The complement regulator CD55 modulates TLR9 signaling and supports survival in marginal zone B cells.

Marginal zone (MZ) B cells bridge innate and adaptive immunity by sensing bloodborne antigens and producing rapid antibody and cytokine responses. CD55 is a membrane-bound complement regulator that interferes with complement activation, an important component of innate immunity. CD55 also regulates adaptive immunity-CD55 downregulation is critical for germinal center reactions. MZ B cells also express low CD55, but its role in MZ B cell function is unknown. Using germline knockout mice, we found that similar numbers of MZ B cells are initially established in 3-week-old CD55-deficient mice compared to wild-type (WT) mice. However, MZ B cells fail to accumulate as mice age and undergo increased apoptosis. Following ex vivo stimulation of MZ B cells through Toll-like receptor 9, we observed a proinflammatory phenotype with increased IL-6 expression. These findings demonstrate a critical role for CD55 in supporting MZ B cell survival while also regulating cellular function.

State-of-the-Art Review: Use of Antimicrobials at the End of Life.

Navigating antibiotics at the end of life is a challenge for infectious disease (ID) physicians who remain deeply committed to providing patient-centered care and engaging in shared decision making. ID physicians, who often see patients in both inpatient and outpatient settings and maintain continuity of care for patients with refractory or recurrent infections, are ideally situated to provide guidance that aligns with patients' goals and values. Complex communication skills, including navigating difficult emotions around end-of-life care, can be used to better direct shared decision making and assist with antibiotic stewardship.

Cathepsin C role in inflammatory gastroenterological, renal, rheumatic, and pulmonary disorders.

Cathepsin C (CatC, syn. Dipeptidyl peptidase I) is a lysosomal cysteine proteinase expressed in several tissues including inflammatory cells. This enzyme is important for maintaining multiple cellular functions and for processing immune cell-derived proteases. While mutations in the CatC gene were reported in Papillon-Lefèvre syndrome, a rare autosomal recessive disorder featuring hyperkeratosis and periodontitis, evidence from clinical and preclinical studies points toward pro-inflammatory effects of CatC in various disease processes that are mainly mediated by the activation of neutrophil serine proteinases. Moreover, tumor-promoting effects were ascribed to CatC. The aim of this review is to highlight current knowledge of the CatC as a potential therapeutic target in inflammatory disorders.

Inhibition of ACAT as a Therapeutic Target for Alzheimer's Disease Is Independent of ApoE4 Lipidation.

APOE4, encoding apolipoprotein E4 (apoE4), is the greatest genetic risk factor for Alzheimer's disease (AD), compared to the common APOE3. While the mechanism(s) underlying APOE4-induced AD risk remains unclear, increasing the lipidation of apoE4 is an important therapeutic target as apoE4-lipoproteins are poorly lipidated compared to apoE3-lipoproteins. ACAT (acyl-CoA: cholesterol-acyltransferase) catalyzes the formation of intracellular cholesteryl-ester droplets, reducing the intracellular free cholesterol (FC) pool. Thus, inhibiting ACAT increases the FC pool and facilitates lipid secretion to extracellular apoE-containing lipoproteins. Previous studies using commercial ACAT inhibitors, including avasimibe (AVAS), as well as ACAT-knock out (KO) mice, exhibit reduced AD-like pathology and amyloid precursor protein (APP) processing in familial AD (FAD)-transgenic (Tg) mice. However, the effects of AVAS with human apoE4 remain unknown. In vitro, AVAS induced apoE efflux at concentrations of AVAS measured in the brains of treated mice. AVAS treatment of male E4FAD-Tg mice (5xFAD+/-APOE4+/+) at 6-8 months had no effect on plasma cholesterol levels or distribution, the original mechanism for AVAS treatment of CVD. In the CNS, AVAS reduced intracellular lipid droplets, indirectly demonstrating target engagement. Surrogate efficacy was demonstrated by an increase in Morris water maze measures of memory and postsynaptic protein levels. Amyloid-beta peptide (Aß) solubility/deposition and neuroinflammation were reduced, critical components of APOE4-modulated pathology. However, there was no increase in apoE4 levels or apoE4 lipidation, while amyloidogenic and non-amyloidogenic processing of APP were significantly reduced. This suggests that the AVAS-induced reduction in Aß via reduced APP processing was sufficient to reduce AD pathology, as apoE4-lipoproteins remained poorly lipidated.

Mental health trends among medical students.

Student mental health concerns can manifest in several forms. Medical students juggling a multitude of trials (i.e., intense academic rigor, financial debt, sleep deprivation, lack of control, continual exposure to sickness and death, and training mistreatment) can help explain the higher prevalence of psychological disorders within this population. Furthermore, these mental health difficulties are not static; certain challenges move into the forefront as students face key transition points in schooling. Primary examples include the entry year of medical school, the shift from preclinical curriculum to clinical training, and the final moments prior to beginning residency. Given the existing mental health trends among medical students at baseline, it can be concluded that the COVID-19 pandemic has exacerbated the stress, anxiety, and depression associated with medical education. Solutions do indeed exist to address the moral injury medical students face, from expanded crisis management training and implementation of peer support networks to destigmatization of and improved access to professional mental health resources. It is up to the curators of the medical education system to make these solutions the new status quo.

Action learning and public health pedagogy: Student reflections from an experiential public health course.

Introduction: Applied practice experiences are essential components of the Masters of Public Health (MPH) curriculum. The objective of this study was to examine students' perspectives on the skills and expertise they developed in an MPH course offering applied practice opportunities. Methods: Of 236 students who took the course from 2008 to 2018, email addresses were obtained for 212 and 104 completed the consent form. Following consent, reflection essays were de-identified and analyzed using a rapid qualitative analysis approach. The essays addressed students' learning experiences and application of the competencies for MPH programs set by the Council for Education in Public Health (CEPH). Deductive and inductive analytical lenses were used to identify the key lessons learned by each cohort of students. Semi-structured guides and matrixes for essay analysis were created using assignment instructions and CEPH competencies. Results: Although the reflection paper assignment varied across the years, commonalities were observed in the student reflections. Key themes included turning theory into practice, navigating the complex environment of public health practice, skill building, critical self-reflection, challenges encountered, and elements that facilitated project success. Students reported developing practical skills, such as planning for independent research (e.g., preparing for institutional review board (IRB) submission, consulting with faculty and other experts), identifying realistic approaches for data extraction during chart reviews and analyses of electronic medical records, and disseminating findings for diverse stakeholders and audiences. Students also reported strengthening cross-cutting skills such as communication, teamwork, and problem-solving that were useful for navigating power dynamics and balancing competing interests and expectations. Students explored their identity as public health professionals as they navigated the dynamics of public health practice. Conclusion: The applied practice experience served as a valuable tool for knowledge and skills acquisition. Moreover, it served as an opportunity for students to engage with the unique organizational cultures of their respective community partners and to deepen their understanding the complexities of conducting meaningful community-engaged research. Implications: This study demonstrates the utility of analyzing students' critical self-reflections as a tool for exploring learning experiences when training future public health professionals. The findings can help educators design future applied practice experiences.

Rapamycin Perfluorocarbon Nanoparticle Mitigates Cisplatin-Induced Acute Kidney Injury.

For nearly five decades, cisplatin has played an important role as a standard chemotherapeutic agent and been prescribed to 10-20% of all cancer patients. Although nephrotoxicity associated with platinum-based agents is well recognized, treatment of cisplatin-induced acute kidney injury is mainly supportive and no specific mechanism-based prophylactic approach is available to date. Here, we postulated that systemically delivered rapamycin perfluorocarbon nanoparticles (PFC NP) could reach the injured kidneys at sufficient and sustained concentrations to mitigate cisplatin-induced acute kidney injury and preserve renal function. Using fluorescence microscopic imaging and fluorine magnetic resonance imaging/spectroscopy, we illustrated that rapamycin-loaded PFC NP permeated and were retained in injured kidneys. Histologic evaluation and blood urea nitrogen (BUN) confirmed that renal structure and function were preserved 48 h after cisplatin injury. Similarly, weight loss was slowed down. Using western blotting and immunofluorescence staining, mechanistic studies revealed that rapamycin PFC NP significantly enhanced autophagy in the kidney, reduced the expression of intercellular adhesion molecule 1 (ICAM-1) and vascular cell adhesion molecule 1 (VCAM-1), as well as decreased the expression of the apoptotic protein Bax, all of which contributed to the suppression of apoptosis that was confirmed with TUNEL staining. In summary, the delivery of an approved agent such as rapamycin in a PFC NP format enhances local delivery and offers a novel mechanism-based prophylactic therapy for cisplatin-induced acute kidney injury.

Phenobarbital for the Management of Alcohol Withdrawal Syndrome in Critically Ill, Surgical-Trauma Patients.

INTRODUCTION: While benzodiazepines (BZD) are the standard of care therapy for the management alcohol withdrawal syndrome (AWS), phenobarbital (PHB) is often used as an alternative agent. The objective of this study is to assess the use of PHB therapy for the management of AWS in trauma-surgical intensive care unit (TSCU) patients. MATERIALS AND METHODS: This is an institutional review board-approved single-center, retrospective study conducted at a large academic medical center. Patients aged ≥ 18 y admitted to the TSCU receiving PHB therapy for primary management of AWS were included. The primary outcome evaluated was the incidence of AWS-related complications (AWSRC) defined as severe agitation, delirium tremens, or seizures following initiation of PHB. Secondary outcomes included the incidence of oversedation and duration of mechanical ventilation. RESULTS: Sixty patients were included in this study. AWSRC following initiation of PHB occurred in 65% of patients. Median time to initiation of PHB (42 versus 18 h, P = 0.001) and rates of oversedation (79.5% versus 28.6%, P < 0.001) were significantly greater among patients who experienced AWSRC compared to those who did not. Univariate analysis revealed use of BZD therapy for ≥ 24 h prior to PHB initiation, time from hospital admission to PHB initiation ≥ 24 h, presence of AWS symptoms at baseline, and baseline MINDS score > 6 were risk factors for AWSRC. CONCLUSIONS: Delays in initiation of PHB appear to be associated with an increased risk for developing AWSRC. Further research is needed to identify an optimal dosing strategy for TSCU patients at high risk for severe AWS.

Coma Recovery Scale-Revised Predicts Disability Rating Scale in Acute Rehabilitation of Severe Traumatic Brain Injury.

OBJECTIVE: To explore the prognostic value of the Coma Recovery Scale-Revised (CRS-R) in predicting disability outcomes in patients with severe traumatic brain injury using the Disability Rating Scale (DRS). DESIGN: Secondary analysis including linear and logistic regressions were performed. SETTING: Data were collected in a previous clinical trial. PARTICIPANTS: One hundred eighty-four participants across 3 countries (N=184). MAIN OUTCOME MEASURES: Disability Rating Scales. RESULTS: Analyses showed an inverse relation between CRS-R scores obtained at baseline and change in DRS scores at 6 weeks. Similarly, changes in CRS-R scores between baseline and 4 weeks were also found to have an inverse relation to change in DRS scores at 6 weeks. CONCLUSIONS: This study generates a tool that can be used to predict the probability that a patient with severe traumatic brain injury lands in 1 of 3 disability categories. The CRS-R may be useful in prognostication of disability in patients with severe traumatic brain injury.

Hydrogel Encapsulation of Genome-Engineered Stem Cells for Long-Term Self-Regulating Anti-Cytokine Therapy.

Biologic therapies have revolutionized treatment options for rheumatoid arthritis (RA) but their continuous administration at high doses may lead to adverse events. Thus, the development of improved drug delivery systems that can sense and respond commensurately to disease flares represents an unmet medical need. Toward this end, we generated induced pluripotent stem cells (iPSCs) that express interleukin-1 receptor antagonist (IL-1Ra, an inhibitor of IL-1) in a feedback-controlled manner driven by the macrophage chemoattractant protein-1 (Ccl2) promoter. Cells were seeded in agarose hydrogel constructs made from 3D printed molds that can be injected subcutaneously via a blunt needle, thus simplifying implantation of the constructs, and the translational potential. We demonstrated that the subcutaneously injected agarose hydrogels containing genome-edited Ccl2-IL1Ra iPSCs showed significant therapeutic efficacy in the K/BxN model of inflammatory arthritis, with nearly complete abolishment of disease severity in the front paws. These implants also exhibited improved implant longevity as compared to the previous studies using 3D woven scaffolds, which require surgical implantation. This minimally invasive cell-based drug delivery strategy may be adapted for the treatment of other autoimmune or chronic diseases, potentially accelerating translation to the clinic.

Epoxy lining influence on recycled water quality during pipeline transit for potable reuse.

An epoxy treatment was applied to a pipeline used to convey advanced treated recycled water from a purification facility to a recharge site. The epoxy treatment was applied to prevent further deterioration (corrosion) of the interior cement mortar lining (CML). A soil column study was conducted to evaluate the effect of the epoxy liner on the clogging potential of water before and after conveyance. The clogging potential was represented by differences in the column's relative hydraulic conductivity and water quality, between the treatment plant and injection site, before and after epoxy lining. Hydraulic conductivity of columns at the injection well site declined rapidly before epoxy and improved considerably after epoxy application. Total suspended solids (TSS) and cellular adenosine triphosphate (cATP) median concentrations improved significantly. Before epoxy, TSS increased with pipeline transit from 0.005 to 0.053 (mg/L) compared with 0.009 mg/L after epoxy. Before epoxy, cATP increased from 0.14 to 1.6 pg/ml across pipeline transit compared with 0.37 pg/ml after epoxy. Aluminum and nitrate followed similar trends. Results indicate that epoxy liner reduced the clogging potential of high purity recycled water, likely due to a decrease in particle and biomass load (clogging constituents) accumulated during pipeline transit. PRACTITIONER POINTS: Clogging potential of advanced treated recycled water increases with pipeline transit. Epoxy lining the pipeline used for conveyance reduces the particulate and microbial loading of the highly purified water. Applying epoxy to pipelines used to convey advanced treated recycled water has the dual benefit of infrastructure protection and improving water quality. Reducing particle and microbial load in the advanced treated recycled water can reduce maintenance frequencies and elongate production periods for MAR applications.

Side-chain modification of collagen-targeting peptide prevents dye aggregation for improved molecular imaging of arthritic joints.

Near-infrared (NIR) dye-peptide conjugates are widely used for tissue-targeted molecular fluorescence imaging of pathophysiologic conditions. However, the significant contribution of both dye and peptide to the net mass of these bioconjugates implies that small changes in either component could alter their photophysical and biological properties. Here, we synthesized and conjugated a type I collagen targeted peptide, RRANAALKAGELYKCILY, to either a hydrophobic (LS1000) or hydrophilic (LS1006) NIR fluorescent dye. Spectroscopic analysis revealed rapid self-assembly of both LS1000 and LS1006 in aqueous media to form stable dimeric/H aggregates, regardless of the free dye's solubility in water. We discovered that replacing the cysteine residue in LS1000 and LS1006 with acetamidomethyl cysteine to afford LS1001 and LS1107, respectively, disrupted the peptide's self-assembly and activated the previously quenched dye's fluorescence in aqueous conditions. These results highlight the dominant role of the octadecapeptide, but not the dye molecules, in controlling the photophysical properties of these conjugates by likely sequestering or extruding the hydrophobic or hydrophilic dyes, respectively. Application of the compounds for imaging collagen-rich tissue in an animal model of inflammatory arthritis showed enhanced uptake of all four conjugates, which retained high collagen-binding affinity, in inflamed joints. Moreover, LS1001 and LS1107 improved the arthritic joint-to-background contrast, suggesting that reduced aggregation enhanced the clearance of these compounds from non-target tissues. Our results highlight a peptide-driven strategy to alter the aggregation states of molecular probes in aqueous solutions, irrespective of the water-solubilizing properties of the dye molecules. The interplay between the monomeric and aggregated forms of the conjugates using simple thiol-modifiers lends the peptide-driven approach to diverse applications, including the effective imaging of inflammatory arthritis joints.

The Role of Antihistamines and Dupilumab in the Management of Alopecia Areata: A Systematic Review.

BACKGROUND: Approximately 30% to 40% of alopecia areata (AA) patients have atopic dermatitis. Studies suggest that antihistamines and dupilumab may be effective treatments; however, the potential benefit of these therapies as either adjunct or monotherapy has yet to be elucidated. OBJECTIVE: To evaluate the use of antihistamines and dupilumab in the treatment of AA. METHODS: A literature search was conducted in August 2021 according to PRISMA guidelines. Inclusion criteria were articles describing the use of antihistamines or dupilumab for AA or those discussing AA development as an adverse event of these therapies. RESULTS: Forty-two articles with 395 patients describe the use of antihistamines or dupilumab in AA. The most common antihistamine regimens were oxatomide 30 mg twice a day, fexofenadine 60 or 120 mg/day, and ebastine 10 mg/day; and the majority of cases reported significant hair regrowth, decreased pruritus, and erythema. Studies on the use of dupilumab for AA demonstrated remarkable hair growth in some patients (n=23), no change in others (n=3), and no new hair loss in a patient with resolved alopecia universalis (AU) (n=1). In contrast, dupilumab therapy for AD has been implicated as a cause of AA (n=21), drug-induced alopecia (n=2), and AA-like psoriasis (n=1). CONCLUSION: Current literature is promising for the use of antihistamines as adjunct treatments for AA, while monotherapy needs to be further explored. The role of dupilumab in AA treatment and/or development also requires further research.J Drugs Dermatol. 2022;21(10):1070-1083. doi:10.36849/JDD.6553.

Proteomic Identification of Potential Target Proteins of Cathepsin W for Its Development as a Drug Target for Influenza.

Influenza A virus (IAV) coopts numerous host factors for efficient replication. The cysteine protease cathepsin W (CTSW) has been identified as one host factor required for IAV entry, specifically for the escape of IAVs from late endosomes. However, the substrate specificity of CTSW and the proviral mechanism are thus far unknown. Here, we show that intracellular but not secreted CTSW promotes viral entry. We reveal 79 potential direct and 31 potential indirect cellular target proteins of CTSW using the high-throughput proteomic approach terminal amine isotopic labeling of substrates (TAILS) and determine the cleavage motif shared by the substrates of CTSW. Subsequent integration with data from RNA interference (RNAi) screens for IAV host factors uncovers first insights into the proviral function of CTSW. Notably, CTSW-deficient mice display a 25% increase in survival and a delay in mortality compared to wild-type mice upon IAV infection. Altogether, these findings support the development of drugs targeting CTSW as novel host-directed antiviral therapies. IMPORTANCE Influenza viruses are respiratory pathogens and pose a constant threat to human health. Although antiviral drugs are available for influenza, the emergence and spread of drug-resistant viruses is cause for concern. Therefore, the development of new antivirals with lower chances of their target viruses acquiring resistance is urgently needed to reduce the high morbidity and mortality caused by influenza. Promising alternatives to drugs targeting viral proteins are those directed against host factors required for viral replication. The cysteine protease cathepsin W (CTSW) is an important host factor for IAV replication, and its proteolytic activity is required for fusion of viral and endosomal membranes. In this work, we identify a number of hitherto unknown CTSW substrates, providing new insights into virus-host interactions, and reveal that CTSW might also play a proviral role in an in vivo model. These results support the development of CTSW as a drug target for next-generation antivirals against influenza.

Caspase-1-driven neutrophil pyroptosis and its role in host susceptibility to Pseudomonas aeruginosa.

Multiple regulated neutrophil cell death programs contribute to host defense against infections. However, despite expressing all necessary inflammasome components, neutrophils are thought to be generally defective in Caspase-1-dependent pyroptosis. By screening different bacterial species, we found that several Pseudomonas aeruginosa (P. aeruginosa) strains trigger Caspase-1-dependent pyroptosis in human and murine neutrophils. Notably, deletion of Exotoxins U or S in P. aeruginosa enhanced neutrophil death to Caspase-1-dependent pyroptosis, suggesting that these exotoxins interfere with this pathway. Mechanistically, P. aeruginosa Flagellin activates the NLRC4 inflammasome, which supports Caspase-1-driven interleukin (IL)-1ß secretion and Gasdermin D (GSDMD)-dependent neutrophil pyroptosis. Furthermore, P. aeruginosa-induced GSDMD activation triggers Calcium-dependent and Peptidyl Arginine Deaminase-4-driven histone citrullination and translocation of neutrophil DNA into the cell cytosol without inducing extracellular Neutrophil Extracellular Traps. Finally, we show that neutrophil Caspase-1 contributes to IL-1ß production and susceptibility to pyroptosis-inducing P. aeruginosa strains in vivo. Overall, we demonstrate that neutrophils are not universally resistant for Caspase-1-dependent pyroptosis.

Peptide-siRNA nanoparticles targeting NF-κB p50 mitigate experimental abdominal aortic aneurysm progression and rupture.

Abdominal aortic aneurysm (AAA) is a progressive vascular condition associated with high risk of mortality if left untreated. AAA is an inflammatory process with excessive local production of extracellular matrix degrading enzymes, leading to dilatation and rupture of the abdominal aorta. We posit that targeting NF-κB, a signaling pathway that controls inflammation, will halt AAA progression and prevent rupture. In an elastase-induced AAA model we observed that NF-κB activation increased progressively post-elastase perfusion. Unexpectedly, we found that AAA progression was marked by predominant nuclear accumulation of the NF-κB p50 subunit at the exclusion of p65. Using the amphipathic peptide p5RHH to form nanocomplexes with siRNA, we sought to mitigate AAA progression by knocking down the expression of different NF-κB subunits. We found that the administration of NF-κB p65 siRNA was only beneficial when given early (day 3 post-elastase perfusion) while p50 siRNA was still effective in mitigating elastase-induced AAA even when delivery was delayed until day 5. Additionally, systemic delivery of p50 siRNA, but not p65 siRNA decreased the risk of aortic rupture and sudden death in the transforming growth factor-beta blockade model of AAA. In both murine models, knockdown of NF-κB was accompanied by a significant decrease in leukocyte infiltrates, inflammatory cytokine release, inducible nitric oxide synthase expression, and cell apoptosis. These results suggest that the NF-κB p50 and p65 subunits contribute differentially at different stages of disease and the timing of in vivo siRNA delivery was of critical importance. The results also provide a rationale for selective targeting of p50 for more specific therapeutic intervention in the medical treatment of small AAA.

Patient Satisfaction and Adverse Effects Following the use of Topical Hair Fiber Fillers.

Introduction: Alopecia (hair loss) commonly affects patients and can severely affect one's confidence and self-esteem. In addition to medical therapy, hair filler fibers can improve the gross appearance of thinning hair in a targeted manner by making hair appear fuller and thicker. The objective of this study is to assess patient use, satisfaction, and adverse effects following the application of a commercially available hair fiber filler product. Materials and Methods: This cross-sectional study was conducted at an academic tertiary dermatology center. Alopecia patients were supplied a keratin hair fiber filler, which best matched their natural hair color. Following 90 days of application, patients were asked to complete questionnaires to assess patient satisfaction and record patient-reported adverse events. Results: Twenty women and 20 men with hair loss participated. Patients reported improved hair volume and increased perceptions of confidence and attractiveness after applying fiber. Most subjects (92.5%) reported a high level of satisfaction with the fiber's ability to match hair color and provide sufficient coverage. No serious adverse effects were reported. Conclusion: Alopecia has a negative impact on quality of life and several psychological domains. Topical hair filler fiber can serve as an effective and safe camouflage for patients with alopecia with high user satisfaction.

Deaths associated with opioids, race and ethnicity, and years of potential life lost in Washington State.

INTRODUCTION: This study examined disparities in years of potential life lost (YPLL) related to opioid use among racial and ethnic groups adjusting for individual- and neighborhood-level characteristics. METHODS: The study obtained data on 5265 geocoded death records associated with opioid use from the Washington State Department of Health. Death certificates included information on race and ethnicity, sex, marital status, and educational attainment. We linked these records to neighborhood-level indicators of rurality, area deprivation, and access to opioid treatment programs. Generalized linear mixed models tested associations between racial and ethnic identity and YPLL controlling for other individual and neighborhood characteristics. RESULTS: Among all decedents from opioid-related causes, the study found that racial and ethnic minorities-including Black, American Indian/Alaska Native, Asian, Native Hawaiian or other Pacific Islander-multiracial, or Hispanic adults died at younger ages than did White adults (33 to 44 vs 45). In the fully adjusted models, the estimated mean for YPLL was higher for Asian or Native Hawaiian or other Pacific Islander, multiracial, and Hispanic adults compared to White adults. Accounting for educational attainment and marital status substantially reduced YPLL differences between groups, by as much as 40% in some cases. CONCLUSIONS: The study observed striking differences in YPLL related to opioid causes among racial and ethnic minorities. Accounting for social determinants of health greatly reduced YPLL across all groups but racial and ethnic disparities in YPLL remained significant. Understanding and alleviating additional causes of disparities in YPLL is warranted to abate the epidemic of opioid related deaths in the United States.