Mammalian ANP32A and ANP32B Proteins Drive Differential Polymerase Adaptations in Avian Influenza Virus.

ANP32 proteins, which act as influenza polymerase cofactors, vary between birds and mammals. In mammals, ANP32A and ANP32B have been reported to serve essential but redundant roles to support influenza polymerase activity. The well-known mammalian adaptation PB2-E627K enables influenza polymerase to use mammalian ANP32 proteins. However, some mammalian-adapted influenza viruses do not harbor this substitution. Here, we show that alternative PB2 adaptations, Q591R and D701N, also allow influenza polymerase to use mammalian ANP32 proteins, whereas other PB2 mutations, G158E, T271A, and D740N, increase polymerase activity in the presence of avian ANP32 proteins as well. Furthermore, PB2-E627K strongly favors use of mammalian ANP32B proteins, whereas D701N shows no such bias. Accordingly, PB2-E627K adaptation emerges in species with strong pro-viral ANP32B proteins, such as humans and mice, while D701N is more commonly seen in isolates from swine, dogs, and horses, where ANP32A proteins are the preferred cofactor. Using an experimental evolution approach, we show that the passage of viruses containing avian polymerases in human cells drove acquisition of PB2-E627K, but not in the absence of ANP32B. Finally, we show that the strong pro-viral support of ANP32B for PB2-E627K maps to the low-complexity acidic region (LCAR) tail of ANP32B. IMPORTANCE Influenza viruses naturally reside in wild aquatic birds. However, the high mutation rate of influenza viruses allows them to rapidly and frequently adapt to new hosts, including mammals. Viruses that succeed in these zoonotic jumps pose a pandemic threat whereby the virus adapts sufficiently to efficiently transmit human-to-human. The influenza virus polymerase is central to viral replication and restriction of polymerase activity is a major barrier to species jumps. ANP32 proteins are essential for influenza polymerase activity. In this study, we describe how avian influenza viruses can adapt in several different ways to use mammalian ANP32 proteins. We further show that differences between mammalian ANP32 proteins can select different adaptive changes and are responsible for some of the typical mutations that arise in mammalian-adapted influenza polymerases. These different adaptive mutations may determine the relative zoonotic potential of influenza viruses and thus help assess their pandemic risk.

A Qualitative Study of Electronic Patient-Reported Outcome Symptom Monitoring After Thoracic Surgery.

INTRODUCTION: Thoracic surgery is a mainstay of therapy for lung cancer and other chronic pulmonary conditions, but recovery is often complicated. Digital health systems can facilitate remote postoperative symptom management yet obstacles persist in their routine clinical adoption. This study aimed to identify patient-perceived barriers and facilitators to using an electronic patient-reported outcome (ePRO) monitoring platform specially designed to detect complications from thoracic surgery postdischarge. METHODS: Patients (n = 16) who underwent thoracic surgery and participated in an ePRO parent study completed semistructured interviews, which were analyzed using thematic content analysis and iterative team-based coding. Themes were mapped onto the three domains of the Capability, Opportunity, and Motivation Model of behavior framework to inform ePRO design and implementation improvements. RESULTS: Analysis demonstrated seven dominant themes, including barriers (1. postoperative patient physical and mental health, 2. lack of access to email and poor internet connectivity, 3. lack of clarity on ePRO use in routine clinical care, and 4. symptom item redundancy) as well as facilitators (5. ease of the ePRO assessment completion, 6. engagement with the surgical care team on ePRO use, and 7. increased awareness of symptom experience through ePRO use). Suggested ePRO improvements included offering alternatives to web-based completion, tailoring symptom assessments to individual patients, and the need for patient education on ePROs for perioperative care. CONCLUSIONS: Addressable barriers and facilitators to implementation of ePRO symptom monitoring in the thoracic surgical patient population postdischarge have been identified. Future work will test the impact of design improvements on implementation outcomes of feasibility and acceptability.

Cancer-related Fatigue in Lung Cancer: A Research Agenda: An Official American Thoracic Society Research Statement.

Background: Fatigue is the most common symptom among cancer survivors. Cancer-related fatigue (CRF) may occur at any point in the cancer care continuum. Multiple factors contribute to CRF development and severity, including cancer type, treatments, presence of other symptoms, comorbidities, and medication side effects. Clinically, increasing physical activity, enhancing sleep quality, and recognizing sleep disorders are integral to managing CRF. Unfortunately, CRF is infrequently recognized, evaluated, or treated in lung cancer survivors despite more frequent and severe symptoms than in other cancers. Therefore, increased awareness and understanding of CRF are needed to improve health-related quality of life in lung cancer survivors. Objectives: 1) To identify and prioritize knowledge and research gaps and 2) to develop and prioritize research questions to evaluate mechanistic, diagnostic, and therapeutic approaches to CRF among lung cancer survivors. Methods: We convened a multidisciplinary panel to review the available literature on CRF, focusing on the impacts of physical activity, rehabilitation, and sleep disturbances in lung cancer. We used a three-round modified Delphi process to prioritize research questions. Results: This statement identifies knowledge gaps in the 1) detection and diagnostic evaluation of CRF in lung cancer survivors; 2) timing, goals, and implementation of physical activity and rehabilitation; and 3) evaluation and treatment of sleep disturbances and disorders to reduce CRF. Finally, we present the panel's initial 32 research questions and seven final prioritized questions. Conclusions: This statement offers a prioritized research agenda to 1) advance clinical and research efforts and 2) increase awareness of CRF in lung cancer survivors.

HES1 is a novel downstream modifier of the SHH-GLI3 Axis in the development of preaxial polydactyly.

Sonic Hedgehog/GLI3 signaling is critical in regulating digit number, such that Gli3-deficiency results in polydactyly and Shh-deficiency leads to digit number reductions. SHH/GLI3 signaling regulates cell cycle factors controlling mesenchymal cell proliferation, while simultaneously regulating Grem1 to coordinate BMP-induced chondrogenesis. SHH/GLI3 signaling also coordinates the expression of additional genes, however their importance in digit formation remain unknown. Utilizing genetic and molecular approaches, we identified HES1 as a downstream modifier of the SHH/GLI signaling axis capable of inducing preaxial polydactyly (PPD), required for Gli3-deficient PPD, and capable of overcoming digit number constraints of Shh-deficiency. Our data indicate that HES1, a direct SHH/GLI signaling target, induces mesenchymal cell proliferation via suppression of Cdkn1b, while inhibiting chondrogenic genes and the anterior autopod boundary regulator, Pax9. These findings establish HES1 as a critical downstream effector of SHH/GLI3 signaling in the development of PPD.

Running Habits and Injury Frequency Following COVID-19 Restrictions in Adolescent Long-Distance Runners.

PURPOSE: A decline in youth running was observed at the start of the COVID-19 pandemic. We investigated whether the resumption of organized running after social distancing restrictions changed running habits or injury frequency in adolescent runners. METHODS: Adolescents (age = 16.1 [2.1] y) who participated in long-distance running activities completed an online survey in the Spring and Fall of 2020. Participants self-reported average weekly running habits and whether they sustained an injury during the Fall 2020 season. Poisson regression models and 1-way analysis of variance compared running habits while Fisher exact test compared differences in frequencies of injuries during Fall 2020 among season statuses (full, delayed, and canceled). RESULTS: All runners, regardless of season status, increased weekly distance during Fall 2020. Only runners with a full Fall 2020 season ran more times per week and more high-intensity runs per week compared with their Spring 2020 running habits. There were no differences in running volume or running-related injury frequency among Fall 2020 season statuses. CONCLUSIONS: There were no significant differences in running-related injury (RRI) frequency among runners, regardless of season status, following the resumption of cross-country. Health care providers may need to prepare for runners to increase running volume and intensity following the resumption of organized team activities.

Physical Therapy Dose After Orthopedic Multilevel Surgery Varies by Ambulatory Status in Children With Cerebral Palsy: A Pilot Study.

PURPOSE: To characterize physical therapy (PT) dose for children with cerebral palsy (CP) after multi-level surgery (MLS) and examine variation by ambulatory status and surgical burden. METHODS: PT dose (Frequency, Intensity, Time, Type) data were extracted from electronic records of children with CP who received outpatient PT the year after MLS. RESULTS: Seventeen children, mean 9 years, female (n=10), ambulatory (n=10), and high surgical burden (n=12) were included. In the year after surgery, 345 visits occurred. Intensity across visits was above average. Time was greatest for pre-functional activities, gait, and transitions/transfers. Types most often delivered were neuromuscular, musculoskeletal, and education/training. Ambulatory children received significantly more visits, higher intensity, and time in pre-functional activities and gait than non-ambulatory children. No differences in type by ambulatory status and PT dose by surgical burden were found. CONCLUSION: PT dose varied the first year after MLS indicating the need for guidelines by ambulatory status. VIDEO ABSTRACT: Supplemental Digital Content available at: http://links.lww.com/PPT/A516.

Transthoracic fundoplication using the Belsey Mark IV technique versus Nissen fundoplication: A systematic review and meta-analysis.

BACKGROUND: Nissen fundoplication is considered the cornerstone surgical treatment for hiatal hernia repair. Belsey Mark IV (BMIV) transthoracic fundoplication is an alternative approach that is rarely utilized in today's minimally invasive era. This study aims to summarize the safety and efficacy of BMIV and to compare it with Nissen fundoplication. METHODS: We searched MEDLINE, Scopus, and Cochrane Library databases for single arm and comparative studies published by March 31st, 2022, according to PRISMA statement. Inverse-variance weights were used to estimate the proportion of patients experiencing the studied outcome and random-effects meta-analyses were performed. RESULTS: 17 studies were identified, incorporating 2136 and 638 patients that underwent Belsey Mark IV or Nissen fundoplication, respectively. A total of 13.8% (95% CI: 9.6-18.6) of the patients that underwent fundoplication with the BMIV technique had non-resolution of their symptoms and 3.5% (95% CI: 2.0-5.4) required a reoperation. Overall, 14.8% (95% CI: 9.5-20.1) of the BMIV arm patients experienced post-operative complications, 5.0% (95% CI: 2.0-9.0) experienced chronic postoperative pain and 6.9% (95% CI: 3.1-11.9) had a hernia recurrence. No statistically significant difference was observed between Belsey Mark IV and Nissen fundoplication in terms of post-interventional non-resolution of symptoms (odds ratio [OR]: 1.49 [95% Confidence Interval (95%CI):0.6-4.0]; p = 0.42), post-operative complications (OR:0.83, 95%CI: 0.5-1.5, p = 0.54) and in-hospital mortality (OR:0.69, 95%CI: 0.13-3.80, p = 0.67). Belsey Mark IV arm had significantly lower reoperation rates compared to Nissen arm (OR:0.28, 95%CI: 0.1-0.7, p = 0.01). CONCLUSIONS: BMIV fundoplication is a safe and effective but technically challenging. The BMIV technique may offer benefits to patients compared to the laparoscopic Nissen fundoplication. These benefits, however, are challenged by the increased morbidity of a thoracotomy.

Correlates of poor clinical outcomes related to COVID-19 among older people with psychiatric illness - a mixed methods study.

OBJECTIVE: COVID-19 may lead to a range of clinical outcomes among older people with psychiatric and medical conditions. Evidence guiding management of future outbreaks among this vulnerable population in psychiatric hospital settings are sparse. In this study, we examined the correlates of poor clinical outcomes related to COVID-19 and explored the perspectives of COVID-19 survivors hospitalized in psychiatry settings. METHOD: The correlates of poor clinical outcomes related to COVID-19 were examined using a retrospective chart review of 81 older people hospitalized in psychiatry settings. Correlates of clinical outcomes related to COVID-19 were assessed by multiple logistic regression models. In addition, the perspectives of 10 COVID-19 survivors were explored by qualitative interviews. The qualitative data was subject to thematic analysis. RESULTS: Although 25.9% (n = 21) participants were asymptomatic, there was high COVID-19 related mortality (14.8%; n = 12). Vitamin-D deficiency, anticholinergic burden, and isolation policies within psychiatric wards were significantly (p < 0.05) related to COVID-19 related deaths. In qualitative interviews, participants emphasized the importance of strengthening local support networks and making vaccination centers more accessible. CONCLUSIONS: Reducing anticholinergic prescriptions and improving isolation policies may help to mitigate poor clinical outcomes. Future research investigating the impact of vitamin-D supplementation on COVID-19 related outcomes is warranted.

Species difference in ANP32A underlies influenza A virus polymerase host restriction.

Influenza pandemics occur unpredictably when zoonotic influenza viruses with novel antigenicity acquire the ability to transmit amongst humans. Host range breaches are limited by incompatibilities between avian virus components and the human host. Barriers include receptor preference, virion stability and poor activity of the avian virus RNA-dependent RNA polymerase in human cells. Mutants of the heterotrimeric viral polymerase components, particularly PB2 protein, are selected during mammalian adaptation, but their mode of action is unknown. We show that a species-specific difference in host protein ANP32A accounts for the suboptimal function of avian virus polymerase in mammalian cells. Avian ANP32A possesses an additional 33 amino acids between the leucine-rich repeats and carboxy-terminal low-complexity acidic region domains. In mammalian cells, avian ANP32A rescued the suboptimal function of avian virus polymerase to levels similar to mammalian-adapted polymerase. Deletion of the avian-specific sequence from chicken ANP32A abrogated this activity, whereas its insertion into human ANP32A, or closely related ANP32B, supported avian virus polymerase function. Substitutions, such as PB2(E627K), were rapidly selected upon infection of humans with avian H5N1 or H7N9 influenza viruses, adapting the viral polymerase for the shorter mammalian ANP32A. Thus ANP32A represents an essential host partner co-opted to support influenza virus replication and is a candidate host target for novel antivirals.

Analysis of Risk Factors, Complications, Reoperations, and Demographics Associated With Open and Arthroscopic Rotator Cuff Repair: An Analysis of a Large National Database.

PURPOSE: To assess the national trends in arthroscopic and open rotator cuff repair surgery and the associated demographics, complications, and risk factors specific to each procedure. METHODS: A retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) dataset between the years 2007 and 2018. Patients were identified using Common Procedural Terminology codes for open and arthroscopic rotator cuff repair. Variables collected including basic demographics, procedural, and outcome specific variables as available through the NSQIP repository. Appropriate statistical measures were used to compare the groups, with the χ2 test used for categorical variables and t test for continuous variables. RESULTS: The arthroscopic cohort comprised 39,013 patients; the open group consisted of 8,664. Reported arthroscopic and open cases increased significantly between 2007 and 2018 from 135 to 7,269 and 65 to 1,168, respectively. Average operative time for arthroscopic procedure was 89 minutes and 76 minutes for open. The open group consisted of a slightly greater percentage of smokers, 18.3% versus 15.2%, and patients with diabetes, 18.2% versus 15.9%, both of which were statistically significant (P < .001). Open cases had an odds ratio of 3.05 for superficial infections and 7.40 for deep infections, both of which were statistically significant (P < .001). The open cohort also had an odds ratio of 1.71 for unplanned readmissions when compared with the arthroscopic cohort, which was also statistically significant (P < .001). CONCLUSIONS: According to the NSQIP database, the increase in arthroscopic procedures is significantly outpacing the increase in open procedures during this study period, which matches the trends seen in previous studies. Patients with diabetes and who smoke also represent a greater risk group for postoperative complications when undergoing open surgery. These findings suggest that perhaps the decision to pursue one technique over the other may be influenced both by provider preference and patient-related factors. LEVEL OF EVIDENCE: III, retrospective comparative trial.

Amino acid substitutions in the H5N1 avian influenza haemagglutinin alter pH of fusion and receptor binding to promote a highly pathogenic phenotype in chickens.

Highly pathogenic H5N1 avian influenza viruses cause devastating outbreaks in farmed poultry with serious consequences for animal welfare and economic losses. Zoonotic infection of humans through close contact with H5N1 infected birds is often severe and fatal. England experienced an outbreak of H5N1 in turkeys in 1991 that led to thousands of farmed bird mortalities. Isolation of clonal populations of one such virus from this outbreak uncovered amino acid differences in the virus haemagglutinin (HA) gene whereby the different genotypes could be associated with distinct pathogenic outcomes in chickens; both low pathogenic (LP) and high pathogenic (HP) phenotypes could be observed despite all containing a multi-basic cleavage site (MBCS) in the HA gene. Using reverse genetics, three amino acid substitutions in HA were examined for their ability to affect pathogenesis in the chicken. Restoration of amino acid polymorphisms close to the receptor binding site that are commonly found in H5 viruses only partially improved viral fitness in vitro and in vivo. A third novel substitution in the fusion peptide, HA2G4R, enabled the HP phenotype. HA2G4R decreased the pH stability of HA and increased the pH of HA fusion. The substitutions close to the receptor binding site optimised receptor binding while modulating the pH of HA fusion. Importantly, this study revealed pathogenic determinants beyond the MBCS.

Elucidating the Interactions between Influenza Virus Polymerase and Host Factor ANP32A.

The avian-origin influenza A virus polymerase is restricted in human cells. This restriction has been associated with species differences in host factor ANP32A. Avian ANP32A supports the activity of an avian-origin polymerase. However, the avian-origin polymerase is incompatible with human ANP32A. Avian ANP32A proteins harbor an additional 33 amino acids compared to human ANP32A proteins, which are crucial for their ability to support the avian-origin influenza virus polymerase. Here, we elucidate the interactions between ANP32A proteins and the influenza A virus polymerase using split luciferase complementation assays, coimmunoprecipitation, and in situ split Venus interaction assays. We show greater interaction of chicken ANP32A than human ANP32A with the viral polymerase and visualize these interactions in situ in the cell nucleus. We demonstrate that the 33 amino acids of chicken ANP32A and the PB2 627 domain of viral polymerase complex both contribute to this enhanced interaction. Finally, we show how these interactions are affected by the presence of viral RNA and the processivity of the polymerase, giving insights into the way that ANP32A might act during virus infection.IMPORTANCE Successful zoonotic transmission of influenza A virus into humans can lead to pandemics in an immunologically naive population. Host-encoded ANP32A proteins are required to support influenza A virus polymerase activity, and species differences in ANP32A can restrict the host range of influenza virus. Understanding how ANP32A proteins support the viral polymerase and how differences in ANP32A affect the ability of the polymerase to coopt these proteins will enhance our understanding of viral replication and species restriction as well as suggesting targeted antiviral approaches to treat influenza virus infection.

Swine ANP32A Supports Avian Influenza Virus Polymerase.

Avian influenza viruses occasionally infect and adapt to mammals, including humans. Swine are often described as "mixing vessels," being susceptible to both avian- and human-origin viruses, which allows the emergence of novel reassortants, such as the precursor to the 2009 H1N1 pandemic. ANP32 proteins are host factors that act as influenza virus polymerase cofactors. In this study, we describe how swine ANP32A, uniquely among the mammalian ANP32 proteins tested, supports the activity of avian-origin influenza virus polymerases and avian influenza virus replication. We further show that after the swine-origin influenza virus emerged in humans and caused the 2009 pandemic, it evolved polymerase gene mutations that enabled it to more efficiently use human ANP32 proteins. We map the enhanced proviral activity of swine ANP32A to a pair of amino acids, 106 and 156, in the leucine-rich repeat and central domains and show these mutations enhance binding to influenza virus trimeric polymerase. These findings help elucidate the molecular basis for the mixing vessel trait of swine and further our understanding of the evolution and ecology of viruses in this host.IMPORTANCE Avian influenza viruses can jump from wild birds and poultry into mammalian species such as humans or swine, but they only continue to transmit if they accumulate mammalian adapting mutations. Pigs appear uniquely susceptible to both avian and human strains of influenza and are often described as virus "mixing vessels." In this study, we describe how a host factor responsible for regulating virus replication, ANP32A, is different between swine and humans. Swine ANP32A allows a greater range of influenza viruses, specifically those from birds, to replicate. It does this by binding the virus polymerase more tightly than the human version of the protein. This work helps to explain the unique properties of swine as mixing vessels.

The Prevalence of Benign Pathology Following Major Pulmonary Resection for Suspected Malignancy.

BACKGROUND: In the era of lung cancer screening with low-dose computed tomography, there is concern that high false-positive rates may lead to an increase in nontherapeutic lung resection. The aim of this study is to determine the current rate of major pulmonary resection for ultimately benign pathology. MATERIALS AND METHODS: A single-institution, retrospective analysis of all patients > 18 y who underwent major pulmonary resection between 2013 and 2018 for suspected malignancy and had benign final pathology was performed. RESULTS: Of 394 major pulmonary resections performed for known or presumed malignancy, 10 (2.5%) were benign. Of these 10, the mean age was 61.1 y (SD 14.6). Most were current or former smokers (60%). Ninety percent underwent a fluorodeoxyglucose positron emission tomography scan. Median nodule size was 27 mm (IQR 21-35) and most were in the right middle lobe (50%). Preoperative biopsy was performed in four (40%) but were nondiagnostic. Video-assisted thoracoscopic lobectomy (70%) was the most common surgical approach. Final pathology revealed three (30%) infectious, three (30%) inflammatory, two (20%) fibrotic, and two (20%) benign neoplastic nodules. Two (20%) patients had perioperative complications, both of which were prolonged air leaks, one (10%) patient was readmitted within 30 d, and there was no mortality. CONCLUSIONS: A small percentage of patients (2.5% in our series) may undergo major pulmonary resection for unexpectedly benign pathology. Knowledge of this rate is useful to inform shared decision-making models between surgeons and patients and evaluation of thoracic surgery program performance.

Multidisciplinary Management of an Aorto-esophageal Injury Caused by Foreign Body Ingestion.

A 37-year-old incarcerated male ingested a complex "X-shaped" foreign body that resulted in a penetrating aorto-esophageal injury. A primary esophagotomy with retrieval of the foreign body and muscle flap closure was performed simultaneously with thoracic endovascular aortic repair. This multidisciplinary surgical approach controls for both immediate exsanguination and postoperative complications to improve patient outcome.

Describing the Delivery of Evidence-Based Physical Therapy Intervention to Individuals With Cerebral Palsy.

PURPOSE: To characterize by evidence grades and examine variation in type of physical therapy intervention delivered in routine clinical care in individuals with cerebral palsy (CP). METHODS: Retrospective data collection from the electronic record over 1 year at a tertiary care pediatric outpatient therapy division. RESULTS: Four hundred sixty-five individuals with CP received 28 344 interventions during 4335 treatment visits. Sixty-six percent of interventions were evidence-based interventions (EBIs). Significant variation was demonstrated across Gross Motor Function Classification System levels, with children classified as level V receiving the least and level III the most. The most frequent EBIs delivered were caregiver education, motor control, functional strengthening, ankle-foot orthoses, treadmill training, and fit of adaptive equipment. CONCLUSIONS: Further work is needed to determine whether amount of EBI is related to better outcomes. Combining this information with other aspects of dose (intensity, time, and frequency) may elucidate the contribution of each with outcomes.

ANP32 Proteins Are Essential for Influenza Virus Replication in Human Cells.

ANP32 proteins have been implicated in supporting influenza virus replication, but most of the work to date has focused on the ability of avian Anp32 proteins to overcome restriction of avian influenza polymerases in human cells. Using a CRISPR approach, we show that the human acidic nuclear phosphoproteins (ANPs) ANP32A and ANP32B are functionally redundant but essential host factors for mammalian-adapted influenza A virus (IAV) and influenza B virus (IBV) replication in human cells. When both proteins are absent from human cells, influenza polymerases are unable to replicate the viral genome, and infectious virus cannot propagate. Provision of exogenous ANP32A or ANP32B recovers polymerase activity and virus growth. We demonstrate that this redundancy is absent in the murine Anp32 orthologues; murine Anp32A is incapable of recovering IAV polymerase activity, while murine Anp32B can do so. Intriguingly, IBV polymerase is able to use murine Anp32A. We show, using a domain swap and point mutations, that the leucine-rich repeat (LRR) 5 region comprises an important functional domain for mammalian ANP32 proteins. Our approach has identified a pair of essential host factors for influenza virus replication and can be harnessed to inform future interventions.IMPORTANCE Influenza virus is the etiological agent behind some of the most devastating infectious disease pandemics to date, and influenza outbreaks still pose a major threat to public health. Influenza virus polymerase, the molecule that copies the viral RNA genome, hijacks cellular proteins to support its replication. Current anti-influenza drugs are aimed against viral proteins, including the polymerase, but RNA viruses like influenza tend to become resistant to such drugs very rapidly. An alternative strategy is to design therapeutics that target the host proteins that are necessary for virus propagation. Here, we show that the human proteins ANP32A and ANP32B are essential for influenza A and B virus replication, such that in their absence cells become impervious to the virus. We map the proviral activity of ANP32 proteins to one region in particular, which could inform future intervention.

Internal genes of a highly pathogenic H5N1 influenza virus determine high viral replication in myeloid cells and severe outcome of infection in mice.

The highly pathogenic avian influenza (HPAI) H5N1 influenza virus has been a public health concern for more than a decade because of its frequent zoonoses and the high case fatality rate associated with human infections. Severe disease following H5N1 influenza infection is often associated with dysregulated host innate immune response also known as cytokine storm but the virological and cellular basis of these responses has not been clearly described. We rescued a series of 6:2 reassortant viruses that combined a PR8 HA/NA pairing with the internal gene segments from human adapted H1N1, H3N2, or avian H5N1 viruses and found that mice infected with the virus with H5N1 internal genes suffered severe weight loss associated with increased lung cytokines but not high viral load. This phenotype did not map to the NS gene segment, and NS1 protein of H5N1 virus functioned as a type I IFN antagonist as efficient as NS1 of H1N1 or H3N2 viruses. Instead we discovered that the internal genes of H5N1 virus supported a much higher level of replication of viral RNAs in myeloid cells in vitro, but not in epithelial cells and that this was associated with high induction of type I IFN in myeloid cells. We also found that in vivo during H5N1 recombinant virus infection cells of haematopoetic origin were infected and produced type I IFN and proinflammatory cytokines. Taken together our data infer that human and avian influenza viruses are differently controlled by host factors in alternative cell types; internal gene segments of avian H5N1 virus uniquely drove high viral replication in myeloid cells, which triggered an excessive cytokine production, resulting in severe immunopathology.

Anesthesia for Resection and Reconstruction of the Trachea and Carina.

Airway surgery poses a host of unique challenges to both the surgical and anesthesiology teams. Accordingly, there are a variety of surgical, anesthetic, and airway management options to be strategically considered. Management can be challenging during multidisciplinary preoperative planning, during the surgical procedure itself, and during recovery. In this review, emphasis is placed on anesthesia challenges for patients undergoing major tracheal or carinal surgery with specific considerations related to perioperative management.

Kras mutant genetically engineered mouse models of human cancers are genomically heterogeneous.

KRAS mutant tumors are largely recalcitrant to targeted therapies. Genetically engineered mouse models (GEMMs) of Kras mutant cancer recapitulate critical aspects of this disease and are widely used for preclinical validation of targets and therapies. Through comprehensive profiling of exomes and matched transcriptomes of >200 KrasG12D-initiated GEMM tumors from one lung and two pancreatic cancer models, we discover that significant intratumoral and intertumoral genomic heterogeneity evolves during tumorigenesis. Known oncogenes and tumor suppressor genes, beyond those engineered, are mutated, amplified, and deleted. Unlike human tumors, the GEMM genomic landscapes are dominated by copy number alterations, while protein-altering mutations are rare. However, interspecies comparative analyses of the genomic landscapes demonstrate fidelity between genes altered in KRAS mutant human and murine tumors. Genes that are spontaneously altered during murine tumorigenesis are also among the most prevalent found in human indications. Using targeted therapies, we also demonstrate that this inherent tumor heterogeneity can be exploited preclinically to discover cancer-specific and genotype-specific therapeutic vulnerabilities. Focusing on Kras allelic imbalance, a feature shared by all three models, we discover that MAPK pathway inhibition impinges uniquely on this event, indicating distinct susceptibility and fitness advantage of Kras-mutant cells. These data reveal previously unknown genomic diversity among KrasG12D-initiated GEMM tumors, places them in context of human patients, and demonstrates how to exploit this inherent tumor heterogeneity to discover therapeutic vulnerabilities.