Targeting refractory/recurrent neuroblastoma and osteosarcoma with anti-CD3×anti-GD2 bispecific antibody armed T cells

BACKGROUND

The survival benefit observed in children with neuroblastoma (NB) and minimal residual disease who received treatment with anti-GD2 monoclonal antibodies prompted our investigation into the safety and potential clinical benefits of anti-CD3×anti-GD2 bispecific antibody (GD2Bi) armed T cells (GD2BATs). Preclinical studies demonstrated the high cytotoxicity of GD2BATs against GD2+cell lines, leading to the initiation of a phase I/II study in recurrent/refractory patients.

METHODS

The 3+3 dose escalation phase I study (NCT02173093) encompassed nine evaluable patients with NB (n=5), osteosarcoma (n=3), and desmoplastic small round cell tumors (n=1). Patients received twice-weekly infusions of GD2BATs at 40, 80, or 160×106 GD2BATs/kg/infusion complemented by daily interleukin-2 (300,000 IU/m2) and twice-weekly granulocyte macrophage colony-stimulating factor (250 µg/m2). The phase II segment focused on patients with NB at the dose 3 level of 160×106 GD2BATs/kg/infusion.

RESULTS

Of the 12 patients enrolled, 9 completed therapy in phase I with no dose-limiting toxicities. Mild and manageable cytokine release syndrome occurred in all patients, presenting as grade 2-3 fevers/chills, headaches, and occasional hypotension up to 72 hours after GD2BAT infusions. GD2-antibody-associated pain was minimal. Median overall survival (OS) for phase I and the limited phase II was 18.0 and 31.2 months, respectively, with a combined OS of 21.1 months. A phase I NB patient had a complete bone marrow response with overall stable disease. In phase II, 10 of 12 patients were evaluable: 1 achieved partial response, and 3 showed clinical benefit with prolonged stable disease. Over 50% of evaluable patients exhibited augmented immune responses to GD2+targets post-GD2BATs, as indicated by interferon-gamma (IFN-γ) EliSpots, Th1 cytokines, and/or chemokines.

CONCLUSIONS

This study demonstrated the safety of GD2BATs up to 160×106 cells/kg/infusion. Coupled with evidence of post-treatment endogenous immune responses, our findings support further investigation of GD2BATs in larger phase II clinical trials.

Phase I study targeting newly diagnosed grade 4 astrocytoma with bispecific antibody armed T cells (EGFR BATs) in combination with radiation and temozolomide

PURPOSE

The purpose of this study was to determine the safety, feasibility, and immunologic responses of treating grade 4 astrocytomas with multiple infusions of anti-CD3 x anti-EGFR bispecific antibody (EGFRBi) armed T cells (EGFR BATs) in combination with radiation and chemotherapy.

METHODS

This phase I study used a 3 + 3 dose escalation design to test the safety and feasibility of intravenously infused EGFR BATs in combination with radiation and temozolomide (TMZ) in patients with newly diagnosed grade 4 astrocytomas (AG4). After finding the feasible dose, an expansion cohort with unmethylated O6-methylguanine-DNA methyltransferase (MGMT) tumors received weekly EGFR BATs without TMZ.

RESULTS

The highest feasible dose was 80 × 109 EGFR BATs without dose-limiting toxicities (DLTs) in seven patients. We could not escalate the dose because of the limited T-cell expansion. There were no DLTs in the additional cohort of three patients with unmethylated MGMT tumors who received eight weekly infusions of EGFR BATs without TMZ. EGFR BATs infusions induced increases in glioma specific anti-tumor cytotoxicity by peripheral blood mononuclear cells (p < 0.03) and NK cell activity (p < 0.002) ex vivo, and increased serum concentrations of IFN-γ (p < 0.03), IL-2 (p < 0.007), and GM-CSF (p < 0.009).

CONCLUSION

Targeting AG4 with EGFR BATs at the maximum feasible dose of 80 × 109, with or without TMZ was safe and induced significant anti-tumor-specific immune responses. These results support further clinical trials to examine the efficacy of this adoptive cell therapy in patients with MGMT-unmethylated GBM.

CLINICALTRIALS

gov Identifier: NCT03344250.

The UHRF1 protein is a key regulator of retrotransposable elements and innate immune response to viral RNA in human cells

While epigenetic mechanisms such as DNA methylation and histone modification are known to be important for gene suppression, relatively little is still understood about the interplay between these systems. The UHRF1 protein can interact with both DNA methylation and repressive chromatin marks, but its primary function in humans has been unclear. To determine what that was, we first established stable UHRF1 knockdowns (KD) in normal, immortalized human fibroblasts using targeting shRNA, since CRISPR knockouts (KO) were lethal. Although these showed a loss of DNA methylation across the whole genome, transcriptional changes were dominated by the activation of genes involved in innate immune signalling, consistent with the presence of viral RNA from retrotransposable elements (REs). We confirmed using mechanistic approaches that 1) REs were demethylated and transcriptionally activated; 2) this was accompanied by activation of interferons and interferon-stimulated genes and 3) the pathway was conserved across other adult cell types. Restoring UHRF1 in either transient or stable KD systems could abrogate RE reactivation and the interferon response. Notably, UHRF1 itself could also re-impose RE suppression independent of DNA methylation, but not if the protein contained point mutations affecting histone 3 with trimethylated lysine 9 (H3K9me3) binding. Our results therefore show for the first time that UHRF1 can act as a key regulator of retrotransposon silencing independent of DNA methylation.

Targeting GD2-positive Refractory/Resistant Neuroblastoma and Osteosarcoma with Anti- CD3 x Anti-GD2 Bispecific Antibody Armed T cells

Background

Since treatment of neuroblastoma (NB) with anti-GD2 monoclonal antibodies provides a survival benefit in children with minimal residual disease and our preclinical study shows that anti-CD3 x anti-GD2 bispecific antibody (GD2Bi) armed T cells (GD2BATs) were highly cytotoxic to GD2+ cell lines, we conducted a phase I/II study in recurrent/refractory patients to establish safety and explore the clinical benefit of GD2BATs.

Methods

The 3+3 dose escalation study (NCT02173093) phase I involved 9 evaluable patients with NB (n=5), osteosarcoma (OST) (n=3), and desmoplastic small round cell tumors (DSRCT) (n=1) with twice weekly infusions of GD2BATs at 40, 80, or 160 x 106 GD2BATs/kg/infusion with daily interleukin 2 (300,000 IU/m2) and twice weekly granulocyte-macrophage colony stimulating factor (250 μg/m2). Phase II portion of the trial was conducted in patients with NB at the dose 3 level of 160 x 106 GD2BATs/kg/infusion but failed to enroll the planned number of patients.

Results

Nine of 12 patients in the phase I completed therapy. There were no dose limiting toxicities (DLTs). All patients developed mild and manageable cytokine release syndrome (CRS) with grade 2-3 fevers/chills, headaches, and occasional hypotension up to 72 hours after GD2BAT infusions. GD2-antibody associated pain was not significant in this study. The median OS for patients in the Phase I and limited Phase II was 18.0 and 31.2 months, respectively, whereas the combined OS was 21.1 months. There was a complete bone marrow response with overall stable disease in one of the phase I patients with NB. Ten of 12 phase II patients were evaluable for response: 1 had partial response. Three additional patients were deemed to have clinical benefit with prolonged stable disease. More than 50% of evaluable patients showed augmented immune responses to GD2+ targets after GD2BATs as measured by interferon-gamma (IFN-γ) EliSpots, Th1 cytokines, and/or chemokines.

Conclusions

Our study demonstrated safety of up to 160 x 106 cells/kg/infusion of GD2BATs. Combined with evidence for the development of post treatment endogenous immune responses, this data supports further investigation of GD2 BATs in larger Phase II clinical trials.

Initial Report of a Randomized Trial Comparing Conventional vs. Novel Treatment Planning Technique to Ameliorate Immunosuppression from Lung SBRT

PURPOSE/OBJECTIVE(S)

SBRT is highly effective against early-stage non-small cell lung cancer. Radiation Therapy (RT) is known to modulate the immune system and contribute to the generation of anti-tumor T cells and stimulate T cell infiltration into tumors. However, this anti-tumor activity is offset by radiation-induced immunosuppression (RIIS) which results in lower tumor control and survival. Lymphocytes are highly radiosensitive and RIIS means destroying existing as well as newly created cytotoxic and helper T lymphocytes. We hypothesized that optimizing RT treatment planning by considering circulating blood and lymphatics as a critical Organ at Risk (OAR) may mitigate RIIS.

MATERIALS/METHODS

We conducted an IRB approved NCI funded clinical trial for 50 early-stage lung cancer patients treated with SBRT alone, from 2020 to 2023, to investigate the ability to reduce RIIS by reducing dose to circulating blood and lymphatics with the aid of a predictive algorithm. All SBRT plans adhered to treatment parameters from RTOG 0813 (central) or RTOG 0915 (peripheral). Patients were randomized to two arms: experimental optimization for RIIS (to reduce dose to blood and lymphatic rich organs) versus standard SBRT planning (without optimization for RIIS). Peripheral blood samples were collected at baseline, end of Tx, 4 weeks and 6 months post Tx. Patients with baseline absolute lymphocyte counts (ALC) less than 0.5x109 cells/L were ineligible for the trial. Data acquired for all blood cell types as well as lymphocyte sub populations CD3+, CD4+, CD8+, CD19+, CD56+. Two sample t-test was used to determine the statistical significance between the cohorts at the time points.

RESULTS

The standard arm had an ALC reduction of 28% at one week post Tx and a nadir at 4 weeks with a 34% reduction. Absolute percentage reductions in ALC from baseline in the optimized arm compared to the standard arm are: end of treatment point (13%, p = 0.03), 4 weeks (12%, p = 0.08), 6 months (15%, p = 0.1), and all three time points together 13% (p = 0.001). ALC recovery appears to be faster in the optimized arm. Radiation induced suppression of all blood cell types are also reduced in the optimized arm with respect to standard arm (relative percentages): ALC (34%), WBC (47%), RBC (46%), platelets (40%), monocytes (100%), and neutrophils (62%) at 4-week mark. Average percentage reductions on integral doses, and V5 (volume receiving a 5 Gy dose) of optimized compared to standard plans are: aorta: 26%, 41% heart: 8%, 33%, vena cava: 32%, 52%, T spine: 51%, 81%, lymph nodes: 35%, 57%, total lung- ITV: 1.6%, 1%, body: 10%, 14%.

CONCLUSION

For the first time, we have shown that it is possible to reduce RIIS in a statistically significant manner, compared to standard of care, via optimized RT planning using a predictive model. This has implications in increasing the efficacy of immunotherapy by preserving the existing tumor reactive T cells in the immune system to enhance anti-tumor activity, and in reducing hospitalizations and improving survival.

The relationship between physical activity, structural deformity, and spinal mobility in adolescent idiopathic scoliosis patients

PURPOSE

Adolescent idiopathic scoliosis (AIS) patients experience structural spinal deformity, but the impact of AIS on physical activity is not widely studied. Reports of physical activity levels between children with AIS and their peers are mixed. This study sought to characterize the relationship between spinal deformity, spinal range of motion, and self-reported physical activity in AIS patients.

METHODS

Patients aged 11-21 completed self-reported measures of physical activity using the HSS Pedi-FABS and PROMIS Physical Activity questionnaires. Radiographic measures were obtained from standing biplanar radiographic imaging. Surface topographic (ST) imaging data was obtained using a whole-body ST scanning system. Hierarchical linear regression models analyzed the relationship between physical activity, ST, and radiographic deformity while controlling for age and BMI.

RESULTS

149 patients with AIS (mean age 14.5 ± 2.0 years, mean Cobb angle 39.7° ± 18.9°) were included. In the hierarchical regression predicting physical activity from Cobb angle, no factors were significant predictors of physical activity. When predicting physical activity from ST ROM measurements, age and BMI served as covariates. No covariates or ST ROM measurements were significant predictors of physical activity levels for either activity measure.

CONCLUSIONS

Physical activity levels of patients with AIS were not predicted by levels of radiographic deformity or surface topographic range of motion. Although patients may experience severe structural deformity and range of motion limitations, these factors do not appear to be associated with decreased physical activity level utilizing validated patient activity questionnaires.

LEVEL OF EVIDENCE

Level II.

Novel anti-CD30/CD3 bispecific antibodies activate human T cells and mediate potent anti-tumor activity

CD30 is expressed on Hodgkin lymphomas (HL), many non-Hodgkin lymphomas (NHLs), and non-lymphoid malignancies in children and adults. Tumor expression, combined with restricted expression in healthy tissues, identifies CD30 as a promising immunotherapy target. An anti-CD30 antibody-drug conjugate (ADC) has been approved by the FDA for HL. While anti-CD30 ADCs and chimeric antigen receptors (CARs) have shown promise, their shortcomings and toxicities suggest that alternative treatments are needed. We developed novel anti-CD30 x anti-CD3 bispecific antibodies (biAbs) to coat activated patient T cells (ATCs) ex vivo prior to autologous re-infusions. Our goal is to harness the dual specificity of the biAb, the power of cellular therapy, and the safety of non-genetically modified autologous T cell infusions. We present a comprehensive characterization of the CD30 binding and tumor cell killing properties of these biAbs. Five unique murine monoclonal antibodies (mAbs) were generated against the extracellular domain of human CD30. Resultant anti-CD30 mAbs were purified and screened for binding specificity, affinity, and epitope recognition. Two lead mAb candidates with unique sequences and CD30 binding clusters that differ from the ADC in clinical use were identified. These mAbs were chemically conjugated with OKT3 (an anti-CD3 mAb). ATCs were armed and evaluated in vitro for binding, cytokine production, and cytotoxicity against tumor lines and then in vivo for tumor cell killing. Our lead mAb was subcloned to make a Master Cell Bank (MCB) and screened for binding against a library of human cell surface proteins. Only huCD30 was bound. These studies support a clinical trial in development employing ex vivo-loading of autologous T cells with this novel biAb.

SARS-CoV-2 Infection in Children with Idiopathic Nephrotic Syndrome: A Multicentric Study

A multicenter retrospective study was conducted to assess the clinical spectrum of 30 severe acute respiratory syndrome coronavirus (SARS-CoV-2)-positive children with idiopathic nephrotic syndrome. Difficult to treat nephrotic syndrome was found to be a high-risk group with a high incidence of acute kidney injury and mortality.

Indian languages, print journals and the UGC-CARE project

Purpose

The purpose of this study is to examine Indian language journals published in Arts, Humanities and Social Sciences (AHSS) included in the UGC-CARE list, which is an initiative of the University Grants Commission (UGC) of India. This study argues that although these journals do not appear in international databases, they are valuable because they frequently publish and have published for years, opinions, memoirs and critical review articles, especially the local culture.

Design/methodology/approach

This study examines 298 journals categorised into two groups: monolingual (189) and multilingual (109). The first group included 189 journals published in 15 Indian languages. Monolingual journals were examined using five criteria: year of publication, subject area, frequency, language and geographical zone of the publisher. Multilingual journals analysed as per languages covered.

Findings

The analysis reveals that the UGC-CARE List includes journals published between 1899 and 2019. The most common languages are Hindi (67), Urdu (31), Sanskrit (9) and Marathi (26). The frequency of majority (114) of journals is quarterly. Associations, universities, individual publishers and learned societies as publishers are dominant. Analysis of multilingual journals indicated that the highest number of journals (34) are published in English and Hindi.

Practical implications

Journals that fulfil the stringer criteria of three UGC-CARE journal analysis protocols find a place in the CARE List. The list is dynamic and is updated quarterly to maintain its currency and therefore its credibility. The list is available at http://ugccare.unipune.ac.in and is the list preferred by Indian Higher Education Institutes.

Originality/value

UGC-CARE List includes journals published by Indian publishers especially in the fields of Arts, Humanities and Social Sciences. It is the first initiative to battle against the predatory journals and effort to bring the Indian legacy of journals on the world map of journals and periodicals.

Phase II Trial of Pembrolizumab and Anti-CD3 x Anti-HER2 Bispecific Antibody-Armed Activated T Cells in Metastatic Castration-Resistant Prostate Cancer

PURPOSE

A phase II study was conducted to evaluate the safety and efficacy of the combination of HER2 bispecific antibody (HER2Bi)-armed activated T cells (HER2 BAT) and programmed death 1 inhibitor, pembrolizumab.

PATIENTS AND METHODS

Patients with metastatic castration-resistant prostate cancer (mCRPC) with 0 to 1 performance status and normal liver, kidney, and marrow function, pre- or post-docetaxel chemotherapy were eligible. Primary endpoint was 6-month progression-free survival (PFS). Peripheral blood mononuclear cells were obtained by a single apheresis, shipped to University of Virginia, activated with OKT3 and expanded for 14 days in IL2, harvested, and armed with HER2Bi and cryopreserved. HER2 BATs were infused twice weekly for 4 weeks and pembrolizumab was administered every 21 days for a maximum duration of 6 months starting 1 to 3 weeks prior to HER2 BATs infusion.

RESULTS

Fourteen patients were enrolled with a median age of 69 (range 57-82 years) and median PSA of 143.4 (range 8.2-4210 ng/dL). Two patients had peritoneal metastases, 1 had lymph node (LN) only metastases and 11 had bone metastases of which 7 had bone and LN metastases. All were pretreated with androgen receptor axis targeted agents and 7 (50%) had prior docetaxel chemotherapy. The toxicities were grade1-2 infusion reactions with fever, chills, headaches, nausea and/or myalgias. Primary endpoint of 6 month PFS was achieved in 5 of 14 patients (38.5%; 95% confidence interval, 19.5%-76.5%). Median PFS was 5 months and median survival was 31.6 months.

CONCLUSIONS

The safety and promising efficacy makes this combination worthy of future investigation in mCRPC.

Antenatal depression and its correlates - a cross-sectional study in an urban resettlement colony of Delhi

Background- Antenatal depression is affecting 10% pregnant women worldwide with higher prevalence in developing countries. This causes poor maternal and foetal outcome and also affects cognitive development of the child. Aim and objective: To estimate magnitude of antenatal depression and its risk factors. Methodology- A cross-sectional survey was done at the antenatal clinic of community health department catering to an urban resettlement colony, East Delhi. Estimated sample size was 216 (including 10% non-response rate). Pregnant women attending the ANC clinic from October 2019 to February 2020 were enrolled. EPDS questionnaire was used to assess depression during pregnancy. Results-The antenatal depression was found in 11.8% subjects as per EPDS score. Working female and belonging to Muslim religion, past history of abortion, complications in previous pregnancy, financial debt, physical violence and substance use in family showed significant association with antenatal depression. Conclusion –Depression was prevalent among antenatal women and was found to be associated with various risk factors.

Therapeutic potential of Pogostemon cablin herb: a comprehensive review

Pogostemon cablin (Pogostemon patchouli or Patchouli) is known for its essential oil and is a popular medicinal herb in Indian Ayurveda and traditional Chinese medicine. This review covers patent articles on the P. cablin plant's therapeutic effects. The patent literature was collected using a thorough, comprehensive search on databases like Thomson Innovation, Espacenet, Patentscope, The Lens and Patent digital libraries of different Jurisdictions, including IPO, USPTO, CNIPA, inPASS, KIPO, JPO, etc. Despite the vast number of review articles on non-patent literature, none of the articles reviewed the patent literature. This current P. cablin literature analysis study will facilitate bridging the gap between further exploring the potential of this plant through novel investigations.

Bispecific antibody-targeted T-cell therapy for acute myeloid leukemia

The management of relapsed or refractory acute myeloid leukemia (AML) continues to be therapeutically challenging. Non-toxic immunotherapy approaches are needed to provide long-term anti-leukemic effects. The goal of this study was to determine whether activated T cells (ATCs) armed with bispecific antibodies (BiAbs) could target and lyse leukemic and leukemic stem cells (LSCs). Anti-CD3 × anti-CD123 BiAb (CD123Bi) and anti-CD3 × anti-CD33GO (gemtuzumab ozogamicin [GO]) BiAb (CD33GOBi) were used to arm ATCs to produce bispecific antibody armed activated T cells (designated CD123 BATs or CD33GO BATs) to target AML cell lines, peripheral blood mononuclear cells from AML patients, and in vivo treatment of AML in xenogeneic NSG mice engrafted with leukemic cells. BATs exhibited high levels of specific cytotoxicity directed at AML cell lines at low 1:1 or 1:2 effector-to-target (E:T) ratios and secrete Th₁ cytokines upon target engagement. In vivo study in AML-engrafted NSG mice showed significantly prolonged survival in mice treated with CD33GO BATs (p < 0.0001) or CD123 BATs (p < 0.0089) compared to ATC-treated control mice. Patient samples containing leukemic blasts and LSCs when treated with CD33GO BATs or CD123 BATs for 18 h showed a significant reduction (50%-100%; p < 0.005) in blasts and 75%-100% reduction in LSCs (p < 0.005) in most cases compared to unarmed ATCs. This approach may provide a potent and non-toxic strategy to target AML blasts and LSCs and enhance chemo-responsiveness in older patients who are likely to develop recurrent diseases.

Novel PE and APC tandems: Additional near-infrared fluorochromes for use in spectral flow cytometry

Recent advances in flow cytometry instrumentation and fluorochrome chemistries have greatly increased fluorescent conjugated antibody combinations that can be used reliably and easily in routine experiments. The Cytek Aurora flow cytometer was first released with three excitation lasers (405, 488, and 640 nm) and incorporated the latest Avalanche Photodiode (APD) technology, demonstrating significant improvement in sensitivity for fluorescent emission signals longer than 800 nm. However, there are limited commercially available fluorochromes capable of excitation with peak emission signals beyond 800 nm. To address this gap, we engineered six new fluorochromes: PE-750, PE-800, PE-830 for the 488 nm laser and APC-750, APC-800, APC-830 for the 640 nm laser. Utilizing the principal of fluorescence resonance energy transfer (FRET), these novel structures were created by covalently linking a protein donor dye with an organic small molecule acceptor dye. Additionally, each of these fluorochrome conjugates were shown to be compatible with fixation/permeabilization buffer reagents, and demonstrated acceptable brightness and stability when conjugated to antigen-specific monoclonal antibodies. These six novel fluorochrome reagents can increase the numbers of fluorochromes that can be used on a spectral flow cytometer.

P271 A masquerading case of Cryptococcus neoformans

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

 

Introduction

Cryptococcal infections are commonly seen in immunocompromised hosts, especially HIV-infected patients and patients on immunosuppressive therapy. Cryptococcus shows a strong tropism for the central nervous system however cutaneous tropism is not uncommon. Here we describe an HIV-negative immunocompromised patient who developed disseminated cryptococcosis with the predominant presentation being painful thigh lesions.

Case Details

A 56-year-old lady presented with skin lesions and burning pain over both thighs for 1 month and a high-grade fever for 15 days. Her thigh lesions were initially treated elsewhere as tinea corporis. Her previous medical history was significant for poorly controlled diabetes, and chronic liver disease (secondary to autoimmune hepatitis or AIH). Her ongoing medications included prednisolone, anti-diabetics, and tenofovir. At presentation, the only significant physical findings were large irregular areas of central hypo-pigmentation with peripheral hyper-pigmentation and superficial small blisters over both thighs. These areas showed signs of inflammation. The empiric antimicrobial therapy included piperacillin-tazobactam and fluconazole (in view of prior urine culture growing Candida species). Over the next 48 h, fever continued, thigh pain worsened and the lesions on thighs blistered with violaceous discoloration. Her blood cultures sent at admission grew Candida kruzei, resistant to fluconazole, sensitive to voriconazole, amphotericin and echinocandins. Beta-D Glucan was also elevated. Fluconazole was discontinued, and anidulafungin was initiated. A repeat culture (prior to the start of anidulafungin) was still positive for C. krusei, but a subsequent blood culture (after the start of anidulafungin) was negative. Echocardiography did not show features of endocarditis. After a transient improvement, she worsened again with breakthrough fever, hypotension, and worsening of thigh lesions with eschar formation. Wound debridement was done, and antibiotics were escalated to carbapenem and polymyxins. Tissue cultures (sent during wound debridement) grew carbapenem-resistant klebsiella pneumonia. With these, the fever and her wounds were better; but the fever still persisted and she described a persisting severe burning pain over both the thigh wounds which did not respond to several analgesics.

A few days later, the fever worsened, and she had hypotension and disorientation. Blood and urine cultures were repeated. Repeat Serum beta D glucan levels were elevated. CSF examination was not possible in view of severe coagulopathy. The blood and wound cultures both grew C. neoformans (confirmed on MaldiTOFF). Antibiotics and anidulafungin were discontinued; liposomal amphotericin and flucytosine were started. Patient had significant improvement in sensorium, fever, and thigh pains within the next 72 h. Later, liposomal amphotericin was switched to conventional amphotericin because of financial constraints. This was followed by acute kidney injury and a flare of AIH. Amphotericin and flucytosine were withheld for a few days; a pulse of methylprednisolone was needed for AIH. Following resolution of acute kidney injury and AIH flare, conventional amphotericin B and flucytosine were restarted (and given for cumulative 3 weeks). This was followed by fluconazole consolidation. At hospital discharge, although there were raw areas over the thighs, these were healthy and she was otherwise well. A total of 3 months later, skin grafting was successfully performed.

Conclusions

Cryptococcus can be a great masquerader, and can mimic a variety of conditions. A high index of suspicion is required to clinch the diagnosis.

Review of 13carbon nuclear magnetic resonance characterizations of dimethyltin carboxylates

Diorganotin carboxylates have received much interest in past decades due to their rich structural chemistry and wide range of applications in various fields. This review study provides an in-depth analysis of carbon NMR data of dimethyltin complexes. The absorptions shown by the carbonyl carbon, methyl groups attached to tin and the other carbons present in the complexes were presented in this study. The effects of nature and the number of substituents attached are also described in this report.

Monkeypox Disease Outbreak (2022): Epidemiology, Challenges, and the Way Forward

The biggest-ever outbreak of monkeypox disease in non-endemic countries started in May, 2022. Though no monkeypox case has been reported from India, till mid-June, 2022, yet, considering the rate of spread to the non-endemic countries, there is an urgent need of better understanding of the monkeypox virus and disease epidemiology to help clinicians, public health specialists, and policymakers to be prepared for any eventuality. This review summarises the monkeypox disease epidemiology, clinical features, therapies, vaccines and outlines the measures for preparedness and response for a possible outbreak. The disease is known to cause severe outcome in children, pregnant women, and immunocompromised hosts and this group need to be given special attention. The monkeypox disease outbreak (2022) in non-endemic countries should be used as an opportunity by India and other low and middle income countries to strengthen public health surveillance and health system capacity for outbreak and epidemic preparedness and response.

Mental health and COVID-19: The impact of a virtual course for family caregivers of adults with intellectual and developmental disabilities

BACKGROUND

The COVID-19 pandemic has significantly impacted family caregivers of adults with intellectual and developmental disabilities (IDD). This study evaluated a virtual course for family caregivers from across Canada, focused on supporting the mental health and well-being of adults with IDD and their families. The evaluation examined the feasibility and acceptability of the course, as well as the impact of the intervention on participants' overall health and well-being.

METHODS

The 6-week virtual course, informed by a parallel Extension for Community Healthcare Outcomes (ECHO) course for service providers, combined didactic instruction with applied activities. A total of 126 family caregiver course participants consented to be part of the research evaluation delivered over three cycles between October 2020 and April 2021. Attendance was measured at each weekly session. Satisfaction was assessed weekly and post-program. Learning, self-efficacy, and well-being were assessed pre- and post-course, and again at follow-up (8 weeks post-course). Mixed-effects models assessed changes between and within individuals across time.

RESULTS

Participants had consistent attendance, low-dropout rates, and reported high satisfaction, with 93% of participants reporting that their expectations for the course were met. Compared with pre-course, participants reported improved self-efficacy and well-being post-course, which were maintained at follow-up.

CONCLUSIONS

An interactive and applied virtual education course delivered to a large group of family caregivers of adults with IDD was both feasible and acceptable. It positively impacted participants' well-being by offering much needed mental health support and creating a peer-led community of practice.

Monkeypox Disease Outbreak (2022): Epidemiology, Challenges, and the Way Forward

The biggest-ever outbreak of monkeypox disease in non-endemic countries started in May, 2022. Though no monkeypox case has been reported from India, till mid-June, 2022, yet, considering the rate of spread to the non-endemic countries, there is an urgent need of better understanding of the monkeypox virus and disease epidemiology to help clinicians, public health specialists, and policymakers to be prepared for any eventuality. This review summarises the monkeypox disease epidemiology, clinical features, therapies, vaccines and outlines the measures for preparedness and response for a possible outbreak. The disease is known to cause severe outcome in children, pregnant women, and immunocompromised hosts and this group need to be given special attention. The monkeypox disease outbreak (2022) in non-endemic countries should be used as an opportunity by India and other low and middle income countries to strengthen public health surveillance and health system capacity for outbreak and epidemic preparedness and response.

Convalescent Plasma for Preventing Critical Illness in COVID-19: a Phase 2 Trial and Immune Profile

The COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an unprecedented event requiring frequent adaptation to changing clinical circumstances. Convalescent immune plasma (CIP) is a promising treatment that can be mobilized rapidly in a pandemic setting. We tested whether administration of SARS-CoV-2 CIP at hospital admission could reduce the rate of ICU transfer or 28-day mortality or alter levels of specific antibody responses before and after CIP infusion. In a single-arm phase II study, patients >18 years-old with respiratory symptoms with confirmed COVID-19 infection who were admitted to a non-ICU bed were administered two units of CIP within 72 h of admission. Levels of SARS-CoV-2 detected by PCR in the respiratory tract and circulating anti-SARS-CoV-2 antibody titers were sequentially measured before and after CIP transfusion. Twenty-nine patients were transfused high titer CIP and 48 contemporaneous comparable controls were identified. All classes of antibodies to the three SARS-CoV-2 target proteins were significantly increased at days 7 and 14 post-transfusion compared with baseline (P < 0.01). Anti-nucleocapsid IgA levels were reduced at day 28, suggesting that the initial rise may have been due to the contribution of CIP. The groups were well-balanced, without statistically significant differences in demographics or co-morbidities or use of remdesivir or dexamethasone. In participants transfused with CIP, the rate of ICU transfer was 13.8% compared to 27.1% for controls with a hazard ratio 0.506 (95% CI 0.165-1.554), and 28-day mortality was 6.9% compared to 10.4% for controls, hazard ratio 0.640 (95% CI 0.124-3.298). IMPORTANCE Transfusion of high-titer CIP to non-critically ill patients early after admission with COVID-19 respiratory disease was associated with significantly increased anti-SARS-CoV-2 specific antibodies (compared to baseline) and a non-significant reduction in ICU transfer and death (compared to controls). This prospective phase II trial provides a suggestion that the antiviral effects of CIP from early in the COVID-19 pandemic may delay progression to critical illness and death in specific patient populations. This study informs the optimal timing and potential population of use for CIP in COVID-19, particularly in settings without access to other interventions, or in planning for future coronavirus pandemics.

A Study on the Effect of Soil and Sediment Types on the Fugacity Based Multimedia Partitioning of a Contact Fungicide Fluopyram: An Equilibrium Quality Criterion (EQC) Level 1 Approach

Equilibrium Quality Criterion (EQC) Level I calculations have been performed with Standard Equilibrium Quality Criterion (EQC) environment to study the environmental partitioning of a fungicide Fluopyram. Equilibrium Quality Criterion (EQC) Level I calculation assumes no degradation of the chemical, steady-state, and equilibrium conditions between the environmental compartments. The results reveal that the concentration of Fluopyram is expected to be maximum in the sediment compartment, followed by soil and water compartments. The effect of soil and sediment types on partitioning has been studied by systematically varying the densities of these two compartments. In the sediment compartment, the Fluopyram concentration is predicted to be highest if the sediment type is ‘sandy’ and the soil type is ‘clay’.

Granzyme B Is a Biomarker for Suspicion of Malignant Seromas Around Breast Implants

BACKGROUND

Granzyme B (GrB) is a serine protease secreted, along with pore-forming perforin, by cytotoxic lymphocytes to mediate apoptosis in target cells. GrB has been detected in tumor cells associated with systemic and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) but its potential use for detection of early BIA-ALCL has not been fully investigated.

OBJECTIVES

Prompted by the increased incidence of BIA-ALCL, the aim of this study was to assess GrB as a new biomarker to detect early disease in malignant seromas and to better understand the nature of the neoplastic cell.

METHODS

A Human XL Cytokine Discovery Magnetic Luminex 45-plex Fixed Panel Performance Assay was used to compare cytokine levels in cell culture supernatants of BIA-ALCL and other T-cell lymphomas, as well as malignant and benign seromas surrounding breast implants. Immunohistochemistry was employed to localize GrB to cells in seromas and capsular infiltrates.

RESULTS

Differences in GrB concentrations between malignant and benign seromas were significant (P < 0.001). GrB was found in and around apoptotic tumor cells, suggesting that the protease may be involved in tumor cell death.

CONCLUSIONS

GrB is a useful marker for early detection of malignant seromas and to identify tumor cells in seromas and capsular infiltrates. Because there is an overlap between the lowest concentrations of soluble GrB in malignant seromas and the highest concentrations of GrB in benign seromas, it is recommended that GrB be used only as part of a panel of biomarkers for the screening and early detection of BIA-ALCL.

LEVEL OF EVIDENCE: 5

LV-GLS is a predictor of all-cause death and cardiovascular MACE events in patients with neuro-immunological disorders

Background

Neuro-immunological disorders encompass several disease states, including multiple sclerosis (MS), autoimmune encephalitis (AE) and myasthenia gravis (MG). These autoimmune conditions are mediated via pro-inflammatory cytokines, and there is growing evidence to suggest cardiovascular involvement within these inflammatory states. Left ventricular global longitudinal strain (LV-GLS) is proposed to be a more sensitive measure of LV systolic function when compared to standard two-dimensional measures such as LV ejection fraction (LVEF).

Purpose

The purpose of this study was to assess for subclinical cardiac dysfunction in a cohort of patients with neuro-immunological disorders and correlate this with the development of outcomes on follow-up.

Methods

Consecutive patients with MS, AE and MG admitted to our institution during 2013–2020 were assessed (n=102). Patients without pre-existing cardiovascular disease, LVEF &lt;50% or lack of comprehensive transthoracic echocardiography during their index admission were included (n=55). This group was compared to age- and gender-matched controls (n=55) LV-GLS was measured offline using vendor-independent software (TomTec Arena, Germany v4.6) by two cardiologists blinded to the patient group or outcomes. These patients were followed for up for the composite outcome of all-cause death and major adverse cardiovascular events (MACE).

Results

A total of 55 patients (31 MS, 14 AE and 10 MG) were age- and gender- matched to 55 controls. There was no significant difference in baseline demographic characteristics or cardiovascular risk factors between groups. Patients with neuro-immunological disorders demonstrated impaired LV-GLS (−17.6±3.5 vs −20.8±1.9; p&lt;0.01) when compared to healthy controls, despite an LVEF within the normal range (60.9±7.7 vs 64.1±5.7; p=0.02) in both groups. There were a total of 9 (16.4%) outcomes during a mean follow-up of 41.0±33.0 months. LV-GLS was the only significant echocardiographic predictor of all-cause death and MACE events (p=0.013) on multi-variate analysis.

Conclusions

Our results suggest that patients with neuro-immunological disorders have subclinical LV dysfunction as assessed by LV-GLS which has prognostic capacity in this population. Further larger studies are required to further characterize this phenomenon.

Funding Acknowledgement

Type of funding sources: None.

Patients with rare autoimmune inflammatory disorders demonstrate sub-clinical left ventricular dysfunction

Background

ANCA-associated Vasculitis (AAV) and inflammatory myositis (IM) are rare inflammatory autoimmune disorders mediated via pro-inflammatory cytokines and result in a systemic inflammatory state with multi-organ involvement. There is growing evidence to suggest cardiovascular involvement within these inflammatory states. Left ventricular global longitudinal strain (LV-GLS) is proposed to be a more sensitive measure of LV systolic function when compared to standard two-dimensional measures such as LV ejection fraction (LVEF).

Purpose

The purpose of this study was to assess for subclinical cardiac dysfunction in these cohorts when compared to controls.

Methods

Consecutive patients with AAV (n=56) and IM (n=68) admitted to our institution during 2013–2021 were assessed. Patients with pre-existing cardiovascular disease, significant renal impairment (eGFR &lt;30mL/min/1.73m2), LVEF &lt;50% or lack of comprehensive transthoracic echocardiography during admission were excluded (n=72). LV-GLS was measured offline using vendor-independent software (TomTec Arena, Germany v4.6).

Results

A total of 52 patients (22 AAV and 30 IM) were age- and gender-matched to 52 controls. In comparison of the two study populations (AAV and IM), patients with AAV had higher rates of renal impairment (p=0.02) but lower rates of interstitial lung disease when compared to IM (p=0.02). There were no differences between the two groups in terms of cardiovascular risk factors, demographics or other laboratory investigations (p&gt;0.05 for all). In comparison to the control population, patients with AAV and IM had higher indexed LV mass and a lower TAPSE, respectively, when compared to controls. These cohorts also demonstrated impaired LV-GLS (−17.7±2.6 vs −20.6±2.4; p&lt;0.01) when compared to healthy controls, despite no differences in LVEF (62.6±7.8 vs 61.8±5.4; p=0.56) between both groups.

Conclusions

Our results suggest that patients with autoimmune inflammatory disorders demonstrate subclinical LV dysfunction which is likely secondary to a chronic inflammatory state.

Funding Acknowledgement

Type of funding sources: None.

Bispecific Antibody Armed Metabolically Enhanced Headless CAR T Cells

Adoptive T cell therapies for solid tumors is challenging. We generated metabolically enhanced co-activated-T cells by transducing intracellular co-stimulatory (41BB, ICOS or ICOS-27) and CD3ζ T cell receptor signaling domains followed by arming with bispecific antibodies (BiAbs) to produce armed “Headless CAR T cells” (hCART). Various hCART armed with BiAb directed at CD3ϵ and various tumor associated antigens were tested for: 1) specific cytotoxicity against solid tumors targets; 2) repeated and dual sequential cytotoxicity; 3) survival and cytotoxicity under in vitro hypoxic condition; and 4) cytokine secretion. The 41BBζ transduced hCART (hCART_41BBζ) armed with HER2 BiAb (HER2 hCART_41BBζ) or armed with EGFR BiAb (EGFR hCART_41BBζ) killed multiple tumor lines significantly better than control T cells and secreted Th₁ cytokines/chemokines upon tumor engagement at effector to target ratio (E:T) of 2:1 or 1:1. HER2 hCART serially killed tumor targets up to 14 days. Sequential targeting of EGFR or HER2 positive tumors with HER2 hCART_41BBζ followed by EGFR hCART_41BBζ showed significantly increased cytotoxicity compared single antigen targeting and continue to kill under in vitro hypoxic conditions. In summary, metabolically enhanced headless CAR T cells are effective serial killers of tumor targets, secrete cytokines and chemokines, and continue to kill under in vitro hypoxic condition.

Phase II clinical trial using anti-CD3 × anti-HER2 bispecific antibody armed activated T cells (HER2 BATs) consolidation therapy for HER2 negative (0-2+) metastatic breast cancer

Background

Metastatic human epidermal growth receptor II (HER2) negative breast cancer remains incurable. Our phase I study showed that anti-CD3 × anti-HER2 bispecific antibody armed activated T cells (HER2 BATs) may be effective against HER2-tumors. This phase II trial evaluates the efficacy and immune responses of HER2 BATs given to patients with metastatic HER2-estrogen and/or progesterone receptor positive (HR+) and triple negative breast cancer (TNBC) as immune consolidation after chemotherapy. The primary objective of this study was to increase the traditional median time to progression after failure of first-line therapy of 2–4 months with the secondary endpoints of increasing overall survival (OS) and immune responses.

Methods

HER2- metastatic breast cancer (MBC) patients received 3 weekly infusions of HER2 BATs and a boost after 12 weeks.

Results

This phase II study included 24 HER2-HR+ and 8 TNBC patients who received a mean of 3.75 and 2.4 lines of prior chemotherapy, respectively. Eight of 32 evaluable patients were stable at 4 months after the first infusion. There were no dose limiting toxicities. Tumor markers decreased in 13 of 23 (56.5%) patients who had tumor markers. The median OS was 13.1 (95% CI 8.6 to 17.4), 15.2 (95% CI 8.6 to 19.8), and 12.3 (95% CI 2.1 to 17.8) months for the entire group, HER2-HR+, and TNBC patients, respectively. Median OS for patients with chemotherapy-sensitive and chemotherapy-resistant disease after chemotherapy was 14.6 (9.6–21.8) and 8.6 (3.3–17.3) months, respectively. There were statistically significant increases in interferon-γ immunospots, Th₁ cytokines, Th₂ cytokines, and chemokines after HER2 BATs infusions.

Conclusions

In heavily pretreated HER2-patients, immune consolidation with HER2 BATs after chemotherapy appears to increase the proportion of patients who were stable at 4 months and the median OS for both groups as well as increased adaptive and innate antitumor responses. Future studies combining HER2 BATs with checkpoint inhibitors or other immunomodulators may improve clinical outcomes.

Priming of pancreatic cancer cells with bispecific antibody armed activated T cells sensitizes tumors for enhanced chemoresponsiveness

In this study, we investigated the ability of bispecific antibody armed activated T cells to target drug resistant pancreatic cancer cells and whether or not “priming” these resistant cancer cells with bispecific antibody armed activated T cells could enhance subsequent responsiveness to chemotherapeutic drugs. Chemotherapeutic responses for pancreatic cancer are either limited or the tumors develop resistance to chemotherapy regimens. The impetus for this study was the remarkable clinical response seen in our earlier phase I/II clinical trial: a pancreatic cancer patient with drug resistant tumors who showed progression of disease following three infusions of anti-CD3 x anti-EGFR bispecific antibody armed activated T cells (EGFR BATs) was restarted on the initial low dose of 5-fluorouracil showed complete response, suggesting that BATs infusions may have sensitized patient’s tumor for chemoresponsiveness. In the current study, we tested the hypothesis that BATs can sensitize tumors for chemoresponsiveness. Gemcitabine or cisplatin-resistant MiaPaCa-2 and L3.6 cell lines were effectively targeted by EGFR BATs. Priming of drug sensitive or resistant cells with EGFR BATs followed by retargeting with lower concentrations of 50% inhibitory concentration of gemcitabine or cisplatin showed enhanced cytotoxicity. Gemcitabine or cisplatin-resistant cell lines show an increased proportion of CD44⁺/CD24⁺/EpCAM⁺ cancer stem like cells as well as an increased number of ABC transporter ABCG2 positive cells compared to the parental cell lines. These data suggest that bispecific antibody armed activated T cells can target and kill chemo-resistant tumor cells and also markedly augment subsequent chemotherapeutic responsiveness, possibly by modulating the expression of ABC transporters.

Diet and Dialogue Skills: An Innovative Approach to Diet Demonstration by Medical Students of Lady Hardinge Medical College

Background:

Nutrition' is a very essential component of undergraduate teaching in MBBS curriculum. In this age of growing diet-consciousness and fitness, skill development of medical graduates in designing healthy and culturally appropriate diet is imperative.

Objective:

To demonstrate the effectiveness of Diet Demonstration Training technique in improving the knowledge about basic principles of nutrition in medical undergraduates.

Methodology:

A pilot pretest-posttest study was conducted among 16 undergraduate medical students participated in a pre-conference workshop. Steps of diet demonstration for Under-graduate students were performed and a pretest - posttest was conducted using a self designed self administered questionnaire.

Results:

The mean marks received by the students were 8.69 & 10.31 out of 15 in the pretest & post-test respectively (p value <0.017). Overall 56.3% & 93.6% students performed well in pre-test and post-test respectively.

Conclusion:

There was significant improvement in nutrition education of participated undergraduates.

Acute Kidney Injury in Hospitalized Children with COVID19

BACKGROUND

Acute kidney injury (AKI) has been recognized as a significant risk factor for mortality among adults with severe acute respiratory syndrome coronavirus infection.

AIM

The aim of this study is to assess the prevalence and risk factors for AKI and mortality in children with coronavirus disease 2019 (COVID19) from a resource-limited setting.

METHODS

Cross-sectional analysis of laboratory confirmed COVID19 children admitted from 1 March to 30 November 2020 in a tertiary care hospital in New Delhi, India was done. Clinical features and associated comorbidities of COVID19 were noted. Baseline serum creatinine (height-independent Hoste's equation) and peak serum creatinine were used for staging of AKI by the 2012 Kidney Disease Improving Global Outcomes serum creatinine criteria. Univariate analysis and Kaplan-Meier survival analysis were used to compare the overall outcome in the AKI vs. the non-AKI group.

RESULTS

A total of 64 810 children between 1 month and 18 years visited the hospital; 3412 were tested for suspected COVID19, 295 tested positive and 105 (54% boys) were hospitalized. Twenty-four hospitalized children (22.8%) developed AKI; 8 in Stage 1 (33.3%), 7 in Stage 2 (29.2%) and 9 in Stage 3 (37.5%) respectively. Overall, three patients received KRT. Highest reported mortality was (66.6%) in AKI Stage 3. Risk factors for AKI included associated sepsis (OR 95% CI, 1.22-9.43, p < 0.01), nephrotic syndrome (OR 95% CI, 1.13-115.5, p < 0.01), vasopressor support (OR 3.59, 95% CI, 1.37-9.40, p value< 0.007), shock at presentation (OR 2.98, 95% CI, 1.16-7.60, p value 0.01) and mechanical ventilation (OR 2.64, 95% CI, 1.04-6.71, p value< 0.03). Mortality (25.71%) was higher in the AKI group (OR 95% CI, 1.14-8.35, p < 0.023) with shock (OR 45.92; 95% CI, 3.44-612.0, p value <0.004) and ventilation (OR 46.24; 95% CI, 1.6-1333.0 p value< 0.02) as significant risk factors for mortality.

CONCLUSION

AKI is an important modifiable risk factor for mortality in children with COVID19 in a resource-limited setting. Our study supports the strengthening of kidney replacement therapy and its timely initiation to reduce the progression of AKI and thus mortality in children.

Cerebral phaeohyphomycosis due to Cladophialophora bantiana in an immunocompetent individual: A case report and brief review of literature

Background and Purpose

Fungal infections of the central nervous system (CNS) are life-threatening conditions that are frequently misdiagnosed with bacterial and viral CNS infections. Cerebral phaeohyphomycosis is a cerebral infection caused by dematiaceous fungi, especially Cladophialophora bantiana. Very few cases of fungal CNS infection have been reported across the world. High clinical suspicion should be cast for the patients with brain abscess that do not respond to conventional antibiotic therapy.

Case report

We report a case of a 21-year-old male presenting with headache, seizures and weakness in the limbs. Radiological examination revealed multiple brain abscesses. After surgical excision and laboratory evaluation, it was found to be caused by C. bantiana. The patient's outcome was good with surgical excision and voriconazole therapy.

Conclusion

Brain abscess caused by C. bantiana is on rise, especially in immunocompromised groups. Thus, high clinical suspicion, accurate diagnosis and management are the fundamentals for good prognosis.

Convalescent plasma for preventing critical illness in COVID-19: A phase 2 trial and immune profile

Rationale

The COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an unprecedented event requiring rapid adaptation to changing clinical circumstances. Convalescent immune plasma (CIP) is a promising treatment that can be mobilized rapidly in a pandemic setting.

Objectives

We tested whether administration of SARS-CoV-2 CIP at hospital admission could reduce the rate of ICU transfer or 28 day mortality.

Methods

In a single-arm phase II study, patients >18 years-old with respiratory symptoms documented with COVID-19 infection who were admitted to a non-ICU bed were administered two units of CIP within 72 hours of admission. Detection of respiratory tract SARS-CoV-2 by polymerase chain reaction and circulating anti-SARS-CoV-2 antibody titers were measured before and at time points after CIP transfusion.

Measurements and Main Results

Twenty-nine patients were transfused CIP and forty-eight contemporaneous controls were identified with comparable baseline characteristics. Levels of anti-SARS-CoV-2 IgG, IgM, and IgA anti-spike, anti-receptor-binding domain, and anti-nucleocapsid significantly increased from baseline to post-transfusion for all proteins tested. In patients transfused with CIP, the rate of ICU transfer was 13.8% compared to 27.1% for controls with a hazard ratio 0.506 (95% CI 0.165-1.554), and 28-day mortality was 6.9% compared to 10.4% for controls, hazard ratio 0.640 (95% CI 0.124-3.298).

Conclusions

Transfusion of high-titer CIP to patients early after admission with COVID-19 respiratory disease was associated with reduced ICU transfer and 28-day mortality but was not statistically significant. Follow up randomized trials may inform the use of CIP for COVID-19 or future coronavirus pandemics.

Biomass derived carbon dot decorated ssDNA for a ‘turn-on’ fluorescent assay for detection of Staphylococcus aureus MNase

A novel ‘turn on’ fluorescence aptasensor based on an energy transfer mechanism has been designed using ssDNA conjugated carbon dots (C-dots) and graphene oxide (GO).

143 Therapeutic efficacy and safety of adipose tissue-derived mesenchymal stem cells in treating mastitis and metritis in dairy cattle

Mastitis and metritis are two inflammatory diseases with high economic impact on dairy industry and farmers are losing revenues. Antibiotic treatment for these disease conditions typically achieve suboptimal outcomes. Moreover, emerging antibiotic resistance in mastitis and metritis worldwide has a severe effect on productivity, fertility, and lifespan of animals. A paradigm shift in treatment strategies is much needed for these animals. Attracting properties of mesenchymal stem cells may act as an alternative strategy for treating these diseases. In addition to their ability to differentiate into multiple types of cells, mesenchymal stem cells can orchestrate immune responses and modulate tissue microenvironments. In the present study, we evaluated the safety and efficacy of adipose tissue–derived mesenchymal stem cells (AT-MSC) for mastitis and metritis. A well-characterised adipose-derived stem cell line with 3–5 passages cells were used for treatment for these diseases. In a safety trial, mastitis- and metritis-infected cattle were administered with 1×106 cells of AT-MSC through different routes (local, IV, IV+local). Animals were clinically evaluated during 15 days of the experimental period and blood samples were collected for hemogram determination. The efficacy was checked under both invivo and invitro conditions. Invitro efficiency of AT-MSC was determined using a transwell plate experiment, in which AT-MSC were co-cultured with bacteria (Escherichia coli and Staphylococcus). Invivo efficiency was evaluated by administration of in 2mL (1×106 cells) of AT-MSC dose; then, somatic cell count (SCC) in milk of mastitic cattle and polymorphonuclear (PMN) cell count in cervical vaginal fluid (CVF) of metritic cattle were determined. Gene expression profiling of antimicrobial (cathelicidin, lipocalin, cystatin) and anti-inflammatory (IL-4, IL-6, IL-10) peptides were quantified in all groups: IV, local, IV+local, and control ATB (antibiotic). Allogenic AT-MSC did not induce any immunological rejection response in treated animals. A significant reduction of bacteria in CVF invitro when co-cultured with AT-MSC was observed. The PMN count was significantly reduced in CVF of the IV+local group. The SCC in milk of mastitic animals was decreased in the local (intramammary) group. Maximum expression of IL-6, IL-10, cathelicidin, lipocalin, and cystatin and angiopoietin genes were observed on Day 3 followed by Day 7 in the local group in case of mastitis. In metritis, expression of IL-6, IL-10, cathelicidin, lipocalin, cystatin, and angiopoietin were observed at Day 3 in the IV+local group. All mastitic and metritic cattle were completely and permanently cured within 30 days after treatment with mesenchymal stem cells. In conclusion, we provide initial evidence for the use of allogenic AT-MSC and their safety and efficacy to treat mastitis and metritis in dairy cattle.

Improvement of Ejection Fraction in Patients undergoing Coronary Artery Bypass Grafting with Impaired Left Ventricular Function

Background Myocardial revascularization surgery has shown better long term survival expectancy compared to medical therapy in patient with impaired left ventricular function. Objective To evaluate the change in ejection fraction after 90 days in patients who underwent coronary artery bypass surgery and had preoperative left ventricular ejection fraction of less than and equal to 45% in a single cardiac center of Nepal over the period of 2 years. Method Out of 82 eligible patients during 2 years, 3 patients expired in immediate postoperatively and 24 patients had loss of 90 days' follow up. So, they were excluded from the study. Total 55 patients were taken for the study for whom statistical analysis was done to compare preoperative ejection fraction with post-operative 90 days' ejection fraction. Result Single vessel disease was present in 2(3.6%) patients, double vessel disease in 7(12.7%) patients and triple vessel disease in 46(83.6%) of the patients. In 2(3.6%) patients 2 grafts, in 18(32.7%) patients 3 grafts, in 33(60%) patients 4 grafts and in 2(3.6%) patients 5 grafts were placed for revascularization. The mean left ventricular EF in preoperative patients was 37.12±5.69% which improved to 45.80±10.00% in postoperative follow up at 90 days which was statistically significant (p=0.000). Conclusion Surgical revascularization of myocardium in preoperatively impaired left ventricular function patients helps improve left ventricular ejection fraction postoperatively. So we suggest surgical revascularization in patient with low ejection fraction for improvement of myocardial function. Hence improve survival rate in these patients.

Peritoneal dialysis in critically ill children in resource-limited setting: A prospective cohort study

BACKGROUND

Peritoneal dialysis (PD) is easily available and simple lifesaving procedure in children with renal impairment. There is paucity of reports on efficacy of PD in critically ill children in presence of shock and those requiring mechanical ventilation.

METHODS

In this prospective observational study, efficacy and outcome of PD were evaluated in 50 critically ill children aged 1 month to 14 years admitted in pediatric intensive care unit of a tertiary care teaching hospital in India.

RESULTS

Indication of PD was acute kidney injury (AKI) in 66% of patients followed by chronic kidney disease with acute deterioration due to infectious complications in 34%. Bacterial sepsis was the most common cause of AKI (22%), others being malaria (14%) and severe dengue (12%). At initiation of PD, 26% of patients were in shock and 46% were mechanically ventilated. PD was effective and improvement in pH, bicarbonate, and lactate started within hours, with consistent improvement in estimated glomerular filtration rate by 24 h, which continued till the end of procedure, including the subgroup of patients with shock and mechanical ventilation. Total complications were seen in 14% and of which peritonitis was present in 4.0% of patients. Mortality was seen in 14% (7/50) of patients. Shock at initiation of PD (odds ratio (OR), 5.03; 95% confidence interval (CI), 0.95-26.69; p < 0.04) and requirement of mechanical ventilation (OR, 9.17; 95% CI, 1.01-83.10; p < 0.02) were associated with mortality.

CONCLUSIONS

Acute PD in critically ill children with renal impairment is a lifesaving procedure. Treatment of shock with resuscitative measures and respiratory failure with mechanical ventilation, along with PD, resulted in favorable renal outcome.