Background: Adults with end-stage renal disease (ESRD) requiring chronic dialysis continue to suffer from poor health outcomes and represent a population rightfully targeted for quality improvement. Electronic dashboards are increasingly used in healthcare to facilitate quality measurement and improvement. However, detailed descriptions of the creation of healthcare dashboards are uncommonly available and formal inquiry into perceptions, satisfaction, and utility by clinical users has been rarely conducted, particularly in the context of dialysis care. Therefore, we characterized the development, implementation and user experience with Veterans Health Administration (VHA) dialysis dashboard. Methods: A clinical-quality dialysis dashboard was implemented, which displays clinical performance measures (CPMs) for Veterans with ESRD receiving chronic hemodialysis at all VHA facilities. Data on user experience and perceptions were collected via an e-mail questionnaire to dialysis medical directors and nurse managers at these facilities. Results: Since 2016 the dialysis dashboard reports monthly on CPMs for approximately 3000 Veterans receiving chronic hemodialysis across 70 VHA dialysis facilities. Of 141 dialysis medical directors and nurse managers, 61 completed the questionnaire. Sixty-six percent of respondents did not find the dashboard difficult to access, 64% agreed that it is easy to use, 59% agreed that its layout is good, and the majority agreed that presentation of data is clear (54%), accurate (56%), and up-to-date (54%). Forty-eight percent of respondents indicated that it helped them improve patient care while 12% did not. Respondents indicated that they used the dialysis dashboard for clinical reporting (71%), quality assessment/performance improvement (QAPI) (62%), and decision-making (23%).

Clinical trials in recent years involving the adoptive transfer of antigen-specific cytotoxic T lymphocytes (CTL) have shown promise in restoring immunity against viral infection and reducing tumor burden in patients with solid and hematological malignancies. However, the large cell number required to achieve efficacy, 10(9) to 10(11), makes routine application of adoptive immunotherapy impractical. Investigation into new methods of CTL expansion may be useful in addressing this problem. Use of stirred suspension bioreactors are one such method that may allow large-scale T-cell expansion. Suspension cultures offer advantages over conventional static culture methods, including providing a homogeneous culture environment, and the potential for optimization and control of culture conditions. We generated cytomegalovirus (CMV)-specific CTL and investigated the potential of stirred bioreactor systems for expansion of large cell numbers. We found that CTL can be readily expanded ( > 200-fold) from cryopreserved stocks by nonspecific stimulation in the presence of allogeneic feeder cells and interleukin-2 (IL-2). Activated CTL inoculated into either suspension or static cultures could be subsequently expanded tenfold, and showed similar growth kinetics and metabolism independent of the culture vessel used. Furthermore, CTL remained specific for CMVpp65 peptide through the expansion phases, as demonstrated by pp65-tetramer staining ( > 95% tetramer(+)) and cytotoxicity assays. This study indicates that suspension reactor systems may be useful in large-scale expansion of antigen-specific CTL lines or clones, and may facilitate the advancement of routine adoptive immunotherapy.

Harnessing the power of the immune system to eliminate infection and cancer is a long-standing goal in clinical immunology. The development of a robust immune response to foreign antigen relies, in part, on communication between cellular components of the immune system. The proteins involved in governing the magnitude and longevity of an immune response are collectively called cytokines. Cytokines act directly on immune cells to induce proliferation, differentiation and tolerance, and signaling errors can lead to autoimmune disease or immune deficiency. Identification of the molecules involved in these signaling processes has allowed investigators to manipulate immune cells for therapeutic effect, both in vivo and ex vivo. While in vivo immune modulation using cytokines has produced some exciting results, the toxicity involved with systemic administration has limited their broad use in the clinic. Therefore, research has been focused on the ex vivo manipulation of immune cells for adoptive transfer to treat cancer and infection. This review will focus on the ex vivo manipulation of immune cells with particular emphasis on stimulating cytotoxic T cell responses. Adoptive transfer of ex vivo generated cell types may then be used to treat malignant and viral disease.

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