The Struggle Is Real: How Residents Learn to Provide High-Value, Cost-Conscious Care.

Phenomenon: Rising healthcare expenditures threaten the accessibility and affordability of healthcare systems. Research has demonstrated that teaching (junior) physicians to deliver high-value, cost-conscious care can be effective when learning is situated in a supportive environment. This study aims to offer insight into how residents learn to provide high-value, cost-conscious care in the workplace and how the postgraduate training environment influences this learning. Approach: Six homogeneous focus groups were held between August 2015 and July 2016 with 36 residents from six residency programs (dermatology, n = 5; elderly care, n = 8; family medicine, n = 5; internal medicine, n = 6; orthopedic surgery, n = 6; surgery, n = 6). An iterative grounded theory approach was used to analyze the qualitative data. Findings: Influential factors in learning of high-value, cost-conscious care delivery operated on three levels: individual resident, training program, and the workplace. On the individual level, we discerned three types of beliefs regarding HV3C. At the training program level, perceived determinants of learning included resident-supervisor interactions, involvement in decision-making over time, and exposure to variation in care delivery. At the workplace level, learning depended on the availability of professional healthcare expertise and the presence of institutional policy. Insights: Residents struggle to seize high-value, cost-conscious care learning opportunities in the workplace setting. Both residency training programs and workplaces can contribute to creating these learning opportunities. An important starting point is being aware of the different personal beliefs of residents and the approaches to high-value, cost-conscious care on the level of the training program and workplace.

Successive crystal structure snapshots suggest the basis for MHC class I peptide loading and editing by tapasin.

MHC-I epitope presentation to CD8+ T cells is directly dependent on peptide loading and selection during antigen processing. However, the exact molecular bases underlying peptide selection and binding by MHC-I remain largely unknown. Within the peptide-loading complex, the peptide editor tapasin is key to the selection of MHC-I-bound peptides. Here, we have determined an ensemble of crystal structures of MHC-I in complex with the peptide exchange-associated dipeptide GL, as well as the tapasin-associated scoop loop, alone or in combination with candidate epitopes. These results combined with mutation analyses allow us to propose a molecular model underlying MHC-I peptide selection by tapasin. The N termini of bound peptides most probably bind first in the N-terminal and middle region of the MHC-I peptide binding cleft, upon which the peptide C termini are tested for their capacity to dislodge the tapasin scoop loop from the F pocket of the MHC-I cleft. Our results also indicate important differences in peptide selection between different MHC-I alleles.

Cytomegalovirus gp40/m152 Uses TMED10 as ER Anchor to Retain MHC Class I.

The murine cytomegalovirus immunoevasin m152/gp40 binds major histocompatibility complex (MHC) class I molecules and retains them in the early secretory pathway by a previously unknown mechanism, preventing antigen presentation to CD8+ T cells. We show that retention of class I and of gp40 itself depends on a lumenal linker sequence in gp40. With unbiased co-immunoprecipitation and mass spectrometry, we find that, through this linker, gp40 binds to TMED10/Tmp21/p24δ1, a member of the p24 family of endoplasmic reticulum (ER)/Golgi transmembrane proteins. We show that the C-terminal KKxxx Golgi-to-ER retrieval signal of TMED10 is required for gp40-mediated retention of class I. We thus identify a viral interaction partner of the p24 proteins and their exploitation for viral immune evasion.

The BRCA1 c. 5096G>A p.Arg1699Gln (R1699Q) intermediate risk variant: breast and ovarian cancer risk estimation and recommendations for clinical management from the ENIGMA consortium.

BACKGROUND: We previously showed that the BRCA1 variant c.5096G>A p.Arg1699Gln (R1699Q) was associated with an intermediate risk of breast cancer (BC) and ovarian cancer (OC). This study aimed to assess these cancer risks for R1699Q carriers in a larger cohort, including follow-up of previously studied families, to further define cancer risks and to propose adjusted clinical management of female BRCA1*R1699Q carriers. METHODS: Data were collected from 129 BRCA1*R1699Q families ascertained internationally by ENIGMA (Evidence-based Network for the Interpretation of Germline Mutant Alleles) consortium members. A modified segregation analysis was used to calculate BC and OC risks. Relative risks were calculated under both monogenic model and major gene plus polygenic model assumptions. RESULTS: In this cohort the cumulative risk of BC and OC by age 70 years was 20% and 6%, respectively. The relative risk for developing cancer was higher when using a model that included the effects of both the R1699Q variant and a residual polygenic component compared with monogenic model (for BC 3.67 vs 2.83, and for OC 6.41 vs 5.83). CONCLUSION: Our results confirm that BRCA1*R1699Q confers an intermediate risk for BC and OC. Breast surveillance for female carriers based on mammogram annually from age 40 is advised. Bilateral salpingo-oophorectomy should be considered based on family history.

The murine cytomegalovirus immunoevasin gp40 binds MHC class I molecules to retain them in the early secretory pathway.

In the presence of the murine cytomegalovirus (mCMV) gp40 (m152) protein, murine major histocompatibility complex (MHC) class I molecules do not reach the cell surface but are retained in an early compartment of the secretory pathway. We find that gp40 does not impair the folding or high-affinity peptide binding of the class I molecules but binds to them, leading to their retention in the endoplasmic reticulum (ER), the ER-Golgi intermediate compartment (ERGIC) and the cis-Golgi, most likely by retrieval from the cis-Golgi to the ER. We identify a sequence in gp40 that is required for both its own retention in the early secretory pathway and for that of class I molecules.

Peptide-independent stabilization of MHC class I molecules breaches cellular quality control.

The intracellular trafficking of major histocompatibility complex class I (MHC-I) proteins is directed by three quality control mechanisms that test for their structural integrity, which is correlated to the binding of high-affinity antigenic peptide ligands. To investigate which molecular features of MHC-I these quality control mechanisms detect, we have followed the hypothesis that suboptimally loaded MHC-I molecules are characterized by their conformational mobility in the F-pocket region of the peptide-binding site. We have created a novel variant of an MHC-I protein, K(b)-Y84C, in which two α-helices in this region are linked by a disulfide bond that mimics the conformational and dynamic effects of bound high-affinity peptide. K(b)-Y84C shows a remarkable increase in the binding affinity to its light chain, beta-2 microglobulin (ß2m), and bypasses all three cellular quality control steps. Our data demonstrate (1) that coupling between peptide and ß2m binding to the MHC-I heavy chain is mediated by conformational dynamics; (2) that the folded conformation of MHC-I, supported by ß2m, plays a decisive role in passing the ER-to-cell-surface transport quality controls; and (3) that ß2m association is also tested by the cell surface quality control that leads to MHC-I endocytosis.

Endoplasmic reticulum targeting alters regulation of expression and antigen presentation of proinsulin.

Peptide ligands presented by MHC class I (MHC-I) molecules are produced by degradation of cytosolic and nuclear, but also endoplasmic reticulum (ER)-resident, proteins by the proteasome. However, Ag processing of ER proteins remains little characterized. Studying processing and presentation of proinsulin, which plays a pivotal role in autoimmune diabetes, we found that targeting to the ER has profound effects not only on how proinsulin is degraded, but also on regulation of its cellular levels. While proteasome inhibition inhibited degradation and presentation of cytosolic proinsulin, as expected, it reduced the abundance of ER-targeted proinsulin. This targeting and protein modifications modifying protein half-life also had profound effects on MHC-I presentation and proteolytic processing of proinsulin. Thus, presentation of stable luminal forms was inefficient but enhanced by proteasome inhibition, whereas that of unstable luminal forms and of a cytosolic form were more efficient and compromised by proteasome inhibitors. Distinct stability of peptide MHC complexes produced from cytosolic and luminal proinsulin suggests that different proteolytic activities process the two Ag forms. Thus, both structural features and subcellular targeting of Ags can have strong effects on the processing pathways engaged by MHC-I-restricted Ags, and on the efficiency and regulation of their presentation.

Each of the four intracellular cysteines of CD36 is essential for insulin- or AMP-activated protein kinase-induced CD36 translocation.

Stimulation of cellular fatty acid uptake by induction of insulin signalling or AMP-kinase (AMPK) activation is due to translocation of the fatty acid-transporter CD36 from intracellular stores to the plasma membrane (PM). For investigating the role of the four Cys-residues within CD36's cytoplasmic tails in CD36 translocation, we constructed CHO-cells expressing CD36 mutants in which all four, two, or one of the intracellular Cys were replaced by Ser. Intracellular and PM localization of all mutants was similar to wild-type CD36 (CD36wt). Hence, the four Cys do not regulate sub-cellular CD36 localization. However, in contrast to CD36wt, insulin or AMPK activation failed to induce translocation of any of the mutants, indicating that all four intracellular Cys residues are essential for CD36 translocation. The mechanism of defective translocation of mutant CD36 is unknown, but appears not due to loss of S-palmitoylation of the cytoplasmic tails or to aberrant oligomerization of the mutants.

Partial suppression of Oxa1 mutants by mitochondria-targeted signal recognition particle provides insights into the evolution of the cotranslational insertion systems.

The biogenesis of hydrophobic membrane proteins involves their cotranslational membrane integration in order to prevent their unproductive aggregation. In the cytosol of bacteria and eukaryotes, membrane targeting of ribosomes that synthesize membrane proteins is achieved by signal recognition particles (SRPs) and their cognate membrane-bound receptors. As is evident from the genomes of fully sequenced eukaryotes, mitochondria generally lack an SRP system. Instead, mitochondrial ribosomes are physically associated with the protein insertion machinery in the inner membrane. Accordingly, deletion of ribosome-binding sites on the Oxa1 insertase and the Mba1 ribosome receptor in yeast leads to severe defects in cotranslational protein insertion and results in respiration-deficient mutants. In this study, we expressed mitochondria-targeted versions of the bacterial SRP protein Ffh and its receptor FtsY in these yeast mutants. Interestingly, Ffh was found to bind to the large subunit of mitochondrial ribosomes, and could relieve, to some degree, the defect of these insertion mutants. Although FtsY could also bind to mitochondrial membranes, it did not improve membrane protein biogenesis in this strain, presumably because of its inability to interact with Ffh. Hence, mitochondrial ribosomes are still able to interact physically and functionally with the bacterial SRP system. Our observations are consistent with a model according to which the protein insertion system in mitochondria evolved in three steps. The loss of genes for hydrophilic polypeptides (step 1) allowed the development of ribosome-binding sites on membrane proteins (step 2), which finally made the existence of an SRP-mediated system dispensable (step 3).

Risk factors for chronic thoracic pain after cardiac surgery via sternotomy.

OBJECTIVE: This study examines the influence of patient demographics and peri- and postoperative (<7 days) characteristics on the incidence of chronic thoracic pain 1 year after cardiac surgery. The impact of chronic thoracic pain on daily life is also documented. METHODS: A prospective cohort study of 146 patients admitted to the intensive care unit after cardiac surgery via sternotomy was carried out. Pain scores (numeric rating scale 0-10) were recorded during the first 7 postoperative days. One year later, a questionnaire was used to evaluate the incidence in the 2 preceding weeks of chronic thoracic pain (numeric rating scale >0) associated with the primary surgery. RESULTS: One year after surgery, 42 (35%) of the 120 responding patients reported chronic thoracic pain. Multivariate regression analysis of patient characteristics revealed that non-elective surgery, re-sternotomy, severe pain (numeric rating scale ≥ 4) on the third postoperative day, and female gender were all independent predictors of chronic thoracic pain. In addition, the chronic sufferers reported more sleep disturbances and more frequent use of analgesics than their cohorts. CONCLUSIONS: We have identified a number of factors correlated with persistent thoracic pain following cardiac surgery with sternotomy. Awareness of these predictors may be useful for further research concerning both the prevention and treatment of chronic thoracic pain, thereby potentially ameliorating the postoperative quality of life of a significant proportion of patients. Meanwhile, chronic thoracic pain should be discussed preoperatively with patients at risk so that they are truly informed about possible consequences of the surgery.

Functional results after through-knee and above-knee amputations: does more length mean better outcome?

The objective was to evaluate our results on functional outcome for both through-knee amputations and above-knee amputations. Functional outcome was measured using the Special Interest Group in Amputee Medicine score, which focuses on walking distance and use of prosthesis. From 1997 to 2006, 39 through-knee amputations (53%) and 34 above-knee amputations (47%) were performed. Eight (21%) of 39 through-knee amputations needed to be converted to above-knee amputations. Fifty patients (24 above-knee amputations, 26 through-knee amputations) were eligible for follow-up. During follow-up, 71% (of above-knee amputations) and 69% (of through-knee amputations) did not walk with a prosthesis, and 29% of above-knee amputations and 27% of through-knee amputations walked more or less than 50 m. In conclusion, only a minority of patients is able to walk with a prosthesis, and a lot of the through-knee amputations need conversion to a higher level. On the basis of this results, it would be preferable to perform a straight above-knee amputation instead of a through-knee amputation if the correct amputation level is in doubt in high-risk patients.