The effects of inhaled corticosteroids on healthy airways.

BACKGROUND: The effects of inhaled corticosteroids (ICS) on healthy airways are poorly defined. OBJECTIVES: To delineate the effects of ICS on gene expression in healthy airways, without confounding caused by changes in disease-related genes and disease-related alterations in ICS responsiveness. METHODS: Randomized open-label bronchoscopy study of high-dose ICS therapy in 30 healthy adult volunteers randomized 2:1 to (i) fluticasone propionate 500 mcg bd daily or (ii) no treatment, for 4 weeks. Laboratory staff were blinded to allocation. Biopsies and brushings were analysed by immunohistochemistry, bulk RNA sequencing, DNA methylation array and metagenomics. RESULTS: ICS induced small between-group differences in blood and lamina propria eosinophil numbers, but not in other immunopathological features, blood neutrophils, FeNO, FEV1, microbiome or DNA methylation. ICS treatment upregulated 72 genes in brushings and 53 genes in biopsies, and downregulated 82 genes in brushings and 416 genes in biopsies. The most downregulated genes in both tissues were canonical markers of type-2 inflammation (FCER1A, CPA3, IL33, CLEC10A, SERPINB10 and CCR5), T cell-mediated adaptive immunity (TARP, TRBC1, TRBC2, PTPN22, TRAC, CD2, CD8A, HLA-DQB2, CD96, PTPN7), B-cell immunity (CD20, immunoglobulin heavy and light chains) and innate immunity, including CD48, Hobit, RANTES, Langerin and GFI1. An IL-17-dependent gene signature was not upregulated by ICS. CONCLUSIONS: In healthy airways, 4-week ICS exposure reduces gene expression related to both innate and adaptive immunity, and reduces markers of type-2 inflammation. This implies that homeostasis in health involves tonic type-2 signalling in the airway mucosa, which is exquisitely sensitive to ICS.

Infertile Jordanian Women's Self-Perception About Societal Violence: An Interpretative Phenomenological Study.

Background: Infertility affects one in six couples globally and is compounded by stigma and violence, particularly for women, in Jordan's culture. While existing research has illuminated societal pressures faced by infertile women, there is, yet no comprehensive understanding of the violence they encounter in their daily lives. Objective: This Interpretative Phenomenological study seeks to unravel the experiences of infertile women regarding societal violence in Jordan. By focusing on different types of community violence - physical, psychological, and emotional - The study aims to provide nuanced insights into the challenges these women confront. It also endeavors to identify contributing factors, including societal attitudes, cultural beliefs, and individual encounters, while informing policy and practice to mitigate this issue. Methods: Employing a qualitative approach, this study conducted semi-structured interviews with purposively sampled infertile women. Thematic analysis was utilized to uncover recurring patterns and themes, facilitating a comprehensive exploration of their experiences. Results: Five main themes were identified: How the surrounding people view me as an infertile woman; I am suffocated by their questions; they interfere in the smallest details; I got burned and turned to ashes, and I have no right to complain; The problem of childbearing and the treatment plan is a matter for me and my husband only; and who supports me and what do I want from those around me? Implications: This study's implications are significant for policy and practice. By foregrounding the prevalent violence faced by infertile women, it underscores the urgency of interventions. Raising awareness, providing education, and extending support can counteract societal stigma and violence. Creating a more compassionate societal fabric can ensure a safer, more inclusive environment for these women.

Advancing Equity in U.S. Hospital Systems: Employee Understandings of Health Equity and Steps for Improvement.

GOALS: Equity in the U.S. healthcare system remains a vital goal for healthcare leaders. Although many hospitals and healthcare systems have adopted a social determinants of health approach to more equitable care, many challenges have limited the effectiveness of their efforts. In this study, we wanted to explore whether healthcare leaders and providers understand the concept of equity and can link the concepts to practical applications within healthcare systems. METHODS: We explored how hospital leadership and providers at a major public hospital in Atlanta, Georgia, understand equity topics both conceptually and at a practical implementation level. We conducted 28 focus groups for >4 months involving 233 staff members, during which participants were asked about their understanding of various equity-related terms and equity implementation within the hospital. PRINCIPAL FINDINGS: Our findings reveal that there is little consensus among staff regarding the conceptual meanings of various health equity-related terms, and only a small minority of staff can articulate a conceptual definition that reflects current research-based understandings of equity. Furthermore, there is little consensus regarding how staff believes that health equity is practically enacted through various hospital programs, even among interviewees who could correctly articulate equity topics. These findings have no association with a role in the organization or length of time employed at the hospital. PRACTICAL APPLICATIONS: These findings indicate a need for a more nuanced understanding of health equity and further clarification and education on how to implement health equity. Although understanding at the conceptual level is an important first step, conceptual knowledge alone is not enough to support health equity at either the individual staff level or the system level. Our recommendations cover strategic development; education specific to the hospital system and its unique needs; consideration of the specific roles of individuals in the organization; and the designation of diversity, equity, and inclusion staff and offices in a hospital organization.

Nepalese indoor cookstove smoke extracts alter human airway epithelial gene expression, DNA methylation and hydroxymethylation.

Household air pollution caused by inefficient cooking practices causes 4 million deaths a year worldwide. In Nepal, 86% of the rural population use solid fuels for cooking. Over 25% of premature deaths associated with air pollution are respiratory in nature. Here we aimed to identify molecular signatures of different cookstove and fuel type exposures in human airway epithelial cells, to understand the mechanisms mediating cook stove smoke induced lung disease. Primary human airway epithelial cells in submerged culture were exposed to traditional cook stove (TCS), improved cook stove (ICS) and liquefied petroleum gas (LPG) stove smoke extracts. Changes to gene expression, DNA methylation and hydroxymethylation were measured by bulk RNA sequencing and HumanMethylationEPIC BeadChip following oxidative bisulphite conversion, respectively. TCS smoke extract alone reproducibly caused changes in the expression of 52 genes enriched for oxidative stress pathways. TCS, ICS and LPG smoke extract exposures were associated with distinct changes to DNA methylation and hydroxymethylation. A subset of TCS induced genes were associated with differentially methylated and/or hydroxymethylated CpGs sites, and enriched for the ferroptosis pathway and the upstream regulator NFE2L2. DNA methylation and hydroxymethylation changes not associated with a concurrent change in gene expression, were linked to biological processes and molecular pathways important to airway health, including neutrophil function, transforming growth factor beta signalling, GTPase activity, and cell junction organisation. Our data identified differential impacts of TCS, ICS and LPG cook stove smoke on the human airway epithelium transcriptome, DNA methylome and hydroxymethylome and provide further insight into the association between indoor air pollution exposure and chronic lung disease mechanisms.

Vaccination and vacci-notions: Understanding the barriers and facilitators of COVID-19 vaccine uptake during the 2020-21 COVID-19 pandemic.

Objective: The COVID-19 pandemic continues to place an inordinate burden on U.S. population health, and vaccination is the most powerful tool for curbing SARS-CoV-2 transmission, saving lives, and promoting economic recovery. However, much of the U.S. population remains hesitant to get vaccinated against COVID-19, despite having access to these life-saving vaccines. This study's objective was to examine the demographic characteristics, experiences, and disease- and vaccine-related risk perceptions that influence an individual's decision to adhere to vaccine recommendations for COVID-19. Study design: A telephone survey was performed with a convenience sample of 57 participants. Methods: This mixed-methods study collected quantitative and qualitative responses about seasonal influenza and COVID-19 vaccine intentions to compare vaccine hesitancies between a novel and routine vaccine. Results: The primary facilitators of uptake for the COVID-19 vaccine were personal protection, protecting others, preserving public health, and general vaccine confidence. Concerns about vaccine side effects, concerns about the COVID-19 vaccine trials, misinformation about vaccination, personal aversions to the vaccine, general distrust in vaccination, complacency, and distrust in government were the primary barriers to vaccine uptake. Race was also associated with COVID-19 vaccine intentions. Conclusions: The results of this research have been condensed into four recommendations designed to optimize public health messaging around the COVID-19 vaccine and maximize future vaccine uptake.

Toward co-design of an AI solution for detection of diarrheal pathogens in drinking water within resource-constrained contexts.

Despite successes on the Sustainable Development Goals for access to improved water sources and sanitation, many low and middle-income countries (LMICs) continue to struggle with high rates of diarrheal disease. In Guatemala, 98% of water sources are estimated to have E. coli contamination. This project moves toward a novel low-cost approach to bridge the gap between the microbiologic identification of E. coli and the vast impact that this pathogen has on human health within marginalized communities using co-designed community-based tools, low-cost technology, and AI. An agile co-design process was followed with water quality stakeholders, community staff, and local graphic design artists to develop a community water quality education mobile app. A series of alpha- and beta-testers completed interactive demonstration, feedback, and in-depth interview sessions. A microbiology lab in Guatemala developed and piloted field protocols with lay community workers to collect and process water samples. A preliminary artificial intelligence (AI) algorithm was developed to detect the presence of E. coli in images generated from community-derived water samples. The mobile app emerged as a pictorial and audio-driven community-facing tool. The field protocol for water sampling and testing was successfully implemented by lay community workers. Feedback from the community workers indicated both desire and ability to conduct the water sampling and testing protocol under field conditions. However, images derived from the low-cost $2 microscope in field conditions were not of a suitable quality for AI object detection of E. coli, and additional low-cost technologies are being considered. The preliminary AI object detection algorithm from lab-derived images performed at 94% accuracy in identifying E. coli in comparison to the Chromocult gold-standard.

DNA Methylation of Fibroblast Phenotypes and Contributions to Lung Fibrosis.

Fibroblasts are an integral part of connective tissue and play a crucial role in developing and modulating the structural framework of tissues by acting as the primary source of extracellular matrix (ECM). A precise definition of the fibroblast remains elusive. Lung fibroblasts orchestrate the assembly and turnover of ECM to facilitate gas exchange alongside performing immune functions including the secretion of bioactive molecules and antigen presentation. DNA methylation is the covalent attachment of a methyl group to primarily cytosines within DNA. DNA methylation contributes to diverse cellular phenotypes from the same underlying genetic sequence, with DNA methylation profiles providing a memory of cellular origin. The lung fibroblast population is increasingly viewed as heterogeneous with between 6 and 11 mesenchymal populations identified across health and lung disease to date. DNA methylation has been associated with different lung fibroblast populations in health and with alterations in lung disease, but to varying extents. In this review, we will discuss lung fibroblast heterogeneity and the evidence for a contribution from DNA methylation to defining cell populations and alterations in disease.

Predominant DNMT and TET mediate effects of allergen on the human bronchial epithelium in a controlled air pollution exposure study.

BACKGROUND: Epidemiological data show that traffic-related air pollution contributes to the increasing prevalence and severity of asthma. DNA methylation (DNAm) changes may elucidate adverse health effects of environmental exposures. OBJECTIVES: We sought to assess the effects of allergen and diesel exhaust (DE) exposures on global DNAm and its regulation enzymes in human airway epithelium. METHODS: A total of 11 participants, including 7 with and 4 without airway hyperresponsiveness, were recruited for a randomized, double-blind crossover study. Each participant had 3 exposures: filtered air + saline, filtered air + allergen, and DE + allergen. Forty-eight hours postexposure, endobronchial biopsies and bronchoalveolar lavages were collected. Levels of DNA methyltransferases (DNMTs) and ten-eleven translocation (TET) enzymes, 5-methylcytosine, and 5-hydroxymethylcytosine were determined by immunohistochemistry. Cytokines and chemokines in bronchoalveolar lavages were measured by electrochemiluminescence multiplex assays. RESULTS: Predominant DNMT (the most abundant among DNMT1, DNMT3A, and DNMT3B) and predominant TET (the most abundant among TET1, TET2, and TET3) were participant-dependent. 5-Methylcytosine and its regulation enzymes differed between participants with and without airway hyperresponsiveness at baseline (filtered air + saline) and in response to allergen challenge (regardless of DE exposure). Predominant DNMT and predominant TET correlated with lung function. Allergen challenge effect on IL-8 in bronchoalveolar lavages was modified by TET2 baseline levels in the epithelium. CONCLUSIONS: Response to allergen challenge is associated with key DNAm regulation enzymes. This relationship is generally unaltered by DE coexposure but is rather dependent on airway hyperresponsiveness status. These enzymes therefore warranted further inquiry regarding their potential in diagnosis, prognosis, and treatment of asthma.

TWIST1 DNA methylation is a cell marker of airway and parenchymal lung fibroblasts that are differentially methylated in asthma.

BACKGROUND: Mesenchymal fibroblasts are ubiquitous cells that maintain the extracellular matrix of organs. Within the lung, airway and parenchymal fibroblasts are crucial for lung development and are altered with disease, but it has been difficult to understand their roles due to the lack of distinct molecular markers. We studied genome-wide DNA methylation and gene expression in airway and parenchymal lung fibroblasts from healthy and asthmatic donors, to identify a robust cell marker and to determine if these cells are molecularly distinct in asthma. RESULTS: Airway (N = 8) and parenchymal (N = 15) lung fibroblasts from healthy individuals differed in the expression of 158 genes, and DNA methylation of 3936 CpGs (Bonferroni adjusted p value < 0.05). Differential DNA methylation between cell types was associated with differential expression of 42 genes, but no single DNA methylation CpG feature (location, effect size, number) defined the interaction. Replication of gene expression and DNA methylation in a second cohort identified TWIST1 gene expression, DNA methylation and protein expression as a cell marker of airway and parenchymal lung fibroblasts, with DNA methylation having 100% predictive discriminatory power. DNA methylation was differentially altered in parenchymal (112 regions) and airway fibroblasts (17 regions) with asthmatic status, with no overlap between regions. CONCLUSIONS: Differential methylation of TWIST1 is a robust cell marker of airway and parenchymal lung fibroblasts. Airway and parenchymal fibroblast DNA methylation are differentially altered in individuals with asthma, and the role of both cell types should be considered in the pathogenesis of asthma.

Estimating birth weight from observed postnatal weights in a Guatemalan highland community.

OBJECTIVE: Low birth weight is one of the leading contributors to global perinatal deaths. Detecting this problem close to birth enables the initiation of early intervention, thus reducing the long-term impact on the fetus. However, in low-and middle-income countries, sometimes newborns are weighted days or months after birth, thus challenging the identification of low birth weight. This study aims to estimate birth weight from observed postnatal weights recorded in a Guatemalan highland community. APPROACH: With 918 newborns recorded in postpartum visits at a Guatemalan highland community, we fitted traditional infant weight models (Count's and Reeds models). The model that fitted the observed data best was selected based on typical newborn weight patterns reported in the medical literature and previous longitudinal studies. Then, estimated birth weights were determined using the weight gain percentage derived from the fitted weight curve. MAIN RESULTS: The best model for both genders was the Reeds2 model, with a mean square error of 0.30 kg2 and 0.23 kg2 for male and female newborns, respectively. The fitted weight curves exhibited similar behavior to those reported in the literature, with a maximum weight loss around three to five days after birth, and birth weight recovery, on average, by day ten. Moreover, the estimated birth weight was consistent with the 2015 Guatemalan National Survey, no having a statistically significant difference between the estimated birth weight and the reported survey birth weights (two-sided Wilcoxon rank-sum test; [Formula: see text]). SIGNIFICANCE: By estimating birth weight at an opportune time, several days after birth, it may be possible to identify low birth weight more accurately, thus providing timely treatment when is required.

A Proxy for Detecting IUGR Based on Gestational Age Estimation in a Guatemalan Rural Population.

In-utero progress of fetal development is normally assessed through manual measurements taken from ultrasound images, requiring relatively expensive equipment and well-trained personnel. Such monitoring is therefore unavailable in low- and middle-income countries (LMICs), where most of the perinatal mortality and morbidity exists. The work presented here attempts to identify a proxy for IUGR, which is a significant contributor to perinatal death in LMICs, by determining gestational age (GA) from data derived from simple-to-use, low-cost one-dimensional Doppler ultrasound (1D-DUS) and blood pressure devices. A total of 114 paired 1D-DUS recordings and maternal blood pressure recordings were selected, based on previously described signal quality measures. The average length of 1D-DUS recording was 10.43 ± 1.41 min. The min/median/max systolic and diastolic maternal blood pressures were 79/102/121 and 50.5/63.5/78.5 mmHg, respectively. GA was estimated using features derived from the 1D-DUS and maternal blood pressure using a support vector regression (SVR) approach and GA based on the last menstrual period as a reference target. A total of 50 trials of 5-fold cross-validation were performed for feature selection. The final SVR model was retrained on the training data and then tested on a held-out set comprising 28 normal weight and 25 low birth weight (LBW) newborns. The mean absolute GA error with respect to the last menstrual period was found to be 0.72 and 1.01 months for the normal and LBW newborns, respectively. The mean error in the GA estimate was shown to be negatively correlated with the birth weight. Thus, if the estimated GA is lower than the (remembered) GA calculated from last menstruation, then this could be interpreted as a potential sign of IUGR associated with LBW, and referral and intervention may be necessary. The assessment system may, therefore, have an immediate impact if coupled with suitable intervention, such as nutritional supplementation. However, a prospective clinical trial is required to show the efficacy of such a metric in the detection of IUGR and the impact of the intervention.

Airway epithelial cell isolation techniques affect DNA methylation profiles with consequences for analysis of asthma related perturbations to DNA methylation.

The airway epithelium forms the interface between the inhaled environment and the lung. The airway epithelium is dysfunctional in asthma and epigenetic mechanisms are considered a contributory factor. We hypothesised that the DNA methylation profiles of cultured primary airway epithelial cells (AECs) would differ between cells isolated from individuals with asthma (n = 17) versus those without asthma (n = 16). AECs were isolated from patients by two different isolation techniques; pronase digestion (9 non-asthmatic, 8 asthmatic) and bronchial brushings (7 non-asthmatic and 9 asthmatic). DNA methylation was assessed using an Illumina Infinium HumanMethylation450 BeadChip array. DNA methylation of AECs clustered by isolation technique and linear regression identified 111 CpG sites differentially methylated between isolation techniques in healthy individuals. As a consequence, the effect of asthmatic status on DNA methylation was assessed within AEC samples isolated using the same technique. In pronase isolated AECs, 15 DNA regions were differentially methylated between asthmatics and non-asthmatics. In bronchial brush isolated AECs, 849 differentially methylated DNA regions were identified with no overlap to pronase regions. In conclusion, regardless of cell isolation technique, differential DNA methylation was associated with asthmatic status in AECs, providing further evidence for aberrant DNA methylation as a signature of epithelial dysfunction in asthma.

Ethically Managing Risks in Global Health Fieldwork: Human Rights Ideals Confront Real World Challenges.

Global health is an interdisciplinary field engaged with implementation of the human right to health, yet ethical dimensions of the on-the-ground realities of this work have been underexplored. Fieldwork in global health produces knowledge through both primary research and the lessons of practical program implementation. Much of this essential knowledge, which often documents health disparities and other human rights abuses, arises from work in dangerous contexts. Work in such environments entails risk to all participants in the global health enterprise, both local and foreign, but affects them differently. The risks of ethical fieldwork must be considered not only for the well-being of project participants and fieldworkers but also in light of how they shape and constrain global health research and program implementation. Drawing on case examples from the authors' fieldwork, this article marks an effort to begin disentangling the realities of risks in the field and the responsibility borne by the fieldworker to undertake ethical action, recognizing that decisions are often made without established protocols or the immediate availability of guidance from colleagues. We call for further engagement within global health on ethical issues distinctive to the complex and dangerous places in which the promise of a right to health is enacted in the real world.

An open source autocorrelation-based method for fetal heart rate estimation from one-dimensional Doppler ultrasound.

OBJECTIVE: Open research on fetal heart rate (FHR) estimation is relatively rare, and evidence for the utility of metrics derived from Doppler ultrasound devices has historically remained hidden in the proprietary documentation of commercial entities, thereby inhibiting its assessment and improvement. Nevertheless, recent studies have attempted to improve FHR estimation; however, these methods were developed and tested using datasets composed of few subjects and are therefore unlikely to be generalizable on a population level. The work presented here introduces a reproducible and generalizable autocorrelation (AC)-based method for FHR estimation from one-dimensional Doppler ultrasound (1D-DUS) signals. APPROACH: Simultaneous fetal electrocardiogram (fECG) and 1D-DUS signals generated by a hand-held Doppler transducer in a fixed position were captured by trained healthcare workers in a European hospital. The fECG QRS complexes were identified using a previously published fECG extraction algorithm and were then over-read to ensure accuracy. An AC-based method to estimate FHR was then developed on this data, using a total of 721 1D-DUS segments, each 3.75 s long, and parameters were tuned with Bayesian optimization. The trained FHR estimator was tested on two additional (independent) hand-annotated Doppler-only datasets recorded with the same device but on different populations: one composed of 3938 segments (from 99 fetuses) acquired in rural Guatemala, and another composed of 894 segments (from 17 fetuses) recorded in a hospital in the UK. MAIN RESULTS: The proposed AC-based method was able to estimate FHR within 10% of the reference FHR values 96% of the time, with an accuracy of 97% for manually identified good quality segments in both of the independent test sets. SIGNIFICANCE: This is the first work to publish open source code for FHR estimation from 1D-DUS data. The method was shown to satisfy estimations within 10% of the reference FHR values and it therefore defines a minimum accuracy for the field to match or surpass. Our work establishes a basis from which future methods can be developed to more accurately estimate FHR variability for assessing fetal wellbeing from 1D-DUS signals.

Epigenetic Changes in Airway Smooth Muscle as a Driver of Airway Inflammation and Remodeling in Asthma.

Epigenetic changes are heritable changes in gene expression, without changing the DNA sequence. Epigenetic processes provide a critical link between environmental insults to the airway and functional changes that determine how airway cells respond to future stimuli. There are three primary epigenetic processes: histone modifications, DNA modification, and noncoding RNAs. Airway smooth muscle has several important roles in the development and maintenance of the pathologic processes occurring in asthma, including inflammation, remodeling, and contraction/hyperresponsiveness. In this review, we describe the evidence for the role of epigenetic changes in driving these processes in airway smooth muscle cells in asthma, with a particular focus on histone modifications. We also discuss how existing therapies may target some of these changes and how epigenetic processes provide targets for the development of novel asthma therapeutics. Epigenetic marks may also provide a biomarker to assess phenotype and treatment responses.