IL-5 antagonism reverses priming and activation of eosinophils in severe eosinophilic asthma

Eosinophils are key effector cells mediating airway inflammation and exacerbation in patients with severe eosinophilic asthma. They are present in increased numbers and activation states in the airway mucosa and lumen. Interleukin-5 (IL-5) is the key eosinophil growth factor that is thought to play a role in eosinophil priming and activation. However, the mechanism of these effects is still not fully understood. The anti-IL-5 antibody mepolizumab reduces eosinophil counts in the airway modestly but has a large beneficial effect on the frequency of exacerbations of severe eosinophilic asthma, suggesting that reduction in eosinophil priming and activation is of central mechanistic importance. In this study, we used the therapeutic effect of mepolizumab and single-cell ribonucleic acid sequencing to investigate the mechanism of eosinophil priming and activation by IL-5. We demonstrated that IL-5 is a dominant driver of eosinophil priming and plays multifaceted roles in eosinophil function. It enhances eosinophil responses to other stimulators of migration, survival, and activation by activating phosphatidylinositol-3-kinases, extracellular signal-regulated kinases, and p38 mitogen-activated protein kinases signaling pathways. It also enhances the pro-fibrotic roles of eosinophils in airway remodeling via transforming growth factor-β pathway. These findings provide a mechanistic understanding of eosinophil priming in severe eosinophilic asthma and the therapeutic effect of anti-IL-5 approaches in the disease.

An effective procedure skills training programme for GIM registrars

Background

The Royal College of Physicians' Acute care toolkit 8 recommends procedural training for medical registrars at all hospitals. We aimed to determine the interest and need, and to pilot the delivery of such training in the procedures outlined by the Joint Royal Colleges of Physicians Training Board (2017).

Methods

An online survey was sent to general internal medicine (GIM) trainees within the Thames Valley Deanery in January 2019. This identified a need for procedure skills training. Ninety per cent of trainees felt simulation training would improve their confidence in the outlined procedures.

We trialled a simulation programme for GIM registrars between September 2019 and October 2019. Sessions lasted 3-3.5 hours and trainees rotated through four stations. Feedback was obtained from trainees and trainers during each pilot session.

Results

Thirty-two trainees attended across both sites. Excellent feedback was obtained and trainee confidence improved by visual analogue scale scoring post-training for all procedures. Almost 90% of trainees felt the sessions would improve safety on GIM on calls.

Conclusion

Simulation training is an effective way to improve trainee confidence in procedural skills and this pilot shows such training is desired and necessitated in higher specialty training. Further work will assess its impact on maintaining trainee skillsets and impact on patient safety.

Successful awake proning is associated with improved clinical outcomes in patients with COVID-19: single-centre high-dependency unit experience

The SARS-CoV-2 can lead to severe illness with COVID-19. Outcomes of patients requiring mechanical ventilation are poor. Awake proning in COVID-19 improves oxygenation, but on data clinical outcomes is limited. This single-centre retrospective study aimed to assess whether successful awake proning of patients with COVID-19, requiring respiratory support (continuous positive airways pressure (CPAP) or high-flow nasal oxygen (HFNO)) on a respiratory high-dependency unit (HDU), is associated with improved outcomes. HDU care included awake proning by respiratory physiotherapists. Of 565 patients admitted with COVID-19, 71 (12.6%) were managed on the respiratory HDU, with 48 of these (67.6%) requiring respiratory support. Patients managed with CPAP alone 22/48 (45.8%) were significantly less likely to die than patients who required transfer onto HFNO 26/48 (54.2%): CPAP mortality 36.4%; HFNO mortality 69.2%, (p=0.023); however, multivariate analysis demonstrated that increasing age and the inability to awake prone were the only independent predictors of COVID-19 mortality. The mortality of patients with COVID-19 requiring respiratory support is considerable. Data from our cohort managed on HDU show that CPAP and awake proning are possible in a selected population of COVID-19, and may be useful. Further prospective studies are required.

Targeted biologic therapy for asthma

BACKGROUND

Asthma is a common and potentially serious condition affecting 300 million people worldwide. For many years, we have relied on a one-size-fits-all approach to its management, using corticosteroids and bronchodilators for all symptomatic patients. However, with more recent advances, it has become clear that asthma is a heterogeneous condition with multiple different underlying pathways. Understanding the different subtypes will be a key to giving us the ability to intervene in a targeted way to personalize care for patients with asthma.

SOURCES OF DATA

Key published literature, guidelines and trials from clinicaltrials.gov.

AREAS OF AGREEMENT

The most widely studied of these subtypes is T2 high eosinophilic asthma, for which there are an increasing number of biologic therapies available. T2 high asthma is associated with the cytokines interleukin (IL)-4, IL-5 and IL-13, for each of which biologics have been developed.

AREAS OF CONTROVERSY

It is currently unclear which of the available biologics provides superior efficacy. It is also unclear how to select which biologic for which patient.

GROWING POINTS

Head-to-head trials of the available T2 biologics will be important to determine superiority, and a suggested order for trialling biologics. Going further than this, we would like to see further analyses of available biologics to allow us to predict responders from non-responders in advance of administering therapy.

AREAS TIMELY FOR DEVELOPING RESEARCH

Non-eosinophilic T2 low asthma is an area that is under-researched and for which there are few treatments available. It is likely that there are different subtypes in this category of asthma and unravelling what these are will be crucial to developing effective treatments.

Developing research priorities for palliative care of people with intellectual disabilities in Europe: a consultation process using nominal group technique

Background

Empirical knowledge around palliative care provision and needs of people with intellectual disabilities is extremely limited, as is the availability of research resources, including expertise and funding. This paper describes a consultation process that sought to develop an agenda for research priorities for palliative care of people with intellectual disabilities in Europe.

Methods

A two-day workshop was convened, attended by 16 academics and clinicians in the field of palliative care and intellectual disability from six European countries. The first day consisted of round-table presentations and discussions about the current state of the art, research challenges and knowledge gaps. The second day was focused on developing consensus research priorities with 12 of the workshop participants using nominal group technique, a structured method which involved generating a list of research priorities and ranking them in order of importance.

Results

A total of 40 research priorities were proposed and collapsed into eleven research themes. The four most important research themes were: investigating issues around end of life decision making; mapping the scale and scope of the issue; investigating the quality of palliative care for people with intellectual disabilities, including the challenges in achieving best practice; and developing outcome measures and instruments for palliative care of people with intellectual disabilities.

Conclusions

The proposal of four major priority areas and a range of minor themes for future research in intellectual disability, death, dying and palliative care will help researchers to focus limited resources and research expertise on areas where it is most needed and support the building of collaborations. The next steps are to cross-validate these research priorities with people with intellectual disabilities, carers, clinicians, researchers and other stakeholders across Europe; to validate them with local and national policy makers to determine how they could best be incorporated in policy and programmes; and to translate them into actual research studies by setting up European collaborations for specific studies that require such collaboration, develop research proposals and attract research funding.

Eukaryotic type II chaperonin CCT interacts with actin through specific subunits

Chaperonins assist the folding of other proteins. Type II chaperonins, such as chaperonin containing TCP-1(CCT), are found in archaea and in the eukaryotic cytosol. They are hexadecameric or nonadecameric oligomers composed of one to eight different polypeptides. Whereas type I chaperonins like GroEL are promiscuous, assisting in the folding of many other proteins, only a small number of proteins, mainly actin and tubulin, have been described as natural substrates of CCT. This specificity may be related to the divergence of the eight CCT subunits. Here we have obtained a three-dimensional reconstruction of the complex between CCT and alpha-actin by cryo-electron microscopy and image processing. This shows that alpha-actin interacts with the apical domains of either of two CCT subunits. Immunolabelling of CCT-substrate complexes with antibodies against two specific CCT subunits showed that actin binds to CCT using two specific and distinct interactions: the small domain of actin binds to CCTdelta and the large domain to CCTbeta or CCTepsilon (both in position 1,4 with respect to delta). These results indicate that the binding of actin to CCT is both subunit-specific and geometry-dependent. Thus, the substrate recognition mechanism of eukaryotic CCT may differ from that of prokaryotic GroEL.

Analysis of chaperonin-containing TCP-1 subunits in the human keratinocyte two-dimensional protein database: further characterisation of antibodies to individual subunits

The chaperonin-containing TCP-1 (CCT), found in the eukaryotic cytosol, is currently the focus of extensive research. CCT consists of at least eight different subunit types encoded by independent but related genes, and a set of antibodies that recognise individual subunits has proved useful in the characterisation and functional analysis of CCT. These antibodies were used to identify subunits of CCT in the human keratinocyte two-dimensional protein database. Accurate values for the pI and molecular mass of human CCT subunits were determined from the database, and biological data was obtained regarding changes in subunit levels in response to extracellular agents and growth conditions. The second part of the study describes the characterisation of seven monoclonal antibodies raised against mouse TCP-1, also known as CCT alpha, using a combination of epitope mapping and immunoblot analysis of protein extracts from different species and tissue types. Some antibodies were not monospecific for TCP-1, and a number of epitope-related proteins were identified.

Peptide mass fingerprinting of chaperonin-containing TCP-1 (CCT) and copurifying proteins

The chaperonin-containing TCP-1 (CCT), found in the eukaryotic cytosol, is currently the focus of extensive research, CCT isolated from mouse testis lysate sediments at 20S in a sucrose gradient and accounts for about 70% of the total protein in this fraction. We intend to identify all the other proteins that copurify with CCT and to compile a reference profile for future studies. Their identification can be accelerated by a combination of protease digestion, matrix-assisted laser desorption-mass spectrometry, and database matching known as peptide mass fingerprinting. We applied this strategy to 32 polypeptides resolved by 2-dimensional gel electrophoresis, and 23 known proteins and 6 novel proteins were identified. We analyzed isoelectric variants of the CCT subunits and differences in the peptide mass spectra of two CCT theta isoforms indicated a novel posttranslational modification of this subunit.

The chaperonin containing t-complex polypeptide 1 (TCP-1). Multisubunit machinery assisting in protein folding and assembly in the eukaryotic cytosol

Many proteins in the cell require assistance from molecular chaperones at stages in their life cycles in order to attain correctly folded states and functional conformations during protein synthesis or during recovery from denatured states. A recently discovered molecular chaperone, which is abundant in the eukaryotic cytosol and is called the chaperonin containing TCP-1 (CCT), has been shown to assist the folding of some proteins in cytosol. This chaperone is a member of the chaperonin family which includes GroEL, 60-kDa heat shock protein (Hsp60), Rubisco subunit binding protein (RBP) and thermophilic factor 55 (TF55), but is distinct from the other members in several respects. Presently the most intriguing feature is the hetero-oligomeric nature of the CCT; at least eight subunit species which are encoded by independent and highly diverged genes are known. These genes are calculated to have diverged around the starting point of the eukaryotic lineage and they are maintained in all eukaryotes investigated, suggesting a specific function for each subunit species. The amino acid sequences of these subunits share approximately 30% identity and have some highly conserved motifs probably responsible for ATPase function, suggesting this function is common to all subunits. Thus, each subunit is thought to have both specific and common functions. These observations, in conjunction with biochemical and genetic analysis, suggest that CCT functions as a very complex machinery for protein folding in the eukaryotic cell and that its chaperone activity may be essential for the folding and assembly of various newly synthesized polypeptides. This complex behaviour of CCT may have evolved to cope with the folding and assembly of certain highly evolved proteins in eukaryotic cells.

The eighth Cct gene, Cctq, encoding the theta subunit of the cytosolic chaperonin containing TCP-1

The chaperonin containing t-complex polypeptide 1 (TCP-1), as one of its subunits, CCT, is a cytosolic heterooligomeric molecular chaperone assisting in the folding of proteins in eukaryotic cytosol. We have isolated a Tcp-1-related 119-bp cDNA fragment from a human cDNA library by polymerase chain reaction, and cloned full-length mouse cDNAs orthologous to the human cDNA by hybridization. The nucleotide (nt) sequence of the longest mouse clone (1844 bp) shows an open reading frame (ORF) encoding a TCP-1-related polypeptide of 548 amino acids (aa) (59,562 Da). This gene is different from Tcp-1 and the six Tcp-1-related genes reported previously, Tcp-1 (Ccta), Cctb, Cctg, Cctd, Ccte, Cctz and Ccth, which encode subunits of CCT. The product of the novel gene was analysed using an antibody raised against the C terminus of the polypeptide deduced from the nt sequence. We found that this gene encodes a subunit of CCT (polypeptide S1; 62 kDa and pI 6.25 by two-dimensional gel analysis). We have named it Cctq, encoding the theta subunit of CCT (CCT theta). The aa sequence of CCT theta shows 23-29% identity to the other CCT subunits, alpha, beta, gamma, delta, epsilon, zeta and eta, and 29% identity to the archaebacterial chaperonin TF55. CCT theta also contains the motifs common to all the other subunits of CCT which are postulated to be involved in ATPase activity.

Antibody characterisation of two distinct conformations of the chaperonin-containing TCP-1 from mouse testis

We describe a panel of antibodies specific to individual subunits of the chaperonin-containing TCP-1 (CCT) and one antibody that reacts with all the subunits of CCT. Immunoblot analysis of CCT purified from mouse testis suggests that the testis-specific subunit, S6, may be related to CCT zeta and that a co-purifying 63 kDa protein may be a novel subunit of CCT. Using these antibodies in the analysis of CCT subjected to nondenaturing IEF we observed the resolution of two distinct conformations of CCT, which differ in their susceptibility to proteolysis and in the number of associated polypeptides.

The mouse t-complex gene, Tcp-11, is under translational control

The mouse t-complex is known to harbour genes which affect male fertility. Tcp-11 is a t-complex gene which is only expressed in male germ cells and from its position is a candidate for a distorter, one of the two types of genetic element involved in transmission ratio distortion. Antibodies raised to TCP-11 protein made in E. Coli were used on thin sections of testis and shown to recognise late spermatids. On Western blots the antibodies bound to a 68-kD protein present in protein extracts from testis. No specific signal could be detected using the antibody on protein extracts from other mouse tissues. Following gentle lysis of the germ cells and fractionation on sucrose gradients, all the material recognised by the anti-Tcp-11 antibody was found to be soluble and unassociated with any membrane fraction or organelle. A comparison of the time course of expression of the Tcp-11 mRNA and the TCP-11 protein revealed that expression of this gene is under translational control.

Primary structure and function of a second essential member of the heterooligomeric TCP1 chaperonin complex of yeast, TCP1 beta

A role for heterooligomeric TCP1 complex as a chaperonin in the eukaryotic cytosol has recently been suggested both by structural similarities with other chaperonins and by in vitro experiments showing it to mediate ATP-dependent folding of actin, tubulin, and luciferase. Here we present the primary structure of a second subunit of the complex and present genetic and functional analyses. The TCP1 beta amino acid sequence, predicted from the cloned gene, bears 35% identity to TCP1, termed here TCP1 alpha, containing the same highly conserved residues found in the collective sequence of chaperonins. The predicted product was identified as the fastest-migrating species of the TCP1 complex purified from soluble extracts of yeast. The TCP1 beta gene, like TCP1 alpha, is essential. Strains containing lethal disruptions of either gene could not be rescued by additional copies of the other. Spores bearing disruption of either gene germinated as single, large-budded cells. Similarly, large-budded cells were observed following shift to 37 degrees C of strains carrying temperature-sensitive mutations in either TCP1 alpha or TCP1 beta. The arrested cells contained replicated DNA present in single nuclear masses, associated with abnormal tubulin staining patterns, supporting the assertion that mitotic spindle formation and function are impaired. We conclude that TCP1 beta supplies an essential function that partially overlaps with that of TCP1 alpha in acting as a molecular chaperone in tubulin and spindle biogenesis.

Identification of six Tcp-1-related genes encoding divergent subunits of the TCP-1-containing chaperonin

BACKGROUND

TCP-1 is a 60 kD subunit of a cytosolic hetero-oligomeric chaperone that is known to be involved in the folding of actin and tubulin. This protein is a member of the chaperonin family, which includes Escherichia coli GroEL, the mitochondrial heat-shock protein Hsp60, the plastid Rubisco-subunit-binding protein and the archaebacterial protein TF55. These chaperonins assist the folding of proteins upon ATP hydrolysis.

RESULTS

Using two-dimensional gel analysis, we have identified nine different subunits of TCP-1-containing chaperonin complexes from mammalian testis and seven different subunits of such complexes from mouse F9 cells. We have isolated full-length mouse cDNAs encoding six novel TCP-1-related polypeptides and show that these cDNAs encode subunits of the TCP-1-containing cytosolic chaperonin. These subunits are between 531 and 545 residues in length. Their sequences are 25-36% identical to one another, 27-35% identical to that of TCP-1 and 32-39% identical to that of the archaebacterial chaperonin, TF55. We have named these genes, Cctb, Cctg, Cctd, Ccte, Cctz and Ccth, which encode the CCT beta, CCT gamma, CCT delta, CCT epsilon, CCT zeta and CCT eta subunits, respectively, of the 'Chaperonin Containing TCP-1' (CCT). All the CCT subunits contain motifs that are also shared by all other known chaperonins of prokaryotes and eukaryotic organelles, and that probably relate to their common ATPase function.

CONCLUSION

It is likely that each CCT subunit has a specific, independent function, as they are highly diverged from each other but conserved from mammals to yeast. We suggest that the expansion in the number of types of CCT subunit, compared with other chaperonins, has allowed CCT to carry out the more complex functions that are required for the folding and assembly of highly evolved eukaryotic proteins.

Expression of three t-complex genes, Tcp-1, D17Leh117c3, and D17Leh66, in purified murine spermatogenic cell populations

Transmission ratio distortion (TRD) is a property of the complete t-haplotype which results in the preferential transmission of the t-haplotype chromosome from heterozygous t/+ males to the majority of the progeny. Available data suggest that in t/+ males, a dysfunction of the wild-type sperm within the female reproductive tract is responsible for the observed deviation from Mendelian segregation ratios. Genetically, Lyon has shown that multiple loci within the t-complex are required for maximum levels of TRD. These loci include multiple t-complex distorters (Tcds) which act upon a single t-complex responder (Tcr). Testis-expressed genes have been cloned which map to the same subregions of the t-complex as the Tcds and Tcr and are thus considered candidate genes for the products of these loci. To begin to understand how the products of these loci biochemically control TRD, the expression of three TRD-candidate genes (Tcp-1, D17Leh117c3, and D17Leh66) has been determined in populations of spermatocytes and differentiated spermatids purified to near homogeneity by unit gravity sedimentation. Fractions covering the entire gradient were analysed resulting in a more accurate picture of the precise timing of expression than previously reported. Transcription of all three genes was up-regulated in pachytene primary spermatocytes and persisted at stable levels through the haploid spermatid stages. Significantly, only levels of mRNA encoded by D17Leh66, the candidate gene for Tcr, increased from early round to elongating-stage spermatids. If this pattern of expression does, in fact, represent Tcr, these data provide the first direct evidence that wild-type and t-haplotype Tcr elements could be differentially expressed in haploid spermatids.

Variation in alcoholism treatment orientation: differential impact upon specific subpopulations

Treatment programs across the State of New York were studied to determine the differential impact of treatment orientations upon various types of alcoholism clients. 1340 patients from 17 alcoholism treatment programs were treated and followed up 3 and 8 months after treatment. The majority of the clients were categorized as either Behaviorally Impaired Drinkers (n = 205) or Alcoholics (n = 814). Each of the treatment programs were classified according to either Peer Group, Rehabilitation Professional, or Medical Orientations. Three different outcome measures were examined: abstinence, amount of alcohol consumed at follow-up, and improvement (life and drinking) at follow-up. The generalizable conclusions were that females had significantly better outcome (78% abstinent) when treated according to a medical orientation. Male Behaviorally Impaired Drinkers had better outcomes when treated in Rehabilitation Professional Orientation (74% abstinent) and male alcoholics had the best outcome in Peer Group (60% abstinent), although male alcoholics achieved similar abstinence rates in Medical (59.5%) and Rehabilitation (55%) orientations.