Support and Assessment for Fall Emergency Referrals (SAFER 1): Cluster Randomised Trial of Computerised Clinical Decision Support for Paramedics

Objective: To evaluate effectiveness, safety and cost-effectiveness of Computerised Clinical Decision Support (CCDS) for paramedics attending older people who fall. Design: Cluster trial randomised by paramedic; modelling. Setting: 13 ambulance stations in two UK emergency ambulance services. Participants: 42 of 409 eligible paramedics, who attended 779 older patients for a reported fall. Interventions: Intervention paramedics received CCDS on Tablet computers to guide patient care. Control paramedics provided care as usual. One service had already installed electronic data capture. Main Outcome Measures: Effectiveness: patients referred to falls service, patient reported quality of life and satisfaction, processes of care. Safety: Further emergency contacts or death within one month. Cost-Effectiveness Costs and quality of life. We used findings from published Community Falls Prevention Trial to model cost-effectiveness. Results: 17 intervention paramedics used CCDS for 54 (12.4%) of 436 participants. They referred 42 (9.6%) to falls services, compared with 17 (5.0%) of 343 participants seen by 19 control paramedics [Odds ratio (OR) 2.04, 95% CI 1.12 to 3.72]. No adverse events were related to the intervention. Non-significant differences between groups included: subsequent emergency contacts (34.6% versus 29.1%; OR 1.27, 95% CI 0.93 to 1.72); quality of life (mean SF12 differences: MCS −0.74, 95% CI −2.83 to +1.28; PCS −0.13, 95% CI −1.65 to +1.39) and non-conveyance (42.0% versus 36.7%; OR 1.13, 95% CI 0.84 to 1.52). However ambulance job cycle time was 8.9 minutes longer for intervention patients (95% CI 2.3 to 15.3). Average net cost of implementing CCDS was £208 per patient with existing electronic data capture, and £308 without. Modelling estimated cost per quality-adjusted life-year at £15,000 with existing electronic data capture; and £22,200 without. Conclusions: Intervention paramedics referred twice as many participants to falls services with no difference in safety. CCDS is potentially cost-effective, especially with existing electronic data capture

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Assessment of CD4+ T Cell Responses to Glutamic Acid Decarboxylase 65 Using DQ8 Tetramers Reveals a Pathogenic Role of GAD65 121–140 and GAD65 250–266 in T1D Development

<div><p>Susceptibility to type 1 diabetes (T1D) is strongly associated with MHC class II molecules, particularly HLA-DQ8 (DQ8: DQA1*03:01/DQB1*03:02). Monitoring T1D-specific T cell responses to DQ8-restricted epitopes may be key to understanding the immunopathology of the disease. In this study, we examined DQ8-restricted T cell responses to glutamic acid decarboxylase 65 (GAD65) using DQ8 tetramers. We demonstrated that GAD65_121–140 and GAD65_250–266 elicited responses from DQ8+ subjects. Circulating CD4+ T cells specific for these epitopes were detected significantly more often in T1D patients than in healthy individuals after in vitro expansion. T cell clones specific for GAD65_121–140 and GAD65_250–266 carried a Th1-dominant phenotype, with some of the GAD65_121–140-specific T cell clones producing IL-17. GAD65_250–266-specific CD4+ T cells could also be detected by direct ex vivo staining. Analysis of unmanipulated peripheral blood mononuclear cells (PBMCs) revealed that GAD65_250–266-specific T cells could be found in both healthy and diabetic individuals but the frequencies of specific T cells were higher in subjects with type 1 diabetes. Taken together, our results suggest a proinflammatory role for T cells specific for DQ8-restricted GAD65_121–140 and GAD65_250–266 epitopes and implicate their possible contribution to the progression of T1D.</p></div

Direct ex vivo analysis of GAD65-specific T cells.

<p>Unmanipulated PBMCs were stained with DQ8/GAD65_250–266 PE-tetramer. Antigen-specific CD4+ T cells were enriched, stained with antibodies against surface markers of interest, and analyzed on a Calibur multi-color flow cytometer. (<b>A</b>) Representative ex vivo analysis of the surface memory marker CD45RO for GAD65_250–266. The frequency of GAD65_250–266-specific CD45RO+CD4+ T cells was 4.4 per million CD4+ T cells for the T1D patient (left panel) and 0.6 per million for the healthy subject (right panel). (<b>B</b>) Ex vivo co-staining of GAD65_250–266-specific cells with DQ8/GAD65_250–266 PE- and DQ8/GAD65_250–266 APC-tetramers. Cells were stained with PE-labeled DQ8/GAD65_250–266 tetramers first. After enrichment, tetramer-positive cells were stained again with APC-labeled DQ8/GAD65_250–266 tetramers at 37°C for 1 h. (<b>C</b>) Cumulative total CD4+ and CD45RO+CD4+ T cell frequencies for GAD65_250–266 in controls (open circles, n = 10) and T1D patients (closed circles, n = 10). <b>***</b> P<0.001, <b>**</b> P<0.01, as evaluated by Mann-Whitney U-test.</p

List of DQ8-restricted GAD65 peptides used in this study.

<p>*IC₅₀ value for the control H1MP_185–204 peptide was 1.4 µM.</p><p>*Predicted binding registers are indicated in boldface.</p><p>List of DQ8-restricted GAD65 peptides used in this study.</p

Summary of ex vivo results for GAD65_250–266.

<p>N/A: not available.</p><p>Summary of ex vivo results for GAD65_250–266.</p

Prevalence of GAD65-specific T cells in T1D and healthy subjects.

<p>Not all peptides were tested on each subject.</p><p>Statistical analysis was performed using two-tailed Fisher's exact tests.</p><p>Prevalence of GAD65-specific T cells in T1D and healthy subjects.</p

Functional analysis of DQ8-specific self-reactive T cells.

<p>T cell clones isolated by DQ8 tetramers were assayed for specificity and functionality. (<b>A</b>) Tetramer staining for GAD65_121–140-specific (clone T1D05-C2), GAD65_250–266-specific (clone T1D04-C1) and unrelated T cell clones. (<b>B</b>) Representative proliferation results of one GAD65_121–140- and two GAD65_250–266-specific T cell clones using APCs from a DR0401/DQ8 homozygous individual. Cells were stimulated with specific or irrelevant control peptide in the absence or presence of 20 µg/ml of L243 (HLA-DR blocking antibody) or SPVL3 (HLA-DQ blocking antibody). SI: stimulation index; cpm of specific peptide divided by cpm of irrelevant peptide. (<b>C</b>) Summary of cytokine-positive clones (for definition see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0112882#s4" target="_blank">Materials and methods</a>) for GAD65_121–140 and GAD65_250–266. T cell clones were stimulated with 50 ng/mL phorbol 12-myristate 13-acetate and 1 µg/mL ionomycin in the presence of 10 µg/mL Brefeldin A in 1 mL of T cell medium for 4 hours at 37°C. Cells were fixed, permeabilized, stained with antibodies for IFN-γ, IL-10, IL-4, and IL-17, and analyzed on a LSRII multicolor flow cytometer. (<b>D</b>) Secretion of IFN-γ, IL-4, and IL-10 from two GAD65_121-140-specific and two GAD65_250–266-specific T cell clones. Clones were stimulated in the presence of 10 µg/ml of specific peptide with DQ8 antigen presenting cells.</p

A Novel Molecular Diagnostic of Glioblastomas: Detection of an Extracellular Fragment of Protein Tyrosine Phosphatase µ12

We recently found that normal human brain and low-grade astrocytomas express the receptor protein tyrosine phosphatase mu (PTPµ) and that the more invasive astrocytomas, glioblastoma multiforme (GBM), downregulate full-length PTPµ expression. Loss of PTPµ expression in GBMs is due to proteolytic cleavage that generates an intracellular and potentially a cleaved and released extracellular fragment of PTPµ. Here, we identify that a cleaved extracellular fragment containing the domains required for PTPµ-mediated adhesion remains associated with GBM tumor tissue. We hypothesized that detection of this fragment would make an excellent diagnostic tool for the localization of tumor tissue within the brain. To this end, we generated a series of fluorescently tagged peptide probes that bind the PTPµ fragment. The peptide probes specifically recognize GBM cells in tissue sections of surgically resected human tumors. To test whether the peptide probes are able to detect GBM tumors in vivo, the PTPµ peptide probes were tested in both mouse flank and intracranial xenograft human glioblastoma tumor model systems. The glial tumors were molecularly labeled with the PTPµ peptide probes within minutes of tail vein injection using the Maestro FLEX In Vivo Imaging System. The label was stable for at least 3 hours. Together, these results indicate that peptide recognition of the PTPµ extracellular fragment provides a novel molecular diagnostic tool for detection of human glioblastomas. Such a tool has clear translational applications and may lead to improved surgical resections and prognosis for patients with this devastating disease