Evaluation of the Efficacy of an Online Learning Module to Increase Wound Care Theoretical Knowledge Amongst Medical Students.

OBJECTIVE: We developed and evaluated an online learning module for teaching wound care basics to junior medical learners, which was assessed for its ability to increase theoretical knowledge of wound care, and medical learners' perceptions on the use of an online module to teach wound care practices. DESIGN: Between February 2022 to November 2022, participants were enrolled into our unblinded, matched-pair single-arm study. Participants completed a pre- and postquiz prior to and after completing the online module, respectively. Scores on the pre- and postquiz were matched by participant and evaluated for improvement. The online module was composed of free text, animated videos with voiceovers, pictorial examples, and tables, as well as unscored knowledge checks, covering the categories of i) normal wound healing physiology, ii) describing wounds/assessment of wounds, iii) choosing dressings for wounds, and iv) addressing and understanding wound aetiologies, including diabetic, arterial, and venous ulcers. SETTING: Participants were enrolled at the University of Toronto in Toronto, Canada. PARTICIPANTS: Participants were recruited from the undergraduate medicine and physician assistant programs at the University of Toronto. Students were provided with information on how to participate in the study through email and in-person recruitment. Thirty-three participants entered the study, and 23 participants completed the study. RESULTS: Across all participants, the prequiz to postquiz score increase averaged 13.29%, representing a statistically significant increase (p = 0.0000013). Ten of the 20 questions and all question categories had a statistically significant increase in the postquiz scores. All respondents found the module very useful (67%) or extremely useful (33%) for learning wound care, and 67% were very satisfied overall with the quality of the module, with the remainder (33%) of respondents somewhat satisfied. CONCLUSIONS: Online learning modules are effective at increasing wound care knowledge in junior medical learners, with high satisfaction amongst learners.

Exploring the psychosocial needs of persons with lower extremity amputation and feasibility of internet cognitive behavioural therapy: a qualitative study.

PURPOSE: Following major lower extremity amputation (LEA), patients experience significant emotional distress and are at risk for anxiety and depression. There is a lack of mental health supports for this population, and internet-based cognitive behavioural therapy (iCBT) may be a useful resource to meet this need. The purpose of this study was to use a qualitative approach to explore the mental health needs of LEA patients and to gauge their attitudes of the use of iCBT to help them cope with their amputation. METHODS: Semi-structured qualitative interviews were conducted with inpatients and outpatients with LEA recruited from a major urban rehabilitation hospital. Data were analysed using inductive codebook thematic analysis (TA). RESULTS: Ten interviews were completed with individuals with LEA. The main themes identified were: (1) Fixating on the past; (2) Worry about the future; (3) Unmet mental health needs; (4) Barriers to Mental Health Support; (5) Importance of peer support; and (6) Tailoring iCBT. CONCLUSIONS: Our findings highlight that patients with LEA are open to learning more about iCBT to meet their mental health needs. Key iCBT implementation considerations include taking into account issues of stigma associated with mental health, timing of delivery, levels of digital literacy, online security, and interactive content.IMPLICATIONS FOR REHABILITATIONFollowing lower extremity amputation (LEA), people experience significant emotional distress and are at risk for the development of anxiety and/or depression.Patients with LEA are receptive to an online mental health resource (i.e., internet-based cognitive behavioural therapy [iCBT]) but it needs to be tailored to meet the various mental health needs and digital literacy of the LEA population.The use of an implementation science approach can help identify factors related to the development and potential uptake of an iCBT for patients with LEA.

Qualitative research in vascular surgery.

Qualitative research aims to understand and describe subjective experiences and perceptions. Qualitative and mixed-methods research, in which quantitative and qualitative research methods are combined, is playing an increasingly bigger role in vascular surgery research. The aim of this review was to describe the fundamentals of qualitative research methods and its application in vascular surgery.

Integration of Th17- and Lymphotoxin-Derived Signals Initiates Meningeal-Resident Stromal Cell Remodeling to Propagate Neuroinflammation.

Tertiary lymphoid tissues (TLTs) have been observed in the meninges of multiple sclerosis (MS) patients, but the stromal cells and molecular signals that support TLTs remain unclear. Here, we show that T helper 17 (Th17) cells induced robust TLTs within the brain meninges that were associated with local demyelination during experimental autoimmune encephalitis (EAE). Th17-cell-induced TLTs were underpinned by a network of stromal cells producing extracellular matrix proteins and chemokines, enabling leukocytes to reside within, rather than simply transit through, the meninges. Within the CNS, interactions between lymphotoxin αß (LTαß) on Th17 cells and LTßR on meningeal radio-resistant cells were necessary for the propagation of de novo interleukin-17 responses, and activated T cells from MS patients expressed elevated levels of LTßR ligands. Therefore, input from both Th17 cells and the lymphotoxin pathway induce the formation of an immune-competent stromal cell niche in the meninges.

A TNF-α-CCL20-CCR6 axis regulates Nod1-induced B cell responses.

Innate immune responses provoke the accumulation of leukocytes at sites of inflammation. In addition to monocytes and granulocytes, B cells also participate in antimicrobial innate immune responses; however, the mechanisms for accumulation of B cells to sites of inflammation are not well understood. To study B cell accumulation following systemic inflammation, we used a model synthetic ligand that stimulates a specific pattern recognition molecule, nucleotide-binding oligomerization domain-containing protein 1 (Nod1). Upon exposure to Nod1 agonists, both B cells and neutrophils rapidly accumulate within the spleen, and dendritic cells migrate into the periarterial lymphoid sheath. Nod1 stimulation led to a marked increase in several chemokines within the spleen, including CXCL13, CCL2, and CCL20. Whereas the lymphotoxin pathway was critical for the induction of the B cell chemoattractant CXCL13 in response to Nod1 agonists, B cell accumulation within the spleen following Nod1-induced systemic inflammation was independent of the lymphotoxin pathway. In contrast, a CCR6/CCL20 chemokine loop instructed rapid increase of B cells in the spleen in response to systemic administration of Nod1 agonists in a TNF-α-dependent manner. Moreover, CCR6 was required to regulate Nod1-mediated B cell responses. These results reveal a novel mechanism of B cells during inflammation and shed light on how B cells participate in innate immune responses to microbial stimulation.

A sphingosine-1-phosphate receptor 1-directed agonist reduces central nervous system inflammation in a plasmacytoid dendritic cell-dependent manner.

Gradients of the sphingolipid sphingosine-1-phosphate (S1P) are responsible for the egress of lymphocytes from lymph nodes by activating the S1P1 receptor expressed on the surface of lymphocytes. Small molecule drugs that downregulate S1P receptors induce the sequestration of lymphocytes within lymph nodes, thus preventing lymphocytes from accessing sites of inflammation. In particular, FTY720, a pan-S1P receptor agonist, has been efficacious in the treatment of multiple sclerosis as well as its animal model, experimental autoimmune encephalomyelitis (EAE), by virtue of its ability to restrain lymphocytes within the lymph nodes, thus precluding their migration into the CNS. However, multiple leukocyte subsets express S1P receptors of varying types, and although it is beneficial to prevent transmigration of proinflammatory lymphocytes into the CNS, allowing access of regulatory leukocyte subsets to the CNS is desirable. In this study, we show that an S1P1-specific agonist (AUY954) is clinically efficacious in ameliorating pre-established EAE in SJL/J mice. Efficacy of AUY954 correlated with a reduction of lymphocytes in the CNS, but access of plasmacytoid dendritic cells (pDCs) to the CNS was unimpaired, and the presence of pDCs was found to be an important cofactor in mediating the clinical efficacy of AUY954. These results indicate that pDCs are important in quieting autoimmune responses during EAE, and that trafficking inhibitors that are permissive for pDC accumulation in the CNS may be of therapeutic value for the treatment of multiple sclerosis.

Fine-tuning of dendritic cell biology by the TNF superfamily.

Members of the tumour necrosis factor (TNF) superfamily have been implicated in a wide range of biological functions, and their expression by cells of the immune system makes them appealing targets for immunomodulation. One common theme for TNF superfamily members is their coordinated expression at the interface between antigen-specific T cells and antigen-presenting dendritic cells and, by virtue of this expression pattern, TNF superfamily members can shape T cell immune responses. Understanding how to manipulate such functions of the TNF superfamily may allow us to tip the balance between immunity and tolerance in the context of human disease.

LTßR and CD40: working together in dendritic cells to optimize immune responses.

Generating an immune response tailored to destroy an infecting organism while limiting bystander damage involves guiding T-cell activation using a variety of cues taken from the immunogen (antigen type, dose, and persistence, accompanying danger signals) as well as the host (tissue environment, T-cell frequency, and affinity for antigen). Dendritic cells (DCs) serve as translators of much of this information and are critically required for effective pathogen and tumor clearance. Moreover, dysregulation of DC activation can lead to autoimmunity. Inhibition of the lymphotoxin (LT) and CD40 pathways has been shown to be effective at quieting inflammation in settings where DC-T-cell interactions are key instigators of disease progression. In this review, we compare and contrast the CD40 and LT pathways in the context of receptor/ligand expression, signal transduction, and DC biology. We provide evidence that these two pathways play complementary roles in DC cytokine secretion, thus indirectly shaping the nature of the CD8(+) T-cell response to foreign antigen. Given the distinct role of these pathways in the context of DC function, we propose that dual therapies targeted at both the CD40 and LTß receptor may have therapeutic potential in silencing DC-driven autoimmunity or in promoting tumor clearance.

LTßR signaling in dendritic cells induces a type I IFN response that is required for optimal clonal expansion of CD8+ T cells.

During an immune response, antigen-bearing dendritic cells (DCs) migrate to the local draining lymph node and present antigen to CD4(+) helper T cells. Antigen-activated CD4(+) T cells then up-regulate TNF superfamily members including CD40 ligand and lymphotoxin (LT)αß. Although it is well-accepted that CD40 stimulation on DCs is required for DC licensing and cross-priming of CD8(+) T-cell responses, it is likely that other signals are integrated into a comprehensive DC activation program. Here we show that a cognate interaction between LTαß on CD4(+) helper T cells and LTß receptor on DCs results in unique signals that are necessary for optimal CD8(+) T-cell expansion via a type I IFN-dependent mechanism. In contrast, CD40 signaling appears to be more critical for CD8(+) T-cell IFNγ production. Therefore, different TNF family members provide integrative signals that shape the licensing potential of antigen-presenting DCs.

Retinoic acid modulates chromatin to potentiate tumor necrosis factor alpha signaling on the DIF2 promoter.

Transcriptional activation by nuclear hormone receptors is well characterized, but their cooperation with other signaling pathways to activate transcription remains poorly understood. Tumor necrosis factor alpha (TNFalpha) and all-trans retinoic acid (RA) induce monocytic differentiation of acute promyelocytic leukemia (APL) cells in a synergistic manner. We used the promoter of DIF2, a gene involved in monocytic differentiation, to model the mechanism underlying the cooperative induction of target genes by RA and TNFalpha. We show a functional RA response element in the DIF2 promoter, which is constitutively bound by PML/RARalpha in APL cells. RA stimulates release of corepressors and recruitment of chromatin modifying proteins and additional transcription factors to the promoter, but these changes cause only a modest induction of DIF2 mRNA. Co-stimulation with RA plus TNFalpha facilitates binding of NF-kappaB to the promoter, which is crucial for full induction of transcription. Furthermore, RA plus TNFalpha greatly enhanced the level of RNA Pol II phosphorylation on the DIF2 promoter, via synergistic recruitment of TFIIH. We propose that RA mediates remodeling of chromatin to facilitate binding of transcription factors, which cooperate to enhance Pol II phosphorylation, providing a mechanism whereby nuclear receptors interact with other signaling pathways on the level of transcription.

Expression of lymphotoxin-alphabeta on antigen-specific T cells is required for DC function.

During an immune response, activated antigen (Ag)-specific T cells condition dendritic cells (DCs) to enhance DC function and survival within the inflamed draining lymph node (LN). It has been difficult to ascertain the role of the tumor necrosis factor (TNF) superfamily member lymphotoxin-alphabeta (LTalphabeta) in this process because signaling through the LTbeta-receptor (LTbetaR) controls multiple aspects of lymphoid tissue organization. To resolve this, we have used an in vivo system where the expression of TNF family ligands is manipulated only on the Ag-specific T cells that interact with and condition Ag-bearing DCs. We report that LTalphabeta is a critical participant required for optimal DC function, independent of its described role in maintaining lymphoid tissue organization. In the absence of LTalphabeta or CD40L on Ag-specific T cells, DC dysfunction could be rescued in vivo via CD40 or LTbetaR stimulation, respectively, suggesting that these two pathways cooperate for optimal DC conditioning.

BAFF induces a hyper-IgA syndrome in the intestinal lamina propria concomitant with IgA deposition in the kidney independent of LIGHT.

BAFF is a peripheral B cell survival factor and can mediate antibody (Ab) class switching. Over-expression of BAFF in mice results in B cell hyperplasia, elevated serum immunoglobulin (Ig), spontaneous germinal centre (GC) reactions and mild glomerulonephritis (GN). Here we show that, in addition to driving excessive levels of serum IgA, BAFF over-expression results in increased IgA levels within the intestinal lamina propria (LP) and deposition of IgA immune complexes in the renal glomerular mesangium. LIGHT has been previously shown to mediate a similar phenotype via signaling through the lymphotoxin-beta receptor (LTbetaR). We evaluated if LIGHT and BAFF cooperate in the etiology of a hyper-IgA syndrome in BAFF-overexpressing transgenic (BAFF-Tg) mice. We find that LIGHT-deficient BAFF-Tg mice exhibit similar levels of IgA in the serum, gut and kidney and develop nephritis to the same degree as LIGHT-sufficient BAFF-Tg mice. Therefore, in the context of BAFF over-expression, LIGHT is dispensable for the generation of a hyper-IgA syndrome accompanied by nephritis.

The lymphotoxin pathway: beyond lymph node development.

The first studies of mice deficient in lymphotoxin-alpha (LTalpha), LTbeta and LTbetaR revealed the seminal discovery that the LTbetaR signaling is critical for the development of lymph nodes and Peyer's patches during embryogenesis. Since these initial findings, it is increasingly appreciated that signaling through the lymphotoxin-beta receptor (LTbetaR) plays a key role in numerous biological processes in the adult animal, including the maintenance of specialized stromal cell types and the homeostatic control of chemokine expression within the lymphoid tissues. A major focus of our laboratory is to understand the relevance of LTbetaR signaling in initiating immune responses both dependent and independent of its role in maintaining the organization of lymphoid tissues. This review will therefore explore new possibilities for how this complex pathway regulates humoral and cellular immunity.