Single-Cell Analysis of Human Mononuclear Phagocytes Reveals Subset-Defining Markers and Identifies Circulating Inflammatory Dendritic Cells.

Human mononuclear phagocytes comprise phenotypically and functionally overlapping subsets of dendritic cells (DCs) and monocytes, but the extent of their heterogeneity and distinct markers for subset identification remains elusive. By integrating high-dimensional single-cell protein and RNA expression data, we identified distinct markers to delineate monocytes from conventional DC2 (cDC2s). Using CD88 and CD89 for monocytes and HLA-DQ and FcεRIα for cDC2s allowed for their specific identification in blood and tissues. We also showed that cDC2s could be subdivided into phenotypically and functionally distinct subsets based on CD5, CD163, and CD14 expression, including a distinct subset of circulating inflammatory CD5-CD163+CD14+ cells related to previously defined DC3s. These inflammatory DC3s were expanded in systemic lupus erythematosus patients and correlated with disease activity. These findings further unravel the heterogeneity of DC subpopulations in health and disease and may pave the way for the identification of specific DC subset-targeting therapies.

Human Innate Lymphoid Cell Subsets Possess Tissue-Type Based Heterogeneity in Phenotype and Frequency.

Animal models have highlighted the importance of innate lymphoid cells (ILCs) in multiple immune responses. However, technical limitations have hampered adequate characterization of ILCs in humans. Here, we used mass cytometry including a broad range of surface markers and transcription factors to accurately identify and profile ILCs across healthy and inflamed tissue types. High dimensional analysis allowed for clear phenotypic delineation of ILC2 and ILC3 subsets. We were not able to detect ILC1 cells in any of the tissues assessed, however, we identified intra-epithelial (ie)ILC1-like cells that represent a broader category of NK cells in mucosal and non-mucosal pathological tissues. In addition, we have revealed the expression of phenotypic molecules that have not been previously described for ILCs. Our analysis shows that human ILCs are highly heterogeneous cell types between individuals and tissues. It also provides a global, comprehensive, and detailed description of ILC heterogeneity in humans across patients and tissues.

A High-Dimensional Atlas of Human T Cell Diversity Reveals Tissue-Specific Trafficking and Cytokine Signatures.

Depending on the tissue microenvironment, T cells can differentiate into highly diverse subsets expressing unique trafficking receptors and cytokines. Studies of human lymphocytes have primarily focused on a limited number of parameters in blood, representing an incomplete view of the human immune system. Here, we have utilized mass cytometry to simultaneously analyze T cell trafficking and functional markers across eight different human tissues, including blood, lymphoid, and non-lymphoid tissues. These data have revealed that combinatorial expression of trafficking receptors and cytokines better defines tissue specificity. Notably, we identified numerous T helper cell subsets with overlapping cytokine expression, but only specific cytokine combinations are secreted regardless of tissue type. This indicates that T cell lineages defined in mouse models cannot be clearly distinguished in humans. Overall, our data uncover a plethora of tissue immune signatures and provide a systemic map of how T cell phenotypes are altered throughout the human body.

Expanding the Spectrum of EWSR1::CREM Fusion Tumors: An Unusual Pediatric Intranasal Myxoid Tumor.

EWSR1::CREM gene fusions are increasingly being recognized in a diverse number of soft tissue tumors, including well-defined entities such as angiomatoid fibrous histiocytoma or clear cell sarcoma, and other unclassifiable tumors. As a group, EWSR1::CREM fused tumors often demonstrate primitive spindle or epithelioid cells, myxoid stroma, and a broad immunophenotype. Herein we present an unusual case of a child diagnosed with an intranasal malignant myxoid tumor harboring an EWSR1::CREM gene fusion. To the best of our knowledge, this is the first case of intranasal myxoid tumor with this particular fusion. Diagnosis and management of the case is discussed.

A comparative analysis of Charlson's weighted index of comorbidity and perforated peptic ulcer scores in predicting postoperative mortality and high comprehensive complication index.

BACKGROUND: Limited data exists on Charlson's weighted index of comorbidity (WIC) predictability for postoperative outcomes following perforated peptic ulcer (PPU) surgery. This study assesses the utility of WIC and other predictive scores in forecasting both postoperative mortality and morbidity in PPU. MATERIALS & METHODS: Patients with PPUs operated between 2018 and 2021 in a Malaysian tertiary referral center were included. Clinical data were retrospectively analyzed for association with mortality and morbidity measured with the Comprehensive Complication Index (CCI). Predictability of WIC and other predictors were examined using area under receiver-operator characteristic (ROC) curve (AUC). RESULTS: Among 110 patients included, 18 died (16.4%) and 36 (32.7%) had significant morbidity postoperatively (High CCI, ≥26.2). Both mortality and high CCI were associated with age >65 years, female sex, comorbidities (diabetes mellitus, hypertension, and renal disease), and American Society of Anesthesiologist score >2. Most patients who died had renal dysfunction, metabolic acidosis, lactate >2 mmol/L upon presentation preoperatively. While surgery >24 h after presentation correlated with mortality and high CCI, the benefit of earlier surgery <6 h or <12 h was not demonstrated. WIC (AUC, 0.89; 95% CI, 0.81-0.99) showed similar predictability to Peptic Ulcer Perforation (PULP) (AUC, 0.97; 95% CI, 0.93-1.00) for mortality. PULP effectively predicted high CCI (AUC, 0.83; 95% CI, 0.73-0.93; p < 0.001). CONCLUSION: WIC is valuable in predicting mortality, highlighting the importance of comorbidity in risk assessment. PULP score was effective in predicting both mortality and high CCI. Early identification of patients with high perioperative risk will facilitate patients' triage for escalated care, leading to a better outcome.

Outcome of childhood epistaxis with treatment of allergic rhinitis: a randomized controlled study.

The purpose of this study is to (1) to determine if treatment of underlying allergic rhinitis (AR) in children will affect epistaxis outcome, (2) to compare efficacy of three outpatient AR treatment regimens in epistaxis outcomes, and (3) to investigate potential factors in the pathogenesis of epistaxis with underlying AR. A single-blind randomized-controlled study was conducted in the Otolaryngology clinic in KK Women's and Children's Hospital. Sixty children aged below 18 years with underlying untreated AR, with first presentation of epistaxis, were randomized to three different AR treatments: treatment 1, antihistamine (20 patients); treatment 2, nasal steroid spray (20 patients); and treatment 3, both antihistamine and nasal steroid spray (20 patients). Epistaxis severity and frequency were assessed. Pre-treatment, 95% of patients within each of the three treatment groups described epistaxis symptoms. Post-treatment, there was improvement in epistaxis outcome (resolution of epistaxis) with 20% (4/20), 40% (8/20), and 60% (12/20) of patients in treatment groups 1 (antihistamine), 2 (nasal steroid spray), and 3 (combined therapy) respectively, who reported resolution of epistaxis. Treatment regimens containing nasal steroid spray resulted in greater improvement of epistaxis severity and frequency. Combined therapy (treatment 3) resulted in the best epistaxis outcome at 1-month follow-up. Majority (90%) reported nose-picking/rubbing behavior. CONCLUSIONS: Intranasal corticosteroids are superior to oral antihistamines in relieving itch or rhinorrhea in AR. Intranasal corticosteroids may be important in treating epistaxis with underlying AR, because digital trauma from itch/rhinorrhea-related nose-picking/rubbing frequently leads to epistaxis. Results from this study will be important to primary and emergency physicians, community pediatricians, and pediatric allergists and otolaryngologists. WHAT IS KNOWN: • Childhood epistaxis commonly co-exists with allergic rhinitis (AR), causing significant symptoms and distress to patients. • There are currently no studies reporti ng on epistaxis outcome aft er treatment of underlying AR. WHAT IS NEW: • This is a single-blind randomized-controlled study of 60 children aged below 18 years with underlying untreated AR, with first presentation of epistaxis to a children's hospital in Singapore Patients were randomized to three different regimens to treat AR: treatment 1, antihistamine; treatment 2, nasal steroid spray; and treatment 3, both antihistamine and nasal steroid spray. • Treatment regimens containing nasal steroid spray improved epistaxis outcomes, with combined therapy of antihistamine and nasal steroid spray resulting in the best outcome for resolution of epistaxis among the three treatment regimens.

Paediatric actinomycosis: A 16-year, single-institution retrospective review of cases.

AIM: Actinomycosis is a rare subacute to chronic granulomatous infection which can mimic other infectious or malignant diseases. This study examined the epidemiology and treatment outcome of actinomycosis in children. METHODS: A retrospective study on children admitted for actinomycosis in a tertiary paediatric hospital in Singapore, from January 2004 to December 2020. Clinical profile, therapeutic interventions and outcomes were examined. RESULTS: A total of 10 patients were identified; 7 were female. The median age at first presentation was 9.8 years (range 4.7-15.7). The most common presenting symptom was fever (n = 6, 60%), followed by facial or neck swelling (n = 3, 30%) and ear pain (n = 3, 30%). Actinomycosis occurred predominantly in the orocervicofacial region (n = 6, 60%). Four patients (40%) had preceding dental infections in the form of dental caries or gingivitis. One patient had poorly controlled insulin-dependent diabetes mellitus. Actinomycosis was confirmed via culture in four patients, histopathology in four patients and both methods in two patients. All except one patient (n = 9, 90%) underwent surgical procedures. All patients received ampicillin or amoxicillin/clavulanate or other beta-lactams, for a median duration of 6.5 months (range 1.5-14). Complications included osteomyelitis (n = 4, 40%), mastoiditis (n = 2, 20%), brain abscess (n = 1, 10%) and recurrent neck abscess (n = 1, 10%). There was no mortality and all patients achieved complete resolution. CONCLUSIONS: Paediatric actinomycosis was rare in our 16-year review, but had a high complication rate. It can occur in immunocompetent patients, and dental infection was the predominant risk factor identified. Prognosis was excellent after surgical intervention and appropriate antimicrobial therapy.

Genetic optimization of mid-infrared filters for a machine learning chemical classifier.

Miniaturized mid-infrared spectrometers present opportunities for applications that range from health monitoring to agriculture. One approach combines arrays of spectral filters with infrared photodetectors, called filter-array detector-array (FADA) microspectrometers. A paper recently reported a FADA microspectrometer in tandem with machine learning for chemical identification. In that work, a FADA microspectrometer with 20 filters was assembled and tested. The filters were band-pass, or band-stop designs that evenly spanned the microspectrometer's operating wavelength range. However, given that a machine learning classifier can be trained on an arbitrary filter basis, it is not apparent that evenly spaced filters are optimal. Here, through simulations with noise, we use a genetic algorithm to optimize six bandpass filters to best identify liquid and gaseous chemicals. We report that the classifiers trained with the optimized filter sets outperform those trained with evenly spaced filter sets and those handpicked to target the absorption bands of the chemicals investigated.

Good hearing outcome in children recovering from non-polio enteroviral meningitis.

AIM: Evaluation of hearing outcome in children following non-polio enteroviral meningitis (EVM). METHODS: We reviewed hearing outcome of children, aged ≤15 years, with EVM managed at our institution over a 4-year period from July 2008 to July 2011 and January-December 2015. Children with concomitant bacterial infections, and those who required intensive care, or with a prior history of hearing impairment or immunodeficiency were excluded. Data on demographics, medical history, presentation and outcome of hearing screen were collected. The children attended post-meningitis review and hearing screen utilising transient-evoked otoacoustic emission testing at 8-10 weeks. Children who failed the transient-evoked otoacoustic emission testing and those with caregiver concerns were referred to otolaryngology for comprehensive audiologic evaluation. RESULTS: The study cohort consisted of 179 children, aged from 3 days to 15 years, of whom 158 (89%) were younger than 90 days of age. Eleven were preterm infants. A total of 158 children had received intravenous gentamicin at 5-7.5 mg/kg/day for a median duration of 2 days. All 179 study participants were found to have good hearing post EVM. CONCLUSION: Hearing outcome in children recovering from EVM is good.

Resolution of sinus bradycardia, high-grade heart block, and left ventricular systolic dysfunction with rituximab therapy in Henoch-Schonlein purpura.

Henoch-Schonlein purpura (HSP) is a rare, typically self-limited, multi-organ vasculitis. Cardiac involvement with HSP carries high morbidity and mortality, thus requiring early aggressive immunosuppressive therapy. We report a case of HSP complicated with acute systolic left ventricular (LV) dysfunction, symptomatic sinus bradycardia and high-grade atrio-ventricular (AV) heart block. Cyclophosphamide, a commonly used agent in HSP, was contraindicated due to the patient's presentation with acute renal failure. Treatment with monoclonal antibody rituximab and corticosteroids was initiated with an improvement in and resolution of LV systolic dysfunction, sinus bradycardia and AV block. We believe this is the first published report on rituximab treatment in HSP with cardiac involvement manifesting with severe LV systolic dysfunction, sinus bradycardia and high-grade AV block.

Novel calcium infusion regimen after parathyroidectomy for renal hyperparathyroidism.

AIM: Calcium infusion is used after parathyroid surgery for renal hyperparathyroidism to treat postoperative hypocalcaemia. We compared a new infusion regimen to one commonly used in Malaysia based on 2003 K/DOQI guidelines. METHODS: Retrospective data on serum calcium and infusion rates was collected from 2011-2015. The relationship between peak calcium efflux (PER) and time was determined using a scatterplot and linear regression. A comparison between regimens was made based on treatment efficacy (hypocalcaemia duration, total infusion amount and time) and calcium excursions (outside target range, peak and trough calcium) using bar charts and an unpaired t-test. RESULTS: Fifty-one and 34 patients on the original and new regimens respectively were included. Mean PER was lower (2.16 vs 2.56 mmol/h; P = 0.03) and occurred earlier (17.6 vs 23.2 h; P = 0.13) for the new regimen. Both scatterplot and regression showed a large correlation between PER and time (R-square 0.64, SE 1.53, P < 0.001). The new regimen had shorter period of hypocalcaemia (28.9 vs 66.4 h, P = 0.04), and required less calcium infusion (67.7 vs 127.2 mmol, P = 0.02) for a shorter duration (57.3 vs 102.9 h, P = 0.001). Calcium excursions, peak and trough calcium were not significantly different between regimens. Early postoperative high excursions occurred when the infusion was started in spite of elevated peri-operative calcium levels. CONCLUSION: The new infusion regimen was superior to the original in that it required a shorter treatment period and resulted in less hypocalcaemia. We found that early aggressive calcium replacement is unnecessary and raises the risk of rebound hypercalcemia.

Subcutaneous implantable cardioverter defibrillator for dialysis patients: a strategy to reduce central vein stenoses and infections.

Central venous stenosis is a common complication of the transvenous leads associated with an implantable cardioverter defibrillator (ICD). Although epicardial leads have been reported to bypass this complication, their placement is much more invasive than the subcutaneous ICDs (SICDs) and requires the services of a cardiothoracic surgeon. Recent data have demonstrated successful defibrillation using an SICD. In this report, we present 4 long-term hemodialysis patients treated successfully with an SICD. 3 patients received the device for primary prevention of sudden cardiac death (cardiomyopathy with low ejection fraction). The patient in the fourth case had a prolonged QT interval and received the device for secondary prevention. 3 patients had an arteriovenous fistula, whereas 1 patient was dialyzing with a tunneled dialysis catheter. Insertion of an SICD is a minimally invasive procedure. By virtue of leaving the venous system untouched, this approach might offer the advantage of reduced risk of central venous stenosis and infection over an endocardial ICD with transvenous leads. SICD is not experimental; it has been approved by the US Food and Drug Administration and is currently being used in the United States and Europe.

GTExome: Modeling commonly expressed missense mutations in the human genome.

A web application, GTExome, is described that quickly identifies, classifies, and models missense mutations in commonly expressed human proteins. GTExome can be used to categorize genomic mutation data with tissue specific expression data from the Genotype-Tissue Expression (GTEx) project. Commonly expressed missense mutations in proteins from a wide range of tissue types can be selected and assessed for modeling suitability. Information about the consequences of each mutation is provided to the user including if disulfide bonds, hydrogen bonds, or salt bridges are broken, buried prolines introduced, buried charges are created or lost, charge is swapped, a buried glycine is replaced, or if the residue that would be removed is a proline in the cis configuration. Also, if the mutation site is in a binding pocket the number of pockets and their volumes are reported. The user can assess this information and then select from available experimental or computationally predicted structures of native proteins to create, visualize, and download a model of the mutated protein using Fast and Accurate Side-chain Protein Repacking (FASPR). For AlphaFold modeled proteins, confidence scores for native proteins are provided. Using this tool, we explored a set of 9,666 common missense mutations from a variety of tissues from GTEx and show that most mutations can be modeled using this tool to facilitate studies of protein-protein and protein-drug interactions. The open-source tool is freely available at https://pharmacogenomics.clas.ucdenver.edu/gtexome/.

A comparative study of anxiety and depression among healthcare workers and non-healthcare workers in Johor, Malaysia during the Covid-19 era.

The outbreak of Coronavirus disease 2019 (Covid-19) has a significant impact on the mental health of the global population. Updates are needed regarding the mental health status among the local population since limited studies were done so far. This research compared the prevalence of anxiety and depression symptoms among HCWs and non-HCWs. We also evaluated the factors associated with anxiety and depression symptoms among these 2 groups. This was a cross-sectional study conducted between September to December 2022. Online questionnaire was distributed to HCWs from 2 tertiary government hospitals. Non-HCWs from various occupational fields were recruited randomly. Generalised Anxiety Disorder 7 (GAD-7) and Patient Health Questionnaire 9 (PHQ-9) were used to screen for anxiety and depression symptoms respectively. Data were analyzed using IBM SPSS version 28.0. 200 questionnaires were distributed to HCWs and non-HCWs respectively. The response rate was 74.5% from HCWs and 82.5% from non-HCWs (P = .07). A total of 236 individuals (105 HCWs and 131 non-HCWs) were included in the study. Majority were female, married, highly educated and worked more than 8 hours per day. There was no significant difference for the prevalence of anxiety (37.2% vs 44.3%, P = .34) and depression symptoms (37.3% vs 35.1%, P = .75) between HCWs and non-HCWs. Among HCWs, poor workplace support (P = .009) and low income (P = .04) were associated with anxiety symptoms. Younger age (P = .02), single status (P = .01) and poor workplace support (P = .006) were associated with depression symptoms. More non-HCWs with a higher educational level were having anxiety and depression symptoms. Single status (P = .03), working away from home (P = .02), poor family support (P = .03) and quarantine as Covid-19 close contact (P = .04) were also associated with depression symptoms among non-HCWs. There is no significant difference between HCWs and non-HCWs experiencing possible anxiety or depressive symptoms in this study. However, attention should be paid to address associated factors identified among each group to promote good mental health.

Process reengineering of preoperative verification, site marking and time-out for patient safety.

In this article, we describe our hospital's journey in implementing the WHO High 5s Project Correct Site Surgery Standard (CSS) protocol. We discuss how we incorporated the protocol into our system by revising the pre-existing checklist, reengineering the existing processes on preoperative verification, site marking and time-out at the Major Operating Theatre (MOT), and performing audit and feedback to ensure effective compliance. We also reflect on the importance of leadership and ministry support, benchmarking and tailoring the practice for each discipline in the pursuit of improving patient safety within the hospital.

Optical fiber speckle spectrometer based on reversed-lens smartphone microscope.

Smartphones are a potentially powerful platform for scientific instruments. Here, we demonstrate speckle spectroscopy with smartphone-level hardware. This technique promises greater performance thresholds than traditional diffraction gratings. Light is injected into an optical fiber and the emergent speckle patterns are imaged by a reversed-lens smartphone camera. The smartphone then uses an algorithm, running on a mobile computing app, to determine, in less than one second, the (hitherto unknown) input spectrum. We reconstruct a variety of visible-wavelength (470-670 nm) single and multi-peaked spectra using a tunable source. The latter also include a metameric pair, i.e., two spectra that are different, yet represent colors that are indistinguishable to the human eye.

GTExome: Modeling commonly expressed missense mutations in the human genome.

A web application, GTExome, is described that quickly identifies, classifies, and models missense mutations in commonly expressed human proteins. GTExome can be used to categorize genomic mutation data with tissue specific expression data from the Genotype-Tissue Expression (GTEx) project. Commonly expressed missense mutations in proteins from a wide range of tissue types can be selected and assessed for modeling suitability. Information about the consequences of each mutation is provided to the user including if disulfide bonds, hydrogen bonds, or salt bridges are broken, buried prolines introduced, buried charges are created or lost, charge is swapped, a buried glycine is replaced, or if the residue that would be removed is a proline in the cis configuration. Also, if the mutation site is in a binding pocket the number of pockets and their volumes are reported. The user can assess this information and then select from available experimental or computationally predicted structures of native proteins to create, visualize, and download a model of the mutated protein using Fast and Accurate Side-chain Protein Repacking (FASPR). For AlphaFold modeled proteins, confidence scores for native proteins are provided. Using this tool, we explored a set of 9,666 common missense mutations from a variety of tissues from GTEx and show that most mutations can be modeled using this tool to facilitate studies of protein-protein and protein-drug interactions. The open-source tool is freely available at https://pharmacogenomics.clas.ucdenver.edu/gtexome/.

COVID-19 related acute limb ischaemia: A case series.

COVID-19 infection or vaccination is rarely associated with arterial occlusive disease of the extremities. The surgical department of a hospital in Johor, Malaysia, recorded a significant increase in the number of COVID-19-related acute limb ischaemia when the rates of COVID-19 were high both locally and internationally. The clinical presentation and management of acute limb ischaemia associated with COVID-19 infection or vaccination are largely underreported in Johor. Herein, we report a case series of 12 patients managed with strategies ranging from purely anticoagulation to catheter-directed thrombolysis and surgical embolectomy. This case series describes the clinical presentation, risk profiles, treatment approaches and limb outcomes of the patients. The amputation rate was high in view of unfavourable factors, including delayed presentation, high-risk factors and severe COVID-19. Three cases of potential COVID-19 vaccine-related acute limb ischaemia were included. COVID-19-related acute limb ischaemia can be minimised with heightened alert, preemptive optimisation with proper hydration and consideration for early prophylactic anticoagulation in high-risk cases.

Metabolovigilance: Associating Drug Metabolites with Adverse Drug Reactions.

The Metabolovigilance database (https://pharmacogenomics.clas.ucdenver.edu/pharmacogenomics/side-effect/) is a single repository of information on over 15,920 pharmaceuticals and the compounds expected to result from metabolism of these drugs. Metabolovigilance functions as both a web server, providing data directly to users and as a web application, applying user inputs to create logic statements that curate the data presented or downloaded. Using this tool, it is easy to collect information on drugs, their side effects, and the metabolites associated with specific side effects. Information on these compounds can be sorted based on physical properties of the drugs and their metabolites. All of this information can be viewed, sorted, and downloaded for use in other applications. This open-access tool will facilitate molecular studies on the causes of adverse drug reactions and is well suited to integrate with genomic data furthering the goals of personalized medicine.