Containing a measles outbreak in Minnesota, 2017: methods and challenges

AIMS

We report on a measles outbreak largely occurring in Minnesota's under-vaccinated Somali community in the spring of 2017. The outbreak was already into its third generation when the first two cases were confirmed, and rapid public health actions were needed. The aim of our response was to quickly end transmission and contain the outbreak.

METHODS

The state public health department performed laboratory testing on suspect cases and activated an Incident Command staffed by subject matter experts that was operational within 2 h of case confirmation. Epidemiologic interviews identified exposures in settings where risk of transmission was high, that is, healthcare, childcare, and school settings. Vaccination status of exposed persons was assessed, and postexposure prophylaxis (PEP) was offered, if applicable. Exposed persons who did not receive PEP were excluded from childcare centers or schools for 21 days. An accelerated statewide measles, mumps, and rubella (MMR) recommendation was made for Somali Minnesota children and children in affected outbreak counties. Partnerships with the Somali Minnesota community were deepened, building off outreach work done with the community since 2008.

RESULTS

Public health identified 75 measles cases from 30 March to 25 August 2017: 43% were female, 81% Somali Minnesotan, 91% unvaccinated, and 28% hospitalized. The median age of cases was 2 years (range: 3 months-57 years). Most transmission (78%) occurred in childcare centers and households. A secondary attack rate of 91% was calculated for unvaccinated household contacts. Over 51,000 doses of MMR were administered during the outbreak above expected baseline. At least 8490 individuals were exposed to measles; 155 individuals received PEP; and over 500 persons were excluded from childcare and school. State and key public health partners spent an estimated $2.3 million on response.

CONCLUSION

This outbreak demonstrates the necessity of immediate, targeted disease control actions and strong public health, healthcare, and community partnerships to end a measles outbreak.

Evaluation of the Function of Primary Human Hepatocytes Co-Cultured with the Human Hepatic Stellate Cell (HSC) Line LI90

Most bioartificial liver devices utilise primary hepatocytes alone although some have considered the use of non parenchymal cells in addition. However the effects of co-culture of human hepatocytes with different sinusoidal cell types has not been fully investigated. In this study we have examined the influence of co-culturing primary human hepatocytes with the human hepatic stellate cell (HSC) line, LI90. Cultures were monitored by light microscopy and on days 4, 8 and 14 urea synthesis and cytochrome P450 activity were measured. Morphologically LI90 cells proliferated to fill spaces between and into adjacent islands of hepatocytes. On day 14 cytochrome P450 activity in co-culture was significantly improved compared to hepatocytes cultured alone. By contrast, urea synthesis in hepatocytes was unaffected by single or co-culture. Therefore it can be concluded that a combination of primary human hepatocytes with LI90 cells is beneficial for growth and some stability of hepatocytes and may therefore be appropriate for seeding bioartificial liver devices.

Abstract P4-01-05: Improving the quality of mammographic positioning

Purpose:

Optimal breast positioning is a key component to high quality screening mammograms to allow the radiologist to make the best interpretation for the patient and referring physician. In addition, the success of newer imaging techniques also depends on breast positioning. The American College of Radiology (ACR) sets the standard of what images should include by outlining 13 criteria of breast positioning. An initial audit of over 100 mammograms at our institution in 2013 found that only a mean of 33% were achieving the ACR criteria. The goal of our project was to increase the percentage of screening mammograms achieving ACR criteria to 90% by June 2015.

Methods:

Our breast imaging center partnered with a quality improvement (QI) team driving a radiology department-wide program on quality improvement. Team members identified 5 key causes that barred achieving the ACR criteria: disagreement on what meets criteria, not having a standard work for acquiring and reading mammograms, lack of communication between the technologist and radiologist, not having a measurement system to track performance, and lack of coaching on technologist techniques for acquiring images. Developments to address these causes included: teaching modules on what meets ACR criteria, standard work for radiologists to recall mammograms that did not meet ACR criteria, system for the technologist to document why criteria were missed, auditing system to track performance, and feedback sessions between technologists and radiologists. Over 1,700 mammograms were audited from the time period of July 2014 to March 2015.

Results:

By October 2014, the percentage of mammograms achieving all 13 of the ACR criteria was 71%, with 4 criteria that prevented reaching the 90% goal. By March 2015, 10 of the 13 ACR criteria were being sustainably met by the target goal of 90% of mammograms, better in all criteria compared to our 2013 data, and better in all but one criterion compared to published 1993 data. Table 1 demonstrates that we have been able to sustain a composite percentage of 12 of the 13 ACR criteria greater than 90% for the last 2 consecutive months.

Table 1 shows the composite percentage of mammograms achieving 12 of the 13 ACR criteria over time.2013 Baseline8/20149/201410/201411/20141/20152/20153/201564%67%77%82%83%81%95%96%The excluded, most difficult criterion (visualization of the opposite breast cleavage) has been achieved at 32% per 1993 published data; we currently achieve it at 40%. 12/2014 audits were not performed due to holidays and changes in staffing.

Conclusion:

Few institutions have published positioning data, with the most recent QI publication on breast positioning dating to 1993. We have conducted a structured process to improve quality of mammographic positioning, including revision of processes that led to poor positioning outcomes and creation of an environment to sustain our improved outcomes. Three ACR criteria continue to be problematic in reaching the 90% goal, with future investigation into whether it is actually feasible to achieve the most difficult criterion at our goal of 90%. Future work also includes assessing how the recent hire of a mammography coach to spread best practices and real-time feedback is able to further improve results and maintain the infrastructure of ongoing QI.

Citation Format: Chen CA, Strain A, Mickelsen JL, Larson DA, Jesinger RA, Botelho D, Fromholz S, Obi CN, Crawley A, Lipson JA, Ikeda DM, Cooper C, Pal S. Improving the quality of mammographic positioning. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-01-05.

Ductular morphogenesis and functional polarization of normal human biliary epithelial cells in three-dimensional culture

BACKGROUND/AIMS

The understanding of the physiology and function of human biliary epithelial cells (hBEC) has been improved by studies in monolayer culture systems. The aim was to develop a polarized model to elucidate the mechanisms of ductular morphogenesis and functional differentiation of hBEC.

METHODS

The morphological, phenotypic and functional properties of hBEC cultured as three-dimensional aggregates in collagen gel were assessed in medium supplemented with (or without) human hepatocyte growth factor (hHGF) and foetal bovine serum.

RESULTS

In the absence of added mitogens and serum, cells maintained as morphologically polarized aggregates, organized around a central lumen, were positive for phenotypic markers of biliary epithelium and negative for markers of other cell types. Functional markers, gamma-glutamyl-transferase, anion exchanger-2, responses to gamma interferon and forskolin induced secretion, were preserved. hHGF increased both the size and number of aggregates and induced hBEC to invade the gel and lumena forming anastomosing networks of cells.

CONCLUSIONS

Collagen gel culture in the absence of added growth factors and serum provides a model for analysis of the polarized functions of hBEC. The formation of poorly organized cords of cells in response to hHGF suggests that collagen gel culture may provide a model for the investigation of atypical ductular morphogenesis of the human biliary tract.

Regulation of expression of 11beta-hydroxysteroid dehydrogenase type 1 in adipose tissue: tissue-specific induction by cytokines

Patients with glucocorticoid excess develop central obesity, yet in simple obesity, circulating glucocorticoid levels are normal. We have suggested that the increased activity and expression of the enzyme 11beta-hydroxysteroid dehydrogenase type 1 (11betaHSD1) generating active cortisol from cortisone within adipose tissue may be crucial in the pathogenesis of obesity. In this study primary cultures of human hepatocytes and adipose stromal cells (ASC) were used as in vitro models to investigate the tissue-specific regulation of 11betaHSD1 expression and activity. Treatment with tumor necrosis factor-alpha (TNFalpha) caused a dose-dependent increase in 11betaHSD1 activity in primary cultures of both sc [1743.1 +/- 1015.4% (TNFalpha, 10 ng/ml); P < 0.05 vs. control (100%)] and omental [375.8 +/- 57.0% (TNFalpha, 10 ng/ml); P < 0.01 vs. control (100%)] ASC, but had no effect on activity in human hepatocytes [90.2 +/- 2.8% (TNFalpha, 10 ng/ml); P = NS vs. control (100%)]. Insulin-like growth factor I (IGF-I) caused a dose-dependent inhibition of 11betaHSD1 activity in sc [49.7 +/- 15.0% (IGF-I, 100 ng/ml]; P < 0.05 vs. control (100%)] and omental [71.6 +/- 7.5 (IGF-I, 100 ng/ml); P < 0.01 vs. control (100%)] stromal cells, but not in human hepatocytes [101.8 +/- 15.7% (IGF-I, 100 ng/ml); P = NS vs. control (100%)]. Leptin treatment did not alter 11betaHSD1 activity in human hepatocytes, but increased activity in omental ASC [135.8 +/- 14.1% (leptin, 100 ng/ml); P = 0.08 vs. control (100%)]. Treatment with interleukin-1beta induced 11betaHSD1 activity and expression in sc and omental ASC in a time- and dose-dependent manner. 15-Deoxy-12,14-PGJ2, the putative endogenous ligand of the orphan nuclear receptor peroxisome proliferator-gamma, significantly increased 11betaHSD1 activity in omental cells [179.7 +/- 29.6% (1 microM); P < 0.05 vs. control (100%)] and sc [185.3 +/- 12.6% (1 microM); P < 0.01 vs. control (100%)] ASC, and it is possible that expression of this ligand may ensure continued cortisol generation to permit adipocyte differentiation. Protease inhibitors used in the treatment of human immunodeficiency virus infection are known to cause a lipodystrophic syndrome and central obesity, but saquinavir, indinavir, and neflinavir caused a dose-dependent inhibition of 11betaHSD1 activity in primary cultures of human omental ASC. 11betaHSD1 expression is increased in human adipose tissue by TNFalpha, interleukin-1beta, leptin, and orphan nuclear receptor peroxisome proliferator-gamma agonists, but is inhibited by IGF-I. This autocrine and/or paracrine regulation is tissue specific and explains recent clinical data and animal studies evaluating cortisol metabolism in obesity. Tissue-specific 11betaHSD1 regulation offers the potential for selective enzyme inhibition within adipose tissue as a novel therapy for visceral obesity.

Evaluation of the function of primary human hepatocytes co-cultured with the human hepatic stellate cell (HSC) line LI90

Most bioartificial liver devices utilise primary hepatocytes alone although some have considered the use of non parenchymal cells in addition. However the effects of co-culture of human hepatocytes with different sinusoidal cell types has not been fully investigated. In this study we have examined the influence of co-culturing primary human hepatocytes with the human hepatic stellate cell (HSC) line, LI90. Cultures were monitored by light microscopy and on days 4, 8 and 14 urea synthesis and cytochrome P450 activity were measured. Morphologically LI90 cells proliferated to fill spaces between and into adjacent islands of hepatocytes. On day 14 cytochrome P450 activity in co-culture was significantly improved compared to hepatocytes cultured alone. By contrast, urea synthesis in hepatocytes was unaffected by single or co-culture. Therefore it can be concluded that a combination of primary human hepatocytes with LI90 cells is beneficial for growth and some stability of hepatocytes and may therefore be appropriate for seeding bioartificial liver devices.

Regulation of 11 beta-hydroxysteroid dehydrogenase type 1 in primary cultures of rat and human hepatocytes

Two isozymes of the enzyme 11 beta-hydroxysteroid dehydrogenase (11 beta-HSD) are responsible for the interconversion of the active glucocorticoid, cortisol in man, (corticosterone in the rodent), to the inactive 11-keto metabolite, cortisone (11-dehydrocorticosterone). We have examined the regulation of type 1 11 beta-HSD (11 beta-HSD1) using primary cultures of rat and human hepatocytes, both of which express only 11 beta-HSD1. Only 11 oxo-reductase activity could be demonstrated in cultured hepatocytes (apparent Km for cortisone 382 +/- 43 nM in human hepatocytes, apparent Km for 11-dehydrocorticosterone 14.6 +/- 1.5 microM in rat hepatocytes). There exists a marked discrepancy between 11 beta-HSD oxo-reductase activity and 11 beta-HSD1 mRNA levels in cultured human hepatocytes and human liver. Thus oxo-reductase specific activity is much higher in the cultured hepatocytes (7.2 +/- 0.01 nmoles cortisol/mg/h vs 0.89 +/- 0.06 for whole liver homogenates) whilst the converse is true for steady state 11 beta-HSD1 mRNA levels (0.78 +/- 0.02 vs 1.94 +/- 0.07 in whole liver, 11 beta-HSD1/18S expressed as arbitrary units). Carbenoxolone has a significant inhibitory effect on 11 oxo-reductase activity in both rat and human hepatocytes. However, there is clear species-specific regulation of 11 oxo-reductase activity by thyroid hormone (tri-iodothyronine (T3)), which increases 11 oxo-reductase activity in rat hepatocytes but has no effect on activity in human hepatocytes, and progesterone which inhibits activity in human hepatocytes, but has no effect on activity in rat hepatocytes. Neither T3 nor progesterone altered 11 beta-HSD1 mRNA levels. A series of growth factors (hepatocyte growth factor, epidermal growth factor, basic fibroblast growth factor, transforming growth factor beta 1) were without effect on 11 oxo-reductase activity in cultured rat hepatocytes. In contrast to homogenates of human liver, cultured hepatocytes express only 11 beta-HSD oxo-reductase activity. This is inhibited by carbenoxolone and shows species-specific regulation by T3 and progesterone. Growth factors do not appear to regulate activity or expression of 11 beta-HSD1. The discrepant enzyme activity data and 11 beta-HSD1 mRNA expression in hepatocytes and whole liver could reflect unstable 11 beta-HSD1 oxo-reductase activity or, alternatively, an additional 11 beta-HSD oxo-reductase isoform in cultured hepatocytes.

Clinical significance of serum hepatocyte growth factor in orthotopic liver transplantation

BACKGROUND

Hepatocyte growth factor (HGF) plays a key role in the regulation of liver regeneration after hepatocyte damage. Changes in HGF production reflect the status of the regeneration process.

METHODS

Serum concentrations of HGF and energy substrates were measured during and after liver transplantation in 30 recipients.

RESULTS

In the patients with compromised grafts (group A) HGF concentrations were persistently high after reperfusion, whereas in the patients with well-functioning grafts (group B), HGF concentrations decreased rapidly and remained low 4 hours after reperfusion. The patients in group A who died had persistently high concentrations of HGF. The surviving patients with reversible primary graft dysfunction in group A exhibited low concentrations 48 hours after reperfusion. The decrease in HGF concentration preceded the decrease in aspartate aminotransferase concentration. The metabolic parameters that reflect carbohydrate metabolism by the graft paralleled the changes in HGF.

CONCLUSIONS

HGF may be more sensitive and specific in predicting early graft function than prothrombin time, ratio, aspartate aminotransferase, or arterial ketone body ratio. The determination of HGF levels after liver transplantation may yield valuable information for evaluating early graft function and making an early decision to repeat a graft procedure in an acutely ill patient.

Expression and function of thyroid hormone receptor variants in normal and chronically diseased human liver

As the liver represents a major target organ for thyroid hormone action, we compared the expression of thyroid hormone receptor (TR) alpha and beta variants in normal human liver and liver affected by primary biliary cirrhosis, sclerosing cholangitis, cryptogenic cirrhosis, and alcoholic cirrhosis (n = 6 in each group). Western blot analysis using specific polyclonal antibodies to alpha 1 or beta 1 TRs or to the related non-T3-binding c-erbA alpha 2 variant revealed abundant expression of TRs in normal and diseased liver, with no difference in size or abundance of TR proteins. Immunocytochemistry likewise revealed abundant nuclear expression of TR proteins in normal and diseased liver, with similar patterns and intensity of staining. Despite abundant TR protein expression, Northern blot hybridization of polyadenylated ribonucleic acid (RNA; 10 micrograms) to TR complementary DNAs revealed only a weak signal for c-erbA alpha 2 messenger RNA (mRNA). Comparison of the level of expression of the thyroid hormone-regulated mRNAs encoding T4-binding globulin, sex hormone-binding globulin, cortisol-binding globulin, and transthyretin in normal and diseased tissue revealed no significant difference, suggesting that hepatocellular expression of these mRNAs is maintained in chronic liver disease despite a marked reduction in circulating T3 concentrations.

Extracellular matrix proteins modulate cytochrome P450 2D6 expression in human hepatocytes

The role of extracellular matrix proteins on the expression of human liver-specific genes has been investigated. Cytochrome P450 2D6 and albumin are two liver-specific genes which are constitutively expressed in hepatocytes. Primary human hepatocytes were cultured on different extracellular matrix proteins, namely collagen, fibronectin, a combination of collagen/fibronectin and EHS-laminin rich gel, and under different culture conditions. After 48 h in culture, primary human hepatocytes showed a peak in DNA-synthesis associated with a downregulation of liver-specific expression of albumin and P450 2D6, indicating the dedifferentiation of the hepatocytes. Differentiation and expression of liver-specific genes started to increase subsequently. Redifferentiation as determined by albumin and P450 2D6 levels was more pronounced if hepatocytes were seeded on fibronectin, compared to cells seeded on EHS-laminin rich gel, collagen or a combination of collagen and fibronectin.

Hepatocyte growth factor and macrophage inflammatory protein 1 beta: structurally distinct cytokines that induce rapid cytoskeletal changes and subset-preferential migration in T cells

T-cell migration into tissue depends on a cascade of rapid and selective adhesive interactions with endothelium. "Triggering" is a step in that cascade required to activate T-cell integrins. Hepatocyte growth factor (HGF) may be a physiologically relevant trigger, since we demonstrate that HGF can induce both adhesion and migration of human T-cell subsets and can be detected immunohistochemically on inflamed endothelium. HGF preferentially induces responses from T cells of memory phenotype, in contrast to macrophage inflammatory protein 1 beta (MIP-1 beta), a chemokine which acts preferentially on naive cells. HGF, like the chemokines, binds to heparin, and HGF retained in extracellular matrix is efficient in promoting migration. Further, both MIP-1 beta and HGF induce actin polymerization within seconds, kinetics that approach those required to contribute to physiologic triggering. HGF is a member of a structural family distinct from the chemokines, whose only known receptor is the tyrosine kinase c-Met. HGF induces tyrosine phosphorylation on T cells apparently via a distinct receptor, since no c-Met is detectable by surface staining, PCR, or anti-phosphotyrosine immunoprecipitation. Thus, promotion of T-cell adhesion and migration are previously undescribed functions of HGF that we propose are relevant to selective T-cell recruitment.

Membrane dihydrolipoamide acetyltransferase (E2) on human biliary epithelial cells in primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is associated with serum antibodies that react with the dihydrolipoamide acetyltransferase component (E2) of the mitochondrial pyruvate dehydrogenase complex. We have sought the presence of E2 on the surface of human intrahepatic biliary epithelial cells (BEC). Cultured BECs from PBC but not normal liver were found to have E2 on the membrane after three days' culture. Isolated, viable cells examined by laser-scanning confocal microscopy revealed the pattern of E2 staining on the membrane to be similar to that seen with the membrane glycoprotein marker, HEA-125. By contrast, BECs from normal liver showed membrane staining only with HEA-125. When BECs were fixed before incubation with antibody to E2, cytoplasmic staining was observed. Our results suggest that E2 is present on the surface of biliary epithelial cells in PBC, and support the idea of a pathogenetic association between antimitochondrial antibodies and bileduct damage.

Participation of hepatocytes in the production of basement membrane components in human and rat liver during the perinatal period

Little is known about the role of the extracellular matrix in cellular growth, migration and differentiation in the developing liver. The distribution and origin of the main constituents of the hepatic extracellular matrix have never been studied during liver differentiation. We have investigated the extracellular and intracellular distribution of fibronectin, laminin and types I, III and IV collagen in both rat and human liver during the perinatal period by light and electron microscopy, using the indirect immunoperoxidase method. All these components were demonstrated extracellularly, located mainly in portal spaces and, to a lesser extent, surrounding central veins. In perisinusoidal spaces, variations in distribution were observed depending on the matrix protein, the age of the donor and the species. In fetal rat liver, fibronectin formed a continuous layer around hepatocyte clusters while laminin and type III procollagen were present in small amounts. Collagens and laminin were visualized more easily in newborn rat liver. Fetal and newborn human liver contained higher amounts of matrix components than their rat counterparts. Fibronectin also reacted strongly in the sinusoid, and laminin and collagens formed discontinuous deposits. The source of this extracellular matrix was demonstrated to be of mixed origin. The major finding was the presence of immunoreactive laminin in the rough endoplasmic reticulum of hepatocytes irrespective of the age or species. In addition, hepatocytes contained large amounts of fibronectin and little of type I collagen. Another basement membrane component, type IV collagen, was also found in hepatocytes from all groups except fetal rat. Perisinusoidal cells also contained various matrix components including laminin, type III procollagen and, again with the exception of fetal rat liver, type IV collagen. The greater amounts of basement membrane components in the sinusoids of developing liver than in adult tissue and the participation of immature hepatocytes in the production of laminin and to a lesser degree of type IV collagen suggest that these matrix proteins play a critical role during liver differentiation.