Inflammatory Consequences: Hepatitis C Virus-Induced Inflammasome Activation and Pyroptosis.

Hepatitis C virus (HCV), despite the availability of effective direct-acting antivirals (DAAs) that clear the virus from >95% of individuals treated, continues to cause significant health care burden due to disease progression that can lead to fibrosis, cirrhosis, and/or hepatocellular carcinoma. The fact that some people who are treated with DAAs still go on to develop worsening liver disease warrants further study into the immunopathogenesis of HCV. Many viral infections, including HCV, have been associated with activation of the inflammasome/pyroptosis pathway. This inflammatory cell death pathway ultimately results in cell lysis and release of inflammatory cytokines, IL-18 and IL-1ß. This review will report on studies that investigated HCV and inflammasome activation/pyroptosis. This includes clinical in vivo data showing elevated pyroptosis-associated cytokines in the blood of individuals living with HCV, studies of genetic associations of pyroptosis-related genes and development of liver disease, and in vitro studies aimed at understanding the mechanism of pyroptosis induced by HCV. Finally, we discuss major gaps in understanding and outstanding questions that remain in the field of HCV-induced pyroptosis.

Optimising diagnosis and management of kidney disease: an implementation trial of a clinical decision support system future health today.

BACKGROUND: Chronic kidney disease affects more than 10% of the world's population and is a non-communicable disease of global concern and priority. There is a significant implementation gap between best practice guideline recommendations and current kidney disease management. Previous research has shown the need to partner with primary care to improve education, collaboration, and kidney disease awareness. This implementation trial will explore use of an innovative clinical decision support software, Future Health Today, to improve screening, diagnosis, and management of kidney disease in primary care. The program will be supported by tertiary care outreach services. The primary aim is to test the hypothesis that the Future Health Today implementation program will improve screening, diagnosis, and management of kidney disease. Secondary aims are to evaluate primary care satisfaction and broader health service impacts. METHODS: This pre-post implementation trial using an interrupted time series design will evaluate the clinical and service outcomes of Future Health Today, using a mixed methods study in twenty general practices with an estimated population size of 150,000. Deidentified patient data will be extracted from participating practices to examine the primary aims of the study. Surveys and semi-structured interviews with general practice will inform secondary hypotheses. Data linkage between primary care and tertiary care data will examine the broader health service impacts. DISCUSSION: This investigator driven trial will assess the impact of Future Health Today software coupled with education and clinical outreach support. Investigators hypothesise that there will be improvement in appropriate screening, diagnosis, and management of kidney disease. This program has the potential to be scaled more broadly. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry: ACTRN12623001096640.

Tuberculosis screening practices and outcomes in an australian dialysis unit.

BACKGROUND: The World Health Organisation (WHO) recommends all dialysis patients undertake routine screening for latent tuberculosis infection (LTBI) in high income countries such as Australia. However, we employ a targeted screening approach in our Australian dialysis unit in line with local and some international guidelines. We analysed our practices to assess the validity of our approach. METHODS: A retrospective review of new dialysis patients during the period 2012-2018 was undertaken. Patient records were reviewed for basic demographic data, comorbidities, LTBI screening using Quantiferon Gold (QFG), and outcomes, including episodes of active TB, to June 2020. RESULTS: 472 patients were included. WHO high risk country of origin patients accounted for 22% (n = 103). 229 patients (48.5%) were screened using QFG. The single main indication for screening was transplantation waitlisting. 34 patients had a positive QFG result. Active tuberculosis developed in two patients during the observation period. Both occurred in the screened cohort, the cases having previously tested negative via QFG at 11 and 16 months, prior to the development of active tuberculosis. No patients in the unscreened cohort developed active tuberculosis during the observation period. WHO high risk country of origin was associated with positive QFG status, odds ratio 10.4 (95% CI 3.3-31.2). CONCLUSION: The data failed to show a benefit from widening of the screening program within our dialysis unit. However, a much larger sample size will be required to confidently assess the impact of the current approach on patient outcomes. Analysis of current screening practices and outcomes across all Australian dialysis services is warranted to assess the risks and benefits of widening the screening practices to include all dialysis patients as recommended by the WHO.

Promiscuous Inflammasomes: The False Dichotomy of RNA/DNA Virus-Induced Inflammasome Activation and Pyroptosis.

It is well-known that viruses activate various inflammasomes, which can initiate the programmed cell death pathway known as pyroptosis, subsequently leading to cell lysis and release of inflammatory cytokines IL-1ß and IL-18. This pathway can be triggered by various sensors, including, but not limited to, NLRP3, AIM2, IFI16, RIG-I, and NLRC4. Many viruses are known either to activate or inhibit inflammasomes as a part of the innate immune response or as a mechanism of pathogenesis. Early research in the field of virus-induced pyroptosis suggested a dichotomy, with RNA viruses activating the NLRP3 inflammasome and DNA viruses activating the AIM2 inflammasome. More recent research has shown that this dichotomy may not be as distinct as once thought. It seems many viruses activate multiple inflammasome sensors. Here, we detail which viruses fit the dichotomy as well as many that appear to defy this clearly false dichotomy. It seems likely that most, if not all, viruses activate multiple inflammasome sensors, and future research should focus on expanding our understanding of inflammasome activation in a variety of tissue types as well as virus activation of multiple inflammasomes, challenging biases that stemmed from early literature in this field. Here, we review primarily research performed on human viruses but also include details regarding animal viruses whenever possible.

Crosstalk Between Pyroptosis and Apoptosis in Hepatitis C Virus-induced Cell Death.

Extensive inflammation in the liver is known to contribute to the pathogenesis of hepatitis C virus (HCV) infection. Apoptosis has, for a long time, been known to act as a mechanism of hepatocyte death, but our previous research also identified inflammasome-mediated pyroptosis in infected and uninfected bystander cells as an additional mechanism of HCV-induced cytopathicity. The purpose of this study was to investigate the mechanism of HCV-induced cell death and to determine the timing and relative contributions of apoptosis and pyroptosis during HCV infection. In a model employing a cell culture-adapted strain of JFH-1 HCV and Huh-7.5 hepatocyte-like cells, we found that pyroptosis occurred earlier than did apoptosis during infection. CRISPR knockout of NLRP3 resulted in decreased caspase-1 activation, but not complete elimination, indicating multiple sensors are likely involved in HCV-induced pyroptosis. Knockout of gasdermin-D resulted in increased activation of apoptosis-related caspase-3, suggesting potential crosstalk between the two cell death pathways. An unexpected decrease in activated caspase-1 levels was observed when caspase-3 was knocked out, implying that caspase-3 may have a role in the initiation of pyroptosis, at least in the context of HCV infection. Lower viral titres in culture fluids and increased ratios of intracellular to extracellular levels of infectious virus were observed in knockout versus wild-type Huh-7.5 cells, suggesting that HCV may induce programmed cell death in order to enhance virus release from infected cells. These results contribute to the understanding of HCV pathogenesis and add to the increasing volume of literature suggesting various programmed cell death pathways are not mutually exclusive.

COVID-19 beliefs and vaccination uptake in dialysis patients: lessons from an anonymous patient survey.

BACKGROUND: There is a lack of data on how to best optimise uptake of COVID-19 vaccination in dialysis patients. AIM: To understand attitudes and beliefs about COVID-19 and vaccination uptake in dialysis patients. METHODS: A single-centre, cross-sectional study involving a clinical audit and an anonymous survey of adult maintenance dialysis patients was conducted. RESULTS: The vaccination uptake during the study period was 77.5% at least single dose, compared with 70% in Victoria during the same period. Participants were more likely to be vaccinated if they believed COVID-19 was a serious problem that is worse for people on dialysis. Those unvaccinated were more likely to overestimate the risk of vaccine complications and less likely to have the annual influenza vaccine. Despite over 80% of participants agreeing that they would have the vaccine if recommended by their nephrologist, less than 40% reported receiving information from this source. A predominant reason for vaccine hesitancy was concern regarding vaccine safety. Over 60% of those who were unvaccinated were still open to the vaccine, indicating a significant opportunity to improve vaccination rates through medical consultation and direction. CONCLUSIONS: Vaccine hesitancy for COVID-19 in dialysis patients associates with less informed health beliefs, both about the disease and the risks of vaccination. Patients are more likely to get vaccinated if it is recommended by their nephrologist. Clinicians caring for dialysis patients have a key role in providing high-quality education and advice, representing an urgent opportunity for improvement in vaccination uptake against COVID-19.

Clinical outcomes and cost-benefit analysis comparing laparoscopic and robotic colorectal surgeries.

BACKGROUND: The introduction of minimally invasive platforms for colorectal surgery-laparoscopy and more recently robotics-allows for smaller incisions, shortened hospital stay, less postoperative pain, and quicker return to normal activity. There exists a lack of evidence-based knowledge comparing the clinical outcomes and cost-benefit analysis of the different types of minimally invasive surgery. The aim of this study was to analyze and compare the short-term clinical outcomes and overall hospital costs between laparoscopic and robotic colorectal surgery. METHODS: After IRB approval, we conducted a retrospective chart review from 131 patients who underwent laparoscopic colorectal surgery and 96 patients who underwent robotic colorectal surgery. Data analyzed included pertinent patient demographics, operative times (OR times), conversion rates, postoperative pathology, complications, length of hospital stay, 90-day readmission rates, 30-day mortality, and overall hospital costs. RESULTS: Two hundred and twenty-seven patients were included-laparoscopic (N = 131) and robotic (N = 96) colorectal surgeries. Mean age of patients in the laparoscopic versus robotic cohort was 70.9 vs 63.6 years, (p < 0.001). Around 62 % were operated on for malignant disease. Mean OR time was 113 min for laparoscopy and 109 min for robotics, p = 0.59. Conversion rates were comparable. Mean length of hospital stay (6.6 vs 5.7 days) and postoperative complications (3.2 vs 7 %) were comparable between the laparoscopic and robotic arms. Overall hospital charges were $114,853 for laparoscopy and $107,220 for robotics, and no significant difference was noted (p = 0.448, NS). CONCLUSION: Robotic colectomies were comparable to laparoscopic colectomies in terms of overall hospital charges and short-term clinical outcomes, including length of stay and conversion rates. Robotic surgery was favored for left-sided colectomy. With shorter learning curves and wider availability, robotic approach offers a safe and economically feasible minimally invasive platform for complex colorectal resections.