Immune responses against neuraminidase (NA) and hemagglutinin (HA) are critical for developing effective influenza vaccines, yet their role in influenza transmission remains unclear. We conducted household transmission studies in Managua, Nicaragua, to assess the impact of anti-NA and anti-HA antibodies induced by natural infection on influenza A/H3N2 susceptibility and infectivity. Using mathematical models capturing household transmission dynamics, we found that high pre-existing antibody levels against the HA head (>31, [95% CrI 13-67]), HA stalk (>35, [95% CrI 11-66]), and NA (>31, [95% CrI 12-68]) are associated with reduced susceptibility to infection (relative susceptibility: HA head, 0.63 [95% CrI 0.42-0.98]; HA stalk, 0.66 [95% CrI 0.44-0.99]; NA, 0.49 [95% CrI 0.30-0.76]). HA stalk (>58 [95% CrI: 47-70]) and NA (>27 [95% CrI: 15-43]) are associated with reduced infectivity (relative infectivity: NA, 0.55 [95% CrI: 0.32-0.98], HA stalk 0.53 [95% CrI: 0.27-0.97]). These findings suggest that influenza vaccines designed to elicit NA immunity in addition to HA immunity may not only enhance protection against infection but also reduce onward transmission.

Abstract Background: Gaps remain in our knowledge of the humoral correlates of protection against influenza A/H3N2, including the role of antibodies against the hemagglutinin stalk, a highly conserved but immunologically sub-dominant region. Methods: Two household studies were conducted in Managua, Nicaragua. Household contacts were tested for influenza using RT-PCR. We compared pre-existing antibody levels against full-length hemagglutinin (FLHA), HA stalk, and neuraminidase (NA) measured by ELISA, along with initial HA inhibition assay (HAI) titers, between infected and uninfected participants. Results: A total of 899 individuals participated in household activation during three A/H3N2 seasons with 329 infections occurring. A four-fold increase in initial HA stalk titers was independently associated with an 18% decrease in the risk of infection (OR=0.82, 95%CI 0.68-0.98, p=0.04). In 0-14-year-olds, anti-NA antibodies (OR=0.67, 95%CI 0.53-0.85, p<0.01) were associated with protection, but anti-HA stalk antibodies were not. In adults, anti-HA stalk antibodies were independently associated with protection (OR=0.72, 95%CI 0.54-0.95,p=0.02). Conclusions: The HA stalk is an independent correlate of protection against A/H3N2 infection, though this protection is age dependent. This supports the continued exploration of the HA stalk as a target for broadly protective influenza vaccines and suggests that the protective benefits may depend on age and influenza exposure history.

Background Influenza virus remains a threat to human health, but gaps remain in our knowledge of the humoral correlates of protection against influenza virus A/H3N2, limiting our ability to generate effective, broadly protective vaccines. The role of antibodies against the hemagglutinin (HA) stalk, a highly conserved but immunologically subdominant region, has not been established for influenza virus A/H3N2. Methods Household transmission studies were conducted in Managua, Nicaragua, across 3 influenza seasons. Household contacts were tested for influenza virus infection using reverse-transcription polymerase chain reaction. We compared preexisting antibody levels against full-length HA, HA stalk, and neuraminidase (NA) measured by enzyme-linked immunosorbent assay, along with hemagglutination inhibition assay titers, between infected and uninfected participants. Results A total of 899 individuals participated in household activation, with 329 infections occurring. A 4-fold increase in initial HA stalk titers was independently associated with an 18% decrease in the risk of infection (adjusted odds ratio [aOR], 0.82 [95% confidence interval {CI}, .68-.98]; P = .04). In adults, anti-HA stalk antibodies were independently associated with protection (aOR, 0.72 [95% CI, .54-.95]; P = .02). However, in 0- to 14-year-olds, anti-NA antibodies (aOR, 0.67 [95% CI, .53-.85]; P < .01) were associated with protection against infection, but anti-HA stalk antibodies were not. Conclusions The HA stalk is an independent correlate of protection against A/H3N2 infection, though this association is age dependent. Our results support the continued exploration of the HA stalk as a target for broadly protective influenza vaccines but suggest that the relative benefits may depend on age and influenza virus exposure history.

Abstract Background Children constitute an important component of the influenza burden and community transmission, but the frequency of asymptomatic infection and post-influenza sequelae at the community level is poorly understood. Methods Two community-based prospective cohort studies (2011–2020, 2017–2020) and 1 case-ascertained study (2012–2017) were conducted in Managua, Nicaragua. Non-immunocompromised children aged 0–14 years with ≥1 influenza infections, determined by polymerase chain reaction and hemagglutination inhibition assay, were included. Results A total of 1272 influenza infections occurred in the household-based portion of the study. Influenza infection was asymptomatic in 84 (6.6%) infections, and the asymptomatic fraction increased with age (1.7%, 3.5%, and 9.1% for ages 0–1, 2–4, and 5–14, respectively; P < .001). Of asymptomatic children, 43 (51.2%) shed virus, compared to 1099 (92.5%) symptomatic children (P < .001). Also, 2140 cases of influenza occurred in the primary care portion of the study. Sequelae of influenza were rare, with the most common being pneumonia (52, 2.4%) and acute otitis media (71, 3.3%). A/H1N1 had higher age-adjusted odds of acute otitis media (odds ratio [OR] 1.99, 95% confidence interval [CI]: 1.14–3.48; P = .015) and hospitalization (OR 3.73, 95% CI: 1.68–8.67; P = .002) than A/H3N2. B/Victoria had higher age-adjusted odds of pneumonia (OR 10.99, 95% CI: 1.34–90.28; P = .026) than B/Yamagata. Conclusions Asymptomatic influenza infection is much less common in children than adults, although viral shedding still occurs in asymptomatic children. Post-influenza sequelae are rare in children in the community setting, and virus strain may be important in understanding the risk of sequelae.

The SARS-CoV-2 pandemic and subsequent interruption of influenza circulation has lowered population immunity to influenza, especially among children with few pre-pandemic exposures. We compared the incidence and severity of influenza A/H3N2 and influenza B/Victoria between 2022 and two pre-pandemic seasons and found an increased frequency of severe influenza in 2022.

Purpose: A major challenge in implementing competency-based medical education (CBME) in undergraduate medical education (UME) is that students are assessed in a wide range of contexts and learning environments. These diverse learning environments may emphasize development of certain competencies more than others. This may be particularly true of the core clerkships, where students encounter a broad spectrum of medical disciplines, each with its own culture,1 values, and approach to patient care. These contextual differences are not necessarily addressed by measures intended to standardize assessment (such as entrustable professional activities or milestones, entrustment scales, and rater training or other faculty development initiatives). One step in optimally implementing competency-based programmatic assessment within clerkship education,2 is to identify which competencies are most culturally valued—and therefore potentially best assessed—by different clerkships. This cross-sectional study investigated how competency assessments correlated with assessment-specific global rating scores (GRS) across all core clinical clerkships and within specific clerkships at the University of Michigan Medical School (UMMS). Method: Clinical assessment forms assess 9 competencies within 6 UMMS competency domains (5 ACGME + 1 institutional) using a 3-point Likert scale, while also soliciting a 9-point GRS. Clinical assessment forms for 524 students who each completed seven core clinical clerkships from 2018–2021 were analyzed (n = 25,995 assessments) using linear mixed models. GRS was regressed on (1) the average competency score per assessment form across all clerkships; (2) each of the 9 individual competency scores per assessment form across all clerkships; and (3) the interaction between the nine individual competency scores and individual clerkships. All models included random intercepts for student and assessor to account for non-independence of the outcome. Results: Overall, average competency score was positively associated with GRS across all clerkships (β = 2.41, P < .0001, r2 = 0.49). Additionally, there were notable differences in the relative strength of association between individual competencies and GRS. Across all clerkships, medical knowledge/knowledge of basic and clinical sciences (MK-SM) was most strongly associated with increases in GRS (β = 0.4162), whereas professionalism/responsibility and accountability to patients, co-workers, and profession (PR-RA) was most weakly associated with GRS (β = 0.1307). Specific competencies were also variably associated with GRS across different clerkships. MK-SM was most strongly associated with GRS in the internal medicine and surgery clerkships. Practice-based learning and improvement/self-directed learning was most strongly associated with GRS in surgery and obstetrics and gynecology. Finally, communication/patients and families (C-PF) was most strongly associated with GRS in the pediatrics and psychiatry clerkships. Some competencies such as patient care/clinical reasoning, patient care/history physical, and patient care/management plan, showed little variation between clerkships. Discussion: These findings demonstrate that individual competencies do not correlate equally with GRS. The MK-SM competency had the strongest association with GRS regardless of clerkship, but the degree to which other competencies correlated with GRS varied significantly between clerkships. One possible explanation is that certain competencies may be valued differently in different clerkships. Patient care competencies are similarly correlated across all clerkships, suggesting these may be universally important competencies. Significance: Understanding how competency-oriented assessments align with global rating assessments can provide valuable insight regarding how to implement programmatic assessment in UME.2,3 These results are consistent with the intuitive concept that different specialties would inherently value different competencies. These findings can help bridge the gap between best practices and implementation, by providing students with clearer expectations regarding competency assessment in different clerkship learning environments. Articulating this aspect of the “hidden curriculum” can help learners navigate the complicated and evolving competency assessment environment, and therefore meaningfully contribute to CBME implementation in UME. Acknowledgments: The authors wish to thank Dr. Douglas Gelb for substantive editing of the abstract.

The 12q13-q14 chromosomal region is recurrently amplified in 25% of fusion-positive (FP) rhabdomyosarcoma (RMS) cases and is associated with a poor prognosis. To identify amplified oncogenes in FP RMS, we compared the size, gene composition, and expression of 12q13-q14 amplicons in FP RMS with those of other cancer categories (glioblastoma multiforme, lung adenocarcinoma, and liposarcoma) in which 12q13-q14 amplification frequently occurs. We uncovered a 0.2 Mb region that is commonly amplified across these cancers and includes CDK4 and 6 other genes that are overexpressed in amplicon-positive samples. Additionally, we identified a 0.5 Mb segment that is only recurrently amplified in FP RMS and includes 4 genes that are overexpressed in amplicon-positive RMS. Among these genes, only serine hydroxymethyltransferase 2 (SHMT2) was overexpressed at the protein level in an amplicon-positive RMS cell line. SHMT2 knockdown in amplicon-positive RMS cells suppressed growth, transformation, and tumorigenesis, whereas overexpression in amplicon-negative RMS cells promoted these phenotypes. High SHMT2 expression reduced sensitivity of FP RMS cells to SHIN1, a direct SHMT2 inhibitor, but sensitized cells to pemetrexed, an inhibitor of the folate cycle. In conclusion, our study demonstrates that SHMT2 contributes to tumorigenesis in FP RMS and that SHMT2 amplification predicts differential response to drugs targeting this metabolic pathway.

Objective To develop a population-specific methodology for estimating glycaemic control that optimises resource allocation for patients with diabetes in rural Sri Lanka.Design Cross-sectional study.Setting Trincomalee, Sri Lanka.Participants Patients with non-insulin-treated type 2 diabetes (n=220) from three hospitals in Trincomalee, Sri Lanka.Outcome measure Cross-validation was used to build and validate linear regression models to identify predictors of haemoglobin A1c (HbA1c). Validation of models that regress HbA1c on known determinants of glycaemic control was thus the major outcome. These models were then used to devise an algorithm for categorising the patients based on estimated levels of glycaemic control.Results Time since last oral intake other than water and capillary blood glucose were the statistically significant predictors of HbA1c and thus included in the final models. In order to minimise type II error (misclassifying a high-risk individual as low-risk or moderate-risk), an algorithm for interpreting estimated glycaemic control was created. With this algorithm, 97.2% of the diabetic patients with HbA1c ≥9.0% were correctly identified.Conclusions Our calibrated algorithm represents a highly sensitive approach for detecting patients with high-risk diabetes while optimising the allocation of HbA1c testing. Implementation of these methods will optimise the usage of resources devoted to the management of diabetes in Trincomalee, Sri Lanka. Further external validation with diverse patient populations is required before applying our algorithm more widely.

Influenza poses a significant disease burden on children worldwide, with high rates of hospitalization and substantial morbidity and mortality. Although the clinical presentation of influenza in children has similarities to that seen in adults, there are unique aspects to how children present with infection that are important to recognize. In addition, children play a significant role in viral transmission within communities. Growing evidence supports the idea that early influenza infection can uniquely establish lasting immunologic memory, making an understanding of how viral immunity develops in this population critical to better protect children from infection and to facilitate efforts to develop a more universally protective influenza vaccine.

Abstract Gene amplification, or an increase in copy number of a confined region on the chromosome arm, has been identified as a critical genetic event that contributes to the development of various cancers. There is increased expression of certain genes within the amplified regions, which alters normal cell growth and survival pathways, and contributes to tumorigenesis. Although previous studies show that some regions are amplified in more than one cancer type, direct analyses comparing the size and gene composition of these amplified regions across tumor types have not been performed. In the current study, we used copy number and RNA sequencing data from our published data and The Cancer Genome Atlas (TCGA) to characterize the commonly affected 12q13-q14 and 12q15 chromosomal regions in rhabdomyosarcoma, glioblastoma multiforme, lung adenocarcinoma, and liposarcoma. Based on our analysis of copy number data from high-density single-nucleotide polymorphism arrays, we observed a 0.08 Mb common region of overlap of the 12q13-q14 amplicons and a 0.20 Mb common region of overlap of the 12q15 amplicons across these tumor types. Differential gene expression analysis between amplified and nonamplified samples showed that OS9, TSPAN31, CDK4, CYP27B1, METTL1, EEF1AKMT3, and TSFM were overexpressed by the 12q13-q14 amplicons. Similarly, MDM2 and CPM were overexpressed by the 12q15 chromosomal amplicons. In addition to the common region of overlap, regions of tumor-type specific amplification were also found in our analysis. The 12q13-q14 amplicon in fusion-positive rhabdomyosarcoma extended 0.48 Mb toward the centromere, while the 12q13-q14 amplicons in dedifferentiated liposarcoma and lung adenocarcinoma extended 0.56 Mb and 0.96 Mb, respectively, toward the telomere. For the 12q15 region, the amplicon in lung adenocarcinoma extended 1.3 Mb toward the centromere, while the amplicons in dedifferentiated liposarcoma and fusion-negative rhabdomyosarcoma extended 1.4 Mb and 1.6 Mb, respectively, toward the telomere. Gene expression analyses showed that some genes from these tumor-specific regions of amplification were preferentially overexpressed in the corresponding tumor types. For example, four genes from the fusion-positive rhabdomyosarcoma-specific 12q13-q14 amplicon (NEMP1, NAB2, SHMT2, and R3HDM2) and two genes from the lung adenocarcinoma-specific 12q15 amplicon (MDM1 and RAP1B) were specifically overexpressed in these two tumor types. Our findings indicate that, in addition to common regions of amplification across multiple tumor types, there are tumor-specific amplified regions and overexpressed genes that indicate the presence of unique features within each cancer category affecting these amplification events. Citation Format: Prasantha L. Vemu, Gregory E. Hoy, Wenyue Sun, Jack Shern, Javed Khan, Frederic G. Barr. Comparing amplification of 12q13-q14 and 12q15 chromosomal regions across cancer types through genomic and transcriptome analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4357.

BACKGROUND:The specialization of human fat deposits is an inquiry of special importance in the study of fetal growth. It has been theorized that maternal lower-body fat is designated specifically for lactation and not for the growth of the fetus. OBJECTIVE:Our goal was to compare the contributions of maternal upper-body versus lower-body adiposity to infant birth weight. We hypothesized that upper-body adiposity would be strongly associated with infant birth weight and that lower-body adiposity would be weakly or negligibly associated with infant birth weight-after adjusting for known determinants. STUDY DESIGN:In this prospective cohort study, 355 women initiated medical pre-natal care during the first trimester of pregnancy at The University of Oklahoma Health Sciences Center during 1990-1993. Maternal anthropometric measurements were assessed at the first clinic visit: (a) height; (b) weight; (c) circumferences of the upper arm, forearm, and thigh; and, (d) skin-fold measurements of the bicep, subscapular region, and thigh. RESULTS:Infant birth weight was regressed on known major determinants to create the foundational model. Maternal anthropometric variables subsequently were added one at a time into this multiple regression model. The highest contribution by a single anthropometric variable to infant birthweight was, in order: subscapular skin-fold, forearm circumference, and thigh circumference. With one upper-body (subscapular skin-fold) and one lower-body (circumference of the thigh) adiposity measure in the model, the z-score regression coefficient (s.e.) was 85.7g (30.8) [p=0.0057] for maternal subscapular skin-fold and 19.0g (31.6) [p=0.5477] for circumference of the thigh. When the second-best upper-body contributor to infant birthweight (circumference of the forearm) was entered with one lower-body measure into the model, the z-score regression coefficient (s.e.) was 77.5g (38.5) [p=0.0451] for maternal forearm circumference and 14.1g (38.5) [p=0.7146] for circumference of the thigh. When both subscapular skinfold and forearm circumference were added to the model in place of BMI, the explained variance (r2=0.5478) was similar to the model using BMI (r2=0.5487). CONCLUSION:Upper-body adiposity - whether operationalized by subscapular skin-fold or circumference of the forearm - was a markedly larger determinant of infant birth weight than lower-body adiposity.