Diabetes Educators' Insights Regarding Connecting Mobile Phone- and Wearable Tracker-Collected Self-Monitoring Information to a Nationally-Used Electronic Health Record System for Diabetes Education: Descriptive Qualitative Study.

BACKGROUND: Diabetes educators are integral to a clinical team in providing diabetes self-management education and support; however, current mobile and Web-based self-management tools are not integrated into clinical diabetes care to support diabetes educators' education efforts. OBJECTIVE: The objective of our study was to seek diabetes educators' insights regarding the development of an interface within the Chronicle Diabetes system, a nationally used electronic health record (EHR) system for diabetes education documentation with behavioral goal-setting functions, to transfer mobile phone- and wearable tracker-collected self-monitoring information from patients to diabetes educators to facilitate behavioral goal monitoring. METHODS: A descriptive qualitative study was conducted to seek educators' perspectives on usability and interface development preferences in developing a connected system. Educators can use the Chronicle Diabetes system to set behavioral goals with their patients. Individual and group interviews were used to seek educators' preferences for viewing mobile phone- and wearable tracker-collected information on diet, physical activity, and sleep in the Chronicle Diabetes system using open-ended questions. Interview data were transcribed verbatim and analyzed for common themes. RESULTS: Five common themes emerged from the discussion. First, educators expressed enthusiasm for and concerns about viewing diet and physical activity data in Chronicle Diabetes system. Second, educators valued viewing detailed dietary macronutrients and activity data; however, they preferred different kinds of details depending on patients' needs, conditions, and behavioral goals and educators' training background. Third, all educators liked the integration of mobile phone-collected data into Chronicle Diabetes system and preferably with current EHR systems. Fourth, a need for a health care team and a central EHR system to be formed was realized for educators to share summaries of self-monitoring data with other providers. Fifth, educators desired advanced features for the mobile app and the connected interface that can show self-monitoring data. CONCLUSIONS: Flexibility is needed for educators to track the details of mobile phone- and wearable tracker-collected diet and activity information, and the integration of such data into Chronicle Diabetes and EHR systems is valuable for educators to track patients' behavioral goals, provide diabetes self-management education and support, and share data with other health care team members to faciliate team-based care in clinical practice.

Rapid clearance of herpes simplex virus type 2 by CD8+ T cells requires high level expression of effector T cell functions.

CD8(+) T cells are important for resolution of HSV-2 lesions from the female genital epithelium. It is uncertain whether optimal clearance of viruses such as HSV-2 that cause a limited, non-systemic infection solely requires expression of effector functions by infiltrating CD8(+) T lymphocytes, or if the clearance rate is reflective of the expression level of critical effector functions. To address this, CD8(+) T cells from normal OT-I mice or OT-I mice deficient in IFNγ (IFNγ(-/-)) or the IFNγ receptor (IFNγR(-/-)) were activated in vitro in the presence of IFNγ or IL-4 to generate a series of effector populations (Tc1 and Tc2-like respectively) that secreted different levels of IFNγ and expressed different levels of HSV-specific cytolytic function. Compared with Tc1 cells, Tc2-like cells produced the type 2 cytokines IL-4 and IL-5, exhibited decreased IFNγ secretion, diminished proliferation in vitro, and decreased antigen-specific cytolysis in vivo. Clearance of an ovalbumin-expressing HSV-2 strain (HSV-2 tk(-) OVA) by adoptively transferred Tc2-like cells was delayed relative to Tc1 cell recipients. Because donor Tc2-like cells proliferated in vivo and infiltrated the infected genital epithelium similar to Tc1 cells, the diminished virus clearance by Tc2-like effector cells correlated with reduced expression of critical effector functions. Together, these results suggest that high level expression of protective T cell functions by effector T cells is necessary for optimal clearance of HSV-2 from the genital epithelium. These results have important implications for vaccines designed to elicit CD8(+) T cells against viruses such as HSV-2 that infect the genital tract.

Herpes simplex virus (HSV)-specific T cells activated in the absence of IFN-gamma express alternative effector functions but are not protective against genital HSV-2 infection.

Interferon gamma (IFNgamma) is important for immune resistance to herpes simplex virus (HSV) infection. To examine the influence of IFNgamma on the development of HSV-specific immune responses and test for IFNgamma-independent adaptive immune mechanisms of protection, IFNgamma-deficient mice (IFNgamma(-/-)) were immunized with thymidine kinase-deficient HSV-2 (HSV-2 333tk(-)). HSV-specific cellular and humoral responses were elicited in immunized IFNgamma(-/-) mice resulting in increased resistance relative to non-immune C57BL/6J (B6) mice following challenge with fully virulent HSV-2. CD8(+) T cells from IFNgamma(-/-) mice displayed cytotoxic activity and secreted TNFalpha. HSV-specific CD4(+) T cells from immunized IFNgamma(-/-) mice secreted IL-4, TNFalpha, and IL-17, but unlike T cells from HSV-immune B6 mice, could not clear virus from genital tissue following adoptive transfer. HSV-immune IFNgamma(-/-) mice produced predominantly IgG(1) HSV-specific antibodies while immune B6 mice produced predominantly IgG(2c) antibodies. Transfer of equivalent amounts of HSV-specific antibodies from either strain to naïve mice imparted equivalent early resistance against infection of the genital epithelia. However, protection against neurological symptoms mediated by immune B6 antibodies was superior late in infection. Taken together, these results demonstrate that the limited resistance of HSV-immune IFNgamma(-/-) mice to HSV-2 infection resulted from the action of HSV-specific Ab rather than IFNgamma-independent effector functions of T cells. Further, protection against neurological manifestations of HSV-2 infection was superior in mice receiving Ab from immune B6 mice suggesting that Ab-mediated protective mechanisms involving IFNgamma-induced IgG subclasses were more effective once virus had spread to neural tissues.

Effector CD4+ T-cell involvement in clearance of infectious herpes simplex virus type 1 from sensory ganglia and spinal cords.

In primary infection, CD8(+) T cells are important for clearance of infectious herpes simplex virus (HSV) from sensory ganglia. In this study, evidence of CD4(+) T-cell-mediated clearance of infectious HSV type 1 (HSV-1) from neural tissues was also detected. In immunocompetent mice, HSV-specific CD4(+) T cells were present in sensory ganglia and spinal cords coincident with HSV-1 clearance from these sites and remained detectable at least 8 months postinfection. Neural CD4(+) T cells isolated at the peak of neural infection secreted gamma interferon, tumor necrosis factor alpha, interleukin-2 (IL-2), or IL-4 after stimulation with HSV antigen. HSV-1 titers in neural tissues were greatly reduced over time in CD8(+) T-cell-deficient and CD8(+) T-cell-depleted mice, suggesting that CD4(+) T cells could mediate clearance of HSV-1 from neural tissue. To examine possible mechanisms by which CD4(+) T cells resolved neural infection, CD8(+) T cells were depleted from perforin-deficient or FasL-defective mice. Clearance of infectious virus from neural tissues was not significantly different in perforin-deficient or FasL-defective mice compared to wild-type mice. Further, in spinal cords and brains after vaginal HSV-1 challenge of chimeric mice expressing both perforin and Fas or neither perforin nor Fas, virus titers were significantly lower than in control mice. Thus, perforin and Fas were not required for clearance of infectious virus from neural tissues. These results suggest that HSV-specific CD4(+) T cells are one component of a long-term immune cell presence in neural tissues following genital HSV-1 infection and play a role in clearance of infectious HSV-1 at neural sites, possibly via a nonlytic mechanism.

Antibody-mediated protection against genital herpes simplex virus type 2 disease in mice by Fc gamma receptor-dependent and -independent mechanisms.

The ability of antibody (Ab) to modulate HSV pathogenesis is well recognized but the mechanisms by which HSV-specific IgG antibodies protect against genital HSV-2 disease are not well understood. The requirement for Ab interactions with Fcgamma receptors (FcgammaR) in protection was examined using a murine model of genital HSV-2 infection. IgG antibodies isolated from the serum of HSV-immune mice protected normal mice against HSV-2 disease when administered prior to genital HSV-2 inoculation. However, protection was significantly diminished in recipient mice lacking the gamma chain subunit utilized in FcgammaRI, FcgammaRIII, FcgammaRIV and FcepsilonRI receptors and in normal mice depleted of Gr-1(+) immune cell populations known to express FcgammaR, suggesting protection was largely mediated by an FcgammaR-dependent mechanism. To test whether neutralizing Ab might provide superior protection, a highly neutralizing HSV glycoprotein D (gD)-specific monoclonal antibody (mAb) was utilized. Similar to results with HSV-specific polyclonal IgG, administration of the gD-specific mAb did not prevent initial infection of the genital tract but resulted in lower virus loads in the vaginal epithelium and provided significant protection against disease and acute infection of the sensory ganglia; however, this protection was independent of host FcgammaR expression and was manifest in mice depleted of Gr-1(+) immune cells. Together, these data demonstrate that substantial Ab-mediated protection against genital HSV-2 disease could be achieved by either FcgammaR-dependent or -independent mechanisms. These studies suggest that HSV vaccines might need to elicit multiple, diverse antibody effector mechanisms to achieve optimal protection.

Early resolution of herpes simplex virus type 2 infection of the murine genital tract involves stimulation of genital parenchymal cells by gamma interferon.

Early clearance of a thymidine kinase-deficient strain of herpes simplex virus type 2 from the female genital tract required T-cell-produced gamma interferon (IFN-gamma). Transfer of activated CD8+ T cells to irradiated C57BL/6 mice resulted in rapid virus clearance, but clearance was greatly delayed in recipients deficient in the IFN-gamma receptor (IFN-gammaR). Early virus clearance was demonstrated in radiation chimeras in which IFN-gammaR expression was limited to parenchymal cells, but resolution was significantly delayed in chimeras deficient in IFN-gammaR expression and chimeras expressing IFN-gammaR only on hematopoietic cells. Together, these results suggest that early IFN-gamma-mediated protection was manifested mainly by stimulation of genital parenchymal cells.

Clearance of herpes simplex virus type 2 by CD8+ T cells requires gamma interferon and either perforin- or Fas-mediated cytolytic mechanisms.

The T-cell-mediated resolution of herpes simplex virus type 2 (HSV-2) genital infections is not fully understood. In these studies, the mechanisms by which CD8+ T cells clear virus from the genital epithelium were examined. Ovalbumin (OVA)-specific CD8+ T cells from OT-I transgenic mice cleared a thymidine kinase-deficient, ovalbumin-expressing HSV-2 virus (HSV-2 tk- OVA) from the genital epithelium of recipient mice, and clearance was abrogated by in vivo neutralization of gamma interferon (IFN-gamma). Further, CD8+ OT-I T cells deficient in IFN-gamma were unable to clear HSV-2 tk- OVA from the vaginal epithelium. The requirement for cytolytic mechanisms in HSV-2 tk- OVA clearance was tested in radiation chimeras by adoptive transfer of wild-type or perforin-deficient OT-I T cells to irradiated Fas-defective or wild-type recipients. Although a dramatic decrease in viral load was observed early after challenge with HSV-2 tk- OVA, full resolution of the infection was not achieved in recipients lacking both perforin- and Fas-mediated cytolytic pathways. These results suggest that IFN-gamma was responsible for an early rapid decrease in HSV-2 virus titer. However, either perforin- or Fas-mediated cytolytic mechanisms were required to achieve complete clearance of HSV-2 from the genital epithelium.

Long-term presence of virus-specific plasma cells in sensory ganglia and spinal cord following intravaginal inoculation of herpes simplex virus type 2.

The tissue sites of long-term herpes simplex virus type 2 (HSV-2)-specific antibody production in mice and guinea pigs were identified. In addition to secondary lymphoid tissue and bone marrow, HSV-specific plasma cells were detected in spinal cords of mice up to 10 months after intravaginal inoculation with a thymidine kinase-deficient HSV-2 strain and in lumbosacral ganglia and spinal cords of guinea pigs inoculated with HSV-2 strain MS. The long-term retention of virus-specific plasma cells in the peripheral and central nervous systems following HSV infection may be important for resistance to reinfection of neuronal tissues or may play a role in modulation of reactivation from latency.

Effects of candidate vaginally-applied microbicide compounds on innate immune cells.

Ideally, a vaginally-applied microbicide would be effective against a broad range of pathogens but would have minimal effects on the female genital tract. The aim of this study was to determine if representative candidate detergent-type and sulfated/sulfonated polymer-type microbicides altered the composition or function of innate immune cells normally found in the vaginal mucosa. The effect of microbicide on the composition of vaginal leukocytes was tested using a flow cytometric approach. Application of the detergent cholic acid, but not the sulfated polysaccharide lambda carrageenan, resulted in a significant increase in macrophages at the vaginal epithelial surface compared to control treatment (19.3% macrophages compared to 2.8%; p<0.0004). Phagocytosis of fluorochrome-labeled bacteria by macrophages was inhibited greater than 50% in the presence of 1.0mg/ml of the sulfonated polymer PRO 2000 but was not inhibited by the same concentration of lambda carrageenan. PRO 2000-pulsed macrophages regained phagocytic function after being washed free of the compound. Culture of macrophages with PRO 2000 also resulted in diminished detection of the surface proteins CD11b and CD18. After treated cells were washed free of PRO 2000, these proteins were detected at levels similar to control treated cells. In conclusion, application of a detergent-type microbicide, but not a sulfated polymer, resulted in the infiltration of inflammatory cells at the vaginal epithelial surface. Phagocytic function of macrophages was lost in the presence of 1mg/ml PRO 2000 which may have reflected masking of important cell surface proteins by the microbicide; however, there was no evidence of permanent loss of function upon removal of the compound.

Effect of candidate vaginally-applied microbicide compounds on recognition of antigen by CD4+ and CD8+ T lymphocytes.

Vaginally applied antimicrobial compounds (microbicides) are being developed as an alternative method for preventing the spread of sexually transmitted diseases. In addition to identifying compounds effective against a spectrum of sexually transmitted pathogens, it will be important to ensure that these compounds are safe. Avoiding toxicity, inflammatory responses, or alteration of the function of resident immune cells are important considerations for the development of vaginally applied microbicides. Studies were performed with two classes of candidate microbicide compounds to determine if they would interfere with the recognition of antigen by CD4(+) and CD8(+) T lymphocytes. The presence of nontoxic concentrations of the anionic detergent cholic acid or the sulfated polymer lambda carrageenan did not inhibit recognition of immune peptide by antigen-specific T cells. However, antigen recognition by both CD4(+) and CD8(+) T lymphocytes was inhibited in the presence of the naphthalene sulfonate polymer PRO 2000. Brief (4-h) exposure of antigen-presenting cells or T cells to PRO 2000 did not result in inhibition of antigen uptake and processing by antigen-presenting cells or the ability of specific T cells to respond to antigen stimulation, suggesting that the inhibition was temporary. Binding of antibodies specific for CD18, CD8, and CD3 was impaired in the presence of PRO 2000, suggesting that the mechanism by which this microbicide inhibits T cell recognition of antigenic peptide may involve masking or internalization of surface proteins involved in T cell signaling or stabilizing T cell-antigen-presenting cell interactions. The assays described in this study represent a useful means to screen candidate topical microbicide compounds for inappropriate interactions with immune cells and may be useful for prioritization of candidate microbicide compounds.

T-cell-mediated mechanisms involved in resolution of genital herpes simplex virus type 2 (HSV-2) infection of mice.

Resolution of a HSV-2 infection of the female genital tract has been shown to be T-cell dependent. The T-cell populations and mechanisms involved in clearance of virus from the genital epithelium were examined in this study. T lymphocytes expressing either alphabeta or gammadelta T-cell receptors (TCR) have been detected in the vaginal epithelium of mice. The involvement of gammadelta T cells in HSV-2 clearance was tested by intravaginal (ivag) challenge of mice depleted of alphabeta T cells by administration of specific antibodies and of mice lacking gammadelta T cells due to specific deletion of the delta TCR gene. The results of these studies strongly suggest that gammadelta T cells are not required for or involved in clearance of HSV-2 from the genital epithelium. Mechanisms of virus clearance employed by alphabeta T cells were also examined. Although HSV-specific lytic activity could be demonstrated ex vivo in populations of vaginal exudate cells from HSV-infected mice, clearance of virus did not require either perforin- or Fas/Fas ligand (FasL)-dependent cytolytic pathways. In contrast, virus resolution was significantly impaired following neutralization of interferon-gamma (IFN-gamma), but not tumor necrosis factor-alpha (TNF-alpha). Together, these results suggest that non-lytic mechanisms mediated by alphabeta T cells were responsible for resolution of a genital HSV-2 infection.

Efficacy of genital T cell responses to herpes simplex virus type 2 resulting from immunization of the nasal mucosa.

Intravaginal (ivag) or intranasal (i.n.) immunization of C57BL/6J (B6) mice with a thymidine kinase-deficient strain (tk-) of herpes simplex virus type 2 (HSV-2) resulted in comparable protection of the genital epithelium and sensory ganglia against HSV-2 challenge. In contrast, protection of these sites was much reduced in i.n.-immunized compared to ivag-immunized B cell-deficient microMT mice. Fewer HSV-specific T cells were detected in the genital epithelium of i.n.-immunized compared to ivag-immunized microMT mice after HSV-2 challenge. Passive transfer of HSV-specific serum to immune microMT mice restored protection of these sites against HSV-2 challenge. These results suggest that protection of genital and neuronal sites may be conferred by i.n. immunization but may be more dependent on antibody-dependent mechanisms than the protection resulting from genital immunization. These results have implications for immunization strategies to elicit high levels of cell-mediated protection of the genital tract and sensory ganglia.