The Role of LFA-1 for the Differentiation and Function of Regulatory T Cells-Lessons Learned from Different Transgenic Mouse Models.

Regulatory T cells (Treg) are essential for the maintenance of peripheral tolerance. Treg dysfunction results in diverse inflammatory and autoimmune diseases with life-threatening consequences. ß2-integrins (CD11a-d/CD18) play important roles in the migration of leukocytes into inflamed tissues and cell signaling. Of all ß2-integrins, T cells, including Treg, only express CD11a/CD18, termed lymphocyte function-associated antigen 1 (LFA-1), on their surface. In humans, loss-of-function mutations in the common subunit CD18 result in leukocyte adhesion deficiency type-1 (LAD-1). Clinical symptoms vary depending on the extent of residual ß2-integrin function, and patients may experience leukocytosis and recurrent infections. Some patients can develop autoimmune diseases, but the immune processes underlying the paradoxical situation of immune deficiency and autoimmunity have been scarcely investigated. To understand this complex phenotype, different transgenic mouse strains with a constitutive knockout of ß2-integrins have been established. However, since a constitutive knockout affects all leukocytes and may limit the validity of studies focusing on their cell type-specific role, we established a Treg-specific CD18-floxed mouse strain. This mini-review aims to delineate the role of LFA-1 for the induction, maintenance, and regulatory function of Treg in vitro and in vivo as deduced from observations using the various ß2-integrin-deficient mouse models.

More Than an ERAS Pathway is Needed to Meet Target Length of Stay After Pancreaticoduodenectomy.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols have been successfully instituted for pancreaticoduodenectomy (PD). This study evaluates reasons patients fail to meet length of stay (LOS) and areas for pathway improvement. MATERIALS AND METHODS: A multidisciplinary team developed and implemented an ERAS protocol for open PD in 2017. The study includes a medical record review of all patients who were perioperatively managed with the ERAS protocol and failed to meet LOS after PD procedures. Target LOS was defined as 7 d. RESULTS: From 2017 to 2020, 44% (93 of 213) of patients using ERAS protocol after PD procedures failed to meet target LOS. The most common reason to fail target LOS was ileus or delayed gastric emptying (47 of 93, LOS 11). Additional reasons included work-up of leukocytosis or pancreatic leak (17 of 93, LOS 14), additional "night" of observation (14 of 93, LOS 8), and orthostatic hypotension (3 of 93, LOS 10). Of these additional 46 patients, 19 patients underwent computed tomography (on or after POD 7) and only four patients received additional inpatient intervention. CONCLUSIONS: The most common reason for PD pathway failure included slow return of gastrointestinal function, a known complication after PD. The remaining patients were often kept for observation without additional intervention. This group represents an actionable cohort to target for improving LOS through surgeon awareness rather than protocol modification.

COVID-19 Medical-Religious Partnerships: Implementation of a Just-In-Time COVID-19 Training in Catholic Schools.

The concept of Just-In-Time Training (JITT) is to provide critical information specific to a public health crisis, allowing individuals to understand and respond to an urgent situation. The design of the JITT curriculum appropriate for school-aged children during the COVID-19 pandemic is vital, as every individual has a role to play in mitigating the spread of SARS-CoV-2. When working with various communities, considering culture and religion is essential, as aligning values and beliefs with the JITT curriculum's objectives may significantly change the community's behavior toward a public health crisis. In this narrative, we describe how a JITT curriculum for the COVID-19 pandemic, created in Maryland, US, and implemented in a Catholic school system, aligned with core Catholic social teachings. This alignment allowed for implementing and delivering the COVID-19 curriculum in Maryland's Archdiocese Catholic school system, culminating in a medical-religious partnership that serves as a model for future public health crises.

Protection from EAE in DOCK8 mutant mice occurs despite increased Th17 cell frequencies in the periphery.

Mutation of Dedicator of cytokinesis 8 (DOCK8) has previously been reported to provide resistance to the Th17 cell dependent EAE in mice. Contrary to expectation, we observed an elevation of Th17 cells in two different DOCK8 mutant mouse strains in the steady state. This was specific for Th17 cells with no change in Th1 or Th2 cell populations. In vitro Th cell differentiation assays revealed that the elevated Th17 cell population was not due to a T cell intrinsic differentiation bias. Challenging these mutant mice in the EAE model, we confirmed a resistance to this autoimmune disease with Th17 cells remaining elevated systemically while cellular infiltration in the CNS was reduced. Infiltrating T cells lost the bias toward Th17 cells indicating a relative reduction of Th17 cells in the CNS and a Th17 cell specific migration disadvantage. Adoptive transfers of Th1 and Th17 cells in EAE-affected mice further supported the Th17 cell-specific migration defect, however, DOCK8-deficient Th17 cells expressed normal Th17 cell-specific CCR6 levels and migrated toward chemokine gradients in transwell assays. This study shows that resistance to EAE in DOCK8 mutant mice is achieved despite a systemic Th17 bias.

Groundwater controls ecological zonation of salt marsh macrophytes.

Ecological zonation of salt marsh macrophytes is strongly influenced by hydrologic factors, but these factors are poorly understood. We examined groundwater flow patterns through surficial sediments in two saltmarshes in the southeastern United States to quantify hydrologic differences between distinct ecological zones. Both sites included tall- or medium-form Spartina alterniflora near the creek bank; short-form Spartina alterniflora in the mid-marsh; salt flats and Salicornia virginica in the high marsh; and Juncus roemarianus in brackish-to-fresh areas adjacent to uplands. Both sites had relatively small, sandy uplands and similar stratigraphy consisting of marsh muds overlying a deeper sand layer. We found significant hydrologic differences between the four ecological zones. In the zones colonized by S. alterniflora, the vertical flow direction oscillated with semi-diurnal tides. Net flow (14-day average) through the tall S. alterniflora zones was downward, whereas the short S. alterniflora zones included significant periods of net upward groundwater flow. An examination of tidal efficiency at these sites suggested that the net flow patterns rather than tidal damping controlled the width of the tall S. alterniflora zone. In contrast to the S. alterniflora zones, hypersaline zones populated by S. virginica were characterized by sustained periods (days) of continuous upward flow of saline water during neap tides. The fresher zone populated by J. roemarianus showed physical flow patterns that were similar to the hypersaline zones, but the upwelling porewaters were fresh rather than saline. These flow patterns were influenced by the hydrogeologic framework of the marshes, particularly differences in hydraulic head between the upland water table and the tidal creeks. We observed increases in hydraulic head of approximately 40 cm from the creek to the upland in the sand layers below both marshes, which is consistent with previous observations that sandy aquifers below fine-grained marsh soils act as conduits for flow from uplands to tidal creeks. This hydrologic framework supports relatively good drainage near the creek, increased waterlogging in the mid-marsh, and the development of hypersalinity adjacent to the freshwater upland. These hydrologic differences in turn support distinct ecological zones.

Detecting changes in seafloor elevation in sandy coastal environments using low-cost opensource tooling.

Knowledge of sediment erosion and deposition can be useful for a variety of engineering, marine science, and environmental applications, but collecting detailed time-series measurements of the sediment-water interface can be challenging, particularly in coastal marine environments. We developed economical and open-source sediment level loggers to record sediment-water interface time-series data with accuracy up to 1 cm. The logger is composed of a programmable Circuit-Python (or Arduino) microcontroller and "breakout boards" that attach to a specially designed printed circuit board (PCB) and an array of evenly spaced photoresistors enclosed in a robust waterproof housing. These instruments were paired with temperature sensors in a study off the coast of Charleston, SC in the South Atlantic Bight where heat was used as a tracer to detect the flow of porewater in the permeable coastal sediments. This approach requires accurate knowledge of the depth of temperature sensors relative to the sediment-water interface. In this application, improved knowledge of the elevation of the sediment-water interface elevation data from the sediment level loggers reduced average root mean squared errors in modeling submarine groundwater discharge by as much as 25 %. The sediment level loggers can be easily installed, withstand long deployment times, and provide long-term recording abilities suitable for a range of environments.

Large-scale groundwater flow and sedimentary diagenesis in continental shelves influence marine chemical budgets.

The major ion chemistry of the ocean has been assumed to be controlled by river input, hydrothermal circulation at mid-ocean ridges, carbonate production, and low-temperature alteration of seafloor basalt, but marine chemical budgets remain difficult to balance. Here we propose that large-scale groundwater flow and diagenetic reactions in continental shelf sediments have been overlooked as an important contributor to major ion budgets in the ocean. Based on data synthesized from 17 passive margin basins, continental shelves contribute fluid exchanges comparable to hydrothermal circulation at mid-ocean ridges. Chemical exchange is similarly significant, indicating removal of Mg2+ from the oceans at rates similar to mid-ocean ridge convection. Continental shelves likely contribute Ca2+ and K+ to the oceans at rates that, in combination with low-temperature basalt alteration, can close current budget deficits. Flow and reaction in continental shelf sediments should be included in a new generation of studies addressing marine isotope budgets.

The Health Education and Training (HEAT) Corps: A Medical-Community Collaboration Response during the COVID-19 Pandemic.

With the declaration of the COVID-19 pandemic by the World Health Organization in March 2020, many elements of society were faced with attempting to assimilate public health recommendations for infectious control. Vital social organizations had to balance delivering their social services while attempting to stay up to date with COVID-19 information and comply with evolving regulations. In the realm of schools and school systems, guidance on how to best adapt to COVID-19 was often limited. School officials and staff had to assist with multiple public health crises as a consequence of the pandemic, from the pandemic's transmission prevention strategies (e.g., face masks and physical distancing) to the recognition that students would have personal tragedies related to COVID-19. In this review, we highlight the process and feasibility of implementing an international COVID-19 school-based initiative over two years of the pandemic, the Health Education and Training (HEAT) Corps program.

Neutrophil extracellular traps and their histones promote Th17 cell differentiation directly via TLR2.

Neutrophils perform critical functions in the innate response to infection, including through the production of neutrophil extracellular traps (NETs) - web-like DNA structures which are extruded from neutrophils upon activation. Elevated levels of NETs have been linked to autoimmunity but this association is poorly understood. By contrast, IL-17 producing Th17 cells are a key player in various autoimmune diseases but are also crucial for immunity against fungal and bacterial infections. Here we show that NETs, through their protein component histones, directly activate T cells and specifically enhance Th17 cell differentiation. This modulatory role of neutrophils, NETs and their histones is mediated downstream of TLR2 in T cells, resulting in phosphorylation of STAT3. The innate stimulation of a specific adaptive immune cell subset provides an additional mechanism demonstrating a direct link between neutrophils, NETs and T cell autoimmunity.

Responding to the Disproportionate Impact of COVID-19 Among Latinx Patients in Baltimore: The JHM Latinx Anchor Strategy.

Latinx immigrants have been profoundly impacted by COVID-19. As the Johns Hopkins Health System faced a surge in admissions of limited English proficiency patients with COVID-19, it became evident that an institutional strategy to address the needs of this patient population was needed. The Johns Hopkins Medicine (JHM) Latinx Anchor Strategy was established in April 2020 with diverse stakeholder engagement to identify the most urgent community needs and develop timely solutions. The JHM Latinx Anchor Strategy provided a platform for information sharing to promote equitable access to resources for Latinxs with limited English proficiency who were impacted by COVID-19. Leveraging institutional, community, and government resources and expertise, the JHM Latinx Anchor Strategy helped establish interventions to improve access to COVID-19 testing and care for low-income immigrants without a primary care doctor and helped mitigate economic vulnerability through the distribution of food for 2,677 individuals and cash to 446 families and 95 individuals (May to August 2020). Expanded linguistic and culturally competent communication through webinars and livestream events reached more than 10,000 community members and partners. Over 7,500 limited English proficiency patients received linguistically congruent direct patient services through the Esperanza Center bilingual hotline, community testing resulting efforts, and inpatient consultations. The first stage of the JHM Latinx Anchor Strategy relied heavily on volunteer efforts. Funding for a sustainable response will be required to address ongoing COVID-19 needs, including expansion of the bilingual/bicultural healthcare workforce, expanded access to primary care, and investments in population health strategies addressing social determinants of health.

Impaired Treg-DC interactions contribute to autoimmunity in leukocyte adhesion deficiency type 1.

Leukocyte adhesion deficiency type 1 (LAD-1) is a rare disease resulting from mutations in the gene encoding for the common ß-chain of the ß2-integrin family (CD18). The most prominent clinical symptoms are profound leukocytosis and high susceptibility to infections. Patients with LAD-1 are prone to develop autoimmune diseases, but the molecular and cellular mechanisms that result in coexisting immunodeficiency and autoimmunity are still unresolved. CD4+FOXP3+ Treg are known for their essential role in preventing autoimmunity. To understand the role of Treg in LAD-1 development and manifestation of autoimmunity, we generated mice specifically lacking CD18 on Treg (CD18Foxp3), resulting in defective LFA-1 expression. Here, we demonstrate a crucial role of LFA-1 on Treg to maintain immune homeostasis by modifying T cell-DC interactions and CD4+ T cell activation. Treg-specific CD18 deletion did not impair Treg migration into extralymphatic organs, but it resulted in shorter interactions of Treg with DC. In vivo, CD18Foxp3 mice developed spontaneous hyperplasia in lymphatic organs and diffuse inflammation of the skin and in multiple internal organs. Thus, LFA-1 on Treg is required for the maintenance of immune homeostasis.

Just Us Dialogues: Harnessing the Transformational Power of Discourse to Prevent Violence.

Anchor Institutions (AIs) provide tremendous value and benefit to the communities where they reside through initiatives, partnerships, and investments. As an academic medical center, Johns Hopkins devised to anchor its community by addressing the epidemic of violence and racial injustice through a series of webinars and a symposium entitled the "Just Us Dialogues." An analysis of all comments and policy recommendations made by panelists and attendees was performed and a series of recommendations emerged regarding how an AI should approach addressing community violence and inequities to promote community wellness. The series consisted of 4 panels: "The 4th Amendment: Use, Misuse, and Case for Police Reform"; "Protecting Our Youth: Confronting Society's Role in the Harmonious Development of Adolescents"; "Immigration Matters: Building Humanity Within a Fractured Immigration Landscape"; and "Decriminalizing Mental Illness: Empathetic Approaches to Mental Health Supports." These 4 panels, symposium discussions, and the keynote address yielded 18 recommendations. The recommendations from the panels and the symposium underscore the power and leverage that AIs possess to identify and implement approaches to address community violence.

Incidence of work related musculoskeletal disorders in medical dosimetry.

Musculoskeletal disorders (MSDs) account for almost 70 million physician office visits per year in the United States and are the most common workplace injuries. These are conditions involving the nerves, tendons, muscles, and supporting structures of the body. Previous studies have concluded that computer users are at high risk of developing work-related musculoskeletal disorders (WRMSDs). As computer users, medical dosimetrists are at risk of developing WRMSDs, yet there is a lack of information regarding the incidence of WRMSDs among medical dosimetrists. The purpose of this study was to determine the incidence of WRMSDs and variables of workstation ergonomics that contribute to the increased risk of WRMSDs in medical dosimetrists. A Qualtrics survey was created to support the 3 research questions guiding this study. The survey was distributed to 2,646 full members of the American Association of Medical Dosimetrists (AAMD), which included only certified medical dosimetrists (CMDs), via email. The distribution of email surveys sent through the AAMD email distribution list resulted in 988 emails opened, for a contact rate of 37% (988/2646). One hundred sixty-four responses were recorded yielding a completion rate of 17% (164/988). Fifty-five percent (90/163) of participants responded that they have experienced WRMSDs. Forty-four percent (289/652) of responses indicated WRMSDs have a slight or moderate interference on work. Sixty-two percent (94/152) of participants felt that their workstations were not ergonomically designed; even greater 68% (104/153) did not feel their workstations were designed for their individually needs. Of those respondents 64% (98/152) would like to see further adaptations made to their workspaces.

Approaching the COVID-19 Pandemic Response With a Health Equity Lens: A Framework for Academic Health Systems.

Racially and ethnically diverse and socioeconomically disadvantaged communities have historically been disproportionately affected by disasters and public health emergencies in the United States. The U.S. Department of Health and Human Services' Office of Minority Health established the National Consensus Panel on Emergency Preparedness and Cultural Diversity to provide guidance to agencies and organizations on developing effective strategies to advance emergency preparedness and eliminate disparities among racially and ethnically diverse communities during these crises. Adopting the National Consensus Panel recommendations, the Johns Hopkins Medicine Office of Diversity, Inclusion, and Health Equity; Language Services; and academic-community partnerships used existing health equity resources and expertise to develop an operational framework to support the organization's COVID-19 response and to provide a framework of health equity initiatives for other academic medical centers. This operational framework addressed policies to support health equity patient care and clinical operations, accessible COVID-19 communication, and staff and community support and engagement, which also supported the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. Johns Hopkins Medicine identified expanded recommendations for addressing institutional policy making and capacity building, including unconscious bias training for resource allocation teams and staff training in accurate race, ethnicity, and language data collection, that should be considered in future updates to the National Consensus Panel's recommendations.

A Novel Protocol for Reducing Intensive Care Utilization After Craniotomy.

BACKGROUND: There is a growing body of evidence suggesting not all craniotomy patients require postoperative intensive care. OBJECTIVE: To devise and implement a standardized protocol for craniotomy patients eligible to transition directly from the operating room to the ward-the Non-Intensive CarE (NICE) protocol. METHODS: We preoperatively identified patients undergoing elective craniotomy for simple neurosurgical procedures with age <65 yr and American Society of Anesthesiologists (ASA) class of 1, 2 or 3. Postoperative eligibility was confirmed by the surgical and anesthesia teams. Upon arrival to the ward, patients were staffed with a neuroscience nurse for hourly neurological examinations for the first 8 h. Patient demographics, clinical characteristics, and outcomes were prospectively collected to evaluate the NICE protocol. RESULTS: From February 2018 to 2019, 63 patients were included in the NICE protocol with a median age of 46 yr and 65% female predominance. Of the operations performed, 38.1% were microvascular decompressions, 31.7% were craniotomy for tumor, 15.9% were cavernous malformation resections, and 14.3% were Chiari decompressions. No patients required transfer to the intensive care unit (ICU). Median length of stay was 2 d. There was an 11.1% overall readmission rate within the median follow-up period of 48 d. Three patients (4.8%) required reoperation at time of readmission within the follow-up period (1 postoperative subdural hematoma, 2 cerebrospinal fluid leak repair). None of these complications could have been identified with a postoperative ICU stay. CONCLUSION: In our pilot trial of the NICE protocol, no patients required postoperative transfer to the ICU.

Quantification of Neutrophil Extracellular Traps Isolated From Mouse Tissues.

One of the most intriguing functions of neutrophils is the production of neutrophil extracellular traps (NETs), which are formed when neutrophils decondense their internal DNA and extrude it along with cytotoxic proteins in a web-like structure. This process allows neutrophils to trap and kill pathogens, and is also associated with multiple hematological and autoimmune conditions. Due to their rapid degradation, there are many challenges in accurately and specifically detecting and quantifying NETs. Microscopy is the gold standard for NET detection, but is not optimal for large-scale screening. Furthermore, methods relying on detection of free DNA or on flow cytometry-based examination of NET-associated markers can be nonspecific, time-consuming, and expensive. Here, we describe an innovative, quick, specific, and inexpensive conventional flow cytometry method for detecting neutrophils on the verge of forming NETs. These methods utilize pulse-shaped analysis (PulSA) to distinguish resting neutrophils from those with decondensed DNA, a prerequisite for NET formation. An increase in DNA-diffuse neutrophils is found in cell populations after exposure to NET-inducing stimuli, consistent with the DNA decondensation expected during neutrophil NET formation. These populations are only observed in granulocytes, validating the specificity of this method. We describe protocols optimized for neutrophils retrieved from mouse blood, spleen, and bone marrow. The relative speed and simplicity of the method described here makes it a useful tool for detecting NET formation in large-scale experiments. © 2020 Wiley Periodicals LLC. Basic Protocol: Detection of nuclear decondensation in neutrophils from stimulated murine bone marrow Alternate Protocol 1: Detection of nuclear decondensation in neutrophils from splenocytes Alternate Protocol 2: Detection of nuclear decondensation in neutrophils from blood Support Protocol 1: Cryopreservation and defrosting of samples Support Protocol 2: Paraformaldehyde fixation of samples.

The Emerging Role of Neutrophil Granulocytes in Multiple Sclerosis.

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system with a strong autoimmune, neurodegenerative, and neuroinflammatory component. Most of the common disease modifying treatments (DMTs) for MS modulate the immune response targeting disease associated T and B cells and while none directly target neutrophils, several DMTs do impact their abundance or function. The role of neutrophils in MS remains unknown and research is ongoing to better understand the phenotype, function, and contribution of neutrophils to both disease onset and stage of disease. Here we summarize the current state of knowledge of neutrophils and their function in MS, including in the rodent based MS model, and we discuss the potential effects of current treatments on these functions. We propose that neutrophils are likely to participate in MS pathogenesis and their abundance and function warrant monitoring in MS.

Nitrogen fate in a subtropical mangrove swamp: Potential association with seawater-groundwater exchange.

Coastal mangrove swamps play an important role in nutrient cycling at the land-ocean boundary. However, little is known about the role of periodic seawater-groundwater exchange in the nitrogen cycling processes. Seawater-groundwater exchange rates and inorganic nitrogen concentrations were investigated along a shore-perpendicular intertidal transect in Daya Bay, China. The intertidal transect comprises three hydrologic subzones (tidal creek, mangrove and bare mudflat zones), each with different physicochemical characteristics. Salinity and hydraulic head measurements taken along the transect were used to estimate the exchange rates between seawater and groundwater over a spring-neap tidal cycle. Results showed that the maximum seawater-groundwater exchange occurred within the tidal creek zone, which facilitated high-oxygen seawater infiltration and subsequent nitrification. In contrast, the lowest exchange rate found in the mangrove zone caused over-loading of organic matter and longer groundwater residence times. This created an anoxic environment conducive to nitrogen loss through the anammox and denitrification processes. Potential oxidation rates of ammonia and nitrite were measured by the rapid and high-throughput method and rates of denitrification and anammox were measured by the modified membrane inlet mass spectrometry (MIMS) with isotope pairing, respectively. In the whole transect, denitrification accounted for 90% of the total nitrogen loss, and anammox accounted for the remaining 10%. The average nitrogen removal rate was about 2.07g per day per cubic meter of mangrove sediments.

Glutamate-Glutamine Transfer and Chronic Stress-Induced Sex Differences in Cocaine Responses.

Substance use disorders (SUD) often co-occur with other mental disorders such as major depression (MD). Our previous findings revealed sex-dependent changes in extracellular levels of glutamate (Glu) and glutamine (Gln) in the nucleus accumbens (NAc) in Long-Evans rats that were exposed to 21 days of chronic social defeat stress (CSDS), which models MD. The current study investigated the role of a Gln transporter called sodium-coupled neutral amino acid transporter subtype 1/2 (SNAT 1/2), phosphate-activated glutaminase (PAG), and astrocytic glutamate transporter-1 (GLT-1) on CSDS animals exposed to cocaine. Before cocaine exposure, CSDS males already showed decreased levels of SNAT 1/2 in the NAc and prefrontal cortex (PFC) compared to non-CSDS controls. The reduction in SNAT 1/2 levels was associated with an increase in Gln localization in the mitochondrial outer membrane in accumbal glutamatergic nerve terminals projecting from the PFC. CSDS females showed increased GLT-1 levels in the NAc and PFC compared to non-CSDS controls. Both acute and repeated cocaine exposure attenuated locomotor responses in CSDS males but increased those in CSDS females. Cocaine reduced SNAT 1/2 levels in the NAc but increased them in the PFC in CSDS males. Additionally, both PAG and GLT-1 levels were increased in the PFC in CSDS males. On the other hand, cocaine reduced SNAT 1/2 and GLT-1 levels in the NAc and PFC in CSDS females. Our results show that CSDS altered locomotor responses upon cocaine exposure in a sex-dependent manner that may be mediated by molecules associated with the Glu-Gln transfer.