Evaluation of the Elements of Short Hairpin RNAs in Developing shRNA-Containing CAR T Cells

Short hairpin RNAs (shRNAs) have emerged as a powerful tool for gene knockdown in various cellular systems, including chimeric antigen receptor (CAR) T cells. However, the elements of shRNAs that are crucial for their efficacy in developing shRNA-containing CAR T cells remain unclear. In this study, we evaluated the impact of different shRNA elements, including promoter strength, orientation, multiple shRNAs, self-targeting, and sense and antisense sequence composition on the knockdown efficiency of the target gene in CAR T cells. Our findings highlight the importance of considering multiple shRNAs and their orientation to achieve effective knockdown. Moreover, we demonstrate that using a strong promoter and avoiding self-targeting can enhance CAR T cell functionality. These results provide a framework for the rational design of CAR T cells with shRNA-mediated knockdown capabilities, which could improve the therapeutic efficacy of CAR T cell-based immunotherapy.

Coastal survey data for Perranporth Beach and Start Bay in southwest England (2006-2021)

Records of beach morphologic change and concurrent hydrodynamic forcing are needed to understand how coastlines in different environments change over time. This submission contains data for the period 2006 to 2021, for two contrasting macrotidal environments in southwest England: (i) cross-shore dominated, dissipative, sandy Perranporth Beach, Cornwall; and (ii) longshore-dominated, reflective gravel beaches within Start Bay, Devon. Data comprise monthly to annual beach profile surveys, annual merged topo-bathymetries, in addition to observed and numerically modelled wave and water levels. These data provide a valuable resource for modelling the behaviour of coastal types not covered by other currently available datasets.

Adolescent suicide assessment and management in primary care

Background

To understand how suicide management occurs within the primary care setting in terms of follow-up assessments and referral practices.

Methods

At an initial primary care visit, adolescents (aged 12–20 years old) completed electronic screening. Data were focused on youth who endorsed a suicidal risk item while completing screening at two Midwestern primary care clinics. Data were collected through retrospective chart reviews to analyze actions taken by the primary care physician at the youth’s initial visit and follow-up visit within the next 12 months.

Results

At initial visits 200 adolescents endorsed a suicidal risk item and 39 (19.5%) were considered to be concerning by their primary care physician. The average age was 14.7 years old (SD ± 2.0). Seventy-two percent (n = 144) were female, and 65% (n = 129) identified as Black. At initial visits, significant differences between suicidal concern groups were found in reporting active suicidal ideation, past suicide attempts, those who were referred to behavioral health counseling, and those who had a diagnosis of depression. Interestingly, only 13% (n = 25) of all patients who endorsed the suicide item were asked whether or not there were weapons in their home and primary care providers asked only 7% (n = 13) of all patients whether they had a safety plan.

Conclusions

There was inconsistent follow-up for adolescents with a history of suicide concerns. At this time, national guidelines do not exist regarding primary care follow-up of youth with suicide concerns. Guidelines are a necessary precursor for practice improvement.

Trial Registration

Clinical Trials Registry: NCT02244138. Registration date, September 1, 2014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03454-4.

Pre-clinical data supporting immunotherapy for HIV using CMV-HIV-specific CAR T cells with CMV vaccine

T cells engineered to express HIV-specific chimeric antigen receptors (CARs) represent a promising strategy to clear HIV-infected cells, but to date have not achieved clinical benefits. A likely hurdle is the limited T cell activation and persistence when HIV antigenemia is low, particularly during antiretroviral therapy (ART). To overcome this issue, we propose to use a cytomegalovirus (CMV) vaccine to stimulate CMV-specific T cells that express CARs directed against the HIV-1 envelope protein gp120. In this study, we use a GMP-compliant platform to engineer CMV-specific T cells to express a second-generation CAR derived from the N6 broadly neutralizing antibody, one of the broadest anti-gp120 neutralizing antibodies. These CMV-HIV CAR T cells exhibit dual effector functions upon in vitro stimulation through their endogenous CMV-specific T cell receptors or the introduced CARs. Using a humanized HIV mouse model, we show that CMV vaccination during ART accelerates CMV-HIV CAR T cell expansion in the peripheral blood and that higher numbers of CMV-HIV CAR T cells were associated with a better control of HIV viral load and fewer HIV antigen p24⁺ cells in the bone marrow upon ART interruption. Collectively, these data support the clinical development of CMV-HIV CAR T cells in combination with a CMV vaccine in HIV-infected individuals.

Diet drinks and dental caries among U.S. adults: cluster analysis

BACKGROUND

In recent years, the consumption of sugar sweetened beverages has been declining, while low calorie sweetener and diet beverage consumption is increasing. Evidence about the effect of diet drinks on dental caries is insufficient, and has not accounted for the complexity of beverage consumption patterns. Therefore, the aim of this study is to examine the association between consuming diet drinks and dental caries among US adults.

METHODS

We analyzed 2011-2014 NHANES dietary data of adults using cluster analysis, with individuals grouped based on their beverage consumption. Clusters were identified based on the R-square statistic and the local peak of the pseudo F statistic. Survey procedure and sample weights were used to account for the complex NHANES sampling design.

RESULTS

Four beverage consumption patterns were identified: "high soda", "high diet drinks", "high coffee/tea" and "high water". The "High soda" cluster was the only one associated with higher DMFT after controlling for confounders (β=1.02, 95% CI=0.42 - 1.63), whereas DT was associated with "high soda" (β=0.45, 95% CI=0.25 - 0.64) and "high coffee/tea" (β=0.24, 95% CI=0.01 - 0.47). On the other hand, the "high diet drinks" cluster was neither associated with DMFT (β=0.69, 95% CI=0.51 - -0.35) nor DT (β=0.07, 95% CI=-0.21 - 0.35).

CONCLUSION

Diet drinks consumption may not be associated with increased risk of dental caries. However, more studies should be conducted in order to confirm this finding.

Dental Erosion: Effect of Diet Drink Consumption on Permanent Dentition

OBJECTIVE

The aim of this study is to examine the effect of diet drinks on dental erosion among a representative sample of US adults.

METHODS

Adult dietary and dental data were analyzed from the 2003-2004 cycle of the National Health and Nutrition Examination Survey. Erosion was measured with a modified tooth wear index and was analyzed as a dichotomous variable. Cluster analysis was performed, and the cluster number was based on having a separate diet drink cluster and the R² values. Survey procedure and sample weights were used.

RESULTS

Most of the population (80%) had some form of dental erosive lesions. When compared with the total sample, people with erosion were more likely to be male (52.5%) and older. People with no erosive lesions were younger (42.3%) and non-Hispanic Black (21.2%). Cluster analysis resulted in 4 distinct clusters: high water, high diet drinks, high coffee/tea, and high soda. The respective percentage of individuals in each cluster who had erosion was 78.9%, 85%, 83.9%, and 76.2%, where the "high diet drinks" cluster showed the highest erosion (P = 0.28). Logistic regression modeling showed that the "high diet drinks" cluster had increased odds of erosion (odds ratio = 1.27; 95% CI = 0.58 to 2.77) when compared with the "high water" cluster, but the relationship was not statistically significant.

CONCLUSION

High diet drinks consumption slightly increased the odds of dental erosion among US adults, although this relationship was not statistically significant. It is thus not yet clear that dentists should recommend diet drinks, as they might be linked to systemic diseases. Further research is needed to explore more about risk factors of erosion.

KNOWLEDGE TRANSFER STATEMENT

The findings of this study are suggestive, though not significantly, that diet drinks may increase risk for dental erosion. While further research is needed, it is not clear that dentists should recommend these drinks as healthy substitutes for sugary drinks.

Role of Atmospheric Indices in Describing Inshore Directional Wave Climate in the United Kingdom and Ireland

Improved understanding of how our coasts will evolve over a range of time scales (years-decades) is critical for effective and sustainable management of coastal infrastructure. A robust knowledge of the spatial, directional and temporal variability of the inshore wave climate is required to predict future coastal evolution and hence vulnerability. However, the variability of the inshore directional wave climate has received little attention, and an improved understanding could drive development of skillful seasonal or decadal forecasts of coastal response. We examine inshore wave climate at 63 locations throughout the United Kingdom and Ireland (1980-2017) and show that 73% are directionally bimodal. We find that winter-averaged expressions of six leading atmospheric indices are strongly correlated (r = 0.60-0.87) with both total and directional winter wave power (peak spectral wave direction) at all studied sites. Regional inshore wave climate classification through hierarchical cluster analysis and stepwise multi-linear regression of directional wave correlations with atmospheric indices defined four spatially coherent regions. We show that combinations of indices have significant skill in predicting directional wave climates (R 2  = 0.45-0.8; p < 0.05). We demonstrate for the first time the significant explanatory power of leading winter-averaged atmospheric indices for directional wave climates, and show that leading seasonal forecasts of the NAO skillfully predict wave climate in some regions.

Mesenchymal Stem Cell exosome delivered Zinc Finger Protein activation of cystic fibrosis transmembrane conductance regulator

Cystic fibrosis is a genetic disorder that results in a multi-organ disease with progressive respiratory decline which leads to premature death. Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene disrupts the capacity of the protein to function as a channel, transporting chloride ions and bicarbonate across epithelial cell membranes. Small molecule treatments targeted at potentiating or correcting CFTR have shown clinical benefits, but are only effective for a small percentage of individuals with specific CFTR mutations. To overcome this limitation, we engineered stromal-derived mesenchymal stem cells (MSC) and HEK293 cells to produce exosomes containing a novel CFTR Zinc Finger Protein fusion with transcriptional activation domains VP64, P65 and Rta to target the CFTR promoter (CFZF-VPR) and activate transcription. Treatment with CFZF-VPR results in robust activation of CFTR transcription in patient derived Human Bronchial Epithelial cells (HuBEC). We also find that CFZF-VPR can be packaged into MSC and HEK293 cell exosomes and delivered to HuBEC cells to potently activate CFTR expression. Connexin 43 appeared to be required for functional release of CFZF-VPR from exosomes. The observations presented here demonstrate that MSC derived exosomes can be used to deliver a packaged zinc finger activator to target cells and activate CFTR. The novel approach presented here offers a next-generation genetic therapy that may one day prove effective in treating patients afflicted with Cystic fibrosis.

Conditionally Replicating Vectors Mobilize Chimeric Antigen Receptors against HIV

Human immunodeficiency virus (HIV) is an attractive target for chimeric antigen receptor (CAR) therapy. CAR T cells have proved remarkably potent in targeted killing of cancer cells, and we surmised that CAR T cells could prove useful in eradicating HIV-infected cells. Toward this goal, we interrogate several neutralizing single-chain variable fragments (scFvs) that target different regions of the HIV envelope glycoprotein, gp120. We find here that CAR T cells with scFv from NIH45-46 antibody demonstrated the highest cytotoxicity. Although NIH45-46 CAR T cells are capable of eliminating antigen-expressing cells, we wanted to address HIV reactivation from ex vivo culture of HIV patient-derived CAR T cells. In order to capitalize on the HIV reactivation, we developed a conditionally replicating lentiviral vector (crLV). The crLV can hijack HIV machinery, forming a chimeric lentivirus (LV) instead of HIV and delivered to uninfected cells. We find that CAR T cells generated with crLVs have similar CAR-mediated functionality as traditional CARs. We also demonstrate crLVs' capability of expanding CAR percentage and protecting CD4 CAR T cell in HIV donors. Collectively, we demonstrate here that the novel crLV NIH45-46 CAR can serve as a strategy to combat HIV, as well as overcome HIV reactivation in CD4⁺ CAR T cells.

A-09 The Relationship Between Subjective Cognitive Complaints, Depression, and Executive Functioning in mTBI Veterans

Objective

Among individuals with mild traumatic brain injury (mTBI), those with depression report greater subjective cognitive complaints than those without depression. In mTBI patients with general cognitive complaints, depression may account for poor performance on objective neuropsychological measures. This study seeks to expand this research by examining depression, subjective executive functioning (EF) complaints, and objective EF performance in Veterans with mTBI.

Method

Fifty-seven Veterans with deployment-related mTBI (12% female; age M = 42.0, SD = 13.6; years education M = 15.0, SD = 1.8) with (n = 29) or without (n = 28) a chart diagnosis of depression. Participants were administered the Behavioral Rating Inventory of Executive Functioning (BRIEF) and objective neuropsychological measures of working memory (i.e., Weschler Adult Intelligence Scale-IV Working Memory Index) and aspects of EF (i.e., Trail Making Test B and Delis-Kaplan Executive Functioning System (D-KEFS) subtests).

Results

Principal component analysis identified similar domains of EF to the BRIEF, including: task monitoring (Trail Making Test B, D-KEFS Letter Fluency, and D-KEFS Tower Test, eigenvalue = 1.93) and shifting (D-KEFS: Color-Word Interference Conditions 3 and 4, and Category Switching, eigenvalue = 1.24). Individuals with depression had greater subjective EF complaints in each BRIEF domain than non-depressed individuals (p’s ≤ .01). However, subjective complaints in these domains were not related to objective performance (r’s = −0.17,-0.19, p’s &gt; .05). Moreover, depressed and non-depressed individuals performed similarly on all EF measures (p’s &gt; .05).

Conclusions

mTBI Veterans with depression report more subjective EF complaints than those without depression. The lack of association between subjective complaints and objective EF performance suggests it is important to treat depression in mTBI patients to remedy perceived cognitive deficits.

Development of a Facile Approach for Generating Chemically Modified CRISPR/Cas9 RNA

The RNA-guided, modified type II prokaryotic CRISPR with CRISPR-associated proteins (CRISPR/Cas9) system represents a simple gene-editing platform with applications in biotechnology and also potentially as a therapeutic modality. The system requires a small guide RNA (sgRNA) and a catalytic Cas9 protein to induce non-homologous end joining (NHEJ) at break sites, resulting in the formation of inactivating mutations, or through homology-directed repair (HDR) can engineer in specific sequence changes. Although CRISPR/Cas9 is a powerful technology, the effects can be limited as a result of nuclease-mediated degradation of the RNA components. Significant research has focused on the solid-phase synthesis of CRISPR RNA components with chemically modified bases, but this approach is technically challenging and expensive. Development of a simple, generic approach to generate chemically modified CRISPR RNAs may broaden applications that require nuclease-resistant CRISPR components. We report here the development of a novel, functional U-replaced trans-activating RNA (tracrRNA) that can be in vitro transcribed with chemically stabilizing 2'-fluoro (2'F)-pyrimidines. These data represent a unique and facile approach to generating chemically stabilized CRISPR RNA.

AutoMicrobic System for Biochemical Identification of Listeria Species Isolated From Foods: Collaborative Study

A collaborative study was conducted to evaluate the performance of the AutoMicrobic System Gram- Positive Identification (GPI) and Gram-Negative Identification (GNI) test kits to biochemically characterize Listeria spp. Thirteen laboratories each tested 97 food and environmental isolates, representing the 7 species of Listeria, as well as 11 additional genera of Gram-positive rods. Each collaborator inoculated both a GPI and a GNI card with a pure culture of each organism. The AutoMicrobic System identified the isolates and printed out the biochemical results. The GPI card is used to obtain a species identification and a mannitol reaction result, and the GNI card is used to obtain rhamnose and xylose reaction results. Organisms are classified into species groups and can be further distinguished on the basis of hemolysis or nitrate reduction tests. The AutoMicrobic System method correctly classified 90.8% of the Listeria spp. isolates and 100% of the non-Listeria isolates. The AutoMicrobic System method was adopted first action by AOAC International for the biochemical characterization of Listeria spp. isolated from food and environmental sources.

Improved Cas9 activity by specific modifications of the tracrRNA

CRISPR/Cas is a transformative gene editing tool, that offers a simple and effective way to target a catalytic Cas9, the most widely used is derived from Streptococcus pyogenes (SpCas9), with a complementary small guide RNA (sgRNA) to inactivate endogenous genes resulting from insertions and deletions (indels). CRISPR/Cas9 has been rapidly applied to basic research as well as expanded for potential clinical applications. Utilization of spCas9 as an ribonuclearprotein complex (RNP) is considered the most safe and effective method to apply Cas9 technology, and the efficacy of this system is critically dependent on the ability of Cas9 to generate high levels of indels. We find here that novel sequence changes to the tracrRNA significantly improves Cas9 activity when delivered as an RNP. We demonstrate that a dual-guide RNA (dgRNA) with a modified tracrRNA can improve reporter knockdown and indel formation at several targets within the long terminal repeat (LTR) of HIV. Furthermore, the sequence-modified tracrRNAs improved Cas9-mediated reduction of CCR5 surface receptor expression in cell lines, which correlated with higher levels of indel formation. It was demonstrated that a Cas9 RNP with a sequence modified tracrRNA enhanced indel formation at the CCR5 target site in primary CD4+ T-cells. Finally, we show improved activity at two additional targets within the HBB locus and the BCL11A GATA site. Overall, the data presented here suggests that novel facile tracrRNA sequence changes could potentially be integrated with current dgRNA technology, and open up the possibility for the development of sequence modified tracrRNAs to improve Cas9 RNP activity.

Targeted Activation of Cystic Fibrosis Transmembrane Conductance Regulator

Cystic fibrosis (CF) is caused by mutations in the CF transmembrane conductance regulator (CFTR) gene. The majority of CFTR mutations result in impaired chloride channel function as only a fraction of the mutated CFTR reaches the plasma membrane. The development of a therapeutic approach that facilitates increased cell-surface expression of CFTR could prove clinically relevant. Here, we evaluate and contrast two molecular approaches to activate CFTR expression. We find that an RNA-guided nuclease null Cas9 (dCas9) fused with a tripartite activator, VP64-p65-Rta can activate endogenous CFTR in cultured human nasal epithelial cells from CF patients. We also find that targeting BGas, a long non-coding RNA involved in transcriptionally modulating CFTR expression with a gapmer, induced both strong knockdown of BGas and concordant activation of CFTR. Notably, the gapmer can be delivered to target cells when generated as electrostatic particles with recombinant HIV-Tat cell penetrating peptide (CPP), when packaged into exosomes, or when loaded into lipid nanoparticles (LNPs). Treatment of patient-derived human nasal epithelial cells containing F508del with gapmer-CPP, gapmer-exosomes, or LNPs resulted in increased expression and function of CFTR. Collectively, these observations suggest that CRISPR/dCas-VPR (CRISPR) and BGas-gapmer approaches can target and specifically activate CFTR.

The Role of Quality of Education in Neurocognitive Functioning in a Diverse Sample with Chronic Opioid Use Disorder

Objective

Literacy is a proxy for quality of education (QoE) and mediates ethnicity-related differences in neurocognitive (NC) performance in some populations (Manly et al., 2002; Rivera Mindt et al., 2008). However, it is unknown whether this relationship exists in the context of chronic opioid use disorder (OUD). This study examined the role of ethnicity, QoE, opioid use severity, and depression in predicting NC performance in a diverse sample of persons with OUD.

Participants and Method

This cross-sectional study included 74 adults with OUD (Age M = 40.3 [SD = 10.5]; Education M = 11.3 [2.5]; 24% female; 68% Latinx and 32% Non-Latinx White [NLW]). All participants completed comprehensive NC testing and psychiatric/substance use questionnaires. Variables included ethnicity (Latinx vs. Non-Latinx White), years of education, QoE (Wide Range Achievement Test, Third Edition; WRAT-3 Reading Standard Scores), opioid use severity (high vs. low OAT dose), current depression (Beck Depression Inventory, Second Edition; BDI-II Total Score), and demographically-corrected NC T-scores were computed and used for average domain T-scores (e.g., learning, memory, verbal fluency, executive function). Bivariate and ANCOVA analyses were used to compare ethnic groups.

Results

There were no significant group differences on opioid use severity or current depression (p’s &gt; .05). However, compared to the NLW group, the Latinx group had lower years of education (M = 10.9 [SD = 1.7] vs. M = 12.2 [SD = 3.5]; t[72)] = 2.1, p &lt; .05), QoE (M = 83.1 [SD = 13.6] vs. M = 94.8 [SD = 9.4]; t[72] = 3.8, p &lt; .001), executive functioning (M = 42.0 [SD = 6.5] vs. M = 45.8 [SD = 8.5]; t[72) = 2.1, p &lt; .05), and learning (M = 32.2 [SD = 8.2] vs. M = 37.8 [SD = 8.7]; t[72)] = 2.7, p &lt; .05), with medium to large effect sizes (Cohen’s d &gt; .50). The overall effect of ethnicity became non-significant for executive functioning after accounting for QoE (F[2,70] = 10.0, p = .002) and years of education (F[2,70)] = 16.8, p &lt; .001).

Conclusions

The current study found that accounting for years of education and QoE attenuates some differences in NC performance between Latinx and Non-Latinx participants.

References

Manly, J. J., Jacobs, D. M., Touradji, P., Small, S. A., & Stern, Y. (2002). Reading level attenuates differences in neuropsychological test performance between African American and White elders. Journal of the International Neuropsychological Society, 8(3), 341-348. Mindt, M. R., Arentoft, A., Germano, K. K., D’Aquila, E., Scheiner, D., Pizzirusso, M., ... & Gollan, T. H. (2008). Neuropsychological, cognitive, and theoretical considerations for evaluation of bilingual individuals. Neuropsychology review, 18(3), 255-268.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Factors associated with health-related quality of life, hip function, and health utility after operative management of femoral neck fractures

Aims

The primary aim of this prognostic study was to identify baseline factors associated with physical health-related quality of life (HRQL) in patients after a femoral neck fracture. The secondary aims were to identify baseline factors associated with mental HRQL, hip function, and health utility.

Patients and Methods

Patients who were enrolled in the Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH) trial completed the 12-item Short Form Health Survey (SF-12), Western Ontario and McMaster Universities Arthritis Index, and EuroQol 5-Dimension at regular intervals for 24 months. We conducted multilevel mixed models to identify factors potentially associated with HRQL.

Results

The following were associated with lower physical HRQL: older age (-1.42 for every ten-year increase, 95% confidence interval (CI) -2.17 to -0.67, p < 0.001); female gender (-1.52, 95% CI -3.00 to -0.05, p = 0.04); higher body mass index (-0.69 for every five-point increase, 95% CI -1.36 to -0.02, p = 0.04); American Society of Anesthesiologists class III ( versus class I) (-3.19, 95% CI -5.73 to -0.66, p = 0.01); and sustaining a displaced fracture (-2.18, 95% CI -3.88 to -0.49, p = 0.01). Additional factors were associated with mental HRQL, hip function, and health utility.

Conclusion

We identified several baseline factors associated with lower HRQL, hip function, and utility after a femoral neck fracture. These findings may be used by clinicians to inform treatment and outcomes. Cite this article: Bone Joint J 2018;100-B:361-9.

Don't ask me what's the matter, ask me what matters: Acute mental health facility experiences of people living with autism spectrum conditions

WHAT IS KNOWN ON THE SUBJECT?: There is a growing body of evidence that many people with an autism spectrum condition suffer anxiety in their daily life and a realization among practitioners that admission to a mental health unit for this population is usually a negative anxiety-inducing experience. Anxiety is driven by the intolerance of uncertainty that is being unsure of what is going to happen, how long the uncertainty will exist and the insistence of sameness which, when compromised, can be anxiety provoking. Equally, confusion in understanding personal emotional responses and those of others is a source of anxiety. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper builds upon existing understanding of anxiety as a causative factor of mental ill-health for people with an autism spectrum condition. Specifically, this paper explores the potentially anxiety-inducing experience of mental health unit admission; how anxiety is felt, triggered, expressed and managed. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: As many different anxiety responses could be exhibited during hospitalization, including violent acts and self-harming, for mental health practitioners working in the inpatient units, it is essential that the thoughts, feelings and responses of the patient with an autistic spectrum condition (ASC) are better understood and that support offered during their stay in a mental health facility is from an informed position.

ABSTRACT

Background This qualitative study explored how mental health inpatients with autistic spectrum conditions (ASCs) experience and cope with anxiety when admitted to an acute mental health inpatient facility in the United Kingdom. Anxiety is a common characteristic for people who live with ASCs and whilst a plethora of studies on anxiety in this population is published which correlate anxiety with mental health service experience, little is known about the actual triggers of anxiety and its manifestations. This study adds to a body of evidence which considers anxiety experienced by people with autism. The rationale for this study includes the need to heighten mental health practitioners' understanding, of the responses, motivations to engage and support required to overcome fears and anxieties when admitted to a mental health inpatient unit. Method The study used a qualitative naturalistic research design, to explore the emotional and psychological experiences of being a mental health inpatient living with an ASC. During 2015-2017. audio-recorded semistructured interviews captured the experiences of 20 adults from the east of England who were former psychiatric inpatients with an established diagnosis of ASC. Interpretative phenomenological analysis enabled the identification of broad themes which explained in rich detail, participant reflections regarding the situations and events within the acute care mental health facility that triggered their anxiety, manifestations of anxiety and responses to their anxiety. Findings Broad response patterns were identified that could be associated with their anxiety that is isolating themselves from others, including patients and staff, ceasing to eat and sleep adequately and all too often self-harming or exhibiting aggressive and violent responses. Conclusions The anxiety caused by the physical environment appears to be overlooked by mental health practitioners so attention to anxiety-inducing encounters is needed when planning acute care mental health service improvement and research is required to clearly understand the experiences of this vulnerable group.

Advances with using CRISPR/Cas-mediated gene editing to treat infections with hepatitis B virus and hepatitis C virus

Chronic infections with hepatitis B and hepatitis C viruses (HBV and HCV) account for the majority of cases of cirrhosis and hepatocellular carcinoma. Current therapies for the infections have limitations and improved efficacy is necessary to prevent complications in carriers of the viruses. In the case of HBV persistence, the replication intermediate comprising covalently closed circular DNA (cccDNA) is particularly problematic. Licensed therapies have little effect on cccDNA and HBV replication relapses following treatment withdrawal. Disabling cccDNA is thus key to curing HBV infections and application of gene editing technology, such as harnessing the clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated 9 (Cas9) system, has curative potential. Several studies have reported good efficacy when employing CRISPR/Cas technologies to disable HBV replication in cultured cells and in hydrodynamically injected mice. Recent advances with HCV drug development have revolutionized treatment of the infection. Nevertheless, individuals may be refractory to treatment. Targeting RNA from HCV with CRISPR/Cas isolated from Francisella novicida may have therapeutic utility. Although preclinical work shows that CRISPR/Cas technology has potential to overcome infection with HBV and HCV, significant challenges need to be met. Ensuring specificity for viral targets and efficient delivery of the gene editing sequences to virus-infected cells are particularly important. The field is at an interesting stage and the future of curative antiviral drug regimens, particularly for treatment of chronic HBV infection, may well entail use of combinations that include derivatives of CRISPR/Cas.

REBOA at Role 2 Afloat: resuscitative endovascular balloon occlusion of the aorta as a bridge to damage control surgery in the military maritime setting

Role 2 Afloat provides a damage control resuscitation and surgery facility in support of maritime, littoral and aviation operations. Resuscitative endovascular balloon occlusion of the aorta (REBOA) offers a rapid, effective solution to exsanguinating haemorrhage from pelvic and non-compressible torso haemorrhage. It should be considered when the patient presents in a peri-arrest state, if surgery is likely to be delayed, or where the single operating table is occupied by another case. This paper will outline the data in support of endovascular haemorrhage control, describe the technique and explore how REBOA could be delivered using equipment currently available in the Royal Navy Role 2 Afloat equipment module. Also discussed are potential future directions in endovascular resuscitation.

ssAAVs containing cassettes encoding SaCas9 and guides targeting hepatitis B virus inactivate replication of the virus in cultured cells

Management of infection with hepatitis B virus (HBV) remains a global health problem. Persistence of stable covalently closed circular DNA (cccDNA) during HBV replication is responsible for modest curative efficacy of currently licensed drugs. Novel gene editing technologies, such as those based on CRISPR/Cas9, provide the means for permanently disabling cccDNA. However, efficient delivery of antiviral sequences to infected hepatocytes is challenging. A limiting factor is the large size of sequences encoding Cas9 from Streptococcus pyogenes, and resultant incompatibility with the popular single stranded adeno-associated viral vectors (ssAAVs). We thus explored the utility of ssAAVs for delivery of engineered CRISPR/Cas9 of Staphylococcus aureus (Sa), which is encoded by shorter DNA sequences. Short guide RNAs (sgRNAs) were designed with cognates in the S open reading frame of HBV and incorporated into AAVs that also encoded SaCas9. Intended targeted mutation of HBV DNA was observed after transduction of cells with the all-in-one vectors. Efficacy against HBV-infected hNTCP-HepG2 cells indicated that inactivation of cccDNA was successful. Analysis of likely off-target mutagenesis revealed no unintended sequence changes. Use of ssAAVs to deliver all components required to disable cccDNA by SaCas9 is novel and the technology has curative potential for HBV infection.

Lipopolysaccharide induced Interleukin-6 production is mediated through activation of ERK 1/2, p38 MAPK, MEK, and NFκB in chicken thrombocytes

Thrombocytes express Toll-like receptor 4 and apparently use both mitogen-activated protein kinase (MAPK) and nuclear factor kappa-light-chain-enhancer of activated B cells (NFKB) pathways for nuclear signaling. However, it is not well known if the same enzyme systems found in mammalian cells are fully functional in chickens. Therefore, kinase inhibitors were used with thrombocytes to block kinases in lipopolysaccharide (LPS) stimulated cells to determine if interleukin (IL)-6 expression and production would be diminished. Results demonstrated that extracellular-signal-regulated kinase (ERK)1/2 and p38 MAPK pathways influence gene expression of IL-6 through treatment with either ERK or p38 MAPK inhibitor. In addition, thrombocyte lysates from cells treated with ERK, p38, mitogen-activated protein kinase kinase (MEK)1/2 and inhibitor of nuclear factor kappa-B kinase (IKK) inhibitor showed different levels of the phosphorylated form of ERK1/2, p38 and NFκB. Furthermore, IL-6 gene expression and production were significantly upregulated in LPS stimulated thrombocytes relative to all inhibitor-treated cells.

Human factors in contingency operations

The UK Defence Medical Services are currently supporting contingency operations following a period of intensive activity in relatively mature trauma systems in Iraq and Afghanistan. Among the key lessons identified, human factors or non-technical skills played an important role in the improvement of patient care. This article describes the importance of human factors on Role 2 Afloat, one of the Royal Navy's maritime contingency capabilities, and illustrates how they are vital to ensuring that correct decisions are made for patient care in a timely manner. Teamwork and communication are particularly important to ensure that limited resources such as blood products and other consumables are best used and that patients are evacuated promptly, allowing the facility to accept further casualties and therefore maintain operational capability. These ideas may be transferred to any small specialist team given a particular role to perform.

Rapid sequence induction

Emergency tracheal intubation undertaken by Rapid sequence induction (RSI) is a fundamental component of military anaesthesia. This common emergency procedure has evolved in both civilian and military practice, since it was first described, as new drugs have become available. Current practice now differs significantly from that undertaken by the procedure’s initial advocates. This is particularly the case in the deployed military environment. As military medicine continues to improve injury survivability, RSI will be undertaken in increasingly unstable casualties, requiring a bespoke emergency induction not commonly practised in the civilian setting.

Bacterial and viral induction of chicken thrombocyte inflammatory responses

Thrombocytes express Toll-like receptors (TLRs) that detect bacterial or viral pathogens to signal the release of cytokines and mediators. We examined inflammatory responses when thrombocytes were exposed to four TLR ligands. Treatment of thrombocytes with TLR ligands demonstrates differential effects on gene expression of interleukin (IL)-6. Among the TLR ligands examined, lipopolysaccharide stimulation led to the most significant up-regulation of the IL-6 gene and a significant amount of active IL-6 in thrombocyte culture media. Lipoteichoic acid stimulation led to only marginal up-regulation of IL-6 gene expression. Although gene expression of inducible nitric oxide synthase (iNOS) did not increase due to different ligand exposure, a low level constitutive expression of iNOS was observed in all cases. Only thrombocytes treated with polyinosinic-polycytidylic acid and thymidine homopolymer phosphorothioate oligodeoxynucleotides induced rapid, significant production of nitric oxide. We also observed that thrombocytes are able to respond faster upon TLR ligand exposure compared to MQ.NCSU macrophages.

Management of young femoral neck fractures: is there a consensus?

BACKGROUND

Femoral neck fractures in young adults (ages <60) are high-energy injuries that are associated with major fracture healing complications such as avascular necrosis, nonunion, and significant shortening. Historically, evidence from small trials has suggested multiple cannulated screws were the optimal implant; however, newer studies and implant designs warrant reevaluation of screws as the gold standard among surgeons. In addition, controversies surrounding reduction technique and urgency of surgical fixation have been previously identified. We aimed to survey surgeon treatment preferences for these challenging fractures.

METHODS

A 17-item survey was developed and tested for validity and reliability prior to administration. The questionnaire characterised surgeon demographics, treatment preferences for displaced and undisplaced fractures, and controversies for future clinical trials. The target population consisted of surgeons from the Canadian Orthopaedic Association, the Orthopaedic Trauma Association, and attendees at an international fracture course.

RESULTS

540 surgeons completed the survey, exceeding our sample size requirement. There was a similar proportion of respondents from academic and community hospitals. Most surgeons (61%) treat 1-5 young adult femoral neck fractures per year. For undisplaced fractures, 78% of respondents prefer to use multiple cannulated screws. For displaced fractures, equal preference for multiple screws (46%) and the sliding hip screw (SHS, 49%) was reported. The majority of surgeons perform an open reduction in less than 25% of cases, and the time to fixation was typically between 8 and 24h.

CONCLUSIONS

Multiple cannulated screws remain the preferred treatment for most surgeons treating undisplaced fractures; however, there is an equal divide in preference between multiple screws and the SHS for displaced fractures. This increased preference for the SHS contradicts previous survey and small trial data recommending multiple screws for all fracture patterns. The lack of surgeon consensus and the high rates of fracture complications associated with fixation of young femoral neck fractures supports the need for definitive clinical trials to optimise patient important outcomes.

Complications following young femoral neck fractures

BACKGROUND

Femoral neck fractures in patients 60 years of age or younger are challenging injuries to treat because of the high-energy trauma mechanisms and the displaced fracture patterns typically found in this patient population. Understanding the burden of disease is an important first step in addressing treatment controversies in this population. The purpose of the current study is to quantitatively pool the incidence of patient important complications following internal fixation of young femoral neck fractures.

METHODS

A comprehensive search of the Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, and Central databases was completed under the direction of a biomedical librarian. Multiple outcomes of interest (complications) were collected and included: reoperation, femoral head avascular necrosis, fracture non-union, infection, implant failure, and malunion.

RESULTS

1558 fractures from 41 studies were included in the meta-analysis. An18.0% pooled reoperation incidence was observed for isolated femoral neck fractures. The total pooled incidence of avascular necrosis (AVN) was 14.3%, and the total incidence of nonunion was 9.3%. When stratified for fracture displacement displaced fractures were more likely to undergo reoperation and to result in AVN or non-union. The total incidence of malunion was 7.1%, implant failure was 9.7%, and surgical site infection was 5.1%. Complications associated with a femoral neck fracture treated in conjunction with an ipsilateral femoral shaft fracture were lower overall than the pooled estimates for isolated neck fractures.

CONCLUSIONS

The results of our analysis demonstrate that the incidence of complications experienced by young femoral neck fracture patients is relatively high. Reoperation following internal fixation of isolated femoral neck fractures occurred in nearly 20% of cases, and AVN and nonunion were the most common complications that likely contributed to repeat surgeries. These results highlight the importance of further efforts to improve the clinical outcomes in this population.

'Vitamin D and cognition in older adults': updated international recommendations

BACKGROUND

Hypovitaminosis D, a condition that is highly prevalent in older adults aged 65 years and above, is associated with brain changes and dementia. Given the rapidly accumulating and complex contribution of the literature in the field of vitamin D and cognition, clear guidance is needed for researchers and clinicians.

METHODS

International experts met at an invitational summit on 'Vitamin D and Cognition in Older Adults'. Based on previous reports and expert opinion, the task force focused on key questions relating to the role of vitamin D in Alzheimer's disease and related disorders. Each question was discussed and voted using a Delphi-like approach.

RESULTS

The experts reached an agreement that hypovitaminosis D increases the risk of cognitive decline and dementia in older adults and may alter the clinical presentation as a consequence of related comorbidities; however, at present, vitamin D level should not be used as a diagnostic or prognostic biomarker of Alzheimer's disease due to lack of specificity and insufficient evidence. This population should be screened for hypovitaminosis D because of its high prevalence and should receive supplementation, if necessary; but this advice was not specific to cognition. During the debate, the possibility of 'critical periods' during which vitamin D may have its greatest impact on the brain was addressed; whether hypovitaminosis D influences cognition actively through deleterious effects and/or passively by loss of neuroprotection was also considered.

CONCLUSIONS

The international task force agreed on five overarching principles related to vitamin D and cognition in older adults. Several areas of uncertainty remain, and it will be necessary to revise the proposed recommendations as new findings become available.