Beyond knowledge and confidence: a mixed methods evaluation of a Project ECHO course on dementia for primary care

Primary care clinicians have an important role in the management of dementia and have expressed interest in continuing education. The authors describe a model they used for providing dementia education in primary care, Project ECHO (Extension for Community Healthcare Outcomes), and an overview of its major features. A partnership including academic institutions and a national healthcare association is then outlined, including the unique features of the ECHO model developed through this partnership. A mixed-methods methodology was used for programmatic evaluation. This use of mixed methods adds vital new knowledge and learner perspectives that are key to planning subsequent ECHO courses related to dementia and primary care. The discussion includes an exploration of the significance of these findings for understanding the motivations of primary care providers for participation in the educational program, as well as the limitations of the current study. A final section explores the next steps in the continued development of the model and its implications for geriatrics education in dementia care, especially the supportive role that ECHO courses can play in meeting the challenges of dementia care.

Constructing custom-made radiotranscriptomic signatures from CT angiograms: an application in COVID-19 vascular inflammation

Background

Advances in computational methodologies have enabled processing of large datasets originating from imaging studies. However, most imaging biomarkers suffer from a lack of direct links with underlying biology, as they are only observationally correlated with pathophysiology.

Purpose

To develop and validate a novel AI-assisted image analysis platform, by applying quantitative radiotranscriptomics that quantifies cytokine-driven vascular inflammation from routine CT angiograms (CTA) performed as part of clinical care in COVID-19.

Methods

We used this platform to train the radiotranscriptomic signature C19-RS, derived from the perivascular space around the aorta and the internal mammary artery in routine chest CTAs, to best describe cytokine-driven vascular inflammation, defined using transcriptomic profiles from RNA sequencing data from human arterial biopsies (A). This signature was validated externally in 358 clinically indicated CT pulmonary angiograms from patients with or without COVID-19 from 3 different geographical regions.

Results

First, 22 patients who had a CTA before the pandemic underwent repeat CTA <6 months post COVID-19 infection (B). Compared with 22 controls (matched for age, gender, and BMI) C19-RS was increased only in the COVID-19 group (C). Next, C19-RS was calculated in a cohort of 331 patients hospitalised during the pandemic, and was higher in COVID-19 positives (adjusted OR=2.97 [95% CI: 1.43–6.27], p=0.004, D). C19-RS had prognostic value for in-hospital mortality in COVID-19, with HR=3.31 ([95% CI: 1.49–7.33], p=0.003) and 2.58 ([95% CI: 1.10–6.05], p=0.028) in two testing cohorts respectively (E, F), adjusted for clinical factors and biochemical biomarkers of inflammation and myocardial injury. The corrected HR for in-hospital mortality was 8.24 [95% CI: 2.16–31.36], p=0.002 for those who received no treatment with dexamethasone, but only 2.27 [95% CI: 0.69–7.55], p=0.18 in those who received dexamethasone subsequently to the C19-RS based image analysis, suggesting that vascular inflammation may have been a therapeutic target of dexamethasone in COVID-19. Finally, C19-RS was strongly associated (r=0.61, p=0.0003) with a whole blood transcriptional module representing dysregulation of coagulation and platelet aggregation pathways.

Conclusion

We present the first proof of concept study that combines transcriptomics with radiomics to provide a platform for the development of machine learning derived radiotranscriptomics analysis of routine clinical CT scans for the development of non-invasive imaging biomarkers. Application in COVID-19 produced C19-RS, a marker of cytokine-driven inflammation driving systemic activation of coagulation, that predicts in-hospital mortality and identifies people who will have better response to anti-inflammatory treatments, allowing targeted therapy. This AI-assisted image analysis platform may have applications across a wide range of vascular diseases, from infections to autoimmune diseases.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): EPSRC, British Heart Foundation, NIHR

The effects of chromium and copper supplementation on mitogen-stimulated T cell proliferation in hypercholesterolaemic postmenopausal women

The purpose of this study was to analyse effects of chromium and/or copper supplementation on immune function in hypercholesterolaemic postmenopausal women. A 2 x 2 factorial research design was used and 40 subjects were supplemented with 0.394 g lactose, 200 microg Cr, 3.0 mg Cu, or 200 microg Cr and 3.0 mg Cu/d for 12 weeks. A significant interactive effect of Cr and Cu supplementation on lymphocyte proliferation was observed with ConA 50 microg/ml stimulation. After 12 weeks of supplementation, ConA-stimulated (50 microg/ml) lymphocyte proliferation was significantly lower when Cu was added to the Cr supplementation group. Moreover, ConA-stimulated (100 microg/ml) lymphocyte proliferation was significantly lower in the Cu supplementation group compared to the Cr supplementation group after 12 weeks of supplementation. These results suggest that Cu blocks enhancement of lymphocyte proliferation by Cr supplementation and that Cu supplementation has potential suppressive effects on the immune function in these subjects.

The dendritic cell populations of mouse lymph nodes

The dendritic cells (DC) of mouse lymph nodes (LN) were isolated, analyzed for surface markers, and compared with those of spleen. Low to moderate staining of LN DC for CD4 and low staining for CD8 was shown to be attributable to pickup of these markers from T cells. Excluding this artifact, five LN DC subsets could be delineated. They included the three populations found in spleen (CD4(+)8(-)DEC-205(-), CD4(-)8(-)DEC-205(-), CD4(-)8(+)DEC-205(+)), although the CD4-expressing DC were of low incidence. LN DC included two additional populations, characterized by relatively low expression of CD8 but moderate or high expression of DEC-205. Both appeared among the DC migrating out of skin into LN, but only one was restricted to skin-draining LN and was identified as the mature form of epidermal Langerhans cells (LC). The putative LC-derived DC displayed the following properties: large size; high levels of class II MHC, which persisted to some extent even in CIITA null mice; expression of very high levels of DEC-205 and of CD40; expression of many myeloid surface markers; and no expression of CD4 and only low to moderate expression of CD8. The putative LC-derived DC among skin emigrants and in LN also showed strong intracellular staining of langerin.

Effect of granulocyte-macrophage colony-stimulating factor on the generation of epidermal Langerhans cells

The role of granulocyte-macrophage colony-stimulating factor (GM-CSF) and Flt3 ligand in the in vivo development of Langerhans cells (LC) was assessed, considering both the steady-state levels of LC in the epidermis and the rate of LC recovery after depletion following lipopolysaccharide (LPS) treatment. The density of LC was determined by counting following IA-specific immunofluorescent staining of epidermal sections from mouse ears. LC levels were compared in beta common chain receptor null (beta c(-/-)) mice that fail to respond to GM-CSF interleukin-5 (IL-5), in GM-CSF transgenic mice with elevated GM-CSF levels, and in mice given daily injections of Flt3 ligand. In the steady state, LC levels were increased in GM-CSF transgenic mice and present at reduced levels in beta c(-/-) mice but unchanged in Flt3 ligand-injected mice. Application of LPS to the ears of control BL/6 mice led to an approximately 70% reduction in LC 4 days later, with recovery beginning by day 8 and a return to normal levels by 2 weeks. This recovery was significantly delayed in beta c(-/-) mice and unchanged in Flt3 ligand-injected mice. These results suggest that GM-CSF (but not Flt3 ligand) enhances recruitment/maturation of LC even though GM-CSF is not essential for their formation.

Protein-kinase-specific inhibitors block Langerhans' cell migration by inhibiting interleukin-1alpha release

Previous studies have shown that depletion of Langerhans' cells (LC) from murine epidermis by the superantigen, staphylococcal enterotoxin A (SEA) involves interleukin-1alpha (IL-1alpha) and is inhibitable by agents that block G-protein-associated kinases. The purpose of this study was to determine whether specific kinase inhibitors block LC depletion by inhibiting IL-1alpha release and to ascertain whether LC depletion by SEA involves cell migration. These goals were addressed by measuring the IL-1alpha release within whole or LC-depleted epidermal cell suspensions in the presence of SEA and/or H-7 (an inhibitor of protein kinase C) or H-8 (an inhibitor of G-protein-associated kinases) and by examining the migration of cells with LC markers in SEA-treated skin sections. The results suggest that LC depletion by SEA involves migration and that this migration is blocked by protein kinase inhibitors, at least in part, through inhibition of SEA-induced IL-1alpha release by epidermal cells.

Superantigen-induced Langerhans cell depletion is mediated by epidermal cell-derived IL-1 alpha and TNF alpha

The purpose of this study was to examine the role of cytokines in staphylococcal enterotoxin-A (SEA)-induced epidermal Langerhans cell (LS) depletion. This was accomplished by analyzing the effect of SEA on cytokine secretion by cultured epidermal cell populations by means of ELISA and by assessing the capacity of cytokines and cytokine-specific antibodies to affect epidermal LC density (as measured by immunoperoxidase staining of epidermal cells bearing surface Ia). The results of this study indicate that SEA induces the secretion of IL-1 alpha and TNF alpha by epidermal cells, that these cytokines induce LC depletion from epidermis, and that antibodies specific for these agents inhibit the depletion of LC by SEA. Taken together, these findings suggest that IL-1 alpha and TNF alpha may play essential roles in SEA-mediated depletion of LC from murine epidermis.

Langerhans' cell depletion by staphylococcal superantigens

Superantigens were examined for effects on the distribution of Langerhans' cells (LC) in mouse skin. This was accomplished by analysing the expression of LC-specific markers, ATPase and IA among the epidermal portion of cultured sections of mouse skin following treatment with staphylococcal enterotoxins. In this study, treatment of skin sections with staphylococcal enterotoxin A or exfoliative toxin but not toxic shock syndrome toxin led to significant depletion of LC. This depletion was inhibited by agents which specifically block the action of GTP binding proteins or their associated kinases (cholera and pertussis toxins and H-8) as well as those which block protein or RNA synthesis. Therefore, signals which lead to LC depletion in response to staphylococcal enterotoxins appear to involve a cholera and pertussis toxin-sensitive GTP-binding protein and protein synthesis. These requirements are identical to those observed previously for LC depletion following exposure of skin to ultraviolet radiation.

High in vitro endotoxin responsiveness of macrophages from an endotoxin-resistant wild rodent species, Sigmodon hispidus

It has been reported that macrophages primarily mediate endotoxin shock and cell death by synthesizing and releasing cytokines, largely tumor necrosis factor (TNF) and interleukin-1 (IL-1). However, macrophages from some laboratory mouse strains such as C3h/HeN are unresponsive to endotoxin both in vivo and in vitro. We found members of a wild rodent species, Sigmodon hispidus, to also be extremely resistant to bacterial endotoxin challenge. Intravenous administration of up to 100,000 micrograms/kg body mass of Escherichia coli O26:B6 endotoxin did not cause lethality in adult S. hispidus. In contrast to the endotoxin-resistant mouse strain, peritoneal macrophages derived from S. hispidus were responsive to in vitro endotoxin challenge as measured by high levels of TNF and IL-1 activity in supernatants of macrophage cultures. Thus, in vitro macrophage responsiveness to endotoxin does not always indicate high host sensitivity to endotoxin challenge.

Requirements for Langerhans' cell depletion following in vitro exposure of murine skin to ultraviolet-B

Langerhans' cells found within the skin and mucous membranes are critical regulators of antimicrobial and allergic responses. Therefore, the depletion of these cells following exposure of skin to solar ultraviolet radiation (UV) has direct functional consequences on immunity within this tissue. In order to understand how Langerhans' cell depletion is regulated following exposure of skin to medium-wave UV (UVB), the role of second messengers in these responses was investigated using a novel in vitro system. This was accomplished by analysing the expression of a specific marker associated with Langerhans' cells (ATPase) among the epidermal portion of cultured sections of mouse skin following treatment with inhibitors specific for second messenger components and subsequent exposure to UVB. In this study, inhibitors of guanosine triphosphate (GTP) binding proteins, H-8, pertussis toxin and cholera toxin as well as inhibitors of RNA and protein synthesis were all capable of blocking Langerhans' cell depletion in response to UVB treatment. In contrast, an inhibitor of protein kinase C (H-7) was incapable of specifically blocking depletion following treatment with this physical agent. These results suggest that Langerhans' cell depletion mediated by UVB may involve a pertussis and cholera toxin-sensitive G protein as well as de novo protein synthesis.

Effects of petrochemicals and ultraviolet radiation on epidermal IA expression in vitro

We previously demonstrated that combined treatment of mice with crude oil and longwave ultraviolet radiation (UVA) led to the depletion of IA-positive cells from the epidermis. In the present study, we have developed an in vitro screening assay for combined effects of purified petrochemicals and UVA on epidermal IA and Thy-1 expression. This method involves removal of skin from donor mice prior to treatment with chemicals and UVA (20,000 J/m2), followed by in vitro culture and subsequent immunoperoxidase staining. In this study, a complete correlation was observed in terms of IA-positive cell density among similarly treated cultured skin and live mice. In vivo and in vitro studies both indicated that anthracene but not phenanthrene or benzo[a]pyrene led to significant depletion of both epidermal Langerhans cells and Thy-1-positive dendritic cells when followed by UVA treatment. The in vitro assay developed for this study should prove to be a valuable tool for the screening of a wide variety of chemicals for contact photosensitizing activity.

Effects of crude oil and ultraviolet radiation on immunity within mouse skin

Previous studies indicate that crude oil leads to increased pigmentation and erythema (sunburn) in response to sunlight in exposed individuals. However, no information is currently available concerning whether crude oil exposure might enhance the immunosuppressive effects of solar ultraviolet radiation (UVR) on the skin. In order to address this question, the back skin of shaved, female C3H/HeN mice was exposed to crude oil with or without subsequent treatment with medium-wavelength (UVB) (200 J/m2) or long-wavelength (UVA) (20,000 J/m2) UVR. Immune function was assessed in treated mice by measuring their ability to mount contact hypersensitivity responses to a hapten (2,4-dinitro-1-flyorobenzene, DNGFB) applied to the site of crude oil and UVR treatment as determined by ear swelling upon subsequent challenge. Since Langerhans cells represent an important component of immunity within the skin and because suppression of contact hypersensitivity following UVR treatment is often accompanied by disappearance of Langerhans cells from the epidermis, the impact of these agents on epidermal Langerhans cell density was also analyzed. This was accomplished by enumerating IA-positive cells within the epidermis of treated skin. In these studies, crude oil alone induced inhibition of contact hypersensitivity but had no effect on epidermal Langerhans cells. In contrast, combined treatment with crude oil and UVA led to suppression of contact hypersensitivity, which was accompanied by depletion of epidermal Langerhans cells.

Tumor-associated macrophages share in vitro growth characteristics with resident but not elicited macrophages

Recent studies have shown that tissue macrophages are capable of proliferation and that this capability is enhanced by various cytokines, including macrophage colony-stimulating factor (M-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF). Tumor-associated macrophages (TAM) have been demonstrated to proliferate in vitro, but no information is currently available on the ability of M-CSF and GM-CSF to enhance this response. To address this problem, limiting dilution analysis was utilized to examine the proliferative ability of macrophages isolated from two murine tumors of distinct origin following growth in secondary hosts. As a means of comparison, resident peritoneal macrophages (RPM) and thioglycolate-elicited macrophages (TEM) were also analyzed. Results indicate that a rare subset of TAM and RPM is capable of proliferation and that M-CSF and GM-CSF enhance the frequency of TAM and RPM which proliferate, but do not enhance the growth of TEM.

Prospective partition analysis of independently assorted sets. Accessory elements supporting clonal lymphoid activation by mitogens

Accessory cells for mitogen-induced clonal proliferation of lymphocytes can be found after in vitro culture of murine spleen cells. Mitogenic activation of T cells (concanavalin A) depends on such accessory cells. When the cultures in which the accessory cells developed are partitioned, assortment of the accessory cells in cultures is found. When small numbers (1-10) of responder cells, T cells, are dispensed into the above cultures, clonal growth of the T cells is achieved. Neither the dose-response profile of accessory cells nor that of responding cells shows single hit kinetics. Re-categorizing the data set reveals that only cultures with over 20 adherent cells were likely to promote T cell growth and single hit kinetics for the responding cell clone and the accessory cell clone were obtained.