ABSTRACT
Background. Coronavirus Disease 2019 (COVID-19) caused by the SARS-CoV-2 virus is associated with dysregulation in the innate immune response including NK cells. NK cells are integral in the innate immune response against viral infections. Canonical NK cells are classified as CD56dim CD16+ and CD56bright CD16-. An unconventional subset of CD56dim CD16 - NK cells has previously been identified in COVID-19 that is not present in other viral infections. Here we characterize phenotypic changes in the NK cells of patients with severe COVID-19 as work towards determining the functional status of this unconventional subset. Methods. Peripheral blood mononuclear cells (PBMCs) and plasma were isolated from healthy donors (n=5) and patients with severe COVID-19 on Extra Corporeal Membrane Oxygenation (ECMO) (n =15). Primary NK cells were stimulated in vitro with plasma from patients with severe COVID-19 or healthy donors. Flow cytometry was used to phenotype the NK cells. A separate cohort of PBMC samples (n =7) from patients requiring hospitalization for COVID-19 underwent Cellular Indexing of Transcriptomes and Epitopes by Sequencing (CITE-Seq) analysis. Results. The CD56bright CD16 - NK subset was expanded in PBMCs from patients with severe COVID-19 as compared to healthy controls. CITE-Seq demonstrated that NK cells without surface CD16 clustered separately based on transcriptional profiling and did express FCGR3A at the translational level. Stimulation with COVID-19 plasma recapitulated the loss of CD16 from primary human NK cells and led to increased activity of Caspase 3/7. a) Representative gating of NK cell subsets by Flow Cytometry in healthy and COVID-19 patient peripheral blood mononuclear cells (PBMCs). b) Percentage of total NK cells belonging to a particular cell subset compared between healthy donor samples (n=4) and COVID-19 patient samples (n =8). Data points represent an individual patient sample. Error bars represent the standard deviation of the mean. Differences between groups was analyzed using a two tailed t-test. *: p< 0.05, ns: not significant Figure 2. NK cells shift from the CD56dim CD16+ subset to the CD56dim CD16-subset after stimulation with COVID-19 plasma in vitro a) Representative gating of NK cell subsets by Flow Cytometry analysis in healthy donor NK cells stimulated by healthy plasma and COVID-19 patient plasma. b)Relative change in percentage of total NK cells belonging to a particular cell subset compared between healthy donor plasma (n=6)and COVID-19 patient plasma (n=15) stimulation conditions. Error bars represent the standard deviation of the mean and the difference between groups was analyzed using a two-tailed T-test. * *: p< 0.01, * * *: p< 0.001, ns: not significant. Conclusion. We demonstrate and characterize a nonclassical population of CD56dim CD16 - NK cells that are present in patients with severe COVID-19 and replicate this phenotype in vitro. Reproduction of this in vivo phenotype in an in vitro system will allow for additional studies on the functional state of NK cell subsets in COVID-19. The presence of this NK cell population may reflect a dysregulated innate immune response and immunopathogenesis of COVID-19.
ABSTRACT
Objective: The paper aims to present a research agenda and advisory panel for scholars, branding practitioners and marketers over a place branding perspective in the Brazilian context. Approach: Bibliographic analysis based on the place image construct built from competitive identity and the achievement of place reputation under a nation branding overview with its economic, political and cultural-critical orientations. Findings: Guidelines and implications on place brand management and place branding meta trends. The management blueprint consists of a place branding organization to coordinate actions and stakeholders in decision-making stages;an umbrella branding program that benefit different sectors of the economy;place brand measurement to monitor results. The meta trends roadmap is related to a green place brand orientation and positioning as a competitive asset;branding places in a digital transformation context;challenges and opportunities for place branding post Covid-19. Contribution: This work outlines that strong leadership and efficient planning for place management should prevail over mistaken political measures that weaken place brand equity, otherwise, the country's socioeconomic development, place image and reputation are at risk of being continuously compromised. Relevance: This research draws attention, stimulates the debate and suggests pathways where place branding principles may provide the lever in need to encourage Brazilian leaderships to cooperate and collaborate more consistently and effectively to properly tackle forward challenges in the 21st century.
ABSTRACT
Atopic dermatitis (AD) is a chronic, recurrent, highly pruritic immune-mediated inflammatory disease, with an unmet need for additional effective therapies. Results from phase IIb and phase III clinical trials demonstrated that upadacitinib (UPA) was efficacious with a favourable benefit-risk profile vs. placebo (PBO) in the treatment of moderate-to-severe AD. Here, we analyse the efficacy and safety of UPA in adolescent and adult subgroups using data from three phase III studies. Data from three randomized, double-blind, placebo-controlled, multicentre phase III studies [Measure Up 1 (NCT03569293), Measure Up 2 (NCT03607422) and AD Up (NCT03568318)] were used to assess the efficacy and safety of UPA in adolescents and adults. Across the three studies, adolescents (aged 12 to < 18years) and adults (aged 18-75years) with moderate-to-severe AD were randomized 1: 1: 1 to UPA 15mg (UPA15), UPA 30mg (UPA30) or PBO orally once daily, either alone (Measure Up 1 and Measure Up 2) or with concomitant topical corticosteroids (AD Up). This analysis includes prespecified efficacy endpoints in adolescents and adults at week 16: achievement of 75% improvement in Eczema Area and Severity Index (EASI-75), validated Investigator's Global Assessment-Atopic Dermatitis score of clear or almost clear (vIGA-AD 0/1), Worst Pruritus Numerical Rating Scale (WP-NRS) improvement of ≥ 4, Dermatology Life Quality Index (DLQI) or Children's DLQI score of 0 or 1 (DLQI 0/1 or CDLQI 0/1), and Hospital Anxiety and Depression Scale (HADS)-Anxiety (HADS-A) < 8 and HADS-Depression (HADS-D) < 8. The primary approach for evaluating categorical endpoints was NRI-C (nonresponder imputation incorporating multiple imputation to handle missing data due to COVID-19). Safety was assessed as treatment-emergent adverse events (AEs) in all patients who received ≥ 1 dose of study drug and analysed as an integrated dataset for all three studies. In total, 124, 104 and 116 adolescents plus 723, 732 and 785 adults were randomized and treated in Measure Up 1, Measure Up 2 and AD Up, respectively. EASI-75 response rates at week 16 across adolescent and adult subgroups for both doses of UPA were consistent with the overall study population results;treatment with UPA30 yielded numerically better results than with UPA15. Most patients in both subgroups achieved EASI-75 with UPA15 (> 55%), and numerically greater proportions of patients achieved EASI-75 for UPA30 (> 72%), with response rates for both UPA doses demonstrating significantly better efficacy than PBO (≥ 30%). vIGA-AD 0/1 was achieved by > 38% and > 50% of patients receiving UPA15 and UPA30, respectively, in both subgroups, with response rates for both UPA doses demonstrating significantly better efficacy than PBO (< 12%). A WP-NRS improvement of ≥ 4 was achieved by > 33% of adolescents and > 42% of adults receiving UPA15 vs. > 50% of adolescents and > 60% of adults receiving UPA30, with response rates for both UPA doses demonstrating significantly better efficacy than PBO (< 16%). CDLQI 0/1 was achieved by > 13% (UPA15) and ≥ 19% (UPA30) of adolescents aged 12 to <16years, while DLQI 0/1 was achieved by ≥ 0% (UPA15) and ≥ 27% (UPA30) of adolescents aged 16 to <18years;most adolescent rates for DLQI 0/1 and CDLQI 0/1 were not significantly greater than PBO. In the adult subgroup, DLQI 0/1 was achieved by > 24% and > 37% receiving UPA15 and UPA30, respectively, both significantly greater than PBO. Achievement of HADS-A<8 and HADS-D<8 was comparable for adolescents and adults, with response rates for both UPA doses being significantly higher than PBO: ≥ 40% for UPA15 and > 41% for UPA30 in both subgroups. Rates of serious AEs and AEs leading to discontinuation were generally similar across treatment groups for both adolescents and adults. Rates of acne-the most common AE-were higher with UPA than PBO, and similar for adolescents and adults. Serious infections were reported infrequently (< 1%) with UPA in both adolescents and adults. Opportunistic infections were reported in < 1% of adults, with n ne in adolescents. Rates of herpes zoster virus infection were higher with UPA than PBO in both adolescents and adults. No adjudicated gastrointestinal perforation, major adverse cardiovascular events or venous thromboembolic events were reported in the UPA groups. No malignancies were reported in adolescents. Adolescent and adult responses to UPA15 and UPA30 treatment were consistent across clinical, quality-of-life and patient-reported outcome assessments, with similar and acceptable safety in both populations.