Identification of the functional PD-L1 interface region responsible for PD-1 binding and initiation of PD-1 signaling.

The PD-1/PD-L1 checkpoint pathway is important for regulating immune responses and can be targeted by immunomodulatory drugs to treat a variety of immune disorders. However, the precise protein-protein interactions required for the initiation of PD-1/PD-L1 signaling are currently unknown. Previously, we designed a series of first-generation PD-1 targeting peptides based on the native interface region of programmed death ligand 1 (PD-L1) that effectively reduced PD-1/PD-L1 binding. In this work, we further characterized the previously identified lead peptide, MN1.1, to identify key PD-1 binding residues and design an optimized peptide, MN1.4. We show MN1.4 is significantly more stable than MN1.1 in serum and retains the ability to block PD-1/PD-L1 complex formation. We further characterized the immunomodulatory effects of MN1.4 treatment by measuring markers of T cell activation in a co-culture model with ovarian cancer cells and peripheral blood mononuclear cells. We found MN1.4 treatment reduced cytokine secretion and suppressed T cell responses in a similar manner as recombinant PD-L1. Therefore, the PD-L1 interface region used to design MN1.4 appeared sufficient to initiate PD-1 signaling and likely represents the minimum necessary region of PD-L1 required for PD-1 recognition. We propose a peptide agonist for PD-1, such as MN1.4, could have several applications for treating autoimmune disorders caused by PD-1 deficiencies such as type 1 diabetes, inflammatory arthritis, or autoimmune side effects arising from monoclonal antibody-based cancer immunotherapies.

Impact of income-based public drug coverage deductibles on adherence to asthma medications.

BACKGROUND: Cost-related nonadherence to medications can be a barrier to asthma management. OBJECTIVE: To quantify the impact of public drug plan deductibles on adherence to asthma medications. METHODS: We used a quasi-experimental regression discontinuity analysis to determine whether thresholds in deductibles for public drug coverage, determined on the basis of annual household income, decreased medication use among lower-income children and adults with asthma in British Columbia from 2013 to 2018. Using dispensed medication records, we evaluated deductible thresholds at annual household incomes of $15,000 (a deductible increase from 0% to 2% of annual household income), and $30,000 (a deductible increase from 2% to 3% annual household income). We evaluated medication costs, use, the ratio of inhaled corticosteroids-containing controller medications to total medications, excessive use of short-acting ß-agonists, and the proportion of days covered by controller therapies. All costs are reported in 2020 Canadian dollars. RESULTS: Overall, 88,935 individuals contributed 443,847 person-years of follow-up (57% of female sex, mean age 31 years). Public drug subsidy decreased by -$41.74 (95% CI, -$28.34 to -$55.13) at the $15,000-deductible threshold, a 28% reduction, and patient costs increased by $48.45 (95% CI, $35.37-$61.53). The $30,000 deductible threshold did not affect public drug costs (P = .31), but patient costs increased by $27.65 (95% CI, $15.22-$40.09), which is an 11% increase. Asthma-related medication use, inhaled corticosteroids-to-total medication ratio, excessive use of short-acting ß-agonists, and proportion of days covered by controller therapies were not impacted by deductible thresholds. CONCLUSION: Income-based deductibles reduced public drug costs with no effect on asthma-related medication use, adherence to controller therapies, or excessive reliever therapy use in lower-income individuals with asthma.

Parental help-seeking behaviour for, and care of, a sick or injured child during the COVID-19 pandemic: a European online survey.

BACKGROUND: Globally, the COVID-19 pandemic had a huge impact on patients and healthcare systems. A decline in paediatric visits to healthcare settings was observed, which might have been due to lower incidence of injury and infectious illness, changes in healthcare services and parental concern. The aim of our study was to examine parental experiences of help-seeking for, and care of, a sick or injured child during COVID-19 lockdown periods in five European countries with different healthcare systems in place. METHODS: An online survey for parents with a child with any kind or illness of injury during COVID-19 lockdowns was circulated through social media in five European countries: Italy, Spain, Sweden, the Netherlands, and the United Kingdom. Parents living in one of these countries with self-identification of a sick or injured child during COVID-19 lockdown periods were eligible to fill in the survey. Descriptive statistics were used for the level of restrictions per country, children's characteristics, family characteristics and reported help-seeking behaviour of parents prior to the lockdown and their real experience during the lockdown. The free text data was subjected to thematic analysis. RESULTS: The survey was fully completed by 598 parents, ranging from 50 to 198 parents per country, during varying lockdown periods from March 2020 until May 2022. Parents who completed the survey were not deterred from seeking medical help for their sick or injured child during the COVID-19 pandemic. This finding was comparable in five European countries with different healthcare systems in place. Thematic analysis identified three main areas: parental experiences of access to healthcare, changes in parents' help-seeking behaviours for a sick or injured child during lockdowns, and the impact of caring for a sick or injured child during the lockdowns. Parents reported limited access to non-urgent care services and were anxious about either their child or themselves catching COVID-19. CONCLUSION: This insight into parental perspectives of help-seeking behaviour and care for a sick or injured child during COVID-19 lockdowns could inform future strategies to improve access to healthcare, and to provide parents with adequate information concerning when and where to seek help and support during pandemics.

Bereavement in the context of homelessness: A rapid review.

It is common for the bereaved who are experiencing homelessness to be unrecognized grievers, who are then not adequately supported in their bereavement. This rapid review gathered published information from 17 references on how bereavement is experienced within the context of homelessness (from 509 references imported for screening). Four themes identified for understanding the bereavement experience were bereavement as a risk factor for homelessness, anticipatory grief, increased frequency of death, and ways of processing grief. Current practices used for support were themed into memorials, advocacy, and trauma-informed care. Themes for gaps and barriers to support were bereavement being systematically overlooked and environmental features present. The summary of findings is intended to help inform future research, policy, legislation, and cultural responses to grief and bereavement with the hope it may reduce people's grief from being disenfranchized.

Part of the solution: A survey of community organisation perspectives on barriers and facilitating actions to Advance Care Planning in British Columbia, Canada.

BACKGROUND: Despite the established benefits of Advance Care Planning (ACP), engagement remains low in British Columbia. Since 2016, a growing number of community-based nonprofits have offered ACP education. To date, no study has focused on the perspectives of nonprofits on ACP in British Columbia. OBJECTIVE: This study aimed to identify barriers and facilitating actions to ACP as perceived by British Columbian nonprofits. DESIGN: A mixed-methods design was used. Data were collected through online surveys and telephone interviews. SETTING AND PARTICIPANTS: Staff and volunteers from British Columbian nonprofits that are providing or interested in providing public education on ACP were recruited for this study. RESULTS: The lack of public awareness of ACP, the emotional difficulty of the conversation, the complicated ACP process, the belief that ACP is synonymous with completing a medical order form, the challenge of introducing ACP in different cultural contexts and the siloed approach to ACP education were rated as the most important barriers to ACP engagement. The most important facilitating actions were developing clear messages, improving ACP literacy, reframing ACP as part of life planning, simplifying ACP documentation and transfer, integrating ACP conversations into clinical practice and better collaboration between the health system and nonprofits. DISCUSSION: This study identifies numerous opportunities to improve ACP engagement in British Columbia from a community lens. To maximize ACP engagement, community-led ACP education should be offered in coordination with the health system. CONCLUSION: Community-led ACP education as well as collaboration and consultation with nonprofits are part of the solution to the low ACP engagement in British Columbia. PUBLIC CONTRIBUTION: Study participants, including staff and volunteers at nonprofits, are members of the public.

Regarding 'Speech-language pathology students' perceptions of simulation-based learning experiences in stuttering'.

As final year medical students, we have had first-hand experience of the significant addition that simulation-based learning can provide for healthcare education. After reading the 2021 paper 'Speech-language pathology students' perceptions of simulation-based learning experiences in stuttering' by Penman et al., we were shown once again the benefits of simulation-based learning. Having said that, we felt there were many crucial aspects omitted in the simulation-based learning program created by Penman et al. for this research article. Therefore, we attempt to highlight these issues with the hope that as students also studying towards a career in healthcare, we can build on the well-developed program created by Penman et al. and make educators aware of the possible areas of improvement in healthcare education.

Caring for a sick or injured child during the COVID-19 pandemic lockdown in 2020 in the UK: An online survey of parents' experiences.

BACKGROUND: During the COVID-19 pandemic, the first UK lockdown (March to May 2020) witnessed a dramatic reduction in children presenting to primary/emergency care, creating concern that fear of the virus was resulting in children presenting late. METHODS: An online survey was co-developed with UK parents to understand the impact of the lockdown on parents' help-seeking for, and care of, their sick/injured child(ren). The survey was advertised through social media and snowballing to parents whose children had been ill/injured during the lockdown. Analysis used descriptive statistics, SPSSv25 and thematic analysis. RESULTS: The survey was fully completed by 198 UK parents. The majority asked for help (144/198): from their family doctor (78), national helplines (48) or an Emergency Department (23). Most reported that their decision-making had not changed, although how they sought help had changed. A few parents reported that the severity and duration of illness had increased because of uncertainty about and/or difficulty accessing services. Parents did not always report seeking help for symptoms rated red or amber by the Royal College of Paediatrics and Child Health. Parents reported accessing information through the internet or using information that they already had. PARENT CONTRIBUTION: This was a collaboration with parents from survey development to dissemination, with two parents being integral members of our research team. CONCLUSIONS: Our questionnaire was completed by parents who were not deterred from seeking help for their sick or injured children. Even for these parents, the lockdown changes to services created uncertainty about, and barriers to, accessing medical help for their children.

Implementing Advance Care Planning Tools in Practice: A Modified World Café to Elicit Barriers and Recommendations from Potential Adopters.

This paper reports findings from a modified World Café conducted at a palliative care professional conference in 2019, where input on tools to support advance care planning (ACP) was solicited from healthcare practitioners, managers and family members of patients. Barriers to ACP tool use included insufficient structures and resources in healthcare, death-avoidance culture and inadequate patient and family member engagement. Recommendations for tool use included clarification of roles and processes, training, mandates and monitoring, leadership support, greater reflection of diversity in tools and methods for public engagement. This paper illuminates factors to consider when implementing ACP tools in healthcare.

Protein painting, an optimized MS-based technique, reveals functionally relevant interfaces of the PD-1/PD-L1 complex and the YAP2/ZO-1 complex.

Protein-protein interactions lie at the heart of many biological processes and therefore represent promising drug targets. Despite this opportunity, identification of protein-protein interfaces remains challenging. We have previously developed a method that relies on coating protein surfaces with small-molecule dyes to discriminate between solvent-accessible protein surfaces and hidden interface regions. Dye-bound, solvent-accessible protein regions resist trypsin digestion, whereas hidden interface regions are revealed by denaturation and sequenced by MS. The small-molecule dyes bind promiscuously and with high affinity, but their binding mechanism is unknown. Here, we report on the optimization of a novel dye probe used in protein painting, Fast Blue B + naphthionic acid, and show that its affinity for proteins strongly depends on hydrophobic moieties that we call here "hydrophobic clamps." We demonstrate the utility of this probe by sequencing the protein-protein interaction regions between the Hippo pathway protein Yes-associated protein 2 (YAP2) and tight junction protein 1 (TJP1 or ZO-1), uncovering interactions via the known binding domain as well as ZO-1's MAGUK domain and YAP's N-terminal proline-rich domain. Additionally, we demonstrate how residues predicted by protein painting are present exclusively in the complex interface and how these residues may guide the development of peptide inhibitors using a case study of programmed cell death protein 1 (PD-1) and programmed cell death 1 ligand 1 (PD-L1). Inhibitors designed around the PD-1/PD-L1 interface regions identified via protein painting effectively disrupted complex formation, with the most potent inhibitor having an IC50 of 5 µm.

Point-of-Care Ultrasonography.

Point-of-care ultrasonography (POCUS) is performed by a physician at the bedside and is standard practice in obstetric, emergency, and musculoskeletal medicine. When compared with formal sonography, POCUS is equivalent in screening for abdominal aortic aneurysm and as accurate in diagnosing deep venous thrombosis. POCUS has high accuracy for diagnosing pneumonia and detecting acute decompensated heart failure but is less accurate than computed tomography for identifying pulmonary embolism. POCUS confirmation of intrauterine pregnancy rules out an ectopic pregnancy. In the third trimester of high-risk pregnancies, umbilical artery Doppler ultrasonography can improve perinatal outcomes. Musculoskeletal POCUS is used to diagnose and guide treatment of many joint and soft tissue conditions. It is as accurate as magnetic resonance imaging in the diagnosis of complete rotator cuff tears. Ultrasound guidance improves outcomes in the placement of central venous catheters and fluid drainage from body cavities and lumbar punctures. Ultrasonography can reduce the use of CT for diagnosis of appendicitis; however, negative scan results do not rule out disease. POCUS can accurately diagnose and rule out gallbladder pathology, and is effective for diagnosing urolithiasis. Focused cardiac ultrasonography can detect pericardial effusion and decreased systolic function, but is less accurate than lung ultrasonography at diagnosing acute heart failure. Limited evidence demonstrates a benefit of diagnosing testicular and gynecologic conditions. The American College of Emergency Physicians, the American Institute of Ultrasound in Medicine, the Society for Academic Emergency Medicine, the American College of Radiology, and others offer POCUS training. Training standards for POCUS have been defined for residency programs but are less established for credentialing.

Ubiquitylation-dependent regulation of NEIL1 by Mule and TRIM26 is required for the cellular DNA damage response.

Endonuclease VIII-like protein 1 (NEIL1) is a DNA glycosylase involved in initiating the base excision repair pathway, the major cellular mechanism for repairing DNA base damage. Here, we have purified the major E3 ubiquitin ligases from human cells responsible for regulation of NEIL1 by ubiquitylation. Interestingly, we have identified two enzymes that catalyse NEIL1 polyubiquitylation, Mcl-1 ubiquitin ligase E3 (Mule) and tripartite motif 26 (TRIM26). We demonstrate that these enzymes are capable of polyubiquitylating NEIL1 in vitro, and that both catalyse ubiquitylation of NEIL1 within the same C-terminal lysine residues. An siRNA-mediated knockdown of Mule or TRIM26 leads to stabilisation of NEIL1, demonstrating that these enzymes are important in regulating cellular NEIL1 steady state protein levels. Similarly, a mutant NEIL1 protein lacking residues for ubiquitylation is more stable than the wild type protein in vivo We also demonstrate that cellular NEIL1 protein is induced in response to ionising radiation (IR), although this occurs specifically in a Mule-dependent manner. Finally we show that stabilisation of NEIL1, particularly following TRIM26 siRNA, contributes to cellular resistance to IR. This highlights the importance of Mule and TRIM26 in maintaining steady state levels of NEIL1, but also those required for the cellular DNA damage response.

The MRCI with juvenile detainees: optimizing performance or emphasizing ecological validity?

The Miranda Rights Comprehension Instruments (MRCI) are intended to be administered to legally involved youths in a setting free from distractions and stressors with the explicit goal of assessing the examinee's best understanding. However, marked disparities have been observed between juveniles' MRCI performance and their unassisted recall of a representative Miranda warning. We hypothesized that youths' very strong MRCI performance might be partially due to prompts and clarifications used whenever incomplete or ambiguous answers are provided. In this archival study, we systematically re-scored three MRCI instruments from 231 legally involved youths to evaluate their original responses (i.e., non-queried scoring). This approach is viewed as more ecologically valid because actual Miranda warnings are typically provided in a routine manner without assistance following each Miranda component. For the large majority of legally involved juveniles, only small differences were noted between standard and non-queried scoring. However, some dramatic decrements were observed, especially on the Comprehension of Miranda Rights-II (CMR-II). More specifically, 15.7% of CMR-II percentiles dropped precipitously by 60% or more, when using the non-queried scores. The results are discussed within the context of optimized performances versus ecological validity as applied to Miranda evaluations.

A Sugar-Derived Room-Temperature Sodium Sulfur Battery with Long Term Cycling Stability.

We demonstrate a room-temperature sodium sulfur battery based on a confining microporous carbon template derived from sucrose that delivers a reversible capacity over 700 mAh/gS at 0.1C rates, maintaining 370 mAh/gS at 10 times higher rates of 1C. Cycling at 1C rates reveals retention of over 300 mAh/gS capacity across 1500 cycles with Coulombic efficiency >98% due to microporous sulfur confinement and stability of the sodium metal anode in a glyme-based electrolyte. We show sucrose to be an ideal platform to develop microporous carbon capable of mitigating electrode-electrolyte reactivity and loss of soluble intermediate discharge products. In a manner parallel to the low-cost materials of the traditional sodium beta battery, our work demonstrates the combination of table sugar, sulfur, and sodium, all of which are cheap and earth abundant, for a high-performance stable room-temperature sodium sulfur battery.

Anode-Free Sodium Battery through in Situ Plating of Sodium Metal.

Sodium-ion batteries (SIBs) have been pursued as a more cost-effective and more sustainable alternative to lithium-ion batteries (LIBs), but these advantages come at the expense of energy density. In this work, we demonstrate that the challenge of energy density for sodium chemistries can be overcome through an anode-free architecture enabled by the use of a nanocarbon nucleation layer formed on Al current collectors. Electrochemical studies show this configuration to provide highly stable and efficient plating and stripping of sodium metal over a range of currents up to 4 mA/cm2, sodium loading up to 12 mAh/cm2, and with long-term durability exceeding 1000 cycles at a current of 0.5 mA/cm2. Building upon this anode-free architecture, we demonstrate a full cell using a presodiated pyrite cathode to achieve energy densities of ∼400 Wh/kg, far surpassing recent reports on SIBs and even the theoretical maximum for LIB technology (387 Wh/kg for LiCoO2/graphite cells) while still relying on naturally abundant raw materials and cost-effective aqueous processing.

Ultrafast Solvent-Assisted Sodium Ion Intercalation into Highly Crystalline Few-Layered Graphene.

A maximum sodium capacity of ∼35 mAh/g has hampered the use of crystalline carbon nanostructures for sodium ion battery anodes. We demonstrate that a diglyme solvent shell encapsulating a sodium ion acts as a "nonstick" coating to facilitate rapid ion insertion into crystalline few-layer graphene and bypass slow desolvation kinetics. This yields storage capacities above 150 mAh/g, cycling performance with negligible capacity fade over 8000 cycles, and ∼100 mAh/g capacities maintained at currents of 30 A/g (∼12 s charge). Raman spectroscopy elucidates the ordered, but nondestructive cointercalation mechanism that differs from desolvated ion intercalation processes. In situ Raman measurements identify the Na(+) staging sequence and isolates Fermi energies for the first and second stage ternary intercalation compounds at ∼0.8 eV and ∼1.2 eV.

Falls in critical care: a local review to identify incidence and risk.

BACKGROUND: Patient falls are the most common adverse event in hospitals, resulting in devastating physical, psychological and financial consequences. Therefore the emphasis on falls assessment and prevention is a key priority. Within hospitals those reported at greatest risk of falls are older patients with little known about the factors within critical care. At a local level, a practice development project was identified to review risk factors contributing to falls in critical care. AIMS: To identify the incidence of falls within adult critical care and the risk factors most likely to contribute to a fall. METHODS: Reported falls incidents were reviewed retrospectively using a local incident reporting system, over a 2-year period from four critical care units. FINDINGS: Forty-two incidents were reviewed indicating a low rate of injury and low rate of occurrence (0·99 falls/1000 bed days). The median age of fallers was 58 years and the most common risk factor for falls was confusion or agitation, followed by patients attempting to mobilize against advice. DISCUSSION: Critically ill patients were less likely to fall and were more likely to be younger than patients falling on an acute care ward. Neuroscience/trauma critically ill patients were more likely to fall than general critically ill patients; this was expected to be because of the increased presence of confusion or agitation in this group. The local system used to report falls produced difficulties in identifying risk factors in a consistent way. Although limitations exist, this review has enabled the development of more suitable local critical care falls risk factor assessment and interventions to minimize the risk of falling. CONCLUSIONS: Fall rates, related injuries and circumstances of falls vary considerably among acute care and critical care specialities. Future work should concentrate on better falls reporting systems and further research should include validating risk factors for critical care falls.

The issue of consent in medical practice.

Following a recent court judgment, legal and moral issues surrounding consent have been thrown into the spotlight. Elizabeth Larner, Solicitor, and Rachel Carter, Partner, of Wollen Michelmore LLP, look at the issues surrounding consent, including where problems arise in the fields of clinical negligence and non-accidental injury and what health care professionals can do to ensure that their advice to a patient about a procedure or treatment is sufficiently cogent and appropriately recorded so as to avoid later criticism and possible legal action. This annotation gives an overview of the legal principles surrounding consent in medical practice including informed consent, refusal of treatment and issues of capacity.

Tumour but not stromal expression of ß3 integrin is essential, and is required early, for spontaneous dissemination of bone-metastatic breast cancer.

Although many preclinical studies have implicated ß3 integrin receptors (αvß3 and αIIbß3) in cancer progression, ß3 inhibitors have shown only modest efficacy in patients with advanced solid tumours. The limited efficacy of ß3 inhibitors in patients could arise from our incomplete understanding of the precise function of ß3 integrin and, consequently, inappropriate clinical application. Data from animal studies are conflicting and indicate heterogeneity with respect to the relative contributions of ß3-expressing tumour and stromal cell populations in different cancers. Here we aimed to clarify the function and relative contributions to metastasis of tumour versus stromal ß3 integrin in clinically relevant models of spontaneous breast cancer metastasis, with particular emphasis on bone metastasis. We show that stable down-regulation of tumour ß3 integrin dramatically impairs spontaneous (but not experimental) metastasis to bone and lung without affecting primary tumour growth in the mammary gland. Unexpectedly, and in contrast to subcutaneous tumours, orthotopic tumour vascularity, growth and spontaneous metastasis were not altered in mice null for ß3 integrin. Tumour ß3 integrin promoted migration, protease expression and trans-endothelial migration in vitro and increased vascular dissemination in vivo, but was not necessary for bone colonization in experimental metastasis assays. We conclude that tumour, rather than stromal, ß3 expression is essential and is required early for efficient spontaneous breast cancer metastasis to bone and soft tissues. Accordingly, differential gene expression analysis in cohorts of breast cancer patients showed a strong association between high ß3 expression, early metastasis and shorter disease-free survival in patients with oestrogen receptor-negative tumours. We propose that ß3 inhibitors may be more efficacious if used in a neoadjuvant setting, rather than after metastases are established.

An Examination of Juveniles' Miranda Abilities: Investigating Differences in Miranda Recall and Reasoning.

Juvenile suspects are routinely expected to possess an accurate recall of written or oral Miranda warnings. This study addresses the Miranda-related comprehension recall and reasoning of legally involved juveniles. It is the first juvenile research to compare systematically two levels of complexity for Miranda warnings with the three modalities (oral, written, or combined) of administration. Unexpectedly, easily read written warnings marginally outperformed the combined modality. In order to examine Miranda reasoning, three juvenile groups were operationalized: impaired, questionable, and likely adequate. Predictably, the impaired and questionable groups possessed significantly lower verbal abilities than the likely-adequate reasoning group. In addition, the likely-adequate group exhibited the strongest appreciation of the adversarial context in which Miranda waiver decisions are rendered. The discussion addresses the marked disparities in Miranda recall from a total recall versus component-by-component understanding of Miranda rights. It also considers more generally how crucially important Miranda misconceptions might be remedied. Copyright © 2016 John Wiley & Sons, Ltd.