Cell Intrinsic Determinants of Alpha Herpesvirus Latency and Pathogenesis in the Nervous System.

Alpha herpesvirus infections (α-HVs) are widespread, affecting more than 70% of the adult human population. Typically, the infections start in the mucosal epithelia, from which the viral particles invade the axons of the peripheral nervous system. In the nuclei of the peripheral ganglia, α-HVs establish a lifelong latency and eventually undergo multiple reactivation cycles. Upon reactivation, viral progeny can move into the nerves, back out toward the periphery where they entered the organism, or they can move toward the central nervous system (CNS). This latency-reactivation cycle is remarkably well controlled by the intricate actions of the intrinsic and innate immune responses of the host, and finely counteracted by the viral proteins in an effort to co-exist in the population. If this yin-yang- or Nash-equilibrium-like balance state is broken due to immune suppression or genetic mutations in the host response factors particularly in the CNS, or the presence of other pathogenic stimuli, α-HV reactivations might lead to life-threatening pathologies. In this review, we will summarize the molecular virus-host interactions starting from mucosal epithelia infections leading to the establishment of latency in the PNS and to possible CNS invasion by α-HVs, highlighting the pathologies associated with uncontrolled virus replication in the NS.

Interferon-λ Activates a Differential Response in Peripheral Neurons That Is Effective against Alpha Herpesvirus Infections.

Alpha herpesviruses (α-HV) infect host mucosal epithelial cells prior to establishing a life-long latent infection in the peripheral nervous system. The initial spread of viral particles from mucosa to the nervous system and the role of intrinsic immune responses at this barrier is not well understood. Using primary neurons cultured in compartmentalized chambers, prior studies performed on Pseudorabies virus (PRV) have demonstrated that type I and type II interferons (IFNs) induce a local antiviral response in axons via distinct mechanisms leading to a reduction in viral particle transport to the neuronal nucleus. A new class of interferons known as type III IFNs has been shown to play an immediate role against viral infection in mucosal epithelial cells. However, the antiviral effects of type III IFNs within neurons during α-HV infection are largely unknown. In this study, we focused on elucidating the antiviral activity of type III IFN against PRV neuronal infection, and we compared the interferon-stimulated gene (ISGs) induction pattern in neurons to non-neuronal cells. We found that IFN pre-exposure of both primary neurons and fibroblast cells significantly reduces PRV virus yield, albeit by differential STAT activation and ISG induction patterns. Notably, we observed that type III IFNs trigger the expression of a subset of ISGs mainly through STAT1 activation to induce an antiviral state in primary peripheral neurons.

Coronary Revascularization in Patients With Diabetes: A Meta-Analysis of Randomized Controlled Trials and Propensity-Matched Studies.

OBJECTIVE: Patients with diabetes have poorer outcomes with coronary artery disease (CAD) and pose a unique clinical population for revascularization. We performed a pairwise meta-analysis of randomized trials (RCTs) and propensity-matched observational studies (PMS) to compare the clinical outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with diabetes. METHODS: A comprehensive literature search was performed to identify RCT and PMS studies comparing CABG with PCI in patients with diabetes with concurrent CAD. Studies were pooled using the random-effects model to perform a pairwise meta-analysis. Primary outcomes included long-term all-cause mortality, cardiac mortality, myocardial infarction (MI), major adverse cardiac and cerebrovascular events (MACCE), and repeat revascularization. Meta-regression was used to explore the effects of baseline risk factors on primary outcomes with moderate to high heterogeneity. RESULTS: A total of 18 RCTs and 9 PMS with 28,846 patients were included. PCI was associated with increased long-term all-cause mortality (risk ratio [RR] = 1.34, P < 0.001), cardiac mortality (RR = 1.52, P < 0.001), MI (RR = 1.51, P = 0.009), MACCE (RR = 1.65, P < 0.001), and repeat revascularization (RR = 2.48, P < 0.001) compared with CABG. There was no difference in long-term stroke between the 2 groups (RR = 0.95, P = 0.82). At meta-regression, a greater proportion of female patients in studies was associated with a decreased protective benefit for CABG for long-term all-cause mortality but an increased protective benefit for long-term MI and repeat revascularization. CONCLUSIONS: Revascularization of patients with diabetes using CABG is associated with significantly reduced long-term mortality, MI, MACCE, and repeat revascularizations. Future studies exploring the influence of gender on revascularization outcomes are necessary to elucidate the ideal treatment modality in patients with diabetes.

Black and Latinx Primary Caregiver Considerations for Developing and Implementing a Machine Learning-Based Model for Detecting Child Abuse and Neglect With Implications for Racial Bias Reduction: Qualitative Interview Study With Primary Caregivers.

BACKGROUND: Child abuse and neglect, once viewed as a social problem, is now an epidemic. Moreover, health providers agree that existing stereotypes may link racial and social class issues to child abuse. The broad adoption of electronic health records (EHRs) in clinical settings offers a new avenue for addressing this epidemic. To reduce racial bias and improve the development, implementation, and outcomes of machine learning (ML)-based models that use EHR data, it is crucial to involve marginalized members of the community in the process. OBJECTIVE: This study elicited Black and Latinx primary caregivers' viewpoints regarding child abuse and neglect while living in underserved communities to highlight considerations for designing an ML-based model for detecting child abuse and neglect in emergency departments (EDs) with implications for racial bias reduction and future interventions. METHODS: We conducted a qualitative study using in-depth interviews with 20 Black and Latinx primary caregivers whose children were cared for at a single pediatric tertiary-care ED to gain insights about child abuse and neglect and their experiences with health providers. RESULTS: Three central themes were developed in the coding process: (1) primary caregivers' perspectives on the definition of child abuse and neglect, (2) primary caregivers' experiences with health providers and medical documentation, and (3) primary caregivers' perceptions of child protective services. CONCLUSIONS: Our findings highlight essential considerations from primary caregivers for developing an ML-based model for detecting child abuse and neglect in ED settings. This includes how to define child abuse and neglect from a primary caregiver lens. Miscommunication between patients and health providers can potentially lead to a misdiagnosis, and therefore, have a negative impact on medical documentation. Additionally, the outcome and application of the ML-based models for detecting abuse and neglect may cause additional harm than expected to the community. Further research is needed to validate these findings and integrate them into creating an ML-based model.

Considerations for development of child abuse and neglect phenotype with implications for reduction of racial bias: a qualitative study.

OBJECTIVE: The study provides considerations for generating a phenotype of child abuse and neglect in Emergency Departments (ED) using secondary data from electronic health records (EHR). Implications will be provided for racial bias reduction and the development of further decision support tools to assist in identifying child abuse and neglect. MATERIALS AND METHODS: We conducted a qualitative study using in-depth interviews with 20 pediatric clinicians working in a single pediatric ED to gain insights about generating an EHR-based phenotype to identify children at risk for abuse and neglect. RESULTS: Three central themes emerged from the interviews: (1) Challenges in diagnosing child abuse and neglect, (2) Health Discipline Differences in Documentation Styles in EHR, and (3) Identification of potential racial bias through documentation. DISCUSSION: Our findings highlight important considerations for generating a phenotype for child abuse and neglect using EHR data. First, information-related challenges include lack of proper previous visit history due to limited information exchanges and scattered documentation within EHRs. Second, there are differences in documentation styles by health disciplines, and clinicians tend to document abuse in different document types within EHRs. Finally, documentation can help identify potential racial bias in suspicion of child abuse and neglect by revealing potential discrepancies in quality of care, and in the language used to document abuse and neglect. CONCLUSIONS: Our findings highlight challenges in building an EHR-based risk phenotype for child abuse and neglect. Further research is needed to validate these findings and integrate them into creation of an EHR-based risk phenotype.

Developing machine learning-based models to help identify child abuse and neglect: key ethical challenges and recommended solutions.

Child abuse and neglect are public health issues impacting communities throughout the United States. The broad adoption of electronic health records (EHR) in health care supports the development of machine learning-based models to help identify child abuse and neglect. Employing EHR data for child abuse and neglect detection raises several critical ethical considerations. This article applied a phenomenological approach to discuss and provide recommendations for key ethical issues related to machine learning-based risk models development and evaluation: (1) biases in the data; (2) clinical documentation system design issues; (3) lack of centralized evidence base for child abuse and neglect; (4) lack of "gold standard "in assessment and diagnosis of child abuse and neglect; (5) challenges in evaluation of risk prediction performance; (6) challenges in testing predictive models in practice; and (7) challenges in presentation of machine learning-based prediction to clinicians and patients. We provide recommended solutions to each of the 7 ethical challenges and identify several areas for further policy and research.

Decellularized versus cryopreserved pulmonary allografts for right ventricular outflow tract reconstruction during the Ross procedure: a meta-analysis of short- and long-term outcomes.

BACKGROUND: The ideal conduit for repair of the right ventricular outflow tract (RVOT) during the Ross procedure remains unclear and has yet to be fully elucidated. We perform a pairwise meta-analysis to compare the short-term and long-term outcomes of decellularized versus cryopreserved pulmonary allografts for RVOT reconstruction during the Ross procedure. MAIN BODY: After a comprehensive literature search, studies comparing decellularized and cryopreserved allografts for patients undergoing RVOT reconstruction during the Ross procedure were pooled to perform a pairwise meta-analysis using the random-effects model. Primary outcomes were early mortality and follow-up allograft dysfunction. Secondary outcomes were reintervention rates and follow-up endocarditis. A total of 4 studies including 1687 patients undergoing RVOT reconstruction during the Ross procedure were included. A total of 812 patients received a decellularized pulmonary allograft, while 875 received a cryopreserved pulmonary allograft. Compared to cryopreserved allografts, the decellularized group showed similar rates of early mortality (odds ratio, 0.55, 95% confidence interval, 0.21-1.41, P = 0.22). At a mean follow-up period of 5.89 years, no significant difference was observed between the two groups for follow-up allograft dysfunction (hazard ratio, 0.65, 95% confidence interval, 0.20-2.14, P = 0.48). Similarly, no difference was seen in reintervention rates (hazard ratio, 0.54, 95% confidence interval, 0.09-3.12, P = 0.49) nor endocarditis (hazard ratio, 0.30, 95% confidence interval, 0.07-1.35, P = 0.12) at a mean follow-up of 4.85 and 5.75 years, respectively. CONCLUSIONS: Decellularized and cryopreserved pulmonary allografts are associated with similar postoperative outcomes for RVOT reconstruction during the Ross procedure. Larger propensity-matched and randomized control trials are necessary to elucidate the efficacy of decellularized allografts compared to cryopreserved allografts in the setting of the Ross.

Evaluation of the effects of altitude on biological signatures of inflammation and anxiety- and depressive-like behavioral responses.

Over sixteen million people suffer from a depressive episode annually in the United States, with females affected at twice the rate of males. Little is known about the effects of exposure to high altitude on the risk of development of major depressive disorder, despite reports of higher suicide rates at higher altitudes. We hypothesize that exposure to hypobaric hypoxia at high altitude increases endophenotypes of self-directed suicidal violence, including biological signatures of chronic inflammation and vulnerability to anxiety-like and depressive-like behavioral responses in a sex-specific manner. Biological signatures of inflammation, including granulocyte:lymphocyte ratios, monocyte cell counts, and monocyte:lymphocyte ratios were assessed using complete blood count data, anhedonia, and anxiety- and depressive-like behavioral responses were evaluated. We assessed biological signatures of inflammation and behavioral responses in the open-field test, sucrose preference test, and modified Porsolt forced swim test in young adult male and female Long-Evans and Sprague Dawley rats. All tests were conducted near sea level (374 ft [114 m] elevation) and at moderate-high altitude (5430 ft [1655 m] elevation) during acclimation periods of one, two, three, four, and five weeks following shipment from a sea level animal breeding facility (N = 320, n = 8 per group). Exposure to moderate-high altitude induced a biological signature of increased inflammation, as evidenced by main effects of altitude for: 1) increased granulocyte:lymphocyte ratio; 2) increased count and relative abundance of circulating monocytes; and 3) increased monocyte:lymphocyte ratios. Exposure to moderate-high altitude also increased anhedonia as assessed in the sucrose preference test in both male and female rats, when data were collapsed across strain and time. Among male and female Long Evans rats, exposure to moderate-high altitude increased immobility in the forced swim test, without changing anxiety-like behaviors in the open-field test. Finally, granulocyte:lymphocyte ratios were correlated with anhedonia in the sucrose preference test. These data are consistent with the hypothesis that hypobaric hypoxia at moderate-high altitude induces persistent endophenotypes of self-directed suicidal violence including biological signatures of inflammation, anhedonia, and depressive-like behavioral responses.

Evaluation of the gut microbiome in association with biological signatures of inflammation in murine polytrauma and shock.

Severe injuries are frequently accompanied by hemorrhagic shock and harbor an increased risk for complications. Local or systemic inflammation after trauma/hemorrhage may lead to a leaky intestinal epithelial barrier and subsequent translocation of gut microbiota, potentially worsening outcomes. To evaluate the extent with which trauma affects the gut microbiota composition, we performed a post hoc analysis of a murine model of polytrauma and hemorrhage. Four hours after injury, organs and plasma samples were collected, and the diversity and composition of the cecal microbiome were evaluated using 16S rRNA gene sequencing. Although cecal microbial alpha diversity and microbial community composition were not found to be different between experimental groups, norepinephrine support in shock animals resulted in increased alpha diversity, as indicated by higher numbers of distinct microbial features. We observed that the concentrations of proinflammatory mediators in plasma and intestinal tissue were associated with measures of microbial alpha and beta diversity and the presence of specific microbial drivers of inflammation, suggesting that the composition of the gut microbiome at the time of trauma, or shortly after trauma exposure, may play an important role in determining physiological outcomes. In conclusion, we found associations between measures of gut microbial alpha and beta diversity and the severity of systemic and local gut inflammation. Furthermore, our data suggest that four hours following injury is too early for development of global changes in the alpha diversity or community composition of the intestinal microbiome. Future investigations with increased temporal-spatial resolution are needed in order to fully elucidate the effects of trauma and shock on the gut microbiome, biological signatures of inflammation, and proximal and distal outcomes.

Upregulation of Multiple CD8+ T Cell Exhaustion Pathways Is Associated with Recurrent Ocular Herpes Simplex Virus Type 1 Infection.

A large proportion of the world's population harbors latent HSV type 1 (HSV-1). Cross-talk between antiviral CD8+ T cells and HSV-1 appear to control latency/reactivation cycles. We found that compared with healthy asymptomatic individuals, in symptomatic (SYMP) patients, the CD8+ T cells with the same HLA-A*0201-restricted HSV-1 epitope specificities expressed multiple genes and proteins associated to major T cell exhaustion pathways and were dysfunctional. Blockade of immune checkpoints with anti-LAG-3 and anti-PD-1 antagonist mAbs synergistically restored the frequency and function of antiviral CD8+ T cells, both 1) ex vivo, in SYMP individuals and SYMP HLA-A*0201 transgenic mice; and 2) in vivo in HSV-1-infected SYMP HLA-A*0201 transgenic mice. This was associated with a significant reduction in virus reactivation and recurrent ocular herpetic disease. These findings confirm antiviral CD8+ T cell exhaustion during SYMP herpes infection and pave the way to targeting immune checkpoints to combat recurrent ocular herpes.

High Frequency of Gamma Interferon-Producing PLZFloRORγtlo Invariant Natural Killer 1 Cells Infiltrating Herpes Simplex Virus 1-Infected Corneas Is Associated with Asymptomatic Ocular Herpesvirus Infection.

Invariant natural killer (iNKT) cells are among the first innate immune cells to elicit early protective immunity that controls invading viral pathogens. The role of the iNKT cell subsets iNKT1, iNKT2, and iNKT17 in herpesvirus immunity remains to be fully elucidated. In this study, we examined the protective role of cornea-resident iNKT cell subsets using the mouse model of ocular herpesvirus infection and disease. Wild-type (WT) C57BL/6 (B6) mice and CD1d knockout (KO) mice were infected ocularly with herpes simplex virus 1 (HSV-1) (strain McKrae). Cornea, spleen, and liver were harvested at 0, 2, 5, 8, and 14 days postinfection (p.i.), and the frequency and function of the three major iNKT cell subsets were analyzed and correlated with symptomatic and asymptomatic corneal herpesvirus infections. The profiles of 16 major pro- and anti-inflammatory cytokines were analyzed in corneal lysates using Western blot and Luminex assays. Early during ocular herpesvirus infection (i.e., day 2), the gamma interferon (IFN-γ)-producing PLZFloRORγtlo (promyelocytic leukemia zinc finger, retinoic acid-related orphan receptor gT) iNKT1 cell subset was the predominant iNKT cell subset in infected asymptomatic corneas. Moreover, compared to the asymptomatic corneas of HSV-1-infected WT mice, the symptomatic corneas CD1d KO mice, with iNKT cell deficiency, had increased levels of the inflammatory cytokine interleukin-6 (IL-6) and decreased levels of IL-12, IFN-γ, and the JAK1, STAT1, NF-κB, and extracellular signal-regulated kinase 1/2 (ERK1/2) pathways. Our findings suggest that IFN-γ-producing PLZFloRORγtlo iNKT1 cells play a role in the protective innate immune response against symptomatic ocular herpes.IMPORTANCE We investigated the protective role of iNKT cell subsets in asymptomatic ocular herpesvirus infection. We found that early during ocular herpesvirus infection (i.e., on day 2 postinfection), IFN-γ-producing PLZFloRORγtlo iNKT1 cells were the predominant iNKT cell subset in infected corneas of asymptomatic B6 mice (with little to no corneal herpetic disease), compared to corneas of symptomatic mice (with severe corneal herpetic disease). Moreover, compared to asymptomatic corneas of wild-type (WT) B6 mice, the symptomatic corneas of CD1d KO mice, which lack iNKT cells, showed (i) decreases in the levels of IFN-γ and IL-12, (ii) an increase in the level of the inflammatory cytokine IL-6; and (iii) downregulation of the JAK1, STAT1, NF-κB, and ERK1/2 pathways. The findings suggest that early during ocular herpesvirus infection, cornea-resident IFN-γ-producing PLZFloRORγtlo iNKT1 cells provide protection from symptomatic ocular herpes.

Blockade of PD-1 and LAG-3 Immune Checkpoints Combined with Vaccination Restores the Function of Antiviral Tissue-Resident CD8+ TRM Cells and Reduces Ocular Herpes Simplex Infection and Disease in HLA Transgenic Rabbits.

Chronic viruses such as herpes simplex virus 1 (HSV-1) evade the hosts' immune system by inducing the exhaustion of antiviral T cells. In the present study, we found that exhausted HSV-specific CD8+ T cells, with elevated expression of programmed death ligand-1 (PD-1) and lymphocyte activation gene-3 (LAG-3) receptors were frequent in symptomatic patients, with a history of numerous episodes of recurrent corneal herpetic disease, compared to asymptomatic patients who never had corneal herpetic disease. Subsequently, using a rabbit model of recurrent ocular herpes, we found that the combined blockade of PD-1 and LAG-3 pathways with antagonist antibodies significantly restored the function of tissue-resident antiviral CD8+ TRM cells in both the cornea and the trigeminal ganglia (TG). An increased number of functional tissue-resident HSV-specific CD8+ TRM cells in latently infected rabbits was associated with protection against recurrent herpes infection and disease. Compared to the PD-1 or LAG-3 blockade alone, the combined blockade of PD-1 and LAG-3 appeared to have a synergistic effect in generating frequent polyfunctional Ki-67+, IFN-γ+, CD107+, and CD8+ T cells. Moreover, using the human leukocyte antigen (HLA) transgenic rabbit model, we found that dual blockade of PD-1 and LAG-3 reinforced the effect of a multiepitope vaccine in boosting the frequency of HSV-1-specific CD8+ TRM cells and reducing disease severity. Thus, both the PD-1 and the LAG-3 exhaustion pathways play a fundamental role in ocular herpes T cell immunopathology and provide important immune checkpoint targets to combat ocular herpes.IMPORTANCE HSV-specific tissue-resident memory CD8+ TRM cells play a critical role in preventing virus reactivation from latently infected TG and subsequent virus shedding in tears that trigger the recurrent corneal herpetic disease. In this report, we determined how the dual blockade of PD-1 and LAG-3 immune checkpoints, combined with vaccination, improved the function of CD8+ TRM cells associated with a significant reduction in recurrent ocular herpes in HLA transgenic (Tg) rabbit model. The combined blockade of PD-1 and LAG-3 appeared to have a synergistic effect in generating frequent polyfunctional CD8+ TRM cells that infiltrated both the cornea and the TG. The preclinical findings using the established HLA Tg rabbit model of recurrent herpes highlight that blocking immune checkpoints combined with a T cell-based vaccine would provide an important strategy to combat recurrent ocular herpes in the clinic.

The Michigan Peer-to-Peer Depression Awareness Program: School-Based Prevention to Address Depression Among Teens.

OBJECTIVE: The Peer-to-Peer Depression Awareness Program (P2P) is a school-based program that aims to decrease mental illness and promote well-being among students by empowering high school students as both learners and educators. Specific goals include improving the school climate around mental health, directing students to resources, and encouraging help-seeking behavior. METHODS: In the 2015-2016 academic year, 121 students across 10 high schools organized into teams and were trained to develop and implement peer-to-peer depression awareness campaigns. Outcomes were assessed via pre- and posttest questionnaires. RESULTS: A total of 878 students completed questionnaires. Outcomes demonstrated improved knowledge and attitudes toward depression, increased confidence in identifying and referring peers with depression, improved help-seeking intentions, and reduced stigma. CONCLUSIONS: The P2P program increased depression literacy through the use of youth-designed and youth-implemented depression awareness and outreach activities, which may ultimately result in earlier detection of depression and in fewer depression sequelae.

Lepidium meyenii (Maca) increases litter size in normal adult female mice.

BACKGROUND: Lepidium meyenii, known as Maca, grows exclusively in the Peruvian Andes over 4000 m altitude. It has been used traditionally to increase fertility. Previous scientific studies have demonstrated that Maca increases spermatogenesis and epididymal sperm count. The present study was aimed to investigate the effects of Maca on several fertility parameters of female mice at reproductive age. METHODS: Adult female Balb/C mice were divided at random into three main groups: i) Reproductive indexes group, ii) Implantation sites group and iii) Assessment of uterine weight in ovariectomized mice. Animals received an aqueous extract of lyophilized Yellow Maca (1 g/Kg BW) or vehicle orally as treatment. In the fertility indexes study, animals received the treatment before, during and after gestation. The fertility index, gestation index, post-natal viability index, weaning viability index and sex ratio were calculated. Sexual maturation was evaluated in the female pups by the vaginal opening (VO) day. In the implantation study, females were checked for implantation sites at gestation day 7 and the embryos were counted. In ovariectomized mice, the uterine weight was recorded at the end of treatment. RESULTS: Implantation sites were similar in mice treated with Maca and in controls. All reproductive indexes were similar in both groups of treatment. The number of pups per dam at birth and at postnatal day 4 was significantly higher in the group treated with Maca. VO day occurred earlier as litter size was smaller. Maca did not affect VO day. In ovariectomized mice, the treatment with Maca increased significantly the uterine weights in comparison to their respective control group. CONCLUSION: Administration of aqueous extract of Yellow Maca to adult female mice increases the litter size. Moreover, this treatment increases the uterine weight in ovariectomized animals. Our study confirms for the first time some of the traditional uses of Maca to enhance female fertility.