Quantitative single molecule analysis of podoplanin clustering in fibroblastic reticular cells uncovers CD44 function.

Upon initial immune challenge, dendritic cells (DCs) migrate to lymph nodes and interact with fibroblastic reticular cells (FRCs) via C-type lectin-like receptor 2 (CLEC-2). CLEC-2 binds to the membrane glycoprotein podoplanin (PDPN) on FRCs, inhibiting actomyosin contractility through the FRC network and permitting lymph node expansion. The hyaluronic acid receptor CD44 is known to be required for FRCs to respond to DCs but the mechanism of action is not fully elucidated. Here, we use DNA-PAINT, a quantitative single molecule super-resolution technique, to visualize and quantify how PDPN clustering is regulated in the plasma membrane of FRCs. Our results indicate that CLEC-2 interaction leads to the formation of large PDPN clusters (i.e. more than 12 proteins per cluster) in a CD44-dependent manner. These results suggest that CD44 expression is required to stabilize large pools of PDPN at the membrane of FRCs upon CLEC-2 interaction, revealing the molecular mechanism through which CD44 facilitates cellular crosstalk between FRCs and DCs.

Purinergic GPCR-integrin interactions drive pancreatic cancer cell invasion.

Pancreatic ductal adenocarcinoma (PDAC) continues to show no improvement in survival rates. One aspect of PDAC is elevated ATP levels, pointing to the purinergic axis as a potential attractive therapeutic target. Mediated in part by highly druggable extracellular proteins, this axis plays essential roles in fibrosis, inflammation response, and immune function. Analyzing the main members of the PDAC extracellular purinome using publicly available databases discerned which members may impact patient survival. P2RY2 presents as the purinergic gene with the strongest association with hypoxia, the highest cancer cell-specific expression, and the strongest impact on overall survival. Invasion assays using a 3D spheroid model revealed P2Y2 to be critical in facilitating invasion driven by extracellular ATP. Using genetic modification and pharmacological strategies, we demonstrate mechanistically that this ATP-driven invasion requires direct protein-protein interactions between P2Y2 and αV integrins. DNA-PAINT super-resolution fluorescence microscopy reveals that P2Y2 regulates the amount and distribution of integrin αV in the plasma membrane. Moreover, receptor-integrin interactions were required for effective downstream signaling, leading to cancer cell invasion. This work elucidates a novel GPCR-integrin interaction in cancer invasion, highlighting its potential for therapeutic targeting.

Inflammatory and thrombotic valvulopathies in autoimmune disease.

Rheumatologic diseases are characterised by loss of immune tolerance, resulting in systemic inflammation. Inflammation and scarring of the endocardium, which lines the inner surface of the heart chambers and valves, can result in valvular thickening and dysfunction. Estimates of prevalence vary depending on the sensitivity of the screening methodology used and range from 30%-50% in systemic lupus and rheumatoid arthritis to 10%-30% in ankylosing spondylitis. Progression of valve disease is a slow process but can result in haemodynamically significant complications. Thromboembolic complications such as cerebrovascular occlusions pose a serious risk of morbidity. The presence of antiphospholipid antibodies increases the risk of valvular disease and thrombotic complications. Anticoagulation is recommended in the presence of antiphospholipid antibodies, but the guidance on the role of immunosuppressive therapy to treat valvular disease is lacking. Surgical valve therapy may be considered in severe disease, but there is increased risk in patients with an autoimmune disease which includes a higher risk of infection, thromboembolic and bleeding complications, as well as cardiovascular events in the setting of premature atherosclerotic heart disease. Therefore, management should be provided in a multidisciplinary team that includes a rheumatologist, a cardiologist and a cardiothoracic surgeon; medical therapy should be optimised before considering a high-risk valve surgery.

Quality of Life After Transcatheter Aortic Valve Replacement in Normal-Flow, Low-Gradient Aortic Stenosis.

Background: Prior studies of aortic valve replacement (AVR) in patients with normal-flow, low-gradient aortic stenosis (NF-LG AS) have demonstrated conflicting results regarding the survival benefit of AVR. Changes in quality of life (QoL) after transcatheter AVR (TAVR) have not been reported in this population. Objectives: The purpose of this study was to compare changes in QoL after TAVR for patients with NF-LG AS to patients with high-gradient aortic stenosis (HG-AS). Methods: Patients who underwent TAVR for severe aortic stenosis (AS) were divided into 4 hemodynamic profiles of AS, including NF-LG AS. Changes in Kansas City Cardiomyopathy Questionnaire-12 score from baseline to 1 year were compared between AS groups. The primary composite outcome indicating clinical improvement consisted of survival to 1 year and improved Kansas City Cardiomyopathy Questionnaire overall summary score of ≥5 points while adjusting for relevant baseline factors. Results: Out of 860 patients who underwent TAVR, high gradient AS was present in 368 (42.8%) patients and NF-LG AS in 245 (28.5%). HG-AS and NF-LG AS groups had a similar proportion of patients who met the primary unadjusted outcome of clinical improvement (70.4% vs 63.9%, respectively; P = 0.189). One-year Kaplan-Meier mortality estimates were higher for NF-LG AS patients than HG-AS patients (12.9% vs 5.8%, P < 0.001). In the primary adjusted analysis, there was no significant difference in the composite outcome between HG and NF-LG AS groups (adjusted OR: 0.72, 95% CI: 0.47-1.11). Conclusions: Selected patients with NF-LG AS experienced similar improvement in QoL after TAVR compared with HG-AS. Further investigation of patients with NF-LG AS will help to inform optimal selection for treatment with TAVR.

Quantitative Super-Resolution Imaging for the Analysis of GPCR Oligomerization.

G-protein coupled receptors (GPCRs) are known to form homo- and hetero- oligomers which are considered critical to modulate their function. However, studying the existence and functional implication of these complexes is not straightforward as controversial results are obtained depending on the method of analysis employed. Here, we use a quantitative single molecule super-resolution imaging technique named qPAINT to quantify complex formation within an example GPCR. qPAINT, based upon DNA-PAINT, takes advantage of the binding kinetics between fluorescently labelled DNA imager strands to complementary DNA docking strands coupled to protein targeting antibodies to quantify the protein copy number in nanoscale dimensions. We demonstrate qPAINT analysis via a novel pipeline to study the oligomerization of the purinergic receptor Y2 (P2Y2), a rhodopsin-like GPCR, highly expressed in the pancreatic cancer cell line AsPC-1, under control, agonistic and antagonistic conditions. Results reveal that whilst the density of P2Y2 receptors remained unchanged, antagonistic conditions displayed reduced percentage of oligomers, and smaller numbers of receptors in complexes. Yet, the oligomeric state of the receptors was not affected by agonist treatment, in line with previous reports. Understanding P2Y2 oligomerization under agonistic and antagonistic conditions will contribute to unravelling P2Y2 mechanistic action and therapeutic targeting.

Right Ventricular Dysfunction and Adverse Outcomes after Renal Transplantation.

INTRODUCTION: Pulmonary hypertension is common among patients with end-stage renal disease, although data regarding the impact of right ventricular (RV) failure on postoperative outcomes remain limited. We hypothesized that echocardiographic findings of RV dilation and dysfunction are associated with adverse clinical outcomes after renal transplant. METHODS: A retrospective review of adult renal transplant recipients at a single institution from January 2008 to June 2010 was conducted. Patients with transthoracic echocardiograms (TTEs) within 1 year leading up to transplant were included. The primary end point was a composite of delayed graft function, graft failure, and all-cause mortality. RESULTS: Eighty patients were included. Mean follow-up time was 9.4 ± 0.8 years. Eight patients (100%) with qualitative RV dysfunction met the primary end point, while 39/65 patients (60.0%) without RV dysfunction met the end point (p = 0.026). Qualitative RV dilation was associated with a significantly shorter time to all-cause graft failure (p = 0.03) and death (p = 0.048). RV systolic pressure was not measurable in 45/80 patients (56%) and was not associated with outcomes in the remaining patients. CONCLUSION: RV dilation and dysfunction are associated with adverse outcomes after renal transplant. TTE assessment of RV size and function should be a standard part of the pre-kidney transplant cardiovascular risk assessment.

Management of heart failure in patients with end-stage kidney disease on maintenance dialysis: a practical guide.

End-stage kidney disease (ESKD) and heart failure (HF) often coexist and must be managed simultaneously. Multidisciplinary collaboration between nephrology and cardiology is critical when treating patients with such complicated physiology. There is no "one-size-fits-all" approach to the evaluation of patients with new left ventricular systolic dysfunction, and diagnostic testing should be adapted to an individual's risk factors. Guideline-directed medical therapy (GDMT) for systolic heart failure should be employed in these patients. While limited randomized data exist, observational data and post hoc analyses suggest that GDMT, including renin angiotensin aldosterone system inhibitors, is associated with improved cardiovascular outcomes and can be safely initiated at low doses with close monitoring of kidney function in this population. Volume status is typically managed through ultrafiltration, so close communication between cardiology and nephrology is necessary to achieve a patient's optimal dry weight and mitigate intradialytic hypotension. Patient education and engagement regarding sodium and fluid restriction is crucial, and symptom burden should be reassessed following changes to the dialysis regimen.

The Impact Of Structured Exercise Programs On Metabolic Syndrome And Its Components: A Systematic Review.

BACKGROUND: The metabolic syndrome (MetS) is highly prevalent and associated with higher risk of diabetes and cardiovascular events. Exercise programs have been shown to improve components of MetS, but the optimal design of a structured exercise program for treatment of the MetS remains unclear. PURPOSE: To assess the impact of different exercise programs on the MetS and its components. METHODS: MEDLINE via PubMed and Embase was searched. Randomized controlled trials of supervised exercise alone and in combination with nutrition programs compared with usual care in adults with the MetS were selected. Two authors independently reviewed articles to select eligible studies and performed data abstraction. Eight studies representing 1218 patients were included. The participants had a median age of 51, median BMI of 29 kg/m2, and were 55% male. Mean weight loss increased with program duration. For combination programs, the mean weight loss was -2.6 kg, -3.7 kg, and -6.5 kg for 3, 6, and 12 months, respectively. The components of the MetS most frequently statistically significantly improved were waist circumference (6/6 studies), blood pressure (4/6 studies), and high-density lipoprotein cholesterol (3/6 studies). LIMITATIONS: Studies did not include long-term follow-up post program completion to evaluate persistence of benefit. It is unknown whether the same results would be found in an older, more obese population. CONCLUSION: Supervised exercise programs yield significant resolution of components of the MetS, particularly in reducing waist circumference. Longer program duration and frequent interval sessions appear to have highest benefit and thus may help reduce cardiovascular risk and diabetes associated with the MetS.

Effects of Race on Statin Prescribing for Primary Prevention With High Atherosclerotic Cardiovascular Disease Risk in a Large Healthcare System.

Background Although guidelines recommend statins with a high level of evidence for 4 primary prevention benefit groups, prescribing disparities still exist. The objective of this study was to evaluate the effects of race on statin prescribing for primary prevention. Methods and Results A retrospective cohort analysis of patients within a large academic health system was performed to investigate statin prescribing among primary prevention groups. The statin benefits groups were patients diagnosed with diabetes mellitus, with an low-density lipoprotein ≥190 mg/dL, or with an atherosclerotic cardiovascular disease (ASCVD) 10-year risk ≥7.5%. Statin prescribing was 20% in the ASCVD ≥7.5% group, followed by 37.8% in the low-density lipoprotein ≥190 mg/dL group and 40.5% in the diabetes mellitus group. Blacks were less likely to be prescribed a statin compared with whites in the diabetes mellitus (odds ratio, 0.64; 95% CI, 0.49-0.82; P=0.001) and ASCVD ≥7.5% groups (odds ratio, 0.38; 95% CI, 0.26-0.54; P<0.0001). Blacks 60 to 69 years of age (odds ratio, 7.97; 95% CI, 3.14-20.2; P=0.003) and 70 to 79 years of age (odds ratio, 4.21; 95% CI, 1.81-9.79; P=0.008) were more likely to be prescribed a statin compared with blacks <60 years of age in the ASCVD ≥7.5% group. Conclusions Blacks are less likely to be prescribed statins in diabetes mellitus and ASCVD ≥7.5% groups compared with whites. Younger blacks with ASCVD risk ≥7.5% are less likely to be prescribed statins compared with older blacks. Future research should focus on tailored interventions to address statin prescribing disparities in blacks.

Clinical Decision Making in Patients with Stroke-Related Dysphagia.

This article aims to highlight stroke considerations in the evaluation and management of dysphagia. Although dysphagia was previously thought to occur only following brainstem or bilateral cortical strokes, the development of brain imaging and dynamic swallowing studies has revealed small, unilateral supratentorial strokes can produce dysphagia. In this article, screening, evaluation, and management of dysphagia are outlined, as well as the clinical decision making that occurs when taking into account cognitive and communication deficits that may be present. For the clinical swallow examination, chart review, interview, informal evaluation of cognition and communication, observation of posture, oral cavity inspection, cranial nerve examination, and the direct swallowing assessment are reviewed along with tailoring of each according to the deficits observed. Specific compensation and rehabilitation strategies are discussed along with how cognitive and communication deficits can guide the clinician's decision-making process to select an appropriate plan of care. A case study is provided to synthesize the process into a real-world scenario.

Impact of a structured lifestyle programme on patients with metabolic syndrome complicated by non-alcoholic fatty liver disease.

BACKGROUND: Lifestyle interventions are first-line therapy for non-alcoholic fatty liver disease (NAFLD). AIMS: To examine the prevalence of NAFLD among participants of the University of Michigan Metabolic Fitness (MetFit) Programme and to assess the impact of this programme on weight, metabolic and liver-related parameters among patients with and without NAFLD. METHODS: Adults who completed the programme between 2008 and 2016 were included. Clinical and laboratory data were collected at enrolment, and at 12 and 24 weeks. NAFLD was defined based on liver biopsy, imaging or clinical diagnosis. RESULTS: The cohort (N = 403; 253 12-week, 150 24-week) consisted primarily of middle-aged (median 54 years) white (88%) men (63%) with severe obesity (median BMI 37.4). 47.6% met criteria for NAFLD. At baseline, NAFLD patients were younger (52 vs 55 years), had higher weights and more metabolic derangements (higher fasting insulin and triglyceride, lower high-density lipoprotein-cholesterol). At programme completion, 30% achieved weight reduction ≥5%, 62% resolution of hypertriglyceridaemia, 33% resolution of low HDL, 27% resolution of impaired fasting glucose and 43% normalisation of alanine aminotransferase. Endpoints were unaffected by NAFLD. Longer programme duration (OR 6.7, 95% CI 3.6-12.3) and white race (OR 3.83, 95% CI 1.04-1.76) were independent predictors of ≥5% weight loss. CONCLUSIONS: Nearly half of the patients referred to a structured lifestyle programme for metabolic syndrome had NAFLD. Although baseline metabolic derangements were more pronounced among NAFLD patients, the programme was equally efficacious in achieving weight loss and resolving metabolic syndrome components. Programme duration was the most important predictor of response.

Long-term outcomes following completion of a structured nutrition and exercise lifestyle intervention program for patients with metabolic syndrome.

INTRODUCTION: Metabolic syndrome is associated with an increased risk of cardiovascular disease and multiple other chronic health conditions. Studies have demonstrated the effectiveness of structured diet and exercise programs to improve the components of metabolic syndrome. The durability of these benefits after program completion is unclear. The aim of this study was to evaluate trends in cardiovascular risk factors 12 months post completion of a 12- or 24-week structured lifestyle intervention program. METHODS: Individuals with metabolic syndrome were referred to the Metabolic Fitness program, a 12- or 24-week lifestyle intervention program consisting of weekly exercise and nutrition education sessions. Patients were assessed at baseline, 12 weeks, and 24 weeks for those in the 24-week program. Data collection included weight, body mass index, waist circumference, body composition percentage, sBP, dBP, fasting blood glucose, total cholesterol, triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol. Unstructured follow-up data were obtained by retrospective chart review for up to 12 months post program completion. RESULTS: Two-hundred twenty-five patients were enrolled in the 12-week program and 121 in the 24-week program. At the conclusion of the 12-week program, patients showed significant improvement in sBP and dBP. At the conclusion of the 24-week program, patients showed significant improvement in body mass index, weight, sBP, dBP, fasting blood glucose, total cholesterol, and triglycerides. However, 12 months after program completion, while the majority of parameters were still improved compared with baseline, only change in low-density lipoprotein cholesterol remained significantly improved compared with the end of 12-week program, and sBP had increased back above baseline in both programs. CONCLUSION: Patients with metabolic syndrome participating in a structured lifestyle intervention program show significant improvement in their cardiovascular risk and metabolic profile at program completion. The durability of these improvements appears to wane over time, however, stressing the need for programs that can facilitate maintenance of long-term behavior change.

An Emerging Theoretical Model of Music Therapy Student Development.

BACKGROUND: Music therapy students negotiate a complex relationship with music and its use in clinical work throughout their education and training. This distinct, pervasive, and evolving relationship suggests a developmental process unique to music therapy. OBJECTIVE: The purpose of this grounded theory study was to create a theoretical model of music therapy students' developmental process, beginning with a study within one large Midwestern university. METHODS: Participants (N = 15) were music therapy students who completed one 60-minute intensive interview, followed by a 20-minute member check meeting. Recorded interviews were transcribed, analyzed, and coded using open and axial coding. RESULTS: The theoretical model that emerged was a six-step sequential developmental progression that included the following themes: (a) Personal Connection, (b) Turning Point, (c) Adjusting Relationship with Music, (d) Growth and Development, (e) Evolution, and (f) Empowerment. The first three steps are linear; development continues in a cyclical process among the last three steps. As the cycle continues, music therapy students continue to grow and develop their skills, leading to increased empowerment, and more specifically, increased self-efficacy and competence. CONCLUSIONS: Further exploration of the model is needed to inform educators' and other key stakeholders' understanding of student needs and concerns as they progress through music therapy degree programs.

Antidepressant-coincident mania in children and adolescents treated with selective serotonin reuptake inhibitors.

Several factors have amplified concern about the possibility that antidepressant medication may contribute to induction of pediatric mania. These include the high rate of antidepressant medication prescription, the recent surge in the rate of diagnosis of pediatric bipolar disorder in the USA, and a growing number of case reports and clinical studies showing coincidence of manic symptoms with antidepressant pharmacotherapy in both youths and adults. However, the question of how medications and manic symptoms might be related is complicated, and decisive research studies with rigorous designs for evaluating the issues have not been published. The situation makes it difficult for practitioners to make good, evidence-based decisions. The scientific literature is ambiguous, and the stakes are high. We review the extant literature, offer seven different conceptual models of how medication and mania might be related, and comment on the evidence and clinical implications of each.

A quantitative and qualitative review of neurocognitive performance in pediatric bipolar disorder.

Bipolar disorder (BD) is an increasingly prevalent diagnosis in youth. As a result, there has been a corresponding increase in interest about neuropsychological and cognitive profiles in children and adolescents diagnosed with BD. Meta-analysis of the existing literature comparing individuals with BD to healthy controls indicated that the largest differences are observed for measures of verbal memory (d = 0.77). Moderate differences were found in the areas of attention (d = 0.62), executive functioning (d = 0.62), working memory (d = 0.60), visual memory (d = 0.51), visual perceptual skills (d = 0.48), and verbal fluency (d = 0.45). Small differences were found for measures of reading (d = 0.40), motor speed (d = 0.33), and full-scale intelligence quotient (IQ) (d = 0.32). Often, few studies have provided relevant information for a particular neurocognitive domain. Despite this, several domains displayed heterogeneity of effect sizes across studies. Methodological factors explained the variance in effect sizes to different extents depending upon the cognitive domain. The changing influence of method artifacts is likely due to variable coverage of cognitive domains across studies and the use of different measures across studies. Findings are consistent with previous meta-analyses of the adult BD neurocognitive literature, suggesting that many of the deficits observed in adults are present earlier in the course of the illness. Study reporting guidelines are offered that may help clarify the impact of illness definitions, mood state, medication status, and other methodological variables on neurocognition in pediatric BD.

Comparing the psychometric properties of multiple teacher report instruments as predictors of bipolar disorder in children and adolescents.

The psychometric properties of four teacher report measures and their utility for accurate diagnosis of pediatric bipolar spectrum disorders (BPSDs) were examined. Participants were 191 youth (65% male; 62% African-American; 23% diagnosed with a BPSD), age 5-18 (M=10.16, SD=3.27) years, 70% recruited from a community mental health center and 30% recruited from a mood disorders clinic. Teachers "who knew the child best" were asked to complete the Achenbach Teacher Report Form (TRF) as well as teacher versions of the General Behavior Inventory (T-GBI), the Child Mania Rating Scale (CMRS-T), and the Young Mania Rating Scale (T-YMRS). Teacher response rates and missing data varied significantly depending on the age of the child. Exploratory factor analysis identified stable and interpretable factors; however, receiver operating characteristic (ROC) and logistic regression analyses showed that teacher report measures were not able to discriminate BPSD cases from non-BPSD cases, or from attention deficit hyperactivity disorder (ADHD) cases. Teacher report appears to be insufficiently specific or sensitive to BPSD for clinical diagnostic use, although teacher scales might have research utility.

Industry sponsorship and financial conflict of interest in the reporting of clinical trials in psychiatry.

OBJECTIVE: Financial conflict of interest has been reported to be prevalent in clinical trials in general medicine and associated with a greater likelihood of reporting results favorable to the intervention being studied. The extent and implications of industry sponsorship and financial conflict of interest in psychiatric clinical trials have not been investigated, to the authors' knowledge. METHOD: The authors examined funding source and author financial conflict of interest in all clinical trials published in the American Journal of Psychiatry, the Archives of General Psychiatry, the Journal of Clinical Psychopharmacology, and the Journal of Clinical Psychiatry between 2001 and 2003. RESULTS: Among 397 clinical trials identified, 239 (60%) reported receiving funding from a pharmaceutical company or other interested party, and 187 studies (47%) included at least one author with a reported financial conflict of interest. Among the 162 randomized, double-blind, placebo-controlled studies examined, those that reported conflict of interest were 4.9 times more likely to report positive results; this association was significant only among the subset of pharmaceutical industry-funded studies. CONCLUSIONS: Author conflict of interest appears to be prevalent among psychiatric clinical trials and to be associated with a greater likelihood of reporting a drug to be superior to placebo.