Quantitative immunopeptidomics reveals a tumor stroma-specific target for T cell therapy

T cell receptor (TCR)-based immunotherapy has emerged as a promising therapeutic approach for the treatment of patients with solid cancers. Identifying peptide-human leukocyte antigen (pHLA) complexes highly presented on tumors and rarely expressed on healthy tissue in combination with high-affinity TCRs that when introduced into T cells can redirect T cells to eliminate tumor but not healthy tissue is a key requirement for safe and efficacious TCR-based therapies. To discover promising shared tumor antigens that could be targeted via TCR-based adoptive T cell therapy, we employed population-scale immunopeptidomics using quantitative mass spectrometry across ~1500 tumor and normal tissue samples. We identified an HLA-A*02:01-restricted pan-cancer epitope within the collagen type VI α-3 (COL6A3) gene that is highly presented on tumor stroma across multiple solid cancers due to a tumor-specific alternative splicing event that rarely occurs outside the tumor microenvironment. T cells expressing natural COL6A3-specific TCRs demonstrated only modest activity against cells presenting high copy numbers of COL6A3 pHLAs. One of these TCRs was affinity-enhanced, enabling transduced T cells to specifically eliminate tumors in vivo that expressed similar copy numbers of pHLAs as primary tumor specimens. The enhanced TCR variants exhibited a favorable safety profile with no detectable off-target reactivity, paving the way to initiate clinical trials using COL6A3-specific TCRs to target an array of solid tumors.

Dipeptidase-1 Is an Adhesion Receptor for Neutrophil Recruitment in Lungs and Liver

A hallmark feature of inflammation is the orchestrated recruitment of neutrophils from the bloodstream into inflamed tissue. Although selectins and integrins mediate recruitment in many tissues, they have a minimal role in the lungs and liver. Exploiting an unbiased in vivo functional screen, we identified a lung and liver homing peptide that functionally abrogates neutrophil recruitment to these organs. Using biochemical, genetic, and confocal intravital imaging approaches, we identified dipeptidase-1 (DPEP1) as the target and established its role as a physical adhesion receptor for neutrophil sequestration independent of its enzymatic activity. Importantly, genetic ablation or functional peptide blocking of DPEP1 significantly reduced neutrophil recruitment to the lungs and liver and provided improved survival in models of endotoxemia. Our data establish DPEP1 as a major adhesion receptor on the lung and liver endothelium and identify a therapeutic target for neutrophil-driven inflammatory diseases of the lungs.

Caregivers' utilization of health services: results from the Medicare Alzheimer's Disease Demonstration, Illinois site

OBJECTIVES

The purpose of this study is to examine the effect of the Medicare Alzheimer's Disease Demonstration and Evaluation (MADDE) conducted in Illinois on the use of health services and Medicare expenditures by caregivers of persons with dementia.

DESIGN

Prospective randomized clinical trial.

SETTING

The MADDE (1989-1994), Illinois site.

PARTICIPANTS

A cohort of 412 Medicare-eligible caregivers of persons with dementia.

MEASUREMENTS

Medicare claims files provided data on the number of hospitalizations, hospital bed days, emergency department visits, and total Medicare Part A expenditures.

RESULTS

After adjustment for baseline variables, the caregivers in the treatment group, when compared with those in the comparison group, had a lower likelihood of any hospitalization during the study period (odds ratio 0.58 (95% confidence interval (CI)=0.35-0.97), P= .037) and a reduced, but not significant, likelihood of emergency department use (odds ratio 0.66 (95% CI=0.40-1.08), P= .095). For those who were hospitalized, there were no significant differences between the treatment and comparison group caregivers in the number of hospitalizations, hospital length of stay, or Medicare payments.

CONCLUSION

These results suggest that enhanced chronic illness case management directed at persons with dementia and their caregivers can reduce the need for acute hospital care.

The effects of a collaborative model of primary care on the mortality and hospital use of community-dwelling older adults

BACKGROUND

This study evaluates the ability of a model of collaborative primary care practice to reduce mortality and hospital use in community-dwelling elderly persons.

METHODS

Four rural and four urban clinic sites in east central Illinois were randomized to form treatment and comparison clinics from which patients were enrolled and followed prospectively for 2 years. Patients from the practices of participating physicians were eligible if they were aged 65 and older, were living in the community, and had at least one risk factor as determined prior to the study. Medicare hospital data were obtained from the Health Care Financing Administration. Demographic and health status measures were obtained by telephone interview every 12 months throughout the study.

RESULTS

The treatment group experienced a 49% reduction in all-cause mortality during the second year of the study (odds ratio, 0.51, 95% confidence interval, 0.29-0.91, p = .02). There were no significant differences between treatment and comparison patients in percentage of persons hospitalized, hospital length of stay, or Medicare payments. Although measures of health status indicated that the treatment group was significantly sicker at baseline at the end of 1 year, these differences disappeared by the end of 2 years.

CONCLUSIONS

The collaborative primary care model evaluated in this study significantly reduced mortality in the second year, without increasing hospital use. These findings suggest that a collaborative primary care team that enhances primary care practice can result in better patient outcomes.

Integrated risk assessment and feedback reporting for clinical decision making in a Medicare Risk plan

The challenge of tapping into the rich resource of population-based, aggregated data to inform and guide clinical processes remains one of the largely unrealized potentials of managed care. This article describes a multifaceted approach of using health-related data to support providers in clinical decision making as an adjunct to case management and primary care delivery. The goal is to provide data that can be used for clinical decision making that is population based, yet individualized for specific patient care situations. Information reporting holds great potential in the clinical care of patients because it can be used to identify persons who could benefit from early detection, intervention, or treatment. It has been suggested that one of the keys to success in managed Medicare is the timely use of information that is detailed, comprehensive, and real-time describing key parameters of clinical encounters.

The community assessment risk screen (CARS): identifying elderly persons at risk for hospitalization or emergency department visit

OBJECTIVE

To develop and validate an instrument for identifying community dwelling elderly patients at increased risk for hospitalizations or emergency department (ED) encounters.

STUDY DESIGN

Prospective cohort study.

PATIENTS AND METHODS

The development cohort consisted of 411 Medicare fee-for-service patients and the validation cohort consisted of 1054 individuals enrolled in a Medicare Risk Demonstration. Baseline demographic, health status, and utilization measures were obtained from telephone interviews and mailed questionnaires. Service utilization data for the development cohort were obtained from Medicare claims files. Utilization and cost data for the validation cohort were obtained from submitted claims.

RESULTS

Logistic regression identified 3 characteristics that were predictors of hospitalizations or ED visits during the following year in the development cohort: having 2 or more comorbidities, taking 5 or more prescription medications, and having had a hospitalization or ED encounter in the previous 12 months. A scoring system (range 0 to 9) was developed for each predictor variable and patients in the validation cohort were assigned to low (0 to 3) and high (4 to 9) risk categories. When compared with the low-risk group, the high-risk group was significantly (P < .01) more likely to be hospitalized (33% versus 14%), to have an ED visit (34% versus 15%), and to have higher per-member-per-month (PMPM) charges ($977 versus $445) during the following 12 months.

CONCLUSION

The Community Assessment Risk Screen (CARS) is a simple instrument that can be used to identify elderly patients who are at higher risk for health service use and increased costs.

Population-based research data as a means to address health outcomes

Health care restructuring efforts have been influenced by changes in public policy, payment mechanisms, and societal values. In today's environment, leading issues focus on quality and cost-effective care. Health care systems are moving from a concentration on structures and processes of care to an expanded view that encompasses the exploration, documentation, and improvement of patient outcomes. This article presents an overview of the domains of health outcomes, widely used surveys in the measurement of outcomes, methodological issues related to interpreting outcome measures, and trends for clinical practice and future research.

Management of nursing within a collaborative physician group practice

Today's changing health care environment suggests the need for integration of high-quality primary medical and nursing care to address the complex psychosocial and environmental aspects of health in the elderly. This article describes a model of geriatric primary collaborative care between nurses and physicians that has been successfully implemented in a large primary care group practice setting.

The Carle Clinic

Confronting the challenge of effective, efficient health care for the elderly has led to many variations in service delivery modalities. The approach employed by the Community Nursing Organization (CNO) is based on nurse coordinated care. Nurses are integrally involved in the authorization, coordination, evaluation and payment of services. The nursing role encompasses case management, including coordination of non-CNO covered services as well as those provided through the capitated payment schedule. Thus, in addition to authorizing CNO services, the nurse also may coordinate services such as physician visits, home repair, transportation, respite services and home-delivered meals, even though they are not covered financially under the auspices of the CNO. Preliminary findings indicate that this model may be successful clinically and financially by determining and utilizing an appropriate mix, intensity and duration of services.

Clinical and health service research needs in the group practice organization

Clinical and health services research will play a more important role in group practice organizations because it provides a vehicle to identify and answer critical questions. Study initiatives can identify, describe, quantify, and help predict trends in clinical practice. Systematic investigation is a means to link structure and processes of care to clinical parameters, patient outcomes, and cost variables. Findings can be used to support sound clinical, quality of care, and educational decision making. The ultimate goal of research is to promote the appropriate access and delivery of quality care in a cost-effective manner.

CRAHCA (Center for Research in Ambulatory Health Care Administration): member involvement leads to practical applications

The research undertaken by CRAHCA results in many new techniques and ideas being adopted by medical practice managers. However, it is not merely a one-way street. In this article, six group practice managers respond to questions about how they have used and been involved with research activities the Center has developed.

Women's participation in community health education: an empirical study

This study identifies reasons for participation in community health education and determines if selected sociodemographic variables correlate with reasons for participation. The subjects were women (N = 400) who had attended hospital-based health education programs in a midwest urban area. An instrument was developed containing 36 items describing the concept "reasons for participation." Factor analysis revealed six interpretable factors: social acceptance, professional/personal advancement, personal insight, personal satisfaction, fulfillment of responsibilities, and self-enrichment. Age, marital status, occupation, number of children, educational attainment, and family income correlated with three of the six factors.

Changes in family patterns six months after a myocardial infarction

Descriptive data were gathered from 15 families on which changes in the family were reported as a result of a myocardial infarction in one family member. Persons surviving their first myocardial infarction and their families were interviewed individually and simultaneously by one of five trained interviewers in each subject's home 6 months after myocardial infarction. Data were analyzed by reduction, display, and comparison of responses. Categories of changes that emerged from the data were those in family and social activities, emotions and personal life-style habits.

Applying geriatric case management in your medical group practice

One of the biggest questions medical groups will have to answer in relation to America's shifting demographics is how to deal with the diverse needs of the elderly effectively. Authors Candace Bruno and Cheryl Schraeder believe one alternative is a case management approach. Their article presents ways in which other medical groups are using case management to meet the needs of the elderly.