Cytosolic and Endosomal DNA-Sensing Pathways Differentially Regulate Inflammatory Arthritis, Autoantibody Production, and Bone Remodeling: A Dissertation

Autoimmune diseases such as rheumatoid arthritis (RA) are associated with debilitating chronic inflammation, autoantibody production, articular bone erosions and systemic bone loss. The underlying mechanisms and cell types that initiate these diseases are not fully understood, and current therapies mainly address downstream mechanisms and do not fully halt disease progression in all patients. Moreover, previous studies have largely focused on the role of adaptive immunity in driving these diseases, and less attention has been given to the contribution of innate immune pathways such as DNA sensor signaling pathways in initiating and/or perpetuating autoimmunity and erosive inflammatory arthritis. Detection of microbial nucleic acids by DNA sensors such as endosomal toll-like receptors (TLRs) and cytosolic sensors is an early form of antiviral defense. Upon detection of nucleic acid, TLRs dependent on Unc93B and cytosolic sensors dependent on the adaptor stimulator of interferon genes (STING) orchestrate production of type 1 interferons and pro-inflammatory cytokines to resolve infection. Additionally, the cytosolic DNA sensor absent in melanoma 2 (AIM2), which is not dependent on STING, also recognizes microbial DNA and coordinates the cleavage of pro-IL-1β. Previous studies have largely focused on the role of these DNA sensors in macrophages and dendritic cells in the context of antiviral immunity. In recent years, however, the inappropriate recognition of host nucleic acids by these sensors has been associated with several autoimmune diseases including RA. This dissertation aims to delineate the mechanisms by which DNA sensors contribute to inflammatory arthritis and bone remodeling in the context of a murine model of autoimmunity. In DNase II deficient mice, excessive accrual of undegraded, endogenous DNA leads to robust production of type 1 interferons (IFNs) and proinflammatory cytokines. The high levels of type 1 IFNs result in anemia and embryonic lethality; therefore, the gene for the type 1 IFN receptor (IFNaR) has also been deleted so that the mice survive. DNase II-/- IFNaR-/- double knockout (DKO) mice develop erosive inflammatory arthritis, anti-nuclear antibodies, and splenomegaly not seen in the DNase II+/- IFNaR-/- (Het) control group. To evaluate whether cytosolic or endosomal DNA sensors contribute to the clinical manifestations of DKO mice, genes involved in TLR or cytosolic sensor signaling were deleted on the DKO background. Genetically altered mice include STING/DNaseII/IFNaR TKO (STING TKO), AIM2/DNase II/IFNaR TKO (AIM2 TKO), and Unc93b/DNase II/IFNaR TKO (Unc93 TKO) mice. Our hypothesis was that the STING, AIM2, and/or Unc93 pathways would contribute to the autoimmune manifestations in DNase II deficient mice. Rigorous examination of inflammation in these lines revealed important roles for both the STING and AIM2 pathways in arthritis. Despite the substantial effects of the STING and AIM2 pathways on arthritis, STING TKO and AIM2 TKO mice still exhibited prominent autoantibody production. Interestingly, inflammation persisted in Unc93 TKO mice while autoantibody production to nucleic acids was abrogated. Collectively, these data indicate that innate immune pathways contribute to the initiation/perpetuation of inflammatory arthritis and demonstrate that cytosolic and endosomal pathways play distinct roles in the manifestations of autoimmunity. Moreover, they reveal a previously undescribed role for AIM2 as a sensor of endogenous nucleic acids in inflammatory arthritis. Thus, therapeutics that target the STING and AIM2 pathways may be beneficial for the treatment of inflammatory joint diseases. While the role of hematopoietic cells in driving autoimmunity has been well established, the contribution of stromal elements to disease pathogenesis is less well understood. Therefore, we generated bone marrow chimeras to delineate the contribution of hematopoietic and non-hematopoietic cells to the various autoimmune manifestations in DKO mice. These studies revealed that both donor hematopoietic and host radioresistant cells are required for inflammation in the joint as well as for other features of autoimmunity in DKO mice, including splenomegaly, extramedullary hematopoiesis, and autoantibody production. This data demonstrates that stromal host cells play a major role in DNA-driven autoimmunity. Moreover, these results suggest that targeting not only hematopoietic but also stromal elements may be advantageous in the setting of inflammatory arthritis. In the final chapter of this thesis, a role for innate immune sensor pathways in bone is described. The majority of inflammatory arthritides have been shown to lead to systemic loss of bone. Surprisingly, however, we found that DKO mice accumulate trabecular bone in the long bones over time as well as ectopic bone in the spleens, both sites of robust DNA accrual. Moreover, deficiency of the STING pathway abrogated this bone accumulation. Collectively, these data demonstrate that DNA accrual promotes dysregulated bone remodeling through innate immune sensing pathways. These findings are the first to reveal a role for the STING pathway in bone and may unveil novel targets for the treatment of diseases associated with bone disorders

Analysis of the effectiveness of an instructional strategy to teach selected problem-solving skills to nursing students

The purpose of this research was to determine if selected problem-solving skills of freshmen nursing students in an associate-degree nursing program could be enhanced by an instructional strategy that combined simulated patient encounters with two types of feedback obtained from experienced nurses. The skills were: (1) the detection, encoding, and retrieval of cues and (2) the generation of tentative problem formulations. Six videotaped simulations of nurse-patient encounters were shown to a group of experienced nurses, who were asked to write tentative problem formulations with relevant cues and summarizing assessments of the situations. Data of the nurses\u27 information processing activities while performing the simulation exercises were additionally collected and analyzed. The results of this analysis were used to develop an instructional package that was tested on a sample of freshmen nursing students.;The sample was randomly assigned to three groups: two treatment groups and a posttest-only control group. The following were hypothesized: (1) that the selected problem-solving skills of the treatment groups would be significantly improved by the instructional strategy, and (2) that the skills would be more greatly enhanced in the treatment group which received outcome and process feedback from the experienced nurses than in the treatment group which received outcome feedback only.;The results of the analysis of covariance supported the first hypothesis but not the second hypothesis. It was found that the mean of the group receiving outcome feedback was significantly higher than the control group, but that there was no difference in the means of the control group and the treatment group which received both outcome and process feedback.;Limitations of the study were related to the samples used; i.e., the number of experienced nurses was small and the sample of students was drawn from an existing nursing program. Implications for future research included: (1) other applications and modifications of the components of the instructional strategy; (2) variation of the types of simulation; (3) further research into problem-solving processes and outcomes of experienced nurses

Digital technology use among disadvantaged Australians: implications for equitable consumer participation in digitally-mediated communication and information exchange with health services

The considerable variation in ICT access and use within lower income and disadvantaged groups must be acknowledged and accommodated by health initiatives and services when delivering digitally-mediated consumer-provider interaction, online health information, or online self-management of health conditions. If services require consumers to participate in digitally-mediated communication exchange, then we suggest they might support skills and technology acquisition, and/or provide non-ICT alternatives, in order to avoid exacerbating health inequities

Vicious cycles: digital technologies and determinants of health in Australia

This is a pre-copyedited, author-produced PDF of an article accepted for publication in Health promotion International following peer review. The version of record [Baum F, Newman L, Biedrzycki K (2014), ‘Vicious cycles: digital technologies and determinants of health’. Health Promotion International, 29 (2), 349-360.] is available online at: http://heapro.oxfordjournals.org/The use of digital technologies continues to bring rapid changes to personal and institutional forms of communication and information. Digital technologies are becoming increasingly important as ways to gain access to most of the important social determinants of health including employment, housing, education and social networks. However, little is known about the impact of the new technologies on opportunities for health and well-being. This paper reports on a focus group study of their impact on people from low socio-economic backgrounds. It uses Bourdieu’s theories of social inequities and the ways in which social, cultural and economic capitals interact to reinforce and reproduce inequities to examine the ways in which digital technologies are contributing to these processes. Six focus group discussions with 55 people were held to examine their access to and views about using digital technologies. These data are analysed to determine what factors facilitate access to digital technologies and what the implications of exclusion from the technologies is likely to be for the social determinants of health. The paper concludes that some people are being caught in a vicious cycle whereby lack of digital access or the inability to make beneficial use reinforces and amplifies existing disadvantage. The paper concludes with a consideration of actions health promoters could take to interrupt this cycle and so contribute to reducing health inequities

Digital technology access and use among socially and economically disadvantaged groups in South Australia

This paper explores digital technology access and use (computers, Internet and mobile phones) among lower income and disadvantaged groups in Australia. It reports focus group research which identified wide differences in frequency and quality of use, and in skills, confidence and trust. It identifies pathways to digital use (or non-use) related to existing socioeconomic inequities which mean that lack of (or limited) digital access or use creates further barriers to improving the underlying determinants of that use. Technological solutions to the digital divide must therefore be accompanied by a broader digital inclusion approach.South Australian Department of Health; South Australian Department of Further Education, Employment, Science & Technology. National Health & Medical Research Institute; Australian Research Counci

A rapid appraisal case study of South Australia's Social Inclusion Initiative

This Rapid Appraisal Case Study of South Australia’s Social Inclusion Initiative was undertaken to contribute to the work of the Social Exclusion Knowledge Network (SEKN) of the Commission on Social Determinants of Health (CSDH). The CSDH was established in 2005 by the World Health Organisation to investigate ways in which international, national, regional and local bodies could take action on the social determinants of health. The knowledge networks are one of the main mechanisms by which the CSDH is gathering evidence. This report provides a rapid assessment of the ways in which South Australia’s Social Inclusion Initiative has originated and operated. The report’s layout follows guidelines developed by the SEKN and draws on documentary and interview evidence. The project was conducted between March and June 2007 by researchers at Flinders University of South Australia, in conjunction with senior staff at South Australia’s Social Inclusion Unit, Department of the Premier and Cabinet. South Australia is a State within a federal system of government and has a population of 1.6 million. The population’s average health and well-being are high by world standards but the State continues to record significant levels of inequality for certain groups and areas, and particularly for its Aboriginal population

Partnership in knowledge creation: lessons learned from a researcher–policy actor partnership to co-produce a rapid appraisal case study of south australia’s social Inclusion Initiative

This paper describes a partnership between researchers and policy actors which was developed within a short time-frame to produce a rapid appraisal case study of a government policy initiative - South Australia’s Social Inclusion Initiative - for the Social Exclusion Knowledge Network of the international Commission on Social Determinants of Health. The paper does not focus on the case study findings or content, but rather on the researcher-policy actor partnership which developed in the process of producing the case study and its report. The paper is set against the broader literature on researcher-policy collaboration and is written to share lessons that may help others quickly establish or improve researcher-policy partnerships. It sets out six key elements for success in a framework for partnership which can meet policy rather than academic time frames and which can effectively co-produce knowledge that meets both research and policy objectives

Phylogenetic Relationships of Malvatheca (Bombacoideae and Malvoideae; Malvaceae sensu lato) as Inferred from Plastid DNA Sequences

Previous molecular phylogenetic analyses have revealed that elements of the former families Malvaceae sensu stricto and Bombacaceae together form a well-supported clade that has been named Malvatheca. Within Malvatheca, two major lineages have been observed; one, Bombacoideae, corresponds approximately to the palmate-leaved Bombacaceae, and the other, Malvoideae, includes the traditional Malvaceae (the mallows or Eumalvoideae). However, the composition of these two groups and their relationships to other elements of Malvatheca remain a source of uncertainty. Sequence data from two plastid regions, ndhF and trnK/matK, from 34 exemplars of Malvatheca and six outgroups were analyzed. Parsimony, likelihood, and Bayesian analyses of the sequence data provided a well-resolved phylogeny except that relationships among five lineages at the base of Malvatheca are poorly resolved. Nonetheless, a 6-bp insertion in matK suggests that Fremontodendreae is sister to the remainder of Malvatheca. Our results suggest that the Malvoideae originated in the Neotropics and that a mangrove taxon dispersed across the Pacific from South America to Australasia and later radiated out of Australasia to give rise to the ca. 1,700 living species of Eumalvoideae. Local clock analyses imply that the plastid genome underwent accelerated molecular evolution coincident with the dispersal out of the Americas and again with the radiation into the three major clades of Eumalvoideae

Cultivated Vaginal Microbiomes Alter HIV-1 Infection and Antiretroviral Efficacy in Colonized Epithelial Multilayer Cultures

There is a pressing need for modeling of the symbiotic and at times dysbiotic relationship established between bacterial microbiomes and human mucosal surfaces. In particular clinical studies have indicated that the complex vaginal microbiome (VMB) contributes to the protection against sexually-transmitted pathogens including the life-threatening human immunodeficiency virus (HIV-1). The human microbiome project has substantially increased our understanding of the complex bacterial communities in the vagina however, as is the case for most microbiomes, very few of the community member species have been successfully cultivated in the laboratory limiting the types of studies that can be completed. A genetically controlled ex vivo model system is critically needed to study the complex interactions and associated molecular dialog. We present the first vaginal mucosal culture model that supports colonization by both healthy and dysbiotic VMB from vaginal swabs collected from routine gynecological patients. The immortalized vaginal epithelial cells used in the model and VMB cryopreservation methods provide the opportunity to reproducibly create replicates for lab-based evaluations of this important mucosal/bacterial community interface. The culture system also contains HIV-1 susceptible cells allowing us to study the impact of representative microbiomes on replication. Our results show that our culture system supports stable and reproducible colonization by VMB representing distinct community state types and that the selected representatives have significantly different effects on the replication of HIV-1. Further, we show the utility of the system to predict unwanted alterations in efficacy or bacterial community profiles following topical application of a front line antiretroviral

Protocols for an Aboriginal-led, Multi-methods Study of the Role of Aboriginal and Torres Strait Islander Health Workers, Practitioners and Liaison Officers in Quality Acute Health Care

ObjectivesAboriginal and Torres Strait Islander Health Workers/Practitioners and Liaison Officers play an important, often critical role providing advocacy and cultural and emotional support for Aboriginal and Torres Strait Islander patients. The main goals of this research are to explore i) how Aboriginal and Torres Strait Islander Health Workers/Practitioners and Liaison Officers are integrated in the routine delivery of care for Aboriginal and Torres Strait Islander peoples in hospital, and ii) how the role of Aboriginal and Torres Strait Islander Health Workers/Practitioners and Liaison Officers facilitates quality health outcomes. MethodsThis study is being conducted in three different hospitals using a multi-method approach including: yarning and Dadirri, patient journey mapping, survey and semi-structured interviews. Ethics approval has been provided from four ethics committees covering the three project sites in Australia (Adelaide, South Australia; Sydney, New South Wales and Alice Springs, Northern Territory). SignificanceThis study uses innovative methodology founded on the privileging of Aboriginal and Torres Strait Islander knowledges to collect Aboriginal and Torres Strait Islander perspectives and understand patient journeys within acute health care systems. This project is led by Aboriginal and Torres Strait Islander researchers and guided by the Project Steering Committee comprised of stakeholders. ImplicationsThere is limited research that explores quality acute care processes and the integration of Aboriginal and Torres Strait Islander Health Workers/Practitioners work within health care teams. This research will make a valuable contribution to understanding how hospital services can achieve quality acute health care experiences for Aboriginal and Torres Strait Islander People