Дисертації з теми "PCMHE"

The Patient-Centered Medical Home (PCMH) model has been touted as one of the most promising reform efforts of the largely inefficient U.S. healthcare system. In comparison to the current primary care system, the PCMH is a care delivery model that is based on the principles of care-coordination, enhanced access, and team-based collaboration as a means of providing comprehensive, patient-centered medical care. The current literature contains a limited number of review articles synthesizing the data of numerous PCMH outcome studies. Even a smaller number draws definitive conclusions as to whether PCMH is a viable model upon which to reform the US healthcare system. This literature review will examine the available results of PCMH studies in light of their ability to 1) decrease the overall cost of healthcare 2) increase the efficiency of the continuity of care and 3) to increase positive patient outcomes through proactive patient care. Additionally, these results will be examined in regard to their longevity as a viable model of reform and specifically as it compares to the current US healthcare system. This review will determine whether there is statistical evidence that the Patient-Centered Medical Home is a successful model to decrease healthcare costs, increase healthcare efficiency as well as increasing positive patient outcomes. In addition, this review hopes to point to ways in which the model could be improved in order to more completely achieve the goals listed above.

Les vaccins à base de cellules dendritiques (DCs) constituent une avenue très populaire en immunothérapie du cancer. Alors que ces cellules peuvent présenter des peptides exogènes ajoutés au milieu, l’efficacité de chargement de ces peptides au le complexe majeur d'histocompatibilité (CMH) de classe II est limitée. En effet, la majorité des molécules du CMH II à la surface des DCs sont très stable et l’échange de peptide spontané est minime. Confinée aux vésicules endosomales, HLA-DM (DM) retire les peptides des molécules du CMH II en plus de leur accorder une conformation réceptive au chargement de peptides. Il est possible, cependant, de muter le signal de rétention de DM de façon à ce que la protéine s’accumule en surface. Nous avons émis l’hypothèse que ce mutant de DM (DMY) sera aussi fonctionnel à la surface que dans la voie endosomale et qu’il favorisera le chargement de peptides exogènes aux DCs. Nous avons utilisé un vecteur adénoviral pour exprimer DMY dans des DCs et avons montrer que la molécule augmente le chargement de peptides. L’augmentation du chargement peptidique par DMY est autant qualitatif que quantitatif. DMY améliore la réponse T auxiliaire (Th) du coté Th1, ce qui favorise l’immunité anti-cancer. Du côté qualitatif, le chargement de peptides résulte en des complexes peptide-CMHII (pCMH) d’une conformation supérieure (conformère). Ce conformère (Type A) est le préféré pour la vaccination et DMY édite avec succès les complexes pCMH à la surface en éliminant ceux de type B, lesquels sont indésirables. La fonction de DM est régulée par HLA-DO (DO). Ce dernier inhibe l’habilité de DM à échanger le peptide CLIP (peptide dérivée de la chaîne invariante) en fonction du pH, donc dans les endosomes tardifs. Mes résultats indiquent que la surexpression de DO influence la présentation des superantigènes (SAgs) dépendants de la nature du peptide. Il est probable que DO améliore indirectement la liaison de ces SAgs au pCMH dû à l’accumulation de complexe CLIP-CMH, d’autant plus qu’il neutralise la polarisation Th2 normalement observée par CLIP. Ensemble, ces résultats indiquent que DMY est un outil intéressant pour renforcer le chargement de peptides exogènes sur les DCs et ainsi générer des vaccins efficaces. Un effet inattendu de DO sur la présentation de certains SAgs a aussi été observé. Davantage de recherche est nécessaire afin de résoudre comment DMY et DO influence la polarisation des lymphocytes T auxiliaires. Cela conduira à une meilleure compréhension de la présentation antigénique et de son étroite collaboration avec le système immunitaire.
Dendritic cell peptide-based vaccines are the most common immunotherapy approach in cancer therapy. While, in principle, dendritic cells (DCs) could be loaded efficiently by exogenously added tumor peptides, their loading efficacy is severely reduced due to low number of peptide-receptive MHC II on cell surface. Most surface MHC II molecules are either occupied by endogenous peptides or are inactive due to a conformation that is not receptive for free peptides. In MHC II antigen presentation pathway, HLA-DM (DM) in acidic endosomal vesicles removes the self-peptides and grants a peptide receptive conformation to MHC II. Mutating of an intracellular sorting motif in DM, renders its accumulation on cell surface. We hypothesized that the mutant DM (DMY) is functional on cell surface and can generate peptide receptive MHC II on surface of DCs for exogenous peptide loading. By using an adenoviral vector that expresses DMY, we found that DMY is functional on surface of DCs. DMY supplied peptide receptive MHC II on surface of DCs and improved exogenous peptide loading. The improvement of peptide loading by DMY is both quantitative and qualitative. DMY improves helper T cell (Th) response in Th1 direction that favors anti-cancer immunity. The qualitative improvement of peptide loading extends to loading of superior conformational isomer (conformer) of peptide-MHC complexes. This superior conformer (type A) is the favourite type for vaccination approaches and DMY successfully edits peptide-MHC conformers on cell surface level by eliminating undesirable one (type B). Function of DM is regulated by HLA-DO (DO) and it is well accepted that in acidic pH of late endosomes, DO inhibits function of DM by preventing removal of class II associated invariant chain peptide (CLIP) from peptide binding groove of MHC II. My results indicate that DO overexpression, changes binding of peptide-dependent superantigens to MHC II molecules. Superantigens (SAgs) are small microbial proteins that bind out side peptide binding groove of MHC II. DO probably enhances binding of peptide-dependent SAgs by forcing the accumulation of CLIP on the cell surface of antigen presenting cells. DO also neutralizes Th2 polarization by CLIP. Collectively, these results indicate that DMY is a valuable tool for improvement of exogenous peptide loading in DCs vaccines. An unnoticed effect of DO on SAgs binding was also recognized. Further investigations are needed to clarify the mechanisms by which, DMY and DO influence Th polarization. This would provide a better understanding of antigen presentation pathway and its interaction with immune system.