Citations

The impact of airway inflammation is mediated by pro-inflammatory cytokines such as tumor necrosis factor alpha (TNFα), which underlies several respiratory diseases, including COVID-19, asthma, chronic bronchitis, and chronic obstructive pulmonary disease (COPD). In human airway smooth muscle (hASM) cells, exposure to TNFα leads to an accumulation of unfolded proteins in the ER, which triggers a homeostatic ER stress response activating a signaling cascade to restore normal function. Previously, we showed that TNFα selectively activates the inositol-requiring enzyme 1α (IRE1α)/X-box binding protein 1 (XBP1) ER stress pathway in hASM cells. Most likely, the protein unfolding in hASM cells caused by TNFα results from an increase in reactive oxygen species (ROS) formation. We hypothesize that ER stress induced by TNFα is mitigated by the ROS scavenger TEMPOL. Primary hASM cells were isolated from bronchiolar tissue samples obtained from 5 patients (both sexes included) who had no history of respiratory diseases. hASM cells were serum deprived for 48 h before treatment with 1) TNFα (20 ng/ml) for 12 h; 2) TEMPOL (500 μM) for 30 min followed by TNFα (20 ng/ml) for 12 h; and 3) untreated control for 12 h. At the end of the treatment period, hASM cells were processed for determination of protein expression through Western blotting. Activation of the ER stress response was assessed by phosphorylation of IRE1α and splicing of XBP1. Confirming our previous results, we found that 12 h TNFα exposure induced an ER stress response in hASM cells, evidence by phosphorylation of IRE1α and XBP1 splicing. Treating hASM cells with TEMPOL before exposure to TNFα mitigated the ER stress response. These results support our hypothesis and indicate that ROS scavenging prevents TNFα induced protein unfolding and triggering of the IRE1α/XBP1 ER stress pathway. R01HL 157984 (GCS) This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Skeletal muscle’s isometric contractile properties are one of the classic structure-function relationships in all of physiology allowing for extrapolation of single fiber mechanical properties to whole muscle properties based on the muscle’s optimal fiber length and physiological cross-sectional area (PCSA). However, this relationship has only been validated in small animals and then extrapolated to human muscles which are much larger in terms of length and PCSA. We leveraged a unique surgical technique in which an intact, living, human gracilis muscle is transferred from the thigh to the arm, restoring elbow flexion after brachial plexus injury. During this surgery we directly measured subject specific gracilis muscle force-length relationship in situ and properties ex vivo. We hypothesized that the human gracilis would have a functional fiber length of about 23 cm, based on the anatomical literature, and a specific tension of 225 kPa, based on the physiological literature. Data are provided as mean±standard deviation of the mean. Twelve subjects (7 males, average age 54±12 years). In situ passive and active tension were directly measured using a buckle force transducer (BFT) placed on the distal gracilis tendon. Passive tension was measured in each of four joint configurations (JC) prior to muscle stimulation, and, to produce active tension, the anterior branch of the obturator nerve was stimulated. The muscle was progressively lengthened by extending the knee and abducting the hip. Since we could not measure optimal fiber length directly in our subjects during isometric testing we used a functional surrogate for optimal fiber length, the full-width at half-maximum (FWHM) defined from their force vs. length relationship. The FWHM is the width of the active force vs. muscle length curve at half the maximum force. A linear relationship between FWHM and optimal fiber length has been established across several mammalian species and muscles. Thus, to calculate FWHM, we fit each patient’s calculated fully active force vs. muscle length data to a quadratic curve and then calculated width at half the calculated maximum force from the equation. Optimal fiber length was then calculated from the previously established linear relationship between FWHM and optimal fiber length. Each subject’s PCSA was calculated from their muscle volume and optimal fiber length.From these experimental data we established a human muscle fiber-specific tension of 171±84 kPa (n=12). We also determined the average gracilis optimal fiber length was 12.9±3.3 cm (n=12). Surprisingly, these fiber lengths were about half of the previously reported optimal fascicle lengths of 23 cm. Thus, the long gracilis muscle appears to be composed of relatively short fibers acting in parallel that may not have been appreciated based on traditional anatomical methods. We thus suggest that the value of 171 kPa be considered the best current estimate of human muscle specific tension. This work was supported the Department of Veterans Affairs grant 1 I01 RX002462 and, in part, by Research Career Scientist Award Number IK6 RX003351 from the United States (U.S.) Department of Veterans Affairs Rehabilitation R&D (Rehab RD) Service. Pilot projects leading to this protocol were supported by the Shirley Ryan AbilityLab Catalyst Grant Program, National Science Foundation Graduate Research Fellowship under Grant No. 1255833 and the Mayo Clinic Graduate School. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Sarcopenia is defined as age-related atrophy of muscle fibers as well as a decrease in specific force (force per cross-sectional area). In the rat diaphragm muscle (DIAm), sarcopenia primarily affects type IIx/IIb fibers that generate greater specific force, have the fastest maximum shortening velocities, but display greater fatigue with repeated activation. We hypothesized that as a result of sarcopenia, maximum shortening velocity and power output of the DIAm decrease with age. DIAm strips ~2-3 mm wide were excised from 6-month and 24-month female (n=4 per age group) and male (n=4 per age group) rats. DIAm strips were suspended in a tissue chamber containing Rees–Simpson solution maintained at 26oC, with the costal margin clamped and the central tendon attached to a Cambridge Dual-Mode force/length transducer. To determine maximum isometric specific force, DIAm strips were stimulated using platinum plate electrodes with supramaximal current (~250 mA) pulses (1 ms) at 75 Hz delivered in 1-s duration train. The muscle strips were then allowed to shorten over a 30-ms period against different percentages of maximum isometric load. Based on the load/velocity relationship, the maximum shortening velocity (Vmax) and peak power output were determined. Subsequently, the muscle strip was repetitively stimulated and allowed to shorten at 30% maximum load (approximating peak power output). In this protocol, the muscle strip was stimulated at 75 Hz an generated isometric force during the initial 225 ms of the 330 ms duration train the muscle. Thereafter, the load was reduced to 30% maximum and the muscle strip was allowed to shorten for the subsequent 105 ms. Finally, the DIAm strip was stretched to ~150% its resting length (corresponding to optimal sarcomere length) and rapidly frozen in melting isopentane. Transverse serial sections of DIAm fibers were cut, and fiber types identified by immunoreactivity to specific myosin heavy chain (MyHC) isoforms. As previously observed, the cross-sectional areas of type IIx/IIb DIAm fibers and maximum isometric specific force were reduced in 24-month compared to 6-month rats confirming sarcopenia. The maximum shortening velocity of the DIAm in 24-month rats was slower than in the 6-month rats and peak power output of the DIAm was reduced in 24-month rats. The duration during which peak power output could be maintained (i.e., endurance) of the DIAm was prolonged in 24-month compared to 6-month rats (120 s vs 60 s, respectively). These results support our hypothesis that aging affects maximum shortening velocity and peak power output of the DIAm. It is important to note that endurance of the DIAm is preserved, consistent with resilience of breathing motor function in old age. Research supported by NIH grant AG44615 This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Background: Hemoglobin, the primary oxygen-carrying protein in humans, provides the intermediate link between pulmonary oxygen uptake and tissue oxygen consumption. Oxygen transport is greatly influenced by the hemoglobin-oxygen affinity, which is commonly characterized by the metric P50 - defined as the oxygen tension at which 50% of hemoglobin is saturated. Humans with rare hemoglobin mutations causing a low P50 (high hemoglobin-oxygen affinity) have demonstrated remarkable preservation of exercise tolerance at high altitude conditions (~3,000m). However, the influence of a low P50 on V̇O2max at extreme altitudes (>5,500m) remains largely unexamined. To examine the dependence of V̇O2max on P50 and altitude, we developed a computational model of oxygen uptake and utilization. We hypothesized that a low P50 would result in a better maintained V̇O2max at extreme altitudes compared to conditions of normal P50 and high P50 (low hemoglobin-oxygen affinity). Methods: We created a model that couples pulmonary oxygen uptake with systemic oxygen utilization to estimate V̇O2max as a function of P50, hemoglobin concentration, and altitude. Fixed values for cardiac output and tissue oxygen demand for V̇O2max at sea level were assigned in accordance with experimental data. The pulmonary oxygen uptake model assumes a single blood compartment exposed to alveolar gas, from which the arterial oxygen tension may be estimated from venous input. Using the alveolar gas equation, we interpolated respiratory parameters from data obtained during human sojourn to the summit of Everest. The systemic oxygen utilization model uses arterial input parameters along with Michaelis-Menten kinetics to compute oxygen consumption. The Fick principle was used to determine the venous oxygen tension, which was assumed to approximate tissue oxygen tension. From these values, systemic oxygen extraction and V̇O2max were determined as a function of P50, hemoglobin concentration, and altitude. Results: We present the results for several cases of P50 (low, normal, and high) and hemoglobin concentrations as a function of altitude. For a low P50, the model demonstrated a greater arterial oxygen saturation, greater oxygen content, and lower systemic extraction at extreme altitudes compared to values determined for cases of normal and high P50. Additionally, a low P50 led to better maintenance of V̇O2max at ~8,850m (~38% decrease from sea-level V̇O2max) compared to values determined for normal P50 and high P50 (~53% and ~67% decrease from sea-level V̇O2max, respectively, P<0.05). Conclusion: This model demonstrates the importance of P50 in the determination of V̇O2max at various altitudes. At low altitudes, a low P50 does not confer an advantage in terms of oxygen utilization, likely due to diffusive oxygen limitations. However, at high and extreme altitudes, a greater convective oxygen transport associated with a low P50 likely outweighs impairments in oxygen diffusivity. This project was supported by the National Institutes of Health R-35-HL139854. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Aim: We have developed StomachSim, an in-silico simulator that is designed to simulate the biomechanics and fluid mechanics of a wide range of gastric conditions as well as gastric surgical procedures. Here we demonstrate its use in quantifying the effects of motility disorders and pyloroplasty on the hydrolysis and emptying of a liquid meal inside the stomach. Methods: A physiologically realistic model of the stomach, including the antral motility, is synthesized based on in-vivo imaging, and the mixing and gastric emptying are simulated using computational fluid dynamics (CFD). The enzymatic biochemistry for protein hydrolysis is also implemented by incorporating the secretion of a proteolytic enzyme from the proximal stomach walls and the subsequent enzymatic reaction with the protein dissolved in the liquid meal. Using this model, we measured the effect of stomach motility and the diameter of the pyloric orifice on the retropulsive and pyloric jets, the rate of hydrolysis in different regions, and the emptying of gastric contents. Results: This study presents a proof-of-concept for the application of StomachSim in gastric disorders and surgeries. The emptying rate of our model for the healthy case agreed with the in-vivo measurements of similar caloric density liquid meals. A stomach with a 50% lower motility amplitude had a 35% lower net emptying rate and a 41% lower emptying rate of the hydrolyzed protein. Furthermore, the emptying rate showed a non-linear variation with respect to the motility of the stomach. For a simulated pyloroplasty procedure where the pyloric orifice diameter is doubled and the orifice stays open permanently, the emptying rate of the lower motility case doubled over its original value. Conclusion: StomachSim offers a novel and potentially effective modality for examining the effect of gastric conditions and gastric surgical procedures on gastric function. Our simulations show that gastroparesis and pyloroplasty not only affect the emptying rate but also alter the mixing of contents thereby changing the rate of hydrolysis. The model helped quantify the changes in the flow of contents in the antro-duodenal region for varying degrees of gastroparesis and pyloroplasty. The authors acknowledge support from NSF award CBET 2019405 and NIH award 1R21GM139073-01. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

BACKGROUND AND OBJECTIVES: No new drug has improved survival for glioblastoma since temozolomide in 2005, due in part to the relative inaccessibility of each patientʼs individualized tumor biology and its response to therapy. We have identified a conserved extracellular metabolic signature of enhancing high-grade gliomas enriched for guanidinoacetate (GAA). GAA is coproduced with ornithine, the precursor to protumorigenic polyamines through ornithine decarboxylase (ODC). AMXT-1501 is a polyamine transporter inhibitor that can overcome tumoral resistance to the ODC inhibitor, difluoromethylornithine (DFMO). We will use DFMO with or without AMXT-1501 to identify candidate pharmacodynamic biomarkers of polyamine depletion in patients with high-grade gliomas in situ . We aim to determine (1) how blocking polyamine production affects intratumoral extracellular guanidinoacetate abundance and (2) the impact of polyamine depletion on the global extracellular metabolome within live human gliomas in situ. METHODS: DFMO, with or without AMXT-1501, will be administered postoperatively in 15 patients after clinically indicated subtotal resection for high-grade glioma. High–molecular weight microdialysis catheters implanted into residual tumor and adjacent brain will be used for postoperative monitoring of extracellular GAA and polyamines throughout therapeutic intervention from postoperative day (POD) 1 to POD5. Catheters will be removed on POD5 before discharge. EXPECTED OUTCOMES: We anticipate that GAA will be elevated in tumor relative to adjacent brain although it will decrease within 24 hours of ODC inhibition with DFMO. If AMXT-1501 effectively increases the cytotoxic impact of ODC inhibition, we expect an increase in biomarkers of cytotoxicity including glutamate with DFMO + AMXT-1501 treatment when compared with DFMO alone. DISCUSSION: Limited mechanistic feedback from individual patientsʼ gliomas hampers clinical translation of novel therapies. This pilot Phase 0 study will provide in situ feedback during DFMO + AMXT-1501 treatment to determine how high-grade gliomas respond to polyamine depletion.

Type 2 diabetes mellitus (T2DM) is a metabolic disorder characterized by hyperglycemia, insulin resistance, and pancreatic islet cell dysfunction. T2DM is associated with non-alcoholic fatty liver disease (NAFLD) because of impaired glucose metabolism in both conditions. However, it is widely assumed that people with T2DM in sub-Saharan Africa (SSA) have a lower prevalence of NAFLD than in other parts of the world. With our recent access to transient elastography, we aimed to investigate the prevalence of, severity of, and contributing factors to NAFLD in persons with T2DM in Ghana. We performed a cross-sectional study recruiting 218 individuals with T2DM at the Kwadaso Seventh-Day Adventist and Mount Sinai Hospitals in the Ashanti region of Ghana using a simple randomized sampling technique. A structured questionnaire was used to obtain socio-demographic information, clinical history, exercise and other lifestyle factors, and anthropometric measurements. Transient elastography was performed using a FibroScan® machine to obtain the Controlled Attenuation Parameter (CAP) score and liver fibrosis score. The prevalence of NAFLD among Ghanaian T2DM participants was 51.4% (112/218), of whom 11.6% had significant liver fibrosis. An evaluation of the NAFLD group (n = 112) versus the non-NAFLD group (n = 106) revealed a higher BMI (28.7 vs. 25.2 kg/m2, p = 0.001), waist circumference (106.0 vs. 98.0 cm, p = 0.001), hip circumference (107.0 vs. 100.5 cm, p = 0.003), and waist-to-height ratio (0.66 vs. 0.62, p = 0.001) in T2DM patients with NAFLD compared to those without NAFLD. Being obese was an independent predictor of NAFLD in persons with T2DM than known history of hypertension and dyslipidaemia.

AbstractBeta‐lactam therapeutic drug monitoring (TDM) can improve precision dosing and clinical outcomes in critically ill patients, but has not been implemented widely in the United States. Mayo Clinic recently implemented a beta‐lactam TDM program. This single‐center experience forms the basis of the manuscript which outlines practical considerations involved with beta‐lactam TDM implementation, including the pharmacist's role as a leader. Our implementation effort focused on three primary domains. First, we aimed to ensure a supportive organizational infrastructure. Early leadership engagement by the pharmacist‐led core team facilitated advocacy for the clinical need, allocation of resources, and assay development. Second, core clinical workflows were developed that addressed the preferred patient population for use, desirable pharmacokinetic and pharmacodynamic targets, and the preferred sampling strategy. Clinical tools to guide pharmacists in interpreting the results (e.g., pharmacokinetics calculator) and documenting decisions were developed. Third, stakeholders were offered repeated exposure to evidence and expertise to facilitate understanding and application of the new practice. This act of ‘individual internalization’ seems to be uniquely important to beta‐lactam TDM implementation compared with the implementation of other antimicrobial TDM programs. Educational strategies and supportive materials that were developed were focused on providing substantive and varied information tailored to the stakeholders' role in the process. For pharmacists, this included both clinical and operational considerations. A continuous improvement plan to support management of the process was instituted to address necessary updates and changes that inevitably emerged. In summary, the described approach to implementation of a pharmacist‐led beta‐lactam TDM program could be used as a roadmap to aid other institutions that aim to develop such a program.

Abstract Introduction Hypoglossal nerve stimulation (HNS) for the treatment of obstructive sleep apnea (OSA) in patients who have failed positive airway pressure (PAP) therapy for one reason or the other is now standard of care. Once the device is implanted and activated, voltage to stimulate the nerve has to be titrated over time, ultimately leading to an HNS titration study. There are 4 possible electrode configurations to stimulate different fibers in the nerve that can be employed for treatment. We present a case of a patient who was a challenge with worsening of OSA with Inspire. Report of case(s) A 65-year-old woman with hypertension, and severe OSA, intolerant of positive airway pressure or oral appliances was implanted with Inspire. Post activation, there was symptomatic improvement with reduction of overall apnea-hypopnea index (AHI) from 34 per hour of sleep to 6.3 per hour. However, patient slept exclusively on the sides with evidence of significant residual disease in REM sleep. During subsequent weeks, patent reported inability to restrict position and discomfort and anxiety associated with up titration. Both awake endoscopy and advanced overnight HNS titration were pursued. All 4 electrode configurations were tested during both procedures. With the exception of (minus-plus-minus) configuration, there was worsening of sleep disordered breathing and higher residual AHI of 60 per hour on polysomnography and evidence of poor tongue motion and collapsed velopharynx on awake endoscopy. Inspire settings were readjusted to (minus-plus-minus) configuration with instructions for very slow outpatient uptitration and co-management of anxiety and discomfort with anxiolytics and sleep aids. Conclusion We make two important conclusions from this case. Firstly, although there are established criteria for patient selection for hypoglossal nerve stimulation therapy, certain other factors that impact success which are not as easily defined include the patients’ expectations, tolerance of discomfort, propensity to anxiety and personality type which impact the ability to successfully titrate voltage with the Inspire device over time. Secondly, as the tongue is a complex muscle, both under titration and over titration may be counterproductive and additionally, electrode configuration may also have varying effects on tongue protrusion and impact success. Support (if any)

Abstract Introduction Multisystem atrophy (MSA) is a neurological degenerative progressive disease affecting multiple systems. These patients are frequently seen in the sleep clinic at specialty centers by sleep neurologists for co-management of sleep disordered breathing and nocturnal respiratory issues. Stridor is a life-threatening condition seen in these patients and requires emergent action. We present a case of MSA with worsening stridor that was missed in the era of virtual telemedicine. Report of case(s) A 53-year-old female with a history of obstructive sleep apnea (OSA) on BiPAP S and multiple system atrophy with parkinsonian subtype presented virtually to sleep clinic for follow up evaluation of her sleep disordered breathing. Six months prior to her visit she was noted to have bilateral vocal fold hypomobility without stridor. At that time, she had a residual apnea-hypopnea index (AHI) of 1.4 with BiPAP-S 16/13 cm H2O and no nocturnal stridor. She was wheelchair bound. She had routine follow up visits with various providers however these were telemedicine visits with her husband doing most of the talking due to weakness. Over the next 5 months she had worsening fatigue and was using BiPAP S during the day intermittently and was referred to the sleep medicine clinic for consideration of supplemental oxygen at night. A repeat overnight oximetry revealed residual oxygen desaturation index (ODI) of 2.5/hr while on BiPAP S. Repeat pulmonary function testing was ordered and patient was recommended to return for immediate in person follow up. When seen in person, patient was noted to have significant stridor which had been ongoing and worsening over last few months including being appreciated while on PAP therapy. Emergent same-day ENT consultation was arranged by sleep providers. Posterior cordectomy was performed shortly thereafter. The patient was scheduled for an AVAPS titration study. Conclusion In cases with progressive neuromuscular disease, stridor may be missed during virtual appointments for a variety of reasons including technical difficulties, or the virtual medium not being sensitive enough to convey stridor. This case highlights the importance of having a high index of suspicion for stridor and impending respiratory failure requiring emergent intervention in patients with neuromuscular disease. Support (if any)