Mechanisms of vitamin D3 metabolite repression of IgE-dependent mast cell activation.

BACKGROUND: Mast cells have gained notoriety based on their detrimental contributions to IgE-mediated allergic disorders. Although mast cells express the vitamin D receptor (VDR), it is not clear to what extent 1α,25-dihydroxyvitamin D3 (1α,25[OH]2D3) or its predominant inactive precursor metabolite in the circulation, 25-hydroxyvitamin D3 (25OHD3), can influence IgE-mediated mast cell activation and passive cutaneous anaphylaxis (PCA) in vivo. OBJECTIVE: We sought to assess whether the vitamin D3 metabolites 25OHD3 and 1α,25(OH)2D3 can repress IgE-dependent mast cell activation through mast cell-25-hydroxyvitamin D-1α-hydroxylase (CYP27B1) and mast cell-VDR activity. METHODS: We measured the extent of vitamin D3 suppression of IgE-mediated mast cell degranulation and mediator production in vitro, as well as the vitamin D3-induced curtailment of PCA responses in WBB6F1-Kit(W/W-v) or C57BL/6J-Kit(W-sh/W-sh) mice engrafted with mast cells that did or did not express VDR or CYP27B1. RESULTS: Here we show that mouse and human mast cells can convert 25OHD3 to 1α,25(OH)2D3 through CYP27B1 activity and that both of these vitamin D3 metabolites suppressed IgE-induced mast cell-derived proinflammatory and vasodilatory mediator production in a VDR-dependent manner in vitro. Furthermore, epicutaneously applied vitamin D3 metabolites significantly reduced the magnitude of skin swelling associated with IgE-mediated PCA reactions in vivo; a response that required functional mast cell-VDRs and mast cell-CYP27B1. CONCLUSION: Taken together, our findings provide a mechanistic explanation for the anti-inflammatory effects of vitamin D3 on mast cell function by demonstrating that mast cells can actively metabolize 25OHD3 to dampen IgE-mediated mast cell activation in vitro and in vivo.

Accelerating Innovation in Primary Care to Support Adolescent Health Discussions.

BACKGROUND AND OBJECTIVES: Adolescent strengths and risks are not routinely captured in systematized and actionable ways in pediatric primary care. To address this problem, we developed a comprehensive adolescent health questionnaire (AHQ) integrated within the electronic health record and evaluated the AHQ's impact on collection of information on prioritized health-related domains. METHODS: We developed and pilot tested the AHQ. We then scaled and assessed the AHQ's impact on data collection. AHQ development used innovation methods and measured feasibility and acceptability outcomes. Scaling and postscaling outcomes included Reach, Effectiveness, Adoption, Implementation, Maintenance and Sustainability measures: Reach (total questionnaires completed), Effectiveness (capture of key information across health domains pre- vs post-AHQ scaling), Adoption (proportion of practices that adopted the AHQ), Implementation (proportion of eligible adolescents who completed the AHQ), and Maintenance (monthly completion rates). RESULTS: AHQ development led to a tool that was feasible and acceptable for use. During scaling (October 2020-December 2021), 22 147 questionnaires were completed by 20 749 unique adolescents aged 13 to 21 years at their preventive visit. Comparing pre- versus post-AHQ scaling data, use of the AHQ increased collection of information across domains, especially for strengths, gun safety, substance use, sexual activity, sexual orientation, and gender identity, from ranges of 0%-25% to 92%-95%. All 31 practices adopted the AHQ with completion at 88.7% of visits (n = 24 968). Two years postscaling, completion rates were >91% per month. CONCLUSIONS: We successfully developed, scaled, and maintained an AHQ in a widely-used electronic health record system, a model for improving adolescent care and foundation for developing future interventions.

Drosophila 14-3-3ε has a crucial role in anti-microbial peptide secretion and innate immunity.

The secretion of anti-microbial peptides is recognised as an essential step in innate immunity, but there is limited knowledge of the molecular mechanism controlling the release of these effectors from immune response cells. Here, we report that Drosophila 14-3-3ε mutants exhibit reduced survival when infected with either Gram-positive or Gram-negative bacteria, indicating a functional role for 14-3-3ε in innate immunity. In 14-3-3ε mutants, there was a reduced release of the anti-microbial peptide Drosomycin into the haemolymph, which correlated with an accumulation of Drosomycin-containing vesicles near the plasma membrane of cells isolated from immune response tissues. Drosomycin appeared to be delivered towards the plasma membrane in Rab4- and Rab11-positive vesicles and smaller Rab11-positive vesicles. RNAi silencing of Rab11 and Rab4 significantly blocked the anterograde delivery of Drosomycin from the perinuclear region to the plasma membrane. However, in 14-3-3ε mutants there was an accumulation of small Rab11-positive vesicles near the plasma membrane. This vesicular phenotype was similar to that observed in response to the depletion of the vesicular Syntaxin protein Syx1a. In wild-type Drosophila immune tissue, 14-3-3ε was detected adjacent to Rab11, and partially overlapping with Syx1a, on vesicles near the plasma membrane. We conclude that 14-3-3ε is required for Rab11-positive vesicle function, which in turn enables antimicrobial peptide secretion during an innate immune response.

Pediatricians' proficiency in the care of the dysphonic child.

OBJECTIVES/HYPOTHESIS: Pediatricians are the first physicians to see a dysphonic child (DC), yet there are limited data on their proficiency in caring for them. The objective of this study was to understand how pediatricians' experience and their comfort in recognizing/diagnosing voice disorders affects their referral patterns and use of basic treatment options. STUDY DESIGN: Survey study. METHODS: A 13-question survey was sent to pediatricians in the Children's Hospital of Philadelphia's primary care network; 45/216 were returned. Statistical analyses were performed using the Student t test, linear/logistic regression model, Fisher exact test, Kruskal-Wallis test, and Spearman's correlation test. RESULTS: Pediatricians practicing longer are more comfortable recognizing dysphonia (P = .0022). They are significantly more likely to refer a DC, even without subjective complaints of hoarseness by the family/patient or compounding medical issues. For each year in practice, the probability of referring increases by 1.55% (P = .0017). Pediatricians with a higher percentage of dysphonic children in their practice are more likely to trust their own perceptual recognition when deciding to refer (P = .0496). Nearly all pediatricians (40/45) would refer to a pediatric otolaryngologist. None would refer to a laryngologist or a voice therapist. No factors significantly affected treatment options. CONCLUSIONS: Veteran pediatricians feel more comfortable diagnosing a voice disorder and are more likely to refer a DC, regardless of patient/parent complaints or compounding factors. Pediatricians are most likely to refer to a pediatric otolaryngologist versus a voice specialist. These findings suggest that education of younger, less-experienced pediatricians about recognizing voice disorders and options for referral is needed. This may improve the overall care of the DC. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1756-1762, 2019.

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children.

Importance: As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources. Objective: To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days. Design, Setting, and Participants: This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019. Exposures: Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers. Main Outcomes and Measures: Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017). Results: Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid. Conclusions and Relevance: In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.

The Nedd4-2/Ndfip1 axis is a negative regulator of IgE-mediated mast cell activation.

Cross-linkage of the high-affinity immunoglobulin E (IgE) receptor (FcɛRI) on mast cells by antigen ligation has a critical role in the pathology of IgE-dependent allergic disorders, such as anaphylaxis and asthma. Restraint of intracellular signal transduction pathways that promote release of mast cell-derived pro-inflammatory mediators is necessary to dampen activation and restore homoeostasis. Here we show that the ligase Nedd4-2 and the adaptor Ndfip1 (Nedd4 family interacting protein 1) limit the intensity and duration of IgE-FcɛRI-induced positive signal transduction by ubiquitinating phosphorylated Syk, a tyrosine kinase that is indispensable for downstream FcɛRI signalosome activity. Importantly, loss of Nedd4-2 or Ndfip1 in mast cells results in exacerbated and prolonged IgE-mediated cutaneous anaphylaxis in vivo. Our findings reveal an important negative regulatory function for Nedd4-2 and Ndfip1 in IgE-dependent mast cell activity.

Pediatric integrated delivery system's experience with pandemic influenza A (H1N1).

OBJECTIVE: To describe 1 pediatric integrated delivery system's experience with the influenza A (H1N1) pandemic in 2009 to illustrate the benefits of coordination, scale, scope, and flexibility in handling large volumes of patients in many locations. METHODS: Through multidisciplinary planning across a large, multisite pediatric delivery system, an effective 3-tier plan was developed to handle anticipated increased volumes associated with the fall 2009 influenza pandemic in the Philadelphia region. RESULTS: Patient demand for services increased to record-setting levels, particularly for emergency department visits and phone calls. The 3-tier plan of response allowed for graded and appropriate response to volumes that more than doubled in many locations. Measured by wait times and leftwithout- being-seen rates, the system appeared to match capacity to demand effectively. Lessons learned in terms of successes and challenges are useful for future planning. CONCLUSIONS: The experience of 1 pediatric delivery system in handling increased volume due to pandemic influenza may hold lessons for other organizations and for policy makers seeking to improve the preparedness, quality, and value of healthcare. These experiences do not imply the need for vertical integration with ownership, but do support tight coordination, communication, integration, and alignment in any management structure.

Evidence that vitamin D(3) promotes mast cell-dependent reduction of chronic UVB-induced skin pathology in mice.

Mast cell production of interleukin-10 (IL-10) can limit the skin pathology induced by chronic low-dose ultraviolet (UV)-B irradiation. Although the mechanism that promotes mast cell IL-10 production in this setting is unknown, exposure of the skin to UVB irradiation induces increased production of the immune modifying agent 1alpha,25-dihydroxyvitamin D(3) (1alpha,25[OH](2)D(3)). We now show that 1alpha,25(OH)(2)D(3) can up-regulate IL-10 mRNA expression and induce IL-10 secretion in mouse mast cells in vitro. To investigate the roles of 1alpha,25(OH)(2)D(3) and mast cell vitamin D receptor (VDR) expression in chronically UVB-irradiated skin in vivo, we engrafted the skin of genetically mast cell-deficient WBB6F(1)-Kit(W/W-v) mice with bone marrow-derived cultured mast cells derived from C57BL/6 wild-type or VDR(-/-) mice. Optimal mast cell-dependent suppression of the inflammation, local production of proinflammatory cytokines, epidermal hyperplasia, and epidermal ulceration associated with chronic UVB irradiation of the skin in Kit(W/W-v) mice required expression of VDR by the adoptively transferred mast cells. Our findings suggest that 1alpha,25(OH)(2)D(3)/VDR-dependent induction of IL-10 production by cutaneous mast cells can contribute to the mast cell's ability to suppress inflammation and skin pathology at sites of chronic UVB irradiation.

14-3-3:Shc scaffolds integrate phosphoserine and phosphotyrosine signaling to regulate phosphatidylinositol 3-kinase activation and cell survival.

Integrated cascades of protein tyrosine and serine/threonine phosphorylation play essential roles in transducing signals in response to growth factors and cytokines. How adaptor or scaffold proteins assemble signaling complexes through both phosphotyrosine and phosphoserine/threonine residues to regulate specific signaling pathways and biological responses is unclear. We show in multiple cell types that endogenous 14-3-3zeta is phosphorylated on Tyr(179) in response to granulocyte macrophage colony-stimulating factor. Importantly, 14-3-3zeta can function as an intermolecular bridge that couples to phosphoserine residues and also directly binds the SH2 domain of Shc via Tyr(179). The assembly of these 14-3-3:Shc scaffolds is specifically required for the recruitment of a phosphatidylinositol 3-kinase signaling complex and the regulation of CTL-EN cell survival in response to cytokine. The biological significance of these findings was further demonstrated using primary bone marrow-derived mast cells from 14-3-3zeta(-/-) mice. We show that cytokine was able to promote Akt phosphorylation and viability of primary mast cells derived from 14-3-3zeta(-/-) mice when reconstituted with wild type 14-3-3zeta, but the Akt phosphorylation and survival response was reduced in cells reconstituted with the Y179F mutant. Together, these results show that 14-3-3:Shc scaffolds can act as multivalent signaling nodes for the integration of both phosphoserine/threonine and phosphotyrosine pathways to regulate specific cellular responses.

Effectiveness of a clinical/billing alert system vs education alone in assisting physicians to correctly bill for asthma nebulization treatments in the pediatric office setting.

Missed billing opportunities can be a negative outcome of the implementation of non-interfaced clinical and billing information systems. We describe a decision support system that prompts physicians with suggested billing options at the point of ordering nebulized medications. A baseline rate of 70% missed billing opportunities decreased to 38% with education alone and to 7% with an alert system. Decision support can best support billing opportunities when automated and appearing at the point of care.

Impact of clinical alerts within an electronic health record on routine childhood immunization in an urban pediatric population.

OBJECTIVES: The objective of this study was to test the hypothesis that clinical alerts for routine pediatric vaccinations within an electronic health record would reduce missed opportunities for vaccination and improve immunization rates for young children in an inner-city population. METHODS: A 1-year intervention study (September 1, 2004, to August 31, 2005) with historical controls was conducted in 4 urban primary care centers affiliated with an academic medical center. All children who were younger than 24 months were enrolled. Electronic health record-based clinical reminders for routine childhood vaccinations were programmed to appear prominently at every patient encounter with vaccines due. The main outcome measures were rates of captured immunization opportunities and overall immunization rates at 24 months of age. RESULTS: Immunization alerts appeared at 15,928 visits during the intervention. Alert implementation was associated with increases in captured immunization opportunities from 78.2% to 90.3% at well visits and from 11.3% to 32.0% at sick visits. Adjusted up-to-date immunization rates at 24 months of age increased from 81.7% to 90.1% from the control to intervention period. Children in the intervention group also became up-to-date earlier than control patients. Patient characteristics were stable throughout the study. CONCLUSIONS: An electronic health record-based clinical alert intervention was associated with increases in captured opportunities for vaccination at both sick and well visits and significant improvements in immunization rates at 2 years of age. As electronic health records become more common in medical practice, such systems may transform immunization delivery to children.