T cells targeting a neuronal paraneoplastic antigen mediate tumor rejection and trigger CNS autoimmunity with humoral activation.

Paraneoplastic neurologic diseases (PND) involving immune responses directed toward intracellular antigens are poorly understood. Here, we examine immunity to the PND antigen Nova2, which is expressed exclusively in central nervous system (CNS) neurons. We hypothesized that ectopic expression of neuronal antigen in the periphery could incite PND. In our C57BL/6 mouse model, CNS antigen expression limits antigen-specific CD4+ and CD8+ T-cell expansion. Chimera experiments demonstrate that this tolerance is mediated by antigen expression in nonhematopoietic cells. CNS antigen expression does not limit tumor rejection by adoptively transferred transgenic T cells but does limit the generation of a memory population that can be expanded upon secondary challenge in vivo. Despite mediating cancer rejection, adoptively transferred transgenic T cells do not lead to paraneoplastic neuronal targeting. Preliminary experiments suggest an additional requirement for humoral activation to induce CNS autoimmunity. This work provides evidence that the requirements for cancer immunity and neuronal autoimmunity are uncoupled. Since humoral immunity was not required for tumor rejection, B-cell targeting therapy, such as rituximab, may be a rational treatment option for PND that does not hamper tumor immunity.

High Rates of COVID-19 Infection Among Indigenous Maya at a US Safety-Net Health System in California.

Coronavirus disease 2019 (COVID-19) has disproportionately and negatively affected communities of color in the United States, especially Black, Latinx, and Indigenous populations. We report a cluster of COVID-19 cases among the Maya in Alameda County, California, most of whom were misclassified in public health data as nonindigenous Spanish-speaking people. We conducted a retrospective cohort study of all COVID-19 tests performed from April 1 through May 31, 2020, at Alameda Health System. A total of 1561 tests from 1533 patients were performed, with an overall test positivity rate of 17.0% (N = 265). We used the language field from the electronic health record to identify 29 patients as speaking an indigenous Mayan language; by medical record review, we identified 52 additional Maya patients. Maya patients had a test positivity rate of 72.8% as compared with 27.1% (P < .001) for nonindigenous Latinx patients and 8.2% (P < .001) for all other patients. In our sample, 39.6% of patients who had a positive test result for COVID-19 were hospitalized, 11.3% required admission to the intensive care unit (ICU), and 4.9% died of COVID-19. Maya patients had lower rates of hospitalization, ICU admission, and 30-day in-hospital mortality than non-Maya patients. We shared our data with the county health department to inform responses for education, testing, and isolation for Maya patients in Alameda County. Ongoing COVID-19 public health efforts should assess the community prevalence of COVID-19 in the Maya community and other indigenous communities and implement interventions that are linguistically and culturally appropriate.

Patient and Physician Race and the Allocation of Time and Patient Engagement Efforts to Mental Health Discussions in Primary Care: An Observational Study of Audiorecorded Periodic Health Examinations.

This study investigated racial differences in patient-physician communication around mental health versus biomedical issues. Data were collected from audiorecorded periodic health examinations of adults with mental health needs in the Detroit area (2007-2009). Patients and their primary care physicians conversed for twice as long, and physicians demonstrated greater empathy during mental health topics than during biomedical topics. This increase varied by patient and physician race. Patient race predicted physician empathy, but physician race predicted talk time. Interventions to improve mental health communication could be matched to specific populations based on the separate contributions of patient and physician race.

Patients with mental health needs are engaged in asking questions, but physicians' responses vary.

Increased patient engagement is of particular interest regarding patients with mental health needs, given the high burden of mental illness in the United States and the potential for greater patient engagement to improve health outcomes. Little is known about the extent to which these patients ask questions of their physicians; how physicians respond; and what the relationship is between patients' questions and visit outcomes. We conducted in-depth mixed-method analyses of 322 audio recordings of primary care visits by people with mental health needs. We found that patients asked many questions-a median of fifteen per visit-but that they were more likely to ask about biomedical topics, such as diabetes, than about mental health topics. Patients received highly varied responses from physicians. Our findings suggest that efforts aimed at improving patient engagement should move beyond simply encouraging patients to ask questions. The goal should also be to support physicians in recognizing patients' concerns and providing the most responsive answers, as well as promoting strong relationships to undergird communication among all members of the care team.

Effectiveness of provider incentives for anaemia reduction in rural China: a cluster randomised trial.

OBJECTIVES: To test the impact of provider performance pay for anaemia reduction in rural China. DESIGN: A cluster randomised trial of information, subsidies, and incentives for school principals to reduce anaemia among their students. Enumerators and study participants were not informed of study arm assignment. SETTING: 72 randomly selected rural primary schools across northwest China. PARTICIPANTS: 3553 fourth and fifth grade students aged 9-11 years. All fourth and fifth grade students in sample schools participated in the study. INTERVENTIONS: Sample schools were randomly assigned to a control group, with no intervention, or one of three treatment arms: (a) an information arm, in which principals received information about anaemia; (b) a subsidy arm, in which principals received information and unconditional subsidies; and (c) an incentive arm, in which principals received information, subsidies, and financial incentives for reducing anaemia among students. Twenty seven schools were assigned to the control arm (1816 students at baseline, 1623 at end point), 15 were assigned to the information arm (659 students at baseline, 596 at end point), 15 to the subsidy arm (726 students at baseline, 667 at end point), and 15 to the incentive arm (743 students at baseline, 667 at end point). MAIN OUTCOME MEASURES: Student haemoglobin concentrations. RESULTS: Mean student haemoglobin concentration rose by 1.5 g/L (95% CI -1.1 to 4.1) in information schools, 0.8 g/L (-1.8 to 3.3) in subsidy schools, and 2.4 g/L (0 to 4.9) in incentive schools compared with the control group. This increase in haemoglobin corresponded to a reduction in prevalence of anaemia (Hb <115 g/L) of 24% in incentive schools. Interactions with pre-existing incentives for principals to achieve good academic performance led to substantially larger gains in the information and incentive arms: when combined with incentives for good academic performance, associated effects on student haemoglobin concentration were 9.8 g/L (4.1 to 15.5) larger in information schools and 8.6 g/L (2.1 to 15.1) larger in incentive schools. CONCLUSIONS: Financial incentives for health improvement were modestly effective. Understanding interactions with other motives and pre-existing incentives is critical. TRIAL REGISTRATION NUMBER: ISRCTN76158086.

High prevalence of Wuchereria bancrofti infection as detected by immunochromatographic card testing in five districts of Orissa, India, previously considered to be non-endemic.

India accounts for over one-third of the world's burden of lymphatic filariasis (LF). Although most coastal districts of Orissa state (eastern India) are LF-endemic, the western districts of Orissa are considered non-endemic. During a large-scale insecticide-treated bed net/microfinance trial, we tested one randomly selected adult (age 15-60 years) for LF from a random sample of microfinance-member households in five districts of western Orissa, using immunochromatographic card testing (ICT). Overall, 354 (adjusted prevalence 21%, 95%CI 17-25%) of 1563 persons were ICT positive, with district-wide prevalence rates ranging from 15-32%. This finding was not explained by immigration, as only 3% of subjects had ever lived in previously known LF-endemic districts. These results therefore suggest ongoing autochthonous transmission in districts where LF control programs are not operational. Our results highlight the importance of broad, systematic surveillance for LF in India and call for the implementation of LF control programs in our study districts.