Using voice biomarkers for frailty classification.

Clinicians use the patient's voice intuitively to evaluate general health and frailty. Voice is an emerging health indicator but has been scarcely studied in the context of frailty. This study explored voice parameters as possible predictors of frailty in older adults. Fifty-three participants over 70 years old were recruited from rehabilitation wards at a tertiary medical center. Participants' frailty was assessed using Rockwood frailty index and they were classified as most-frail (n = 33, 68%) or less-frail (n = 20, 32%). Participants were recorded counting from 1 to 10 and backwards using a smartphone recording application. The following voice biomarkers were derived: peak and average volume, peak/average volume ratio, pauses' total length, and pause length standard deviation. The most-frail group had a higher peak volume/average volume ratio (p = 0.03) and greater variance in lengths of pauses between speech segments (p = 0.002). These parameters indicate greater speech irregularity in the most-frail, compared to the less-frail. The most-frail group also had a longer total duration of pauses (p = 0.02). No statistically significant difference was found in peak and average volume (p = 0.75 and 0.39). Most-frail participants' speech had different characteristics, compared to participants in the less-frail group. This is a first step to developing an AI-based frailty assessment tool that can assist in identifying our most vulnerable patients.

[NOT ONLY FOR CANCER PATIENTS - PALLIATIVE CARE FOR NON-ONCOLOGIC PATIENTS AT THE END OF LIFE IN A GERIATRIC - INTERNAL MEDICINE DEPARTMENT].

AIMS: This article presents our ongoing experience in the care of palliative patients suffering from non-oncologic diseases. BACKGROUND: Palliative care is an approach intended to improve quality of life in patients facing life-threatening illness. This approach entails early identification, thorough assessment and treatment of pain and suffering as well as establishing a goals-directed care plan in order to improve these patients' quality of life. While in oncology patients there is a steady increase in the awareness of the need for palliative care, in non-oncology patients there is a marked deficit regarding identification of patients needing palliative care, determination of goals of care and delivery of palliative care throughout the disease and at the end of life. Furthermore, there is a lack of appropriate platforms to deliver such care. In Israel, the majority of deaths occur in-hospital. Therefore, it makes sense to implement good palliative care platforms in hospitals, in order to meet the need for palliative care. In January 2018, we opened an inpatient palliative care unit within the Geriatric-Internal Medicine Department in the Tel Aviv Sourasky Medical Center. METHODS: This is a retrospective study of all the patients who died in the Geriatric Internal Medicine Department, during the period 1.1.2018-31.7.2020. RESULTS: A total of 2,335 patients were admitted to the ward during the period 1.1.2018-31.7.2020. Within this group, 371 (16%) died during hospitalization, 257 died from oncologic diseases, 8 died unexpectedly and 106 died from non-oncologic diseases. Patients who suffered from non-oncologic diseases were older, with a shorter length of stay (9.6 vs. 10.5 days) and were more likely to be bed-ridden. The most common cause of death was infection (48%), pneumonia being the most prevalent. Most end-of-life decisions were made during hospitalization, with the guidance of the next of kin. CONCLUSIONS: Patients suffering from non-oncologic diseases represent a considerable number of palliative care patients. However, there is a marked deficit in the ability to recognize their palliative needs, prognostication and therefore, identifying the right platform to care for them. We have described such a platform in the Geriatric Internal ward.

Non-Parametric Combined Reference Regions and Prediction of Clinical Risk.

BACKGROUND: Many clinical decisions depend on estimating patient risk of clinical outcomes by interpreting test results relative to reference intervals, but standard application of reference intervals suffers from two major limitations that reduce the accuracy of clinical decisions: (1) each test result is assessed separately relative to a univariate reference interval, ignoring the rich pathophysiologic information in multivariate relationships, and (2) reference intervals are intended to reflect a population's biological characteristics and are not calibrated for outcome prediction. METHODS: We developed a combined reference region (CRR), derived CRRs for some pairs of complete blood count (CBC) indices (RBC, MCH, RDW, WBC, PLT), and assessed whether the CRR could enhance the univariate reference interval's prediction of a general clinical outcome, 5-year mortality risk (MR). RESULTS: The CRR significantly improved MR estimation for 21/21 patient subsets defined by current univariate reference intervals. The CRR identified individuals with >2-fold increase in MR in many cases and uniformly improved the accuracy for all five pairs of tests considered. Overall, the 95% CRR identified individuals with a >7× increase in 5-year MR. CONCLUSIONS: The CRR enhances the accuracy of the prediction of 5-year MR relative to current univariate reference intervals. The CRR generalizes to higher numbers of tests or biomarkers, as well as to clinical outcomes more specific than MR, and may provide a general way to use existing data to enhance the accuracy and precision of clinical decisions.

Transcriptional signature of human pro-inflammatory TH17 cells identifies reduced IL10 gene expression in multiple sclerosis.

We have previously reported the molecular signature of murine pathogenic TH17 cells that induce experimental autoimmune encephalomyelitis (EAE) in animals. Here we show that human peripheral blood IFN-γ+IL-17+ (TH1/17) and IFN-γ-IL-17+ (TH17) CD4+ T cells display distinct transcriptional profiles in high-throughput transcription analyses. Compared to TH17 cells, TH1/17 cells have gene signatures with marked similarity to mouse pathogenic TH17 cells. Assessing 15 representative signature genes in patients with multiple sclerosis, we find that TH1/17 cells have elevated expression of CXCR3 and reduced expression of IFNG, CCL3, CLL4, GZMB, and IL10 compared to healthy controls. Moreover, higher expression of IL10 in TH17 cells is found in clinically stable vs. active patients. Our results define the molecular signature of human pro-inflammatory TH17 cells, which can be used to both identify pathogenic TH17 cells and to measure the effect of treatment on TH17 cells in human autoimmune diseases.

The TREM2-APOE Pathway Drives the Transcriptional Phenotype of Dysfunctional Microglia in Neurodegenerative Diseases.

Microglia play a pivotal role in the maintenance of brain homeostasis but lose homeostatic function during neurodegenerative disorders. We identified a specific apolipoprotein E (APOE)-dependent molecular signature in microglia from models of amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), and Alzheimer's disease (AD) and in microglia surrounding neuritic ß-amyloid (Aß)-plaques in the brains of people with AD. The APOE pathway mediated a switch from a homeostatic to a neurodegenerative microglia phenotype after phagocytosis of apoptotic neurons. TREM2 (triggering receptor expressed on myeloid cells 2) induced APOE signaling, and targeting the TREM2-APOE pathway restored the homeostatic signature of microglia in ALS and AD mouse models and prevented neuronal loss in an acute model of neurodegeneration. APOE-mediated neurodegenerative microglia had lost their tolerogenic function. Our work identifies the TREM2-APOE pathway as a major regulator of microglial functional phenotype in neurodegenerative diseases and serves as a novel target that could aid in the restoration of homeostatic microglia.

Risk Factors for Urinary Retention Following Surgical Repair of Hip Fracture in Female Patients.

BACKGROUND/OBJECTIVES: Postoperative urinary retention (POUR) is a common event following surgical procedures. An increase in the number of elderly individuals who undergo hip fracture repair procedures is inevitable due to the aging of population. Postoperative urinary retention is associated with both early (infections, delirium) and late complications (urinary incontinence) of surgery. The objective of the current study is to direct attention to the less studied population of patients admitted to a geriatric rehabilitation ward following hip fracture repair who are at risk of POUR. DESIGN: Prospective single-center cohort study. SETTING: Academic tertiary hospital. MEASUREMENT: Postvoid bladder volume by ultrasonography (US). RESULTS: Postvoid bladder volume was measured by US in 88 consecutive female patients on the morning following their admission to the geriatric rehabilitation department. The mean age of the patients was 82.5 ± 6.5 years, and the frequency of POUR (defined as postvoid bladder volume ≥200 mL) was 37.5%. The POUR (n = 33) and non-POUR (n = 55) groups were similar with respect to most demographic and disease states. Multivariable stepwise logistic regression revealed a significant effect for opioid use (relative risk [RR] = 8.0, P < .001) and for treatment with anticholinergic medication (RR = 1.3, P = .046). There was an unexpectedly high proportion of patients with asymptomatic urinary retention (29 of the 33 patients, 88%). CONCLUSION: The high incidence of asymptomatic POUR in elderly patients calls for the need for improved screening tools for early identification and treatment.

High Frequency of GBA Gene Mutations in Dementia With Lewy Bodies Among Ashkenazi Jews.

IMPORTANCE: Mutations in the glucocerebrosidase (GBA) gene are a risk factor for the development of dementia with Lewy bodies (DLB). These mutations are common among Ashkenazi Jews (AJ) and appear to have an effect on the natural history of the disease. OBJECTIVES: To evaluate the clinical and genetic characteristics of an AJ cohort of patients diagnosed with DLB, assess the association of phenotype of DLB with GBA mutations, and explore the effects of these mutations on the clinical course of the disease. DESIGN, SETTING, AND PARTICIPANTS: Thirty-five consecutively recruited AJ patients with newly diagnosed clinically probable or possible DLB underwent genotyping for the 7 known AJ GBA mutations and the LRRK2 G2019S mutation. Two patients with the LRRK2 G2019S mutation were excluded from the final analysis. Data were collected from July 1, 2013, to July 31, 2015. MAIN OUTCOMES AND MEASURES: Assessment of clinical markers included the following standardized scales: Autonomic Scale for Outcomes in Parkinson's Disease (SCOPA-AUT), REM (Rapid Eye Movement) Sleep Behavior Disorder Single-Question Screen, Geriatric Depression Scale, and Montreal Cognitive Assessment. Motor symptoms were assessed with the Unified Parkinson's Disease Rating Scale motor part III. A subset of 15 patients also underwent assessment with the Color Trail Making Test, FAS verbal fluency, Digit Span, Hooper Visual Organization Test, and Stroop test. RESULTS: Among the 35 patients with DLB (23 men [66%] and 12 women [34%]; mean [SD], 69.6 [8.2] years), 11 (31%) were carriers of mutations in the GBA gene. Among the 33 patients undergoing further analysis, the GBA mutation carriers were younger at symptom onset (mean [SD] age, 65.7 [11.7] vs 72.1 [5.1] years; P = .03), had more frequent visual hallucinations that did not achieve significance (9 of 11 [82%] compared with 12 of 22 [55%]; P = .052), and had higher scores on the RBD questionnaire (mean [SD], 7.8 [2.2] vs 5.1 [3.3]; P = .03). After adjusting for age and duration of symptoms, testing revealed that GBA mutation carriers had poorer cognition as assessed by the Montreal Cognitive Assessment Battery (mean [SD] score, 18.75 [5.99] vs 23.23 [3.16]; P = .03), lower scores on tests of verbal fluency (adjusted z scores, 0.50 vs -2.02; P = .02), worse scores on tests of visuospatial function (adjusted t scores, 68.55 vs 79.57; P = .046), and higher mean (SD) scores on the Unified Parkinson's Disease Rating Scale motor part III (36.72 [10.62] vs 25.72 [10.32]; P = .03). CONCLUSIONS AND RELEVANCE: One in 3 AJ patients diagnosed with DLB were carriers of a GBA mutation, making it the most common genetic mutation identified in association with this disease and with any dementia disorder. Mutations in the GBA gene were associated with more severe motor and cognitive dysfunction, supporting a specific contribution of the GBA gene or lysosome function to this clinical syndrome.

Therapeutic potential of targeting microRNA-10b in established intracranial glioblastoma: first steps toward the clinic.

MicroRNA-10b (miR-10b) is a unique oncogenic miRNA that is highly expressed in all GBM subtypes, while absent in normal neuroglial cells of the brain. miR-10b inhibition strongly impairs proliferation and survival of cultured glioma cells, including glioma-initiating stem-like cells (GSC). Although several miR-10b targets have been identified previously, the common mechanism conferring the miR-10b-sustained viability of GSC is unknown. Here, we demonstrate that in heterogeneous GSC, miR-10b regulates cell cycle and alternative splicing, often through the non-canonical targeting via 5'UTRs of its target genes, including MBNL1-3, SART3, and RSRC1. We have further assessed the inhibition of miR-10b in intracranial human GSC-derived xenograft and murine GL261 allograft models in athymic and immunocompetent mice. Three delivery routes for the miR-10b antisense oligonucleotide inhibitors (ASO), direct intratumoral injections, continuous osmotic delivery, and systemic intravenous injections, have been explored. In all cases, the treatment with miR-10b ASO led to targets' derepression, and attenuated growth and progression of established intracranial GBM. No significant systemic toxicity was observed upon ASO administration by local or systemic routes. Our results indicate that miR-10b is a promising candidate for the development of targeted therapies against all GBM subtypes.

The Host Shapes the Gut Microbiota via Fecal MicroRNA.

The host gut microbiota varies across species and individuals but is relatively stable over time within an individual. How the host selectively shapes the microbiota is largely unclear. Here, we show that fecal microRNA (miRNA)-mediated inter-species gene regulation facilitates host control of the gut microbiota. miRNAs are abundant in mouse and human fecal samples and present within extracellular vesicles. Cell-specific loss of the miRNA-processing enzyme, Dicer, identified intestinal epithelial cells (IEC) and Hopx-positive cells as predominant fecal miRNA sources. These miRNAs can enter bacteria, such as F. nucleatum and E. coli, specifically regulate bacterial gene transcripts, and affect bacterial growth. IEC-miRNA-deficient (Dicer1(ΔIEC)) mice exhibit uncontrolled gut microbiota and exacerbated colitis, and WT fecal miRNA transplantation restores fecal microbes and ameliorates colitis. These findings identify both a physiologic role by which fecal miRNA shapes the gut microbiota and a potential strategy for manipulating the microbiome.

Identification and characterization of latency-associated peptide-expressing γδ T cells.

γδ T cells are a subset of lymphocytes specialized in protecting the host against pathogens and tumours. Here we describe a subset of regulatory γδ T cells that express the latency-associated peptide (LAP), a membrane-bound TGF-ß1. Thymic CD27+IFN-γ+CCR9+α4ß7+TCRγδ+ cells migrate to the periphery, particularly to Peyer's patches and small intestine lamina propria, where they upregulate LAP, downregulate IFN-γ via ATF-3 expression and acquire a regulatory phenotype. TCRγδ+LAP+ cells express antigen presentation molecules and function as antigen presenting cells that induce CD4+Foxp3+ regulatory T cells, although TCRγδ+LAP+ cells do not themselves express Foxp3. Identification of TCRγδ+LAP+ regulatory cells provides an avenue for understanding immune regulation and biologic processes linked to intestinal function and disease.

Pathogenic Transdifferentiation of Th17 Cells Contribute to Perpetuation of Rheumatoid Arthritis during Anti-TNF Treatment.

T-helper cells producing interleukin (IL)-17A and IL-17F cytokines (Th17 cells) are considered the source of autoimmunity in rheumatoid arthritis (RA). In this study, we characterized specific pathogenic features of Th17 cells in RA. By using nano-string technology, we analyzed transcription of 419 genes in the peripheral blood CCR6(+)CXCR3(-) CD4(+) cells of 14 RA patients and 6 healthy controls and identified 109 genes discriminating Th17 cells of RA patients from the controls. Th17 cells of RA patients had an aggressive pathogenic profile and in addition to signature cytokines IL-17, IL-23 and IL-21, and transcriptional regulators RAR-related orphan receptor gamma of T cells (RORγt) and Janus kinase 2 (JAK2), they produced high levels of IL-23R, C-C chemokine ligand type 20 (CCL20), granulocyte-monocyte colony-stimulating factor (GM-CSF ) and transcription factor Tbet required for synovial homing. We showed that Th17 cells are enriched with Helios-producing Foxp3- and IL2RA-deficient cells, indicating altered regulatory profile. The follicular T-helper (Tfh) cells presented a functional profile of adaptor molecules, transcriptional regulator Bcl-6 and B-cell activating cytokines IL-21, IL-31 and leukemia inhibitory factor (LIF ). We observed that anti-tumor necrosis factor (TNF) treatment had a limited effect on the transcription signature of Th17 cells. Patients in remission retained the machinery of receptors (IL-23R and IL-1R1), proinflammatory cytokines (IL-17F, IL-23, IL-21 and TNF ) and adaptor molecules (C-X-C chemokine receptor 5 [CXCR5] and cytotoxic T-lymphocyte-associated protein 4 [CTLA-4]), essential for efficient transdifferentiation and accumulation of Th17 cells. This study convincingly shows that the peripheral blood CCR6(+)CXCR3(-) CD4(+) cells of RA patients harbor pathogenic subsets of Th17 and Tfh cells, which may transdifferentiate from Tregs and contribute to perpetuation of the disease.

Targeting miR-155 restores abnormal microglia and attenuates disease in SOD1 mice.

OBJECTIVE: To investigate miR-155 in the SOD1 mouse model and human sporadic and familial amyotrophic lateral sclerosis (ALS). METHODS: NanoString microRNA, microglia and immune gene profiles, protein mass spectrometry, and RNA-seq analyses were measured in spinal cord microglia, splenic monocytes, and spinal cord tissue from SOD1 mice and in spinal cord tissue of familial and sporadic ALS. miR-155 was targeted by genetic ablation or by peripheral or centrally administered anti-miR-155 inhibitor in SOD1 mice. RESULTS: In SOD1 mice, we found loss of the molecular signature that characterizes homeostatic microglia and increased expression of miR-155. There was loss of the microglial molecules P2ry12, Tmem119, Olfml3, transcription factors Egr1, Atf3, Jun, Fos, and Mafb, and the upstream regulators Csf1r, Tgfb1, and Tgfbr1, which are essential for microglial survival. Microglia biological functions were suppressed including phagocytosis. Genetic ablation of miR-155 increased survival in SOD1 mice by 51 days in females and 27 days in males and restored the abnormal microglia and monocyte molecular signatures. Disease severity in SOD1 males was associated with early upregulation of inflammatory genes, including Apoe in microglia. Treatment of adult microglia with apolipoprotein E suppressed the M0-homeostatic unique microglia signature and induced an M1-like phenotype. miR-155 expression was increased in the spinal cord of both familial and sporadic ALS. Dysregulated proteins that we identified in human ALS spinal cord were restored in SOD1(G93A) /miR-155(-/-) mice. Intraventricular anti-miR-155 treatment derepressed microglial miR-155 targeted genes, and peripheral anti-miR-155 treatment prolonged survival. INTERPRETATION: We found overexpression of miR-155 in the SOD1 mouse and in both sporadic and familial human ALS. Targeting miR-155 in SOD1 mice restores dysfunctional microglia and ameliorates disease. These findings identify miR-155 as a therapeutic target for the treatment of ALS.

Differential roles of microglia and monocytes in the inflamed central nervous system.

In the human disorder multiple sclerosis (MS) and in the model experimental autoimmune encephalomyelitis (EAE), macrophages predominate in demyelinated areas and their numbers correlate to tissue damage. Macrophages may be derived from infiltrating monocytes or resident microglia, yet are indistinguishable by light microscopy and surface phenotype. It is axiomatic that T cell-mediated macrophage activation is critical for inflammatory demyelination in EAE, yet the precise details by which tissue injury takes place remain poorly understood. In the present study, we addressed the cellular basis of autoimmune demyelination by discriminating microglial versus monocyte origins of effector macrophages. Using serial block-face scanning electron microscopy (SBF-SEM), we show that monocyte-derived macrophages associate with nodes of Ranvier and initiate demyelination, whereas microglia appear to clear debris. Gene expression profiles confirm that monocyte-derived macrophages are highly phagocytic and inflammatory, whereas those arising from microglia demonstrate an unexpected signature of globally suppressed cellular metabolism at disease onset. Distinguishing tissue-resident macrophages from infiltrating monocytes will point toward new strategies to treat disease and promote repair in diverse inflammatory pathologies in varied organs.

Identification of a unique TGF-ß-dependent molecular and functional signature in microglia.

Microglia are myeloid cells of the CNS that participate both in normal CNS function and in disease. We investigated the molecular signature of microglia and identified 239 genes and 8 microRNAs that were uniquely or highly expressed in microglia versus myeloid and other immune cells. Of the 239 genes, 106 were enriched in microglia as compared with astrocytes, oligodendrocytes and neurons. This microglia signature was not observed in microglial lines or in monocytes recruited to the CNS, and was also observed in human microglia. We found that TGF-ß was required for the in vitro development of microglia that express the microglial molecular signature characteristic of adult microglia and that microglia were absent in the CNS of TGF-ß1-deficient mice. Our results identify a unique microglial signature that is dependent on TGF-ß signaling and provide insights into microglial biology and the possibility of targeting microglia for the treatment of CNS disease.

Opioids, survival, and advanced cancer in the hospice setting.

OBJECTIVE: Although pain is common among advanced cancer patients, it can be controlled in a large proportion of patients. Several barriers hinder this, including the concern that opioids hasten death. We examined whether opioids influence survival among advanced cancer patients. DESIGN: Retrospective observational study from September 2006 to October 2007. SETTING: In-patient hospice unit. PARTICIPANTS: Participants were 114 consecutive hospice patients (mean age 71.7 ± 13.9 years). OUTCOME MEASUREMENT: Analysis of survival (days) following admission, according to opioid usage. Standardized Oral Morphine Equivalents (OME mg/d) were calculated. RESULTS: On admission 74.6% received opioids, rising to 92.1% at death. Mean opioid dosage was OME of 146 ± 245 mg/d, and mean survival was 12.3 ± 12.15 days. Mean survival, according to opioid dosage of 0, 1 to 119, and greater than or equal to 120 OME mg/d respectively at admission, was 16.7 ± 13.4, 11.2 ± 12.1, 10.0 ± 10.2 (P = .009), and according to dose at death was 17.0 ± 15.1, 12.3 ± 12.1, 11.1 ± 11.3 (P = ns). Increasing overall opioid dosage was associated with improved survival compared with no change or decreasing overall dosage (mean survival 14.0 ± 12.7 days versus 9.3 ± 9.8 versus 9.1 ± 11.4, days respectively, P = .01). Adjusting for clinical variables in Cox proportional hazards models, no significant association was found between mortality and of the following aspects of opioid usage: (1) dose on admission (Hazard Ratio [HR] 1.009, 95% confidence interval [CI] 0.999-1.019); (2) dose at death (HR 1.004, 95% CI 0.996-1.013); (3) mean dose (HR 1.006, 95% CI 0.997-1.016); (4) overall dose increase (HR 0.733, 95% CI 0.417-1.288) and decrease (HR 0.967, 95% CI 0.472-1.984); (5) day-by-day dosage changes (HR 1.005, 95% CI 0.996-1.013). CONCLUSIONS: Opioid usage, even at high dosages, had no effect on survival among advanced cancer patients in a hospice setting.