Vaccination generates functional progenitor tumor-specific CD8 T cells and long-term tumor control.

Background: Immune checkpoint blockade (ICB) therapies are an important treatment for patients with advanced cancers; however only a subset of patients with certain types of cancer achieves durable remissions. Cancer vaccines are an attractive strategy to boost patient immune responses, but less is known about whether and how immunization can induce long-term tumor immune reprogramming and arrest cancer progression. We developed a clinically-relevant genetic cancer mouse model in which hepatocytes sporadically undergo oncogenic transformation. We compared how tumor-specific CD8 T cells (TST) differentiate in mice with early sporadic lesions as compared to late lesions and tested how immunotherapeutic strategies, including vaccination and ICB, reprogram TST and impact liver cancer progression. Methods: Mice with a germline floxed allele of the SV40 large T antigen (TAG) undergo spontaneous recombination and activation of the TAG oncogene, leading to rare early pre-cancerous lesions that inevitably progress to established liver cancer. We assessed the immunophenotype and function of TAG-specific CD8 T cells in mice with early and late liver lesions. We vaccinated mice, either alone or in combination with ICB, to test whether these immunotherapeutic interventions could stop liver cancer progression. Results: In mice with early lesions, a subset of TST were PD1 + TCF1 + TOX - and could produce IFNγ, while TST present in mice with late liver cancers were PD1 + TCF1 lo/- TOX + and unable to make effector cytokines. Strikingly, vaccination with attenuated TAG epitope-expressing Listeria monocytogenes (LM TAG ) blocked liver cancer development and led to a population of TST that were TCF1 + TOX - TST and polyfunctional cytokine producers. In contrast, ICB administration did not slow cancer progression or improve LM TAG vaccine efficacy. Conclusion: Vaccination, but not ICB, generated a population of progenitor TST and halted cancer progression in a clinically relevant model of sporadic liver cancer. In patients with early cancers or at high-risk of cancer recurrence, immunization may be the most effective strategy. What is already known on this topic: Immunotherapy, including immune checkpoint blockade and cancer vaccines, fails to induce long-term remissions in most patients with cancer. What this study adds: Hosts with early lesions but not hosts with advanced cancer retain a progenitor TCF1+ TST population. This population can be reprogrammed and therapeutically exploited by vaccination, but not ICB, to block tumor progression. How this study might affect research practice or policy: For people at high-risk of cancer progression, vaccination administered when a responsive progenitor TST population is present may be the optimal immunotherapy to induce long-lasting progression-free survival.

Tumor-Reactive CD8+ T Cells Enter a TCF1+PD-1- Dysfunctional State.

T cells recognize several types of antigens in tumors, including aberrantly expressed, nonmutated proteins, which are therefore shared with normal tissue and referred to as self/shared-antigens (SSA), and mutated proteins or oncogenic viral proteins, which are referred to as tumor-specific antigens (TSA). Immunotherapies such as immune checkpoint blockade (ICB) can activate T-cell responses against TSA, leading to tumor control, and also against SSA, causing immune-related adverse events (irAE). To improve anti-TSA immunity while limiting anti-SSA autoreactivity, we need to understand how tumor-specific CD8+ T cells (TST) and SSA-specific CD8+ T (SST) cells differentiate in response to cognate antigens during tumorigenesis. Therefore, we developed a genetic cancer mouse model in which we can track TST and SST differentiation longitudinally as liver cancers develop. We found that both TST and SST lost effector function over time, but while TST persisted long term and had a dysfunctional/exhausted phenotype (including expression of PD1, CD39, and TOX), SST exited cell cycle prematurely and disappeared from liver lesions. However, SST persisted in spleens in a dysfunctional TCF1+PD-1- state: unable to produce effector cytokines or proliferate in response to ICB targeting PD-1 or PD-L1. Thus, our studies identify a dysfunctional T-cell state occupied by T cells reactive to SSA: a TCF1+PD-1- state lacking in effector function, demonstrating that the type/specificity of tumor antigen may determine tumor-reactive T-cell differentiation.

Hallmarks of CD8+ T cell dysfunction are established within hours of tumor antigen encounter before cell division.

Tumor-specific CD8+ T cells (TST) in patients with cancer are dysfunctional and unable to halt cancer progression. TST dysfunction, also known as exhaustion, is thought to be driven by chronic T cell antigen receptor (TCR) stimulation over days to weeks. However, we know little about the interplay between CD8+ T cell function, cell division and epigenetic remodeling within hours of activation. Here, we assessed early CD8+ T cell differentiation, cell division, chromatin accessibility and transcription in tumor-bearing mice and acutely infected mice. Surprisingly, despite robust activation and proliferation, TST had near complete effector function impairment even before undergoing cell division and had acquired hallmark chromatin accessibility features previously associated with later dysfunction/exhaustion. Moreover, continued tumor/antigen exposure drove progressive epigenetic remodeling, 'imprinting' the dysfunctional state. Our study reveals the rapid divergence of T cell fate choice before cell division in the context of tumors versus infection.

Nurses' perceptions of mandatory bedside clinical handovers: An Australian hospital study.

AIMS: The research explores (a) nurses' views of the change to mandatory bedside handovers, and (b) these nurses' perceptions of their skills in managing this new practice in an Australian hospital. BACKGROUND: In Australia, nursing bedside handovers are now considered essential in many hospitals, although most nurses received minimal training at the time this policy was instituted. This research establishes a unique quantitative tool to investigate nurses' views of, and self-reported actions related to, bedside handovers. METHOD: Prior to the implementation of mandatory bedside handovers in a hospital in Canberra, Australia, nurses in two wards (n = 66) were recruited to complete the new Bedside Handover Attitudes and Behaviours (BHAB) questionnaire. RESULTS: Most nurses strongly value bedside handovers and have confidence in their ability to lead this clinical practice. CONCLUSIONS: Researchers identified a high level of alignment between the nurses' acceptance of bedside handovers and nurses' self-reported actions in conducting this communication process. IMPLICATIONS FOR NURSING MANAGEMENT: Future research should explore the links between nurses' views of, and skills in, the management of bedside handovers, as well as the effects of professional training for this practice. Furthermore, the BHAB questionnaire may be employed in different nursing contexts in future research.

Benefits of Health Care Communication Training for Nurses Conducting Bedside Handovers: An Australian Hospital Case Study.

BACKGROUND: This study aimed to examine the effects of communication training on nurses' ability to conduct bedside handovers in hospital. METHOD: Of the 26 participating nurses, 13 had recently completed specialized training in bedside handovers using the Connect, Ask, Respond, and Empathize (CARE) and Past, Present, and Future (PPF) of the patient journey and condition protocols for health care communication. The other 13 nurses did not participate in this training. Researchers videotaped and evaluated these nurses' handover practices using the Bedside Handover Evaluation Form. RESULTS: Nurses who had received the specific training in bedside handovers interacted with their patients to a far greater extent, asked more questions, and stated more complete information about their patient's medical journey. CONCLUSION: Nurses who participate in health care communication training on bedside handovers subsequently demonstrate a significantly better ability to lead these clinical interactions. This is evidenced by their articulation of more detailed medical information, their more respectful and multifaceted interactions with patients, and their more inclusive approach to all participants in the handover. J Contin Educ Nurs. 2018;49(7):329-336.

Complexities of emergency communication: clinicians' perceptions of communication challenges in a trilingual emergency department.

AIMS AND OBJECTIVES: To understand the challenges that clinicians face in communicating with patients and other clinicians within a Hong Kong trilingual emergency department. BACKGROUND: Effective communication has long been recognised as fundamental to the delivery of quality health care, especially in high-risk and time-constrained environments such as emergency departments. The issue of effective communication is particularly relevant in Hong Kong emergency departments, due to the high volume of patients and the linguistic complexity of this healthcare context. In Hong Kong, emergency department clinicians are native speakers of Chinese, but have received their medical training in English. The clinicians read and record virtually all of their medical documentation in English, yet they communicate verbally with patients in Cantonese and Mandarin. In addition, communication between clinicians occurs in spoken Cantonese, mixed with medical English. Thus, medical information is translated numerous times within one patient journey. This complex linguistic environment creates the potential for miscommunication. DESIGN: A mixed-methods design consisting of a quantitative survey with a sequential qualitative interview. METHODS: Data were collected in a survey from a purposive sample of 58 clinicians and analysed through descriptive statistics. Eighteen of the clinicians were then invited to take part in semi-structured interviews, the data from which were then subjected to a manifest content analysis. RESULTS: Nearly half of the clinicians surveyed believed that medical information may be omitted or altered through repeated translation in a trilingual emergency department. Eighty-three per cent of clinicians stated that there are communication problems at triage. Over 40% said that they have difficulties in documenting medical information. Around 50% believed that long work hours reduced their ability to communicate effectively with patients. In addition, 34% admitted that they rarely or never listen to patients during a consultation. CONCLUSION: The findings reveal that the quality of communication in this Hong Kong emergency department is compromised by specific factors inherent in the linguistic complexity of Hong Kong emergency departments. These factors include the constant translation of medical information, inadequate documentation of medical information and significant professional and cultural pressures. Each of these issues increases the likelihood that healthcare communication will be difficult, incomplete or incorrect. This research provides empirical evidence for, and justifies the development of, an effective framework to enable clinicians to overcome communication challenges. RELEVANCE TO CLINICAL PRACTICE: The findings of this study may shed light on the unique conditions faced by clinicians, particularly in relation to communication, in the complex trilingual healthcare context of an emergency department similar to those in Hong Kong, and provide potential policy solutions for barriers to improve communication in such settings.

Factors affecting communication in emergency departments: doctors and nurses' perceptions of communication in a trilingual ED in Hong Kong.

BACKGROUND: This study investigates clinicians' views of clinician-patient and clinician-clinician communication, including key factors that prevent clinicians from achieving successful communication in a large, high-pressured trilingual Emergency Department (ED) in Hong Kong. METHODS: Researchers interviewed 28 doctors and nurses in the ED. The research employed a qualitative ethnographic approach. The interviews were audio-recorded, transcribed, translated into English and coded using the Nvivo software. The researchers examined issues in both clinician-patient and clinician-clinician communication. Through thematic analyses, they identified the factors that impede communication most significantly, as well as the relationship between these factors. This research highlights the significant communication issues and patterns in Hong Kong EDs. RESULTS: The clinician interviews revealed that communication in EDs is complex, nuanced and fragile. The data revealed three types of communication issues: (1) the experiential parameter (i.e. processes and procedures), (2) the interpersonal parameter (i.e. clinicians' engagements with patients and other clinicians) and (3) contextual factors (i.e. time pressures, etc.). Within each of these areas, the specific problems were the following: compromises in knowledge transfer at key points of transition (e.g. triage, handover), inconsistencies in medical record keeping, serious pressures on clinicians (e.g. poor clinician-patient ratio and long working hours for clinicians) and a lack of focus on interpersonal skills. CONCLUSIONS: These communication problems (experiential, interpersonal and contextual) are intertwined, creating a complex yet weak communication structure that compromises patient safety, as well as patient and clinician satisfaction. The researchers argue that hospitals should develop and implement best-practice policies and educational programmes for clinicians that focus on the following: (1) understanding the primary causes of communication problems in EDs, (2) accepting the tenets and practices of patient-centred care, (3) establishing clear and consistent knowledge transfer procedures and (4) lowering the patient-to-clinician ratio in order to create the conditions that foster successful communication. The research provides a model for future research on the relationship between communication and the quality and safety of the patient safety.

Comparison of two homogeneous cell-based kinase assays for JAK2 V617F: SureFire pSTAT5 and GeneBLAzer fluorescence resonance energy transfer assays.

The Janus kinase (JAK)/signal transducer and activator of transcription (STAT) signaling pathway plays an important role in cellular responses to cytokines and growth factors. Recent studies have identified a recurrent somatic activating mutation (JAK2 V617F) in majority of patients with myeloproliferative disorders (MPDs). Development of drugs that target JAK2 V617F is, therefore, of therapeutic relevance. To discover small molecule inhibitors for this target, robust and reliable cell-based assays are important. Here, we present a comparison of two homogeneous, 384-well plate-based cellular assays using Invitrogen's CellSensor® JAK2 V617F interferon regulatory factor-1 (irf1)-beta-lactamase (bla) human erythroleukemia line (HEL): (1) SureFire® pSTAT5 AlphaScreen® assay from PerkinElmer; and (2) GeneBLAzer® fluorescence resonance energy transfer assay from Invitrogen. HEL cells are growth factor-independent due to JAK2 V617F mutation that causes constitutive STAT5 activation. The SureFire assay measures levels of phosphorylated STAT5 downstream of JAKs, while the GeneBLAzer assay is a reporter assay that monitors bla activity further downstream of STAT5. Evaluation of a number of chemically diverse JAK2 inhibitors in the two cellular assays yielded comparable half-maximal inhibitory concentration (IC50) values, boding well for the utility of these assay formats in compound profiling.

Modification of CellSensor irf1-bla TF-1 and irf1-bla HEL assays for direct comparison of wild-type JAK2 and JAK2 V617F inhibition.

The Janus kinase (JAK)-signal transducer and activator of transcription pathway is an important therapeutic target because of its role in the regulation of cell growth. Aberrant, constitutive activation of JAK2 signaling has been implicated in myeloproliferative disorders with a single, activating somatic V617F mutation in the JH2 pseudokinase domain of JAK2 as the prevalent molecular lesion. Invitrogen has developed the CellSensor(®) cell lines interferon regulatory factor-1 (irf1)-beta-lactamase (bla) TF-1 and irf1-bla HEL for use in evaluating inhibitors of wild-type JAK2 and mutant JAK2 V617F, respectively. Both contain a bla reporter gene downstream of the irf1 response element stably integrated into either TF-1 or HEL cells. A fluorescence resonance energy transfer-based bla substrate is utilized to give a robust detection of JAK2 activity. Examination of Invitrogen's protocols for the two cell lines revealed significant differences that are not conducive to direct comparison of inhibitor activities against wild-type and mutant JAK2. Systematic changes to standardize the two assays were incorporated and evaluated for effects on assay response ratio, assay quality, and potency for a diverse series of inhibitors.