Patterns of healthcare services utilization associated with intimate partner violence (IPV): Effects of IPV screening and receiving information on support services in a cohort of perinatal women.

BACKGROUND:While women experiencing intimate partner violence (IPV) face significant health consequences, their patterns of healthcare services (HCS) utilization are unclear, as are the effects of IPV screening and receiving information on these patterns. OBJECTIVES:1. Compare utilization patterns of five HCS (visits to family physician, gynecologist, specialist and emergency room, and hospitalization) in a cohort of perinatal women who reported experiencing versus not experiencing any IPV and IPV types (physical and/or sexual; emotional and/or verbal; social and economic); 2. Examine whether IPV screening, receiving information on support services, or both, affect patterns; and 3. Compare these associations between ethnic groups (Arab and Jewish women). METHODS:We conducted a prospective study using registry data on HCS utilization obtained from Israel's largest Health Fund (Clalit) in the year following a 2014-2015 survey of a cohort of 868 perinatal women in Israel (327 Arab minority, 542 Jewish) on their reports of experiencing IPV, IPV screening, and receiving information. Using multivariate analysis, we calculated adjusted odds ratios (AOR) and 95% confidence intervals (CI) for the five HCS utilizations in association with reports of any IPV and IPV types. We adjusted for IPV screening, receiving information about services, and both, in the total sample, and separately among ethnic groups. RESULTS:Any IPV and IPV types had significant associations with some HCS utilization variables, with different directions and patterns for the ethnic groups. Experiencing IPV was associated with higher HCS utilization among Arab women, lower utilization in Jewish women. Arab women experiencing IPV were twice as likely to visit a gynecologist than women not experiencing IPV (AOR (95% CI) was 2.00, 1.14-3.51 for any IPV; 2.17, 1.23-3.81 for emotional and/or verbal IPV, and 1.83, 1.04-3.22, for social and economic IPV). Among Jewish women, experiencing any IPV was associated with lower likelihood of emergency-room visits (0.62, 0.41-0.93); and experiencing physical and/or sexual IPV was associated with lower likelihood of family physician visits (OR = 0.20, 0.05-0.82). Both IPV screening and receiving information were associated with lower HCS utilization among Arab women only. CONCLUSIONS:Different HCS utilization patterns among women who reported experiencing versus not experiencing IPV in different ethnic groups suggest complex relationships that hinge on how HCS address women's needs, starting with IPV screening and providing information. This might inform tailored programs to tackle IPV at the HCS, particularly for minority women

Development of Allogeneic NK Cell Adoptive Transfer Therapy in Metastatic Melanoma Patients: In Vitro Preclinical Optimization Studies

<div><p>Natural killer (NK) cells have long been considered as potential agents for adoptive cell therapy for solid cancer patients. Until today most studies utilized autologous NK cells and yielded disappointing results. Here we analyze various modular strategies to employ allogeneic NK cells for adoptive cell transfer, including donor-recipient HLA-C mismatching, selective activation and induction of melanoma-recognizing lysis receptors, and co-administration of antibodies to elicit antibody-dependent cell cytotoxicity (ADCC). We show that NK cell activation and induction of the relevant lysis receptors, as well as co-administration of antibodies yield substantial anti-cancer effects, which are functionally superior to HLA-C mismatching. Combination of the various strategies yielded improved effects. In addition, we developed various clinically-compatible <i>ex vivo</i> expansion protocols that were optimized according to fold expansion, purity and expression of lysis receptors. The main advantages of employing allogeneic NK cells are accessibility, the ability to use a single donor for many patients, combination with various strategies associated with the mechanism of action, e.g. antibodies and specific activation, as well as donor selection according to HLA or CD16 genotypes. This study rationalizes a clinical trial that combines adoptive transfer of highly potent allogeneic NK cells and antibody therapy.</p> </div

HLA-C matched and mismatched NK donors and melanoma patients.

<p>The table shows the identity of each of the two alleles of HLA-A, HLA-B and HLA-C for two melanoma patients (Mel008 and Mel10) and seven healthy NK donors (depicted as “HD” followed by a serial number). The table indicates whether one of the HLA-A alleles or HLA-B alleles is a KIR-ligand (highlighted in gray). Similarly, the table indicates whether each HLA-C is of C1 or C2 subgroup, effectively classifying all patients to homozygotes of C1 or C2, or C1–C2 heterozygotes (highlighted in gray). The table is arranged to demonstrate melanoma-NK pairs that are either HLA-C matched or mismatched.</p

ADCC killing effect against melanoma.

<p>(A) A highly significant effect of pre-incubation with anti-GD3 mAbs, but not with isotype control (IC) on the potency of NK cells cultured over night with 100 IU/ml of IL-2 against melanoma; (B) GD3-targeted ADCC can be stimulated only against GD3-positive melanoma cells and is dependent on pre-incubation of the effector cells with IL-2 overnight; (C) Combination of ADCC and HLA-C mismatching. The NK cultures and their matching status towards each melanoma culture are indicated in the figure. E:T ratios were 10∶1. Y axis denotes specific killing (%). Figure shows the mean of four independent experiments. *denotes statistical significance in <i>t-tests</i> of P<0.05 and **of P<0.01. Error bars represent SEM.</p

The effect of HLA-C mismatching on NK-mediated killing.

<p>(A) Killing of NK cells cultured over night with 100 IU/ml of IL-2 tested in HLA-C matched and mismatched setting; (B) Individual NK cultures in matched and mismatched setting out of 3 performed. E:T ratios were 10∶1. Y axis denotes specific killing (%). Figure shows the mean of five independent experiments performed. **denotes statistical significance in <i>t-tests</i> of P = 0.01. Error bars represent SEM.</p

Combining ex-vivo NK cell activation, ADCC stimulation and HLA-C mismatching against melanoma cells.

<p>The indicated NK cultures were tested against HLA-C mismatched melanoma cells in the presence of anti-GD3 or isotype control (IC) antibodies. Y axis denotes specific killing (%). Figure shows the mean results of three independent experiments. *denotes statistical significance in <i>t-tests</i> of P = 0.01. Error bars represent SEM.</p

Optimizing ex-vivo expansion; Addition of OKT-3.

<p>CD3-depleted cells were expanded in AIM-V or X-VIVO 10 medium with 500 IU/ml IL-2 and one or two rounds of irradiated feeder cells in the presence (“with”) or absence (w/o) of the anti-CD3 antibody OKT3 (30 ng/ml). On the day of initiation OKT3 was added directly to the ready culture comprised of irradiated feeder cells and CD3-depleted cells (10∶1) (“OKT3 directly”) or irradiated feeder were pre-incubated with OKT3 and washed before mixing them with the CD3-depleted cells (“OKT3 pre-incubated”). NK and T cell frequency was defined by flow cytometry analysis in gated live cells. (A) Fold expansion of NK cells after 14 days of expansion; (B) NK cell frequency (%) after 14 days; (C) Fold expansion of NK cells after 21 days; (D) NK cell frequency (%) after 21 days, (E) CD3 T-cell frequency (%) after 21 days; (F) Fold expansion of NK cells after 14 days; (G) Fold expansion of NK cells after 21 days; (H) CD3 T-cell frequency (%) after 21 days.</p

Frequency of KIR-ligand genotyping among analyzed subjects.

<p>(A) HLA-C KIR-ligands: C1 and C2 represent subjects who are homozygous for HLA-C from group C1 or C2, respectively. C1 & C2 stands for subjects with one allele from C1 and one C2; (B) Number of different KIR-ligand groups identified per subject: “1” stands for only KIR ligand group C1 or C2. “2” means one of the follow combinations: C1 & A (03 or 11), C1 & Bw4, C2 & A (03 or 11) or C2 & Bw4. “3” means C1 & Bw4 & A (03 or 11) or C2 & Bw4 & A (03 or 11).</p

NK cell potency against primary melanoma cultures in relation to NK lysis receptor surface expression following <i>ex-vivo</i> expansion protocols.

<p>Cultured NK cells were analyzed at different time points: ”d1” following culturing with only IL-2 for overnight, “d14” and “d21” indicate 14 and 21 days in culture respectively. The letters “K”, “H” and “L” indicate culture condition set as delineated in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0057922#pone-0057922-g004" target="_blank">Figure 4</a>. (A–B) shows the results of comparing selected culturing conditions: (A) killing activity of representative NK cultures in HLA-C matched and mismatched settings. The mean results of three independent experiments is shown; (B) expression of the indicated NK lysis receptors by the various NK cultures; (C) killing activity of representative NK cultures against MHC class I negative lymphoma cells (721.221) and melanoma cells (1106mel). The mean results of three independent experiments is shown; (D–E) shows the results of comparing different time points along culture in the optimal culturing condition H: (D) expression of the indicated NK lysis receptors by the various NK cultures; (E) killing activity in HLA-C mismatched setting in the presence of IgG1 isotype control antibodies or the indicated blocking antibodies. E:T ratios were 10∶1. MFI means Median Fluorescence Intensity. Figure shows the mean of three independent experiments. *denotes statistical significance in <i>t-tests</i> of P<0.05. Error bars represent SEM.</p