Spatial comparison of molecular features associated with resistance to pembrolizumab in BCG unresponsive bladder cancer

Intravenous immune checkpoint inhibition achieves a 40% 3-month response in BCG-unresponsive non-muscle invasive bladder cancer (NMIBC) with carcinoma in situ. Yet, only half of the early responders will continue to be disease-free by 12 months, and resistance mechanisms are poorly defined. We performed spatial profiling of BCG-unresponsive tumors from patients responsive or resistant to intravenous pembrolizumab treatment, analyzing samples both before initiating and 3 months post-intravenous pembrolizumab treatment. We analyzed 119 regions of interest, which included 59 pairs of epithelial and adjacent stromal segments across five patients: two responders and three non-responders. We demonstrate that BCG unresponsive tumors with an inflamed PanCK+ tumor area and an infiltrated stromal segment respond better to intravenous pembrolizumab. Furthermore, using segment-specific gene signatures generated from a cohort of BCG unresponsive NMIBC treated with intravesical BCG+pembrolizumab, we find that non-inflamed, immune-cold tumors that do not respond to intravenous pembrolizumab exhibit a favorable outcome to the combined application of BCG and pembrolizumab. For the first time, we have identified molecular features of tumors associated with response and resistance to intravenous pembrolizumab in BCG unresponsive NMIBCs. Further research with more patients and alternative checkpoint inhibitors is essential to validate our findings. We anticipate that using a transcriptomics signature like the one described here can help identify tumors with a higher possibility of responding to intravenous pembrolizumab.

Behavioral Activation: Values-Aligned Activity Engagement as a Transdiagnostic Intervention for Common Geriatric Conditions

Scalable, transdiagnostic interventions are needed to meet the needs of a growing population of older adults experiencing multimorbidity and functional decline. Behavioral activation (BA) is a pragmatic, empirically supported treatment for depression that focuses on increasing engagement in values-aligned activities. We propose BA is an ideal transdiagnostic intervention approach for older adults because it (a) specifically targets activity restriction, a shared characteristic of common conditions of aging; and (b) has strong potential for scalability through delivery by a broad range of clinician and nonclinician interventionists and via telehealth. We describe the history of BA and review recent literature demonstrating impacts beyond depression including on cognition, social isolation, and disability. We also describe the feasibility of delivering BA across interventionists, settings, and modalities. Our approach advances scholarship by proposing BA as a scalable, transdiagnostic behavioral intervention to address functional decline in older adults with common geriatric conditions.

Risk factors for oral infection and dry socket post-tooth extraction in medically complex patients in the absence of antibiotic prophylaxis: A case-control study

INTRODUCTION

Dry socket and infection are complications of tooth extractions. The objective was to determine risk factors for post-extraction complications in patients without antibiotic prophylaxis stratified by early- and late-complications and complication type (oral infection and dry socket).

METHODS

Retrospective, case (with complications)-control (without complications) study of patients (n = 708) who had ≥1 extraction performed at any Veterans Health Administration facility between 2015-2019 and were not prescribed an antibiotic 30 days pre-extraction.

RESULTS

Early complication cases (n = 109) were more likely to be female [odds ratio (OR) = 2.06; 95% confidence interval (CI):1.05-4.01], younger (OR = 0.29; 95% CI:0.09-0.94 patients ≥ 80 years old, reference:18-44 years), Native American/Alaska Native (OR = 21.11; 95% CI:2.33-191.41) and have fewer teeth extracted (OR = 0.53 3+ teeth extracted; 95% CI:0.31-0.88, reference:1 tooth extracted). Late complication cases (n = 67) were more likely to have a bipolar diagnosis (OR = 2.98; 95% CI:1.04-8.57), history of implant placement (OR = 8.27; 95% CI:1.63-41.82), and history of past smoking (OR = 2.23; 95% CI:1.28-3.88).

CONCLUSION

Predictors for post-extraction complications among patients who did not receive antibiotic prophylaxis were similar to prior work in cohorts who received prophylaxis. Unique factors identified in a medically complex population included being younger, Native American/Alaska Native, having mental health conditions, history of a dental implant, and fewer teeth extracted.

Implementation of Direct-to-Patient Mobile Teledermatology in VA

BACKGROUND

Innovative technology can enhance patient access to healthcare but must be successfully implemented to be effective.

OBJECTIVE

We evaluated Department of Veterans Affairs' (VA's) implementation of My VA Images, a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person.

DESIGN /PARTICIPANTS/APPROACH

Following pilot testing at 3 facilities, the app was introduced to 28 facilities (4 groups of 7) every 3 months using a stepped-wedge cluster-randomized design. Using the Organizational Theory of Implementation Effectiveness, we examined the app's implementation using qualitative and quantitative data consisting of encounter data from VA's corporate data warehouse; app usage from VA's Mobile Health database; bi-monthly reports from facility representatives; phone interviews with clinicians; and documented communications between the operational partner and facility staff.

KEY RESULTS

Implementation policies and practices included VA's vision to expand home telehealth and marketing/communication strategies. The COVID-19 pandemic dominated the implementation climate by stressing staffing, introducing competing demands, and influencing stakeholder attitudes to the app, including its fit to their values. These factors were associated with mixed implementation effectiveness, defined as high quality consistent use. Nineteen of 31 exposed facilities prepared to use the app; 10 facilities used it for actual patient care, 7 as originally intended. Residents, nurse practitioners, and physician assistants were more likely than attendings to use the app. Facilities exposed to the app pre-pandemic were more likely to use and sustain the new process.

CONCLUSIONS

Considerable heterogeneity existed in implementing mobile teledermatology, despite VA's common mission, integrated healthcare system, and stakeholders' broad interest. Identifying opportunities to target favorable facilities and user groups (such as teaching facilities and physician extenders, respectively) while addressing internal implementation barriers including incomplete integration with the electronic health record as well as inadequate staffing may help optimize the initial impact of direct-to-patient telehealth. The COVID pandemic was a notable extrinsic barrier.

CLINICAL TRIALS REGISTRATION

NCT03241589.

Determinants of referral network size for screening colonoscopies in the Veterans Health Administration after the implementation of the MISSION Act

OBJECTIVE

To measure key characteristics of the Veterans Health Administration's (VHA) Community Care (CC) referral network for screening colonoscopy and identify market and institutional factors associated with network size.

DATA SOURCES

VHA electronic health records, CC claim data, and National Plan and Provider Enumeration System.

STUDY DESIGN

In this retrospective cross-sectional study, we measure the size of the VHA's CC referral networks over time and by VHA parent facility (n = 137). We used a multivariable linear regression to identify factors associated with network size at the market-year level. Network size was measured as the number of physicians who performed at least one VHA-purchased screening colonoscopy per 1000 enrollees at baseline.

DATA EXTRACTION

Data were extracted for all Veterans (n = 102,119) who underwent a screening colonoscopy purchased by the VHA from a non-VHA physician from 2018 to 2021.

PRINCIPAL FINDINGS

From 2018 to 2021, median network volume of screening colonoscopies per 1000 enrollees grew from 1.6 (IQR: 0.6, 4.6) to 3.6 (IQR: 1.6, 6.6). The median network size grew from 0.63 (IQR: 0.30, 1.26) to 0.92 (IQR: 0.57, 1.63). Finally, the median procedures per physician increased from 2.5 (IQR: 1.6, 4.2) to 3.2 (IQR: 2.4, 4.7). After adjusting for baseline market characteristics, volume of screening colonoscopies was positively related to network size (β = 0.15, 95% CI: [0.10, 0.20]), negatively related to procedures per physician (β = -0.12, 95% CI: [-0.18, -0.05]), and positively associated with the percent of rural enrollees (β = 0.01, 95% CI: [0.00, 0.01]).

CONCLUSIONS

VHA facilities with a higher volume of VHA-purchased screening colonoscopies and more rural enrollees had more non-VHA physicians providing care. Geographic variation in referral networks may also explain differences in the effects of the MISSION Act on access to care and patient outcomes.

Intestinal FFA2 promotes obesity by altering food intake in Western diet-fed mice

Short-chain fatty acids (SCFAs) are key nutrients that play a diverse set of roles in physiological function, including regulating metabolic homeostasis. Generated through the fermentation of dietary fibers in the distal colon by the gut microbiome, SCFAs and their effects are partially mediated by their cognate receptors, including free fatty acid receptor 2 (FFA2). FFA2 is highly expressed in the intestinal epithelial cells, where its putative functions are controversial, with numerous in vivo studies relying on global knockout mouse models to characterize intestine-specific roles of the receptor. Here, we used the Villin-Cre mouse line to generate a novel, intestine-specific knockout mouse model for FFA2 (Vil-FFA2) to investigate receptor function within the intestine. Because dietary changes are known to affect the composition of the gut microbiome, and can thereby alter SCFA production, we performed an obesogenic challenge on male Vil-FFA2 mice and their littermate controls (FFA2-floxed, FFA2fl/fl) to identify physiological changes on a high-fat, high-sugar 'Western diet' (WD) compared to a low-fat control diet (CD). We found that the WD-fed Vil-FFA2 mice were transiently protected from the obesogenic effects of the WD and had lower fat mass and improved glucose homeostasis compared to the WD-fed FFA2fl/fl control group during the first half of the study. Additionally, major differences in respiratory exchange ratio and energy expenditure were observed in the WD-fed Vil-FFA2 mice, and food intake was found to be significantly reduced at multiple points in the study. Taken together, this study uncovers a novel role of intestinal FFA2 in mediating the development of obesity.

The economic impact of cannabis use disorder and dementia diagnosis in veterans diagnosed with traumatic brain injury

Background

Studies have demonstrated that individuals diagnosed with traumatic brain injury (TBI) frequently use medical and recreational cannabis to treat persistent symptoms of TBI, such as chronic pain and sleep disturbances, which can lead to cannabis use disorder (CUD). We aimed to determine the Veterans Health Administration (VHA) healthcare utilization and costs associated with CUD and dementia diagnosis in veterans with TBI.

Methods

This observational study used administrative datasets from the population of post-9/11 veterans from the Long-term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium and the VA Data Warehouse. We compared the differential VHA costs among the following cohorts of veterans: (1) No dementia diagnosis and No CUD group, (2) Dementia diagnosis only (Dementia only), (3) CUD only, and (4) comorbid dementia diagnosis and CUD (Dementia and CUD). Generalized estimating equations and negative binomial regression models were used to estimate total annual costs (inflation-adjusted) and the incidence rate of healthcare utilization, respectively, by dementia diagnosis and CUD status.

Results

Data from 387,770 veterans with TBI (88.4% men; median [interquartile range (IQR)] age at the time of TBI: 30 [14] years; 63.5% white) were followed from 2000 to 2020. Overall, we observed a trend of gradually increasing healthcare costs 5 years after TBI onset. Interestingly, in this cohort of veterans within 5 years of TBI, we observed substantial healthcare costs in the Dementia only group (peak = $46,808) that were not observed in the CUD and dementia group. Relative to those without either condition, the annual total VHA costs were $3,368 higher in the CUD only group, while no significant differences were observed in the Dementia only and Dementia and CUD groups.

Discussion

The findings suggest that those in the Dementia only group might be getting their healthcare needs met more quickly and within 5 years of TBI diagnosis, whereas veterans in the Dementia and CUD group are not receiving early care, resulting in higher long-term healthcare costs. Further investigations should examine what impact the timing of dementia and CUD diagnoses have on specific categories of inpatient and outpatient care in VA and community care facilities.

MICB Genomic Variant Is Associated with NKG2D-mediated Acute Lung Injury and Death

Rationale: Acute lung injury (ALI) carries a high risk of mortality but has no established pharmacologic therapy. We previously found that experimental ALI occurs through natural killer (NK) cell NKG2D receptor activation and that the cognate human ligand, MICB, was associated with ALI after transplantation. Objectives: To investigate the association of a common missense variant, MICBG406A, with ALI. Methods: We assessed MICBG406A genotypes within two multicenter observational study cohorts at risk for ALI: primary graft dysfunction (N = 619) and acute respiratory distress syndrome (N = 1,376). Variant protein functional effects were determined in cultured and ex vivo human samples. Measurements and Main Results: Recipients of MICBG406A-homozygous allografts had an 11.1% absolute risk reduction (95% confidence interval [CI], 3.2-19.4%) for severe primary graft dysfunction after lung transplantation and reduced risk for allograft failure (hazard ratio, 0.36; 95% CI, 0.13-0.98). In participants with sepsis, we observed 39% reduced odds of moderately or severely impaired oxygenation among MICBG406A-homozygous individuals (95% CI, 0.43-0.86). BAL NK cells were less frequent and less mature in participants with MICBG406A. Expression of missense variant protein MICBD136N in cultured cells resulted in reduced surface MICB and reduced NKG2D ligation relative to wild-type MICB. Coculture of variant MICBD136N cells with NK cells resulted in less NKG2D activation and less susceptibility to NK cell killing relative to the wild-type cells. Conclusions: These data support a role for MICB signaling through the NKG2D receptor in mediating ALI, suggesting a novel therapeutic approach.

Understanding rural-urban differences in veterans' internet access, use and patient preferences for telemedicine

BACKGROUND

The expansion of telemedicine (e.g., telephone or video) in the Veterans Health Administration (VA) raises concerns for health care disparities between rural and urban veterans. Factors impeding telemedicine use (e.g., broadband, digital literacy, age) disproportionally affect rural veterans.

PURPOSE

To examine veteran-reported broadband access, internet use, familiarity with, and preferences for telemedicine stratified by residential rurality.

METHODS

Three hundred fifty veterans with a VA primary care visit in March 2022 completed a 30-min computer-assisted telephone interview. The sampling design stratified veterans by residential rurality (i.e., rural or urban) and how primary care was delivered (i.e., in-person or by video). Counts and weighted percentages are reported.

FINDINGS

After accounting for survey weights, 96.2% of respondents had in-home internet access and 89.5% reported functional connection speeds. However, rural- compared to urban-residing veterans were less likely to experience a telemedicine visit in the past year (74.1% vs. 85.2%; p = 0.02). When comparing telemedicine to in-person visits, rural versus urban-residing veterans rated them not as good (45.3% vs. 36.8%), just as good (51.1% vs. 53.1%), or better (3.5% vs. 10.0%) (p = 0.05). To make telemedicine visits easier, veterans, regardless of where they lived, recommended technology training (46.4%), help accessing the internet (26.1%), or provision of an internet-enabled device (25.9%).

CONCLUSIONS

Though rural-residing veterans were less likely to experience a telemedicine visit, the same actionable facilitators to improve telemedicine access were reported regardless of residential rurality. Importantly, technology training was most often recommended. Policy makers, patient advocates, and other stakeholders should consider novel initiatives to provide training resources.

The Relevance of Animal Models of Social Isolation and Social Motivation for Understanding Schizophrenia: Review and Future Directions

BACKGROUND AND HYPOTHESES

Social dysfunction in schizophrenia includes symptoms of withdrawal and deficits in social skills, social cognition, and social motivation. Based on the course of illness, with social withdrawal occurring prior to psychosis onset, it is likely that the severity of social withdrawal/isolation contributes to schizophrenia neuropathology.

STUDY DESIGN

We review the current literature on social isolation in rodent models and provide a conceptual framework for its relationship to social withdrawal and neural circuit dysfunction in schizophrenia. We next review preclinical tasks of social behavior used in schizophrenia-relevant models and discuss strengths and limitations of existing approaches. Lastly, we consider new effort-based tasks of social motivation and their potential for translational studies in schizophrenia.

STUDY RESULTS

Social isolation rearing in rats produces profound differences in behavior, pharmacologic sensitivity, and neurochemistry compared to socially reared rats. Rodent models relevant to schizophrenia exhibit deficits in social behavior as measured by social interaction and social preference tests. Newer tasks of effort-based social motivation are being developed in rodents to better model social motivation deficits in neuropsychiatric disorders.

CONCLUSIONS

While experimenter-imposed social isolation provides a viable experimental model for understanding some biological mechanisms linking social dysfunction to clinical and neural pathology in schizophrenia, it bypasses critical antecedents to social isolation in schizophrenia, notably deficits in social reward and social motivation. Recent efforts at modeling social motivation using effort-based tasks in rodents have the potential to quantify these antecedents, identify models (eg, developmental, genetic) that produce deficits, and advance pharmacological treatments for social motivation.

Chronic basal forebrain activation improves spatial memory, boosts neurotrophin receptor expression, and lowers BACE1 and Aβ42 levels in the cerebral cortex in mice

The etiology of Alzheimer's dementia has been hypothesized in terms of basal forebrain cholinergic decline, and in terms of reflecting beta-amyloid neuropathology. To study these different biological elements, we activated the basal forebrain in 5xFAD Alzheimer's model mice and littermates. Mice received 5 months of 1 h per day intermittent stimulation of the basal forebrain, which includes cholinergic projections to the cortical mantle. Then, mice were behaviorally tested followed by tissue analysis. The 5xFAD mice performed worse in water-maze testing than littermates. Stimulated groups learned the water maze better than unstimulated groups. Stimulated groups had 2-3-fold increases in frontal cortex immunoblot measures of the neurotrophin receptors for nerve growth factor and brain-derived neurotrophic factor, and a more than 50% decrease in the expression of amyloid cleavage enzyme BACE1. Stimulation also led to lower Aβ42 in 5xFAD mice. These data support a causal relationship between basal forebrain activation and both neurotrophin activation and reduced Aβ42 generation and accumulation. The observation that basal forebrain activation suppresses Aβ42 accumulation, combined with the known high-affinity antagonism of nicotinic receptors by Aβ42, documents bidirectional antagonism between acetylcholine and Aβ42.

Effect of a Predictive Analytics-Targeted Program in Patients on Opioids: a Stepped-Wedge Cluster Randomized Controlled Trial

BACKGROUND

Risk of overdose, suicide, and other adverse outcomes are elevated among sub-populations prescribed opioid analgesics. To address this, the Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM)-a provider-facing dashboard that utilizes predictive analytics to stratify patients prescribed opioids based on risk for overdose/suicide.

OBJECTIVE

To evaluate the impact of the case review mandate on serious adverse events (SAEs) and all-cause mortality among high-risk Veterans.

DESIGN

A 23-month stepped-wedge cluster randomized controlled trial in all 140 VHA medical centers between 2018 and 2020.

PARTICIPANTS

A total of 44,042 patients actively prescribed opioid analgesics with high STORM risk scores (i.e., percentiles 1% to 5%) for an overdose or suicide-related event.

INTERVENTION

A mandate requiring providers to perform case reviews on opioid analgesic-prescribed patients at high risk of overdose/suicide.

MAIN MEASURES

Nine serious adverse events (SAEs), case review completion, number of risk mitigation strategies, and all-cause mortality.

KEY RESULTS

Mandated review inclusion was associated with a significant decrease in all-cause mortality within 4 months of inclusion (OR: 0.78; 95% CI: 0.65-0.94). There was no detectable effect on SAEs. Stepped-wedge analyses found that mandated review patients were five times more likely to receive a case review than non-mandated patients with similar risk (OR: 5.1; 95% CI: 3.64-7.23) and received more risk mitigation strategies than non-mandated patients (0.498; CI: 0.39-0.61).

CONCLUSIONS

Among VHA patients prescribed opioid analgesics, identifying high risk patients and mandating they receive an interdisciplinary case review was associated with a decrease in all-cause mortality. Results suggest that providers can leverage predictive analytic-targeted population health approaches and interdisciplinary collaboration to improve patient outcomes.

TRIAL REGISTRATION

ISRCTN16012111.

Job Characteristics Associated With Intent to Quit Among Nursing Home Employees and Managers

BACKGROUND AND OBJECTIVES

High turnover and recruitment challenges of nursing home employees and managers are an ongoing concern. This study's objective was to examine intent to quit among all staff and assess the roles of job characteristics and job satisfaction. Employees and managers within one nursing home chain working in direct patient care or nursing were compared.

RESEARCH DESIGN AND METHODS

Data came from the Work, Family, Health Network 18-month follow-up survey in 2012 (total = 1,000, managers = 101, employees = 899). A cumulative logit model controlling for demographics was estimated for intent to quit. Herzberg's Two-Factor Theory of Work Motivation guided the study.

RESULTS

Employees scored significantly lower on family-supportive supervisor behaviors (FSSBs), schedule control, and decision authority than managers. Employees and managers did not differ on job satisfaction, intent to quit, or job demands. Satisfied workers had an 83% decrease in the odds of reporting an intent to quit compared to workers who were neutral or disagreed (odds ratio [OR] = 0.17, p < .0001). Decision authority (OR = 3.49) and schedule control (OR = 5.18) were independently related to greater odds of reporting an intent to quit. In contrast, FSSBs (OR = 0.69), safety compliance (OR = 0.71), and the combination of high decision authority with high schedule control (OR = 0.72) were related to lower odds of reporting an intent to quit.

DISCUSSION AND IMPLICATIONS

Among nursing home staff, lower intent to quit may be achieved through improving job satisfaction, the quality of supervision, safety culture, and job enrichment through more schedule control and decision-making power.

Insomnia symptoms and postoperative healthcare utilization in veterans undergoing decompressive laminectomy for lumbar spinal stenosis

Study Objectives

Lumbar spinal stenosis is an age-related spine condition that contributes to pain and disability. Decompressive laminectomy (DL) is regularly performed to alleviate symptoms. Insomnia symptoms are common among people living with chronic pain and may affect key DL outcomes, such as healthcare utilization. We examined associations of insomnia symptom severity with post-DL healthcare utilization in veterans with lumbar spinal stenosis.

Methods

Veterans (N = 200) with lumbar spinal stenosis undergoing DL were recruited into a prospective cohort study and self-reported insomnia symptom severity on the Insomnia Severity Index prior to DL. Post-DL, veterans reported on pain and non-pain-related monthly healthcare office visits, emergency room visits, hospitalizations, and mental health visits for 1 year. Incident rate ratios (IRRs) obtained via negative binomial regression evaluated associations of insomnia symptom severity with healthcare utilization rates.

Results

Approximately 51% of participants endorsed insomnia symptoms of at least mild severity. Participants who reported at least mild insomnia symptoms had more healthcare office visits (IRR = 1.23, p = .04), general mental health visits (IRR = 3.98, p < .0001), and pain-related mental health visits (IRR = 9.55, p = .01) than those without insomnia symptoms. Adjusting for covariates, rates of mental health visits, overall (IRR = 3.13, p = .001) and pain-related (IRR = 6.93, p = .02), remained statistically significantly higher.

Conclusions

Insomnia symptoms are associated with postoperative healthcare utilization lending support for future work to examine the value of assessing and intervening on insomnia symptoms prelaminectomy.

Emerging precision neoadjuvant systemic therapy for patients with resectable non-small cell lung cancer: current status and perspectives

Over the past decade, targeted therapy for oncogene-driven NSCLC and immune checkpoint inhibitors for non-oncogene-driven NSCLC, respectively, have greatly improved the survival and quality of life for patients with unresectable NSCLC. Increasingly, these biomarker-guided systemic therapies given before or after surgery have been used in patients with early-stage NSCLC. In March 2022, the US FDA granted the approval of neoadjuvant nivolumab and chemotherapy for patients with stage IB-IIIA NSCLC. Several phase II/III trials are evaluating the clinical efficacy of various neoadjuvant immune checkpoint inhibitor combinations for non-oncogene-driven NSCLC and neoadjuvant molecular targeted therapies for oncogene-driven NSCLC, respectively. However, clinical application of precision neoadjuvant treatment requires a paradigm shift in the biomarker testing and multidisciplinary collaboration at the diagnosis of early-stage NSCLC. In this comprehensive review, we summarize the current diagnosis and treatment landscape, recent advances, new challenges in biomarker testing and endpoint selections, practical considerations for a timely multidisciplinary collaboration at diagnosis, and perspectives in emerging neoadjuvant precision systemic therapy for patients with resectable, early-stage NSCLC. These biomarker-guided neoadjuvant therapies hold the promise to improve surgical and pathological outcomes, reduce systemic recurrences, guide postoperative therapy, and improve cure rates in patients with resectable NSCLC.

Veteran Acceptance of Sleep Health Information Technology: a Mixed-Method Study

Sleep disturbances, including chronic insomnia and sleep apnea, are major concerns for US veterans, with rising rates and detrimental effects on physical, mental, and social well-being. Sleep disturbances in veterans are also underdiagnosed and undertreated for reasons that include limited sleep clinician availability, long wait times, and the time commitment for treatment. Greater use of sleep health information technologies could improve access to assessment and treatment of sleep disturbances. However, the assessment of acceptance of these technologies among veterans is still ongoing. This mixed-method study combines data from two separate but similar randomized controlled trials to assess acceptance of sleep health information technologies for veterans with chronic insomnia. Sleep health information technologies included in these trials were the following: (1) a WatchPAT sleep monitor for home-based sleep assessment, including detection of sleep apnea, and (2) the VA mobile app Cognitive Behavioral Therapy for Insomnia (CBT-i Coach), which supports self-management of insomnia. The combined sample of 37 veterans receiving care within one New England VA medical center completed a six-week trial using both health information technology tools. Participants completed a survey and interview at the end of the 6 weeks. Overall, participants found the tools acceptable, easy to use, and useful and reported they would use them in the future. Thus, these sleep health information technologies appear to provide an acceptable remote option for assessing and managing sleep issues for veterans. ClinicalTrials.gov NCT02392000; http://clinicaltrials.gov/ct2/show/NCT02392000 and ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354.

Diminished cell proliferation promotes natural killer cell adaptive-like phenotype by limiting FcεRIγ expression

Human adaptive-like natural killer (NK) cells express low levels of FcεRIγ (FcRγ-/low) and are reported to accumulate during COVID-19 infection; however, the mechanism underlying and regulating FcRγ expression in NK cells has yet to be fully defined. We observed lower FcRγ protein expression in NK cell subsets from lung transplant patients during rapamycin treatment, suggesting a link with reduced mTOR activity. Further, FcRγ-/low NK cell subsets from healthy donors displayed reduced mTOR activity. We discovered that FcRγ upregulation is dependent on cell proliferation progression mediated by IL-2, IL-15, or IL-12, is sensitive to mTOR suppression, and is inhibited by TGFβ or IFNα. Accordingly, the accumulation of adaptive-like FcRγ-/low NK cells in COVID-19 patients corresponded to increased TGFβ and IFNα levels and disease severity. Our results show that an adaptive-like NK cell phenotype is induced by diminished cell proliferation and has an early prognostic value for increased TGFβ and IFNα levels in COVID-19 infection associated with disease severity.

Survival analysis of localized prostate cancer with deep learning

In recent years, data-driven, deep-learning-based models have shown great promise in medical risk prediction. By utilizing the large-scale Electronic Health Record data found in the U.S. Department of Veterans Affairs, the largest integrated healthcare system in the United States, we have developed an automated, personalized risk prediction model to support the clinical decision-making process for localized prostate cancer patients. This method combines the representative power of deep learning and the analytical interpretability of parametric regression models and can implement both time-dependent and static input data. To collect a comprehensive evaluation of model performances, we calculate time-dependent C-statistics [Formula: see text] over 2-, 5-, and 10-year time horizons using either a composite outcome or prostate cancer mortality as the target event. The composite outcome combines the Prostate-Specific Antigen (PSA) test, metastasis, and prostate cancer mortality. Our longitudinal model Recurrent Deep Survival Machine (RDSM) achieved [Formula: see text] 0.85 (0.83), 0.80 (0.83), and 0.76 (0.81), while the cross-sectional model Deep Survival Machine (DSM) attained [Formula: see text] 0.85 (0.82), 0.80 (0.82), and 0.76 (0.79) for the 2-, 5-, and 10-year composite (mortality) outcomes, respectively. In addition to estimating the survival probability, our method can quantify the uncertainty associated with the prediction. The uncertainty scores show a consistent correlation with the prediction accuracy. We find PSA and prostate cancer stage information are the most important indicators in risk prediction. Our work demonstrates the utility of the data-driven machine learning model in prostate cancer risk prediction, which can play a critical role in the clinical decision system.

Calpain-mediated protein targets in cardiac mitochondria following ischemia-reperfusion

Calpain 1 and 2 (CPN1/2) are calcium-dependent cysteine proteases that exist in cytosol and mitochondria. Pharmacologic inhibition of CPN1/2 decreases cardiac injury during ischemia (ISC)-reperfusion (REP) by improving mitochondrial function. However, the protein targets of CPN1/2 activation during ISC-REP are unclear. CPN1/2 include a large subunit and a small regulatory subunit 1 (CPNS1). Genetic deletion of CPNS1 eliminates the activities of both CPN1 and CPN2. Conditional cardiomyocyte specific CPNS1 deletion mice were used in the present study to clarify the role of CPN1/2 activation in mitochondrial damage during ISC-REP with an emphasis on identifying the potential protein targets of CPN1/2. Isolated hearts from wild type (WT) or CPNS1 deletion mice underwent 25 min in vitro global ISC and 30 min REP. Deletion of CPNS1 led to decreased cytosolic and mitochondrial calpain 1 activation compared to WT. Cardiac injury was decreased in CPNS1 deletion mice following ISC-REP as shown by the decreased infarct size compared to WT. Compared to WT, mitochondrial function was improved in CPNS1 deletion mice following ischemia-reperfusion as shown by the improved oxidative phosphorylation and decreased susceptibility to mitochondrial permeability transition pore opening. H2O2 generation was also decreased in mitochondria from deletion mice following ISC-REP compared to WT. Deletion of CPNS1 also resulted in less cytochrome c and truncated apoptosis inducing factor (tAIF) release from mitochondria. Proteomic analysis of the isolated mitochondria showed that deletion of CPNS1 increased the content of proteins functioning in regulation of mitochondrial calcium homeostasis (paraplegin and sarcalumenin) and complex III activity. These results suggest that activation of CPN1 increases cardiac injury during ischemia-reperfusion by impairing mitochondrial function and triggering cytochrome c and tAIF release from mitochondria into cytosol.

A Novel Approach to Link Genetics and Human MRI Identifies AKAP7-Dependent Subicular/Prefrontal Functional Connectivity as Altered in Suicidality

Background

Brain imaging and genetics are fields acquiring data at increasing speed, but more information does not always result in a better understanding of the underlying biology. We developed the ProcessGeneLists (PGL) approach to use genetics and mRNA gene expression data to generate regions of interest for imaging studies.

Methods

We applied PGL to past suicide attempt (ATT): We averaged the mRNA expression levels of genes (n = 130) possibly associated with ATT (p ≤ 10-3 in a published genome-wide association study, GWAS) in each brain region studied in the Human Allen Brain Atlas (6 ex-vivo brains, 158 to 946 regions/brain have mRNA expression data) and compared that to the averaged mRNA expression levels of all other genes in each region in each brain in the atlas.

Results

PGL revealed 8 regions where "attempt-related genes" were differentially expressed (Wilcoxon test with Bonferroni correction 8.88-11 = 

Conclusion

PGL uncovered a brain function/genotype interaction in ATT by using published GWAS data to inform imaging studies. This could inform individualized therapies in the future.

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Key Words

• AKAP-7
• dorsolateral prefrontal cortex
• habenula
• resting state functional connectivity
• subiculum
• suicide

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MESH Headings Collapse

Grants

• I01 CX000994 CSRD VA
• I01 CX001937 CSRD VA
• Office of Research and Development
• National Alliance for Research on Schizophrenia and Depression
• American Foundation for Suicide Prevention
• Robert and Janice McNair Foundation

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Decreased Brain Ventricular Volume in Psychiatric Inpatients with Serotonin Reuptake Inhibitor Treatment

Background

Brain ventricles have been reported to be enlarged in several neuropsychiatric disorders and in aging. Whether human cerebral ventricular volume can decrease over time with psychiatric treatment is not well-studied. The aim of this study was to examine whether inpatients taking serotonin reuptake inhibitors (SRI) exhibited reductions in cerebral ventricular volume.

Methods

Psychiatric inpatients, diagnosed mainly with depression, substance use, anxiety, and personality disorders, underwent two imaging sessions (Time 1 and Time 2, approximately 4 weeks apart). FreeSurfer was used to quantify volumetric features of the brain, and ANOVA was used to analyze ventricular volume differences between Time 1 and Time 2. Inpatients' brain ventricle volumes were normalized by dividing by estimated total intracranial volume (eTIV). Clinical features such as depression and anxiety levels were collected at Time 1, Time 1.5 (approximately 2 weeks apart), and Time 2.

Results

Inpatients consistently taking SRIs (SRI + , n = 44) showed statistically significant reductions of brain ventricular volumes particularly for their left and right lateral ventricular volumes. Reductions in their third ventricular volume were close to significance (p = .068). The inpatients that did not take SRIs (SRI-, n = 25) showed no statistically significant changes in brain ventricular volumes. The SRI + group also exhibited similar brain structural features to the healthy control group based on the 90% confidence interval comparsions on brain ventricular volume parameters, whereas the SRI- group still exhibited relatively enlarged brain ventricular volumes after treatment.

Conclusions

SRI treatment was associated with decreased brain ventricle volume over treatment.

Neural Changes in Reward Processing Following Approach Avoidance Training for Depression

Altered approach motivation is hypothesized to be critical for the maintenance of depression. Computer-administered approach-avoidance training programs to increase approach action tendencies toward positive stimuli produce beneficial outcomes. However, there have been few studies examining neural changes following approach-avoidance training. Participants with Major Depressive Disorder were randomized to an Approach Avoidance Training (AAT) manipulation intended to increase approach tendencies for positive social cues (n=13) or a control procedure (n=15). We examined changes in neural activation (primary outcome) and connectivity patterns using Group Iterative Multiple Model Estimation during a social reward anticipation task (exploratory). A laboratory-based social affiliation task was also administered following the manipulation to measure affect during anticipation of real-world social activity. Individuals in the AAT group demonstrated increased activation in reward processing regions during social reward anticipation relative to the control group from pre to post-training. Following training, connectivity patterns across reward regions were observed in the full sample and connectivity between the medial PFC and caudate was associated with anticipatory positive affect before the social interaction; preliminary evidence of differential connectivity patterns between the two groups also emerged. Results support models whereby modifying approach-oriented behavioral tendencies with computerized training leads to alterations in reward circuitry. (NCT02330744).

Risk factors for adverse outcomes among 35 879 veterans with and without diabetes after diagnosis with COVID-19

INTRODUCTION

Risk factors and mediators of associations of diabetes with COVID-19 outcomes are unclear.

RESEARCH DESIGN AND METHODS

We identified all veterans receiving Department of Veterans Affairs healthcare with ≥1 positive nasal swab for SARS-CoV-2 (28 February-31 July 2020; n=35 879). We assessed associations of diabetes (with and without insulin use) with hospitalization, intensive care unit (ICU) admission, or death at 30 days, and with hazard of death until the censoring date. Among participants with diabetes (n=13 863), we examined associations of hemoglobin A1c and antihyperglycemic medication use with COVID-19 outcomes. We estimated mediation between diabetes and outcomes by comorbidities (cardiovascular disease, heart failure, and chronic kidney disease), statin or ACE inhibitor/angiotensin receptor blocker (ARB) use, and cardiac biomarkers (brain natriuretic peptide and troponin).

RESULTS

Diabetes with and without insulin use was associated with greater odds of hospitalization, ICU admission, and death at 30 days, and with greater hazard of death compared with no diabetes (OR 1.73, 1.76 and 1.63, and HR 1.61; and OR 1.39, 1.49 and 1.33, and HR 1.37, respectively, all p<0.0001). Prior sulfonylurea use was associated with greater odds of hospitalization and prior insulin use with hospitalization and death among patients with diabetes; among all participants, statin use was associated with lower mortality and ARB use with lower odds of hospitalization. Cardiovascular disease-related factors mediated <20% of associations between diabetes and outcomes.

CONCLUSIONS

Diabetes is independently associated with adverse outcomes from COVID-19. Associations are only partially mediated by common comorbidities.

Consistent ultra-long DNA sequencing with automated slow pipetting

BACKGROUND

Oxford Nanopore Technologies' instruments can sequence reads of great length. Long reads improve sequence assemblies by unambiguously spanning repetitive elements of the genome. Sequencing reads of significant length requires the preservation of long DNA template molecules through library preparation by pipetting reagents as slowly as possible to minimize shearing. This process is time-consuming and inconsistent at preserving read length as even small changes in volumetric flow rate can result in template shearing.

RESULTS

We have designed SNAILS (Slow Nucleic Acid Instrument for Long Sequences), a 3D-printable instrument that automates slow pipetting of reagents used in long read library preparation for Oxford Nanopore sequencing. Across six sequencing libraries, SNAILS preserved more reads exceeding 100 kilobases in length and increased its libraries' average read length over manual slow pipetting.

CONCLUSIONS

SNAILS is a low-cost, easily deployable solution for improving sequencing projects that require reads of significant length. By automating the slow pipetting of library preparation reagents, SNAILS increases the consistency and throughput of long read Nanopore sequencing.

Ncor2/PPARα-Dependent Upregulation of MCUb in the Type 2 Diabetic Heart Impacts Cardiac Metabolic Flexibility and Function

The contribution of altered mitochondrial Ca²⁺ handling to metabolic and functional defects in type 2 diabetic (T2D) mouse hearts is not well understood. In this study, we show that the T2D heart is metabolically inflexible and almost exclusively dependent on mitochondrial fatty acid oxidation as a consequence of mitochondrial calcium uniporter complex (MCUC) inhibitory subunit MCUb overexpression. Using a recombinant endonuclease-deficient Cas9-based gene promoter pulldown approach coupled with mass spectrometry, we found that MCUb is upregulated in the T2D heart due to loss of glucose homeostasis regulator nuclear receptor corepressor 2 repression, and chromatin immunoprecipitation assays identified peroxisome proliferator-activated receptor α as a mediator of MCUb gene expression in T2D cardiomyocytes. Upregulation of MCUb limits mitochondrial matrix Ca²⁺ uptake and impairs mitochondrial energy production via glucose oxidation by depressing pyruvate dehydrogenase complex activity. Gene therapy displacement of endogenous MCUb with a dominant-negative MCUb transgene (MCUb^W246R/V251E) in vivo rescued T2D cardiomyocytes from metabolic inflexibility and stimulated cardiac contractile function and adrenergic responsiveness by enhancing phospholamban phosphorylation via protein kinase A. We conclude that MCUb represents one newly discovered molecular effector at the interface of metabolism and cardiac function, and its repression improves the outcome of the chronically stressed diabetic heart.

Gut Microbiota Modulation and Fecal Transplantation: An Overview on Innovative Strategies for Hepatic Encephalopathy Treatment

Hepatic encephalopathy (HE) is a major complication of cirrhosis, which is associated with gut microbial composition and functional alterations. Current treatments largely focus on gut microbiota using lactulose, rifaximin and other agents. However, despite these treatments, patients with HE have a high rate of readmission, morbidity and cognitive impairment. Fecal microbiota transplant (FMT) involves introduction of a donor microbiota into a recipient and is currently mainly used for recurrent C. difficile infection (rCDI). The role of FMT in cirrhosis and HE is evolving. There have been two randomized clinical trials (RCT) and several case reports/series in cirrhosis. Both RCTs were safety-focused phase 1 trials. One involved pre-FMT antibiotics and FMT enema versus standard of care, while the other involved 15 FMT capsules versus placebo without pre-FMT antibiotics. There was evidence of safety in both trials and the FMT group demonstrated reduction in hospitalizations compared to the non-FMT group. Changes in microbial function centered around short-chain fatty acids, bile acids and brain function showed improvement in the FMT groups. Long-term follow-up demonstrated continued safety and reduction in the antibiotic-resistance gene carriage. However, larger trials of FMT in HE are needed that can refine the dose, duration and route of FMT administration.

Metabolic Control and Determinants Among HIV-Infected Type 2 Diabetes Mellitus Patients Attending a Tertiary Clinic in Botswana

PURPOSE

We primarily aimed at determining the prevalence of metabolic syndrome and abnormal individual metabolic control variables in HIV-infected participants as compared to HIV-uninfected participants given current concerns. Our secondary objective was to determine the predictors of metabolic syndrome and individual metabolic control variables among the study participants to guide future management.

PATIENTS AND METHODS

A descriptive, case-matched cross-sectional study for four months from 15th June 2019 to 15th October 2019 at Block 6 Diabetes Reference Clinic in Gaborone, Botswana. We compared the proportions of metabolic syndrome and individual metabolic control variables based on gender and HIV status by means of bivariate analysis (Chi-squared test or Fisher's exact test) to determine factors associated with metabolic control. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Overall, 86% of the study participants were found to have metabolic syndrome by International Diabetes Federation (IDF) criteria with 79.8% among HIV-infected and 89.1% among HIV-negative participants (p-value = 0.018). Older age was significantly associated with metabolic syndrome (p-value = 0.008). Female gender was significantly associated with metabolic syndrome as compared to male gender (P-value < 0.001), and with a statistically significant higher proportion of low HDL-C compared to males (P-value < 0.001). Female participants were significantly more likely to be obese as compared to males (P-value < 0.001). High triglycerides were more common in HIV-infected compared to HIV-negative participants (P-value = 0.004). HIV-negative participants were more likely to be obese as compared to HIV-infected participants (P-value = 0.003).

CONCLUSION

Metabolic syndrome is an appreciable problem in this tertiary clinic in Botswana for both HIV-infected and HIV-negative participants. Future prospective studies are warranted in our setting and similar sub-Saharan settings to enhance understanding of the role played by HAART in causing the metabolic syndrome, and the implications for future patient management.

Adapting urban best management practices for resilience to long-term environmental changes

Stormwater best management practices (BMPs) help mitigate the adverse effects of urban development on stream hydrology and water quality, and are widely specified in development requirements and watershed management plans. However, design of stormwater BMPs largely relies on experience with historic climate, which may not be a reliable guide to the future. To inform BMP design that is robust to future conditions, it is important to examine how potential changes in precipitation, temperature, and potential evapotranspiration will affect the performance of BMPs. We use continuous simulation modeling to examine BMP performance under current and potential future climatic conditions and determine the changes needed in site configuration to address future impacts. We perform modeling for five development types in five different regions of the United States and explore both conventional ("gray") and green infrastructure (GI) stormwater management approaches. If stormwater designs are adapted to address potential future climate conditions, this study suggests that the most cost-effective approaches may use both gray and green BMPs. If the magnitude of extreme weather events increases dramatically, then gray practices that provide detention storage may have better cost-effectiveness. Incorporating risk of future climate impacts into stormwater design may help communities become more resilient. PRACTITIONER POINTS: There is a risk that projected changes in meteorological forcing will negatively affect stormwater BMP performance. Under projected future climate conditions, this study suggests the most cost-effective approaches may use both gray and green BMPs. If the magnitude of extreme weather events increases dramatically, gray practices that provide detention storage may have better cost-effectiveness. Flexibility is beneficial in adaptation and resilience planning due to uncertainty in projected precipitation volume and intensity changes.

Mathematically Modeling Anhedonia in Schizophrenia: A Stochastic Dynamical Systems Approach

OBJECTIVE

Anhedonia, traditionally defined as a diminished capacity for pleasure, is a core symptom of schizophrenia (SZ). However, modern empirical evidence indicates that hedonic capacity may be intact in SZ and anhedonia may be better conceptualized as an abnormality in the temporal dynamics of emotion.

METHOD

To test this theory, the current study used ecological momentary assessment (EMA) to examine whether abnormalities in one aspect of the temporal dynamics of emotion, sustained reward responsiveness, were associated with anhedonia. Two experiments were conducted in outpatients diagnosed with SZ (n = 28; n = 102) and healthy controls (n = 28; n = 71) who completed EMA reports of emotional experience at multiple time points in the day over the course of several days. Markov chain analyses were applied to the EMA data to evaluate stochastic dynamic changes in emotional states to determine processes underlying failures in sustained reward responsiveness.

RESULTS

In both studies, Markov models indicated that SZ had deficits in the ability to sustain positive emotion over time, which resulted from failures in augmentation (ie, the ability to maintain or increase the intensity of positive emotion from time t to t+1) and diminution (ie, when emotions at time t+1 are opposite in valence from emotions at time t, resulting in a decrease in the intensity of positive emotion over time). Furthermore, in both studies, augmentation deficits were associated with anhedonia.

CONCLUSIONS

These computational findings clarify how abnormalities in the temporal dynamics of emotion contribute to anhedonia.

Extracellular Superoxide Dismutase Regulates Early Vascular Hyaluronan Remodeling in Hypoxic Pulmonary Hypertension

Chronic hypoxia leads to pathologic remodeling of the pulmonary vasculature and pulmonary hypertension (PH). The antioxidant enzyme extracellular superoxide dismutase (SOD3) protects against hypoxia-induced PH. Hyaluronan (HA), a ubiquitous glycosaminoglycan of the lung extracellular matrix, is rapidly recycled at sites of vessel injury and repair. We investigated the hypothesis that SOD3 preserves HA homeostasis by inhibiting oxidative and enzymatic hyaluronidase-mediated HA breakdown. In SOD3-deficient mice, hypoxia increased lung hyaluronidase expression and activity, hyaluronan fragmentation, and effacement of HA from the vessel wall of small pulmonary arteries. Hyaluronan fragmentation corresponded to hypoxic induction of the cell surface hyaluronidase-2 (Hyal2), which was localized in the vascular media. Human pulmonary artery smooth muscle cells (HPASMCs) demonstrated hypoxic induction of Hyal2 and SOD-suppressible hyaluronidase activity, congruent to our observations in vivo. Fragmentation of homeostatic high molecular weight HA promoted HPASMC proliferation in vitro, whereas pharmacologic inhibition of hyaluronidase activity prevented hypoxia- and oxidant-induced proliferation. Hypoxia initiates SOD3-dependent alterations in the structure and regulation of hyaluronan in the pulmonary vascular extracellular matrix. These changes occurred soon after hypoxia exposure, prior to appearance of PH, and may contribute to the early pathogenesis of this disease.

Bystro: rapid online variant annotation and natural-language filtering at whole-genome scale

Accurately selecting relevant alleles in large sequencing experiments remains technically challenging. Bystro ( https://bystro.io/ ) is the first online, cloud-based application that makes variant annotation and filtering accessible to all researchers for terabyte-sized whole-genome experiments containing thousands of samples. Its key innovation is a general-purpose, natural-language search engine that enables users to identify and export alleles and samples of interest in milliseconds. The search engine dramatically simplifies complex filtering tasks that previously required programming experience or specialty command-line programs. Critically, Bystro's annotation and filtering capabilities are orders of magnitude faster than previous solutions, saving weeks of processing time for large experiments.

Virulence genes and subclone status as markers of experimental virulence in a murine sepsis model among Escherichia coli sequence type 131 clinical isolates from Spain

OBJECTIVE

To assess experimental virulence among sequence type 131 (ST131) Escherichia coli bloodstream isolates in relation to virulence genotype and subclone.

METHODS

We analysed 48 Spanish ST131 bloodstream isolates (2010) by PCR for ST131 subclone status (H30Rx, H30 non-Rx, or non-H30), virulence genes (VGs), and O-type. Then we compared these traits with virulence in a murine sepsis model, as measured by illness severity score (ISS) and rapid lethality (mean ISS ≥ 4).

RESULTS

Of the 48 study isolates, 65% were H30Rx, 21% H30 non-Rx, and 15% non-H30; 44% produced ESBLs, 98% were O25b, and 83% qualified as extraintestinal pathogenic E. coli (ExPEC). Of 49 VGs, ibeA and iss were associated significantly with non-H30 isolates, and sat, iha and malX with H30 isolates. Median VG scores differed by subclone, i.e., 12 (H30Rx), 10 (H30 non-Rx), and 11 (non-H30) (p < 0.01). Nearly 80% of isolates represented a described virotype. In mice, H30Rx and non-H30 isolates were more virulent than H30 non-Rx isolates (according to ISS [p = 0.03] and rapid lethality [p = 0.03]), as were ExPEC isolates compared with non-ExPEC isolates (median ISS, 4.3 vs. 2.7: p = 0.03). In contrast, most individual VGs, VG scores, VG profiles, and virotypes were not associated with mouse virulence.

CONCLUSIONS

ST131 subclone and ExPEC status, but not individual VGs, VG scores or profiles, or virotypes, predicted mouse virulence. Given the lower virulence of non-Rx H30 isolates, hypervirulence probably cannot explain the ST131-H30 clade's epidemic emergence.