Tumor MHC class I expression alters cancer-associated myelopoiesis driven by host NK cells

Downregulation of MHC class I (MHCI) molecules on tumor cells is recognized as a resistance mechanism of cancer immunotherapy. Given that MHCI molecules are potent regulators of immune responses, we postulated that the expression of MHCI by tumor cells influences systemic immune responses. Accordingly, mice-bearing MHCI-deficient tumor cells showed reduced tumor-associated extramedullary myelopoiesis in the spleen. Depletion of natural killer (NK) cells abrogated these differences, suggesting an integral role of immune-regulatory NK cells during tumor progression. Cytokine-profiling revealed an upregulation of TNF-α by NK cells in tumors and spleen in mice-bearing MHCI expressing tumors, and inhibition of TNF-α enhanced host myelopoiesis in mice receiving adoptive transfer of tumor-experienced NK cells. Our study highlights a critical role of NK cells beyond its identity as a killer lymphocyte and more importantly, the potential host responses to a localized tumor as determined by its MHCI expression.

Temporal trends in end-stage renal disease in patients with heart failure with or without diabetes: a nationwide study from 2002 to 2017

Background

Advances in treatment of heart failure (HF) have increased survival rates. However, whether the improved life expectancy for HF patients has resulted in an increased risk of a significant comorbidity like end-stage renal disease (ESRD) is less clear. Renal dysfunction is associated with increased morbidity and mortality in HF and constitutes an important prognostic factor for HF. Further, diabetes (DM) is closely related to both HF and ESRD, but it is unknown how DM affects the risk of ESRD in patients with HF.

Purpose

To investigate temporal trends in ESRD in patients with HF and the subsequent risk of mortality stratified by DM.

Methods

Using Danish nationwide registies, we identified patients, aged 18 to 100 years, with incident HF between 2002 and 2017. The outcomes were ESRD (defined as dialysis treatment), worsening of HF (wHF, defined as rehospitalization for HF) and all-cause mortality. Three study periods were investigated 2002–2006, 2007–2011 and 2012–2017. We estimated crude 5-year incidence rates (per 1000/person-years) of the outcomes stratified by DM. Multivariate Cox regression models were performed for all outcomes stratified by DM. Further, we computed the 1-year all-cause mortality risk after diagnosis with ESRD.

Results

Of 124,141 patients with HF, 50,690 (41%) were women and the median age was 74.5 years [95% confidence interval (CI) 64.5–82.8]. At baseline DM was present in 20% of the patients. These patients were older, more often men and more comorbid than HF patients without DM. Over time (2002–2006 to 2012–2017) the incidence rates of ESRD (9.0 to 7.9 and 2.1 to 1.9 per 1000/person-years for DM and no-DM, respectively) and wHF (124.0 to 124.8 and 84.3 to 81.9 per 1000/person-years for DM and no-DM) remained stable, while all-cause mortality rates decreased (217.0 to 170.3 and 172.9 to 127.8 per 1000/person-years for DM and no-DM). The incidence of ESRD was lower compared with the incidence of wHF and all-cause mortality [Figure 1]. HF patients with DM had significantly higher associated rates of all three outcomes (in 2012–2017 the rates for DM vs no-DM of ESRD: 3.99 [3.27–4.86], wHF: 1.42 [1.36–1.49], all-cause mortality: 1.36 [1.31–1.41]) compared with patients without DM. We found no significant interaction between time period and DM on the rates of outcomes (p>0.05 for all) [Figure 2]. One-year all-cause mortality risk after diagnosis with ESRD was high both for HF patients with and without DM through all time periods (identical risks and 95% CI in 2012–2017: 32% [0.25–0.39]).

Conclusions

We did not observe a change over time in the 5-year risk of ESRD for HF patients. The incidence of ESRD remained low compared to wHF and all-cause mortality. DM was associated with increased rates of all three events, not changed over time. Conversely, all-cause mortality after diagnosis with ESRD was markedly high, irrespectively of DM. Our analyses suggest that ESRD is a less common, but fatal event in HF patients.

Funding Acknowledgement

Type of funding sources: None.

Temporal trends in infection-related hospitalizations in patients with heart failure: a nationwide study from 1997 to 2017

Background

Over the last 20 years mortality has decreased for patients with heart failure (HF). However, re-hospitalization for HF is still a challenge. Further, whether the improved survival has resulted in increased rates of non HF hospitalization is unknown.

Purpose

This study examined the temporal trends in infection-related hospitalizations among new-onset HF patients and compared it to temporal trends in risk of worsening HF and death.

Methods

The study population included all Danish patients aged between 18 and 100 years old, with new-onset HF (defined according to the ICD10-code system) diagnosed between 1st January 1997 and 31st December 2017. Patients who were diagnosed with any type of cancer up to five years before their HF diagnosis were excluded to avoid cancer related infections.

The outcomes of interest were infections (defined according to the ICD10-code system) and worsening of heart failure (defined as a hospital admission with HF covering at least to dates).

The Aalen Johansen's estimator was used to estimate unadjusted 5-year absolute risk for all outcomes. Furthermore, a multivariate Cox analysis was made, and hazard ratios were estimated for the four time periods presented in a forest plot with the period 1997–2001 being the reference group. Adjustments for sex, age and history of comorbidities were conducted. Additionally, we stratified the infection outcome on different types of infections illustrated in 5-year cumulative incidence curves.

Results

The total population consisted of 147,737 patients. Over time there was a slight decrease in median age (1997–2001: 76.8 years, 2011–2017: 73.1 years) and the patients were more likely to be male (1997–2001: 53.5%, 2011–2017: 60%).

Figure 1 illustrates overall absolute risk of death decreased over time 1997–2001 (62.7% [95% CI 62.2–63.2]) vs. 2011–2017 (57.9% [95% CI 41.5–42.7]). Unadjusted curves for absolute risk showed that patients with HF had a higher risk of infection over time 1997–2001 (16.4% [95% CI 16.0–16.8] vs. 2011–2017 (24.5% [95% CI 24.0–24.9]). In contrast, they have a lower risk of worsening HF 1997–2011 (26.5% [95% CI 26.1–27.0] vs. 2011–2017 (23.2% [95% CI 22.8–23.7]). Adjusted analyses provided the same result for all outcomes illustrated in figure 2.

The risk of infection stratified by infection type, mark the risk of pneumonia infection as the most significant in all subintervals 1997–2001 (11.4% [95% CI 11.1–11.7]) vs. 2011–2017 (16.1% [95% CI 15.7–16.5]). The second most important was the risk of urogenital infection 1997–2001 (3.5% [95% CI 3.31–3.69]) vs. 2011–2017 (7.8% [95% CI 7.52–8.12]).

Conclusion

In this nationwide study, we observed that overall mortality risk and risk of hospitalization for worsening HF decreased from 1997 to 2017. In contrast, an increase in the risk of hospitalization for infection, especially pneumonia infections, increased during the same period. Future HF management programs should include strategies to prevent infections.

Funding Acknowledgement

Type of funding sources: None.

FOXO1 and FOXO3 Cooperatively Regulate Innate Lymphoid Cell Development

Natural killer (NK) cells play roles in viral clearance and early surveillance against malignant transformation, yet our knowledge of the underlying mechanisms controlling their development and functions remain incomplete. To reveal cell fate-determining pathways in NK cell progenitors (NKP), we utilized an unbiased approach and generated comprehensive gene expression profiles of NK cell progenitors. We found that the NK cell program was gradually established in the CLP to preNKP and preNKP to rNKP transitions. In line with FOXO1 and FOXO3 being co-expressed through the NK developmental trajectory, the loss of both perturbed the establishment of the NK cell program and caused stalling in both NK cell development and maturation. In addition, we found that the combined loss of FOXO1 and FOXO3 caused specific changes to the composition of the non-cytotoxic innate lymphoid cell (ILC) subsets in bone marrow, spleen, and thymus. By combining transcriptome and chromatin profiling, we revealed that FOXO TFs ensure proper NK cell development at various lineage-commitment stages through orchestrating distinct molecular mechanisms. Combined FOXO1 and FOXO3 deficiency in common and innate lymphoid cell progenitors resulted in reduced expression of genes associated with NK cell development including ETS-1 and their downstream target genes. Lastly, we found that FOXO1 and FOXO3 controlled the survival of committed NK cells via gene regulation of IL-15Rβ (CD122) on rNKPs and bone marrow NK cells. Overall, we revealed that FOXO1 and FOXO3 function in a coordinated manner to regulate essential developmental genes at multiple stages during murine NK cell and ILC lineage commitment.

Process Development for Adoptive Cell Therapy in Academia: A Pipeline for Clinical-Scale Manufacturing of Multiple TCR-T Cell Products

Cellular immunotherapies based on T cell receptor (TCR) transfer are promising approaches for the treatment of cancer and chronic viral infections. The discovery of novel receptors is expanding considerably; however, the clinical development of TCR-T cell therapies still lags. Here we provide a pipeline for process development and clinical-scale manufacturing of TCR-T cells in academia. We utilized two TCRs specific for hepatitis C virus (HCV) as models because of their marked differences in avidity and functional profile in TCR-redirected cells. With our clinical-scale pipeline, we reproduced the functional profile associated with each TCR. Moreover, the two TCR-T cell products demonstrated similar yield, purity, transduction efficiency as well as phenotype. The TCR-T cell products had a highly reproducible yield of over 1.4 × 10⁹ cells, with an average viability of 93%; 97.8–99% of cells were CD3+, of which 47.66 ± 2.02% were CD8+ T cells; the phenotype was markedly associated with central memory (CD62L+CD45RO+) for CD4+ (93.70 ± 5.23%) and CD8+ (94.26 ± 4.04%). The functional assessments in 2D and 3D cell culture assays showed that TCR-T cells mounted a polyfunctional response to the cognate HCV peptide target in tumor cell lines, including killing. Collectively, we report a solid strategy for the efficient large-scale manufacturing of TCR-T cells.

A tractable microscopy- and flow cytometry-based method to measure natural killer cell-mediated killing and infiltration of tumor spheroids

Understanding the anti-tumor activity of immune cells and testing cancer immunotherapies requires conditions that are as life-like as possible. The tumor microenvironment (TME) describes a complex sum of cellular and acellular actors that influence both immune cells and tumor cells as well as their interplay. Yet in development phases of new immunotherapies, the screening of drugs and adoptive cell products benefits from reproducible and controlled conditions. Two-dimensional (2D) cell cultures cannot simultaneously meet these two challenges therefore lacking considerably predictive power owing to their artificial nature. Various 3D tumor models have therefore been implemented to mimic the architecture and intrinsic heterogeneity of a microtumor. This protocol provides an easy-to-follow, time-efficient, material-limited method for live cell killing and infiltration of single tumor spheroids. It uses multicellular tumor spheroids grown scaffold-free and allows co-culture with immune cells. This protocol is optimized for natural killer (NK) cell functionality assays. However, it can be transferred to other immune cells, in particular cytotoxic T cells. This assay can be analysed using life cell imaging (here with the IncuCyte S3 system) and/or flow cytometry.

The Effect of Mesenchymal Stromal Cells Derived From Endometriotic Lesions on Natural Killer Cell Function

Endometriosis is an inflammatory disease that presents with ectopic endometriotic lesions. Reduced immunosurveillance of these lesions has been proposed to be playing a role in the pathology of endometriosis. Mesenchymal stromal cells (MSC) are found in ectopic lesions and may decrease immunosurveillance. In the present study, we examined if MSC contribute to reduced immunosurveillance through their immunosuppressive effects on natural killer (NK) cells. Stromal cells from endometriotic ovarian cysts (ESC_cyst) and eutopic endometrium (ESC_endo) of women with endometriosis and their conditioned medium were used in co-cultures with allogeneic peripheral blood NK cells. Following culture, NK cells were examined phenotypically for their expression of activating, inhibitory, maturation, and adhesion receptors and co-receptors, as well as the degranulation (CD107a) marker and the immunostimulatory (interferon-γ) and immunosuppressive (transforming growth factor beta 1 and interleukin-10) cytokines. Moreover, NK cell cytotoxicity was examined using chromium 51 release killing assays. There were no differences between ESC_cyst and ESC_endo regarding their effects on NK cell cytotoxicity in both conditioned medium and direct co-culture experiments. Additionally, there were no differences between ESC_cyst and ESC_endo regarding their impact on NK cells’ phenotype and degranulation in both conditioned medium and direct co-culture experiments. Although there were no differences found for DNAX accessory molecule-1 (DNAM-1) and NKp44, we found that the expression of the NK cell ligand CD155 that binds DNAM-1 and proliferating cell nuclear antigen (PCNA) that binds NKp44 was significantly less on ESC_cyst than on ESC_endo. These findings were not supported by the results that the expression of the known and unknown ligands on ESC_cyst for DNAM-1 and NKp44 using chimeric proteins was not significantly different compared to ESC_endo. In conclusion, the results suggest that ectopic MSC may not contribute to reduced immunosurveillance in endometriosis through their inhibitory effects on NK cells. This suggests that NK cell inhibition in the pelvic cavity of women with endometriosis develops due to other factors.

Improved survival in multiple Myeloma patients undergoing autologous stem cell transplantation is entirely in the standard cytogenetic risk groups

INTRODUCTION

Novel drugs and drug combinations have improved outcomes for multiple myeloma patients. However, subgroups of patients still have a poor progression-free survival (PFS) and overall survival (OS). In an attempt to identify how the novel drugs affect the outcome in standard-risk and high-risk patients, respectively, we have investigated 715 multiple myeloma (MM) patients who have undergone high dose treatment followed by autologous stem cell transplantation at our center during 1995 - 2020. Outcomes during three time periods, 1995-1999 (period I), 2000-2009 (period II), and 2010-2020 (period III), were compared separately for standard-risk and high-risk patients. Risk stratification was based on chromosome analysis for periods II and III.

RESULTS

The whole cohort of patients showed significantly improved OS with time during the three periods being at a median of 5.8, 7.0, and 10.0 years, respectively. There is also a weak tendency for improved PFS, that is, a median of 2.4, 2.6, and 2.9 years, respectively, during the same periods. However, the separate analysis of standard-risk and high-risk patients showed that the overall improvement with time was due to improved standard-risk patients (median OS 8.4 years for the period I and not reached for period II and III). In contrast, no significant improvement was seen in high-risk patients. For patients with del17p, PFS was even worse during period III as compared to period II (median 1.6 vs 3.2 years respectively).

CONCLUSION

Our results show that the dramatic improvement in outcome for MM patients during the last 20 years only applies for standard-risk patients, while high-risk MM patients still are doing poorly, indicating that the novel drugs developed during this time are preferentially effective in standard-risk patients. New treatment modalities like CAR-T cells, CAR-NK cells, and/or bispecific antibodies should be tried in clinical studies early in the course of the disease, especially in patients with high-risk cytogenetics.

Comparative evaluation of involved free light chain and monoclonal spike as markers for progression from monoclonal gammopathy of undetermined significance to multiple myeloma

Monoclonal gammopathy of undetermined significance (MGUS) is a premalignant clonal plasma cell disorder, with a 1% yearly risk of progression to multiple myeloma (MM). Evolution of M-spike and serum free light chain (sFLC) during follow-up could identify patients at high risk of progression. In this region-wide study, including 4756 individuals, 987 patients with MGUS were identified, and baseline factors as well as evolving involved FLC (iFLC) were evaluated as potential markers for risk of progression from MGUS to MM. Furthermore, evolving iFLC and M-spike were assessed quarterly for a median of 5 years. At baseline, patients that progressed had significantly higher iFLC compared to non-progressors. The risk factors of M-spike >1.5 g/dL, age >65 years and iFLC >100 mg/L were all independently associated with increased risk of MGUS to MM progression. For patients that had any two or three risk factors, the 5-year cumulative probability of progression was significantly higher (31%) compared to no risk factors (2%). Evolving iFLC >100 mg/L during follow-up was consistently associated with increased risk of progression. Based on our observations, we propose to include iFLC as a monitoring tool for all MGUS patients. Furthermore, we recommend a quarterly monitoring in all high-risk patients. Finally, we suggest that the risk of MGUS progression should be stratified with age, M-spike, and iFLC at baseline.

CD73 immune checkpoint defines regulatory NK cells within the tumor microenvironment

High levels of ecto-5'-nucleotidase (CD73) have been implicated in immune suppression and tumor progression, and have also been observed in cancer patients who progress on anti-PD-1 immunotherapy. Although regulatory T cells can express CD73 and inhibit T cell responses via the production of adenosine, less is known about CD73 expression in other immune cell populations. We found that tumor-infiltrating NK cells upregulate CD73 expression and the frequency of these CD73-positive NK cells correlated with larger tumor size in breast cancer patients. In addition, the expression of multiple alternative immune checkpoint receptors including LAG-3, VISTA, PD-1, and PD-L1 was significantly higher in CD73-positive NK cells than in CD73-negative NK cells. Mechanistically, NK cells transport CD73 in intracellular vesicles to the cell surface and the extracellular space via actin polymerization-dependent exocytosis upon engagement of 4-1BBL on tumor cells. These CD73-positive NK cells undergo transcriptional reprogramming and upregulate IL-10 production via STAT3 transcriptional activity, suppressing CD4-positive T cell proliferation and IFN-γ production. Taken together, our results support the notion that tumors can hijack NK cells as a means to escape immunity and that CD73 expression defines an inducible population of NK cells with immunoregulatory properties within the tumor microenvironment.

Impact of performance status on overall survival in patients with relapsed and/or refractory multiple myeloma: Real-life outcomes of daratumumab treatment

BACKGROUND

Little is reported on the real-life impact of daratumumab in relapsed and/or refractory multiple myeloma patients (RRMM). We analyzed a cohort of 156 patients who received daratumumab as a single agent concerning ECOG status, eGFR, cytogenetics, lines of prior treatment, and their impact on survival.

RESULTS

Eighty-two (53%) patients were triple refractory, 54 (35%) patients were single or double refractory, and 20 (12%) patients were non-refractory. Following daratumumab treatment, the progression-free survival (PFS) in these groups was 7.2%, 11.4%, and 53% (P < .001), and overall survival (OS) was 34%, 73%, and 58% (P < .001) at 36 months, respectively. Poor ECOG, three lines of prior treatment, and triple refractoriness were all associated with inferior PFS and OS in a multivariate analysis including ECOG, high-risk chromosomal aberrations, refractoriness, number of treatment lines, and eGFR.

CONCLUSION

Daratumumab remains an attractive treatment option, especially in patients with poor performance and increased frailty. Furthermore, our observations suggest that patients with ECOG 2 and 3 status require additional supportive and/or palliative therapies to compensate for a potentially effective but encompassing late-line therapy. In conclusion, further prospective studies are needed to elucidate the impact of ECOG 2 and 3 status in patients with RRMM.

Generation of Retinal Pigment Epithelial Cells Derived from Human Embryonic Stem Cells Lacking Human Leukocyte Antigen Class I and II

Human embryonic stem cell-derived retinal pigment epithelial (hESC-RPE) cells could serve as a replacement therapy in advanced stages of age-related macular degeneration. However, allogenic hESC-RPE transplants trigger immune rejection, supporting a strategy to evade their immune recognition. We established single-knockout beta-2 microglobulin (SKO-B2M), class II major histocompatibility complex transactivator (SKO-CIITA) and double-knockout (DKO) hESC lines that were further differentiated into corresponding hESC-RPE lines lacking either surface human leukocyte antigen class I (HLA-I) or HLA-II, or both. Activation of CD4+ and CD8+ T-cells was markedly lower by hESC-RPE DKO cells, while natural killer cell cytotoxic response was not increased. After transplantation of SKO-B2M, SKO-CIITA, or DKO hESC-RPEs in a preclinical rabbit model, donor cell rejection was reduced and delayed. In conclusion, we have developed cell lines that lack both HLA-I and -II antigens, which evoke reduced T-cell responses in vitro together with reduced rejection in a large-eyed animal model.

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hESC-RPEs are immunosuppressive but can elicit T-cell and NK cell responses in vitro

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hESC-RPEs lacking HLA-I and -II evade T-cell response

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hESC-RPEs lacking HLA-I and -II do not increase NK cell cytotoxic activity

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When xeno-transplanted, these immune-modified hESC-RPEs show reduced rejection

Iron and Ferritin Modulate MHC Class I Expression and NK Cell Recognition

The ability of pathogens to sequester iron from their host cells and proteins affects their virulence. Moreover, iron is required for various innate host defense mechanisms as well as for acquired immune responses. Therefore, intracellular iron concentration may influence the interplay between pathogens and immune system. Here, we investigated whether changes in iron concentrations and intracellular ferritin heavy chain (FTH) abundance may modulate the expression of Major Histocompatibility Complex molecules (MHC), and susceptibility to Natural Killer (NK) cell cytotoxicity. FTH downregulation, either by shRNA transfection or iron chelation, led to MHC surface reduction in primary cancer cells and macrophages. On the contrary, mouse embryonic fibroblasts (MEFs) from NCOA4 null mice accumulated FTH for ferritinophagy impairment and displayed MHC class I cell surface overexpression. Low iron concentration, but not FTH, interfered with IFN-γ receptor signaling, preventing the increase of MHC-class I molecules on the membrane by obstructing STAT1 phosphorylation and nuclear translocation. Finally, iron depletion and FTH downregulation increased the target susceptibility of both primary cancer cells and macrophages to NK cell recognition. In conclusion, the reduction of iron and FTH may influence the expression of MHC class I molecules leading to NK cells activation.

TBI Rehabilomics Research: Conceptualizing a humoral triad for designing effective rehabilitation interventions

Most areas of medicine use biomarkers in some capacity to aid in understanding how personal biology informs clinical care. This article draws upon the Rehabilomics research model as a translational framework for programs of precision rehabilitation and intervention research focused on linking personal biology to treatment response using biopsychosocial constructs that broadly represent function and that can be applied to many clinical populations with disability. The summary applies the Rehabilomics research framework to the population with traumatic brain injury (TBI) and emphasizes a broad vision for biomarker inclusion, beyond typical brain-derived biomarkers, to capture and/or reflect important neurological and non-neurological pathology associated with TBI as a chronic condition. Humoral signaling molecules are explored as important signaling and regulatory drivers of these chronic conditions and their impact on function. Importantly, secondary injury cascades involved in the humoral triad are influenced by the systemic response to TBI and the development of non-neurological organ dysfunction (NNOD). Biomarkers have been successfully leveraged in other medical fields to inform pre-randomization patient selection for clinical trials, however, this practice largely has not been utilized in TBI research. As such, the applicability of the Rehabilomics research model to contemporary clinical trials and comparative effectiveness research designs for neurological and rehabilitation populations is emphasized. Potential points of intervention to modify inflammation, hormonal, or neurotrophic support through rehabilitation interventions are discussed. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".

The effects of post-traumatic depression on cognition, pain, fatigue, and headache after moderate-to-severe traumatic brain injury: a thematic review

BACKGROUND

Post-traumatic depression (PTD) is one of the most common secondary complications to develop after moderate-to-severe traumatic brain injury (TBI). However, it rarely manifests singularly, and often co-occurs with other common TBI impairments.

OBJECTIVE

The objective of this thematic review is to evaluate studies examining the relationships between PTD and cognition, fatigue, pain, and headache among individuals with moderate-to-severe TBI.

RESULTS

We reviewed 16 studies examining the relationship between PTD and cognition (five articles), fatigue (five articles), pain (four articles), and headache (two articles). Two studies failed to identify the significant associations between PTD and neuropsychological test performance, while one study found a positive association. Two other studies found that early PTD was associated with later executive dysfunction. Studies on fatigue suggest it is a cause, not consequence, of PTD. Individuals with PTD tended to report more pain than those without PTD. Studies examining relationships between PTD and post-traumatic headache were equivocal.

CONCLUSIONS

Studies evaluating the effects of PTD on common TBI impairments have yielded mixed results. Evidence suggests PTD precedes the development of executive dysfunction, and a strong link exists between fatigue and PTD, with fatigue preceding PTD. Future prospective studies evaluating PTD relationships to pain and headache are warranted to elucidate causality.

Independent control of natural killer cell responsiveness and homeostasis at steady-state by CD11c+ dendritic cells

During infection and inflammation, dendritic cells (DC) provide priming signals for natural killer (NK) cells via mechanisms distinct from their antigen processing and presentation functions. The influence of DC on resting NK cells, i.e. at steady-state, is less well studied. We here demonstrate that as early as 1 day after DC depletion, NK cells in naïve mice downregulated the NKG2D receptor and showed decreased constitutive phosphorylation of AKT and mTOR. Subsequently, apoptotic NK cells appeared in the spleen concomitant with reduced NK cell numbers. At 4 days after the onset of DC depletion, increased NK cell proliferation was seen in the spleen resulting in an accumulation of Ly49 receptor-negative NK cells. In parallel, NK cell responsiveness to ITAM-mediated triggering and cytokine stimulation dropped across maturation stages, suggestive of a functional deficiency independent from the homeostatic effect. A role for IL-15 in maintaining NK cell function was supported by a gene signature analysis of NK cell from DC-depleted mice as well as by in vivo DC transfer experiments. We propose that DC, by means of IL-15 transpresentation, are required to maintain not only homeostasis, but also function, at steady-state. These processes appear to be regulated independently from each other.

Dynamic Regulation of NK Cell Responsiveness

Natural killer (NK) cells deliver cytotoxic granules and immunomodulatory cytokines in response to transformed and virally infected cells. NK cell functions are under the control of a large number of germline-encoded receptors that recognize various ligands on target cells, but NK cells also respond to cytokines in the surrounding environment. The interaction between NK cell receptors and their ligands delivers either inhibitory or activating signals. The cytokine milieu further shapes NK cell responses, either directly or by influencing the way inhibitory or activating signals are perceived by NK cells. In this review, we discuss how NK cell function is controlled by inhibitory receptors and MHC-I molecules, how activating receptors contribute to NK cell education, and finally, how cytokines secreted by the surrounding cells affect NK cell responsiveness. Inputs at these three levels involve different cell types and are seamlessly integrated to form a functional NK cell population.

Retuning of Mouse NK Cells after Interference with MHC Class I Sensing Adjusts Self-Tolerance but Preserves Anticancer Response

Natural killer (NK) cells are most efficient if their targets do not express self MHC class I, because NK cells carry inhibitory receptors that interfere with activating their cytotoxic pathway. Clinicians have taken advantage of this by adoptively transferring haploidentical NK cells into patients to mediate an effective graft-versus-leukemia response. With a similar rationale, antibody blockade of MHC class I-specific inhibitory NK cell receptors is currently being tested in clinical trials. Both approaches are challenged by the emerging concept that NK cells may constantly adapt or "tune" their responsiveness according to the amount of self MHC class I that they sense on surrounding cells. Hence, these therapeutic attempts would initially result in increased killing of tumor cells, but a parallel adaptation process might ultimately lead to impaired antitumor efficacy. We have investigated this question in two mouse models: inhibitory receptor blockade in vivo and adoptive transfer to MHC class I-disparate hosts. We show that changed self-perception via inhibitory receptors in mature NK cells reprograms the reactivity such that tolerance to healthy cells is always preserved. However, reactivity against cancer cells lacking critical MHC class I molecules (missing self-reactivity) still remains or may even be increased. This dissociation between activity against healthy cells and tumor cells may provide an answer as to why NK cells mediate graft-versus-leukemia effects without causing graft-versus-host disease and may also be utilized to improve immunotherapy.

Acute CSF interleukin-6 trajectories after TBI: associations with neuroinflammation, polytrauma, and outcome

Traumatic brain injury (TBI) results in a significant inflammatory burden that perpetuates the production of inflammatory mediators and biomarkers. Interleukin-6 (IL-6) is a pro-inflammatory cytokine known to be elevated after trauma, and a major contributor to the inflammatory response following TBI. Previous studies have investigated associations between IL-6 and outcome following TBI, but to date, studies have been inconsistent in their conclusions. We hypothesized that cohort heterogeneity, temporal inflammatory profiles, and concurrent inflammatory marker associations are critical to characterize when targeting subpopulations for anti-inflammatory therapies. Toward this objective, we used serial cerebrospinal fluid (CSF) samples to generate temporal acute IL-6 trajectory (TRAJ) profiles in a prospective cohort of adults with severe TBI (n=114). We examined the impact of injury type on IL-6 profiles, and how IL-6 profiles impact sub-acute (2weeks-3months) serum inflammatory marker load and long-term global outcome 6-12months post-injury. There were two distinct acute CSF IL-6 profiles, a high and low TRAJ group. Individuals in the high TRAJ had increased odds of unfavorable Glasgow Outcome Scale (GOS) scores at 6months (adjusted OR=3.436, 95% CI: 1.259, 9.380). Individuals in the high TRAJ also had higher mean acute CSF inflammatory load compared to individuals in the low TRAJ (p⩽0.05). The two groups did not differ with respect acute serum profiles; however, individuals in the high CSF IL-6 TRAJ also had higher mean sub-acute serum IL-1β and IL-6 levels compared with the low TRAJ group (p⩽0.05). Lastly, injury type (isolated TBI vs. TBI+polytrauma) was associated with IL-6 TRAJ group (χ(2)=5.31, p=0.02). Specifically, there was 70% concordance between those with TBI+polytrauma and the low TRAJ; in contrast, isolated TBI was similarly distributed between TRAJ groups. These data provide evidence that sustained, elevated levels of CSF IL-6 are associated with an increased inflammatory load, and these increases are associated with increased odds for unfavorable global outcomes in the first year following TBI. Future studies should explore additional factors contributing to IL-6 elevations, and therapies to mitigate its detrimental effects on outcome.

Exploratory associations with tumor necrosis factor-α, disinhibition and suicidal endorsement after traumatic brain injury

PURPOSE

To examine the relationship of Tumor Necrosis Factor (TNF)-α to disinhibition and suicidal endorsement after traumatic brain injury (TBI).

PARTICIPANTS

Adults with moderate to severe TBI (acute serum levels: n=48, n=543 samples; acute CSF levels: n=37, n=389 samples; chronic serum levels: n=48, n=326 samples).

MAIN MEASURES

TNFα levels (CSF, Serum) from time of injury to 12 months post-injury; Frontal Systems Behavior Scale - Disinhibition Subscale at 6 and 12 months post-injury; Patient Health Questionnaire at 6 and 12 months post-injury.

RESULTS

Participants with TBI had significantly higher CSF and serum TNFα levels than healthy controls (p<0.05). Acute and chronic serum TNFα was significantly associated with disinhibition at 6 months post-injury (p=0.009, p=0.029 respectively), and 6 month disinhibition was associated with suicidal endorsement at both 6 and 12 months (p=0.045, p=0.033 respectively) and disinhibition at 12 months post-injury (p<0.001).

CONCLUSION

These preliminary data suggest a biological to behavioral pathway of suicidality after TBI, from TNFα to disinhibition to suicidal endorsement. Future investigation is warranted to validate these findings and clarify what biological mechanisms might underlie these relationships.

Have we improved use of medicines in developing and transitional countries and do we know how to? Two decades of evidence

OBJECTIVE

To assess progress in improving use of medicines in developing and transitional countries by reviewing empirical evidence, 1990-2009, concerning patterns of primary care medicine use and intervention effects.

METHODS

We extracted data on medicines use, study setting, methodology and interventions from published and unpublished studies on primary care medicine use. We calculated the medians of six medicines use indicators by study year, country income level, geographic region, facility ownership and prescriber type. To estimate intervention impacts, we calculated greatest positive (GES) and median effect sizes (MES) from studies meeting accepted design criteria.

RESULTS

Our review comprises 900 studies conducted in 104 countries, reporting data on 1033 study groups from public (62%), and private (mostly for profit) facilities (26%), and households. The proportion of treatment according to standard treatment guidelines was 40% in public and <30% in private-for-profit sector facilities. Most indicators showed suboptimal use and little progress over time: Average number of medicines prescribed per patient increased from 2.1 to 2.8 and the percentage of patients receiving antibiotics from 45% to 54%. Of 405 (39%) studies reporting on interventions, 110 (27%) used adequate study design and were further analysed. Multicomponent interventions had larger effects than single component ones. Median GES was 40% for provider and consumer education with supervision, 17% for provider education alone and 8% for distribution of printed education materials alone. Median MES showed more modest improvements.

CONCLUSIONS

Inappropriate medicine use remains a serious global problem.

TBI translational rehabilitation research in the 21st Century: exploring a Rehabilomics research model

Globally, traumatic brain injury (TBI) is a leading cause of death and persistent disability. Although improvements in standard of care have reduced the overall mortality rates associated with this disease, there is a paucity of effective neuroprotective therapies. However, some rehabilitation focused strategies have shown promise with enhancing neurorecovery. One major challenge in identifying effective therapies is that TBI is an inherently heterogeneous disease. Despite many patients having similar injury factors and clinical care after their TBI, recovery and outcomes can be very different. This commentary discusses the value of treatment effectiveness research that also incorporates theranostic principles of individualized care. Key to this concept is the utilization of state-of-the-art biomarker platforms and technologies that can identify relevant molecular or physiological fingerprints that can assist rehabilitation practitioners in delineating long term outcome that can be linked to plasticity, treatment response, and natural recovery. This commentary proposes a unique concept of "Rehabilomics" as a field of study involving the systematic collection and study of rehabilitation relevant phenotypes, in conjunction with a transdisciplinary evaluation of biomarkers, in order to better understand the biology, function, prognosis, complications, treatments, adaptation, and recovery for persons with disabilities. Specific Rehabilomics applications to TBI research, as well as relevance to the National Institutes of Health Roadmap, are discussed.

Characterization of the recombinant Rieske [2Fe-2S] proteins HcaC and YeaW from E. coli

Three genes within the genome of E. coli K12 are predicted to encode proteins containing the typical Rieske iron-sulfur cluster-binding motifs. Two of these, hcaC and yeaW, were overexpressed in E. coli BL21 and Tuner (DE3) pLacI. The recombinant proteins were purified and analyzed by UV/Vis- and EPR-spectroscopy. HcaC and YeaW display the typical redox-dependent UV/Vis-spectra of iron-sulfur proteins. The EPR spectrum of reduced HcaC shows characteristic g-values of a Rieske cluster whereas the g-values for YeaW are close to the upper limit for this type of iron-sulfur cluster. Both iron-sulfur clusters could be reduced by dithionite, but not by ascorbate, confirming their classification as low-potential Rieske proteins as derived from the amino acid sequences. A phylogenetic analysis of the two proteins reveals that HcaC clearly segregates with the Rieske ferredoxins of class IIB oxygenases whereas the classification of YeaW remains doubtful.

Gender and environmental effects on regional brain-derived neurotrophic factor expression after experimental traumatic brain injury

Alterations in brain-derived neurotrophic factor expression have been reported in multiple brain regions acutely after traumatic brain injury, however neither injury nor post-injury environmental enrichment has been shown to affect hippocampal brain-derived neurotrophic factor gene expression in male rats chronically post-injury. Studies have demonstrated hormone-related neuroprotection for female rats after traumatic brain injury, and estrogen and exercise both influence brain-derived neurotrophic factor levels. Despite recent studies suggesting that exposure post-traumatic brain injury to environmental enrichment improves cognitive recovery in male rats, we have shown that environmental enrichment mediated improvements with spatial learning are gender specific and only positively affect males. Therefore the purpose of this study was to evaluate the effect of gender and environmental enrichment on chronic post-injury cortical and hippocampal brain-derived neurotrophic factor protein expression. Sprague-Dawley male and cycling female rats were placed into environmental enrichment or standard housing after controlled cortical impact or sham surgery. Four weeks post-surgery, hippocampal and frontal cortex brain-derived neurotrophic factor expression were examined using Western blot. Results revealed significant increases in brain-derived neurotrophic factor expression in the frontal cortex ipsilateral to injury for males (P=0.03). Environmental enrichment did not augment this effect. Neither environmental enrichment nor injury significantly affected cortical brain-derived neurotrophic factor expression for females. In the hippocampus ipsilateral to injury brain-derived neurotrophic factor expression for both males and females was half (49% and 51% respectively) of that observed in shams housed in the standard environment. For injured males, there was a trend in this region for environmental enrichment to restore brain-derived neurotrophic factor levels to sham values. However, there were robust increases in hippocampal brain-derived neurotrophic factor expression ipsilateral to the injury for injured females in environmental enrichment compared with both sham and injured females placed in standard housing (P<or=0.005). In the hippocampus contralateral to injury, there were also significant injury-related increases in brain-derived neurotrophic factor expression for females (P<or=0.05) that were not further augmented by environmental enrichment. These results show significant, region-specific gender differences in brain-derived neurotrophic factor expression with both injury and environmental enrichment that may be important for recovery. However, these data do not support a critical role for brain-derived neurotrophic factor in environmental enrichment mediated improvements with spatial learning.

Controlled cortical impact injury affects dopaminergic transmission in the rat striatum

The therapeutic benefits of dopamine (DA) agonists after traumatic brain injury (TBI) imply a role for DA systems in mediating functional deficits post-TBI. We investigated how experimental TBI affects striatal dopamine systems using fast scan cyclic voltammetry (FSCV), western blot, and d-amphetamine-induced rotational behavior. Adult male Sprague-Dawley rats were injured by a controlled cortical impact (CCI) delivered unilaterally to the parietal cortex, or were naïve controls. Amphetamine-induced rotational behavior was assessed 10 days post-CCI. Fourteen days post-CCI, animals were anesthetized and underwent FSCV with bilateral striatal carbon fiber microelectrode placement and stimulating electrode placement in the medial forebrain bundle (MFB). Evoked DA overflow was assessed in the striatum as the MFB was electrically stimulated at 60 Hz for 10 s. In 23% of injured animals, but no naïve animals, rotation was observed with amphetamine administration. Compared with naïves, striatal evoked DA overflow was lower for injured animals in the striatum ipsilateral to injury (p < 0.05). Injured animals exhibited a decrease in V(max) (52% of naïve, p < 0.05) for DA clearance in the hemisphere ipsilateral to injury compared with naïves. Dopamine transporter (DAT) expression was proportionally decreased in the striatum ipsilateral to injury compared with naïve animals (60% of naïve, p < 0.05), despite no injury-related changes in vesicular monoamine transporter or D2 receptor expression (DRD2) in this region. Collectively, these data appear to confirm that the clinical efficacy of dopamine agonists in the treatment of TBI may be related to disruptions in the activity of subcortical dopamine systems.

Segmented regression analysis of interrupted time series studies in medication use research

Interrupted time series design is the strongest, quasi-experimental approach for evaluating longitudinal effects of interventions. Segmented regression analysis is a powerful statistical method for estimating intervention effects in interrupted time series studies. In this paper, we show how segmented regression analysis can be used to evaluate policy and educational interventions intended to improve the quality of medication use and/or contain costs.

An internship for college students in physical medicine and rehabilitation: effects on awareness, career choice, and disability perceptions

OBJECTIVE

To show the impact that an internship program in Physical Medicine and Rehabilitation (PM&R) for college students has on their knowledge about the field, career choice, and perceptions about people with disabilities.

DESIGN

Twelve students were selected to participate in the study. Students observed patient therapies and followed faculty and physiatry resident physicians. Students also participated in research studies in rehabilitation research. Group discussions regarding specific projects, research methods, career choice, and perceptions about disability were part of a didactic curriculum. Surveys about PM&R knowledge, attitudes toward people with disabilities, demographics, and course evaluations were administered.

RESULTS

Results showed that the program increased knowledge about PM&R (P < 0.008). Premedical students missed significantly fewer questions (8.2 vs. 11.7; P = 0.04) on this survey than did other participants. Results also showed that this program affected their attitudes toward people with disabilities and student choice to pursue a career in health care.

CONCLUSIONS

This type of internship experience provides an educational environment for college students to become acquainted with PM&R, interact positively with people with disabilities, and influence career choice in the allied health professions.

A history and review of quantitative electroencephalography in traumatic brain injury

The electroencephalogram (EEG) is a physiologic measure of cerebral function that has been used by some to assess coma and prognosticate survival and global outcome after traumatic brain injury (TBI). Surface recordings of the brain's electrical activity reveal distinct patterns that indicate injury severity, depth of unconsciousness, and patient survival. The data produced with traditional qualitative studies, however, does not allow resolution and quantification of the wave frequency spectrum present in the brain. As a result, conventional EEG typically has only been used for gross and qualitative analyses and is not practical for use in long-term patient monitoring or as a sophisticated prognostic tool. One area of investigation that is working to address the limitations of conventional EEG has been the development and implementation of Fourier Transform (FT) EEG which resolves and quantifies frequency bands present in the brain. When FT analysis is applied to EEG, it provides concurrent and continuous monitoring, resolution, and quantification of all frequencies emitted. This review discusses the history and significance of conventional EEG and provides a review of how FT-EEG, commonly referred to as Quantitative EEG (QEEG), is being used in the clinical setting. The specific applications and significance of QEEG methods regarding treatment of patients with TBI are discussed in detail. The advantages, disadvantages, and future directions of QEEG in TBI are also discussed.

Use of injury severity variables in determining disability and community integration after traumatic brain injury

BACKGROUND

Long-term outcome is important in managing traumatic brain injury (TBI), an epidemic in the United States. Many injury severity variables have been shown to predict major morbidity and mortality. Less is known about their relationship with specific long-term outcomes.

METHODS

Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity Score, along with other demographic and premorbid values, were obtained for 378 consecutive patients hospitalized after TBI at a Level I trauma center between September 1997 and May 1998. Of this cohort, 120 patients were contacted for 1-year follow-up assessment with the Disability Rating Scale, Community Integration Questionnaire, and employment data.

RESULTS

Univariate analyses showed these to be significant single predictors of 1-year outcome. Multivariate analyses revealed that the Revised Trauma Score and Glasgow Coma Scale had significant additive value in predicting injury variables Disability Rating Scale scores when combined with other demographic and premorbid variables studied. Predictive models of 1-year outcome were developed.

CONCLUSION

Injury severity variables are significant single outcome predictors and, in combination with premorbid and demographic variables, help predict long-term disability and community integration for individuals hospitalized with TBI.

Intentional traumatic brain injury: epidemiology, risk factors, and associations with injury severity and mortality

BACKGROUND

Intentional injury is associated with significant morbidity and mortality and has been associated with certain demographic and socioeconomic groups. Less is known about the relationship of intentional traumatic brain injury (TBI) to injury severity, mortality, and demographic and socioeconomic profile. The objective of this study was to delineate demographic and event-related factors associated with intentional TBI and to evaluate the predictive value of intentional TBI on injury severity and mortality.

METHODS

Prospective data were obtained for 2,637 adults sustaining TBIs between January 1994 and September 1998. Descriptive, univariate, and multivariate analyses were conducted to determine the predictive value of intentional TBI on injury severity and mortality.

RESULTS

Gender, minority status, age, substance abuse, and residence in a zipcode with low average income were associated with intentional TBI. Multivariate analysis found minority status and substance abuse to be predictive of intentional injury after adjusting for other demographic variables studied. Intentional TBI was predictive of mortality and anatomic severity of injury to the head. Penetrating intentional TBI was predictive of injury severity with all injury severity markers studied.

CONCLUSION

Many demographic variables are risk factors for intentional TBI, and such injury is a risk factor for both injury severity and mortality. Future studies are needed to definitively link intentional TBI to disability and functional outcome.

The value of trauma scores: predicting discharge after traumatic brain injury

OBJECTIVE

To determine the association of acute variables with disposition after acute hospitalization.

DESIGN

Revised Trauma Score (RTS), Injury Severity Score (ISS), and the Combined Trauma Score Injury Severity Score (TRISS(RTS)) were compared with discharge disposition after acute hospitalization of 378 consecutive patients who sustained a traumatic brain injury (TBI) and were treated at a level 1 trauma center between September 1997 and May 1998.

RESULTS

Logistic regression modeling found TRISS(RTS) to predict discharge to home with or without home health assistance or inpatient rehabilitation vs. nursing home placement or death. Subsequent modeling, excluding patients who died or went to nursing homes, identified RTS and ISS as predictors of discharge to home with or without home health vs. inpatient rehabilitation. A sensitivity of 97.78% and 93.91% were achieved with these two models when tested on a population of 4,625 patients with TBI treated during the last 10 yr at the same facility.

CONCLUSIONS

The results suggest that RTS, ISS, and TRISS(RTS) are predictors of discharge disposition after acute hospitalization with TBI and may be useful measures of rehabilitation services resource planning early in the course of TBI management.

The impact of a single seizure on health status and health care utilization

PURPOSE

To assess the health status of patients after a single seizure.

METHODS

We compared single-seizure patients (SS) with patients who had well-controlled epilepsy (WC), and uncomplicated hypertension (HT). Patients were adults screened from emergency and outpatient units of two urban teaching hospitals using predefined criteria. The 83 patients (SS, 30; WC, 29; HT, 24) were interviewed by phone about functional status (SF-36), comorbid illness, cause of illness, number of visits to health providers, and drug side effects.

RESULTS

No significant differences were found among groups for health status, SF-36 domain, or occurrence of drug side effects. SS patients had significantly lower scores on vitality (p < 0.03) and a trend toward lower role physical function (p < 0.07) compared with age-adjusted population norms. SS reported more visits to health providers than WC or HT, and the number of visits remained high at interview 1 year later. Patient knowledge of the "reason" for the seizure was not associated with health status or number of visits.

CONCLUSIONS

Health status of patients within 1 year of a single seizure is similar to that of patients with well-controlled epilepsy or hypertension, but SS patients have greater health care utilization.

A Kiswahili version of the SF-36 Health Survey for use in Tanzania: translation and tests of scaling assumptions

The objective of the study was to translate and adapt the SF-36 Health Survey for use in Tanzania and to test the psychometric properties of the Kiswahili SF-36. A cross-sectional study was conducted as part of a household survey of a representative sample of the adult population of Dar es Salaam, Tanzania. The IQOLA method of forward and backward translation was used to translate the SF-36 into Kiswahili. The translated questionnaire was administered by trained interviewers to 3,802 adults (50% women, mean (SD) age 31 (13) years, 50% married and 60% with primary education). Data quality and psychometric assumptions underlying the scoring of the eight SF-36 scales were evaluated for the entire sample and separately for the least educated subgroup (n = 402), using multitrait scaling analysis. Forward and backward translation procedures resulted in a Kiswahili SF-36 that was considered conceptually equivalent to the US English SF-36. Data quality was excellent: only 1.2% of respondents were excluded because they answered less than half of the items for one or more scales; ninety percent of respondents answered mutually exclusive items consistently. Median item-scale correlations across the eight scales ranged from 0.47 to 0.81 for the entire sample. Median scaling success rates were 100% (range 87.5-100.0). The median internal consistency reliability of the eight scales for the entire sample was 0.81 (range 0.70-0.92). Floor effects were low and ceiling effects were high on five of the eight scales. Results for n = 402 people without formal education did not differ substantially from those of the entire sample. The results of data quality and psychometric tests support the scoring of the eight scales using standard scoring algorithms. The Kiswahili translation of the SF-36 may be useful in estimating the health of people in Dar es Salaam. Evidence for the validity of the SF-36 for use in Tanzania needs to be accumulated.

Validation of the Kiswahili version of the SF-36 Health Survey in a representative sample of an urban population in Tanzania

The objective of this study was to assess the validity of a Kiswahili translation of the SF-36 Health Survey (SF-36) among an urban population in Tanzania, using the method of known-groups validation. People were randomly selected from a demographic surveillance system in Dar es Salaam. The representative sample consisted of 3,802 adults (15 years and older). Health status differences were hypothesized among groups, who differed in sex, age, socioeconomic status and self-reported morbidity. Mean SF-36 scale scores were calculated and compared using t-test and ANOVA. Women had significantly lower mean SF-36 scale scores (indicating worse health status) than men on all scales and scores were lower for older people than younger on all domains, as hypothesized. On five of the eight SF-36 scales, means were higher for people of higher socioeconomic status compared to those of lower socioeconomic status. People who reported an illness within the previous 2 weeks scored significantly lower on all scales compared to those who were healthy, as did people who said they had a disability or a chronic condition.

Evaluation of ENCOREplus. A community-based breast and cervical cancer screening program

BACKGROUND

Minority women and women with low income levels are significantly less likely to practice appropriate mammography and Pap test screening. ENCOREplus is a health promotion program that provides outreach, education, referral, and other service that facilitate breast and cervical cancer screening for medically underserved women. The program is delivered through a network of community-based nonprofit organizations (YWCA of the U.S.A). The purpose of this study was to assess the effectiveness of ENCOREplus in promoting mammography and Pap test screening among women who were nonadherent to screening guidelines.

METHODS

Baseline data were collected from women participating in the program. Follow-up occurred within six months of baseline to assess whether or not enrollees received recommended screenings. Screening-completion rates were compared to rates from other published intervention studies.

RESULTS

Data from the program's second implementation year show that 27,494 women participated in the ENCOREplus program. Over half the women were racial/ethnic minorities, over 75% reported annual incomes under $15,000, and 49% reported no insurance. Among women 40 and over, 69.7% were nonadherent to ACS mammography screening guidelines at baseline. Among participants 18 and older, 68.9% were nonadherent to Pap test screening guidelines. Of nonadherent participants, 57.8% received mammograms and 36.5% received Pap tests. Both mammography and Pap test screening-completion rates compared favorably with other programs.

CONCLUSION

This study demonstrates that programs implemented through community-based organizations can be successful in increasing mammography and Pap test screening among low-income and minority women.

Independent acquisition and insertion into different chromosomal locations of the same pathogenicity island in Yersinia pestis and Yersinia pseudotuberculosis

We show that Yersinia pestis and pesticin-sensitive isolates of Y. pseudotuberculosis possess a common 34 kbp DNA region that has all the hallmarks of a pathogenicity island and is inserted into different asparaginyl tRNA genes at different chromosomal locations in each species. This pathogenicity island (YP-HPI) is marked by IS100, has a G + C content different from its host, is flanked by 24 bp direct repeats, encodes a putative, P4-like integrase and contains the iron uptake virulence genes from the pgm locus of Y. pestis. These findings indicate independent horizontal acquisition of this island by Y. pestis and Y. pseudotuberculosis. The two YP-HPI locations and their possession of an integrase gene support a model of site-specific integration of the YP-HPI into these bacteria.

Pharmaceutical donations by the USA: an assessment of relevance and time-to-expiry

This paper assesses the relevance and time-to-expiry of pharmaceutical donations by the USA by means of a convenience sample of two private voluntary organizations. Data were collected on 16,566 donations shipped between 1994 and 1997 for the two organizations to a total of 129 countries. For three field study countries (Armenia, Haiti, and the United Republic of Tanzania), between 37% and 65% of donated unique drug products were on the recipient countries' essential drugs lists, and between 50% and 80% were either on these lists or were permissible therapeutic alternatives. Between 10% and 42% were not listed on either the national essential drugs lists or the WHO Model List of Essential Drugs, nor were they permissible therapeutic alternatives. For the worldwide data set, the median times to expiry when shipment by the organizations took place were 599 and 550 days; about 30% of shipment items had a year or less of shelf-life, and about 6% had less than 100 days of shelf-life. Although a majority of the donations fulfilled the criteria of relevance and time-to-expiry, a substantial proportion failed to do so. Actions are proposed with a view to improving the relevance and time-to-expiry of USA pharmaceutical donations.

Cross-cultural comparisons of the content of SF-36 translations across 10 countries: results from the IQOLA Project. International Quality of Life Assessment

Increasingly, translated and culturally adapted health-related quality of life measures are being used in cross-cultural research. To assess comparability of results, researchers need to know the comparability of the content of the questionnaires used in different countries. Based on an item-by-item discussion among International Quality of Life Assessment (IQOLA) investigators of the content of the translated versions of the SF-36 in 10 countries, we discuss the difficulties that arose in translating the SF-36. We also review the solutions identified by IQOLA investigators to translate items and response choices so that they are appropriate within each country as well as comparable across countries. We relate problems and solutions to ratings of difficulty and conceptual equivalence for each item. The most difficult items to translate were physical functioning items that refer to activities not common outside the United States and items that use colloquial expressions in the source version. Identifying the origin of the source items, their meaning to American English-speaking respondents and American English synonyms, in response to country-specific translation issues, greatly helped the translation process. This comparison of the content of translated SF-36 items suggests that the translations are culturally appropriate and comparable in their content.

Patient-based health status measurement in clinical practice: a study of its impact on epilepsy patients' care

The objective was to assess the potential benefits of the routine use of the MOS SF-36 Health Survey (SF-36) in the care of ambulatory patients. The design was a longitudinal, prospective, randomized, controlled study set in the outpatient neurology clinic at the New England Medical Center. There were 163 consecutive patients with epilepsy who had 210 follow-up visits with one of two epileptologists. The patients completed the SF-36 before the patient-physician encounter and the forms were optically scanned. The SF-36 results of the intervention group patients were given to the physicians before the encounter and withheld for control group patients. For intervention group patients, the physicians completed a questionnaire assessing the impact of the SF-36 on the process of care. After the visit, all patients completed a satisfaction questionnaire. The main outcome measures were the physicians' responses to standardized questions about the usefulness of the SF-36 for communication with and management of epilepsy patients and the patients' responses to standardized questions about their satisfaction with care. The physicians indicated that the SF-36 provided new information in 63% of the intervention group encounters. A change in therapy was prompted in 13%. The physicians rated the SF-36 as at least moderately useful for communication in 14% of the encounters and to management in 8%. The lower (indicating worse health status) the patients' SF-36 scale scores, the more useful the SF-36 results were rated by the physicians for communication and management. It was concluded that the routine use of health status measures may enhance patients' care.

The health status of adults with epilepsy compared with that of people without chronic conditions

STUDY OBJECTIVES

To examine the feasibility of administering and the psychometric properties of a general health status questionnaire in adults with epilepsy, and to assess the health status of these patients.

DESIGN

Prospective, cross-sectional, observational study.

SETTING

Neurology clinic of a tertiary care medical center.

PATIENTS

One hundred forty-eight ambulatory adults with epilepsy.

INTERVENTIONS

Patients completed the SF-36, a general health status questionnaire. Respondent burden and data quality as well as psychometric characteristics were evaluated. Patients' SF-36 scale scores, adjusted for comorbidities, were compared with those of 641 people without chronic conditions with the same sociodemographic characteristics.

MEASUREMENTS AND MAIN RESULTS

Administering the SF-36 to adult outpatients with epilepsy is feasible and results are psychometrically sound. Compared with those who were not ill, patients had significantly (p < 0.001) lower (0 = worst, 100 = best) scores in six of the eight SF-36 domains: general health perceptions (57.7 vs 82.1), mental health (61.3 vs 79.6), vitality (53.5 vs 67.8), role limitations owing to physical (69.6 vs 95.0) and emotional problems (67.2 vs 88.4), and social functioning (75.2 vs 89.9).

CONCLUSIONS

Lower SF-36 scores may reflect patients' assessments of the balance among epilepsy, seizures, and antiepileptic drug therapy-related effects. Incorporating health status information into therapeutic decision making may help to attain the ultimate goal of improving patients' health.

The routine use of health-related quality of life measures in the care of patients with epilepsy: rationale and research agenda

Reliable and valid patient-completed questionnaires to assess the health related quality of life (HRQOL) of people with epilepsy are becoming increasingly available. At present, however, they are not routinely used in epilepsy patients' care. The use of HRQOL measurement in clinical practice settings may improve the quality of care for people with epilepsy through (1) increasing the detection of patients' problems with daily functioning and well-being: (2) guiding therapeutic management; and (3) leading to improvements in patients' HRQOL and satisfaction with care. To realize the potential benefits of HRQOL assessment in the care of people with epilepsy, research into the feasibility of the office-based use of HRQOL questionnaires, measurement quality, and the impact of routine HRQOL assessment on the quality of epilepsy patients' care needs to be undertaken. The transfer of HRQOL questionnaires from research tools into clinical tools requires the collaboration of social scientists, health services researchers, and clinicians. HRQOL questionnaires have the potential to become a new clinical tool which could enhance the quality of care physicians are able to provide for their patients with epilepsy.

Advances in methods for assessing the impact of epilepsy and antiepileptic drug therapy on patients' health-related quality of life

We studied 31 previously validated and newly developed generic and epilepsy-specific scales to evaluate their usefulness for assessing the impact of epilepsy and anti-epileptic drug (AED) therapy on health-related quality of life (HRQOL). Included were the MOS SF-36 Health Survey, additional measures of mental health, cognition, epilepsy-specific perception of control, behavioural problems, distress, worries and experiences, the Liverpool Epilepsy Impact and Seizure Severity scales, and a patient-completed symptom checklist. Questionnaires were completed twice by 136 patients on AED therapy in a multicentre study in the UK. Validity was assessed in relation to disease severity, defined as time since last seizure, and to patient-reported symptoms. Statistical analyses to estimate the contribution of HRQOL information of each scale relative to that of others were conducted. The 171-item questionnaire could be completed by out-patients with epilepsy with good data quality. With few exceptions, generic and epilepsy-specific measures satisfied psychometric tests of hypothesized item groupings and scale score reliability (internal consistency and test-retest reliability) and differentiated well between groups of patients differing in time since last seizure and in symptom impact, regardless of time since last seizure. However, scales differed widely in their validity in discriminating between groups of patients known to differ clinically. The SF-36 Role Physical scale best discriminated among groups differing in disease severity. The epilepsy-specific Mastery, Impact, Experience, Worry, Distress, and Agitation scales were among the 10 best measures in discriminating among groups differing in disease severity. Generic measures, especially measures of social and role functioning and mental health, were best at differentiating groups of patients differing in symptom impact. Recommendations are offered for concepts and specific scales most likely to be useful in future studies of the HRQOL burden of epilepsy and the HRQOL benefits of AED therapy.