Immunoinformatic Risk Assessment of Host Cell Proteins During Process Development for Biologic Therapeutics

The identification and removal of host cell proteins (HCPs) from biologic products is a critical step in drug development. Despite recent improvements to purification processes, biologics such as monoclonal antibodies, enzyme replacement therapies, and vaccines that are manufactured in a range of cell lines and purified using diverse processes may contain HCP impurities, making it necessary for developers to identify and quantify impurities during process development for each drug product. HCPs that contain sequences that are less conserved with human homologs may be more immunogenic than those that are more conserved. We have developed a computational tool, ISPRI-HCP, that estimates the immunogenic potential of HCP sequences by evaluating and quantifying T cell epitope density and relative conservation with similar T cell epitopes in the human proteome. Here we describe several case studies that support the use of this method for classifying candidate HCP impurities according to their immunogenicity risk.

Successful AAV8 re-administration: Suppression of capsid-specific neutralizing antibodies by a combination treatment of bortezomib and CD20 mAb in a mouse model of Pompe disease

BACKGROUND

A major challenge to AAV mediated gene therapy is the presence of anti-AAV capsid neutralizing antibodies (NAbs), which can block viral vector transduction even at very low titers. Here we examined the ability of a combination immunosuppression (IS) treatment with bortezomib and a mouse-specific CD20 mAb to suppress anti-AAV NAbs and enable re-administration of AAV vectors of the same capsid in mice.

METHODS

An AAV8 vector (AAV8-CB-hGAA) that ubiquitously expresses human α-glucosidase was used for initial gene therapy and a second AAV8 vector (AAV8-LSP-hSEAP) that contains a liver-specific promoter to express human secreted alkaline phosphatase was used for AAV re-administration. Plasma samples were used for determination of anti-AAV8 NAb titers. Cells isolated from whole blood, spleen, and bone marrow were analyzed for B-cell depletion by flow cytometry. The efficiency of AAV re-administration was determined by the secretion of hSEAP in blood.

RESULTS

In näive mice, an eight-week IS treatment along with AAV8-CB-hGAA injection effectively depleted CD19⁺ B220⁺ B cells from blood, spleen, and bone marrow and prevented the formation of anti-AAV8 NAbs. Following administration of AAV8-LSP-hSEAP, increasing levels of hSEAP were detected in blood for up to 6 weeks, indicating successful AAV re-administration. In mice pre-immunized with AAV8-CB-hGAA, comparison of IS treatment for 8, 12, 16, and 20 weeks revealed that the 16-week IS treatment demonstrated the highest plasma hSEAP level following AAV8-LSP-hSEAP re-administration.

CONCLUSIONS

Our data suggest that this combination treatment is an effective IS approach that will allow retreatment of patients with AAV mediated gene therapy.

Multimodal Precision Prevention - A New Direction in Alzheimer's Disease

At least 40% of all dementia has been linked to modifiable risk factors suggesting a clear potential for preventative approaches targeting these factors. Despite the recent promising findings from anti-amyloid monoclonal antibodies, a limited proportion of patients are expected to be eligible for these novel AD treatments. Given the heterogeneous nature of AD and the complex multi-level pathological processes leading to dementia (involving, e.g., shared risk factors, interaction of different pathology mechanisms, and their putative synergistic effects on cognition), targeting a single pathology may not be sufficient to halt or significantly impact disease progression. With exponentially increasing numbers of patients world-wide, in parallel to the unprecedented population ageing, new multimodal therapy approaches targeting several modifiable risk factors and disease mechanisms simultaneously are urgently required. Developing the next generation of combination therapies with lifestyle intervention and pharmacological treatments, implementing the right interventions for the right people at the right time, and defining accessible and sustainable strategies worldwide are crucial. Here, we summarize the state-of-the-art multimodal lifestyle-based approaches, especially findings and lessons learned from the FINGER trial, for prevention and risk reduction of cognitive impairment and dementia. We also discuss some emerging underlying biological mechanisms and the current development of precision prevention approaches. We present an example of a novel trial design combining healthy lifestyle changes with a repurposed putative disease-modifying drug and place this study in the context of the World-Wide FINGERS, the first interdisciplinary network of multimodal trials dedicated to the prevention and risk reduction of cognitive impairment and dementia.

Multimodal Preventive Trial for Alzheimer's Disease: MIND-ADmini Pilot Trial Study Design and Progress

Background

Interventions simultaneously targeting multiple risk factors and mechanisms are most likely to be effective in preventing cognitive impairment. This was indicated in the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) testing a multidomain lifestyle intervention among at-risk individuals. The importance of medical food at the early symptomatic disease stage, prodromal Alzheimer’s disease (AD), was emphasized in the LipiDiDiet trial. The feasibility and effects of multimodal interventions in prodromal AD are unclear.

Objectives

To evaluate the feasibility of an adapted FINGER-based multimodal lifestyle intervention, with or without medical food, among individuals with prodromal AD.

Methods

MIND-ADmini is a multinational proof-of-concept 6-month randomized controlled trial (RCT), with four trial sites (Sweden, Finland, Germany, France). The trial targeted individuals with prodromal AD defined using the International Working Group-1 criteria, and with vascular or lifestyle-related risk factors. The parallel-group RCT includes three arms: 1) multimodal lifestyle intervention (nutritional guidance, exercise, cognitive training, vascular/metabolic risk management and social stimulation); 2) multimodal lifestyle intervention+medical food (Fortasyn Connect); and 3) regular health advice/ care (control group). Primary outcomes are feasibility and adherence. Secondary outcomes are adherence to the individual intervention domains and healthy lifestyle changes.

Results

Screening began on 28 September 2017 and was completed on 21 May 2019. Altogether 93 participants were randomized and enrolled. The intervention proceeded as planned.

Conclusions

For the first time, this pilot trial tests the feasibility and adherence to a multimodal lifestyle intervention, alone or combined with medical food, among individuals with prodromal AD. It can serve as a model for combination therapy trials (non-pharma, nutrition-based and/or pharmacological interventions).

Multidomain Interventions to Prevent Cognitive Impairment, Alzheimer's Disease, and Dementia: From FINGER to World-Wide FINGERS

Alzheimer’s disease (AD) and dementia are a global public health priority, and prevention has been highlighted as a pivotal component in managing the dementia epidemic. Modifiable risk factors of dementia and AD include lifestyle-related factors, vascular and metabolic disorders, and psychosocial factors. Randomized controlled clinical trials (RCTs) are needed to clarify whether modifying such factors can prevent or postpone cognitive impairment and dementia in older adults. Given the complex, multifactorial, and heterogeneous nature of late-onset AD and dementia, interventions targeting several risk factors and mechanisms simultaneously may be required for optimal preventive effects. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) is the first large, long-term RCT to demonstrate that a multidomain lifestyle-based intervention ameliorating vascular and lifestyle-related risk factors can preserve cognitive functioning and reduce the risk of cognitive decline among older adults at increased risk of dementia. To investigate the multidomain intervention in other populations and diverse cultural and geographical settings, the World-Wide FINGERS (WW-FINGERS) network was recently launched (https://alz.org/wwfingers). Within this network, new FINGER-type trials with shared core methodology, but local culture and context-specific adaptations, will be conducted in several countries. The WW-FINGERS initiative facilitates international collaborations, provides a platform for testing multidomain strategies to prevent cognitive impairment and dementia, and aims at generating high-quality scientific evidence to support public health and clinical decision-making. Furthermore, the WW-FINGERS network can support the implementation of preventive strategies and translation of research findings into practice.

Influenza vaccine effectiveness against laboratory-confirmed influenza in a vaccine-mismatched influenza B-dominant season

BACKGROUND

The 2017-2018 influenza season in Israel was characterized by the predominance of influenza B Yamagata, with a lesser circulation of influenza A(H1N1)pdm09 and influenza A(H3N2). We estimated vaccine effectiveness (VE) of the inactivated influenza vaccine which was selected for use that season.

METHODS

End-of-season VE and 95% confidence intervals (CI) against laboratory-confirmed influenza-like illness (ILI) were estimated by means of the test-negative design. Age-specific VE analysis was carried out using a moving age interval.

RESULTS

Specimen were obtained from 1,453 community ILI patients; 610 (42.0%) were influenza-positive, among which 69.7% were B, 17.2% A(H1N1)pdm09 and 13.4% A(H3N2). A 98.6% of molecularly characterized influenza B belonged to the Yamagata lineage. Of the sampled individuals, 1320 were suitable for VE analysis. Of those vaccinated, 90.6% received the inactivated trivalent influenza vaccine (TIV) containing a Victoria lineage influenza B-like virus. VE against influenza A differed by age, with the highest VE of 72.9% (95%CI 31.9-89.2%) observed in children 0.5-14 years old, while all ages VE was 46.6% (95%CI 10.4-68.2%). All ages VE against influenza B was 23.2% (95%CI -10.1-46.4%) with age-specific analysis showing non-significant VE estimates. Utilizing a moving age interval of 15 years, afforded a detailed age-specific insight into influenza VE against the influenza viruses circulating during the 2017-2018 season.

CONCLUSIONS

The moderate-high 2017-2018 influenza A VE among children and adolescents, supports seasonal influenza vaccination at a young age. The low VE against influenza B in Israel, is most likely the result of influenza B/TIV-mismatch.

Primary Cutaneous Follicle Center Lymphoma (PCFCL) with Parotid Gland Involvement

Introduction/Objective

Primary cutaneous follicle center lymphoma (PCFCL) is the most common primary cutaneous B-cell lymphoma. It arises from mature germinal center B lymphocytes. Here we report two cases of PCFCL with parotid gland involvement.

Methods

First case is a 66-year-old male with an enlarging forehead mass for nine months and a painless nodule on the right pre-auricular skin. Second is a 39-year-old male with a history of a recurring scalp spindle cell B-cell lymphoma now presenting with an enlarging lesion on the scalp and “fullness” in the right neck. There was no nodal or other extranodal involvement found in either case. Skin and parotid gland biopsies were obtained in both cases.

Results

Case one: The skin and parotid gland demonstrated sheets of predominantly medium sized infiltrating lymphoma cells, positive for CD20, Bcl-6, CD5 (dim) and Bcl-2 (dim), and negative for CD10, Bcl-1, and MUM-1. The epidermis was spared.

Case two demonstrated medium sized, spindle shaped lymphoma cells. The skin showed a vague follicular growth pattern, sparing the epidermis. The parotid gland showed diffuse infiltration by lymphoma cells, positive for CD20 and Bcl-6, Bcl-2 (dim) and no definite positivity for CD10.

Fluorescent in situ hybridization for t(14;18) translocation was absent in both cases.

Conclusion

Dissemination of PCFCL to extracutaneous sites is uncommon (~10% of cases) and to our knowledge, has not been reported in the parotid gland. Here we present two unique cases, which in the absence of nodal disease, prove the diagnosis of PCFCL with parotid gland involvement.

Is low or high body mass index in patients operated for oral squamous cell carcinoma associated with the perioperative complication rate?

The aim of this study was to analyse the effect of body mass index (BMI), both low and high values, on the perioperative complication rate in patients with oral squamous cell carcinoma (OSCC). The medical records of 259 patients operated between 2014 and 2017 for OSCC were reviewed. Univariate and multivariate analyses were performed. Sixty of the 259 patients developed 87 complications. Low or high BMI was not associated with the perioperative complication rate. A longer operating time and increased blood loss were associated with a higher perioperative complication rate and higher Clavien-Dindo grade. Low BMI, American Society of Anesthesiologists score 2 and 3, a longer operating time, and increased blood loss were associated with a longer hospital stay. Low BMI was associated with a longer hospital stay. Neither low nor high BMI was associated with the perioperative complication rate. A longer operating time and increased blood loss were associated with a higher perioperative complication rate and higher Clavien-Dindo grade.

The epidemiology and prehospital care of motorcycle crashes in a sub-Saharan African urban center

OBJECTIVE

Road traffic crashes (RTCs) are common among motorcyclists in Kigali, Rwanda. The Service d'Aide Medicale Urgente (SAMU), a prehospital ambulance service, responds to many of these crashes. We aimed to describe motorcycle-related RTCs managed by SAMU.

METHODS

SAMU clinical data including demographic information, injury characteristics, and management details were analyzed descriptively for all motorcycle crashes occurring between December 2012 and July 2016.

RESULTS

Every patient included in this study was injured. These patients all called the ambulance for their injuries after a motorcycle crash. There were 2,912 motorcycle-related RTCs over the study period, representing 26% of all patients managed by SAMU. The incidence of motorcycle crashes in Kigali was 258 crashes per 100,000 people over the 3.5-year study period. The average age was 30 years and 80% were males. The most common injuries were to the lower extremities (n = 958, 33%), head (n = 878, 30%), or upper extremities (n = 453, 16%). Injuries often resulted in fractures of extremities (n = 740, 25%) and external hemorrhage anywhere in the body (unspecified region; n = 660, 23%), yet few were severe based on the Kampala Trauma Score (n = 23, 2%) and Glasgow Coma Scale (n = 42, 1.5%). The most common interventions were provision of diclofenac (n = 1,526, 52.5%), peripheral intravenous (IV) access (n = 1,217, 42%), and administration of IV fluids (n = 1,048, 36%).

CONCLUSION

Motorcycle-related RTCs represent a large burden of disease for patients treated by SAMU in Kigali, Rwanda. Young men are most at risk of injury, which imposes a financial strain on society. Though injuries occurred frequently, critical trauma cases from motorcycle crashes were uncommon. This may be a result of several initiatives in Rwanda to improve road safety.

P1716Dual antiplatelet therapy on veno arterial ECMO to bleed or not to bleed?

Background

Patients presenting with INTERMACS-1 cardiogenic shock and necessitating VA-ECMO, often undergo coronary angiography and percutaneous coronary intervention (PCI). Therefore, a substantial subset of VA-ECMO patients will have an indication for dual antiplatelet therapy (DAPT) plus unfractionated heparin (UFH). According to atrial fibrillation registry data, bleeding incidence on DAPT combined with oral anticoagulation is significantly higher as compared to anticoagulation alone. Although it has been reported that the addition of low dose aspirin to UFH did not increase bleeding or transfusion in VenoVenous (VV)-ECMO patients, it remains to be elucidated whether the addition of DAPT to UFH on VA-ECMO-therapy enhances bleeding.

Methods

We report single center data for 100 VA-ECMO patients between 2011 and 2019. VA-ECMO-patients post-surgery were excluded. Patient demographics, blood product transfusions and reported/radiographically diagnosed bleeding or thrombotic complications were analysed. All VA-ECMO patients received UFH, aiming for an anti-Xa levels of at least 0,3 U/ml. Targets were hemoglobin 7 g/dl, fibrinogen 100 mg/dl (or 150 mg/dl when active bleeding) and platelet counts above 50/fL. DAPT-patients were on a low dose aspirin plus a P2Y12-inhibitor (clopidogrel or ticagrelor).

Results

51% Of the VA-ECMO-group received DAPT (59% clopidogrel and 41% ticagrelor). UFH-levels were comparable between both groups. Patients on DAPT were significantly older (DAPT 52.8 vs. Control 41.3; p<0.001) and predominantly male (DAPT 76% vs. Control 63%). Total bleedings (DAPT 52% vs. Control 55%; p=0,68) and major bleedings (BARC score of 3 or more; DAPT 41% vs. Control 45%; p=0,71) did not differ significantly. We observed a significant lower number of clinically or radiographically overt arterial/venous thromboses (DAPT 13.7% vs. Control 36.2%; p=0,02) in the DAPT-group. When comparing fresh frozen plasma (FFP), red blood cell and platelet pool transfusions between both groups, only FFP-tranfusion (DAPT 0.47 units/day vs. Control 1.18 units/day; p=0,047) intends to be lower for the DAPT-group.

DAPT (plus UFH) vs control (plus UFH)

Conclusions

Haemorrhage is frequent during extracorporeal support. However, in our cohort, DAPT on top of UFH in the treatment of VA-ECMO-supported ischemic cardiogenic shock does not increase the risk of major bleeding. Therefore, DAPT should not necessarily be witheld in the setting of VA-ECMO. Interestingly, our data support a lower incidence of overt thromboses and a trend towards less FFP-transfusion. These findings suggest DAPT-induced platelet inhibition being protective against both thrombotic events and posibly consumptive coagulopathy without paying a price for major bleeding.

P1718Veno-arterial ECMO versus Left Impella bleeding complications in cardiogenic shock patients on dual antiplatelet therapy

Background

Selective groups of patients, presenting with INTERMACS-1 cardiogenic shock due to acute ischaemic heart failure, may benefit from mechanical circulatory support (MCS). Patients with biventricular failure, severe septic shock or oxygenation problems should be selected for VA-ECMO, although the left Impella-CP heart pump can be considered as a less invasive alternative in supporting predominantly left ventricular failure. Bleeding issues are a major concern in patients on MCS, especially in this group where triple anticoagulation therapy (unfractionated heparin (UFH) for prevention of pump thrombosis and dual antiplatelet therapy (DAPT) after coronary stenting) is necessitated. We aim to investigate the bleeding and transfusion rate in DAPT-patients on VA-ECMO versus Impella.

Methods

We report single center data for 51 VA-ECMO and 8 Impella patients between 2011 and 2019. Indication for MCS was acute ischaemic cardiogenic shock. Patient demographics, transfusions and reported/radiographically diagnosed bleeding (BARC-classification) complications were analyzed. All patients received UFH and low dose aspirin plus clopidogrel or ticagrelor. Impella flow was at least 2.5 L/min. Transfusion targets were Hb >7 g/dl, fibrinogen >100 mg/dl (or >150 mg/dl when active bleeding) and platelet count >50/fL.

Results

Impella patients were significantly older (VA-ECMO 52.8 vs. Impella 62.4; p=0.02) as compared to the VA-ECMO group. Anti-Xa-levels and length of the MCS-run (mean 7.9 VA-ECMO vs. 6.4 days Impella) were comparable in both groups. Occurrences of minor bleeds was comparable between both groups (mainly oozing from the insertion site in the ImpellaTM group 63% vs. VA-ECMO 72%; p>0.05) but major bleedings with BARC score of 3 or more were significantly lower in the Impella group (13% vs. VA-ECMO 65%; p=0.005). Platelet and red blood cell transfusions were significantly lower in the Impella group (0.1 units of platelets per day vs. 1.1 units of platelets per day on VA-ECMO; p=0.002 and 0.8 units of RBCs per day vs. 2.6 units of RBCs per day on VA-ECMO; p=0.02).

Bleeding/transfusion VA-ECMO vs Impella

Conclusions

Bleeding is a frequent complication of MCS. However, in our cohort, triple anticoagulation in acute cardiogenic shock due to ischaemic left ventricle failure resulted in a lower major bleeding rate when support was given by the left Impella device as compared with VA-ECMO therapy group. As a result, platelet and red blood cell transfusions were lower in the Impella group. These findings are likely to be partly explained by the increased number and size of cannulas in VA-ECMO, as well as the increased risk of haemolysis and consumptive coagulopathy due to the complexity and extensive foreign body surface of the ECMO-circuit. We conclude that Impella support should be considered as a safer option than VA-ECMO with regards to bleeding in patients with ischaemic left ventricular failure who require DAPT and MCS as a bridge to recovery or other definitive therapy.

Abstract 3516: A genomics model to predict immune-related adverse events in cancer patients treated with checkpoint inhibitors

The overall objective of this study is to use next-generation sequencing technology and bioinformatics to better inform the safety of immunotherapy treatment for cancer. Cancer patients commonly develop immune-related adverse events (irAEs) during and after treatment with checkpoint inhibitors. These irAEs can be serious or even fatal. Therefore, a biomarker for prediction of irAE development could have utility for heightened surveillance, personalized therapy decisions, and regulatory evaluation of drugs. Due to the similarity between irAEs and autoimmune diseases and the high heritability of autoimmune diseases, we hypothesized that certain patients could have a genetic predisposition for developing irAEs. To test this hypothesis, we conducted whole exome sequencing on an Illumina NextSeq to interrogate germline genomes of solid tumor patients (n=50) treated with an anti-PD-L1 antibody (NCT01772004). Relevant clinical data, such as adverse events and irAE classification, were provided for this retrospective analysis; twenty percent of patients (10/50) had irAEs. A preliminary germline genetic model of irAEs was constructed using short variant calls from this initial training set. This was generated using a proprietary algorithm that implements a Monte-Carlo simulation expansion of Fisher’s regularized linear discriminant analysis (RLDA) in a multidimensional measurement system to create a model that maximizes separation between two groups. This model consists of 131 genes, each of which make a relatively small contribution to the overall signature. The ten genes with the highest contribution coefficients together account for 21% of the signature. Ingenuity Pathway Analysis (IPA) identified a network associated with infectious diseases, antimicrobial response, and inflammatory response that contains 21 interconnected genes from the signature. IPA also revealed that genes in the signature have a variety of molecular and cellular functions, the most significant of which are cell death and survival, cellular movement, and cell-to-cell signaling and interaction. This model has 100% sensitivity, specificity, and accuracy on the training set. Future directions will test the performance of this putative genomic model on a new dataset to assess the validity and utility of the model as a predictive biomarker to identify patients at risk for developing irAEs in response to checkpoint inhibition.

Citation Format: Emma C. Scott, Dickran Kazandjian, Luis Santana-Quintero, Tigran Ghazanchyan, Svetlana Petrovskaya, Yong Zhang, Amy Rosenberg, V. Ashutosh Rao, Jennifer L. Marte, Gideon M. Blumenthal, Marc R. Theoret, Richard Pazdur, James L. Gulley, Julia A. Beaver. A genomics model to predict immune-related adverse events in cancer patients treated with checkpoint inhibitors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3516.

Common inpatient hypoglycemia phenotypes identified from an automated electronic health record-based prediction model

PURPOSE

Common inpatient hypoglycemia risk factor patterns (phenotypes) from an electronic health record (EHR)-based prediction model and preventive strategies were identified.

METHODS

Patients admitted to 2 large academic medical centers who were in the top fifth percentile of a previously developed hypoglycemia risk score and developed hypoglycemia (blood glucose [BG] of <50mg/dL) were included in the study. Frequencies of all combinations of ≥4 risk factors contributing to the risk score among these patients were determined to identify common risk patterns. Clinical pharmacists developed clinical vignettes for each common pattern and formulated medication therapy management recommendations for hypoglycemia prevention.

RESULTS

A total of 401 admissions with a hypoglycemic event were identified among 1,875 admissions whose hypoglycemic risk was in the top fifth percentile among all admissions that received antihyperglycemic drugs and evaluated. Five distinct phenotypes emerged: (1) frail patients with history of hypoglycemia receiving insulin on hospital day 1, (2) a rapid downward trend in BG values in patients receiving an insulin infusion or with a history of hypoglycemia, (3) administration of insulin in the presence of an active nothing by mouth order in frail patients, (4) repeated low BG level in frail patients, and (5) inadequate night-time BG monitoring for patients on long-acting insulin. The 5 themes jointly described 53.0% of high-risk patients who experienced hypoglycemia.

CONCLUSION

Five distinct phenotypes that are prevalent in patients at greatest risk for inpatient hypoglycemia were identified.

Capnocytophaga spp. infection causing chorioamnionitis: an unusual suspect

Capnocytophaga spp. are not often considered as a cause of perinatal infection. However, Capnocytophaga spp. are a commensal of the human oral cavity and can be opportunistic pathogens. The present case illustrates the ability of a species from the human oral cavity, C. sputigena, to cause an ascending infection of the genital tract in a healthy pregnant woman.

Hepatotoxicity of immune checkpoint inhibitors: An evolving picture of risk associated with a vital class of immunotherapy agents

Immune checkpoint inhibitors (ICIs) block CTLA-4, PD-1 and PD-L1, or other molecules that control antitumour activities of lymphocytes. These products are associated with a broad array of immune-related toxicities affecting a variety of organs, including the liver. ICI-associated immune-mediated hepatitis (IMH) ranges in severity between mild and life-threatening and is marked by findings that bear both similarities as well as differences with idiopathic autoimmune hepatitis. Hepatotoxic events are often detected in clinical trials of ICIs that are powered for efficacy. Risk levels for ICI-induced liver injury may be impacted by the specific checkpoint molecule targeted for treatment, the ICI dose levels, and the presence of a pre-existing autoimmune diathesis, chronic infection or tumour cells which infiltrate the liver parenchyma. When patients develop liver injury during ICI treatment, a prompt assessment of the cause of injury, in conjunction with the application of measures to optimally manage the adverse event, should be made. Strategies to manage the risk of IMH include the performance of pretreatment liver tests with regular monitoring during and after ICI treatment and patient education. Using Common Terminology Criteria for Adverse Events developed at the National Cancer Institute to measure the severity level of liver injury, recommended actions may include continued ICI treatment with close patient monitoring, ICI treatment suspension or discontinuation and/or administration of corticosteroids or, when necessary, a non-steroidal immunosuppressive agent. The elucidation of reliable predictors of tumour-specific ICI treatment responses, as well as an increased susceptibility for clinically serious immune-related adverse events, would help optimize treatment decisions for individual patients.

Development and validation of a childhood self-efficacy for functional constipation questionnaire

BACKGROUND

Children with functional constipation fear painful bowel movements leading to stool withholding behavior. Self-efficacy is the belief that an individual can accomplish a given goal. If children with constipation avoid defecation because they think that they are unable defecate comfortably, this low self-efficacy may prevent treatment success. The aim of the current study was to develop and validate a constipation specific self-efficacy scale.

METHODS

The self-efficacy for functional constipation questionnaire (SEFCQ) was developed by the authors and evaluated by 10 children and seven experts. Ninety-nine healthy children and 122 children with functional constipation completed the SEFCQ and three other questionnaires measuring related constructs.

KEY RESULTS

Minor changes were made in wording based on feedback from experts and children. Factor analysis showed two scales, a 7 item Action scale (Cronbach's α = 0.88) and a 7 item Emotion scale (Cronbach α = 0.86). The SEFCQ total scale correlated positively with general self-efficacy (r = .32, P < .001) and quality of life (r = .20; P < .01) and negatively with anxiety (r = -.15; P < .05). Scores on the SEFCQ were higher in children without functional constipation compared to those with functional constipation (53.33 + 3.38 vs 39.34 + 7.19, P < .001).

CONCLUSIONS & INFERENCES

We developed a constipation specific self-efficacy questionnaire with good initial internal reliability, excellent face validity and adequate content validity. A low self-efficacy for defecation, may make the child resist their physical urge to defecate and hence, the need for further studies to assess its effect on treatment outcomes.

High dose IVIG successfully reduces high rhGAA IgG antibody titers in a CRIM-negative infantile Pompe disease patient

Alglucosidase alfa (rhGAA) has altered the course of an otherwise fatal outcome in classic infantile Pompe disease (IPD), which presents with cardiomyopathy and severe musculoskeletal involvement. However, the response to therapy is determined by several factors including the development of high and sustained antibody titers (HSAT) to rhGAA. Cross-reactive immunologic material (CRIM) negative patients are at the highest risk for development of HSAT. Immune tolerance induction (ITI) with methotrexate, rituximab, and intravenous immunoglobulin (IVIG) has been largely successful in preventing the immune response and in achieving tolerance when done in conjunction with enzyme replacement therapy (ERT) initiation. Reducing antibody titers in cases with an entrenched immune response remains a challenge in the field despite the use of multiple immunomodulatory agents. Success has been shown with addition of bortezomib to the ITI regimen, yet the prolonged course and potential risks with the use of such agents' demands caution. We present here a 7-year-old CRIM-negative IPD patient who was not successfully tolerized by an ITI regimen with rituximab, methotrexate, and IVIG due to intolerability to the regimen and recurrent infections. She went on to develop HSAT, with significant clinical decline, loss of all motor abilities, and a fragile medical state, which made it challenging to institute the bortezomib based regimen to reduce HSAT. She had severe developmental delay, respiratory failure with invasive ventilation and tracheostomy, persistent hypotonia, ptosis of eyelids, diffuse severe osteopenia, contractures, and was completely G-tube fed. As a rescue mechanism, we treated her with high dose and high frequency IVIG in an attempt to reduce rhGAA IgG antibody titers (antibody titers; titers). Her titers saw a steady decline on weekly IVIG doses at 1g/kg for 20weeks. Subsequently when the IVIG regimen was altered to 1g/kg every month, rising titers were detected and therefore the regimen was changed to a biweekly regimen. High dose IVIG resulted in an eightfold decrease in antibody titers. Clinically, she showed improvement with partial recovery of previously lost motor abilities, especially hand movements and better head and neck control than before. The regimen was safely tolerated with no hospitalizations. The effectiveness of IVIG as a single agent, in this case with multiple comorbidities and fragile clinical status, was lifesaving and may represent an effective, perhaps lifesaving rescue approach to reduce antibody titers.

Serum levels of the immunomodulatory protein, the progesterone induced blocking factor (PIBF) which is found in high levels during pregnancy is not higher in women with progesterone (P) receptor (R) positive vs. negative breast cancer

PURPOSE

To determine if serum levels of the immunomodulatory protein, the progesterone induced blocking factor (PIBF), which is present in high levels during normal pregnancy, is present in higher levels in women with breast cancer positive for progesterone receptors. The study would also determine whether the presence or absence of the estrogen receptor in any way modifies PIBF expression.

MATERIALS AND METHODS

PIBF using a research ELISA was evaluated in the follicular phase in 21 women with receptor status as follows: seven with estrogen receptor (ER)+ and progesterone receptor (PR)+, seven with ER- and PR+, and seven with ER+ and PR.

RESULTS

The results showed no differences in serum PIBF in the three groups. The serum PIBF levels were no different than historical controls in the follicular phase.

CONCLUSIONS

Measurement of serum PIBF does not seem to be an important marker to use to either detect women with breast cancer or to help determine tumor virulence or potential specific therapies. If PIBF plays a role in helping cancer cells to escape immune surveillance, it seems that the intracytoplasmic PIBF would be the form most likely operative.

Role of Chemotherapy and Rituximab for Treatment of Posttransplant Lymphoproliferative Disorder in Solid Organ Transplantation

Objective:

To evaluate the role of chemotherapy and/or rituximab for treatment of posttransplant lymphoproliferative disorder (PTLD) in solid organ transplantation.

Data Sources:

A MEDLINE search (1966–May 2007) was conducted using the key words posttransplant lymphoproliferative disorder, solid organ transplantation, chemotherapy, and rituximab. References of relevant articles and abstracts from recent hematology, oncology, and transplantation scientific meetings (2004–May 2007) were also reviewed.

Study Selection and Data Extraction:

Prospective and retrospective studies identified from the data sources were evaluated, and all information deemed relevant was included for this review.

Data Synthesis:

Overall response rates ranged from 53% to 68%, 25% to 83%, and 74% to 100% for rituximab monotherapy, chemotherapy, and chemotherapy plus rituximab, respectively. Positive response to treatment was influenced by prognostic factors, including presence of Epstein-Barr virus in tumor cells, normal lactate dehydrogenase levels, good performance status, early disease onset after transplantation, and early disease stages. These factors in study patients likely contribute to the variability in response rates seen between treatment options. Severe adverse effects, ranging from grade 3 neutropenia to infection resulting in death, occurred more frequently in patients receiving chemotherapy than in patients receiving only rituximab.

Conclusions:

Although reduction in immunosuppressive medications remains the first-line therapy for PTLD treatment, many cases do not respond to this treatment alone, especially monomorphic or more aggressive cases of lymphoma. Therefore, it is reasonable to begin active treatment including rituximab and/or chemotherapy initially, along with reduction in immunosuppression in many cases. Further prospective, comparative studies are urgently needed to confirm the efficacy of these treatment strategies as well as to clarify which subset of patients may benefit most from them.

Immune response to enzyme replacement therapies in lysosomal storage diseases and the role of immune tolerance induction

The US Food and Drug Administration (FDA) and National Organization for Rare Disease (NORD) convened a public workshop titled "Immune Responses to Enzyme Replacement Therapies: Role of Immune Tolerance Induction" to discuss the impact of anti-drug antibodies (ADAs) on efficacy and safety of enzyme replacement therapies (ERTs) intended to treat patients with lysosomal storage diseases (LSDs). Participants in the workshop included FDA staff, clinicians, scientists, patients, industry, and advocacy group representatives. The risks and benefits of implementing prophylactic immune tolerance induction (ITI) to reduce the potential clinical impact of antibody development were considered. Complications due to immune responses to ERT are being recognized with increasing experience and lengths of exposure to ERTs to treat several LSDs. Strategies to mitigate immune responses and to optimize therapies are needed. Discussions during the workshop resulted in the identification of knowledge gaps and future areas of research, as well as the following proposals from the participants: (1) systematic collection of longitudinal data on immunogenicity to better understand the impact of ADAs on long-term clinical outcomes; (2) development of disease-specific biomarkers and outcome measures to assess the effect of ADAs and ITI on efficacy and safety; (3) development of consistent approaches to ADA assays to allow comparisons of immunogenicity data across different products and disease groups, and to expedite reporting of results; (4) establishment of a system to widely share data on antibody titers following treatment with ERTs; (5) identification of components of the protein that are immunogenic so that triggers and components of the immune responses can be targeted in ITI; and (6) consideration of early ITI in patients who are at risk of developing clinically relevant ADA that have been demonstrated to worsen treatment outcomes.

Development and characterization of the α3β4α5 nicotinic receptor cellular membrane affinity chromatography column and its application for on line screening of plant extracts

The α3β4α5 nAChR has been recently shown to be a useful target for smoking cessation pharmacotherapies. Herein, we report on the development and characterization of the α3β4α5 nicotinic receptor column by frontal displacement chromatography. The binding affinity of the nicotine and minor alkaloids found in tobacco smoke condensates were determined for both the α3β4 and α3β4α5 nicotinic receptors. It was demonstrated that while no subtype selectivity was observed for nicotine and nornicotine, anabasine was selective for the α3β4α5 nicotinic receptor. The non-competitive inhibitor binding site was also studied and it was demonstrated while mecamylamine was not selective between subtypes, buproprion showed subtype selectivity for the α3β4 nicotinic receptor. The application of this methodology to complex mixtures was then carried out by screening aqueous-alcoholic solutions of targeted plant extracts, including Lycopodium clavatum L. (Lycopodiaceae) and Trigonella foenum graecum L. (Fabaceae) against both the α3β4 and α3β4α5 nAChRs.

Refractive index measurements of poly(methyl methacrylate) (PMMA) from 0.4-1.6 μm

Using a transmission-spectrum-based method, the refractive index of a 50 μm thick sample of poly(methyl methacrylate) (PMMA) was measured as a function of wavelength. To mitigate the effects of nonplane-parallel surfaces, the sample was measured at 16 different locations. The technique resulted in the measurement of index at several thousand independent wavelengths from 0.42 to 1.62 μm, with a relative RMS accuracy <0.5×10(-4) and absolute accuracy <2×10(-4).

Distinct Profiles for Mitochondrial t-RNAs and Small Nucleolar RNAs in Locally Invasive and Metastatic Colorectal Cancer

PURPOSE

To gain insight into factors involved in tumor progression and metastasis, we examined the role of noncoding RNAs in the biologic characteristics of colorectal carcinoma, in paired samples of tumor together with normal mucosa from the same colorectal carcinoma patient. The tumor and healthy tissue samples were collected and stored under stringent conditions, thereby minimizing warm ischemic time.

EXPERIMENTAL DESIGN

We focused particularly on distinctions among high-stage tumors and tumors with known metastases, performing RNA-Seq analysis that quantifies transcript abundance and identifies novel transcripts.

RESULTS

In comparing 35 colorectal carcinomas, including 9 metastatic tumors (metastases to lymph nodes and lymphatic vessels), with their matched healthy control mucosa, we found a distinct signature of mitochondrial transfer RNAs (MT-tRNA) and small nucleolar RNAs (snoRNA) for metastatic and high-stage colorectal carcinoma. We also found the following: (i) MT-TF (phenylalanine) and snord12B expression correlated with a substantial number of miRNAs and mRNAs in 14 colorectal carcinomas examined; (ii) an miRNA signature of oxidative stress, hypoxia, and a shift to glycolytic metabolism in 14 colorectal carcinomas, regardless of grade and stage; and (iii) heterogeneous MT-tRNA/snoRNA fingerprints for 35 pairs.

CONCLUSIONS

These findings could potentially assist in more accurate and predictive staging of colorectal carcinoma, including identification of those colorectal carcinomas likely to metastasize.

Induction of antigen specific transplantation tolerance using chimeric antigen receptor type T cells engineered to kill allospecific T cells by a gene therapy immunotherapeutic approach (TRAN2P.968)

Development of specific immunotherapies to prevent graft rejection and graft-versus-host disease offers the promise of selectively deleting only allospecific immune responses. Veto activity is the ability of a cell to specifically suppress/delete only T cells directed against antigens of the veto cells themselves, but not against third-party antigens. In the present study, we reasoned that providing TCR-like signaling to allogeneic major histocompatibility complex (MHC) molecules on the surface of CD8+CTLs might result in enhanced veto function. To generate the donor antigen specific veto cells, we have utilized the Chimeric Antigen Receptor (CAR) T cell approach, in which CD8+CTLs express an MHC alloantigen fused to signaling molecule apparatuses. We fused mouse MHC class I alloantigen (H-2Dd) to the hinge and trans-membrane domains of the mouse CD8 chain plus intracellular signaling sequences derived from mouse 4-1BB, and CD3-ζ chain creating various CAR constructs. These CARs were cloned into retroviral vectors. Ex-vivo transduced T cells (FVB-Dd) were adoptively transferred in the recipient parental mice strain (FVB-H-2q) which do not express Dd. Two weeks post-adoptive transfer, we detected low levels of Dd+CD8+ T cells in lymph node and spleen, ranging from 0.2-1.2% of total CD8+ T cells. Veto activity of these Dd+CD8+T cells will be examined by in vitro Dd specific CTL assays, proliferation assays, and rejection of Dd skin grafts in parental strain (FVB) mice.

The national incidence and clinical picture of SLE in children in Australia – a report from the Australian Paediatric Surveillance Unit

Objectives

The objectives of this paper are to prospectively determine the incidence of paediatric systemic lupus erythematosus (pSLE) in Australia as well as describe the demographics, clinical presentation and one-year outcome.

Study design

Newly diagnosed cases of pSLE were ascertained prospectively from October 2009 to October 2011 through the Australian Paediatric Surveillance Unit (a national monthly surveillance scheme for notification of childhood rare diseases) as well as national subspecialty groups. Questionnaires were sent to notifying physicians at presentation and at one year.

Results

The annual incidence rate was 0.32 per 105 children aged less than 16 years. The incidence was significantly higher in children of Asian or Australian Aboriginal and Torres Strait Islander parents. Approximately one-third of children underwent a renal biopsy at presentation and 7% required dialysis initially although only one child had end-stage kidney disease (ESKD) at one-year follow-up.

Conclusion

The incidence of pSLE in Australia is comparable to that worldwide with a significantly higher incidence seen in children of Asian and Australian Aboriginal and Torres Strait Islander backgrounds. Renal involvement is common but progression to ESKD, at least in the short term, is rare.

Rescue of vaccine T cell memory following sublethal gamma irradiation (VAC3P.952)

Subsequent to sublethal γ radiation exposure, survivors reacquire immune competence, but lose vaccine immunity. Our goal is to rescue CD8+ T cell-mediated memory responses following γ radiation exposure. In a mouse model of Listeria monocytogenes (LM) infection, we found that rapid revaccination (rescue) of immunized mice following irradiation preserves CD8+ T cell mediated immunity. Rescued mice are able to survive a wild type LM challenge infection when the rescue vaccine strain, LM-deltaActA, is given 0-3 days following radiation exposure. A signature of rescue was revealed in gene profiling studies in which a group of cytokines and chemokines were uniquely up regulated in the spleens of LM-rescued animals as compared to mice irradiated without rescue. These included factors important in resistance to LM, such as proinflammatory factors CCL2, TNFα, and IL-6 and bacterocidal factors CXCL9, 10, and 11 as well as anti-apoptotic factors including IL-15 and IER3, which may have a role in rescue of memory CTL. RAW264.7, a macrophage cell line, produced a similar cytokine profile when irradiated and infected with LM, suggesting a probable myeloid source for the majority of these factors. Monocyte activation by the combination of irradiation and LM infection may thus create conditions of rescue by producing cytokines and chemokines that enhance clearance of LM and rescue CD8+ CTL mediating vaccine immunity.

New FDA draft guidance on immunogenicity

A "Late Breaking" session was held on May 20 at the 2013 American Association of Pharmaceutical Scientists-National Biotech Conference (AAPS-NBC) to discuss the US Food and Drug Administration's (FDA) 2013 draft guidance on Immunogenicity Assessment for Therapeutic Protein Products. The session was initiated by a presentation from the FDA which highlighted several key aspects of the 2013 draft guidance pertaining to immunogenicity risk, the potential impact on patient safety and product efficacy, and risk mitigation. This was followed by an open discussion on the draft guidance which enabled delegates from biopharmaceutical companies to engage the FDA on topics that had emerged from their review of the draft guidance. The multidisciplinary audience fostered an environment that was conducive to scientific discussion on a broad range of topics such as clinical impact, immune mitigation strategies, immune prediction and the role of formulation, excipients, aggregates, and degradation products in immunogenicity. This meeting report highlights several key aspects of the 2013 draft guidance together with related dialog from the session.