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Interferon γ limits the effectiveness of melanoma peptide vaccines
Hyun-Il Cho, Young-Ran Lee and Esteban Celis
Blood 2011 117:135-144; doi: https://doi.org/10.1182/blood-2010-08-298117
Hyun-Il Cho
Immunology Program, Moffitt Cancer Center, Tampa, FL; and
Young-Ran Lee
Esteban Celis
Immunology Program, Moffitt Cancer Center, Tampa, FL; and Departments of Oncologic Sciences and Molecular Medicine, University of South Florida, Tampa, FL
The development of effective therapeutic vaccines to generate tumor-reactive cytotoxic T lymphocytes (CTLs) continues to be a top research priority. However, in spite of some promising results, there are no clear examples of vaccines that eradicate established tumors. Most vaccines are ineffective because they generate low numbers of CTLs and because numerous immunosuppressive factors abound in tumor-bearing hosts. We designed a peptide vaccine that produces large numbers of tumor-reactive CTLs in a mouse model of melanoma. Surprisingly, CTL tumor recognition and antitumor effects decreased in the presence of interferon γ (IFNγ), a cytokine that can provide therapeutic benefit. Tumors exposed to IFNγ evade CTLs by inducing large amounts of noncognate major histocompatibility complex class I molecules, which limit T-cell activation and effector function. Our results demonstrate that peptide vaccines can eradicate large, established tumors in circumstances under which the inhibitory activities of IFNγ are curtailed.
Because cytotoxic T lymphocytes (CTLs) have the ability to recognize and kill tumor cells, considerable efforts are being devoted to the development of T-cell immunotherapies for cancer.1⇓–3 CTLs express the CD8 coreceptor and recognize antigen on tumor cells as peptide/major histocompatibility class I (MHC-I) complexes. As a consequence of antigen recognition, CD8 CTLs exert antitumor function via the perforin-granzyme cytolytic pathway or through cytokines such as interferon gamma (IFNγ) and tumor necrosis factor alpha (TNFα), which exhibit cytostatic activity. The MHC-I–binding peptides recognized by tumor-reactive CD8 T lymphocytes are usually derived from genes preferentially expressed by transformed cells or from tissue-differentiation antigens. The identification of MHC-I–binding peptides that serve as tumor-rejection CD8 T-cell epitopes has opened the door to developing synthetic peptide cancer vaccines.4 The discovery of melanoma T-cell epitopes for humans and mice has led to studies assessing the utility of peptide vaccines for the treatment of established disease states. In many of these studies, promising, but ultimately not outstanding, therapeutic effects were attained, indicating that the use of synthetic peptides alone, with commonly used adjuvants such as incomplete Freund adjuvant, or in combination with cytokines constitute relatively weak and ineffective vaccines.5⇓⇓–8 Thus, several groups, including ours, have focused on optimizing peptide vaccines with the use of Toll-like receptor agonists and costimulatory antibodies as immunologic adjuvants.9⇓⇓⇓⇓–14
Our goal was to design a peptide immunization strategy that generates T-cell responses similar to those observed during an acute viral infection, in which 10% to 50% of all CD8 T cells are specific for the pathogen. We recently described a vaccine that we call TriVax (named for its 3 components: synthetic peptide, polyriboinosinic-polyribocytidylic acid [poly-IC], and anti-CD40 antibody), which achieved our stated goal.15,16 In addition to generating large CD8 T-cell responses to a melanosomal epitope (Trp2180), significant therapeutic effects (60% long-term survival) were observed against 3-day established B16 melanomas. The therapeutic effect of TriVax disappeared when CD8 T cells were depleted with antibodies or in perforin-deficient mice. Conversely, the elimination of CD4 T lymphocytes and natural killer cells had no significant effect.16 These results indicated that the major effector mechanism of TriVax is mediated by classic CD8 CTLs through perforin-mediated lysis of tumor cells. Nevertheless, the therapeutic effect of TriVax decreased if vaccination was administered in more advanced disease states, even though large numbers of functional CD8 T cells were detected in the tumor-bearing mice, suggesting that immune-suppressive activity at the tumor site was responsible for the tumor's evasion from the T cells. During these studies, we observed that the therapeutic effectiveness of TriVax was significantly higher in IFNγ-deficient mice compared with the immune-competent cohorts (100% vs 60% survival, respectively).16 These paradoxical results suggested that IFNγ, a lymphokine generally known for its therapeutic effects against infectious agents and tumors,17⇓–19 may trigger immune-inhibitory activities, limiting the effectiveness of T cell–based therapies against cancer. We present data supporting this notion and describe a novel mechanism by which IFNγ renders tumor cells resistant to T-cell recognition and eradication. These findings should help to increase the effectiveness of cancer vaccines by helping to design strategies to reduce the negative effects of IFNγ.
Six- to 8-week-old female C57BL/6 (B6) mice were obtained from the National Cancer Institute/Charles River Program. IFNγ-deficient (IFNγ−/−) and Pmel-1 T-cell receptor (TCR)-transgenic20 mice were obtained from The Jackson Laboratory. All animal care and experiments were conducted according to our institutional animal care and use committee guidelines, and were approved by the H. Lee Moffitt Cancer Center institutional review board.
The murine melanoma cell line B16 (derived from B16F10, but passaged several times in mice21) was provided by Dr Alan Houghton (Memorial Sloan-Kettering Cancer Center, New York, NY). The chemically induced melanomas JB/MS and JB/RH were isolated by Berkelhammer et al,22 and were provided by V. Hearing (National Cancer Institute, National Institutes of Health). The JB/RH cells do not express H-2Kb and are referred to here as JB/RHKb−. The B16Kb− cell line is a variant of B16F10 selected in our laboratory. A subline of B16F1 that does not express H-2Kb (B16F1Kb−) was provided by R. Vile (Mayo Clinic, Rochester MN). The murine thymoma EL4 and fresh aliquots of B16F0, B16F1, and B16F10 were obtained from ATCC. An immortalized, nontumorigenic melanosomal cell line from B6 mice23 was provided by R. Halaban (Yale University, New Haven, CT). All of the cell lines were cultured in medium supplemented with 10% fetal bovine serum, as recommended by the providers. Transfected B16 cells were prepared with SuperFect reagent (QIAGEN) using various cDNA plasmids: a dominant-negative IFNγR124 (IFNγRDN) construct (W. Lee, University of Pennsylvania, Philadelphia, PA); a short hairpin RNA (shRNA) construct for the immunoproteasome PA28α subunit25 (H. Udono, RIKEN Yokohama Institute, Yokohama, Japan); a construct encoding a single-chain trimer H-2Kb-β2M-Ova257 (scKbOva)26 molecule (J. Connolly, Washington University, St. Louis, MO); and a plasmid encoding the heavy chain of H-2Kb (L. Pease, Mayo Clinic, Rochester, MN). After transfection, stable clones were isolated with a combination of drug selection, flow cytometric sorting, and cell cloning at limiting dilutions. Expression of the transfected products was assessed by either flow cytometry or Western blot analysis.
Peptides, antibodies, and tetramers
Synthetic peptides representing the CD8 T-cell epitopes, Trp2180 (SVYDFFVWL; H-2Kb–restricted),27 a heteroclitic analog Trp1455 (TAPDNLGYM, H-2Db–restricted),28 Hugp10025 (KVPRNQDWL; H-2Db–restricted),20 and Ova55 (KVVRFDKL; H-2Kb–restricted) were purchased from A&A Laboratories. The purity (> 95%) and identity of peptides were determined by high-performance liquid chromatography and mass spectrometry analysis. Rat anti–mouse CD40 monoclonal antibody (FGK45.5) was prepared from hybridoma culture supernatants. Anti–mouse programmed death ligand-1 (PD-L1; 10F.9G2)29 was purchased from BioXCell. H-2Kb/Trp2180 and H-2Db/Trp1455 tetramers were provided by the National Institute of Allergy and Infectious Diseases (NIAID) Tetramer Facility (Emory University Vaccine Center, Atlanta, GA). Fluorescent antibodies for flow cytometry were purchased from eBioscience.
For TriVax immunizations, mice were injected intravenously with a mixture of 200 μg of peptide, 100 μg of anti-CD40 monoclonal antibody (mAb), and 50 μg of a stabilized form of poly-IC (Poly-ICLC/Hiltonol; Oncovir). Approximately 2 weeks after the primary immunization, the mice were given an identical booster. For generating Pmel-1 TCR-transgenic CTLs, B6 mice received 1 × 106 splenocytes from Pmel-1 mice, and the next day they were vaccinated with Hugp10025TriVax. CTLs for all in vitro immunologic assays were obtained from TriVax-immunized mice 6 to 7 days after the second immunization.
Evaluation of cellular immune responses
Immunologic assays were performed as described previously.16 Briefly, for tetramer staining, cells were stained with fluorescein isothiocyanate-anti-MHC class II, PerCP Cy5.5-anti-CD8α, and PE-conjugated tetramers. Fluorescence was measured using a FACSCalibur flow cytometer (BD Biosciences), and analyzed using FlowJo software (TreeStar). Tetramer analyses were done by gating out the MHC-II–positive population and gating on the CD8+ population. Percent tetramer-positive cells refers to the percentage of the CD8+ population. Enzyme-linked immunosorbent spot (ELISPOT) and enzyme-linked immunosorbent assay (ELISA) (IFNγ and TNFα) were performed using purified CD8 T cells (Miltenyi Biotec) following the directions provided by the manufacturer (Mabtech). Spot counting was done with an ELISPOT reader system (Autoimmun Diagnostika). For cytotoxicity determinations, conventional 5-hour chromium-release assays were performed using freshly isolated CD8 T cells (effectors) against various target cells that were labeled with 51Cr in triplicate in 96-well V-bottom plates using various effector-to-target (E:T) ratios.
Antitumor effects
To study the therapeutic effects of vaccination, mice first received subcutaneous or intravenous B16 tumor inoculations (3 × 105 or 1 × 105 cells, respectively), and 7 days later were given their first immunization. Antitumor effects were evaluated by examination and measurements of tumor masses or by counting the number of lung tumor nodules (∼ 4 weeks after tumor injections, when the mice in the unvaccinated control group started to appear ill). Tumor growth was monitored every 2 to 4 days in individual tagged mice by measuring 2 opposing diameters with a set of calipers. Results are presented as the mean tumor size (area in square millimeters) ± SD for every treatment group at various time points until the termination of the experiment.
Statistical significance to assess the numbers of antigen-specific CD8 T cells (ELISPOT), cytokine levels (ELISA), and absolute number of lung tumor nodules were determined by unpaired Student t tests. Tumor sizes between 2 populations throughout time and cytotoxicity assays at various E:T ratios were analyzed for significance using 2-way analysis of variance (ANOVA). All analyses and graphics were done using Prism 5.01 software (GraphPad).
IFNγ inhibits the therapeutic effects of peptide vaccination
To evaluate the inhibitory effects of IFNγ in the therapeutic effectiveness of TriVax against established B16 tumors, responses of wild-type (WT) mice were compared with those obtained in IFNγ−/− mice in a 7-day subcutaneous tumor model using TriVax-containing Trp2180 peptide (H-2Kb restricted).27 All of the Trp2180TriVax-immunized IFNγ−/− mice rejected the tumors, while the WT mice did not, but WT mice were able to decrease the rate of tumor growth (Figure 1A). The inhibitory effects of IFNγ with Trp2180TriVax were also evident in a 7-day lung melanoma model (Figure 1B; supplemental Figure 1A, available on the Blood Web site; see the Supplemental Materials link at the top of the online article). Similar results were obtained in the subcutaneous tumor model using TriVax containing a different T-cell epitope, Trp1455 (H-2Db–restricted28; supplemental Figure 1B).
IFNγ inhibits the therapeutic activity of peptide vaccination and decreases the capacity of CD8 T cells to recognize tumor cells. (A) Therapeutic effects induced by Trp2180TriVax against 7-day-established subcutaneous B16 tumors in WT and IFNγ−/− mice. Mice (4/group) were inoculated with tumor and vaccinated intravenously with TriVax (200 μg of Trp2180 peptide, 100 μg of anti-CD40 mAb, and 50 μg of poly-IC) on days 7 and 18 (arrows). Nonvaccinated mice (No Vax) were included as controls. Tumor sizes are presented as mean tumor areas in square millimeters. Points, mean for each group; bars, SD. (B) Mice (4/group) received B16 cells intravenously and were vaccinated with Trp2180TriVax or Ova55TriVax, as described. On day 28, the numbers of B16 pulmonary nodules were evaluated in individual mice. Horizontal lines, means of each group. (C) Freshly isolated purified CD8 T cells from Trp2180TriVax-immunized WT mice were evaluated for cytolytic activity against various targets: Trp2180 peptide-pulsed and unpulsed EL4 cells (triangles), nontreated B16, B16 incubated with 100 U/mL IFNγ for 6 or 24 hours (circles), and B16/IFNγ cells (24 hours) pulsed with Trp2180 peptide (diamonds). (D) Cytokine-release EliSpot assays using purified CD8 T cells from Trp2180TriVax-immunized WT mice were performed using several stimulator cells: Trp2180 peptide-pulsed and unpulsed EL4, IFNγ-treated (100 U/mL, 24 hours), and nontreated B16. P values were calculated with 2-way ANOVA (A,C) or unpaired Student t tests (B,D). Experiments were repeated 3 times with similar results.
IFNγ decreases the recognition of tumor cells by CTLs
These effects of IFNγ are confounding because this cytokine is associated with the production of antitumor effects.17,30 Moreover, it is known throughout the field that in vitro treatment of tumor cells with IFNγ increases their capacity to be recognized by CTLs. Notwithstanding this assumption, we observed the opposite effect, in which IFNγ-treated B16 decreased its susceptibility to lysis by freshly isolated CD8 T cells from Trp2180TriVax-immunized mice (Figure 1C). The inhibitory effects of IFNγ became evident as early as 6 hours after IFNγ treatment, but were more profound 24 hours after treatment. The IFNγ-treated B16 cells were effectively recognized by the CTLs if they were pulsed with Trp2180 peptide (Figure 1C), suggesting that IFNγ somehow decreases the antigenicity of the tumor cells. The decreased capacity of CD8 T cells from Trp2180TriVax-immunized mice to recognize the IFNγ-treated B16 was also evident in ELISPOT cytokine (IFNγ and TNFα) release assays (Figure 1D). The reduced antigenicity of the IFNγ-treated B16 was also observed using Trp1455TriVax-generated CD8 T cells (supplemental Figure 2A-B). The results obtained in the ELISPOT assays indicate that approximately 50% of tumor-reactive CD8 T cells were unable to recognize IFNγ-treated B16. Furthermore, visual examination of the ELISPOT plates clearly showed that the intensity of the spots, which is correlated with the amount of cytokine produced by each cell, was substantially lower in wells containing IFNγ-treated B16 compared with wells containing untreated B16 (supplemental Figure 2C). Notably, the decreased CD8 T-cell response observed with IFNγ-treated B16 was not evident when the tumor cells were treated with other cytokines such as IFNα, TNFα, or interleukin-10 (IL-10; supplemental Figure 3). It is possible that the unexpected observations on the negative effects of IFNγ could be limited to the particular B16 cell line that we were using (B16F10).21 However, 3 separate B16 cell lines (B16F0, B16F1, and B16F10, which were obtained directly from ATCC), a chemically induced melanoma cell line (JB/MS),22 and an immortalized, nontumorigenic melanocyte cell line23 all behaved in the same manner (supplemental Figure 4).
The inhibitory effect of IFNγ primarily targets the tumor
The above observations suggest that the inhibitory effects of IFNγ in the eradication of established tumors by TriVax could be due to effects that solely affect the tumor cells, such as the decrease of the antigenicity of B16 for MHC-I restricted CD8 T cells. However, it is also possible that IFNγ could exert additional inhibitory activities in other cells within the host, decreasing the effectiveness of TriVax. Thus, to evaluate whether the suppression by IFNγ was mostly mediated via its effects on the tumor, the B16 tumor was transduced with a plasmid a encoding a dominant-negative IFNγ receptor (IFNγRDN).24 Two B16 clones were isolated, one expressing high levels of IFNγRDN (B16-IFNγRDN/Hi) and another one expressing low IFNγRDN levels (B16-IFNγRDN/Lo). Treatment of the B16-IFNγRDN/Hi with IFNγ enhanced expression of MHC-I, MHC-II, or PD-L1 significantly less than B16 and B16-IFNγRDN/Lo (Figure 2A), and did not reduce the reactivity of these cells with the antigen-specific CD8 T cells compared with the nontransduced B16 cells or the B16-IFNγRDN/Lo cells (Figure 2B). More importantly, the therapeutic effectiveness of Trp2180TriVax was significantly higher against B16-IFNγRDN/Hi compared with B16-IFNγRDN/Lo or the parental B16 (Figure 2C). These results suggest that the inhibitory effects of IFNγ in limiting the effectiveness of TriVax are mediated mostly though its direct activity on the tumor.
Expression of IFNγRDN in tumor cells overcomes the inhibitory effects of IFNγ. (A) Expression levels of IFNγR1, MHC-I (H-2Kb and H-2Db), MHC-II (I-Ab), and PD-L1 on B16 and 2 stable B16 clones expressing high or low levels of a IFNγRDN receptor. B16, B16-IFNγRDN/Hi, and B16-IFNγRDN/Lo cells were incubated (IFNγ) or not (No Tx) with 100 U/mL of IFNγ for 40 hours, and stained with specific antibodies as indicated, followed by flow-cytometry analysis. (B) Freshly isolated and purified CD8 T cells from Trp1455TriVax or Trp2180TriVax-immunized WT mice (as indicated) were tested for cytolytic activity against several target cells treated (IFNγ) and nontreated (No Tx) with IFNγ (100 U/mL, 24 hours): Parental B16 and 2 stable B16 clones expressing high (B16-IFNγRDN/Hi) or low (B16-IFNγRDN/Lo) levels of IFNγRDN. (C) Therapeutic effects induced by Trp2180TriVax in WT mice against 7-day-established subcutaneous B16 tumors expressing or not IFNγRDN. P value (2-way ANOVA) compares Trp2180TriVax-immunized mice bearing B16-IFNγRDN/Hi with Trp2180TriVax-immunized mice bearing B16. *50% of the Trp2180TriVax-immunized mice bearing B16-IFNγRDN/Hi rejected their tumors. These experiments were repeated twice with similar results.
Mechanisms involved in the inhibitory effects of IFNγ
A gene-chip analysis has revealed that IFNγ increases the expression (> 5-fold) of more than 1000 genes in B16 (data not shown), and many of these genes could be involved in decreasing tumor-cell recognition by CD8 T lymphocytes. One of the most likely explanations could be that the increased expression of the immunoproteasome by IFNγ could reduce the production of the Trp2180 and Trp1455 epitopes. There are reports that immunoproteasomes reduce the generation of some melanoma CTL epitopes.31 However, there is evidence that processing of the Trp2180 epitope is not compromised by the immunoproteasome.25,32 Nevertheless, interference RNA technology with the shRNA plasmid was used to inhibit the expression of the PA28α subunit,25 which is required for the immunoproteasome assembly and function. Although a significant reduction (> 90%) in the expression of PA28α in shPA28α-transduced B16 was achieved, these cells were not recognized by CTLs when treated with IFNγ (supplemental Figure 5). It has been reported that IFNγ can alter the extent of CD8 T-cell responses by inducing the expression of indoleamine 2,3-dioxygenase (IDO), which depletes tryptophan from the microenvironment.33 In addition, IFNγ can trigger autophagy, altering the cell's antigenic composition.34,35 Nevertheless, the addition of 1-methyl tryptophan (1MT, an IDO inhibitor),33 an excess of L-tryptophan, or inhibitors of autophagy (rapamycin and wortmannin) also fail to reverse the inhibitory effects of IFNγ on tumor-cell recognition by CD8 T cells (supplemental Figure 6A-B). Another possible way that IFNγ could reduce the capacity of CD8 T cells to interact with B16 cells could be through the increased expression of the inhibitory ligand PD-L1 (Figure 2A). However, adding blocking antibodies to PD-L1 or to PD1 to the in vitro immunologic assays did not reverse the effects of IFNγ (supplemental Figure 6C). Notwithstanding these findings, we observed that the implementation of in vivo PD1 blockade significantly increased the therapeutic effectiveness of Trp2180TriVax and Trp1455TriVax (Figure 3A-B). However, no tumor eradications like those observed in the IFNγ−/− mice were obtained, indicating that IFNγ inhibits the effectiveness of TriVax through more than one mechanism. Administration of the IDO inhibitor 1MT to tumor-bearing mice did not significantly increase the effectiveness of TriVax (supplemental Figure 7), suggesting that this inhibitory pathway may not be relevant in this model.
PD1 blockade increases the therapeutic efficacy of TriVax. WT mice (4/group) were inoculated subcutaneously with B16, and vaccinated with Trp2180TriVax (A) or Trp1455TriVax (B). Anti-PD-L1 mAb (10F.9G2) was administered intraperitoneally on days 2, 4, 6, and 8 after each TriVax administration at 200 μg/dose. Nonvaccinated mice (No Vax) and Ova55TriVax were included as controls. Arrows, days when TriVax administered; gray bars, time when anti–PD-L1 mAb was administered. Tumor sizes were determined in individual mice by measuring 2 opposing diameters and are presented as tumor areas in square millimeters. Points indicate means for each group of mice; and bars, SD. P values were calculated using 2-way ANOVA test comparing with the TriVax alone with TriVax plus anti–PD-L1 mAb. These experiments were repeated twice with similar results.
Noncognate MHC-I levels reduce the ability of CTL to recognize tumor cells
The above results suggested that, in addition to inhibiting CD8 T-cell function in vivo via the PD1 pathway, IFNγ decreases the overall antigenicity of melanoma cells in an immunoproteasome-independent manner, and that both mechanisms interfere with the therapeutic effectiveness of TriVax. We hypothesized that the CD8 T-cell-epitope density (ratio of cognate peptide/MHC-I complexes to total peptide/MHC-I complexes), and not necessarily the total amount of cognate peptide/MHC-I complexes per cell, could be critical for determining whether CD8 T lymphocytes recognize antigen-presenting cells (APCs). Thus, a large increase of noncognate peptide/MHC-I complexes induced by IFNγ would decrease the T-cell-epitope density if the cognate peptide/MHC-I complexes were not increased proportionally. To test this hypothesis, B16 cells expressing high levels of noncognate peptide/MHC-I complexes were produced by transfection using a plasmid encoding for a single-chain trimer H-2Kb-β2M-Ova257 (scKbOva) construct that allows the expression of surface peptide/MHC-I complexes in a transporter associated with antigen processing (TAP)- and proteasome-independent manner.26 Furthermore, the use of B16-scKbOva cells allowed an assessment of whether an increase of noncognate peptide/MHC-I in the absence of IFNγ treatment would decrease the tumor cell's antigenicity with CD8 T cells. The total levels of H-2Kb increased approximately 10-fold in the B16-scKbOva cells compared with the parental B16 cells, while IFNγ treatment increased by approximately 50-fold the expression of H-2Kb in the B16 cells; however, the levels of H-2Db in the B16-scKbOva cells were not significantly different (Figure 4A). In agreement with our hypothesis, the presence of noncognate Ova257/H-2Kb complexes in B16 cells in the absence of IFNγ treatment reduced the reactivity of the tumor cells with Trp1455- and Trp2180-reactive CD8 T cells (Figure 4B). The extent of the reduction of the T-cell response was similar to the one observed using IFNγ-treated B16. Another way to test the epitope-density hypothesis would be to lessen the large increase of noncognate peptide/MHC-I complexes induced by IFNγ. B16 tumors deficient in H-2Kb (H-2Kb-loss variants) would express lower levels of total surface MHC-I after IFNγ treatment compared with the parental B16 cells, and should be efficiently recognized by H-2Db-restricted CD8 T cells. Treatment of 3 different H-2Kb-loss variants, B16F1Kb−, B16Kb− (isolated by us), and JB/RHKb− (a chemically induced melanoma22), with IFNγ increased the expression of H-2Db and PD-L1, but not H-2Kb (Figure 5A). The effect of IFNγ on the immunogenicity of the H-2Kb− cells was assessed using freshly isolated Trp1455TriVax-derived CD8 T cells. As shown in Figure 5B, IFNγ treatment minimally decreased the antigenicity of B16Kb− and JB/RHKb−. Conversely, a substantial increase of antigenicity was observed in B16F1Kb−, while a substantial decrease was seen with the H-2Kb–expressing B16 cells. Similar findings were observed using Pmel-1 TCR-transgenic CD8 T cells specific for the H-2Db–restricted gp10025 epitope,20 except that IFNγ increased the antigenicity of all 3 H-2Kb-loss variants (supplemental Figure 8).
Expression levels of noncognate peptide/MHC-I complexes dictate the antigenicity of B16 cells. (A) Expression levels of MHC-I (H-2Kb and H-2Db, top panels) and H-2Kb/Ova257 complexes (bottom panel) on a stable B16 clone expressing single-chain H-2Kb/Ova257 (B16-scKbOva) compared with B16 and IFNγ-treated B16 (100 U/mL, 24 hours) cells measured by flow cytometry. Levels of H-2Kb/Ova257 complexes were measured using antibody 25-D1.16.53 (B) Antigenicity of B16-scKbOva was evaluated with freshly isolated CD8 T cells from Trp1455TriVax- and Trp2180TriVax-immunized WT mice using cytokine release ELISA. IFNγ-treated (100 U/mL, 24 hours) and nontreated parental B16 cells were included for comparison. Cultures consisted of 3 × 105 CD8 T cells coincubated with 1 × 105 stimulator cells for 40 hours before removing culture supernatants for cytokine measurements. Results represent the average values of IFNγ (columns) and SD (error bars) from triplicate wells. These experiments were repeated twice with similar results.
IFNγ-treated H-2Kb-loss tumor variants are recognized by H-2Db–restricted CD8 T cells. (A) Expression levels of MHC-I and PD-L1 on H-2Kb–loss variants (B16Kb−, B16F1Kb−, and JB/RHKb−). The cells were incubated (IFNγ) or not (No Tx) with 100 U/mL of IFNγ for 24 hours, and stained with antibodies as indicated, followed by flow cytometric analysis. (B) CD8 T cells, which were freshly isolated from mice vaccinated with Trp1455TriVax (H-2Db–restricted), were evaluated for their capacity to recognize B16, 2 B16 H-2Kb-loss variants (B16Kb− and B16F1Kb−), and an H-2Kb− chemically induced melanoma (JB/RHKb−) using a cytokine-release ELISA assay. The cells were either incubated with IFNγ (100 U/mL, 24 hours) or not (No Tx). Cultures consisted of 3 × 105 CD8 T cells coincubated with stimulator cells (3:1 ratio) for 40 hours before removing culture supernatants for cytokine measurements. Results represent the average values of IFNγ (columns) and SD (error bars) from triplicate wells. Numbers above columns represent the percentage response of the IFNγ-treated cells compared with that of the nontreated group.
Increasing CD8 coreceptor levels overcomes the inhibition of IFNγ
The above results indicate that the reduction in immunogenicity observed in the IFNγ-treated melanoma cells was due to a large increase in noncognate peptide/MHC-I complexes. It is possible that such increase could hinder the ability of TCR to encounter the respective cognate peptide/MHC-I complexes. Alternatively, the possibility exists that the large amount of noncognate peptide/MHC-I sequesters CD8 coreceptor/Lck complexes away from the cognate peptide/MHC molecules in the immune synapse, decreasing Lck function and interfering with proper T-cell activation. To investigate the second possibility, we took advantage of the observation that placing CD8 T cells from TriVax-immunized mice in tissue culture for 1 week resulted in enhanced expression levels (∼ 4-fold) of surface CD8 molecules compared with the freshly isolated T cells (Figure 6A). By increasing the levels of CD8 on the T cells, it should be possible to offset the inhibition caused by an excess of noncognate peptide/MHC-I. Indeed, tissue-cultured Trp1455-reactive CD8 T cells were significantly more effective in recognizing the IFNγ-treated B16 and the B16-scKbOva cells compared with freshly isolated Trp1455-reactive T cells (Figure 6B). Similar results were obtained using Pmel-1 T cells (supplemental Figure 9) and TriVax-generated Trp2180 reactive CD8 T cells (data not presented). Although these results suggest that the enhancement of CD8 coreceptor expression in the cultured T lymphocytes could be responsible for overcoming the negative effects of IFNγ on tumor cell recognition, it is possible that other changes on the T cells when they were placed in tissue culture may have helped to increase their function.
Up-regulation of CD8 coreceptors after in vitro culture restores the capacity of T cells to recognize B16 cells expressing high levels of noncognate MHC-I. Tissue-culture CD8 T cells were produced by placing the purified CD8 T cells from Trp1455TriVax-immunized mice in medium containing 50 U/mL IL-2 and 20 ng/mL IL-7 for 7 days. (A) Comparison of the levels of CD8α expression between freshly isolated and cultured CD8 T cells from Trp1455TriVax-immunized mice compared with naive CD8 T cells from nonvaccinated mice. MFI, mean fluorescence intensity of CD8α. Right panel shows histograms gating on the Trp1455 tetramer-positive populations. (B) Antigen-induced IFNγ production of cultured and freshly isolated CD8 T cells from Trp1455TriVax-immunized mice evaluated by ELISA. CD8 T cells were evaluated for their capacity to recognize B16 treated or not with IFNγ (100 U/mL, 24 hours) and B16-scKbOva. CD8 T cells (3 × 105) were incubated with tumor cells (1 × 105) for 40 hours, and supernatants were removed for cytokine measurements. Supernatants from T cells without tumor cells (T cell alone) were included as controls. Results represent the average amounts of IFNγ and SD (error bars) from triplicate cultures. These experiments were repeated twice with similar results.
Overcoming the negative effects of IFNγ results in tumor eradication by TriVax
In view of the above results, TriVax should be highly effective in controlling tumors that do not substantially increase the levels of noncognate MHC-I as the result of IFNγ. Thus, a B16 tumor line expressing low levels of H-2Kb after IFNγ treatment was produced by transfecting B16Kb− cells with a plasmid encoding the heavy chain of H-2Kb. The resulting B16-KbLo cell line up-regulated to the same extent the levels of H-2Db (and PD-L1) compared with the parental B16 in response to IFNγ (Figure 7A). In contrast, the levels of H-2Kb in the IFNγ-treated B16-KbLo cells were approximately 10-fold lower compared with the IFNγ-treated parental B16 cells. As predicted, IFNγ treatment of B16-KbLo did not substantially reduce their reactivity with Trp1455 or Trp2180 CD8 T cells (Figure 7B). Next, we assessed the therapeutic effectiveness of Trp1455TriVax against 7-day-established, subcutaneous B16-KbLo tumors. Because the B16-KbLo expresses high PD-L1 levels when exposed to IFNγ (Figure 7A), one group of mice received PD1 blockade therapy in addition to TriVax. The results presented in Figure 7C-E show that TriVax immunization was effective in completely eradicating large, established tumors in the majority of the mice when administered in combination with anti–PD-L1 antibodies, with tumors that do not overly express noncognate MHC-I as a consequence of exposure to IFNγ. Furthermore, even in the absence of PD1 blockade, the therapeutic effects of TriVax were quite dramatic. Similar remarkable results were obtained in a more advanced disease stage (12-day-established B16-KbLo subcutaneous tumors; supplemental Figure 10).
Decreasing noncognate MHC-I levels together with PD1 blockade allows TriVax to eliminate advanced tumors in WT mice. (A) Expression levels of H-2Kb, H-2Db, and PD-L1 in B16-KbLo cells treated or not with IFNγ (100 U/mL, 24 hours). Results with IFNγ-treated parental B16 cells are included for comparison. (B) Responses (ELISPOT) of freshly isolated CD8 T cells from Trp1455TriVax- and Trp2180TriVax-immunized WT mice against IFNγ treated and nontreated B16-KbLo cells. Results represent the average number of spots from triplicate wells with SD (error bars) of the means. (C) Therapeutic effects induced by Trp1455TriVax against 7-day-established B16-KbLo tumors in WT mice. Mice (8/group) were inoculated with B16-KbLo cells and immunized with Trp1455TriVax or Ova55TriVax as indicated. Anti-PD-L1 mAb was administered intraperitoneally on days 2, 4, 6, and 8 after TriVax administration. Nonvaccinated mice (No Vax) were also included as controls. Arrows, days when the vaccines were administered; gray bars, period of anti–PD-L1 mAb treatment. (D-E). Tumor-growth curves are shown for individual mice from the Trp1455TriVax and Trp1455TriVax plus anti–PD-L1 groups. Tumor sizes were determined in individual mice by measurements of 2 opposing diameters and are presented as tumor areas in square millimeters. Points, mean for each group of mice; bars, SD. P < .0001, between the Trp1455TriVax and the Trp1455TriVax + anti–PD-L1 mAb group (obtained using a 2-way ANOVA analysis). *Seven of 8 mice in Trp1455TriVax + anti–PD-L1 mAb rejected their tumors; **1 mouse from Trp1455TriVax rejected its tumor. These experiments were repeated twice with similar results.
We have demonstrated that IFNγ interferes with the effectiveness of antigen-specific CD8 T cells to eliminate tumors with a therapeutic peptide vaccine in a mouse melanoma model. At the present time, we do not know if these observations will extend to other types of vaccines, other tumor types, or human tumors. However, it is likely that in any circumstance in which tumors are induced to express high levels of noncognate MHC-I and PD-L1, effective recognition by CD8 T cells may be compromised. The present findings are perplexing because IFNγ has long been considered to provide antitumor benefits through its antiproliferative activity and its ability to enhance antigen processing for both MHC-I and MHC-II pathways.30 However, our results indicate that by blocking the function of IFNγ directly on the tumor cells, vaccine-generated CD8 T lymphocytes were able to eradicate large, established tumors. IFNγ generates tumor resistance to MHC-I–restricted CD8 T lymphocytes through 2 main mechanisms: (1) induction of high levels of PD-L1 (B7-H1), which inhibits the survival and function of T lymphocytes,36⇓⇓–39 and (2) as described here, by reducing the capacity of the tumor cells to be recognized by CD8 T cells. It is known that exposure to IFNγ enhances the expression of PD-L1 in numerous cell types, including tumors.39 Because signaling of PD1 reduces the ability of T lymphocytes to become fully activated, proliferate, and exert effector function, PD1 blockade using anti-PD1 or anti PD-L1 antibodies has been used to improve the therapeutic effectiveness of T cells against chronic viral infections37 and tumors.40 Indeed, in combination with TriVax, PD1 blockade significantly increased the antitumor effects against B16 melanoma, but no complete cures were achieved. It was not so well known—and was actually counterintuitive—that IFNγ would reduce the capacity of tumor cells to stimulate CD8 T lymphocytes, since this cytokine is known to enhance the expression and function of various antigen-processing components.30 We considered the possibility that immunoproteasomes induced by IFNγ reduced the generation of the T-cell epitopes studied here in a manner similar to that described in other systems.31 However, reports in the literature for Trp218025,32 and our results with Trp1455 using shRNA to inhibit the immunoproteasome do not support this possibility. Conversely, a substantial increase of specific peptide/MHC-I complexes induced by IFNγ could result in the induction of high-antigen-dose tolerance (or anergy), inhibiting T-cell effector function.41,42 However, the results indicate that this was not the case in our model system, because the addition of exogenous peptide to the IFNγ-treated B16 tumor cells resulted in enhanced T-cell recognition of the tumor cells (Figure 1C).
In addition to the effects that IFNγ exerts directly on the tumor cells, which decrease the efficacy of TriVax, it is possible that this cytokine could also affect quantitatively and qualitatively the CD8 T-cell response to vaccination. Indeed, we observed that the cytolytic activity of TriVax-generated CTLs from IFNγ-deficient mice was slightly higher (∼ 20%) compared with CTLs from WT mice.16 In contrast, we found no significant differences in the percentages of tetramer-positive CD8 T cells (or the total numbers of tumor-reactive T cells) between IFNγ and WT mice in the same studies. It has been reported in some cancer models that the administration of IL-12 induces effective antitumor responses through the expression of the IFNγ-inducible chemokines interferon γ–induced protein 10 kDa (IP-10) and monokine induced by IFN-γ (MIG).43,44 Our studies in IFNγ-deficient mice suggest that efficient infiltration of TriVax-generated CD8 T cells occurs in the absence of IFNγ. It will be important to study the type of signals that attract the TriVax-generated CD8 T cells into the tumor site and other effects that this cytokine may exert on the tumor-bearing host that could positively or negatively affect the outcome of therapeutic vaccination.
The results presented herein point to the likelihood that high levels of noncognate MHC-I induced by IFNγ on tumor cells could be detrimental to their recognition by CTLs. This possibility is supported by the findings that the expression of high levels of noncognate MHC-I in the tumor cells without IFNγ treatment using the scKbOva construct reproduced the results using IFNγ-treated B16. Moreover, the results using H-2Kb− cells that generate lower levels of total noncognate MHC-I compared with the parental cells after IFNγ treatment provide additional support to this novel concept. Although we do not know exactly how an excess of noncognate MHC-I on APCs could decrease the ability of CD8 T lymphocytes to become activated when recognizing antigen, we considered the possibility that the noncognate MHC-I could be competing with cognate MHC-I for access to CD8 molecules on the T cells. Our results showing that augmenting the expression of CD8 molecules using tissue-cultured T cells reduced the inhibitory effects of IFNγ agree with this presumption. The CD8 coreceptor plays an important role in T-cell activation by delivering the Src-family tyrosine kinase Lck into the proximity of the CD3 subunits in the TCR complex.45⇓–47 Lck sequestration from the TCR/CD3 complex plays a role in T cell–positive selection in the thymus,48 and it has been proposed to regulate ongoing immune responses and to help maintain peripheral tolerance and MHC restriction.49⇓–51 The present findings indicate that coreceptor tuning for MHC-I–restricted T lymphocytes is not only regulated by levels of CD8 on the T cells, but also by the overall levels of MHC-I on the APCs. While low levels of noncognate MHC-I may enhance APC/T-cell interactions by facilitating cell-to-cell adhesion,52 high levels of noncognate MHC-I decrease T-cell activation.
We believe that the reduction of tumor-cell reactivity with MHC-I–restricted T lymphocytes induced by IFNγ has not been previously demonstrated because most researchers perform in vitro cultures (to expand and activate the effector T cells) before performing immunologic tests such as cytotoxicity assays and, as shown here, the increase of CD8 coreceptor levels obscures this phenomenon. In addition, in many cases, immune responses using cytokine-release assays (ELISPOT and intracellular cytokine staining) are only measured using peptide-pulsed APCs and not tumor cells. Because TriVax generates such extensive T-cell responses, we were able to perform cytotoxicity assays using freshly isolated CD8 T cells, which express lower levels of CD8 coreceptor molecules compared with cultured T cells. Thus, the use of tumor cells in ELISPOT/ELISA assays and the use of freshly isolated CD8 T cells in cytotoxicity assays allowed us to recognize this novel mechanism of immune evasion evoked by tumors as a consequence of exposure to IFNγ. It is tempting to speculate that one of the functions of IFNγ during infections is to protect noninfected cells from cross-reactive T cells by increasing noncognate MHC-I (and PD-L1) levels, and that tumor cells simply maintain this benefit to avoid immune destruction. Nevertheless, our results suggest that blocking the action of IFNγ in cancer patients undergoing T cell–based immunotherapy could improve their therapeutic outcome.
Contribution: E.C. and H.C. designed and conceptualized the research, analyzed the data, and wrote the manuscript; and H.C. and Y.L. performed all of the experiments.
Conflict-of-interest disclosure: The authors declare no competing financial interests.
Correspondence: Esteban Celis, Moffitt Cancer Center, 12902 Magnolia Dr, SRB2, Tampa, FL 33612; e-mail: ecelis{at}moffitt.org.
We thank A. Salazar for providing Poly-ICLC (Hiltonol) and the NIH Tetramer Core Facility for providing peptide/MHC tetramers.
This work was supported by NIH grants R01CA103921 and R01CA136828 and by funds provided by the Donald A. Adam Comprehensive Melanoma Research Center of the Moffitt Cancer Center and the Bankhead Coley Pre-Specialized Programs of Research Excellence at the Moffitt Cancer Center.
R01CA103921R01CA136828National Institutes of Health
The online version of this article contains a data supplement.
The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked "advertisement" in accordance with 18 USC section 1734.
Submitted July 30, 2010.
Accepted September 30, 2010.
© 2011 by The American Society of Hematology
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DOI: https://doi.org/10.1182/blood-2010-08-298117
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1. Beat eggs in small bowl with fork or wire whisk until yolks and whites are well mixed.
2. Heat butter in 8-inch skillet over medium-high heat until butter is hot and sizzling. As butter melts, tilt skillet to coat bottom with butter.
3. Quickly pour eggs into skillet. While rapidly sliding skillet back and forth over heat, quickly stir eggs with a fork to spread them continuously over the bottom of the skillet as they thicken. When they are thickened, let stand over heat a few seconds to lightly brown bottom of omelet. Do not overcook... the omelet will continue to cook after being folded. Sprinkle with cheese.
4. Tilt skillet and run a spatula under edge of omelet, then jerk skillet sharply to loosen omelet from bottom of skillet. Fold portion of omelet nearest you just to center. Allow for a portion of the omelet to slide up side of skillet. Turn omelet onto warm plate, flipping folded portion of omelet over so far side is on bottom. Tuck sides of omelet under if desired. Sprinkle with salt and pepper and additional cheese if desired.
Nothing fancy. Just your fantastic basic cheese omelette. Try it with your favorite cheese or combination of cheeses.
What do you think of Cheese Omelette?
View all 190 comments for this recipe.
Simple... yet delicious and nutritious. I added Parmesan cheese to make it even more interesting. My son went crazy when he had it. I am sure he will be asking for another really soon.
Hey... I love this recipe. This is a very quick and easy cheese recipe for breakfast. I will definitely try this with my favorite goat cheese soon too.
Was so good. And so easy. My twelve year old can make it by herself! She says it's really yummy and the more cheese the better! Thank you!
Simple but deliciously so. I mix Cheddar cheese and Pepper Jack so I get a little spice. Sometimes also mix a teaspoon of diced mild jalepeno from a can in with the eggs. Good recipe.
I loved it. Make it twice a week at least.
I usually fry it with oil and use the normal cheese slices... but I love this even more then usual as the fragrance of butter and cheese melting is yummy. Thanks for recipe!
I loved it. My wife loved. I don't EVER cook, so this was a big step for me. Thanks!
If you like a basic omelette, it's very good.
I put two crispy bacon strips long-ways in each omelet. Yum!
Wow! I make it for my parents... They always ask for more.
This was really great and super easy, plus I added onions.
If you beat the eggs with a Tablespoon of milk and 2 teaspoons flour, you get a fluffier omelette.
I added chopped ham - just chopped up slices from a lunch meat pack. I'm a super amateur cook - so this was very impressive coming from me. Good tasting recipe!
I put American cheese and two spoons of leftover chili in the middle. I never cook, but my wife said it was great. I agree - I did good!
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Though vague, Lauren Jenkin's first memory of Bonnie Brae was when she was about 6 or 7: she remembers walking on the grass through campus, seeing the ropes course, the gym and the climbing wall. She recalls sharing a meal with her parents in the cafeteria, attending a few Scottish Games events as well as a holiday performance. Her impression then was that Bonnie Brae was a homey and inviting place, not very different from the school she was attending.
Those early memories were the stepping stones to her building a lifetime of memories about Bonnie Brae and the mission of helping young men in-crisis. As a teenager she knew that the young men living at Bonnie Brae had a lot of problems at home, but she didn't quite understand the depth and breadth of the mission until years later when she became a member of Bonnie Brae's Board of Trustees.
Join us in the Osborne Corner every month, for updates and perspective from Lauren Jenkins.


text:
RAV HOME » Services » Redress Support Services
Relationships Australia Victoria has been funded to provide support to people contemplating or going through the National Redress Scheme. Redress Support Services are available for people who have experienced sexual abuse as children (under the age of 18 years) in institutional contexts before the commencement of the Redress Scheme on 1 July 2018.
Support services aim to be accessible, inclusive and considerate of the varied needs of people who have experienced institutional child sexual abuse.
The primary objective of support services is to provide flexible, timely and transparent practical assistance and emotional support to people engaging with the Scheme.
Practical support includes providing information about the Scheme, assisting clients to complete the Scheme's application form, and supporting people to access other appropriate services such as legal and financial counselling or other community services.
Emotional support includes providing brief counselling, case management, professional supervision and similar arrangements to provide people with a safe environment to engage with the Scheme.
Support services can play a key role in managing client expectations about the Scheme by providing clear information about what the Scheme is, how it can be accessed and what a person can reasonably expect through the process of applying and potentially accepting an offer of redress.
Services can also support people who clearly do not fit the parameters of the Scheme with referrals to more appropriate supports. Services may assist affected family members where they think it is in the best interest in meeting the critical needs of the client.
Services are delivered across Victoria through face-to-face settings, outreach services and national telephone and/or online support to ensure accessibility for people across Australia who are engaging with the Scheme.
For information, support or to make an appointment, please contact us via email or by calling our dedicated National Redress Scheme number - 1800 052 674. We will talk with you about your situation and what support you need, then refer you to the right specialist practitioner in a location that best suits you, who will provide you with ongoing support.
To view the Redress Support Services brochure click here.
The National Redress Scheme is the Australian Government's response to the Royal Commission into Institutional Responses to Child Sexual Abuse. The Scheme offers acknowledgement and support to people who:
experienced institutional child sexual abuse before 1 July 2018, and
were born before 30 June 2010, and
are Australian citizens or permanent residents.
Redress is an alternative to seeking compensation through the courts. The Scheme offers three components of Redress:
access to counselling
a Redress payment
acknowledgement and recognition, for those who want it, through a direct personal response (a direct apology) from the institution responsible for the abuse.
The National Redress Scheme commenced on 1 July 2018. Applications for the Scheme will be accepted until 30 June 2027.
If you would like more information about the Scheme, please visit www.nationalredress.gov.au
or contact the National Redress Scheme by calling 1800 737 377.
The National Redress Scheme is open for enquiries from 8am-5pm local time, Monday to Friday (excluding public holidays). If you're calling from overseas, please call +61 3 6222 3455 and ask to speak to someone from the National Redress Scheme.
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Relationships Australia Victoria was previously funded to provide Reclaim Support Services, including:
Specialist counselling and support for individuals, couples and family members.
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Support at Royal Commission private sessions, when and where requested.
Relationships Australia Victoria will continue to support survivors and their families through our existing range of services. For more information, please call 1300 364 277.
Royal Commission Final Report
The Final Report and other publications from the Royal Commission are available to download from here. Content warning: Please be aware that many of these documents contain information and personal accounts of child sexual abuse which may be upsetting or triggering.
Statements and media releases
Submission: Relationships Australia Submission to the Senate Inquiry into the Commonwealth Redress Scheme for Institutional Responses to Child Sexual Abuse Bill 2017 & related bill: 2 February 2018
Statement: Response to the Conclusion of the Royal Commission into Institutional Responses to Child Sexual Abuse. 21 December 2017
Submission: RAV Response to the Royal Commission into Institutional Responses to Child Sexual Abuse Issues Paper 10 - Advocacy & Support &Therapeutic Treatment Services: 30 November 2015
Media Release: Reclaim Support Services: supporting survivors of child sexual abuse 25 May 2015

redpajama_set_name: RedPajamaCommonCrawl


text:
using System;
using System.Collections.Generic;
using System.Linq;
using BlueSheep.Common.IO;

namespace BlueSheep.Common.Protocol.Types
{

public class CharacterMinimalAllianceInformations : CharacterMinimalGuildInformations
{

public new const short ID = 444;
public override short TypeId
{
    get { return ID; }
}

public Types.BasicAllianceInformations alliance;

public CharacterMinimalAllianceInformations()
{
}

public CharacterMinimalAllianceInformations(int id, byte level, string name, Types.EntityLook entityLook, Types.BasicGuildInformations guild, Types.BasicAllianceInformations alliance)
         : base(id, level, name, entityLook, guild)
        {
            this.alliance = alliance;
        }

public override void Serialize(BigEndianWriter writer)
{

base.Serialize(writer);
            alliance.Serialize(writer);

}

public override void Deserialize(BigEndianReader reader)
{

base.Deserialize(reader);
            alliance = new Types.BasicAllianceInformations();
            alliance.Deserialize(reader);

}

}

}

redpajama_set_name: RedPajamaGithub


text:
wendymmcdonald_pswbdi / March 22, 2017
Beautiful Books: All American Boys
All American Boys
by Jason Reynolds and Brendan Kiely
From the back cover: A bag of chips. That's all sixteen-year-old Rashad is looking for at the corner bodega. What he finds instead is a fist-happy cop, Paul Galluzzo, who mistakes Rashad for a shoplifter, mistakes Rashad's pleadings that he's stolen nothing for belligerence, mistakes Rashad's resistance to leave the bodega as resisting arrest, mistakes Rashad's every flinch at every punch the cop throws as further resistance and refusal to STAY STILL as ordered. But how can you stay still when someone is pounding your face into the concrete pavement?
There were witnesses: Quinn Collins—a varsity basketball player and Rashad's classmate who has been raised by Paul since his own father died in Afghanistan—and a video camera. Soon the beating is all over the news and Paul is getting threatened with accusations of prejudice and racial brutality. Quinn refuses to believe that the man who has basically been his savior could possibly be guilty. But then Rashad is absent. And absent again. And again. And the basketball team—half of whom are Rashad's best friends—start to take sides. As does the school. And the town. Simmering tensions threaten to explode as Rashad and Quinn are forced to face decisions and consequences they had never considered before.
I was nervous picking this book up—would I want to run away from what I found? I didn't.
Would it be preachy? It's not.
The book is like a basketball game, the ball moving from boy to boy and world to world, but always staying on the same court. Both Rashad and Quinn are surrounded by teammates and coaches in the form of friends, family, neighbors, pastors, and teachers.
The alternating narrators in All American Boys work like a dialogue. The first and last narrative chapters are Rashad's. This is fitting, given that his character—and his worth—are attacked. Even Rashad's father initially believes the police report. He wants to know why his son shoplifted…dressed the wrong way…resisted…and why Rashad foolishly ignored all the advice he'd heard, over and over again, about how to behave when dealing with the police. But Rashad did everything right, and he still ended up in the hospital.
Quinn's attempts to understand what happened come slowly and awkwardly. When he broaches the subject with his teammate, Rashad's friend English—claiming Paul was just doing his job—English doesn't smile or make it easy. He calls Quinn out on his assumptions and the naivety that comes with being white. Up to this point Quinn has taken advantage of the fact that nobody saw him. To his credit, he doesn't dismiss English's criticism, but lets it in and gives it serious weight as he decides what to do. Make an official statement? Attend the protest? Stand by Paul? Keep his head down until it's all over?
Rashad must find a way to process his ordeal even though he's stuck in the hospital. Just as he couldn't escape the beating, neither can he escape the video of himself getting pounded into the pavement—it's all over the news, every day. So he mutes the TV and watches it over and over again. He talks with a woman who lived through the civil rights movement, his nurse, his brother and friends, and eventually his father. He turns to his sketchpad. Gradually, Rashad pieces together what he thinks, how he feels, and what he wants to do—because his friends are helping plan the protest.
Did All American Boys make me uncomfortable? Definitely. And it should, because this story plays out over and over again right here in the United States. Racism and police brutality are true and serious problems, and too many of us don't want to admit that, let alone speak out or act.
Did it make me cry? Several times. I cried in frustration, in fear, and sometimes in relief.
For April 5: mockingbird by Kathryn Erskine
Beautiful Books, Diverse Books, Police Brutality, Racism, YA
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South Africa en-sa
Webhelp Payment Services
International Credit Management
Marketplace Payment Management
Know Your Customer (KYC)
Webhelp Enterprise
B2B Buyer Interactions
Working at Webhelp
Webhelp UK Celebrate Success with Team Tribute Day
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Webhelp UK has furthered its commitment to people development by hosting a company-wide tribute day across its 12 UK sites on Friday 9 October.
Throughout the day, employees across the country were invited to the fun-filled event where whole teams were praised by senior management for their ongoing dedication and commitment to delivering exceptional customer experience for a range of clients.
Entertainment and refreshments were provided and thank you cards were gifted to those excelling in their role.
David Turner, CEO at Webhelp UK, has acknowledged another exceptional year for the business and attributes this success to the dedication of the teams across its UK network.
He also believes it is vitally important to recognise hard work and provide a spotlight to company talent.
David said: "People are at the heart of what we do, so much so that we feel it is important to take the time to recognise those who are instrumental in pushing the business forward and to encourage them to keep on delivering such a high calibre of work.
"Advisor Day which celebrates the hard of our people world-wide is a great opportunity for those at Webhelp UK to take the time to meet up in a relaxed atmosphere and share their successes. Thanks to the ongoing commitment from our advisors we have been able to achieve sustained growth.
Webhelp UK is part of the Webhelp Group; a global business process outsourcing provider that employs 30,000 people in 81 locations worldwide.
From 12 locations across the UK, with its operational headquarters in Falkirk, Webhelp UK has grown its revenues by 112% in the last four years and operates six Scottish customer experience centres in Falkirk, Glasgow, Dunoon, Rothesay, Greenock and Kilmarnock.
Article by: Webhelp
Webhelp Celebrates Excellence with Annual Star Awards
Leading global customer experience outsourcer, Webhelp, celebrated the dedication and commitment of its colleagues at the company's annual Star Awards last night (Sep 8) in the sumptuous surroundings of South Queensferry's Hopetoun House. Representatives from sites across the UK, India and South Africa, the company's head office in Paris and some of Webhelp's key clients,...
Webhelp raises awareness of homelessness in South Africa
Webhelp executives in SA to join The CEO SleepOut™ JOHANNESBURG, July 27, 2016 – Craig Gibson, CEO of Webhelp SA, and finance director, Mark Reynolds, will join around 250 CEOs to spend tomorrow night (Thursday, July 28), sleeping rough on Johannesburg's iconic Nelson Mandela Bridge. From...
Co Name' is an Appointed Representative of Telecom Service Centres Ltd which is authorised and regulated in the UK by the Financial Conduct Authority (FRN 311964) and part of the Webhelp Group


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The Zacks Analyst Blog Highlights: Deckers, Malibu, Guess', Time Warner and Wolverine
Zacks Equity Research March 29, 2018
MBUU	DECK	WWW	GES
You follow Press Releases - edit
Chicago, IL – March 29, 2018 – Zacks.com announces the list of stocks featured in the Analyst Blog. Every day the Zacks Equity Research analysts discuss the latest news and events impacting stocks and the financial markets. Stocks recently featured in the blog include Deckers Outdoor Corporation (DECK - Free Report)	, Malibu Boats, Inc. (MBUU - Free Report)	, Guess', Inc. (GES - Free Report)	, Time Warner Inc. and Wolverine World Wide, Inc. (WWW - Free Report)	.
Here are highlights from Wednesday's Analyst Blog:
White House Confirms Economy Is Firming: Top 5 Gainers
The White House issued a statement on Mar 27 underlining Trump administration's efforts to bolster economic growth. The White House categorically said that consumer and business sentiments continue to improve as Trump's business-friendly policies are aiding the U.S. economy expand after eight years of stagnation. That's welcome news coming from a White House that has been in the eye of the storm of late.
Since Americans gained optimism over an improving economy and declining unemployment, things have been looking up for consumer discretionary stocks.
Tax Cut Policy
Corporate America has received a massive permanent tax break, which will boost profit margin. The House of Representatives approved the biggest overhaul of the U.S. tax code in 30 years. In a headline-grabbing move, the corporate tax rate was lowered from 35% to 21%. Republicans also repealed the 20% corporate alternative minimum tax, while any income brought back from overseas will be taxed 8% to 15.5%, instead of the current 35% (read more: GOP Passes Landmark Tax Bill: Best & Worst for Stocks).
Thanks to the new GOP tax reform law, a staggering 89% of companies plan to enhance compensation to their employees, per the EY Tax Reform Dollar Deployment Survey, conducted jointly by Ernst & Young LLP's Transaction Advisory Services and tax businesses. EY Americas Vice Chair Bill Casey added that "we're seeing that the majority of the savings from tax reform is going to be put back in growth and innovation, which is great news for the U.S. economy."
Economy in Good Shape
The U.S. economy is in the pink of health, soaring to the highest point since President George W. Bush had taken office, according to Pew Research Center. The survey showed that more than half of the Americans rate the economy high, saying that it is in best shape in nearly 18 years.
The National Association for Business Economics, in the meantime, estimated that the economy will expand at an annualized rate of 2.9% this year, compared with 2.5% projected last December. Kevin Swift, the group's vice president said that the "NABE Outlook panelists are more optimistic about the U.S. economy in 2018 than they were three months ago."
Labor Market Strengthens
Unemployment rate has been a cause of concern for Americans for the past two years. But, now the jobless rate is near a 17-year low, while the number of Americans worried about unemployment rate down to 36% from the high of 59% in 2010, as per GALLUP.
Initial jobless claims remain near the lowest level since 1970 and the number of people collecting unemployment benefits tanked to a fresh 45-year low. Job openings, on the other hand, continue to increase by around 645,000 to a seasonally adjusted 6.3 million.
The U.S. Agriculture Department added that "the number of food stamp dependent Americans hit a six-year low in President Donald Trump's first year in office, reflecting robust economy and drop in unemployment."
Consumer Sentiments Upbeat
American consumers are gaining confidence in the current state of the economy. Consumer confidence did crush expectations and hit a fresh 14-year high this month as households felt more optimistic about the economy, according to the University of Michigan.
The Consumer confidence index, however, dropped to 127.7 this month from a revised 130 in February. However, it stayed put near an 18-year high. Lynn Franco, director of Consumer Conference Board, said that "despite the modest retreat in confidence, index levels remain historically high and suggest further strong growth in the months ahead."
5 Stocks to Gain
With consumer confidence holding up well, picking consumer discretionary stocks will be a smart move. Solid consumer sentiment, historically, has been good at predicting spending levels for the next three to six months. More the confidence households generate the more will they spend.
We have, thus, selected five consumer discretionary stocks that flaunt a Zacks Rank #1 (Strong Buy) or 2 (Buy). Such stocks boast a VGM Score of A or B. Here V stands for Value, G for Growth and M for Momentum and the score is a weighted combination of these three metrics. Such a score allows you to eliminate the negative aspects of stocks and select winners.
Deckers Outdoor Corporation designs, markets, and distributes footwear, apparel, and accessories for casual lifestyle use and high performance activities. The stock has a Zacks Rank #1 and a VGM Score of A. The Zacks Consensus Estimate for its current-year earnings rose 24.3% in the last 60 days. The company is expected to return 42.3% this year, higher than the industry's projected return of 7.3%.
Malibu Boats, Inc. designs, manufactures, distributes, markets, and sells recreational powerboats. The stock has a Zacks Rank #2 and a VGM Score of B. The Zacks Consensus Estimate for its current-year earnings moved up 13.1% in the last 60 days. The company is expected to return 44.2% this year, better than the industry's estimated return of 24.9%.
Guess', Inc. designs, markets, distributes, and licenses lifestyle collections of apparel and accessories for men, women, and children. The stock has a Zacks Rank #1 and a VGM Score of A. The Zacks Consensus Estimate for its current-year earnings climbed 14.3% in the last 60 days. The company is expected to return 37.1% this year, higher than the industry's estimated return of 13.5%. You can see the complete list of today's Zacks #1 Rank stocks here.
Time Warner Inc. operates as a media and entertainment company in the United States and internationally. The stock has a Zacks Rank #2 and a VGM Score of A. The Zacks Consensus Estimate for its current-year earnings rose 16.7% in the last 60 days. The company is expected to return 19.5% this year, higher than the industry's projected return of 10.6%.
Wolverine World Wide, Inc. designs, manufactures, sources, markets, licenses, and distributes footwear, apparel, and accessories. The stock has a Zacks Rank #2 and a VGM Score of A. The Zacks Consensus Estimate for its current-year earnings rose 4.7% in the last 60 days. The company is expected to return 23.2% this year, higher than the industry's estimated return of 7.3%.
Will You Make a Fortune on the Shift to Electric Cars?
Here's another stock idea to consider. Much like petroleum 150 years ago, lithium power may soon shake the world, creating millionaires and reshaping geo-politics. Soon electric vehicles (EVs) may be cheaper than gas guzzlers. Some are already reaching 265 miles on a single charge.
With battery prices plummeting and charging stations set to multiply, one company stands out as the #1 stock to buy according to Zacks research.
It's not the one you think.
See This Ticker Free >>
Zacks Investment Research is under common control with affiliated entities (including a broker-dealer and an investment adviser), which may engage in transactions involving the foregoing securities for the clients of such affiliates.
support@zacks.com
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Past performance is no guarantee of future results. Inherent in any investment is the potential for loss. This material is being provided for informational purposes only and nothing herein constitutes investment, legal, accounting or tax advice, or a recommendation to buy, sell or hold a security. No recommendation or advice is being given as to whether any investment is suitable for a particular investor. It should not be assumed that any investments in securities, companies, sectors or markets identified and described were or will be profitable. All information is current as of the date of herein and is subject to change without notice. Any views or opinions expressed may not reflect those of the firm as a whole. Zacks Investment Research does not engage in investment banking, market making or asset management activities of any securities. These returns are from hypothetical portfolios consisting of stocks with Zacks Rank = 1 that were rebalanced monthly with zero transaction costs. These are not the returns of actual portfolios of stocks. The S&P 500 is an unmanaged index. Visit http://www.zacks.com/performance for information about the performance numbers displayed in this press release.
Malibu Boats, Inc. (MBUU) - free report >>
Deckers Outdoor Corporation (DECK) - free report >>
Wolverine World Wide, Inc. (WWW) - free report >>
Guess?, Inc. (GES) - free report >>
The Zacks Analyst Blog Highlights: Verona, Squibb, Protagonist and Amgen


We think we just found our spiritual home.
On Friday, Saturday – or really any night of the week – in London, the city's cocktail bars are full to bursting, whether you're after a pre-theatre tipple in Covent Garden or battling your friends on Mario Kart in a gaming bar in Peckham.
Londoner's appetites are continuously growing for the next new thing on the bar scene, but with so much choice (and not always a whole lot of space) it can be hard to know where to go to seek out your next favourite.
Enter Cocktails in the City: a collaboration of 25 of London's coolest, most interesting bars and the people behind them, all under one roof ready to show you what they got.
From the 4 – 6 April, Bourne and Hollingsworth are putting together the event in the Waterloo Vaults. If you've never ventured that way before, the Vaults are an underground maze of arches and passageways, all of which will be the temporary home of a different bar and sensory experience.
You might already recognise some of the names attending, such as the London Cocktail Club, Cahoots, Trailer Happiness and Mr Fogg's – all of which have designed an all-singing, all-dancing, all-drinking pop-up bar for the event.
As you work your way around the converted railway tunnels, watch out for the Secret Garden by B&H Buildings and Mr Fogg's, overflowing with botanicals and complete with sensory Greenhouse from which you can pick your own cocktail garnishes from hanging baskets.
There's also a cocktail laboratory, where inside famed industry mavericks will be showing off their near-magic skills creating some exciting concoctions, and an underground bunker courtesy of speakeasy Cahoots, who are bringing an old-fashioned tube carriage along with them to transport you back in time.
Tickets are priced at £20 which gets you one cocktail, with all others priced at £7.50 throughout the evening.
Cocktails in the City will also be touring the rest of the country throughout spring and summer, visiting Edinburgh and Manchester in May and Liverpool in June.


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Port of Oakland forecasts steady growth as partners invest
Oakland, Calif. – March 30, 2018: Containerized cargo volume moving through this city is expected to increase 2 percent annually for the next five years. The catalyst for growth: a nearly $700 million injection of capital from outside investors. That's the message Port of Oakland officials delivered to trade and transportation leaders here this week. "This is good,… Read More
Oakland International Airport traffic up 5.3 percent in February
Oakland, Calif. – March 28, 2018: Oakland International Airport (OAK) reports 849,529 airline passengers for the month of February, a 5.3% increase over February 2017. Total airline seat capacity of 1,187,141 increased 4.7% over last year and the load factor (percent of seats occupied by passengers) of 75.4% increased by 0.4% over last year. Passenger… Read More
Sundays at Jack London Square serve up real food and local goods
Farmers Market video here Oakland, Calif. – March 28, 2018: Family friendly Sundays are a significant part of Jack London Square's schedule of free community events throughout the year. Every Sunday, Farmers Market offers fresh produce and artisanal food from 10 a.m. to 3 p.m., rain or shine. The Buck is a new event providing… Read More
Port of Oakland ready for Japan's merged shipping lines to call
Oakland, Calif. – March 27, 2018: Port of Oakland officials said today they expect little difficulty when Japan's newly merged shipping line arrives next month. The Port predicted normal operations as container carriers MOL, NYK and K Line consolidate under a new flag. The three Japanese ocean carriers merged in 2017 to form a new company,… Read More
Port of Oakland ag exports are up 42.7 percent in last four years
Oakland, Calif. – March 26, 2018: Agricultural exports shipped from here have increased 42.7 percent in volume since 2013, the Port of Oakland said today. Port officials said that the vigorous growth reflects continued strong overseas demand for U.S. farm goods. They added that export growth could stall if foreign governments tax American goods in retaliation for… Read More
Oakland Airport head appointed to four-year term with national industry association
Oakland, CA: (March 19, 2018) – When beginning his tenure at Oakland International Airport (OAK) two years ago this month, a featured Forbes.com writer penned him the "Ultimate Airport Guy." Director Bryant L. Francis, C.M. has proven such at OAK, bringing with him an extensive career of Aviation experience and leadership, a record number of… Read More
Step back in time with Tall Ships at Jack London Square
Tall Ships video here Oakland, Calif. – March 14, 2018: Tall Ships are sailing back into port at Jack London Square Friday. Lady Washington and Hawaiian Chieftain will berth at the foot of Broadway and be open to the public beginning Saturday for on-dock tours and weekend sailing adventures. The sailing ships provide a peek at maritime… Read More
Port of Oakland imports jumped 14.9 percent last month
Oakland, Calif. – March 14, 2018: Port of Oakland containerized import volume increased 14.9 percent last month, according to data released today. The Port said February container volume grew in all categories, setting records along the way. Oakland's performance follows release of a new 5-year strategic plan calling for record cargo volume annually through 2022…. Read More
Port of Oakland's new 5-year strategy: 'Growth with Care'
Oakland, Calif. – March 12, 2018: The Port of Oakland released a new 5-year strategic plan today that pairs business expansion with community benefits. Called "Growth with Care," the plan envisions more jobs and economic stimulus as the Port grows. "We can grow, but we want our neighbors to grow with us," said Port of… Read More
New open air market kicks off this Saturday at Jack London Square
Oakland, Calif. – March 8, 2018: Second Saturday, a new event at Jack London Square, rolls out March 10, from 10 a.m. to 5 p.m. and runs throughout the year. It transforms Jack London Square into a lively, open-air market featuring up to 100 unique vendors, live entertainment, children's activities and food. The market is every… Read More
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Fear not cheer: That's the holiday spirit at the Capitol
'None of us like it,' but many are resigned
A Capitol worker hauls a Christmas tree to the loading dock in the basement of the Hart Senate Office Building on Jan. 2, 2020. (Bill Clark/CQ Roll Call)
By Chris Cioffi
Posted December 3, 2021 at 12:06pm
Walk around the Capitol right about now and you'll probably hear someone humming, "It's the least wonderful time of the year."
This happens every December, and it's been this way for decades. Legislative items pile up, and the threat of a calamitous event like a partial government shutdown or default brings lawmakers to the negotiating table before the holiday break. No amount of tree-lighting ceremonies, boozy K Street receptions or "sprint to the finish" metaphors can disguise the foul mood that settles over Congress. It's like a running joke, but nobody's amused.
"None of us like it," said Sen. Tim Kaine, D-Va. "All of us have Christmas plans with our families, and things like that, and we don't want to have those at risk."
Congressional staffers relive memories of times their bosses pushed things right to the brink, like when the Senate spent Christmas Eve passing the Obama-era health care overhaul in 2009, or when the fiscal cliff of 2012 left people scrambling.
"Hahahahahahaha," responded one Senate staffer, when asked about the mood at work as another holiday season unfolds.
"Flexible plane tickets baby!" they said, asking not to be identified to freely discuss their travel plans.
The frustration among both staff and members is real, but so is the acceptance that pileups happen almost every year like clockwork.
"Our new driver is crestfallen about not being able to make plans," said a House Democratic staffer. "Business as usual for me and the others."
[Political Theater podcast: Coal in your legislative stockings]
Some of the worst is over, after Congress cleared a bill Thursday to avert a government shutdown and provide leaders until Feb. 18 to hammer out a fiscal 2022 appropriations deal. But Democrats still have an improbable to-do list, including finding a solution to address the debt limit by Dec. 15, passing a 2022 defense bill and handling their party's $2.2 trillion reconciliation package.
Senate Majority Leader Charles E. Schumer initially wanted to pass all that before Christmas, though both chambers were scheduled to recess next Friday until January. Hardly anyone on Capitol Hill believes that schedule will hold.
Lawmakers entered the final stretch of the year in full complaint mode, bemoaning the drama that has become routine. "Any old … handful of members who believe strongly in something can say, 'I'm going to shut down the government unless I get what I want.' If people do that, it's chaos," Schumer said Wednesday, when Republicans like Mike Lee of Utah were demanding a defunding of the Biden administration's vaccine-or-test rule.
Despite the gripes, one thing is missing — anger that turns into action. As with most of the legislative body's ailments, Congress could heal itself, if enough members could agree on how. Instead, the prevailing emotion at the Capitol, once you cut through all the grumbling, is resignation.
"We surely aren't thrilled, haha, but aren't surprised. We've fully been expecting to be in session the week of the 13th," a Democratic Senate staffer said in a text message, asking for anonymity to speak candidly.
"Threatening to cancel the Christmas recess is a holiday tradition, but both sides tend to come together" in time, said a Republican Senate staffer. While this year feels like more of the same, he did make one change: "I did most of my Christmas shopping early because I didn't want to risk having gifts be late due to supply chain issues."
Little political will exists in Congress to end the last-minute culture that many decry, especially the tradition of blowing past the Oct. 1 deadline to fund the government and instead setting up a year-end showdown with a series of continuing resolutions. While some lawmakers have proposed legislative solutions, they've gone nowhere.
A few senators have put forth anti-shutdown bills in recent years, including one from Virginia Sen. Mark Warner titled the "Stop STUPIDITY Act." (The acronym stands for "Shutdowns Transferring Unnecessary Pain and Inflicting Damage In The Coming Years.")
Another bill from Ohio Sen. Rob Portman drew 14 GOP co-sponsors, while a bipartisan push from Oklahoma Sen. James Lankford got 10 fellow Republicans and a handful of Democrats. Lankford's bill would automatically enact a continuing resolution if appropriations bills aren't done on time. It would also cut government funding for member travel, making it difficult for politicians to leave Washington until the chamber finishes its work.
But some say that takes away the power of the purse from appropriators and the party that holds the majority.
It also could become a crutch to fall back on to avoid the sometimes prickly work of appropriating, especially right now, Kaine said. Lawmakers had already twice extended the fiscal 2021 year appropriations package that was enacted by a GOP Senate majority and former President Donald Trump in the White House.
"We want to do our own budget," Kaine said. "We've got majorities in both houses, and so the automatic CR thing would produce a result that would not be a good result for us."
Sen. Susan Collins has said she isn't in favor of bills that weaken the power of the Appropriations Committee, adding that if the Senate's time was better spent, pileups could be avoided in the first place.
"It certainly seems to me that an awful lot of time was wasted on low-level nominees when we could have been doing the NDAA, or bringing appropriations bills to the Senate floor," the Maine Republican said.
Congressional observers trace the current incarnation of the December crunch to the 1990s, citing the era of Newt Gingrich. "The big picture of this has to do with the parties becoming more internally aligned and empowering leadership to control what's on the table," said Daniel Schuman of Demand Progress, a left-leaning advocacy group.
"Leadership routinely used end-of-the-year deadlines to create pressure on members and Congress to act. It is a hard-nosed way to govern, exacerbated by the filibuster and partisan dysfunction in the Senate where a small minority can hold almost any measure hostage."
Most years, the only thing that's certain is that the cycle will repeat again in future Decembers, like an annoying Christmas carol on repeat. The gripes will surely continue too.
"I think we manufacture crises when they're unnecessary," said Sen. Angus King, I-Maine.
King, who is a co-sponsor on Lankford's bill, dismissed the critics who say automatic continuing resolutions would take away leadership's power of the purse.
"If they do their job, we wouldn't even be having this discussion," he said. "All you got to do is pass a budget every year."


The 6th Annual Opportunity Knocks Aboriginal Youth Career Planning Conference is scheduled for November 14 – 16, 2019! This event aims at providing youth approaching graduation, with an overview of opportunities and possibilities for Creative Career Pathways.
Attendees enjoy an empowering conference with Elders, inspiring guest speakers, interactive educational workshops, traditional activities, a career and education fair, and much more! Topics include Post-secondary education, trades, apprenticeships, entrepreneurship, scholarships, bursaries and world readiness.


The Security Configuration Guides provide an overview of features in Mac OS X that can be used to enhance security, known as hardening your computer.
The guides are designed to give instructions and recommendations for securing Mac OS X and for maintaining a secure computer.
To use these guides, you should be an experienced Mac OS X user, be familiar with the Mac OS X user interface, and have at least some experience using the Terminal application's command-line interface. You should also be familiar with basic networking concepts.
Certain instructions in the guides are complex, and deviation could result in serious adverse effects on the computer and its security. The guides should only be used by experienced Mac OS X users, and any changes made to your settings should be thoroughly tested.


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Nursing, College of
Women, Child, and Family Health Science, Department of
Publications - Women, Child, and Family Health Science
Prospective parents' perspectives on antenatal decision making for the anticipated birth of a periviable infant
Edmonds, Brownsyne Tucker
Savage, Teresa A.
Kimura, Robert E.
Kilpatrick, Sarah J.
Kuppermann, Miriam
Grobman, William
Kavanaugh, Karen
Objective: To examine prospective parents' perceptions of management options and outcomes in the context of threatened periviable delivery, and the values they apply in making antenatal decisions during this period. Study Design: Qualitative analysis of 46 antenatal interviews conducted at three tertiary-care hospitals with 54 prospective parents (40 pregnant women, 14 partners) who had received counseling for threatened periviable delivery (40 cases). Results: Participants most often recalled being involved in resuscitation, cerclage and delivery mode decisions. Over half (63.0%) desired a shared decision-making role. Most (85.2%) recalled hearing about morbidity and mortality, with many reiterating terms like "brain damage," "disability," and "handicap." The potential for disability influenced decision making to variable degrees. In describing what mattered most, participant spoke of giving their child a "fighting chance;" others voiced concerns about "best interest," a "healthy baby," "pain and suffering," and religious faith. Conclusion: Our findings underscore the importance of presenting clear information on disability and eliciting the factors that parents deem most important in making decisions about periviable birth.
Tucker Edmonds, B., Savage, T. A., Kimura, R. E., Kilpatrick, S. J., Kuppermann, M., Grobman, W., & Kavanaugh, K. (2019). Prospective parents' perspectives on antenatal decision making for the anticipated birth of a periviable infant. Journal of Maternal-Fetal and Neonatal Medicine, 32(5), 820-825. doi:10.1080/14767058.2017.1393066
parents, values
antenatal counseling
Date available in INDIGO