Efficacy of T cell assays for the diagnosis of primary defects in cytotoxic lymphocyte exocytosis.

Primary hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder associated with autosomal recessive variants in genes required for perforin-mediated lymphocyte cytotoxicity. A rapid diagnosis is crucial for successful treatment. Although defective cytotoxic T lymphocyte (CTL) function causes pathogenesis, quantification of natural killer (NK) cell exocytosis triggered by K562 target cells currently represents a standard diagnostic procedure for primary HLH. We have prospectively evaluated different lymphocyte exocytosis assays in 213 patients referred for evaluation for suspected HLH and related hyperinflammatory syndromes. A total of 138 patients received a molecular diagnosis consistent with primary HLH. Compared to routine K562 cell-based assays, assessment of Fc receptor-triggered NK-cell and T cell receptor-triggered CTL exocytosis displayed higher sensitivity and improved specificity for the diagnosis of primary HLH, with these assays combined providing a sensitivity of 100% and specificity of 98.3%. By comparison, NK-cell exocytosis following K562 target cell stimulation displayed a higher inter-individual variability, in part explained by differences in NK-cell differentiation or large functional reductions following shipment. We thus recommend combined analysis of T cell receptor-triggered CTL and Fc receptor-triggered NK-cell exocytosis for the diagnosis of patients with suspected familial HLH or atypical manifestations of congenital defects in lymphocyte exocytosis.

The impact of metabolic syndrome in breast reconstruction decision-making and postoperative outcomes: A nationwide analysis.

BACKGROUND: Metabolic syndrome (MetS) is a cluster of cardiometabolic abnormalities including hypertension, obesity, insulin resistance, and dyslipidemia. The safety profiles of patients with MetS undergoing breast reconstruction remain underreported. This study aims to evaluate the impact of MetS on the BR decision-making process and postoperative complication rates. METHODS: The ACS-NSQIP database was utilized to identify women who underwent BR between 2012 and 2021. Baseline characteristics were compared based on the presence of MetS, defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Group differences were assessed using t tests and Fisher's exact tests. Multivariate logistic regression models evaluated postoperative complications between the groups. RESULTS: A total of 160,115 patients underwent BR. A total of 4570 had a diagnosis of MetS compared to 155,545 without MetS. No statistically significant differences were observed in the type of BR patients received across cohorts. Logistic regression models demonstrated a higher likelihood of postoperative wound complications (OR 2.21; 95% CI 1.399, 3.478; p = 0.001), and readmission rates (OR 2.045; 95% CI 1.337, 3.128; p = 0.001) in the MetS group compared to the non-MetS patients. No significant differences were identified in other postoperative complications between groups. CONCLUSIONS: Patients with MetS appear to have an increased risk of postoperative wound complications and readmission after breast reconstruction. The synergistic effects of these comorbidities on postoperative outcomes underscore the importance of addressing MetS as a holistic condition and considering choosing Delayed breast reconstruction over Immediate Breast Reconstruction in this population. Thus, integrating MetS management and patient counseling at various stages of BR may improve outcomes and facilitate patient decision-making.

Unsettling Settler Colonialism in Research: Strategies Centering Native American Experience and Expertise in Responding to Substance Misuse and Co-occurring Sexual Risk-Taking, Alcohol-Exposed Pregnancy, and Suicide Prevention Among Young People.

Native American (NA) populations in the USA (i.e., those native to the USA which include Alaska Natives, American Indians, and Native Hawaiians) have confronted unique historical, sociopolitical, and environmental stressors born of settler colonialism. Contexts with persistent social and economic disadvantage are critical determinants of substance misuse and co-occurring sexual risk-taking and suicide outcomes, as well as alcohol exposed pregnancy among NA young people (i.e., adolescents and young adults). Despite intergenerational transmission of resistance and resiliencies, NA young people face continued disparities in substance misuse and co-occurring outcomes when compared to other racial and ethnic groups in the USA. The failure in progress to address these inequities is the result of a complex set of factors; many of which are structural and rooted in settler colonialism. One of these structural factors includes barriers evident in health equity research intended to guide solutions to address these disparities yet involving maintenance of a research status quo that has proven ineffective to developing these solutions. Explicitly or implicitly biased values, perspectives, and practices are deeply rooted in current research design, methodology, analysis, and dissemination and implementation efforts. This status quo has been supported, intentionally and unintentionally, by researchers and research institutions with limited experience or knowledge in the historical, social, and cultural contexts of NA communities. We present a conceptual framework illustrating the impact of settler colonialism on current research methods and opportunities to unsettle its influence. Moreover, our framework illustrates opportunities to resist settler colonialism in research. We then focus on case examples of studies from the Intervention Research to Improve Native American Health program, funded by the NIH, that impact substance use and co-occurring health conditions among NA young people.

Women in Microsurgery Fellowships: Trends and Impact on Future Practice Patterns.

BACKGROUND: While the number of female plastic surgeons has continued to increase over time, plastic surgery has historically been a male-dominated profession with only 15% of practicing plastic surgeons being female. Microsurgery, as a subspecialty, has been long perceived as an even more male-centric career path. The objective of this study was to determine the representation of females in the subspecialty field of microsurgery and the impact of microsurgical fellowship training. METHODS: A review of all microsurgery fellowship programs participating in the microsurgery fellowship match from 2010 to 2019 were analyzed. Fellows were identified through fellowship Web site pages or direct contact with fellowship program coordinators and directors. The current type of practice and performance of microsurgery were also identified through a Web search and direct contact with fellowship program coordinators and directors. RESULTS: A total of 21 programs and 317 fellows over a 10-year period were analyzed. Over this 10-year period, there was a total of 100 (31.5%) female microsurgery fellows and 217 (68.5%) male microsurgery fellows. There was a small, statistically insignificant increase in the yearly percentage of female microsurgery fellows over this 10-year period with an average yearly increase of 2.7% (p = 0.60; 95% confidence interval: -6.9 to 13.2%). There were significantly fewer females who continued to practice microsurgery compared to males (75 [75.0%] vs. 186 [85.7%], p = 0.02). There was no significant difference in the current practice types (academic, private, and nonacademic hospital) between females and males (p = 0.29). CONCLUSION: Women are underrepresented in the field of microsurgery to a similar extent as they are underrepresented in overall plastic surgery. While there is a small insignificant increase in the number of female microsurgery fellows every year, a significantly smaller proportion of females continue to practice microsurgery compared to males.

Rectus Plication Does Not Increase Risk of Thromboembolic Events Following Abdominal Body Contouring: A Matched Case-Control Analysis.

BACKGROUND: Rectus abdominis plication increases intra-abdominal pressure and lower-extremity venous stasis, which may increase the incidence of venous thromboembolism (VTE) events. OBJECTIVES: The aim of this study was to investigate the potential association between VTE and rectus abdominis muscle plication during surgery. METHODS: A retrospective review of all patients who underwent abdominal body contouring at the authors' institution between 2010 and 2020 was completed. Cases were those with postoperative VTEs and were matched to controls (1:4) via potential confounders. Variables collected include demographic data, operative details, comorbidities, and postoperative complications. Statistical analysis was performed with parametric, nonparametric, and multivariable regression modeling. RESULTS: Overall, 1198 patients were included; 19 (1.59%) experienced a postoperative VTE and were matched to 76 controls. The overall cohort was 92.7% female with an average age of 44 years, an average Charlson Comorbidity Index of 1 point, and an average BMI of 30.1 kg/m2. History of cerebrovascular events (14.5% vs 36.8%, P = 0.026) differed significantly between cohorts, but no significant associations were noted in all other baseline demographics. Additionally, VTE cases were more likely to have received intraoperative blood transfusions (odds ratio = 8.4, P = 0.04). Bivariate analysis demonstrated cases were significantly more likely to experience concurrent complications, including delayed wound healing (0% vs 5.3%, P = 0.044), seroma formation (5.3% vs 21.1%, P = 0.027), and fat necrosis (0% vs 5.3%, P = 0.044). However, these findings were not significant in a multivariable regression model. Plication was not associated with VTE outcomes. CONCLUSIONS: Rectus plication does not increase the risk of VTE. However, the odds of VTE are significantly increased in patients who received intraoperative blood products compared with those who did not.

Respiratory viral infections in otherwise healthy humans with inherited IRF7 deficiency.

Autosomal recessive IRF7 deficiency was previously reported in three patients with single critical influenza or COVID-19 pneumonia episodes. The patients' fibroblasts and plasmacytoid dendritic cells produced no detectable type I and III IFNs, except IFN-ß. Having discovered four new patients, we describe the genetic, immunological, and clinical features of seven IRF7-deficient patients from six families and five ancestries. Five were homozygous and two were compound heterozygous for IRF7 variants. Patients typically had one episode of pulmonary viral disease. Age at onset was surprisingly broad, from 6 mo to 50 yr (mean age 29 yr). The respiratory viruses implicated included SARS-CoV-2, influenza virus, respiratory syncytial virus, and adenovirus. Serological analyses indicated previous infections with many common viruses. Cellular analyses revealed strong antiviral immunity and expanded populations of influenza- and SARS-CoV-2-specific memory CD4+ and CD8+ T cells. IRF7-deficient individuals are prone to viral infections of the respiratory tract but are otherwise healthy, potentially due to residual IFN-ß and compensatory adaptive immunity.

"Being on the Walk Put It Somewhere in My Body": The Meaning of Place in Health for Indigenous Women.

Relationship to place is integral to Indigenous health. A qualitative, secondary phenomenological analysis of in-depth interviews with four non-Choctaw Indigenous women participating in an outdoor, experiential tribally-specific Choctaw health leadership study uncovered culturally grounded narratives using thematic analysis as an analytic approach. Results revealed that physically being in historical trauma sites of other Indigenous groups involved a multi-faceted process that facilitated embodied stress by connecting participants with their own historical and contemporary traumas. Participants also experienced embodied resilience through connectedness to place and collective resistance. Implications point to the role of place in developing collective resistance and resilience through culturally and methodologically innovative approaches.

The transcription factor Bcl11b promotes both canonical and adaptive NK cell differentiation.

Epigenetic landscapes can provide insight into regulation of gene expression and cellular diversity. Here, we examined the transcriptional and epigenetic profiles of seven human blood natural killer (NK) cell populations, including adaptive NK cells. The BCL11B gene, encoding a transcription factor (TF) essential for T cell development and function, was the most extensively regulated, with expression increasing throughout NK cell differentiation. Several Bcl11b-regulated genes associated with T cell signaling were specifically expressed in adaptive NK cell subsets. Regulatory networks revealed reciprocal regulation at distinct stages of NK cell differentiation, with Bcl11b repressing RUNX2 and ZBTB16 in canonical and adaptive NK cells, respectively. A critical role for Bcl11b in driving NK cell differentiation was corroborated in BCL11B-mutated patients and by ectopic Bcl11b expression. Moreover, Bcl11b was required for adaptive NK cell responses in a murine cytomegalovirus model, supporting expansion of these cells. Together, we define the TF regulatory circuitry of human NK cells and uncover a critical role for Bcl11b in promoting NK cell differentiation and function.

Chronic non-bacterial osteomyelitis masquerading as fibrous dysplasia.

Chronic non-bacterial osteomyelitis is a rare auto-inflammatory bone disease seen predominantly in the paediatric population. We describe a unique case of a 30-year-old female who presented with right-sided jaw pain and intermittent swelling over the course of 6 years. She was initially treated with antibiotics for possible osteomyelitis, then temporarily diagnosed with fibrous dysplasia. She underwent extensive investigations consisting of an infectious workup, numerous imaging modalities, and three separate biopsies of her right jaw. She was ultimately diagnosed with chronic non-bacterial osteomyelitis based upon her history of recurrent episodes of painful swelling, response to non-steroidal anti-inflammatories, previously raised acute phase reactants, and magnetic resonance imaging findings. Unfortunately, she became refractory to non-steroidal anti-inflammatory therapy. Consequently, she was successfully treated with pamidronate, achieving clinical remission with improvement in her imaging findings. This case highlights the difficulty of diagnosis of chronic non-bacterial osteomyelitis and the need for increased awareness of the disease in the adult population. Additionally, the effective treatment with pamidronate supports the use of a bisphosphonate as an early intervention for adult-onset chronic non-bacterial osteomyelitis in patients who have failed non-steroidal anti-inflammatory therapy.

The Immunology of Multisystem Inflammatory Syndrome in Children with COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is typically very mild and often asymptomatic in children. A complication is the rare multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19, presenting 4-6 weeks after infection as high fever, organ dysfunction, and strongly elevated markers of inflammation. The pathogenesis is unclear but has overlapping features with Kawasaki disease suggestive of vasculitis and a likely autoimmune etiology. We apply systems-level analyses of blood immune cells, cytokines, and autoantibodies in healthy children, children with Kawasaki disease enrolled prior to COVID-19, children infected with SARS-CoV-2, and children presenting with MIS-C. We find that the inflammatory response in MIS-C differs from the cytokine storm of severe acute COVID-19, shares several features with Kawasaki disease, but also differs from this condition with respect to T cell subsets, interleukin (IL)-17A, and biomarkers associated with arterial damage. Finally, autoantibody profiling suggests multiple autoantibodies that could be involved in the pathogenesis of MIS-C.

Manipulation of the Innate Immune Response by Varicella Zoster Virus.

Varicella zoster virus (VZV) is the causative agent of chickenpox (varicella) and shingles (herpes zoster). VZV and other members of the herpesvirus family are distinguished by their ability to establish a latent infection, with the potential to reactivate and spread virus to other susceptible individuals. This lifelong relationship continually subjects VZV to the host immune system and as such VZV has evolved a plethora of strategies to evade and manipulate the immune response. This review will focus on our current understanding of the innate anti-viral control mechanisms faced by VZV. We will also discuss the diverse array of strategies employed by VZV to regulate these innate immune responses and highlight new knowledge on the interactions between VZV and human innate immune cells.

Granzyme B Cleaves Multiple Herpes Simplex Virus 1 and Varicella-Zoster Virus (VZV) Gene Products, and VZV ORF4 Inhibits Natural Killer Cell Cytotoxicity.

Immune regulation of alphaherpesvirus latency and reactivation is critical for the control of virus pathogenesis. This is evident for herpes simplex virus 1 (HSV-1), where cytotoxic T lymphocytes (CTLs) prevent viral reactivation independent of apoptosis induction. This inhibition of HSV-1 reactivation has been attributed to granzyme B cleavage of HSV infected cell protein 4 (ICP4); however, it is unknown whether granzyme B cleavage of ICP4 can directly protect cells from CTL cytotoxicity. Varicella zoster virus (VZV) is closely related to HSV-1; however, it is unknown whether VZV proteins contain granzyme B cleavage sites. Natural killer (NK) cells play a central role in VZV and HSV-1 pathogenesis and, like CTLs, utilize granzyme B to kill virally infected target cells. However, whether alphaherpesvirus granzyme B cleavage sites could modulate NK cell-mediated cytotoxicity has yet to be established. This study aimed to identify novel HSV-1 and VZV gene products with granzyme B cleavage sites and assess whether they could protect cells from NK cell-mediated cytotoxicity. We have demonstrated that HSV ICP27, VZV open reading frame 62 (ORF62), and VZV ORF4 are cleaved by granzyme B. However, in an NK cell cytotoxicity assay, only VZV ORF4 conferred protection from NK cell-mediated cytotoxicity. The granzyme B cleavage site in ORF4 was identified via site-directed mutagenesis and, surprisingly, the mutation of this cleavage site did not alter the ability of ORF4 to modulate NK cell cytotoxicity, suggesting that ORF4 has a novel immunoevasive function that is independent from the granzyme B cleavage site.IMPORTANCE HSV-1 causes oral and genital herpes and establishes life-long latency in sensory ganglia. HSV-1 reactivates multiple times in a person's life and can cause life-threatening disease in immunocompromised patients. VZV is closely related to HSV-1, causes chickenpox during primary infection, and establishes life-long latency in ganglia, from where it can reactivate to cause herpes zoster (shingles). Unlike HSV-1, VZV only infects humans, and there are limited model systems; thus, little is known concerning how VZV maintains latency and why VZV reactivates. Through studying the link between immune cell cytotoxic functions, granzyme B, and viral gene products, an increased understanding of viral pathogenesis will be achieved.

Functional paralysis of human natural killer cells by alphaherpesviruses.

Natural killer (NK) cells are implicated as important anti-viral immune effectors in varicella zoster virus (VZV) infection. VZV can productively infect human NK cells, yet it is unknown how, or if, VZV can directly affect NK cell function. Here we demonstrate that VZV potently impairs the ability of NK cells to respond to target cell stimulation in vitro, leading to a loss of both cytotoxic and cytokine responses. Remarkably, not only were VZV infected NK cells affected, but VZV antigen negative NK cells that were exposed to virus in culture were also inhibited. This powerful impairment of function was dependent on direct contact between NK cells and VZV infected inoculum cells. Profiling of the NK cell surface receptor phenotype by multiparameter flow cytometry revealed that functional receptor expression is predominantly stable. Furthermore, inhibited NK cells were still capable of releasing cytotoxic granules when the stimulation signal bypassed receptor/ligand interactions and early signalling, suggesting that VZV paralyses NK cells from responding. Phosflow examination of key components in the degranulation signalling cascade also demonstrated perturbation following culture with VZV. In addition to inhibiting degranulation, IFN-γ and TNF production were also repressed by VZV co-culture, which was most strongly regulated in VZV infected NK cells. Interestingly, the closely related virus, herpes simplex virus type 1 (HSV-1), was also capable of efficiently infecting NK cells in a cell-associated manner, and demonstrated a similar capacity to render NK cells unresponsive to target cell stimulation-however HSV-1 differentially targeted cytokine production compared to VZV. Our findings progress a growing understanding of pathogen inhibition of NK cell function, and reveal a previously unreported strategy for VZV to manipulate the immune response.

IL2RB maintains immune harmony.

How the IL-2 receptor ß-chain specifically shapes immunity has remained enigmatic. In this issue of JEM, Zhang et al. (https://doi.org/10.1084/jem.20182304) and Fernandez et al. (https://doi.org/10.1084/jem.20182015) independently report the first observations of autosomal recessive mutations in IL2RB, revealing a requirement for IL2RB in immunity and peripheral immune tolerance.

Operative Management of Abdominal Wound Dehiscence: Outcomes and Factors Influencing Time to Healing in Patients Undergoing Surgical Debridement With Primary Closure.

INTRODUCTION: Plastic surgeons are often consulted by other surgical teams for management of wound dehiscence following abdominopelvic surgery. OBJECTIVE: The purpose of this study is to determine whether operative debridement and primary closure of abdominopelvic wounds are safe and expeditious for patients. MATERIALS AND METHODS: A retrospective analysis was conducted on a database of patients who underwent operative debridement and closure at a single institution between January 2011 and December 2015 for dehisced abdominal or pelvic wounds acquired from prior obstetric, gynecologic, transplant, plastic, or general surgery procedures. RESULTS: Of the 163 patient records identified, 43 patients met inclusion criteria. The median time from final debridement and primary surgical closure to complete wound healing was 27 days. Time to healing differed significantly by index procedure type (P = .004), with obstetric procedures requiring the shortest median time (12.0 days) and general surgery procedures requiring the longest (39.5 days). Wound healing took 3.6 times longer for patients with diabetes (P = .046) and 11.4 times longer for patients who experienced delayed superficial wound healing or redehiscence (P = .003). Nevertheless, with the exception of 4 patients who died of other causes, all wounds (39/39; 100%) achieved complete wound closure. CONCLUSIONS: Operative debridement and closure of abdominopelvic wound dehiscence through a multidisciplinary team approach with plastic surgery results in expeditious wound healing with minimal complications, and it may be safer and more cost effective than healing by secondary intention.

From Ambivalence to Revitalization: Negotiating Cardiovascular Health Behaviors Related to Environmental and Historical Trauma in a Northwest American Indian Community.

Cardiovascular disease is the number one cause of death among American Indians and Alaska Natives (AI/AN). Utilizing narratives from members of a Pacific Northwest tribe, this paper explores perceptions about behaviors affecting cardiovascular health through tribal members' lived experiences related to place-based environmental historical trauma. Findings from narrative analysis indicate that ambivalence is an effect of historical trauma and complicates the adoption of protective cardiovascular health behaviors. Tribal narratives indicate a path to overcome this ambivalence stemming from historical environmental trauma through revitalization, adaptation, and re-integration of traditional cultural practices to contemporary contexts. By creating their own health promotion response, one that is not imposed or colonizing, tribal members are re-generating cultural practices and health behaviors associated with lowered risks of cardiovascular disease.

Varicella zoster virus productively infects human natural killer cells and manipulates phenotype.

Varicella zoster virus (VZV) is a ubiquitous human alphaherpesvirus, responsible for varicella upon primary infection and herpes zoster following reactivation from latency. To establish lifelong infection, VZV employs strategies to evade and manipulate the immune system to its advantage in disseminating virus. As innate lymphocytes, natural killer (NK) cells are part of the early immune response to infection, and have been implicated in controlling VZV infection in patients. Understanding of how VZV directly interacts with NK cells, however, has not been investigated in detail. In this study, we provide the first evidence that VZV is capable of infecting human NK cells from peripheral blood in vitro. VZV infection of NK cells is productive, supporting the full kinetic cascade of viral gene expression and producing new infectious virus which was transmitted to epithelial cells in culture. We determined by flow cytometry that NK cell infection with VZV was not only preferential for the mature CD56dim NK cell subset, but also drove acquisition of the terminally-differentiated maturity marker CD57. Interpretation of high dimensional flow cytometry data with tSNE analysis revealed that culture of NK cells with VZV also induced a potent loss of expression of the low-affinity IgG Fc receptor CD16 on the cell surface. Notably, VZV infection of NK cells upregulated surface expression of chemokine receptors associated with trafficking to the skin -a crucial site in VZV disease where highly infectious lesions develop. We demonstrate that VZV actively manipulates the NK cell phenotype through productive infection, and propose a potential role for NK cells in VZV pathogenesis.

"They Gave Me Life": Motherhood and Recovery in a Tribal Community.

OBJECTIVE: This study explored factors related to substance misuse and recovery among Native mothers in a Pacific Northwest tribe, focusing on motherhood as a motivating factor in seeking treatment and sustaining recovery. METHOD: Using a community-based participatory research approach, we conducted a thematic analysis of 20 in-depth interviews and one focus group (N = 12) with Native women 18 years and older living on or near the reservation. RESULTS: Qualitative findings highlighted challenges, motivations and strategies for seeking treatment and recovery in four major themes: (a) the close relationship between interpersonal violence and substance misuse; (b) traditional healing in recovery; (c) community-specific challenges to recovery; and (d) the motivating role of motherhood in seeking treatment and successful recovery. CONCLUSIONS: A central finding of this work is that pregnancy and motherhood may be underexplored factors in Native women's substance use. Results support previous work suggesting that Native women are at high risk of interpersonal trauma and that trauma contributes to substance misuse. Findings offer several rich implications for treatment and recovery among Native mothers in tribal communities including the necessity of trauma-informed treatment, community and culturally-based interventions, more integration of treatment services with Child Protective Services, and drawing on motherhood as a motivation for seeking and succeeding in recovery.