Development of 'gastrostomy tube - is it for me?', a web-based patient decision aid for people living with motor neurone disease considering having a gastrostomy tube placed.

Objective: To develop and pilot a web-based patient decision aid (PDA) to support people living with motor neurone disease (plwMND) considering having a gastrostomy tube placed. Methods: In Phase 1, content and design were informed by semi-structured interviews, literature reviews and a prioritization survey. In Phase 2, the prototype PDA was tested with users and developed iteratively with feedback from surveys and 'think-aloud' interviews. Phase 1 and 2 participants were plwMND, carers and healthcare professionals (HCPs). In Phase 3, the PDA was evaluated by plwMND using validated questionnaires and HCPs provided feedback in focus groups. Results: Sixteen plwMND, 16 carers and 25 HCPs took part in Phases 1 and 2. Interviews and the literature review informed a prioritization survey with 82 content items. Seventy-seven per cent (63/82) of the content of the PDA was retained. A prototype PDA, which conforms to international standards, was produced and improved during Phase 2. In Phase 3, 17 plwMND completed questionnaires after using the PDA. Most plwMND (94%) found the PDA completely acceptable and would recommend it to others in their position, 88% had no decisional conflict, 82% were well prepared and 100% were satisfied with their decision-making. Seventeen HCPs provided positive feedback and suggestions for use in clinical practice. Conclusion: Gastrostomy Tube: Is it for me? was co-produced with stakeholders and found to be acceptable, practical and useful. Freely available from the MND Association website, the PDA is a valuable tool to support the shared decision-making process for gastrostomy tube placement.

Reduced dietary intake of pro-inflammatory Toll-like receptor stimulants favourably modifies markers of cardiometabolic risk in healthy men.

BACKGROUND AND AIMS: Because pro-inflammatory stimulants of Toll-like receptor-2 and TLR4 (pathogen-associated molecular patterns, PAMPs), are abundant in some processed foods, we explored the effects of diets enriched or depleted in these molecules on markers of cardiometabolic risk in man. METHODS AND RESULTS: Adherence to a low PAMP diet for 7 days reduced LDL-cholesterol (-0.69 mM, P = 0.024) and abdominal circumference (-1.6 cm, P = 0.001) in 11 habitual consumers of high PAMP foodstuffs, and these markers, together with leukocyte counts (+14%, P = 0.017) increased significantly after 4 days consuming predominantly high PAMP foods. Change in LDL-cholesterol and leukocyte counts correlated well with change in frequency of intake of high PAMP foodstuffs per individual (r = 0.540, P = 0.0095 and r = 0.6551, P = 0.0009, respectively). In an independent group of 13 healthy men, leukocyte counts and expression of the activation marker CD11b on granulocytes and monocytes were significantly reduced after a fresh onion meal (P < 0.05), but these effects were reversed by a high PAMP equivalent meal. CONCLUSIONS: A low PAMP diet is associated with reduced levels of several cardiometabolic risk factors, while a high PAMP diet reverses these effects. These findings suggest a novel potential mechanistic explanation for the observed association between processed food consumption and risk of cardiometabolic diseases. The study is registered at clinicaltrials.org (reference NCT02430064).

The functional maturation of M cells is dramatically reduced in the Peyer's patches of aged mice.

The transcytosis of antigens across the follicle-associated epithelium (FAE) of Peyer's patches by microfold cells (M cells) is important for the induction of efficient immune responses to mucosal antigens. The mucosal immune response is compromised by ageing, but effects on M cells were unknown. We show that M-cell density in the FAE of aged mice was dramatically reduced. As a consequence, aged Peyer's patches were significantly deficient in their ability to transcytose particulate lumenal antigen across the FAE. Ageing specifically impaired the expression of Spi-B and the downstream functional maturation of M cells. Ageing also dramatically impaired C-C motif chemokine ligand 20 expression by the FAE. As a consequence, fewer B cells were attracted towards the FAE, potentially reducing their ability to promote M-cell maturation. Our study demonstrates that ageing dramatically impedes the functional maturation of M cells, revealing an important ageing-related defect in the mucosal immune system's ability to sample lumenal antigens.

Stimulants of Toll-like receptors 2 and 4 are elevated in saliva of periodontitis patients compared with healthy subjects.

AIM: Because the absorption of stimulants of Toll-like receptor (TLR)2 and TLR4 from the gastrointestinal tract into the circulation has been proposed to promote the development of atherosclerosis and insulin resistance, we aimed to quantify the abundance of stimulants of TLR2 and TLR4 in human saliva. METHODS: A recently developed bioassay based upon measurement of NF-κB activation in TLR-deficient human embryonic kidney (HEK)-293 cells transfected with human TLR2 or TLR4 and calibrated with synthetic bacterial lipopeptide (Pam(3) CSK(4) ) or Escherichia coli lipopolysaccharide (LPS), was used to establish the normal range of TLR stimulants in saliva of 20 healthy subjects and 20 subjects with periodontal disease. RESULTS: Median soluble stimulants of TLR2 and TLR4 were significantly higher in saliva of periodontitis patients compared with saliva of healthy subjects; 3450 versus 77 ng/ml Pam(3) CSK(4) equivalents (p<0.0001) and 138 versus 7 ng/ml LPS equivalents, respectively (p<0.0001). Salivary TLR stimulant levels remained relatively stable in healthy subjects over several days. Six strains of oral Gram-negative bacteria, including Tannerella forsythensis, Lysobacter enzymogenes, Prevotella intermedia, Prevotella oris and Porphyromonas gingivalis, from a panel of nine examined did not stimulate TLR4-dependent signalling. CONCLUSIONS: Elevated salivary TLR stimulants may represent a novel mechanism by which periodontitis increases the risk of developing cardiovascular disease and insulin resistance.

Vascular cell responsiveness to Toll-like receptor ligands in carotid atheroma.

BACKGROUND: Atherosclerosis is potentiated by stimulation of Toll-like receptors (TLRs), which serve to detect pathogen associated molecular patterns (PAMPs). However little is known of which PAMPs may be present in atheroma, or capable of stimulating inflammatory signalling in vascular cells. MATERIALS AND METHODS: DNA extracted from human carotid atheroma samples was amplified and sequenced using broad-range 16S gene specific primers to establish historical exposure to bacterial PAMPs. Responsiveness of primary human arterial and venous endothelial and smooth muscle cells to PAMPs specific for each of the TLRs was assessed by measurement of interleukin-8 secretion and E-selectin expression. RESULTS: Extracts of atheromatous tissue stimulated little or no signalling in TLR-transfected HEK-293 cells. However, sequencing of bacterial DNA amplified from carotid atheroma revealed the presence of DNA from 17 different bacterial genera, suggesting historical exposure to bacterial lipopeptide, lipopolysaccharide and flagellin. All cells examined were responsive to the ligands of TLR3 and TLR4, poly inosine:cytosine and lipopolysaccharide. Arterial cells were responsive to a wider range of PAMPs than venous cells, being additionally responsive to bacterial flagellin and unmethylated cytosine-phosphate-guanosine DNA motifs, the ligands of TLR5 and TLR9, respectively. Cells were generally unresponsive towards the ligands of human TLR7 and TLR8, loxoribine and single stranded RNA. Only coronary artery endothelial cells expressed TLR2 mRNA and responded to the TLR2 ligand Pam(3)CSK(4). CONCLUSIONS: Vascular cells are responsive to a relatively diverse range of TLR ligands and may be exposed, at least transiently, to ligands of TLR2, TLR4, TLR5 and TLR9 during the development of carotid atheroma.