Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation.

Background: People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care. Objectives: The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration. Design: This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach. Setting: The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust. Participants: Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19). Outcomes: Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes. Results: Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support. Limitations: The availability and quality of data imposed limitations on the reliability of some analyses. Future work: Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department. Study registration: The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.

People who experience mental health crises often go to a hospital emergency department and can be admitted to a psychiatric hospital. Emergency departments and psychiatric wards are not always the best environments for supporting people in a crisis. Emergency departments are overcrowded and waits can be very long; psychiatric wards are also very busy. Psychiatric decision units have been introduced to reduce pressure and improve experiences of crisis care. Psychiatric decision units are short-stay hospital-based units where people can be assessed and signposted to the most appropriate care. This study aimed to evaluate the effect of psychiatric decision units on emergency department visits, psychiatric admissions and the cost of mental health care, and to consider the best way for psychiatric decision units to be structured. We looked at research on similar units internationally and identified all psychiatric decision units in England. We evaluated the impact of psychiatric decision units four mental health NHS trusts on emergency department visits and psychiatric admissions by examining electronic patient records in the 2 years before and after units opened, and by comparing records in areas with and without psychiatric decision units using data from NHS Digital. We compared mental health services used by people in the 9 months before and after their first psychiatric decision unit stay. We interviewed people about their experiences of the psychiatric decision unit and crisis care. We also interviewed staff working on and referring people to psychiatric decision units. There were some reductions in psychiatric admissions, emergency department visits and wait times following opening of psychiatric decision units. The resulting cost savings were small and did not outweigh the costs of running psychiatric decision units. People mostly found units safe, calming and supportive, except where they were discharged too quickly. Psychiatric decision units worked best to reduce psychiatric admissions and improve quality of crisis care where stays were longer and staffing levels higher. Psychiatric decision units had more impact on emergency departments where they were larger and stays were shorter.

A retrospective study of vector borne disease prevalence among anemic dogs in North Carolina.

BACKGROUND: Anemia is an important cause of morbidity and mortality in dogs. Further understanding of the prevalence of vector borne diseases (VBD) in anemic dogs is needed. OBJECTIVES: The objective of this retrospective study was to describe the rate of exposure to or infection with VBD among anemic dogs presented to a teaching hospital in North Carolina and to further characterize the anemia in dogs with VBD exposure. ANIMALS: A total of 597 anemic dogs that were concurrently tested for VBD were examined at a referral veterinary hospital between January 2012 and December 2018. METHODS: Retrospective descriptive study. Demographic, clinicopathologic, and VBD testing data were obtained from medical records. RESULTS: Of the 597 anemic dogs examined, 180 (30.15%; 95% CI: 26.49-34.01%) tested positive for one or more VBD. There was no difference in the severity of anemia or the proportion of dogs displaying a regenerative anemia between dogs testing positive and negative for VBD. CONCLUSIONS: A large proportion of anemic dogs from this region test positive for exposure to or infection with VBD. Our study supported the use of PCR and serology run in parallel to maximize the chance of detecting exposure to or infection with VBD compared to either serology or PCR alone. At this time, it is unknown whether infection with VBD contributed to the development of anemia in these patients. However, given the prevalence of VBD exposure in anemic dogs, testing for VBD in anemic patients from this region of the United States is warranted.

CRISPR/Cas9 Directed Reprogramming of iPSC for Accelerated Motor Neuron Differentiation Leads to Dysregulation of Neuronal Fate Patterning and Function.

Neurodegeneration causes a significant disease burden and there are few therapeutic interventions available for reversing or slowing the disease progression. Induced pluripotent stem cells (iPSCs) hold significant potential since they are sourced from adult tissue and have the capacity to be differentiated into numerous cell lineages, including motor neurons. This differentiation process traditionally relies on cell lineage patterning factors to be supplied in the differentiation media. Genetic engineering of iPSC with the introduction of recombinant master regulators of motor neuron (MN) differentiation has the potential to shorten and streamline cell developmental programs. We have established stable iPSC cell lines with transient induction of exogenous LHX3 and ISL1 from the Tet-activator regulatory region and have demonstrated that induction of the transgenes is not sufficient for the development of mature MNs in the absence of neuron patterning factors. Comparative global transcriptome analysis of MN development from native and Lhx-ISL1 modified iPSC cultures demonstrated that the genetic manipulation helped to streamline the neuronal patterning process. However, leaky gene expression of the exogenous MN master regulators in iPSC resulted in the premature activation of genetic pathways characteristic of the mature MN function. Dysregulation of metabolic and regulatory pathways within the developmental process affected the MN electrophysiological responses.

Development, validity, and test-retest reliability of a new neurocognitive functional performance test: The choice-reaction hop test.

OBJECTIVES: To validate a choice-reaction hop test (CRHT) by assessing differences in timing versus the side-hop test (SHT), and to determine the CRHT's test-retest reliability. DESIGN: Test-retest reliability. SETTING: Laboratory. PARTICIPANTS: Forty-nine healthy adults participated (16 female; age = 22.7 ± 3.4 years; height = 174.9 ± 9.1 cm; mass = 75.4 ± 14.8 kg). MAIN OUTCOME MEASURES: Participants completed three trials each of the SHT and the CRHT in a counterbalanced order. Participants returned one-week later to repeat the CRHT. The fastest and the mean of the three trials were compared. RESULTS: Participants took significantly longer to complete the CRHT (Mean across 3 trials = 21.4 ± 3.4s, Fastest trial = 19.7 ± 3.0s) compared to the traditional SHT (10.4 ± 2.0s, p < 0.001). The CRHT demonstrated good-excellent test-retest reliability across testing days for both the mean across 3 trials (r = 0.890, p < 0.001, SEM = 1.13) and the fastest trial (r = 0.828, p < 0.001, SEM = 1.24). CONCLUSION: Compared to the SHT, the CRHT took longer to complete indicating its ability to stress neurocognitive function during an FPT. The CRHT demonstrated good-excellent test-retest reliability, which may allow it to be a useful measure in serial evaluations such as during rehabilitation benchmarking. The CRHT may be an effective FPT to assess combined physical and neurocognitive function to assist clinicians in evidence-based decision-making.

Service use preceding and following first referral for psychiatric emergency care at a short-stay crisis unit: A cohort study across three cities and one rural area in England.

BACKGROUND: Internationally, hospital-based short-stay crisis units have been introduced to provide a safe space for stabilisation and further assessment for those in psychiatric crisis. The units typically aim to reduce inpatient admissions and psychiatric presentations to emergency departments. AIMS: To assess changes to service use following a service user's first visit to a unit, characterise the population accessing these units and examine equality of access to the units. METHODS: A prospective cohort study design (ISCTRN registered; 53431343) compared service use for the 9 months preceding and following a first visit to a short-stay crisis unit at three cities and one rural area in England. Included individuals first visited a unit in the 6 months between 01/September/2020 and 28/February/2021. RESULTS: The prospective cohort included 1189 individuals aged 36 years on average, significantly younger (by 5-13 years) than the population of local service users (<.001). Seventy percent were White British and most were without a psychiatric diagnosis (55%-82% across sites). The emergency department provided the largest single source of referrals to the unit (42%), followed by the Crisis and Home Treatment Team (20%). The use of most mental health services, including all types of admission and community mental health services was increased post discharge. Social-distancing measures due to the COVID-19 pandemic were in place for slightly over 50% of the follow-up period. Comparison to a pre-COVID cohort of 934 individuals suggested that the pandemic had no effect on the majority of service use variables. CONCLUSIONS: Short-stay crisis units are typically accessed by a young population, including those who previously were unknown to mental health services, who proceed to access a broader range of mental health services following discharge.

Intravenous administration of viral vectors expressing prostate cancer antigens enhances the magnitude and functionality of CD8+ T cell responses.

BACKGROUND: The use of immunotherapeutic vaccination in prostate cancer is a promising approach that likely requires the induction of functional, cytotoxic T cells . The experimental approach described here uses a well-studied adenovirus-poxvirus heterologous prime-boost regimen, in which the vectors encode a combination of prostate cancer antigens, with the booster dose delivered by either the intravenous or intramuscular (IM) route. This prime-boost regimen was investigated for antigen-specific CD8+ T cell induction. METHODS: The coding sequences for four antigens expressed in prostate cancer, 5T4, PSA, PAP, and STEAP1, were inserted into replication-incompetent chimpanzee adenovirus Oxford 1 (ChAdOx1) and into replication-deficient modified vaccinia Ankara (MVA). In four strains of mice, ChAdOx1 prime was delivered intramuscularly, with an MVA boost delivered by either IM or intravenous routes. Immune responses were measured in splenocytes using ELISpot, multiparameter flow cytometry, and a targeted in vivo killing assay. RESULTS: The prime-boost regimen was highly immunogenic, with intravenous administration of the boost resulting in a sixfold increase in the magnitude of antigen-specific T cells induced and increased in vivo killing relative to the intramuscular boosting route. Prostate-specific antigen (PSA)-specific responses were dominant in all mouse strains studied (C57BL/6, BALBc, CD-1 and HLA-A2 transgenic). CONCLUSION: This quadrivalent immunotherapeutic approach using four antigens expressed in prostate cancer induced high magnitude, functional CD8+ T cells in murine models. The data suggest that comparing the intravenous versus intramuscular boosting routes is worthy of investigation in humans.

Falling Short: The Contribution of Central Insulin Receptors to Gait Dysregulation in Brain Aging.

Insulin resistance, which manifests as a reduction of insulin receptor signaling, is known to correlate with pathological changes in peripheral tissues as well as in the brain. Central insulin resistance has been associated with impaired cognitive performance, decreased neuronal health, and reduced brain metabolism; however, the mechanisms underlying central insulin resistance and its impact on brain regions outside of those associated with cognition remain unclear. Falls are a leading cause of both fatal and non-fatal injuries in the older population. Despite this, there is a paucity of work focused on age-dependent alterations in brain regions associated with ambulatory control or potential therapeutic approaches to target these processes. Here, we discuss age-dependent alterations in central modalities that may contribute to gait dysregulation, summarize current data supporting the role of insulin signaling in the brain, and highlight key findings that suggest insulin receptor sensitivity may be preserved in the aged brain. Finally, we present novel results showing that administration of insulin to the somatosensory cortex of aged animals can alter neuronal communication, cerebral blood flow, and the motivation to ambulate, emphasizing the need for further investigations of intranasal insulin as a clinical management strategy in the older population.

Short-stay crisis units for mental health patients on crisis care pathways: systematic review and meta-analysis.

BACKGROUND: Internationally, an increasing proportion of emergency department visits are mental health related. Concurrently, psychiatric wards are often occupied above capacity. Healthcare providers have introduced short-stay, hospital-based crisis units offering a therapeutic space for stabilisation, assessment and appropriate referral. Research lags behind roll-out, and a review of the evidence is urgently needed to inform policy and further introduction of similar units. AIMS: This systematic review aims to evaluate the effectiveness of short-stay, hospital-based mental health crisis units. METHOD: We searched EMBASE, Medline, CINAHL and PsycINFO up to March 2021. All designs incorporating a control or comparison group were eligible for inclusion, and all effect estimates with a comparison group were extracted and combined meta-analytically where appropriate. We assessed study risk of bias with Risk of Bias in Non-Randomized Studies - of Interventions and Risk of Bias in Randomized Trials. RESULTS: Data from twelve studies across six countries (Australia, Belgium, Canada, The Netherlands, UK and USA) and 67 505 participants were included. Data indicated that units delivered benefits on many outcomes. Units could reduce psychiatric holds (42% after intervention compared with 49.8% before intervention; difference = 7.8%; P < 0.0001) and increase out-patient follow-up care (χ2 = 37.42, d.f. = 1; P < 0.001). Meta-analysis indicated a significant reduction in length of emergency department stay (by 164.24 min; 95% CI -261.24 to -67.23 min; P < 0.001) and number of in-patient admissions (odds ratio 0.55, 95% CI 0.43-0.68; P < 0.001). CONCLUSIONS: Short-stay mental health crisis units are effective for reducing emergency department wait times and in-patient admissions. Further research should investigate the impact of units on patient experience, and clinical and social outcomes.

Sensitivity of the S1 neuronal calcium network to insulin and Bay-K 8644 in vivo: Relationship to gait, motivation, and aging processes.

Neuronal hippocampal Ca2+ dysregulation is a critical component of cognitive decline in brain aging and Alzheimer's disease and is suggested to impact communication and excitability through the activation of a larger after hyperpolarization. However, few studies have tested for the presence of Ca2+ dysregulation in vivo, how it manifests, and whether it impacts network function across hundreds of neurons. Here, we tested for neuronal Ca2+ network dysregulation in vivo in the primary somatosensory cortex (S1) of anesthetized young and aged male Fisher 344 rats using single-cell resolution techniques. Because S1 is involved in sensory discrimination and proprioception, we tested for alterations in ambulatory performance in the aged animal and investigated two potential pathways underlying these central aging- and Ca2+ -dependent changes. Compared to young, aged animals displayed increased overall activity and connectivity of the network as well as decreased ambulatory speed. In aged animals, intranasal insulin (INI) increased network synchronicity and ambulatory speed. Importantly, in young animals, delivery of the L-type voltage-gated Ca2+ channel modifier Bay-K 8644 altered network properties, replicating some of the changes seen in the older animal. These results suggest that hippocampal Ca2+ dysregulation may be generalizable to other areas, such as S1, and might engage modalities that are associated with locomotor stability and motivation to ambulate. Further, given the safety profile of INI in the clinic and the evidence presented here showing that this central dysregulation is sensitive to insulin, we suggest that these processes can be targeted to potentially increase motivation and coordination while also reducing fall frequency with age.

Warning Signs of Potential Black Swan Outbreaks in Infectious Disease.

Black swan events in infectious disease describe rare but devastatingly large outbreaks. While experts are skeptical that such events are predictable, it might be possible to identify the warning signs of a black swan event. Specifically, following the initiation of an outbreak, key differentiating features could serve as alerts. Such features could be derived from meta-analyses of large outbreaks for multiple infectious diseases. We hypothesized there may be common features among the pathogen, environment, and host epidemiological triad that characterize an infectious disease black swan event. Using Los Alamos National Laboratory's tool, Analytics for Investigation of Disease Outbreaks, we investigated historical disease outbreak information and anomalous events for several infectious diseases. By studying 32 different infectious diseases and global outbreaks, we observed that in the past 20-30 years, there have been potential black swan events in the majority of infectious diseases analyzed. Importantly, these potential black swan events cannot be attributed to the first introduction of the disease to a susceptible host population. This paper describes our observations and perspectives and illustrates the value of broad analysis of data across the infectious disease realm, providing insights that may not be possible when we focus on singular infectious agents or diseases. Data analytics could be developed to warn health authorities at the beginning of an outbreak of an impending black swan event. Such tools could complement traditional epidemiological modeling to help forecast future large outbreaks and facilitate timely warning and effective, targeted resource allocation for mitigation efforts.

Optimization of Application-Driven Development of In Vitro Neuromuscular Junction Models.

Neuromuscular junctions (NMJs) are specialized synapses responsible for signal transduction between motor neurons (MNs) and skeletal muscle tissue. Malfunction at this site can result from developmental disorders, toxic environmental exposures, and neurodegenerative diseases leading to severe neurological dysfunction. Exploring these conditions in human or animal subjects is restricted by ethical concerns and confounding environmental factors. Therefore, in vitro NMJ models provide exciting opportunities for advancements in tissue engineering. In the last two decades, multiple NMJ prototypes and platforms have been reported, and each model system design is strongly tied to a specific application: exploring developmental physiology, disease modeling, or high-throughput screening. Directing the differentiation of stem cells into mature MNs and/or skeletal muscle for NMJ modeling has provided critical cues to recapitulate early-stage development. Patient-derived inducible pluripotent stem cells provide a personalized approach to investigating NMJ disease, especially when disease etiology cannot be resolved down to a specific gene mutation. Having reproducible NMJ culture replicates is useful for high-throughput screening to evaluate drug toxicity and determine the impact of environmental threat exposures. Cutting-edge bioengineering techniques have propelled this field forward with innovative microfabrication and design approaches allowing both two-dimensional and three-dimensional NMJ culture models. Many of these NMJ systems require further validation for broader application by regulatory agencies, pharmaceutical companies, and the general research community. In this summary, we present a comprehensive review on the current state-of-art research in NMJ models and discuss their ability to provide valuable insight into cell and tissue interactions. Impact statement In vitro neuromuscular junction (NMJ) models reveal the specialized mechanisms of communication between neurons and muscle tissue. This site can be disrupted by developmental disorders, toxic environmental exposures, or neurodegenerative diseases, which often lead to fatal outcomes and is therefore of critical importance to the medical community. Many bioengineering approaches for in vitro NMJ modeling have been designed to mimic development and disease; other approaches include in vitro NMJ models for high-throughput toxicology screening, providing a platform to limit or replace animal testing. This review describes various NMJ applications and the bioengineering advancements allowing for human NMJ characteristics to be more accurately recapitulated. While the extensive range of NMJ device structures has hindered standardization attempts, there is still a need to harmonize these devices for broader application and to continue advancing the field of NMJ modeling.

Correlation of cytology to histology in a case of canine granulomatous colitis in a Boxer dog.

A 2-year-old castrated male mixed breed dog presented to the North Carolina State Veterinary Teaching Hospital for chronic diarrhea with hematochezia and weight loss. Cytology performed on a rectal scraping revealed macrophages containing magenta, light pink, and variably blue granular inclusions, and phagocytosed material concerning for infectious organisms. Histopathology was consistent with granulomatous colitis and identified intra-histiocytic bacterial organisms, confirmed by fluorescent in situ hybridization (FISH)-tissue culture-confirmed Escherichia coli. Based on these findings, a diagnosis of granulomatous colitis was made. The patient was successfully treated with oral enrofloxacin, and near-complete remission of signs was achieved within 6 weeks. This report describes a case of granulomatous colitis in a mixed breed dog, and is the first published description of the cytologic features of this uncommon disease, offering a valuable cytologic-histologic correlation. In this case, the cytology was helpful in identifying features consistent with granulomatous colitis and prioritizing the differential diagnoses and diagnostic plan.

Safety and Immunogenicity of a Novel Intranasal Influenza Vaccine (NasoVAX): A Phase 2 Randomized, Controlled Trial.

Annual influenza vaccination greatly reduces morbidity and mortality, but effectiveness remains sub-optimal. Weaknesses of current vaccines include low effectiveness against mismatched strains, lack of mucosal and other effective tissue-resident immune responses, weak cellular immune responses, and insufficiently durable immune responses. The safety and immunogenicity of NasoVAX, a monovalent intranasal influenza vaccine based on a replication-deficient adenovirus type 5 platform, were evaluated in a placebo-controlled single ascending-dose study. Sixty healthy adults (18-49 years) received a single intranasal dose of 1×109 viral particles (vp), 1 × 1010 vp, or 1 × 1011 vp of NasoVAX or placebo. NasoVAX was well-tolerated and elicited robust influenza-specific systemic and mucosal immune responses. The highest NasoVAX dose and the approved Fluzone® influenza vaccine elicited comparable hemagglutination inhibition (HAI) geometric mean titers (152.8 vs. 293.4) and microneutralization (MN) geometric mean titers (142.5 vs. 162.8), with NasoVAX HAI titers maintained more than 1-year on average following a single dose. Hemagglutinin-specific T cells responses were also documented in peripheral mononuclear cell (PBMC) preparations. Consistent with the intranasal route of administration, NasoVAX elicited antigen-specific mucosal IgA responses in the nasopharyngeal cavity with an increase of approximately 2-fold over baseline GMT at the mid- and high-doses. In summary, NasoVAX appeared safe and elicited a broad immune response, including humoral, cellular, and mucosal immunity, with no impact of baseline anti-adenovirus antibody at the most immunogenic dose.

The psychiatric decision unit as an emerging model in mental health crisis care: a national survey in England.

Psychiatric decision units have been developed in many countries internationally to address the pressure on inpatient services and dissatisfactory, long waits people in mental health crisis can experience in emergency departments. Research into these units lags behind their development, as they are implemented by healthcare providers to address these problems. This is the first-ever national survey to identify their prevalence, structure, activities, and contextual setting within health services, in order to provide a robust basis for future research. The response rate was high (94%), and six PDUs in England were identified. The results indicated that PDUs open 24/7, accept only voluntary patients, provide recliner chairs for sleeping rather than beds, and limit stays to 12-72 hours. PDUs are predominantly staffed by senior, qualified mental health nurses and healthcare assistants, with psychiatry input. Staff:patient ratios are high (1:2.1 during the day shift). Differences in PDU structure and activities (including referral pathway, length of stay, and staff:patient ratios) were identified, suggesting the optimal configuration for PDUs has not yet been established. Further research into the efficacy of this innovation is needed; PDUs potentially have a role in an integrated crisis care pathway which provides a variety of care options to service users.

Global transcriptome profile of the developmental principles of in vitro iPSC-to-motor neuron differentiation.

BACKGROUND: Human induced pluripotent stem cells (iPSC) have opened new avenues for regenerative medicine. Consequently, iPSC-derived motor neurons have emerged as potentially viable therapies for spinal cord injuries and neurodegenerative disorders including Amyotrophic Lateral Sclerosis. However, direct clinical application of iPSC bears in itself the risk of tumorigenesis and other unforeseeable genetic or epigenetic abnormalities. RESULTS: Employing RNA-seq technology, we identified and characterized gene regulatory networks triggered by in vitro chemical reprogramming of iPSC into cells with the molecular features of motor neurons (MNs) whose function in vivo is to innervate effector organs. We present meta-transcriptome signatures of 5 cell types: iPSCs, neural stem cells, motor neuron progenitors, early motor neurons, and mature motor neurons. In strict response to the chemical stimuli, along the MN differentiation axis we observed temporal downregulation of tumor growth factor-ß signaling pathway and consistent activation of sonic hedgehog, Wnt/ß-catenin, and Notch signaling. Together with gene networks defining neuronal differentiation (neurogenin 2, microtubule-associated protein 2, Pax6, and neuropilin-1), we observed steady accumulation of motor neuron-specific regulatory genes, including Islet-1 and homeobox protein HB9. Interestingly, transcriptome profiling of the differentiation process showed that Ca2+ signaling through cAMP and LPC was downregulated during the conversion of the iPSC to neural stem cells and key regulatory gene activity of the pathway remained inhibited until later stages of motor neuron formation. Pathways shaping the neuronal development and function were well-represented in the early motor neuron cells including, neuroactive ligand-receptor interactions, axon guidance, and the cholinergic synapse formation. A notable hallmark of our in vitro motor neuron maturation in monoculture was the activation of genes encoding G-coupled muscarinic acetylcholine receptors and downregulation of the ionotropic nicotinic acetylcholine receptors expression. We observed the formation of functional neuronal networks as spontaneous oscillations in the extracellular action potentials recorded on multi-electrode array chip after 20 days of differentiation. CONCLUSIONS: Detailed transcriptome profile of each developmental step from iPSC to motor neuron driven by chemical induction provides the guidelines to novel therapeutic approaches in the re-construction efforts of muscle innervation.

HPV and HPV Vaccination Knowledge and Attitudes Among Medical Students in Alabama.

In addition to being the most common sexually transmitted infection, the human papillomavirus (HPV) is associated with six types of cancer in men and women. The HPV vaccine provides long-lasting, effective protection from high-risk HPV infection, thus serving as a means of cancer prevention. An effective healthcare provider recommendation is well-established as the most significant influence on HPV vaccine uptake, and, as emerging providers, it is critical that medical students receive comprehensive training in this area. However, the type and extent of such training for current medical students in the USA is unclear. An online survey assessing HPV and HPV vaccine knowledge, attitudes, and vaccine status was distributed to all medical students at an Alabama university. Scales were developed to assess composite HPV and HPV knowledge scores and HPV vaccination intentions. Of those age-eligible, 32.1% reported completion of the HPV vaccine series while 15.2% reported partial completion. Knowledge of both HPV and HPV vaccination significantly increased with program year (p < 0.0001 and p = 0.0069, respectively); however, there were knowledge gaps across all years regarding HPV-associated cancers. Attitudes and intentions showed a similar association, with more advanced students demonstrating more positive attitudes toward HPV vaccination (p = 0.0003). There is a need within the current curriculum to include more education and training on HPV, HPV vaccination, and counseling-particularly for students in the first 2 years of their program. Implementation of a classroom module or interactive workshop would likely improve knowledge and attitudes, better preparing students for their future role as potential immunizers.

Electrophysiological and Imaging Calcium Biomarkers of Aging in Male and Female 5×FAD Mice.

BACKGROUND: In animal models and tissue preparations, calcium dyshomeostasis is a biomarker of aging and Alzheimer's disease that is associated with synaptic dysfunction, neuritic pruning, and dysregulated cellular processes. It is unclear, however, whether the onset of calcium dysregulation precedes, is concurrent with, or is the product of pathological cellular events (e.g., oxidation, amyloid-ß production, and neuroinflammation). Further, neuronal calcium dysregulation is not always present in animal models of amyloidogenesis, questioning its reliability as a disease biomarker. OBJECTIVE: Here, we directly tested for the presence of calcium dysregulation in dorsal hippocampal neurons in male and female 5×FAD mice on a C57BL/6 genetic background using sharp electrodes coupled with Oregon-green Bapta-1 imaging. We focused on three ages that coincide with the course of amyloid deposition: 1.5, 4, and 10 months old. METHODS: Outcome variables included measures of the afterhyperpolarization, short-term synaptic plasticity, and calcium kinetics during synaptic activation. Quantitative analyses of spatial learning and memory were also conducted using the Morris water maze. Main effects of sex, age, and genotype were identified on measures of electrophysiology and calcium imaging. RESULTS: Measures of resting Oregon-green Bapta-1 fluorescence showed significant reductions in the 5×FAD group compared to controls. Deficits in spatial memory, along with increases in Aß load, were detectable at older ages, allowing us to test for temporal associations with the onset of calcium dysregulation. CONCLUSION: Our results provide evidence that reduced, rather than elevated, neuronal calcium is identified in this 5×FAD model and suggests that this surprising result may be a novel biomarker of AD.

Elevating Insulin Signaling Using a Constitutively Active Insulin Receptor Increases Glucose Metabolism and Expression of GLUT3 in Hippocampal Neurons.

Insulin signaling is an integral component of healthy brain function, with evidence of positive insulin-mediated alterations in synaptic integrity, cerebral blood flow, inflammation, and memory. However, the specific pathways targeted by this peptide remain unclear. Previously, our lab used a molecular approach to characterize the impact of insulin signaling on voltage-gated calcium channels and has also shown that acute insulin administration reduces calcium-induced calcium release in hippocampal neurons. Here, we explore the relationship between insulin receptor signaling and glucose metabolism using similar methods. Mixed, primary hippocampal cultures were infected with either a control lentivirus or one containing a constitutively active human insulin receptor (IRß). 2-NBDG imaging was used to obtain indirect measures of glucose uptake and utilization. Other outcome measures include Western immunoblots of GLUT3 and GLUT4 on total membrane and cytosolic subcellular fractions. Glucose imaging data indicate that neurons expressing IRß show significant elevations in uptake and rates of utilization compared to controls. As expected, astrocytes did not respond to the IRß treatment. Quantification of Western immunoblots show that IRß is associated with significant elevations in GLUT3 expression, particularly in the total membrane subcellular fraction, but did not alter GLUT4 expression in either fraction. Our work suggests that insulin plays a significant role in mediating neuronal glucose metabolism, potentially through an upregulation in the expression of GLUT3. This provides further evidence for a potential therapeutic mechanism underlying the beneficial impact of intranasal insulin in the clinic.

Molecular elevation of insulin receptor signaling improves memory recall in aged Fischer 344 rats.

As demonstrated by increased hippocampal insulin receptor density following learning in animal models and decreased insulin signaling, receptor density, and memory decline in aging and Alzheimer's diseases, numerous studies have emphasized the importance of insulin in learning and memory processes. This has been further supported by work showing that intranasal delivery of insulin can enhance insulin receptor signaling, alter cerebral blood flow, and improve memory recall. Additionally, inhibition of insulin receptor function or expression using molecular techniques has been associated with reduced learning. Here, we sought a different approach to increase insulin receptor activity without the need for administering the ligand. A constitutively active, modified human insulin receptor (IRß) was delivered to the hippocampus of young (2 months) and aged (18 months) male Fischer 344 rats in vivo. The impact of increasing hippocampal insulin receptor expression was investigated using several outcome measures, including Morris water maze and ambulatory gait performance, immunofluorescence, immunohistochemistry, and Western immunoblotting. In aged animals, the IRß construct was associated with enhanced performance on the Morris water maze task, suggesting that this receptor was able to improve memory recall. Additionally, in both age-groups, a reduced stride length was noted in IRß-treated animals along with elevated hippocampal insulin receptor levels. These results provide new insights into the potential impact of increasing neuronal insulin signaling in the hippocampus of aged animals and support the efficacy of molecularly elevating insulin receptor activity in vivo in the absence of the ligand to directly study this process.

Student pharmacist perceptions of learning after strengths-based leadership skills lab and escape room in pharmacy practice skills laboratory.

BACKGROUND AND PURPOSE: Leadership is a required component of doctor of pharmacy programs. There is opportunity for students to receive instructional education on leadership concepts through serious games. EDUCATIONAL ACTIVITY AND SETTING: First-year pharmacy students (n = 146) participated in a required skills-based leadership lab including a team-based escape room activity. FINDINGS: Students reported a statistically significant increase in understanding of leadership concepts and application at the end of the global lab activities (p < 0.01) and a majority of the students found the escape room activity "very useful" (56%). SUMMARY: Escape rooms present a unique opportunity to engage students in active learning and problem solving. A majority of the students found the escape room activity useful and enjoyed the interactive application of leadership concepts. Potential challenges to implementing escape rooms such as time to develop, physical space requirements, supplies, and volunteers to facilitate the experience should be considered prior to implementation. Serious gaming is an emerging pedagogy, and this data supplements existing literature to support use in pharmacy education.