Characterisation of HBV and co-infection with HDV and HIV through spatial transcriptomics.

Background and aims: The intrahepatic processes associated with chronic hepatitis B (CHB), especially in the context of hepatitis delta virus (HDV) and HIV co-infection, require a better understanding. Spatial transcriptomics can provide new insights into the complex intrahepatic biological processes, guiding new personalised treatments. Our aim is to evaluate this method characterising the intrahepatic transcriptional landscape, cellular composition and biological pathways in liver biopsy samples from patients with hepatitis B virus (HBV) and HDV or HIV co-infection. Method: The NanoString GeoMx digital spatial profiling platform was employed to assess expression of HBV surface antigen and CD45 in formalin-fixed paraffin-embedded (FFPE) biopsies from three treatment-naïve patients with chronic HBV and HDV or HIV co-infection. The GeoMx Human Whole Transcriptome Atlas assay quantified the expression of genes enriched in specific regions of interest (ROIs). Cell type proportions within ROIs were deconvoluted using a training matrix from the human liver cell atlas. A weighted gene correlation network analysis evaluated transcriptomic signatures across sampled regions. Results: Spatially discrete transcriptomic signatures and distinct biological pathways were associated with HBV infection/disease status and immune responses. Shared features including 'cytotoxicity' and 'B cell receptor signalling' were consistent across patients, suggesting common elements alongside individual traits. HDV/HBV co-infection exhibited upregulated genes linked to apoptosis and immune cell recruitment, whereas HIV/HBV co-infection featured genes related to interferon response regulation. Varied cellular characteristics and immune cell populations, with an abundance of γδT cells in the HDV/HBV sample, were observed within analysed regions. Transcriptional differences in hepatocyte function suggest disrupted metabolic processes in HDV/HBV co-infection potentially impacting disease progression. Conclusion: This proof-of-principle study shows the value of this platform in investigating the complex immune landscape, highlighting relevant host pathways to disease pathogenesis.

Multiscale topology classifies cells in subcellular spatial transcriptomics.

Spatial transcriptomics measures in situ gene expression at millions of locations within a tissue1, hitherto with some trade-off between transcriptome depth, spatial resolution and sample size2. Although integration of image-based segmentation has enabled impactful work in this context, it is limited by imaging quality and tissue heterogeneity. By contrast, recent array-based technologies offer the ability to measure the entire transcriptome at subcellular resolution across large samples3-6. Presently, there exist no approaches for cell type identification that directly leverage this information to annotate individual cells. Here we propose a multiscale approach to automatically classify cell types at this subcellular level, using both transcriptomic information and spatial context. We showcase this on both targeted and whole-transcriptome spatial platforms, improving cell classification and morphology for human kidney tissue and pinpointing individual sparsely distributed renal mouse immune cells without reliance on image data. By integrating these predictions into a topological pipeline based on multiparameter persistent homology7-9, we identify cell spatial relationships characteristic of a mouse model of lupus nephritis, which we validate experimentally by immunofluorescence. The proposed framework readily generalizes to new platforms, providing a comprehensive pipeline bridging different levels of biological organization from genes through to tissues.

Late Treatment With Autologous Expanded Regulatory T-cell Therapy After Alemtuzumab Induction Is Safe and Facilitates Immunosuppression Minimization in Living Donor Renal Transplantation.

BACKGROUND: The TWO Study (Transplantation Without Overimmunosuppression) aimed to investigate a novel approach to regulatory T-cell (Treg) therapy in renal transplant patients, using a delayed infusion protocol at 6 mo posttransplant to promote a Treg-skewed lymphocyte repopulation after alemtuzumab induction. We hypothesized that this would allow safe weaning of immunosuppression to tacrolimus alone. The COVID-19 pandemic led to the suspension of alemtuzumab use, and therefore, we report the unique cohort of 7 patients who underwent the original randomized controlled trial protocol. This study presents a unique insight into Treg therapy combined with alemtuzumab and is therefore an important proof of concept for studies in other diseases that are considering lymphodepletion. METHODS: Living donor kidney transplant recipients were randomized to receive autologous polyclonal Treg at week 26 posttransplantation, coupled with weaning doses of tacrolimus, (Treg therapy arm) or standard immunosuppression alone (tacrolimus and mycophenolate mofetil). Primary outcomes were patient survival and rejection-free survival. RESULTS: Successful cell manufacturing and cryopreservation until the 6-mo infusion were achieved. Patient and transplant survival was 100%. Acute rejection-free survival was 100% in the Treg-treated group at 18 mo after transplantation. Although alemtuzumab caused a profound depletion of all lymphocytes, including Treg, after cell therapy infusion, there was a transient increase in peripheral Treg numbers. CONCLUSIONS: The study establishes that delayed autologous Treg therapy is both feasible and safe, even 12 mo after cell production. The findings present a new treatment protocol for Treg therapy, potentially expanding its applications to other indications.

Determining the Impact of Hurricane Dorian and the Covid-19 Pandemic on Moral Distress in Emergency Medical Providers at the Rand Memorial Hospital: Moral distress in emergency medical personnel.

OBJECTIVES: The aim of this work was to determine the impact of Moral Distress (MD) in emergency physicians, nurses, and emergency medical service staff at the Rand Memorial Hospital (RMH) in the Bahamas, and the impact of Hurricane Dorian and the COVID-19 pandemic on Moral Distress. METHOD: A cross-sectional study utilizing a 3-part survey, which collected sociodemographic information, Hurricane Dorian and COVID-19 experiences, as well as responses to a validated modified Moral Distress Scale (MDS). RESULTS: Participants with 2 negatively impactful experiences from COVID-19 had statistically significantly increased MD compared to participants with only 1 negatively impactful experience (40.4 vs. 23.6, P = 0.014). Losing a loved one due to COVID-19 was associated with significantly decreased MD (B = - 0.42, 95% CI -19.70 to -0.88, P = 0.03). Losing a loved one due to Hurricane Dorian had a non-statistically significant trend towards higher MD scores (B = 0.34, 95% CI -1.23 to 28.75, P = 0.07). CONCLUSION: The emergency medical staff at the RMH reported having mild - moderate MD. This is one of the first studies to look at the impact of concurrent disasters on MD in emergency medical providers in the Bahamas.

Banff 2022 Vascularized Composite Allotransplantation Meeting Report: Diagnostic criteria for vascular changes.

As more data become available, the Banff 2007 working classification of skin-containing vascularized composite allograft (VCA) pathology is expected to evolve and develop. This report represents the Banff VCA Working Group's consensus on the first revision of the 2007 scoring system. Prior to the 2022 Banff-CanXadian Society of Transplantation Joint Meeting, 83 clinicians and/or researchers were invited to a virtual meeting to discuss whether the 2007 Banff VCA system called for a revision. Unanimously, it was determined that the vascular changes were to be included in the first revision. Subsequently, 2 international online surveys, each followed by virtual discussions, were launched. The goals were (1) to identify which changes define severe rejection, (2) to grade their importance in the evaluation of severe rejection, and (3) to identify emerging criteria to diagnose rejection. A final hybrid (in-person and virtual) discussion at the Banff/Canadian Society of Transplantation Joint Meeting finalized the terminology, the definition, a scoring system, and a reporting system of the vascular changes. This proposal represents an international consensus on this topic and establishes the first revision of the Banff 2007 working classification of skin-containing vascularized composite allograft pathology.

Socially Mediated Shift in Neural Circuits Activation Regulated by Synergistic Neuromodulatory Signaling.

Animals exhibit context-dependent behavioral decisions that are mediated by specific motor circuits. In social species these decisions are often influenced by social status. Although social status-dependent neural plasticity of motor circuits has been investigated in vertebrates, little is known of how cellular plasticity translates into differences in motor activity. Here, we used zebrafish (Danio rerio) as a model organism to examine how social dominance influences the activation of swimming and the Mauthner-mediated startle escape behaviors. We show that the status-dependent shift in behavior patterns whereby dominants increase swimming and reduce sensitivity of startle escape while subordinates reduce their swimming and increase startle sensitivity is regulated by the synergistic interactions of dopaminergic, glycinergic, and GABAergic inputs to shift the balance of activation of the underlying motor circuits. This shift is driven by socially induced differences in expression of dopaminergic receptor type 1b (Drd1b) on glycinergic neurons and dopamine (DA) reuptake transporter (DAT). Second, we show that GABAergic input onto glycinergic neurons is strengthened in subordinates compared with dominants. Complementary neurocomputational modeling of the empirical results show that drd1b functions as molecular regulator to facilitate the shift between excitatory and inhibitory pathways. The results illustrate how reconfiguration in network dynamics serves as an adaptive strategy to cope with changes in social environment and are likely conserved and applicable to other social species.

Single cell spatial analysis reveals inflammatory foci of immature neutrophil and CD8 T cells in COVID-19 lungs.

Single cell spatial interrogation of the immune-structural interactions in COVID -19 lungs is challenging, mainly because of the marked cellular infiltrate and architecturally distorted microstructure. To address this, we develop a suite of mathematical tools to search for statistically significant co-locations amongst immune and structural cells identified using 37-plex imaging mass cytometry. This unbiased method reveals a cellular map interleaved with an inflammatory network of immature neutrophils, cytotoxic CD8 T cells, megakaryocytes and monocytes co-located with regenerating alveolar progenitors and endothelium. Of note, a highly active cluster of immature neutrophils and CD8 T cells, is found spatially linked with alveolar progenitor cells, and temporally with the diffuse alveolar damage stage. These findings offer further insights into how immune cells interact in the lungs of severe COVID-19 disease. We provide our pipeline [Spatial Omics Oxford Pipeline (SpOOx)] and visual-analytical tool, Multi-Dimensional Viewer (MDV) software, as a resource for spatial analysis.

Syndromic Surveillance Implementation During Disaster Events.

INTRODUCTION: Disease surveillance is an integral part of public health. These systems monitor disease trends and detect outbreaks, whereas they should be evaluated for efficacy. The United States Centres for Disease Control and Prevention publish Guidelines for Evaluating Surveillance Systems to encourage efficient and effective use of public health surveillance that are accepted worldwide. OBJECTIVE: This study reviews syndromic surveillance during natural and man-made disasters internationally. It aims to (1) review the performance of syndromic surveillance via pre-specified attributes during disaster and to (2) understand its strengths and limitations. METHODS: PubMed was systematically searched for the articles assessing syndromic surveillance during a disaster. A narrative review was carried out based on those articles. Updated Guidelines for Evaluating Public Health Surveillance Systems were used to review performance of systems. RESULTS: 5,059 studies from PubMed were evaluated, and 16 met inclusion criteria. The majority of these studies considered the implementation of syndromic surveillance useable during disaster events. Studies described systems giving relevant and timely information. Simplicity and timeliness were the most highlighted attributes. CONCLUSION: Syndromic surveillance is simple, flexible, useful and usable during a disaster. Timely data can be obtained, but the quality of this type of data is sensitive to incomplete and erroneous reporting; because of this, a standardized approach is necessary to optimize these systems.

Combating the Opioid Crisis and Its National Security Threat Through CReDO: A Multidisciplinary Solution With Disaster Medicine Implications.

For the first time in history, the United States surpassed 100 000 overdose-related deaths in a 12-month period, driven by synthetic opioids such as fentanyl. Also, for the first time, potential chemical weapons are readily available on the streets and the dark web. Opioids represent a rare trifecta, used for licit pain management, as an illicit drug of abuse, and with potential use as a weapon of terror. Community-based Response to Drug Overdose (CReDO) is an initiative to unite agencies, disciplines, government, and private partners in 1 coordinated opioid emergencies response plan under nationwide standards, and can be integrated into the disaster medicine discipline due to the risk of mass casualty incidents involving fentanyl or its derivatives. Attention to the opioid crisis through CReDO will save lives by promoting information sharing between disciplines, shortened response time to overdose clusters, community collaboration to identify criminal distribution networks, and holistic approaches to addiction.

Factors associated with international humanitarian aid appeal for disasters from 1995 to 2015: A retrospective database study.

INTRODUCTION: International humanitarian aid during disasters should be needs-based and coordinated in response to appeals from affected governments. We identify disaster and population factors associated with international aid appeal during disasters and hence guide preparation by international humanitarian aid providers. METHODS: In this retrospective database analysis, we searched the Emergency Events Database for all disasters from 1995 to 2015. Disasters with and without international aid appeals were compared by location, duration, type of disaster, deaths, number of people affected, and total estimated damage. Logistic regression was used to examine the association of each factor with international aid appeal. RESULTS: Of 13,961 disasters recorded from 1995 to 2015, 168 (1.2%) involved international aid appeals. Aid appeals were more likely to be triggered by disasters which killed more people (OR 1.29 [95% confidence interval (CI) 1.02-1.64] log10 persons), affected more people (OR 1.85 [95%CI 1.57-2.18] / log10 persons), and occurred in Africa (OR 1.67 [95%CI 1.06-2.62). Earthquakes (OR 4.07 [95%CI 2.16-7.67]), volcanic activity (OR 6.23 [95%CI 2.50-15.53]), and insect infestations (OR 12.14 [95%CI 3.05-48.35]) were more likely to trigger international aid appeals. International aid appeals were less likely to be triggered by disasters which occurred in Asia (OR 0.46 [95%CI 0.29-0.73]) and which were transport accidents (OR 0.12 [95%CI 0.02-0.89]). CONCLUSION: International aid appeal during disasters was associated with greater magnitude of damage, disasters in Africa, and specific types of disasters such as earthquakes, volcanic activity, and insect infestations. Humanitarian aid providers can focus preparation on these identified factors.

Research and Innovation in Organ Donation: Recommendations From an International Consensus Forum.

This report provides recommendations from the Research and Innovation domain as part of the International Donation and Transplantation Legislative and Policy Forum (hereafter the Forum) to provide expert guidance on the structure of an ideal organ and tissue donation and transplantation system. The recommendations focus on deceased donation research and are intended for clinicians, investigators, decision-makers, and patient, family, and donor (PFD) partners involved in the field. Methods: We identified topics impacting donation research through consensus using nominal group technique. Members performed narrative reviews and synthesized current knowledge on each topic, which included academic articles, policy documents, and gray literature. Using the nominal group technique, committee members discussed significant findings, which provided evidence for our recommendations. The Forum's scientific committee then vetted recommendations. Results: We developed 16 recommendations in 3 key areas to provide stakeholders guidance in developing a robust deceased donor research framework. These include PFD and public involvement in research; donor, surrogate, and recipient consent within a research ethics framework; and data management. We highlight the importance of PFD and public partner involvement in research, we define the minimum ethical requirements for the protection of donors and recipients of both target and nontarget organ recipients, and we recommend the creation of a centrally administered donor research oversight committee, a single specialist institutional review board, and a research oversight body to facilitate coordination and ethical oversight of organ donor intervention research. Conclusions: Our recommendations provide a roadmap for developing and implementing an ethical deceased donation research framework that continually builds public trust. Although these recommendations can be applied to jurisdictions developing or reforming their organ and tissue donation and transplantation system, stakeholders are encouraged to collaborate and respond to their specific jurisdictional needs related to organ and tissue shortages.

Computerized adaptive testing for the patient evaluation measure (PEM) in patients undergoing cubital tunnel syndrome surgery.

In outcome measures, item response theory (IRT) validation can deliver interval-scaled high-quality measurement that can be harnessed using computerized adaptive tests (CATs) to pose fewer questions to patients. We aimed to develop a CAT by developing an IRT model for the Patient Evaluation Measure (PEM) for patients undergoing cubital tunnel syndrome (CuTS) surgery. Nine hundred and seventy-nine completed PEM responses of patients with CuTS in the United Kingdom Hand Registry were used to develop and calibrate the CAT. Its performance was then evaluated in a simulated cohort of 1000 patients. The CAT reduced the original PEM length from ten to a median of two questions (range two to four), while preserving a high level of precision (median standard error of measurement of 0.27). The mean error between the CAT score and full-length score was 0.08%. A Bland-Altman analysis showed good agreement with no signs of bias. The CAT version of the PEM can substantially reduce patient burden while enhancing construct validity by harnessing IRT for patients undergoing CuTS surgery.

Direct correction of haemoglobin E ß-thalassaemia using base editors.

Haemoglobin E (HbE) ß-thalassaemia causes approximately 50% of all severe thalassaemia worldwide; equating to around 30,000 births per year. HbE ß-thalassaemia is due to a point mutation in codon 26 of the human HBB gene on one allele (GAG; glutamatic acid → AAG; lysine, E26K), and any mutation causing severe ß-thalassaemia on the other. When inherited together in compound heterozygosity these mutations can cause a severe thalassaemic phenotype. However, if only one allele is mutated individuals are carriers for the respective mutation and have an asymptomatic phenotype (ß-thalassaemia trait). Here we describe a base editing strategy which corrects the HbE mutation either to wildtype (WT) or a normal variant haemoglobin (E26G) known as Hb Aubenas and thereby recreates the asymptomatic trait phenotype. We have achieved editing efficiencies in excess of 90% in primary human CD34 + cells. We demonstrate editing of long-term repopulating haematopoietic stem cells (LT-HSCs) using serial xenotransplantation in NSG mice. We have profiled the off-target effects using a combination of circularization for in vitro reporting of cleavage effects by sequencing (CIRCLE-seq) and deep targeted capture and have developed machine-learning based methods to predict functional effects of candidate off-target mutations.

An Immune Atlas of T Cells in Transplant Rejection: Pathways and Therapeutic Opportunities.

Short-term outcomes in allotransplantation are excellent due to technical and pharmacological advances; however, improvement in long-term outcomes has been limited. Recurrent episodes of acute cellular rejection, a primarily T cell-mediated response to transplanted tissue, have been implicated in the development of chronic allograft dysfunction and loss. Although it is well established that acute cellular rejection is primarily a CD4 + and CD8 + T cell mediated response, significant heterogeneity exists within these cell compartments. During immune responses, naïve CD4 + T cells are activated and subsequently differentiate into specific T helper subsets under the influence of the local cytokine milieu. These subsets have distinct phenotypic and functional characteristics, with reported differences in their contribution to rejection responses specifically. Of particular relevance are the regulatory subsets and their potential to promote tolerance of allografts. Unraveling the specific contributions of these cell subsets in the context of transplantation is complex, but may reveal new avenues of therapeutic intervention for the prevention of rejection.

Opportunities for High-plex Spatial Transcriptomics in Solid Organ Transplantation.

The last 5 y have seen the development and widespread adoption of high-plex spatial transcriptomic technology. This technique detects and quantifies mRNA transcripts in situ, meaning that transcriptomic signatures can be sampled from specific cells, structures, lesions, or anatomical regions while conserving the physical relationships that exist within complex tissues. These methods now frequently implement next-generation sequencing, enabling the simultaneous measurement of many targets, up to and including the whole mRNA transcriptome. To date, spatial transcriptomics has been foremost used in the fields of neuroscience and oncology, but there is potential for its use in transplantation sciences. Transplantation has a clear dependence on biopsies for diagnosis, monitoring, and research. Transplant patients represent a unique cohort with multiple organs of interest, clinical courses, demographics, and immunosuppressive regimens. Obtaining high complexity data on the disease processes underlying rejection, tolerance, infection, malignancy, and injury could identify new opportunities for therapeutic intervention and biomarker identification. In this review, we discuss currently available spatial transcriptomic technologies and how they can be applied to transplantation.

Barriers to Treg therapy in Europe: From production to regulation.

There has been an increased interest in cell based therapies for a range of medical conditions in the last decade. This explosion in novel therapeutics research has led to the development of legislation specifically focused on cell and gene based therapies. In Europe, the European medicines agency (EMA) designates any medicines for human use which are based on genes, tissues, or cells as advanced therapy medicinal products or advanced therapy medicinal products (ATMPs). In this article we discuss the hurdles to widespread adoption of ATMPs in Europe, with a focus on regulatory T cells (Tregs). There are numerous barriers which must be overcome before mainstream adoption of Treg therapy becomes a reality. The source of the cells, whether to use autologous or allogenic cells, and the methods through which they are isolated and expanded, must all meet strict good manufacturing practice (GMP) standards to allow use of the products in humans. GMP compliance is costly, with the equipment and reagents providing a significant cost barrier and requiring specialized facilities and personnel. Conforming to the regulations set centrally by the EMA is difficult, and the different interpretations of the regulations across the various member states further complicates the regulatory approval process. The end products then require a complex and robust distribution network to ensure timely delivery of potentially life saving treatments to patients. In a European market whose logistics networks have been hammered by COVID and Brexit, ensuring rapid and reliable delivery systems is a more complex task than ever. In this article we will examine the impact of these barriers on the development and adoption of Tregs in Europe, and potential approaches which could facilitate more widespread use of Tregs, instead of its current concentration in a few very specialized centers.

Terrorism-Related Attacks in East Asia from 1970 through 2020.

AIM: This study aims to analyze and describe terrorism-related attacks in East Asia from 1970 through 2020. BACKGROUND: East Asia consists of South Korea, North Korea, Singapore, Hong Kong, China, Japan, Taiwan, and Macao. According to the Global Terrorism Index (GTI) 2022, the impact of terrorism in East Asia is very low. However, the assassination of former Japanese Prime Minister Shinzo Abe on July 8, 2022 demonstrates that East Asia is not safe from terrorist attacks. This descriptive analysis of terrorist attacks in East Asia will help first responders, Emergency Medical Services (EMS), hospital-based medical providers, and policymakers establish a more refined hazard vulnerability assessment (HVA) framework and develop a Counter-Terrorism Medicine (CTM) mitigation, preparedness, response, and recovery plan. METHODS: This is a descriptive observational study drawing data from the Global Terrorism Database (GTD) from January 1, 1970 through December 31, 2020. Epidemiology outcomes included primary weapon type, primary target type, the country where the incident occurred, and the number of total deaths and injured collected. Data from 2021 were not yet available at the time of this study. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. RESULTS: There were 779 terrorism-related events in East Asia from 1970 through 2020. In total, the attacks resulted in 1,123 deaths and 9,061 persons injured. The greatest number of attacks (371; 47.63%) occurred in Japan and the second most occurred in China (268; 34.4%). Explosives were the most used primary weapon type (308; 39.54%) in the region, followed by incendiary devices (260; 33.38%). Terrorist attacks drastically diminished from their peak of 92 in 1990, but there were additional peaks of 88 in 1996, 18 in 2000, 20 in 2008, and 36 attacks in 2014. CONCLUSIONS: A total of 779 terrorist attacks occurred from 1970 through 2020 in East Asia, resulting in 1,123 deaths and 9,061 injuries. Of those, 82.03% attacks occurred in Japan and China. Terrorist attacks drastically diminished since their peak in 1996, but there is an overall uptrend in attacks since 1999.