Self-driving armored CAR-T cells overcome a suppressive milieu and eradicate CD19+ Raji lymphoma in preclinical models.

Chimeric antigen receptor (CAR) T cells typically use a strong constitutive promoter to ensure maximal long-term CAR expression. However, recent evidence suggests that restricting the timing and magnitude of CAR expression is functionally beneficial, whereas constitutive CAR activation may lead to exhaustion and loss of function. We created a self-driving CD19-targeting CAR, which regulates its own function based on the presence of a CD19 antigen engaged by the CAR itself, by placing self-driving CAR19 constructs under transcriptional control of synthetic activator protein 1 (AP1)-nuclear factor κB (NF-κB) or signal transducer and activator of transcription (STAT)5 promoters. CD19 antigen-regulated expression was observed for self-driving AP1-NFκB-CAR19, with CAR19 upregulation within 18 h after exposure to target CD19, and corresponded to the level of tumor burden. Self-driving CAR-T cells showed enhanced tumor-dependent activation, expansion, and low exhaustion in vitro as compared to constitutively expressed EF1α and murine stem cell virus (MSCV) CARs and mediated tumor regression and survival in Raji-bearing NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ (NSG) mice. Long-term CAR function correlated with upregulated CAR expression within 24 h of exposure to tumor antigen. The self-driving AP1-NFκB-CAR19 circuit was also used to inducibly express dominant-negative transforming growth factor ß receptor II (TGFBRIIdn), which effectively countered the negative effects of TGF-ß on CAR-T activation. Thus, a self-driving CAR approach may offer a new modality to express CAR and auxiliary proteins by enhancing CAR-T functional activity and limiting exhaustion.

Effects of multicomponent primary care-based intervention on immunization rates and missed opportunities to vaccinate adults.

BACKGROUND: Adult immunization rates are below Healthy People 2020 targets. Our objective was to evaluate the effectiveness of a multicomponent intervention to improve adult immunization rates. METHODS: This prospective interventional before-and-after non-randomized study was conducted through the American Academy of Family Physicians National Research Network with 43 primary care physicians from a large multi-specialty healthcare organization (multicomponent intervention group n = 23; comparator group n = 20) in the United States. The multicomponent intervention included provider reminders, quarterly provider-level performance reports, provider education, patient visual aid materials, and standing orders on adult pneumococcal, influenza, and zoster immunizations. We assessed individual and comparative provider-level vaccination rates and missed opportunities detailing concordance with targets established by Healthy People 2020 for pneumococcal, influenza, and zoster immunizations. RESULTS: Vaccination rates increased after 12 months in intervention and comparator groups respectively for: a). influenza from 44.4 ± 16.7 to 51.3% ± 12.9% (by 6.9 percentage points, p = 0.001) and from 35.1 ± 19.1 to 41.3% ± 14.2%, (by 6.2 percentage points, p = 0.01); b). pneumococcal vaccinations in older adults from 62.8 ± 17.6 to 81.4% ± 16.6% (by 18.6 percentage points, for p < 0.0001) and from 55.9 ± 20.0 to 72.7% ± 18.4% (by 16.7 percentage points, p < 0.0001); and c). zoster from 37.1 ± 13.4 to 41.9% ± 13.1% (by 4.8 percentage points, p < 0.0001) and from 35.0 ± 18.7 to 42.3% ± 20.9% (7.3 percentage points, p = 0.001). Pneumococcal vaccinations in adults at risk did not change from baseline in intervention group (35.7 ± 19.6 to 34.5% ± 19.0%, p = 0.3) and improved slightly in comparator group (24.3 ± 20.1 to 28.2% ± 20.0%, p = 0.003). Missed opportunities reduced after 12 months, most noticeably, for: a). for influenza from 57.7 to 48.6% (by 9.1 percentage points, p < 0.0001) and from 69.7 to 59.6% (by 10.1 percentage points, p < 0.0001); b). pneumococcal vaccinations in older adults from 18.1 to 11.5% (by 6.6 percentage points p < 0.0001) and from 24.6 to 20.4% (by 4.3 percentage points, p < 0.0001) in intervention and comparator groups respectively. CONCLUSIONS: Multicomponent interventions show promise in improving vaccination rates and reducing missed opportunities in older adults for pneumococcal and zoster vaccines and vaccination against influenza. Provider reminders remain the most effective strategy when delivered either as a component of these interventions or alone.

Cell-Cell Sensing of Viral Infection by Plasmacytoid Dendritic Cells.

All cells possess signaling pathways designed to trigger antiviral responses, notably characterized by type I interferon (IFN) production, upon recognition of invading viruses. Especially, host sensors recognize viral nucleic acids. Nonetheless, virtually all viruses have evolved potent strategies that preclude host responses within the infected cells. The plasmacytoid dendritic cell (pDC) is an immune cell type known as a robust type I IFN producer in response to viral infection. Evidence suggests that such functionality of the pDCs participates in viral clearance. Nonetheless, their contribution, which is likely complex and varies depending on the pathogen, is still enigmatic for many viruses. pDCs are not permissive to most viral infections, and consistently, recent examples suggest that pDCs respond to immunostimulatory viral RNA transferred via noninfectious and/or noncanonical viral/cellular carriers. Therefore, the pDC response likely bypasses innate signaling blockages induced by virus within infected cells. Importantly, the requirement for cell-cell contact is increasingly recognized as a hallmark of the pDC-mediated antiviral state, triggered by evolutionarily divergent RNA viruses.

Missed opportunities for improving practice performance in adult immunizations: a meta-narrative review of the literature.

BACKGROUND: We sought to characterize how the term "missed opportunities" is reported in the literature in the context of immunization rates and to assess how missed opportunities can be operationalized. METHODS: Peer-reviewed literature searches were conducted in April - May, 2015, to answer: "What methods research studies used to operationalize missed opportunities to vaccinate?" A meta-narrative review methodology was used. RESULTS: Seven studies met inclusion criteria. The methodologies for quantifying missed opportunities fell into two general categories based on: 1. the number of healthcare encounters per patient without appropriate vaccination services, defined as a number of visits per patient with no vaccination related services (Missed opportunities per patient); 2. vaccination status as "non-vaccinated" among a group of patients who had a healthcare encounter where the vaccination should/could have had happened (Missed opportunities per population). CONCLUSIONS: Our study provided an initial overview of the methods reported in the literature, and concluded that the quantifiable missed opportunity holds promise as a measurable outcome (variable) for research and quality improvement projects aimed to increase adult immunization recommendation and uptake in primary care.

Lipid droplet-binding protein TIP47 regulates hepatitis C Virus RNA replication through interaction with the viral NS5A protein.

The nonstructural protein NS5A has emerged as a new drug target in antiviral therapies for Hepatitis C Virus (HCV) infection. NS5A is critically involved in viral RNA replication that takes place at newly formed membranes within the endoplasmic reticulum (membranous web) and assists viral assembly in the close vicinity of lipid droplets (LDs). To identify host proteins that interact with NS5A, we performed a yeast two-hybrid screen with the N-terminus of NS5A (amino acids 1-31), a well-studied α-helical domain important for the membrane tethering of NS5A. Our studies identified the LD-associated host protein, Tail-Interacting Protein 47 (TIP47) as a novel NS5A interaction partner. Coimmunoprecipitation experiments in Huh7 hepatoma cells confirmed the interaction of TIP47 with full-length NS5A. shRNA-mediated knockdown of TIP47 caused a more than 10-fold decrease in the propagation of full-length infectious HCV in Huh7.5 hepatoma cells. A similar reduction was observed when TIP47 was knocked down in cells harboring an autonomously replicating HCV RNA (subgenomic replicon), indicating that TIP47 is required for efficient HCV RNA replication. A single point mutation (W9A) in NS5A that disrupts the interaction with TIP47 but preserves proper subcellular localization severely decreased HCV RNA replication. In biochemical membrane flotation assays, TIP47 cofractionated with HCV NS3, NS5A, NS5B proteins, and viral RNA, and together with nonstructural viral proteins was uniquely distributed to lower-density LD-rich membrane fractions in cells actively replicating HCV RNA. Collectively, our data support a model where TIP47--via its interaction with NS5A--serves as a novel cofactor for HCV infection possibly by integrating LD membranes into the membranous web.

Evasion of superinfection exclusion and elimination of primary viral RNA by an adapted strain of hepatitis C virus.

Cells that are productively infected by hepatitis C virus (HCV) are refractory to a second infection by HCV via a block in viral replication known as superinfection exclusion. The block occurs at a postentry step and likely involves translation or replication of the secondary viral RNA, but the mechanism is largely unknown. To characterize HCV superinfection exclusion, we selected for an HCV variant that could overcome the block. We produced a high-titer HC-J6/JFH1 (Jc1) viral genome with a fluorescent reporter inserted between NS5A and NS5B and used it to infect Huh7.5 cells containing a Jc1 replicon. With multiple passages of these infected cells, we isolated an HCV variant that can superinfect cells at high levels. Notably, the superinfectious virus rapidly cleared the primary replicon from superinfected cells. Viral competition experiments, using a novel strategy of sequence-barcoding viral strains, as well as superinfection of replicon cells demonstrated that mutations in E1, p7, NS5A, and the poly(U/UC) tract of the 3' untranslated region were important for superinfection. Furthermore, these mutations dramatically increased the infectivity of the virus in naive cells. Interestingly, viruses with a shorter poly(U/UC) and an NS5A domain II mutation were most effective in overcoming the postentry block. Neither of these changes affected viral RNA translation, indicating that the major barrier to postentry exclusion occurs at viral RNA replication. The evolution of the ability to superinfect after less than a month in culture and the concomitant exclusion of the primary replicon suggest that superinfection exclusion dramatically affects viral fitness and dynamics in vivo.

Rapid intracellular competition between hepatitis C viral genomes as a result of mitosis.

Cells infected with hepatitis C virus (HCV) become refractory to further infection by HCV (T. Schaller et al., J. Virol. 81:4591-4603, 2007; D. M. Tscherne et al., J. Virol. 81:3693-3703, 2007). This process, termed superinfection exclusion, does not involve downregulation of surface viral receptors but instead occurs inside the cell at the level of RNA replication. The originally infecting virus may occupy replication niches or sequester host factors necessary for viral growth, preventing effective growth of viruses that enter the cell later. However, there appears to be an additional level of intracellular competition between viral genomes that occurs at or shortly following mitosis. In the setting of cellular division, when two viral replicons of equivalent fitness are present within a cell, each has an equal opportunity to exclude the other. In a population of dividing cells, the competition between viral genomes proceeds apace, randomly clearing one or the other genome from cells in the span of 9 to 12 days. These findings demonstrate a new mechanism of intracellular competition between HCV strains, which may act to further limit HCV's genetic diversity and ability to recombine in vivo.

Lifestyle nursing: a leadership opportunity for UK nurses.

This article aims to consider the 'lifestyle medicine' approach to nursing, which focuses on patients with conditions that would benefit from a lifestyle nursing approach, supporting and empowering people to make lifestyle changes that would benefit their health. Lifestyle medicine in nursing is gaining momentum in the USA and could be a nursing leadership opportunity in the UK. This article explores the importance of lifestyle approaches to health care and why nurses have a pivotal role in the movement.

Regulation of lymph node vascular growth by dendritic cells.

Lymph nodes grow rapidly and robustly at the initiation of an immune response, and this growth is accompanied by growth of the blood vessels. Although the vessels are critical for supplying nutrients and for controlling cell trafficking, the regulation of lymph node vascular growth is not well understood. We show that lymph node endothelial cells begin to proliferate within 2 d of immunization and undergo a corresponding expansion in cell numbers. Endothelial cell proliferation is dependent on CD11c+ dendritic cells (DCs), and the subcutaneous injection of DCs is sufficient to trigger endothelial cell proliferation and growth. Lymph node endothelial cell proliferation is dependent on vascular endothelial growth factor (VEGF), and DCs are associated with increased lymph node VEGF levels. DC-induced endothelial cell proliferation and increased VEGF levels are mediated by DC-induced recruitment of blood-borne cells. Vascular growth in the draining lymph node includes the growth of high endothelial venule endothelial cells and is functionally associated with increased cell entry into the lymph node. Collectively, our results suggest a scenario whereby endothelial cell expansion in the draining lymph node is induced by DCs as part of a program that optimizes the microenvironment for the ensuing immune response.

CD11c(hi) dendritic cells regulate the re-establishment of vascular quiescence and stabilization after immune stimulation of lymph nodes.

Lymph node expansion during immune responses is accompanied by rapid vascular expansion. The re-establishment of quiescence and stabilization of the newly expanded vasculature and the regulatory mechanisms involved have not been well studied. We show that although initiation of vascular expansion in immune-stimulated nodes is associated with upregulated endothelial cell proliferation, increased high endothelial venule trafficking efficiency and VCAM-1 expression, and disrupted perivascular fibroblastic reticular cell organization, the re-establishment of vascular quiescence and stabilization postexpansion is characterized by reversal of these phenomena. Although CD11c(med) cells are associated with the initiation of vascular expansion, CD11c(hi)MHC class II (MHC II)(med) dendritic cells (DCs) accumulate later, and their short-term depletion in mice abrogates the re-establishment of vascular quiescence and stabilization. CD11c(hi)MHC II(med) cells promote endothelial cell quiescence in vitro and, in vivo, mediate quiescence at least in part by mediating reduced lymph node vascular endothelial growth factor. Disrupted vascular quiescence and stabilization in expanded nodes is associated with attenuated T cell-dependent B cell responses. These results describe a novel mechanism whereby CD11c(hi)MHC II(med) DCs regulate the re-establishment of vascular quiescence and stabilization after lymph node vascular expansion and suggest that these DCs function in part to orchestrate the microenvironmental alterations required for successful immunity.

Self-rostering, work-life balance and job satisfaction in UK nursing: a literature review.

Nursing vacancies are high across the UK, with some nurses considering leaving the profession. Evidence suggests that employers, including the NHS, need to be more flexible about working times to support employees' work-life balance and job satisfaction. Self-rostering is one approach that has the potential to enhance nurses' work-life balance and job satisfaction, enabling scope for greater autonomy. This could in turn lead to fewer nurses leaving the profession and contribute to making nursing more attractive as a career. This literature review focused on nurses in the NHS and found that self-rostering had a positive effect on their work-life balance and job satisfaction. However, a move to self-rostering can pose challenges and it should be assessed for suitability before implementation. Given the nursing vacancy crisis in the UK and many nurses' intentions to leave the profession, the potential benefits of self-rostering for nurses cannot be overlooked.

Armored BCMA CAR T Cells Eliminate Multiple Myeloma and Are Resistant to the Suppressive Effects of TGF-ß.

CAR T-cell therapies targeting the B-cell maturation antigen eliminate tumors in relapsed/refractory multiple myeloma patients, however durable remissions remain difficult to attain. Transforming growth factor beta (TGF-ß) is a multifunctional cytokine abundantly expressed in the multiple myeloma bone marrow niche, where it promotes an immunosuppressive tumor microenvironment. We hypothesized that BCMA CAR T-cells armored to resist the suppressive effects of TGF-ß will provide an advantage in treating multiple myeloma. The armored B2ARM CAR T cells, co-expressing BCMA targeting CAR with TGF-ß dominant-negative receptor II, were generated by lentiviral transduction of primary human CD4+ and CD8+ T cells. The B2ARM CAR T cells eliminated MM.1S multiple myeloma targets in long-term cytotoxicity assays, even under TGF-ß-high conditions, whereas cytotoxic function of the non-armored B2 CAR -T cells was inhibited by TGF-ß. Concordantly, after long-term exposure to targets in the presence of TGF-ß, the B2ARM CAR T cells were enriched for Granzyme B, CD107a, Ki67 and polyfunctional cells T-cells (double or triple-positive for IFN-γ, IL-2 and/or TNF-α), as determined by flow cytometry. In addition, the B2ARM CAR T-cells, but not the conventional B2 CAR T-cells, resisted the TGF-ß-mediated suppression of activation (CD25), exhaustion (PD-1, LAG3), and differentiation to T effectors (CD45RA+ CD45RO-CD62L-). In NSG mice bearing RPMI-8226 tumors overexpressing TGF-ß, the B2ARM CAR mediated 100% tumor rejection and survival, superior infiltration of tumors on day 7 post CAR T treatment (%CD3+CAR+), and greater expression of IFN-γ, TNF-α, Ki67, Granzyme B, and PD-1, as compared to tumor-infiltrating non-armored B2 CAR T-cells. In NSG RPMI-8226 xenograft model in which tumors were additionally supplemented with TGF-ß injections on days -1 through 11 of CAR T treatment, the B2ARM CAR T cells rejected tumors faster than the non-armored B2 CARs, and showed greater numbers of CD3+ and CD3+CAR+, central memory (CD45RO+CD62L+) and effector memory (CD45RO+CD62L-) T cells in the peripheral blood 18 days after treatment. In summary, the armored B2ARM CAR T cells mediate superior persistence, proliferation, multi-functionality, effector differentiation and anti-tumor function in pre-clinical models of multiple myeloma, while abrogating TGF-ß-mediated suppression.

Using passive extraction of real-world data from eConsent, electronic patient reported outcomes (ePRO) and electronic health record (EHR) data loaded to an electronic data capture (EDC) system for a multi-center, prospective, observational study in diabetic patients.

As clinical trial complexity has increased over the past decade, using electronic methods to simplify recruitment and data management have been investigated. In this study, the Optum Digital Research Network (DRN) has demonstrated the use of electronic source (eSource) data to ease subject identification, recruitment burden, and used data extracted from electronic health records (EHR) to load to an electronic data capture (EDC) system. This study utilized electronic Informed Consent, electronic patient reported outcomes (SF-12) and included three sites using 3 different EHR systems. Patients with type 2 diabetes with an HbA1c ≥ 7.0% treated with metformin monotherapy were recruited. Endpoints consisted of changes in HbA1c, medications, and quality of life measures over 12-weeks of study participation using data from the subjects' eSources listed above. The study began in June of 2020 and the last patient last visit occurred in January of 2021. Forty-eight participants were consented and enrolled. HbA1c was repeated for 33 and ePRO was obtained from all subjects at baseline and 28 at 12-week follow-up. Using eSource data eliminated transcription errors. Medication changes, healthcare encounters and lab results were identified when they occurred in standard clinical practice from the EHR systems. Minimal data transformation and normalization was required. Data for this observational trial where clinical outcomes are available using lab results, diagnoses, and encounters may be achieved via direct access to eSources. This methodology was successful and could be expanded for larger trials and will significantly reduce staff effort and exemplified clinical research as a care option.

Combined targeting of soluble latent TGF-ß and a solid tumor-associated antigen with adapter CAR T cells.

Solid tumors consist of malignant and nonmalignant cells that together create the local tumor microenvironment (TME). Additionally, the TME is characterized by the expression of numerous soluble factors such as TGF-ß. TGF-ß plays an important role in the TME by suppressing T cell effector function and promoting tumor invasiveness. Up to now CAR T cells exclusively target tumor-associated antigens (TAA) located on the cell membrane. Thus, strategies to exploit soluble antigens as CAR targets within the TME are needed. This study demonstrates a novel approach using Adapter CAR (AdCAR) T cells for the detection of soluble latent TGF-ß within the TME of a pancreatic tumor model. We show that AdCARs in combination with the respective adapter can be used to sense soluble tumor-derived latent TGF-ß, both in vitro and in vivo. Sensing of the soluble antigen induced cellular activation and effector cytokine production in AdCAR T cells. Moreover, we evaluated AdCAR T cells for the combined targeting of soluble latent TGF-ß and tumor cell killing by targeting CD66c as TAA in vivo. In sum, our study broadens the spectrum of targetable moieties for AdCAR T cells by soluble latent TGF-ß.

Titratable Pharmacological Regulation of CAR T Cells Using Zinc Finger-Based Transcription Factors.

Chimeric antigen receptor (CAR) T cell therapy has emerged as an attractive strategy for cancer immunotherapy. Despite remarkable success for hematological malignancies, excessive activity and poor control of CAR T cells can result in severe adverse events requiring control strategies to improve safety. This work illustrates the feasibility of a zinc finger-based inducible switch system for transcriptional regulation of an anti-CD20 CAR in primary T cells providing small molecule-inducible control over therapeutic functions. We demonstrate time- and dose-dependent induction of anti-CD20 CAR expression and function with metabolites of the clinically-approved drug tamoxifen, and the absence of background CAR activity in the non-induced state. Inducible CAR T cells executed fine-tuned cytolytic activity against target cells both in vitro and in vivo, whereas CAR-related functions were lost upon drug discontinuation. This zinc finger-based transcriptional control system can be extended to other therapeutically important CARs, thus paving the way for safer cellular therapies.

Regulatory Focus and Conspiratorial Perceptions: The Importance of Personal Control.

We examine when and why people subscribe to conspiratorial beliefs, suggesting that promotion focus reduces conspiratorial perceptions by activating a sense of personal control. Study 1 established that individuals primed with promotion focus are less likely to perceive conspiracies than those in a baseline condition. However, individuals primed with prevention focus and those in a baseline condition did not differ in their levels of conspiratorial beliefs. Study 2 demonstrated that soldiers higher in promotion focus were less likely to endorse conspiracy theories because of their heightened sense of control; this relationship did not emerge for soldiers higher in prevention focus. Study 3 found that conspiratorial beliefs increased when individuals primed with promotion focus recalled personal control loss, whereas those primed with prevention focus were unaffected by personal control loss. Using measures and manipulations of regulatory focus and personal control, we establish when and why promotion focus reduces conspiracy theories.