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Levic DS, Niedzwiecki D, Kandakatla A, Karlovich NS, Juneja A, Park J, Stolarchuk C, Adams S, Willer JR, Schaner MR, Lian G, Beasley C, Marjoram L, Flynn AD, Valentine JF, Onken JE, Sheikh SZ, Davis EE, Evason KJ, Garman KS, Bagnat M. TNF promoter hypomethylation is associated with mucosal inflammation in IBD and anti-TNF response. medRxiv 2024:2024.02.05.24302343. [PMID: 38370739 PMCID: PMC10871362 DOI: 10.1101/2024.02.05.24302343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Background and aims Inflammatory Bowel Diseases (IBD) are chronic inflammatory conditions influenced heavily by environmental factors. DNA methylation is a form of epigenetic regulation linking environmental stimuli to gene expression changes and inflammation. Here, we investigated how DNA methylation of the TNF promoter differs between inflamed and uninflamed mucosa of IBD patients, including anti-TNF responders and non-responders. Methods We obtained mucosal biopsies from 200 participants (133 IBD and 67 controls) and analyzed TNF promoter methylation using bisulfite sequencing, comparing inflamed with uninflamed segments, in addition to paired inflamed/uninflamed samples from individual patients. We conducted similar analyses on purified intestinal epithelial cells from bowel resections. We also compared TNF methylation levels of inflamed and uninflamed mucosa from a separate cohort of 15 anti-TNF responders and 17 non-responders. Finally, we sequenced DNA methyltransferase genes to identify rare variants in IBD patients and functionally tested them using rescue experiments in a zebrafish genetic model of DNA methylation deficiency. Results TNF promoter methylation levels were decreased in inflamed mucosa of IBD patients and correlated with disease severity. Isolated IECs from inflamed tissue showed proportional decreases in TNF methylation. Anti-TNF non-responders showed lower levels of TNF methylation than responders in uninflamed mucosa. Our sequencing analysis revealed two missense variants in DNMT1, one of which had reduced function in vivo. Conclusions Our study reveals an association of TNF promoter hypomethylation with mucosal inflammation, suggesting that IBD patients may be particularly sensitive to inflammatory environmental insults affecting DNA methylation. Together, our analyses indicate that TNF promoter methylation analysis may aid in the characterization of IBD status and evaluation of anti-TNF therapy response.
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Affiliation(s)
- Daniel S. Levic
- Department of Cell Biology, Duke University, Durham, NC, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Apoorva Kandakatla
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, NC, USA
| | - Norah S. Karlovich
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, NC, USA
| | - Arjun Juneja
- Department of Cell Biology, Duke University, Durham, NC, USA
| | - Jieun Park
- Department of Cell Biology, Duke University, Durham, NC, USA
| | - Christina Stolarchuk
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, NC, USA
| | - Shanté Adams
- Center for Human Disease Modeling, Duke University Medical Center, Durham, NC, USA
| | - Jason R. Willer
- Center for Human Disease Modeling, Duke University Medical Center, Durham, NC, USA
| | - Matthew R. Schaner
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Grace Lian
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caroline Beasley
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Ann D. Flynn
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah Health, Salt Lake City, Utah
| | - John F. Valentine
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah Health, Salt Lake City, Utah
| | - Jane E. Onken
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, NC, USA
| | - Shehzad Z. Sheikh
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Genetics, Curriculum in Genetics and Molecular Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Erica E. Davis
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Cell and Molecular Biology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Kimberley J. Evason
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Katherine S. Garman
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, NC, USA
| | - Michel Bagnat
- Department of Cell Biology, Duke University, Durham, NC, USA
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Clay AS, Andolsek KM, Niederhoffer K, Kandakatla A, Zhang G, Price M, Alagesan P, Jeffs S, DeLaura I, Nicholson CP, Chudgar SM, Narayan AP, Knudsen NW, Blazar M, Edwards P, Buckley EG. Creation of an asynchronous faculty development curriculum on well-written narrative assessments that avoid bias. BMC Med Educ 2023; 23:244. [PMID: 37060081 PMCID: PMC10103041 DOI: 10.1186/s12909-023-04237-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/06/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND The COVID-19 pandemic in parallel with concerns about bias in grading resulted in many medical schools adopting pass/fail clinical grading and relying solely on narrative assessments. However, narratives often contain bias and lack specificity. The purpose of this project was to develop asynchronous faculty development to rapidly educate/re-educate > 2000 clinical faculty spread across geographic sites and clinical disciplines on components of a well-written narrative and methods to minimize bias in the assessment of students. METHODS We describe creation, implementation, and pilot data outcomes for an asynchronous faculty development curriculum created by a committee of volunteer learners and faculty. After reviewing the literature on the presence and impact of bias in clinical rotations and ways to mitigate bias in written narrative assessments, the committee developed a web-based curriculum using multimedia learning theory and principles of adult learning. Just-in-time supplemental materials accompanied the curriculum. The Dean added completion of the module by 90% of clinical faculty to the department chairperson's annual education metric. Module completion was tracked in a learning management system, including time spent in the module and the answer to a single text entry question about intended changes in behavior. Thematic analysis of the text entry question with grounded theory and inductive processing was used to define themes of how faculty anticipate future teaching and assessment as a result of this curricula. OUTCOMES Between January 1, 2021, and December 1, 2021, 2166 individuals completed the online module; 1820 spent between 5 and 90 min on the module, with a median time of 17 min and an average time of 20.2 min. 15/16 clinical departments achieved completion by 90% or more faculty. Major themes included: changing the wording of future narratives, changing content in future narratives, and focusing on efforts to change how faculty teach and lead teams, including efforts to minimize bias. CONCLUSIONS We developed a faculty development curriculum on mitigating bias in written narratives with high rates of faculty participation. Inclusion of this module as part of the chair's education performance metric likely impacted participation. Nevertheless, time spent in the module suggests that faculty engaged with the material. Other institutions could easily adapt this curriculum with provided materials.
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Affiliation(s)
- Alison S Clay
- Department of Medical Education, School of Medicine, Duke University, 8 Searle Center Drive, TSCHE 1074, Durham, NC, 27710, USA.
| | - Kathryn M Andolsek
- Department of Family Medicine and Community Health, School of Medicine, Duke University, Durham, NC, USA
| | | | - Apoorva Kandakatla
- Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Gloria Zhang
- School of Medicine, Duke University, Durham, NC, USA
| | - Meghan Price
- Department of Internal Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Sydney Jeffs
- Medical Scientist Training Program, School of Medicine, Duke University, Durham, NC, USA
| | | | - C Phifer Nicholson
- School of Medicine, Duke University, Durham, NC, USA
- Divinity School, Duke University, Durham, NC, USA
| | - Saumil M Chudgar
- Department of Medicine, School of Medicine, Duke University, Durham, NC, USA
| | - Aditee P Narayan
- Department of Pediatrics, School of Medicine, Duke University, Durham, NC, USA
| | - Nancy W Knudsen
- Department of Anesthesiology, School of Medicine, Duke University, Durham, NC, USA
| | - Melinda Blazar
- Department of Family Medicine and Community Health, School of Medicine, Duke University, Durham, NC, USA
- Duke Physician Assistant Program, School of Medicine, Duke University, Durham, NC, USA
| | | | - Edward G Buckley
- Department of Ophthalmology, School of Medicine, Duke University, Durham, NC, USA
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Wesevich A, Key-Solle M, Kandakatla A, Feeney C, Pollak KI, LeBlanc TW. Utilization of Text Messages to Supplement Rounding Communication: a Randomized Feasibility Study. J Gen Intern Med 2022; 37:2991-2997. [PMID: 35212877 PMCID: PMC9485328 DOI: 10.1007/s11606-021-07285-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Fragmented communication with patients and families during hospitalizations often leaves patients confused about the daily plan. OBJECTIVE To pilot a supplemental text message-based platform for improving bidirectional communication about the clinical plan and patients' goals. DESIGN Randomized controlled trial PARTICIPANTS: Thirty adult patients, thirty caregivers of pediatric patients, and the interns caring for them on inpatient general medicine and pediatric services. INTERVENTIONS Patients and caregivers were texted or emailed daily to report their personal goal and assess their understanding of the team's clinical plan. Interns were texted daily to report the team's clinical plan and to assess their understanding of the patient's personal goal. MAIN MEASURES Primary outcomes were feasibility, defined as survey response rates, and acceptability. Secondary outcomes were patient comprehension of the clinical plan, trainee comprehension of the patient's goal, patient-centered communication scores, and educational satisfaction scores. KEY RESULTS Thirty adult patients, thirty caregivers of pediatric patients, fourteen general medicine interns, and six general pediatric interns enrolled. Intervention feasibility was met, with survey response rates of 80% for general medicine trainees, 67% for general pediatric trainees, 58% for adult patients, and 70% for caregivers. Patients and caregivers in the intervention arm had higher understanding of medication changes (76% vs 50%, p = 0.02) and new consultations (90% vs 61%, p = 0.002). Interns had higher understanding of patients' goals in the intervention arm (93% vs 40%, p < 0.001), particularly for adult patients (97% vs 17%, p < 0.001). Caregivers rated communication higher regarding information to help make decisions (p = 0.04). Interviews demonstrated high acceptability. CONCLUSIONS Our text message-based communication intervention was feasible and acceptable to all involved participants, with preliminary signals of efficacy. The intervention may contribute to improved understanding of medication changes and new consultations, as well as help in making decisions. A large, randomized efficacy trial of this intervention is warranted. Graphical abstract.
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Affiliation(s)
- Austin Wesevich
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
- Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA.
| | - Mikelle Key-Solle
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | | | - Colby Feeney
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Kathryn I Pollak
- Cancer Prevention and Control, Duke Cancer Institute, Durham, NC, USA
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Smith P, Kandakatla A, Frankel CW, Bacon DR, Bush E, Mentz RJ, Snyder LD. Sleep quality, depressive symptoms, and transplant outcomes: Follow-up analyses from the ADAPT prospective pilot study. Gen Hosp Psychiatry 2021; 72:53-58. [PMID: 34298477 DOI: 10.1016/j.genhosppsych.2021.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 06/14/2021] [Accepted: 06/24/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Previous studies suggested that depressive symptoms and sleep quality may be important for long-term clinical outcomes following cardiothoracic transplant. Few studies, however, have systematically examined objective markers of these behavioral factors among ambulatory transplant recipients, or their association with clinical outcomes. METHODS We examined sleep quality and depressive symptoms with subsequent clinical outcomes (hospitalizations and death) in a sample of 66 lung or heart transplant recipients using a single-center, prospective cohort study. Recipients were assessed at approximately 6 months post-transplant and completed one week of actigraphy assessment to examine sleep quality and self-report measures of mood (Centers for Epidemiologic Studies of Depression [CESD]). Recipients were followed for clinical outcomes. RESULTS At 6-months following transplantation, recipients spent the majority of daytime activity at a sedentary level (61% of daily activity [SD = 10]) and elevated depressive symptoms were common (subclinical = 17%, mild = 12%, or moderate = 8%). Over a median follow-up of 4.5 years (IQR = 0.9, 5.1), 51 participants (77%) had at least one unplanned hospitalization and 11 (17%) participants died. In addition, sleep efficiency measurements suggested that a subset of participants exhibited suboptimal sleep (mean efficiency = 87% [SD = 7]). Poorer sleep quality, indexed by lower sleep efficiency and greater sleep fragmentation, was associated with greater depressive symptoms (r's = 0.37-0.50, P < .01). Better sleep quality at 6-months (HR = 0.75 [0.60, 0.95], P = .015), including sleep efficiency (HR = 0.74 [0.56, 0.99], P = .041) and sleep fragmentation (HR = 0.71 [0.53, 0.95], P = .020) were associated with lower risk of hospitalization or death. Compared with individuals without elevated depressive symptoms or sleep difficulties, individuals with either factor (HR = 1.72 [1.05, 2.81], P = .031) or both factors (HR = 2.37 [1.35, 4.18], P = .003) exhibited greater risk of clinical events in adjusted analyses. CONCLUSIONS Sleep quality is associated with depressive symptoms among cardiothoracic transplant recipients and enhances the prognostic association between biobehavioral risk factors and clinical outcomes.
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Affiliation(s)
- PatrickJ Smith
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, United States of America; Duke University Medical Center, Department of Medicine, Durham, NC, United States of America; Duke Clinical Research Institute, Durham, NC, United States of America.
| | - Apoorva Kandakatla
- Duke University Medical Center, Department of Medicine, Durham, NC, United States of America
| | - Courtney W Frankel
- Duke University Medical Center, Department of Medicine, Durham, NC, United States of America
| | - Daniel R Bacon
- University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, United States of America
| | - Erika Bush
- Duke University Medical Center, Department of Medicine, Durham, NC, United States of America
| | - Robert J Mentz
- Duke University Medical Center, Department of Medicine, Durham, NC, United States of America; Duke Clinical Research Institute, Durham, NC, United States of America
| | - Laurie D Snyder
- Duke University Medical Center, Department of Medicine, Durham, NC, United States of America; Duke Clinical Research Institute, Durham, NC, United States of America
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5
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Faust A, Kandakatla A, van der Merwe Y, Ren T, Huleihel L, Hussey G, Naranjo JD, Johnson S, Badylak S, Steketee M. Urinary bladder extracellular matrix hydrogels and matrix-bound vesicles differentially regulate central nervous system neuron viability and axon growth and branching. J Biomater Appl 2017; 31:1277-1295. [PMID: 28447547 DOI: 10.1177/0885328217698062] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Central nervous system neurons often degenerate after trauma due to the inflammatory innate immune response to injury, which can lead to neuronal cell death, scarring, and permanently lost neurologic function. Extracellular matrix bioscaffolds, derived by decellularizing healthy tissues, have been widely used in both preclinical and clinical studies to promote positive tissue remodeling, including neurogenesis, in numerous tissues, with extracellular matrix from homologous tissues often inducing more positive responses. Extracellular matrix hydrogels are liquid at room temperature and enable minimally invasive extracellular matrix injections into central nervous system tissues, before gelation at 37℃. However, few studies have analyzed how extracellular matrix hydrogels influence primary central nervous system neuron survival and growth, and whether central nervous system and non-central nervous system extracellular matrix specificity is critical to neuronal responses. Urinary bladder extracellular matrix hydrogels increase both primary hippocampal neuron survival and neurite growth to similar or even greater extents, suggesting extracellular matrix from non-homologous tissue sources, such as urinary bladder matrix-extracellular matrix, may be a more economical and safer alternative to developing central nervous system extracellular matrices for central nervous system applications. Additionally, we show matrix-bound vesicles derived from urinary bladder extracellular matrix are endocytosed by hippocampal neurons and positively regulate primary hippocampal neuron neurite growth. Matrix-bound vesicles carry protein and RNA cargos, including noncoding RNAs and miRNAs that map to the human genome and are known to regulate cellular processes. Thus, urinary bladder matrix-bound vesicles provide natural and transfectable cargoes which offer new experimental tools and therapeutic applications to study and treat central nervous system neuron injury.
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Affiliation(s)
- Anne Faust
- 1 Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,2 McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
| | - Apoorva Kandakatla
- 1 Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,2 McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
| | - Yolandi van der Merwe
- 1 Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,2 McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA.,3 Swanson School of Engineering, Department of Bioengineering University of Pittsburgh, Pittsburgh, PA, USA
| | - Tanchen Ren
- 1 Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,2 McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
| | - Luai Huleihel
- 2 McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA.,4 Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - George Hussey
- 2 McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA.,4 Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Juan Diego Naranjo
- 2 McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA.,4 Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott Johnson
- 2 McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA.,4 Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen Badylak
- 2 McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA.,4 Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Steketee
- 1 Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,2 McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA.,5 Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
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