CD4+ T cell calibration of antigen-presenting cells optimizes antiviral CD8+ T cell immunity.

Antiviral CD8+ T cell immunity depends on the integration of various contextual cues, but how antigen-presenting cells (APCs) consolidate these signals for decoding by T cells remains unclear. Here, we describe gradual interferon-α/interferon-ß (IFNα/ß)-induced transcriptional adaptations that endow APCs with the capacity to rapidly activate the transcriptional regulators p65, IRF1 and FOS after CD4+ T cell-mediated CD40 stimulation. While these responses operate through broadly used signaling components, they induce a unique set of co-stimulatory molecules and soluble mediators that cannot be elicited by IFNα/ß or CD40 alone. These responses are critical for the acquisition of antiviral CD8+ T cell effector function, and their activity in APCs from individuals infected with severe acute respiratory syndrome coronavirus 2 correlates with milder disease. These observations uncover a sequential integration process whereby APCs rely on CD4+ T cells to select the innate circuits that guide antiviral CD8+ T cell responses.

Adenosine A2A Receptor (A2AR) Agonist Apadenoson Promotes Survival in K28-hACE2 Mice and Syrian Hamsters Infected with Sars-CoV-2

Purpose: To determine if Apadenoson or Regadenoson has a therapeutic effect in attenuating hyper-inflammation and improving survival rate in K18-hACE2mice or Syrian hamsters infected with SARS-CoV-2. Method(s): 6-8 weeks old male K18-hACE2mice were divided into Control group that received vehicle;Test group 1 that received the drug (Apadenoson or Regadenoson) 24hrs prior to challenge with SARS-CoV-2;and Test Group 2 (Drug-delay), that received the drug with a 5 hr delay post-viral infection (n=6/grp). Viral dose was 1250 PfuHong Kong/VM20001061/2020 delivered via intranasal route. Drug was delivered subcutaneously using 1007D ALZET pumps. 6 weeks old Syrian hamsters were divided into Control group that received Vehicle and Virus (n=4) and 2 test groups (n=5/group) that received Apadenoson+Virus and Regadenoson+Virus. Drugs were delivered by 2ML2 ALZET pumps (4ug/kg/hr). Hamsters were inoculated intratracheally with 750PFU SARS-CoV-2 WA1 strain prior to treatment. Mice were weighed and clinical scores recorded daily. Bronchoalveolar lavage fluid (BALF) and serum were collected along with lungs. Plethysmography was done on days 0, 2, 4 and 7. Result(s): Apadenoson administered post-infection was efficacious in decreasing weight loss, improving clinical score, and increasing the survival rate in K18-hACE2 mice, i.e. 50% survival was observed at Day 5 and at Day 7 post-infection for drug given before or after infection respectively. Apadenoson given post-infection improved the histopathology that was observed in the vehicle control group, decreased pro-inflammatory IL-6, IFN-gamma, MCCP-1, MIP-1beta, IP-10, and Rantes in serum, increased anti-inflammatory Ang1-7 levels, and decreased monocytes in BALF. 42% of mice that received Regadenoson pre-challenge survived infection compared to 6.25% in the vehicle or Drug delay (drug given post-infection) groups. Viral titers in the lungs of Regadenoson-treated mice were found decreased. Treatment also significantly decreased CD4+, CD8+T cells, eosinophils, and neutrophils in BALF. Plethysmography, in hamsters, showed significant improvement of pulmonary function parameters, Rpef and PenH, following treatment with Apadenoson given post-infection. Apadenoson cleared the virus from BALF and maintained Ang1-7 levels. Both drugs decreased plasma IFN-gamma levels. Conclusion(s): Treatment with Apadenoson attenuated inflammation, improved pulmonary function, decreased weight loss, and enhanced survival rate following infection with SARS-CoV-2 virus. The results demonstrate the translational significance of Apadenoson in the treatment of COVID-19.

Increased SARS-CoV-2 Infection, Protease, and Inflammatory Responses in Chronic Obstructive Pulmonary Disease Primary Bronchial Epithelial Cells Defined with Single-Cell RNA Sequencing.

Rationale: Patients with chronic obstructive pulmonary disease (COPD) develop more severe coronavirus disease (COVID-19); however, it is unclear whether they are more susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and what mechanisms are responsible for severe disease. Objectives: To determine whether SARS-CoV-2 inoculated primary bronchial epithelial cells (pBECs) from patients with COPD support greater infection and elucidate the effects and mechanisms involved. Methods: We performed single-cell RNA sequencing analysis on differentiated pBECs from healthy subjects and patients with COPD 7 days after SARS-CoV-2 inoculation. We correlated changes with viral titers, proinflammatory responses, and IFN production. Measurements and Main Results: Single-cell RNA sequencing revealed that COPD pBECs had 24-fold greater infection than healthy cells, which was supported by plaque assays. Club/goblet and basal cells were the predominant populations infected and expressed mRNAs involved in viral replication. Proteases involved in SARS-CoV-2 entry/infection (TMPRSS2 and CTSB) were increased, and protease inhibitors (serpins) were downregulated more so in COPD. Inflammatory cytokines linked to COPD exacerbations and severe COVID-19 were increased, whereas IFN responses were blunted. Coexpression analysis revealed a prominent population of club/goblet cells with high type 1/2 IFN responses that were important drivers of immune responses to infection in both healthy and COPD pBECs. Therapeutic inhibition of proteases and inflammatory imbalances reduced viral titers and cytokine responses, particularly in COPD pBECs. Conclusions: COPD pBECs are more susceptible to SARS-CoV-2 infection because of increases in coreceptor expression and protease imbalances and have greater inflammatory responses. A prominent cluster of IFN-responsive club/goblet cells emerges during infection, which may be important drivers of immunity. Therapeutic interventions suppress SARS-CoV-2 replication and consequent inflammation.

Utilisation and time in range outcomes of real-time continuous glucose monitoring systems in Germany, Sweden, and the United Kingdom (2018-2020)

Aims: Regional variations in adoption of real-time continuous glucose monitoring (RT-CGM) may be reflected in population-level metrics of glycaemic control. In this observational study, we characterised the impact of two different RT-CGM systems in three European countries. Methods: Anonymised data from users in Germany, Sweden, and the UK who transitioned from Dexcom's G5 to its G6 RT-CGM System in 2018 and uploaded data from both systems were analysed. The G6 (but not G5) feature set includes a predictive alert designed to mitigate hypoglycaemia. Endpoints were time in range (TIR, 3.9-10.0mmol/ L), retention rates, and intraday/interday device utilisation. Metrics were computed for three month intervals in the two year study window following G6 launches. Results: Utilisation among G5-to- G6 transitioners improved across all countries, and the user retention rate at the end of the study was 85.5%. Overall mean TIR increased from 60.1% (final three months of G5) to 62.8% (two years after switching to G6), and the proportion achieving >70% TIR increased from 28.3% to 37.9%.Regional TIR differences were observed in 2020 and may have been influenced by covid-19 lockdown approaches. Pandemic-related increases in TIR were evident in the UK and Germany, where stringent lockdown measures were introduced;TIR changes in Sweden, where lockdowns were less restrictive, were negligible. Conclusions: Population-level analysis of RT-CGM data can reveal nationwide trends and disparities in the adequacy of glycaemic control. These may be impacted by factors including features and performance attributes of the RT-CGM system itself, and by public health measures such as lockdowns.

Hypercoagulation by rotational thromboelastometry (ROTEM) predicts mortality in COVID-19: A prospectiveobservational study

Background : Severe disease due to COVID-19 has been shown to be associated with coagulopathy with a high rate of micro-and macrothrombosis, and early identification of prothrombotic patients may guide treatment. Rotational Thromboelastometry (ROTEM) is an established point-of-care (POC) blood test, used for detecting and monitoring hypo-and hypercoagulation. Aims : The primary aim of this study was to assess whether analysis by ROTEM alone or in combination with other risk markers can be a predictor of mortality in COVID-19. Methods : This was a single center, prospective, observational study where COVID-19 positive patients over 18 years in need of hospitalization were eligible for inclusion. Conventional coagulation tests and ROTEM were taken day 1-3 after hospital admission and patients were followed for 30 days. A logistic regression approach was applied to the ROTEM data and possible important covariates. Results : 141 patients were included, 62 % men, median age 63 years. 18 patients (13%) died within 30 days. Comorbidities were common, and most patients had laboratory markers indicating hypercoagulation (e.g. d-dimer, P-fibrinogen and ROTEM). The logistic model presented that the risk of death within 30 days for a patient hospitalized due to COVID-19 was increased with increased age, respiratory frequency and the ROTEM variable EXTEM-MCF (all predictors P < 0.05). When the model is applied to the data, the ROC curve AUC is 0.91. FIGURE 1 Predicted probability of death vs risk score Figure 1. Prediction model using logistic regression. Distribution of patients across range of risk scores, with the three predictor variables at inclusion (EXTEM-MCF, age and respiratory frequency). In lower part of figure, a histogram showing the distribution of risk scores for the present data. Conclusions : The results support that hypercoagulation in COVID-19, as measured using ROTEM, is associated with an increased risk of death. In our prediction model, increased EXTEM-MCF, age and respiratory frequency on admission were associated with increased mortality within 30 days.

A statewide medical dental integration initiative

Background: Wisconsin has a significant gap to improve access to pediatric oral health care. Only 1 in 5 Wisconsin Medicaid eligible children ages 0-5 years received preventive dental services, in 2018. By the time children in Head Start are 5 years old, half have developed caries. Dental hygienists can now practice in medical clinics without the direct supervision of a dentist due to the 2017 Wisconsin ACT 20 legislation. As 80,000 children ages 0-5 enrolled in Wisconsin Medicaid in 2018 had a medical visit, but no dental visit, a medical dental integration model offers the opportunity to leverage medical visits to incorporate oral health care. Methodology: Utilizing a modified version of the Institute for Healthcare Improvement's Breakthrough Collaborative Model, the Wisconsin Medical Dental Integration (WI-MDI) project aims to: 1) Expand access to preventive oral health services;2) Reduce the prevalence of caries experience and untreated dental caries;and 3) Develop a financially sustainable model for integrated oral health care that redefines how preventive oral health care is provided to children. This three-year project started in January 2019 with the creation of an Advisory Council composed of representatives from multiple healthcare systems, federally qualified health centers, professional associations, and state agencies. The WI-MDI driver diagram (Figure 1) was created to assist clinic teams in implementing system changes required to integrate oral health into primary care. Data is collected in Life QI, an online quality improvement platform used to assist with project oversight to both track and analyze improvement data. Discussion: Six Advisory Council meetings have occurred to date with the partnership growing over time (N=15-20 partners). Clinical team's readiness to implement the MDI model was assessed through their identification of readiness to proceed with each of the drivers (Figure 2). A yearlong Learning Collaborative started in October 2019, with two learning sessions to date, and five monthly Collaborative calls addressing primary drivers clinics were not ready on yet (yellow/red colors). Three federally qualified health clinics (FQHCs) are currently participating with dental hygienists integrated into their medical teams. Participants engagement has been enhanced through a complementary stipend from a dental partner. Conclusion: Recruitment of healthcare systems to engage in this Project has taken longer than anticipated, however, intentions to adopt the model remain high. System changes necessary to incorporate a new provider into primary care delivery revealed several key barriers: incorporating dental documentation into existing medical records, updating billing systems to bill dental codes, investment of hiring new staff, and greater challenges for large systems' acceptance compared with FQHCs. Due to COVID-19 pandemic, modifications have been made to now include virtual monthly team calls to help systems overcome these barriers with plans to start Learning Collaborative Wave 2 in March 2021.