting in EDTA samples 24 h after collection; and is suitable for cord blood and peripheral blood. The data is highly reproducible with intra-assay and inter-assay coefficients of variation less than 3% and 11%, respectively. This assay does not produce the DC-T lymphocyte conjugates that result in DC counting abnormalities in conventional gradient-density separation procedures. Using the TruCOUNT assay, we established that absolute blood DC counts reduce with age in healthy individuals. In preliminary studies, we found a significantly lower absolute blood CD11c(+)CD16(+) DC count in stage III/IV versus stage I/II breast carcinoma patients and a lower absolute blood CD123(hi) DC count in multiple myeloma patients, compared to age-matched controls. These data indicate that scientific progress in DC counting technology will lead to the global standardization of DC counting and allow clinically meaningful data to be obtained.

CD40 and CD86 upregulation with divergent CMRF44 expression on blood dendritic cells in inflammatory bowel diseases

OBJECTIVE

Dendritic cells (DC) are the only antigen-presenting cells that can activate naïve T lymphocytes and initiate a primary immune response. They are also thought to have a role in immune tolerance. DC traffic from the blood to peripheral tissue where they become activated. They then present antigen and the costimulating signals necessary to initiate an immune response. In this study, we investigated the number, subsets, and activation pattern of circulating and intestinal DC from patients with clinically mild ulcerative colitis (UC) or Crohn's disease.

METHODS

Patients were recruited, if they were not taking immunosuppressive therapy, and were assessed for clinical severity of their disease using for UC, the Clinical Activity Index, and for Crohn's disease, the Crohn's Disease Activity Index. Blood CD11c+ and CD11c- DC subsets, expression of costimulatory antigens, CD86 and CD40, and the early differentiation/activation antigen, CMRF44, were enumerated by multicolor flow cytometry of lineage negative (lin- = CD3-, CD19-, CD14-, CD16-) HLA-DR+ DC. These data were compared with age-matched healthy and the disease control groups of chronic noninflammatory GI diseases (cGI), acute noninflammatory GI diseases (aGI), and chronic non-GI inflammation (non-GI). In addition, cryostat sections of colonoscopic biopsies from healthy control patients and inflamed versus noninflamed gut mucosa of inflammatory bowel disease (IBD) patients were examined for CD86+ and CD40+ lin- cells.

RESULTS

Twenty-one Crohn's disease and 25 UC patients, with mean Crohn's Disease Activity Index of 98 and Clinical Activity Index of 3.1, and 56 healthy controls, five cGI, five aGI, and six non-GI were studied. CD11c+ and CD11c- DC subsets did not differ significantly between Crohn's, UC, and healthy control groups. Expression of CD86 and CD40 on freshly isolated blood DC from Crohn's patients appeared higher (16.6%, 31%) and was significantly higher in UC (26.6%, 46.3%) versus healthy controls (5.5%, 25%) (p = 0.004, p = 0.012) and non-GI controls (10.2%, 22.8%) (p = 0.012, p = 0.008), but not versus cGI or aGI controls. CD86+ and CD40+ DC were also present in inflamed colonic and ileal mucosa from UC and Crohn's patients but not in noninflamed IBD mucosa or normal mucosa. Expression of the CMRF44 antigen was low on freshly isolated DC, but it was upregulated after 24-h culture on DC from all groups, although significantly less so on DC from UC versus Crohn's or healthy controls (p = 0.024). The CMRF44+ antigen was mainly associated with CD11c+ DC, and in UC was inversely related to the Clinical Activity Index (r = -0.69, p = 0.0002).

CONCLUSIONS

There is upregulation of costimulatory molecules on blood DC even in very mild IBD but surprisingly, there is divergent expression of the differentiation/activation CMRF44 antigen. Upregulation of costimulatory molecules and divergent expression of CMRF44 in blood DC was also apparent in cGI and aGI but not in non-GI or healthy controls, whereas intestinal CD86+ and CD40+ DC were found only in inflamed mucosa from IBD patients. Persistent or distorted activation of blood DC or divergent regulation of costimulatory and activation antigens may have important implications for gut mucosal immunity and inflammation.

Design of an integrated optical magic T for astronomy applications

A new integrated optical component is introduced that performs the function of the well-known microwave magic T, i.e., that produces the sum and the difference of the two input optical signals. Two structures are proposed and tested theoretically for this purpose. The first is based on the symmetric Y junction, and the second is based on interference phenomena in a multimode waveguide. The theoretical design is tested with a beam-propagation method simulation, and good performance is obtained. The effects of the geometrical design parameters on the structures' performance (bandwidth, cross talk, and losses) are also investigated.

Analysis of maternal and child health policies in Malawi: The methodological perspective

The question of why most health policies do not achieve their intended results continues to receive a considerable attention in the literature. This is in the light of the recognized gap between policy as intent and policy as practice, which calls for substantial research work to understand the factors that improve policy implementation. Although there is substantial work that explains the reasons why policies achieve or fail to achieve their intended outcomes, there are limited case studies that illustrate how to analyze policies from the methodological perspective. In this article, we report and discuss how a mixed qualitative research method was applied for analyzing maternal and child health policies in Malawi. For the purposes of this article, we do not report research findings; instead we focus our dicussion on the methodology of the study and draw lessons for policy analysis research work. We base our disusssion on our experiences from a study in which we analyzed maternal and child health policies in Malawi over the period from 1964 to 2008. Noting the multifaceted nature of maternal and child health policies, we adopted a mixed qualitative research method, whereby a number of data collection methods were employed. This approach allowed for the capturing of different perspectives of maternal and child health policies in Malawi and for strengthening of the weaknesses of each method, especially in terms of data validity. This research suggested that the multidimensional nature of maternal and child health policies, like other health policies, calls for a combination of research designs as well as a variety of methods of data collection and analysis. In addition, we suggest that, as an emerging research field, health policy analysis will benefit more from case study designs because they provide rich experiences in the actual policy context.