Spreading a Strategy to Prevent Suicide After Psychiatric Hospitalization: Results of a Quality Improvement Spread Initiative.

BACKGROUND: Suicide after psychiatric hospitalization is a major concern. Poor treatment engagement may contribute to risk. The World Health Organization Brief Intervention and Contact (BIC) Program is an evidence-based practice shown to prevent suicide after psychiatric discharge in international trials. There have been no efforts to implement BIC into routine practice in US populations. METHODS: The authors conducted a 12-month quality improvement (QI) collaborative at six US Department of Veterans Affairs (VA) medical centers serving a large rural population. Sites had low to moderate performance on a VA quality measure of mental health postdischarge care; a measure assessing the proportion of discharged patients who achieve the required number of visits ≤ 30 days. Sites received programmatic support to implement BIC locally. Implementation was assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. RESULTS: Overall, teams had high participation in programmatic activities and enrolled 85% of eligible patients that they approached. Among 70 enrolled patients, 81.4% achieved the VA quality measure of mental health postdischarge care, suggesting good treatment engagement. On average, patients rated BIC as excellent. Team members agreed that BIC was easy to use, implementable, possible, and doable. Factors facilitating implementation included standardized operating procedures to standardize processes. Barriers included insufficient staffing and loss to follow-up. Most sites plan to continue to enroll patients and to expand BIC to other areas. CONCLUSION: A QI collaborative can facilitate implementation of BIC in six VA facilities that provide inpatient psychiatric treatment. BIC may appeal to patients and providers and may improve treatment engagement.

VEGFR2 promotes central endothelial activation and the spread of pain in inflammatory arthritis.

Chronic pain can develop in response to conditions such as inflammatory arthritis. The central mechanisms underlying the development and maintenance of chronic pain in humans are not well elucidated although there is evidence for a role of microglia and astrocytes. However in pre-clinical models of pain, including models of inflammatory arthritis, there is a wealth of evidence indicating roles for pathological glial reactivity within the CNS. In the spinal dorsal horn of rats with painful inflammatory arthritis we found both a significant increase in CD11b+ microglia-like cells and GFAP+ astrocytes associated with blood vessels, and the number of activated blood vessels expressing the adhesion molecule ICAM-1, indicating potential glio-vascular activation. Using pharmacological interventions targeting VEGFR2 in arthritic rats, to inhibit endothelial cell activation, the number of dorsal horn ICAM-1+ blood vessels, CD11b+ microglia and the development of secondary mechanical allodynia, an indicator of central sensitization, were all prevented. Targeting endothelial VEGFR2 by inducible Tie2-specific VEGFR2 knock-out also prevented secondary allodynia in mice and glio-vascular activation in the dorsal horn in response to inflammatory arthritis. Inhibition of VEGFR2 in vitro significantly blocked ICAM-1-dependent monocyte adhesion to brain microvascular endothelial cells, when stimulated with inflammatory mediators TNF-α and VEGF-A165a. Taken together our findings suggest that a novel VEGFR2-mediated spinal cord glio-vascular mechanism may promote peripheral CD11b+ circulating cell transmigration into the CNS parenchyma and contribute to the development of chronic pain in inflammatory arthritis. We hypothesise that preventing this glio-vascular activation and circulating cell translocation into the spinal cord could be a new therapeutic strategy for pain caused by rheumatoid arthritis.

Transforming growth factor beta receptor type III is a tumor promoter in mesenchymal-stem like triple negative breast cancer.

INTRODUCTION: There is a major need to better understand the molecular basis of triple negative breast cancer (TNBC) in order to develop effective therapeutic strategies. Using gene expression data from 587 TNBC patients we previously identified six subtypes of the disease, among which a mesenchymal-stem like (MSL) subtype. The MSL subtype has significantly higher expression of the transforming growth factor beta (TGF-ß) pathway-associated genes relative to other subtypes, including the TGF-ß receptor type III (TßRIII). We hypothesize that TßRIII is tumor promoter in mesenchymal-stem like TNBC cells. METHODS: Representative MSL cell lines SUM159, MDA-MB-231 and MDA-MB-157 were used to study the roles of TßRIII in the MSL subtype. We stably expressed short hairpin RNAs specific to TßRIII (TßRIII-KD). These cells were then used for xenograft tumor studies in vivo; and migration, invasion, proliferation and three dimensional culture studies in vitro. Furthermore, we utilized human gene expression datasets to examine TßRIII expression patterns across all TNBC subtypes. RESULTS: TßRIII was the most differentially expressed TGF-ß signaling gene in the MSL subtype. Silencing TßRIII expression in MSL cell lines significantly decreased cell motility and invasion. In addition, when TßRIII-KD cells were grown in a three dimensional (3D) culture system or nude mice, there was a loss of invasive protrusions and a significant decrease in xenograft tumor growth, respectively. In pursuit of the mechanistic underpinnings for the observed TßRIII-dependent phenotypes, we discovered that integrin-α2 was expressed at higher level in MSL cells after TßRIII-KD. Stable knockdown of integrin-α2 in TßRIII-KD MSL cells rescued the ability of the MSL cells to migrate and invade at the same level as MSL control cells. CONCLUSIONS: We have found that TßRIII is required for migration and invasion in vitro and xenograft growth in vivo. We also show that TßRIII-KD elevates expression of integrin-α2, which is required for the reduced migration and invasion, as determined by siRNA knockdown studies of both TßRIII and integrin-α2. Overall, our results indicate a potential mechanism in which TßRIII modulates integrin-α2 expression to effect MSL cell migration, invasion, and tumorigenicity.

Established and novel methods of interrogating two-dimensional cell migration.

The regulation of cell motility is central to living systems. Consequently, cell migration assays are some of the most frequently used in vitro assays. This article provides a comprehensive, detailed review of in vitro cell migration assays both currently in use and possible with existing technology. Emphasis is given to two-dimensional migration assays using densely organized cells such as the scratch assay. Assays are compared and categorized in an outline format according to their primary biological readout and physical parameters. The individual benefits of the various methods and quantification strategies are also discussed. This review provides an in-depth, structured overview of in vitro cell migration assays as a means of enabling the reader to make informed decisions among the growing number of options available for their specific cell migration application.

Magnetically attachable stencils and the non-destructive analysis of the contribution made by the underlying matrix to cell migration.

Cell migration is controlled by the integration of numerous distinct components. Consequently, the analysis of cell migration is advancing towards comprehensive, multifaceted in vitro models. To accurately evaluate the contribution of an underlying substrate to cell motility in complex cellular environments we developed a migration assay using magnetically attachable stencils (MAts). When attached to a culture surface, MAts create a defined void in the cell monolayer without disrupting the cells or damaging the underlying substrate. Quantitative analysis of migration into this void reveals the substrate's contribution to migration. The magnetically-guided placement of a microfabricated stencil allows for full experimental control of the substrate on which migration is analyzed. MAts enable the evaluation of intact, defined matrix, and make it possible to analyze migration on unique surfaces such as micropatterned proteins, nano-textured surfaces, and pliable hydrogels. These studies also revealed that mechanical disruption, including the damage that occurs during scratch assays, diminishes migration and confounds the analysis of individual cell behavior. Analysis of migration on increasingly complex biomaterials reveals that the contribution of the underlying matrix depends not only on its molecular composition but also its organization and the context in which it is presented.

Lack of transforming growth factor-ß signaling promotes collective cancer cell invasion through tumor-stromal crosstalk.

INTRODUCTION: Transforming growth factor beta (TGF-ß) has a dual role during tumor progression, initially as a suppressor and then as a promoter. Epithelial TGF-ß signaling regulates fibroblast recruitment and activation. Concurrently, TGF-ß signaling in stromal fibroblasts suppresses tumorigenesis in adjacent epithelia, while its ablation potentiates tumor formation. Much is known about the contribution of TGF-ß signaling to tumorigenesis, yet the role of TGF-ß in epithelial-stromal migration during tumor progression is poorly understood. We hypothesize that TGF-ß is a critical regulator of tumor-stromal interactions that promote mammary tumor cell migration and invasion. METHODS: Fluorescently labeled murine mammary carcinoma cells, isolated from either MMTV-PyVmT transforming growth factor-beta receptor II knockout (TßRII KO) or TßRIIfl/fl control mice, were combined with mammary fibroblasts and xenografted onto the chicken embryo chorioallantoic membrane. These combinatorial xenografts were used as a model to study epithelial-stromal crosstalk. Intravital imaging of migration was monitored ex ovo, and metastasis was investigated in ovo. Epithelial RNA from in ovo tumors was isolated by laser capture microdissection and analyzed to identify gene expression changes in response to TGF-ß signaling loss. RESULTS: Intravital microscopy of xenografts revealed that mammary fibroblasts promoted two migratory phenotypes dependent on epithelial TGF-ß signaling: single cell/strand migration or collective migration. At epithelial-stromal boundaries, single cell/strand migration of TßRIIfl/fl carcinoma cells was characterized by expression of α-smooth muscle actin and vimentin, while collective migration of TßRII KO carcinoma cells was identified by E-cadherin+/p120+/ß-catenin+ clusters. TßRII KO tumors also exhibited a twofold greater metastasis than TßRIIfl/fl tumors, attributed to enhanced extravasation ability. In TßRII KO tumor epithelium compared with TßRIIfl/fl epithelium, Igfbp4 and Tspan13 expression was upregulated while Col1α2, Bmp7, Gng11, Vcan, Tmeff1, and Dsc2 expression was downregulated. Immunoblotting and quantitative PCR analyses on cultured cells validated these targets and correlated Tmeff1 expression with disease progression of TGF-ß-insensitive mammary cancer. CONCLUSION: Fibroblast-stimulated carcinoma cells utilize TGF-ß signaling to drive single cell/strand migration but migrate collectively in the absence of TGF-ß signaling. These migration patterns involve the signaling regulation of several epithelial-to-mesenchymal transition pathways. Our findings concerning TGF-ß signaling in epithelial-stromal interactions are important in identifying migratory mechanisms that can be targeted as recourse for breast cancer treatment.

Targeting tumor cell motility to prevent metastasis.

Mortality and morbidity in patients with solid tumors invariably result from the disruption of normal biological function caused by disseminating tumor cells. Tumor cell migration is under intense investigation as the underlying cause of cancer metastasis. The need for tumor cell motility in the progression of metastasis has been established experimentally and is supported empirically by basic and clinical research implicating a large collection of migration-related genes. However, there are few clinical interventions designed to specifically target the motility of tumor cells and adjuvant therapy to specifically prevent cancer cell dissemination is severely limited. In an attempt to define motility targets suitable for treating metastasis, we have parsed the molecular determinants of tumor cell motility into five underlying principles including cell autonomous ability, soluble communication, cell-cell adhesion, cell-matrix adhesion, and integrating these determinants of migration on molecular scaffolds. The current challenge is to implement meaningful and sustainable inhibition of metastasis by developing clinically viable disruption of molecular targets that control these fundamental capabilities.

Single-photon-counting detector for increased sensitivity in two-photon laser scanning microscopy.

We present the use and characterization of a photon-counting detector for increased sensitivity at low signal levels in fluorescence laser scanning microscopy (LSM). Conventional LSM photomultiplier tube detectors utilize analog current integration and thus suffer from excessive noise at low signal levels, introduced during current measurement. In this Letter we describe the implementation of a fast single-photon-counting (SPC) detector on a conventional two-photon laser scanning microscope and detail its use in imaging low fluorescence intensities. We show that for a low photon flux, the SPC detector is shot-noise limited and thus provides increased detection sensitivity compared with analog current integration.