Pharmacist Screening for Risk of Osteoporosis in Elderly Veterans.

OBJECTIVE: To assess the effect of pharmacist screening for osteoporosis risk with increased bone mineral density (BMD) testing. DESIGN: Prospective, quasi-experiment. SETTING: Veterans Affairs medical center Community Living Centers (CLC), home-based primary care, and outpatient geriatric clinic. PARTICIPANTS: Patients with a routine pharmacist interaction were included. Exclusion criteria included hospice, dialysis, and respite care. INTERVENTIONS: Risk assessment with recommendations communicated by progress notes to consider BMD testing or interventions in the settings described. A second phase of the project was conducted in CLC patients to evaluate the effect of an interdisciplinary team with the inclusion of a physician to assess clinical appropriateness of interventions. MAIN OUTCOME MEASURE(S): Proportion of patients meeting guidelines for BMD testing and change in proportion of patients with BMD testing ordered after intervention. Secondary measures included response to recommendations and initiation of osteoporosis pharmacotherapies. RESULTS: A total of 219 patients were included in the first phase of the project, with 120 (54.8%) identified as candidates for BMD testing with recommendations documented. Of this population, 5 patients without previous dual-energy absorptiometry results had BMD testing ordered (P = 0.6). In the second phase, 22 high-risk patients in the CLC met criteria for BMD testing, with 14 determined to have reasons for not pursuing BMD testing. CONCLUSION: Most patients in the settings described met guidelines for BMD testing. Pharmacist recommendations to consider BMD testing did not increase the rate of testing. Including a physician on an interdisciplinary team appeared to help determine appropriateness and improve the rate of testing, though the increase in testing was not statistically significant.

Gene expression signature for biliary atresia and a role for interleukin-8 in pathogenesis of experimental disease.

UNLABELLED: Biliary atresia (BA) is a progressive fibroinflammatory obstruction of extrahepatic bile ducts that presents as neonatal cholestasis. Due to the overlap in clinical, biochemical, and histological features with other causes of cholestasis, the diagnosis requires an intraoperative cholangiogram. Thus, we determined whether diseased livers express a gene expression signature unique to BA. Applying stringent statistical analysis to a genome-wide liver expression platform of 64 infants with BA at the time of diagnosis, 14 age-appropriate subjects with intrahepatic cholestasis as diseased controls and seven normal controls, we identified 15 genes uniquely expressed in BA with an accuracy of 92.3%. Among these genes, IL8 and LAMC2 were sufficient to classify subjects with BA distinctly from diseased controls with an area under the curve of 0.934 (95% confidence interval [CI]: 0.84-1.03), sensitivity of 96.9%, and specificity of 85.7% using their combined first principal component. Direct measurement of interleukin (IL)8 protein in the serum, however, was not different between the two groups. To investigate whether the liver-restricted increase in IL8 was relevant to disease pathogenesis, we inactivated the signaling of IL8 homologs by genetic targeting of the Cxcr2 receptor in a murine model of experimental BA. Disruption of Cxcr2 shortened the duration of cholestasis, decreased the incidence of bile duct obstruction, and improved survival above wild-type neonatal mice. CONCLUSION: The hepatic expression of IL8 and LAMC2 has high sensitivity for BA at diagnosis and may serve as a biomarker of disease, with an important role for the IL8 signaling in experimental BA.

Identification of intramural epithelial networks linked to peribiliary glands that express progenitor cell markers and proliferate after injury in mice.

UNLABELLED: Peribiliary glands (PBGs) are clusters of epithelial cells residing in the submucosal compartment of extrahepatic bile ducts (EHBDs). Though their function is largely undefined, they may represent a stem cell niche. Here, we hypothesized that PBGs are populated by mature and undifferentiated cells capable of proliferation in pathological states. To address this hypothesis, we developed a novel whole-mount immunostaining assay that preserves the anatomical integrity of EHBDs coupled with confocal microscopy and found that PBGs populate the entire length of the extrahepatic biliary tract, except the gallbladder. Notably, in addition to the typical position of PBGs adjacent to the duct mucosa, PBGs elongate and form intricate intramural epithelial networks that communicate between different segments of the bile duct mucosa. Network formation begins where the cystic duct combines with hepatic ducts to form the common bile duct (CBD) and continues along the CBD. Cells of PBGs and the peribiliary network stain positively for α-tubulin, mucins, and chromogranin A, as well as for endoderm transcription factors SRY (sex determining region Y)-box 17 and pancreatic and duodenal homeobox 1, and proliferate robustly subsequent to duct injury induced by virus infection and bile duct ligation. CONCLUSION: PBGs form elaborate epithelial networks within the walls of EHBDs, contain cells of mature and immature phenotypes, and proliferate in response to bile duct injury. The anatomical organization of the epithelial network in tubules and the link with PBGs support an expanded cellular reservoir with the potential to restore the integrity and function of the bile duct mucosa in diseased states.

Subcutaneous thrombotic vasculopathy syndrome: an ominous condition reminiscent of calciphylaxis: calciphylaxis sine calcifications?

Ischemic skin necrosis can be a cause of severe morbidity and mortality. It can be due to a number of systemic conditions such as (1) thrombotic vasculopathy syndromes, (2) calciphylaxis, (3) septic or cholesterol emboli, and (4) cutaneous vasculitis. We present 3 patients with a clinicopathological syndrome consisting of ischemic skin necrosis associated with histological pattern of subcutaneous thrombotic vasculopathy-extensive microvascular thrombosis confined to small vessels and capillaries of the subcutaneous tissue. All 3 patients were obese and had severe pre-existing medical conditions. Skin biopsies showed intravascular thrombosis involving small arterioles and capillaries of the subcutaneous tissue. Distribution of vascular involvement by thrombotic process was similar to that observed in calciphylaxis, but calcifications were not observed. Two patients died within 3 months of diagnosis. One patient died 2 years after the presentation. Review of 15 biopsies of calciphylaxis revealed areas of subcutaneous thrombotic vasculopathy in 11 cases (73%). Our study shows that subcutaneous thrombotic vasculopathy syndrome is a potentially lethal condition showing overlapping features between thrombotic vasculopathy syndromes and calciphylaxis. Clinicopathological analysis suggests that it may be a rare variant of calciphylaxis sine calcifications or an early prodromal stage of calciphylaxis. This conclusion is in keeping with increasing appreciation of importance of thrombosis and vascular injury in calciphylaxis.

Decoupling functionalization from sensor array assembly using detachable cantilevers.

Cantilevers are useful as sensor devices with high sensitivity and have shown great promise for dense, multianalyte arrays. One of the difficulties has been the fabrication of multianalyte arrays that are capable of the simultaneous detection of a wide range of chemical and biological species. Functionalization procedures for one class of analytes are often incompatible with other classes and cross contamination is a significant concern when ink-jet deposition processes are used. In this study, we used surface micromachined cantilevers designed and fabricated using Sandia National Laboratories SUMMiT V MEMS process. The cantilevers are fabricated with a base that can be detached from the parent substrate after functionalization and mounted into a daughter array. We have utilized an IBM-fabricated 8-cantilever array chip as our daughter substrate due to its compatibility with a Scentris 8-cantilever readout system. Our initial work demonstrates that this is a feasible procedure for decoupling functionalization from array assembly.

Natural killer cells promote long-term hepatobiliary inflammation in a low-dose rotavirus model of experimental biliary atresia.

UNLABELLED: Biliary atresia is a rapidly progressive obstructive cholangiopathy of infants. Mechanistic studies in the mouse model of Rhesus rotavirus (RRV)-induced biliary atresia have linked the importance of effector lymphocytes to the pathogenesis of extrahepatic bile duct (EHBD) injury and obstruction in experimental biliary atresia; however, studies of the progressive liver injury have been limited by early death of newborn mice. Here, we aimed to determine 1) if a lower inoculum of RRV induces obstruction of EHBDs while allowing for ongoing liver inflammation, and 2) if NK cells regulate intrahepatic injury. The administration of 0.25 x 10(6) fluorescence forming units of RRV induced an obstructive extrahepatic cholangiopathy, but allowed for restoration of the duct epithelium, increased survival, and the development of a progressive intrahepatic inflammatory injury with molecular and cellular signatures equivalent to the traditional infectious model. Investigating the mechanisms of liver injury, we found that NK cell depletion at the onset of jaundice decreased liver inflammation, suppressed the expression of fibrosis and inflammation/immunity genes, lowered plasma ALT and bilirubin and improved survival. CONCLUSIONS: Lower inoculation of RRV-induced progressive liver injury and fibrosis via NK cells. These findings point to the potential use of NK cell-depleting strategies to block progression of liver disease in biliary atresia.

Biliary repair and carcinogenesis are mediated by IL-33-dependent cholangiocyte proliferation.

Injury to the biliary epithelium triggers inflammation and fibrosis, which can result in severe liver diseases and may progress to malignancy. Development of a type 1 immune response has been linked to biliary injury pathogenesis; however, a subset of patients with biliary atresia, the most common childhood cholangiopathy, exhibit increased levels of Th2-promoting cytokines. The relationship among different inflammatory drivers, epithelial repair, and carcinogenesis remains unclear. Here, we determined that the Th2-activating cytokine IL-33 is elevated in biliary atresia patient serum and in the livers and bile ducts of mice with experimental biliary atresia. Administration of IL-33 to WT mice markedly increased cholangiocyte proliferation and promoted sustained cell growth, resulting in dramatic and rapid enlargement of extrahepatic bile ducts. The IL-33-dependent proliferative response was mediated by an increase in the number of type 2 innate lymphoid cells (ILC2s), which released high levels of IL-13 that in turn promoted cholangiocyte hyperplasia. Induction of the IL-33/ILC2/IL-13 circuit in a murine biliary injury model promoted epithelial repair; however, induction of this circuit in mice with constitutive activation of AKT and YAP in bile ducts induced cholangiocarcinoma with liver metastases. These findings reveal that IL-33 mediates epithelial proliferation and suggest that activation of IL-33/ILC2/IL-13 may improve biliary repair and disruption of the circuit may block progression of carcinogenesis.

Integrative genomics identifies candidate microRNAs for pathogenesis of experimental biliary atresia.

BACKGROUND: Biliary atresia is a fibroinflammatory obstruction of extrahepatic bile duct that leads to end-stage liver disease in children. Despite advances in understanding the pathogenesis of biliary atresia, very little is known about the role of microRNAs (miRNAs) in onset and progression of the disease. In this study, we aimed to investigate the entire biliary transcriptome to identify miRNAs with potential role in the pathogenesis of bile duct obstruction. RESULTS: By profiling the expression levels of miRNA in extrahepatic bile ducts and gallbladder (EHBDs) from a murine model of biliary atresia, we identified 14 miRNAs whose expression was suppressed at the times of duct obstruction and atresia (≥2 fold suppression, P < 0.05, FDR 5%). Next, we obtained 2,216 putative target genes of the 14 miRNAs using in silico target prediction algorithms. By integrating this result with a genome-wide gene expression analysis of the same tissue (≥2 fold increase, P < 0.05, FDR 5%), we identified 26 potential target genes with coordinate expression by the 14 miRNAs. Functional analysis of these target genes revealed a significant relevance of miR-30b/c, -133a/b, -195, -200a, -320 and -365 based on increases in expression of at least 3 target genes in the same tissue and 1st-to-3rd tier links with genes and gene-groups regulating organogenesis and immune response. These miRNAs showed higher expression in EHBDs above livers, a unique expression in cholangiocytes and the subepithelial compartment, and were downregulated in a cholangiocyte cell line after RRV infection. CONCLUSIONS: Integrative genomics reveals functional relevance of miR-30b/c, -133a/b, -195, -200a, -320 and -365. The coordinate expression of miRNAs and target genes in a temporal-spatial fashion suggests a regulatory role of these miRNAs in pathogenesis of experimental biliary atresia.

Differential colonization with segmented filamentous bacteria and Lactobacillus murinus do not drive divergent development of diet-induced obesity in C57BL/6 mice.

Alterations in the gut microbiota have been proposed to modify the development and maintenance of obesity and its sequelae. Definition of underlying mechanisms has lagged, although the ability of commensal gut microbes to drive pathways involved in inflammation and metabolism has generated compelling, testable hypotheses. We studied C57BL/6 mice from two vendors that differ in their obesogenic response and in their colonization by specific members of the gut microbiota having well-described roles in regulating gut immune responses. We confirmed the presence of robust differences in weight gain in mice from these different vendors during high fat diet stress. However, neither specific, highly divergent members of the gut microbiota (Lactobacillus murinus, segmented filamentous bacteria) nor the horizontally transmissible gut microbiota were found to be responsible. Constitutive differences in locomotor activity were observed, however. These data underscore the importance of selecting appropriate controls in this widely used model of human obesity.

Does participation in organized sports predict future physical activity for adolescents from diverse economic backgrounds?

PURPOSE: To examine cross-sectional and longitudinal associations between socioeconomic status (SES), gender, sports participation and moderate-to-vigorous physical activity (MVPA) in adolescents. METHODS: Project EAT (Eating Among Teens), a population-based longitudinal study followed a socioeconomically and ethnically diverse sample of 1709 adolescents in 1998-1999 (Time 1) and 2003-2004 (Time 2). Mixed model regression analyses were used to examine longitudinal trends in MVPA as a function of SES and previous sports involvement. RESULTS: For both genders, participation in organized sports and weekly hours of MVPA were positively associated with SES. On average, MVPA decreased between high school and young adulthood for both genders. Adolescents who participated in sports during high school showed a steeper decline in weekly hours of MVPA than their non-sports-participating counterparts. SES had a significant moderating effect on the change in MVPA over time for boys who participated in organized sports, with low SES boys showing a steeper decline in MVPA between time periods than higher SES boys. Although on average, a statistically significant difference in MVPA between previous sports participants and nonparticipants remained at Time 2, for all SES groups and both genders, the gap between hours of MVPA was either overcome or significantly narrowed by young adulthood. CONCLUSIONS: Increased dependence on organized sports for MVPA may be insufficient to meet the needs of youth following high school, especially for low SES youth. Designing physical activity promotions that reach and address the unique needs of lower SES youth and families is a public health priority.