Time well spent: the association between time and effort allocation and intent to leave among clinical faculty.

PURPOSE: To explore the relationship between clinical faculty members' time/effort in four mission areas, their assessment of the distribution of that time/effort, and their intent to leave the institution and academic medicine. METHOD: Faculty from 14 U.S. medical schools participated in the 2011-2012 Faculty Forward Engagement Survey. The authors conducted multivariate logistic regression analyses to evaluate relationships between clinical faculty members' self-reported time/effort in each mission area, assessment of time/effort, and intent to leave the institution and academic medicine. RESULTS: Of the 13,722 clinical faculty surveyed, 8,349 (60.8%) responded. Respondents reported an average of 54.5% time/effort in patient care. The authors found no relationship between time/effort in patient care and intent to leave one's institution. Respondents who described spending "far too much/too much" time in patient care were more likely to report intent to leave their institution (odds ratio 2.12, P<.001). Those who assessed their time/effort in all mission areas as "about right" were less likely to report intent to leave their institution (64/1,135; 5.6%) than those who reported "far too little/too little" or "far too much/too much" time/effort in one or more mission areas (535/3,671; 14.6%; P<.001). CONCLUSIONS: Although the authors found no relationship between reported time/effort in patient care and intent to leave, the perception of "far too much/too much" time/effort spent in that mission area was correlated with intent to leave the institution. Efforts to align time/effort spent in each mission area with faculty expectations may improve retention.

Novel microRNA correlations in the severely injured.

PURPOSE: Severe injury initiates an inflammatory response that can perpetuate immunological dysfunction, uncontrolled inflammation, and subsequent multisystem organ failure. MicroRNAs (miRNAs) have recently been identified as regulators of this inflammatory response. Our study sought to identify the differential expression of unique miRNAs and their correlations with genes of the Toll-like receptor (TLR) pathways, and clinical parameters in the severely injured. METHODS: Fourteen trauma patients requiring transfusion were prospectively enrolled in this institutional review board-approved study. Inclusion criteria consisted of adult patients deemed clinically to be in hemorrhagic shock necessitating transfusion in the acute phase of their injury care. Peripheral blood samples were obtained after admission to the surgical intensive care unit. Expression of circulating mature miRNA from each patient, as well as from 10 healthy, age-matched controls, was determined and compared using the HiSeq 2500 sequencing system and the R software system. Gene expression of TLR signaling pathways for each patient was examined using custom gene expression polymerase chain reaction arrays. Statistical analyses were performed using general linear models and empirical Bayes methods to determine differential expression and Spearman's nonparametric correlation analysis. RESULTS: Subjects were 21-77 years old (mean, 42), 80% male, Injury Severity Score 11-43 (mean, 26), with 11 blunt and 3 penetrating injuries. Three were intubated and 5 received blood products before arrival. Base deficit upon hospital admission was 3 to 20 (mean, 9). All patients required blood transfusion secondary to blood loss sustained during injury. Survival to discharge was 93%. Controls were 27-64 years old (mean, 40) and 60% male. Sequencing analysis revealed 69 differentially expressed miRNAs (P < .05) in the severely injured. Within the differentially expressed miRNAs, there were 12 direct and 6 indirect correlations with multiple genes involved in the TLR3 and TLR4 signaling pathways. The relationships between these same miRNAs and clinical parameters were also analyzed. We discovered 4 direct correlations with base deficit and HCO3, and 7 indirect correlations involving total fresh frozen plasma transfused, base deficit, HCO3, and PaCO2 levels. CONCLUSION: Differential expression and correlations between miRNAs, genes of the TLR pathways, and clinical parameters are unique findings in the severely injured and may lead to a greater understanding of the regulation of sterile inflammation after severe injury.

Toll-like receptors in tonsillar epithelial cells.

OBJECTIVE: The Waldeyer's ring, comprised of the nasopharyngeal tonsil, the paired tubal tonsils, the paired palatine tonsils, and the lingual tonsil, is arranged in a circular orientation around the wall of the throat. The location of the palatine tonsils, specifically, enables these structures to come in direct contact with potentially harmful inhaled and ingested material that exist in their native form since digestive enzymes are not present in the oral cavity. Thus, the tonsillar epithelium must not only serve a protective role but it must also function in an antigen-sampling role. Previous studies involving the tissues of the Waldeyer's ring have been focused on the adaptive immune system, with little consideration toward the innate immune system. Studies have demonstrated that the tonsils are capable of producing proinflammatory and antiviral cytokines and chemokines. In addition, other studies have highlighted the importance of epithelial cells in this response. Therefore, we postulate that toll-like receptors (TLRs), which recognize components of pathogenic organisms, may play a key role in the innate immune response in tonsillar epithelial cells. TLRs are innate pattern recognition receptors, which produce proinflammatory cytokines and chemokines upon ligation. In this study, we examine the expression and function of TLRs in the tonsillar epithelial cell lines, UT-SCC-60A and UT-SCC-60B. Additionally, we demonstrate successful isolation of primary tonsillar epithelial cells and examine TLR expression in these cells. METHODS: We utilized endpoint RT-PCR, real time RT-PCR, and flow cytometric analysis to determine TLR expression. To assess TLR function, cells were stimulated with TLR ligands and supernatants were assayed for secretion of cytokines. RESULTS: UT-SCC-60A and UTSCC-60B express TLR mRNA and TLR protein, and the observed responses to the TLR ligands, Pam3Cys and Poly I:C suggest that TLR2 and TLR3 are functional in these cells. Additionally, primary tonsillar epithelial cells express TLRs. CONCLUSIONS: TLRs are expressed in human tonsillar epithelial cells and may play a vital role in the immunological outcomes in this tissue.

Toll-like receptor expression in the human nasopharyngeal tonsil (adenoid) and palantine tonsils: a preliminary report.

OBJECTIVE: The Waldeyer's ring, comprised of the nasopharyngeal tonsil (adenoid), the paired tubal tonsils, the paired palantine tonsils, and the lingual tonsil, is arranged in a circular orientation around the wall of the throat. This orientation allows direct contact between the tissues of the Waldeyer's ring and inhaled or ingested material, which may contain potential antigenic substances. Previous studies involving the tissues of the Waldeyer's ring have been focused on the adaptive immune system, with little consideration toward the innate immune system. Since studies have demonstrated that the adenoids and tonsils are capable of producing proinflammatory cytokines, we postulate that toll-like receptors (TLRs), which recognize components of pathogenic organisms, may be involved in the immune response in these tissues. TLRs are innate pattern recognition receptors, which produce proinflammatory cytokines and chemokines upon ligation. In this pilot study, we address expression of TLRs, which are vital components of the innate immune system, in adenoid and tonsil tissue. METHODS: To determine whether TLRs are expressed in the human adenoid and palantine tonsils, we utilized endpoint RT-PCR and real time RT-PCR. Endpoint PCR was performed on all tissue obtained from adenotonsillectomy patients. Real time RT-PCR was performed only on adenoid tissue. RESULTS: All of the ten TLRs examined are expressed in the adenoid and tonsil tissue with varying band intensities. TLR3, TLR7, TLR8, and TLR9 expression is highly variable between patients. CONCLUSIONS: TLRs are expressed in human adenoid and tonsil tissue, and may play a vital role in the immunological outcomes of these tissues.

17Beta-estradiol suppresses TLR3-induced cytokine and chemokine production in endometrial epithelial cells.

BACKGROUND: The human endometrium is an important site for contact between the host and pathogens ascending the reproductive tract, and thus plays an important role in female reproductive tract immunity. Previous work in our laboratory has suggested that Toll-like receptors (TLRs) are involved in endometrial epithelial recognition of pathogens and that ligation of endometrial TLRs results in the production of cytokines and chemokines important for both immune and reproductive functions of the endometrium. We have also demonstrated cyclic regulation of TLR3 mRNA and protein expression in human endometrium, suggesting that steroid hormones might play a role in the expression and function of TLR3. In this study, the effects of 17beta-estradiol (E2) and progesterone (P) on TLR3 expression and function in endometrial cell lines were investigated. METHODS: Endometrial epithelial cell lines were cultured and examined for the presence of TLR3 and hormone receptors by endpoint RT-PCR. For hormonal studies, cells were pre-treated with ethanol vehicle, 10(-8) M E2, and/or 10(-7) M P. For antagonist assays, cells were treated with the ER antagonist, ICI 182, 780, or the PR antagonist, RU486, for two hours prior to treatment with hormones. Following hormone or hormone/antagonist pre-treatment, cells were stimulated with vehicle, the synthetic TLR3 ligand, polyinosinic-polycytidylic acid (Poly I:C), a negative dsDNA control, or a positive control. Cytokine and chemokine production post-stimulation was measured by ELISA. The effects of E2 and P on TLR3 mRNA and protein expression were measured using Real Time RT-PCR and FACS analysis, respectively. RESULTS: Stimulation of TLR3-expressing cells with the synthetic TLR3 ligand, Poly I:C, resulted in the production of cytokines and chemokines important for endometrial function and regulation. Suppression of Poly I:C-induced cytokine and chemokine production by cells treated with 10(-8) M E2, but not cells treated with 10(-7) M P, was observed in endometrial epithelial cell lines expressing TLR3 and estrogen receptor alpha (ERalpha). The effects of E2 were not observed on cells which did not express ERalpha or in cells pre-treated with the ER antagonist, ICI 182, 780. Treatment with E2 did not affect TLR3 mRNA or protein expression. However, treatment with E2 did suppress cytokine and chemokine production resulting from TLR3 stimulation with Poly I:C, suggesting that E2 modulates TLR3 function. CONCLUSION: The data presented in this study are the first indication that E2 can markedly alter the innate immune response to dsRNA, providing a previously unreported process by which E2 can alter immune responses.

Human endometrial epithelial cells cyclically express Toll-like receptor 3 (TLR3) and exhibit TLR3-dependent responses to dsRNA.

Toll-like receptor 3 (TLR3) responds to dsRNA, a product of most viral life cycles, and initiates production of proinflammatory and antiviral cytokines. The role of TLR3 in human mucosal immunity of the endometrium has not been examined. The effects of TLR3 ligation in endometrial epithelium could be significant as the endometrium is a significant site for viral entry and infection. Additionally, the cytokine milieu plays an essential role in normal functions of the endometrium such as uterine cycle progression, epithelial proliferation and shedding, and embryo implantation. In this study, we demonstrated cycle dependent expression of functional TLR3 in primary endometrial epithelial tissue and expression of intracellular TLR3 in human endometrial epithelial cell lines. We established that stimulation of TLR3-positive cell lines and primary human endometrial epithelial cells with dsRNA leads to TLR3-dependent expression of interleukin (IL)-6, IL-8, interferon (IFN)-inducible protein 10, RANTES, and IFN-beta. These results indicate that the cytokine profile of human endometrial epithelial cells can be modified through TLR3 stimulation. Our findings suggest that TLR3 is involved in the immune responses of endometrial epithelial cells after exposure to dsRNA and has the potential to alter the cytokine milieu and influence the outcome and consequences of infection.

Expression of Toll-like receptors in human endometrial epithelial cells and cell lines.

PROBLEM: Are toll-like receptors (TLRs) expressed by human endometrium and endometrial cell lines? METHODS OF STUDY: Expression of each TLR mRNA species was determined by reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of proliferative-phase human endometrium, separated endometrial epithelial cells, and the Ishikawa and RL95-2 endometrial epithelial cell lines. U-937 and SKW 6.4 cell lines were used as positive controls. Functional relevance of PCR findings was tested by enzyme-linked immunsorbent assay (ELISA)analysis of IL-8 production after stimulating cell lines with ligands for TLR2-5. RESULTS: TLR1-6 and 9 mRNA species were detected in both whole endometrium and separated endometrial epithelial cells. Ishikawa cells expressed TLR2 and TLR5, while RL95-2 cells expressed TLR3, 5, and 9. Response of RL95-2, Ishikawa, and U-937 cells to TLR2-5 ligands was consistent with RT-PCR findings except response to flagellin by Ishikawa cells. CONCLUSION: These studies provide the first evidence of TLR expression in the endometrium of any species and suggest the usefulness of endometrial cell lines to study TLR function.