Nanoparticle/Engineered Bacteria Based Triple-Strategy Delivery System for Enhanced Hepatocellular Carcinoma Cancer Therapy

Background

New treatment modalities for hepatocellular carcinoma (HCC) are desperately critically needed, given the lack of specificity, severe side effects, and drug resistance with single chemotherapy. Engineered bacteria can target and accumulate in tumor tissues, induce an immune response, and act as drug delivery vehicles. However, conventional bacterial therapy has limitations, such as drug loading capacity and difficult cargo release, resulting in inadequate therapeutic outcomes. Synthetic biotechnology can enhance the precision and efficacy of bacteria-based delivery systems. This enables the selective release of therapeutic payloads in vivo.

Methods

In this study, we constructed a non-pathogenic Escherichia coli (E. coli) with a synchronized lysis circuit as both a drug/gene delivery vehicle and an in-situ (hepatitis B surface antigen) Ag (ASEc) producer. Polyethylene glycol (CHO-PEG2000-CHO)-poly(ethyleneimine) (PEI25k)-citraconic anhydride (CA)-doxorubicin (DOX) nanoparticles loaded with plasmid encoded human sulfatase 1 (hsulf-1) enzyme (PNPs) were anchored on the surface of ASEc (ASEc@PNPs). The composites were synthesized and characterized. The in vitro and in vivo anti-tumor effect of ASEc@PNPs was tested in HepG2 cell lines and a mouse subcutaneous tumor model.

Results

The results demonstrated that upon intravenous injection into tumor-bearing mice, ASEc can actively target and colonise tumor sites. The lytic genes to achieve blast and concentrated release of Ag significantly increased cytokine secretion and the intratumoral infiltration of CD4/CD8+T cells, initiated a specific immune response. Simultaneously, the PNPs system releases hsulf-1 and DOX into the tumor cell resulting in rapid tumor regression and metastasis prevention.

Conclusion

The novel drug delivery system significantly suppressed HCC in vivo with reduced side effects, indicating a potential strategy for clinical HCC therapy.

Phosphatidylserine-exposing extracellular vesicles in body fluids are an innate defence against apoptotic mimicry viral pathogens

Some viruses are rarely transmitted orally or sexually despite their presence in saliva, breast milk, or semen. We previously identified that extracellular vesicles (EVs) in semen and saliva inhibit Zika virus infection. However, the antiviral spectrum and underlying mechanism remained unclear. Here we applied lipidomics and flow cytometry to show that these EVs expose phosphatidylserine (PS). By blocking PS receptors, targeted by Zika virus in the process of apoptotic mimicry, they interfere with viral attachment and entry. Consequently, physiological concentrations of EVs applied in vitro efficiently inhibited infection by apoptotic mimicry dengue, West Nile, Chikungunya, Ebola and vesicular stomatitis viruses, but not severe acute respiratory syndrome coronavirus 2, human immunodeficiency virus 1, hepatitis C virus and herpesviruses that use other entry receptors. Our results identify the role of PS-rich EVs in body fluids in innate defence against infection via viral apoptotic mimicries, explaining why these viruses are primarily transmitted via PS-EV-deficient blood or blood-ingesting arthropods rather than direct human-to-human contact.

A Purposefully Designed pH/GSH-Responsive MnFe-Based Metal-Organic Frameworks as Cascade Nanoreactor for Enhanced Chemo-Chemodynamic-Starvation Synergistic Therapy

Metal-organic frameworks (MOFs) have emerged as promising novel therapeutics for treating malignancies due to their tunable porosity, biocompatibility, and modularity to functionalize with various chemotherapeutics drugs. However, the design and synthesis of dual-stimuli responsive MOFs for controlled drug release in tumor microenvironments are vitally essential but still challenging. Meanwhile, the catalytic effect of metal ions selection and ratio optimization in MOFs for enhanced chemodynamic therapy (CDT) is relatively unexplored. Herein, a series of MnFe-based MOFs with pH/glutathione (GSH)-sensitivity are synthesized and then combined with gold nanoparticles (Au NPs) and cisplatin prodrugs (DSCP) as a cascade nanoreactor (SMnFeCGH) for chemo-chemodynamic-starvation synergistic therapy. H+ and GSH can specifically activate the optimal SMnFeCGH nanoparticles in cancer cells to release Mn2+/4+ /Fe2+/3+ , Au NPs, and DSCP rapidly. The optimal ratio of Mn/Fe shows excellent H2 O2 decomposition efficiency for accelerating CDT. Au NPs can cut off the energy supply to cancer cells for starvation therapy and strengthen CDT by providing large amounts of H2 O2 . Then H2 O2 is catalyzed by Mn2+ /Fe2+ to generate highly toxic •OH with the depletion of GSH. Meanwhile, the reduced DSCP accelerates cancer cell regression for chemotherapy. The ultrasensitivity cascade nanoreactor can enhance the anticancer therapeutic effect by combining chemotherapy, CDT, and starvation therapy.

Modulation of Pro-Inflammatory IL-6 Trans-Signaling Axis by Splice Switching Oligonucleotides as a Therapeutic Modality in Inflammation

Interleukin-6 (IL-6) is a pleiotropic cytokine that plays a crucial role in maintaining normal homeostatic processes under the pathogenesis of various inflammatory and autoimmune diseases. This context-dependent effect from a cytokine is due to two distinctive forms of signaling: cis-signaling and trans-signaling. IL-6 cis-signaling involves binding IL-6 to the membrane-bound IL-6 receptor and Glycoprotein 130 (GP130) signal-transducing subunit. By contrast, in IL-6 trans-signaling, complexes of IL-6 and the soluble form of the IL-6 receptor (sIL-6R) signal via membrane-bound GP130. Various strategies have been employed in the past decade to target the pro-inflammatory effect of IL-6 in numerous inflammatory disorders. However, their development has been hindered since these approaches generally target global IL-6 signaling, also affecting the anti-inflammatory effects of IL-6 signaling too. Therefore, novel strategies explicitly targeting the pro-inflammatory IL-6 trans-signaling without affecting the IL-6 cis-signaling are required and carry immense therapeutic potential. Here, we have developed a novel approach to specifically decoy IL-6-mediated trans-signaling by modulating alternative splicing in GP130, an IL-6 signal transducer, by employing splice switching oligonucleotides (SSO), to induce the expression of truncated soluble isoforms of the protein GP130. This isoform is devoid of signaling domains but allows for specifically sequestering the IL-6/sIL-6R receptor complex with high affinity in serum and thereby suppressing inflammation. Using the state-of-the-art Pip6a cell-penetrating peptide conjugated to PMO-based SSO targeting GP130 for efficient in vivo delivery, reduced disease phenotypes in two different inflammatory mouse models of systemic and intestinal inflammation were observed. Overall, this novel gene therapy platform holds great potential as a refined therapeutic intervention for chronic inflammatory diseases.

The cellular response to extracellular vesicles is dependent on their cell source and dose

Extracellular vesicles (EVs) have been established to play important roles in cell-cell communication and shown promise as therapeutic agents. However, we still lack a basic understanding of how cells respond upon exposure to EVs from different cell sources at various doses. Thus, we treated fibroblasts with EVs from 12 different cell sources at doses between 20 and 200,000 per cell, analyzed their transcriptional effects, and functionally confirmed the findings in various cell types in vitro, and in vivo using single-cell RNA sequencing. Unbiased global analysis revealed EV dose to have a more significant effect than cell source, such that high doses down-regulated exocytosis and up-regulated lysosomal activity. However, EV cell source-specific responses were observed at low doses, and these reflected the activities of the EV's source cells. Last, we assessed EV-derived transcript abundance and found that immune cell-derived EVs were most associated with recipient cells. Together, this study provides important insights into the cellular response to EVs.

Identification of scaffold proteins for improved endogenous engineering of extracellular vesicles

Extracellular vesicles (EVs) are gaining ground as next-generation drug delivery modalities. Genetic fusion of the protein of interest to a scaffold protein with high EV-sorting ability represents a robust cargo loading strategy. To address the paucity of such scaffold proteins, we leverage a simple and reliable assay that can distinguish intravesicular cargo proteins from surface- as well as non-vesicular proteins and compare the EV-sorting potential of 244 candidate proteins. We identify 24 proteins with conserved EV-sorting abilities across five types of producer cells. TSPAN2 and TSPAN3 emerge as lead candidates and outperform the well-studied CD63 scaffold. Importantly, these engineered EVs show promise as delivery vehicles in cell cultures and mice as demonstrated by efficient transfer of luminal cargo proteins as well as surface display of different functional entities. The discovery of these scaffolds provides a platform for EV-based engineering.

Exploiting the biogenesis of extracellular vesicles for bioengineering and therapeutic cargo loading

Extracellular vesicles (EVs) are gaining increasing attention for diagnostic and therapeutic applications in various diseases. These natural nanoparticles benefit from favorable safety profiles and unique biodistribution capabilities, rendering them attractive drug-delivery modalities over synthetic analogs. However, the widespread use of EVs is limited by technological shortcomings and biological knowledge gaps that fail to unravel their heterogeneity. An in-depth understanding of their biogenesis is crucial to unlocking their full therapeutic potential. Here, we explore how knowledge about EV biogenesis can be exploited for EV bioengineering to load therapeutic protein or nucleic acid cargos into or onto EVs. We summarize more than 75 articles and discuss their findings on the formation and composition of exosomes and microvesicles, revealing multiple pathways that may be stimulation and/or cargo dependent. Our analysis further identifies key regulators of natural EV cargo loading and we discuss how this knowledge is integrated to develop engineered EV biotherapeutics.

Surface display of functional moieties on extracellular vesicles using lipid anchors

Extracellular vesicles (EVs) are efficient natural vehicles for intercellular communication and are under extensive investigation for the delivery of diverse therapeutics including small molecule drugs, nucleic acids, and proteins. To understand the mechanisms behind the biological activities of EVs and develop EV therapeutics, it's fundamental to track EVs and engineer EVs in a customized manner. In this study, we identified, using single-vesicle flow cytometry and microscopy, the lipid DOPE (dioleoyl phosphatidyl ethanolamine) as an efficient anchor for isolated EVs. Notably, DOPE associated with EVs quickly, and the products remained stable under several challenging conditions. Moreover, conjugating fluorophores, receptor-targeting peptides or albumin-binding molecule with DOPE enabled tracking the cellular uptake, enhanceing cellular uptake of engineered EVs or extending the circulation time in mice, respectively. Taken together, this study reports an efficient lipid anchor for exogenous engineering of EVs and further showcases its versatility for the functionalization of EVs.

Helium line ratio imaging in the C-2W divertor

A 2D imaging instrument has been designed and deployed on C-2W ("Norman") [H. Gota et al., Nucl. Fusion 61, 106039 (2021)] to study the plasma in the expander divertor by simultaneously measuring three neutral helium spectral lines. Ratios of these images, in conjunction with a collisional-radiative model, yield 2D maps of electron temperature and density. Almost the entire radial plasma cross-section (∼60 cm) can be mapped with a spatial resolution ≲1 cm. These data can, in principle, be acquired at 3 kHz. The neutral helium target is provided by a custom-built supersonic gas injector located inside the divertor vessel, which injects helium toward the magnetic axis and perpendicular to the camera sight-cone. Images of helium emission and reconstructed electron density and temperature profiles of the plasma produced from an end gun are presented. Voltages applied to concentric annular electrodes located in the divertors are used to stabilize beam-driven field reversed configuration plasmas. Magnetic field expansion is also employed to thermally isolate electrons from the end electrodes. Measurements of electron temperature and density in the divertor are important in order to study the effects of both the electrostatic biasing and the divertor magnetic field on electron confinement, neutral gas transport, and the overall machine performance.

OC-003 PORT POSITIONS IN TEP FOR SHORT PATIENTS: OUR EXPERIENCE

Introduction

Totally extraperitoneal repair (TEP) is a popular technique for repair of inguinal hernia. One common technique of TEP involves placement of one 10 mm port 1–2 cm below the umbilicus just off the midline, one 5 mm port 2–3 cm above the pubic symphysis, and a third 5 mm port between these 2 ports in the midline (Figure 1a). In case the distance from the superior border of the symphysis pubis to the inferior edge of the umbilicus is less than 15 cm, this leads to crowding of instruments and results in ergonomic problems during the operation. Daes has popularized eTEP for this indication. The aim is to shift the first 10 mm port to a position 5 cm superior and 4 cm lateral to the umbilicus (Figure 1b). eTEP has also found application in the repair of ventral hernias. However, for most inguinal hernias, we feel that eTEP is an overkill.

Methods

We place the first 10 mm port at the level of the superior border of the umbilicus and just lateral to it (Figure 1c). The two 5 mm ports are placed in the midline. Initial dissection is performed telescopically.

Results

This technique provides 2–3 cm of extra working space, which improves ergonomics while operating on patients with a short pubo-umbilical distance. Other parameters like operating time, postoperative pain and other complications remain the same.

Conclusion

We recommend placement of the 10 mm port at the superior border of the umbilicus, particularly in short patients.

P-011 FEASIBILITY OF VENTRAL-TAPP FOR VENTRAL HERNIA REPAIR IN A LOW INCOME COUNTRY LIKE INDIA

Aim

Minimal invasive repair is now the established procedure for ventral hernia. Surgeons are now validating newer techniques each year to deal with the ventral hernia. It becomes difficult to choose, best fit technique from this large armamentarium. For a low income country like India, ventral- trans abdominal preperitoneal (TAPP) technique is cost effective and uses simple polyester or polypropylene mesh.

Methods

For this article we used our experience with ventral-TAPP performed from July 1, 2021 to May 31, 2022. Patients were followed up for 6 months.

Results

In the above time period, we had performed 10 ventral-TAPP. Out of these, 3 had completed the follow up. Median age was 45.0 years, BMI was 26.56 kg/m2. One patient was male (33.33%). All patients were presented to surgery due to bulge or pain in the anterior abdominal wall.

The median hernia defect measured 80 mm, median mesh diameter was 15 cm and median operative time was 125 min. No intraoperative complications occurred.

Postoperatively, none of the patients developed complications. Length of hospital stay was 3.0 days. Six months after surgery, neither recurrence nor chronic pain were recorded.

Conclusion

We have concluded that mesh used in repair with ventral-TAPP costs one fourth to one-fifth to that of composite mesh used in intraperitoneal onlay mesh (IPOM) repair with the comparable results. So in a low income country like India, ventral TAPP should be a preferred approach.

Extracellular vesicles engineered to bind albumin demonstrate extended circulation time and lymph node accumulation in mouse models

Extracellular vesicles (EVs) have shown promise as potential therapeutics for the treatment of various diseases. However, their rapid clearance after administration could be a limitation in certain therapeutic settings. To solve this, an engineering strategy is employed to decorate albumin onto the surface of the EVs through surface display of albumin binding domains (ABDs). ABDs were either included in the extracellular loops of select EV‐enriched tetraspanins (CD63, CD9 and CD81) or directly fused to the extracellular terminal of single transmembrane EV‐sorting domains, such as Lamp2B. These engineered EVs exert robust binding capacity to human serum albumins (HSA) in vitro and mouse serum albumins (MSA) after injection in mice. By binding to MSA, circulating time of EVs dramatically increases after different routes of injection in different strains of mice. Moreover, these engineered EVs show considerable lymph node (LN) and solid tumour accumulation, which can be utilized when using EVs for immunomodulation, cancer‐ and/or immunotherapy. The increased circulation time of EVs may also be important when combined with tissue‐specific targeting ligands and could provide significant benefit for their therapeutic use in a variety of disease indications.

Resonance Excitations in ^{7}Be(d,p)^{8}Be^{*} to Address the Cosmological Lithium Problem

The anomaly in lithium abundance is a well-known unresolved problem in nuclear astrophysics. A recent revisit to the problem tried the avenue of resonance enhancement to account for the primordial ^{7}Li abundance in standard big-bang nucleosynthesis. Prior measurements of the ^{7}Be(d,p)^{8}Be^{*} reaction could not account for the individual contributions of the different excited states involved, particularly at higher energies close to the Q value of the reaction. We carried out an experiment at HIE-ISOLDE, CERN to study this reaction at E_{c.m.}=7.8  MeV, populating excitations up to 22 MeV in ^{8}Be for the first time. The angular distributions of the several excited states have been measured and the contributions of the higher excited states in the total cross section at the relevant big-bang energies were obtained by extrapolation to the Gamow window using the talys code. The results show that by including the contribution of the 16.63 MeV state, the maximum value of the total S factor inside the Gamow window comes out to be 167 MeV b as compared to earlier estimate of 100 MeV b. However, this still does not account for the lithium discrepancy.

Differentiating border-zone tissue from post-infarct scar using ripple mapping during VT ablation

Funding Acknowledgements

Type of funding sources: None.

Background

Areas of post-infarct ventricular scar and border-zone slow conduction are often highlighted on a bipolar voltage map with generalized values 0.5mV–1.5mV. The true voltage that differentiates regions of conducting from non-conducting tissue is unknown. Ripple Mapping (RM)displays allows conducting tissue to be seen as areas supporting Ripple activation, and non-conducting tissue as areas devoid of Ripple activation.

Purpose

We describe application of Ripple Maps to differentiate areas of scar from conducting tissue during ischemic VT ablation.

Methods

Dense bipolar voltage maps were created (Pentaray catheter, pacing 80-100bpm) and presented as a single value (e.g. 0.5mV-0.5mV) to binarize the color display (red and purple). RMs were superimposed on the voltage map and played above a pre-set noise threshold (>0.05mV). The voltage map mV limit was sequentially reduced ("border-zone threshold") until only those areas devoid of Ripple bars appeared red. The surrounding border-zone supporting ripple activation thus appeared purple. We performed off-line analysis of border-zone voltage thresholds from a series of RM guided VT ablations.

Results

10 consecutive patients (LVEF 32.3±7.5%) with remote myocardial infarction underwent VT ablation (median 19days (IQR 8-33) since last VT). Bipolar voltage mapping (5873±2841 points, median shell area 224cm2), revealed voltages<0.5mV covered a median 11% (IQR 7-17%) of the shell. The border-zone voltage threshold was median 0.2mV (range 0.12mV - 0.3mV). Non-conducting tissue below this value covered only median 5% (IQR 3-7%) of the entire shell. VT was mappable in 4 patients, and the isthmus was bordered by tissue below the same border-zone threshold as found in normal rhythm. The border-zone was homogenized with ablation(40-50W, median 29 mins (IQR 22-33), and clinical VT was non-inducible in all, and 9 pts (91%) remain sustained VT-free at median 90-day follow-up (IQR 23-139), 2-weeks blanking period).

Picture 1 presents an infero-lateral LV infarct collected in an RV paced rhythm (7340points) and displayed at conventional bipolar voltage settings 0.5-1.5mV. Tissue with voltages<0.5mV appear red and cover 30% of the total area. In this case, this border-zone voltage threshold was defined as 0.25mV. Non-conducting tissue, seen as areas devoid of ripple bars below this value, now appeared as red, and covered only 11% of the total area. Picture 2 demonstrates the morphologies of 4 poorly tolerated induced VTs during this case. Each had near perfect pacemaps to the exit sites of border-zone tissue defined using this approach, and were targets for ablation resulting in complete non-inducibility and no VT recurrence in early follow-up.

Conclusion

The bipolar voltage that differentiates putative scar from bordering conducting tissue is unique to each patient, and far lower than 0.5mV-1.5mV. RM presents a practical approach to visualize the border-zone activation to guide ablation.

Hematopoietic stem cell transplantation for hemoglobinopathies: Progress and prospects

Allogeneic bone marrow transplantation from an HLA-identical donor is currently the only means of curing thalassemia . Transplant outcome depends upon the presence of risk factors (hepatomegaly, portal fibrosis and poor quality of chelation). patients are defined to have class I - if no risk factor, class II with one or two and class III - if all three risk factors are present. For patients under 16 years of age, for class I, class II and III the probabilities of survival are approximately 95%, >80% and 60-70%, respectively. The risk of transplant related morbidity& mortality is low when transplant is done at an early age. Currently, busulfan, cyclophospahmide and antithymocyte globulin based combination is used for conditioning. More than 200 patients with sickle cell disease (SCD) have undergone allogeneic SCT with long term survival in >80% of patients. Results are better if donor is an HLA-identical sibling and if transplant is done early in the course of disease. Presently, experience with reduced intensity SCT and matched unrelated donor transplant is limited to recommend their routine use.

Growth Media Conditions Influence the Secretion Route and Release Levels of Engineered Extracellular Vesicles

Extracellular vesicles (EVs) are nanosized cell-derived vesicles produced by all cells, which provide a route of intercellular communication by transmitting biological cargo. While EVs offer promise as therapeutic agents, the molecular mechanisms of EV biogenesis are not yet fully elucidated, in part due to the concurrence of numerous interwoven pathways which give rise to heterogenous EV populations in vitro. The equilibrium between the EV-producing pathways is heavily influenced by factors in the extracellular environment, in such a way that can be taken advantage of to boost production of engineered EVs. In this study, a quantifiable EV-engineering approach is used to investigate how different cell media conditions alter EV production. The presence of serum, exogenous EVs, and other signaling factors in cell media alters EV production at the physical, molecular, and transcriptional levels. Further, it is demonstrated that the ceramide-dependent EV biogenesis route is the major pathway to production of engineered EVs during optimized EV-production. These findings suggest a novel understanding to the mechanisms underlying EV production in cell culture which can be applied to develop advanced EV production methods.

Primitive neuroectodermal tumor of the kidney: a rare case

Background

Primitive neuroectodermal tumor commonly occurs in bones and is equivalent to Ewing’s sarcoma. Very few cases have been reported in the literature and they had a very different presentation and very aggressive behavior.

Case presentation

We present a case of a young 23-year-old male who presented with complaints of pain in left lumbar region of abdomen since 8 months and hematuria off and on. CT scan of the abdomen was done which revealed a large heterogeneously enhancing mass lesion in the left lumbar region arising from the superior and mid-pole of left kidney showing multiple non-enhancing necrotic areas. A diagnosis of left renal cell carcinoma was kept. Through the transperitoneal approach, the left kidney was approached and a left radical nephrectomy was done. The histopathology report revealed the tumor cells to be positive for CD99 and focally positive for Vimentin and negative for cytokeratin thereby making a diagnosis of primary neuroectodermal tumor (PNET).

Conclusions

Renal PNET is a rare renal malignancy that should be kept in the differential diagnosis of a renal SOL especially when it is a presenting feature in adolescent and young adult. It has a very aggressive course and multimodal therapy has to be considered in its treatment

COVID-19-associated mucormycosis presenting to the Emergency Department-an observational study of 70 patients

BACKGROUND

Mucormycosis (MM) is a deadly opportunistic fungal infection and a large surge in COVID-19-associated mucormycosis (CAM) is occurring in India.

AIM

Our aim was to delineate the clinico-epidemiological profile and identify risk factors of CAM patients presenting to the Emergency Department (ED).

DESIGN

This was a retrospective, single-centre, observational study.

METHODS

We included patients who presented with clinical features or diagnosed MM and who were previously treated for COVID-19 in last 3 months of presentation (recent COVID-19) or currently being treated for COVID-19 (active COVID-19). Information regarding clinical features of CAM, possible risk factors, examination findings, diagnostic workup including imaging and treatment details were collected.

RESULTS

Seventy CAM patients (median age: 44.5 years, 60% males) with active (75.7%) or recent COVID-19 (24.3%) who presented to the ED in between 6 May 2021 and 1 June 2021, were included. A median duration of 20 days (interquartile range: 13.5-25) was present between the onset of COVID-19 symptoms and the onset of CAM symptoms. Ninety-three percent patients had at least one risk factor. Most common risk factors were diabetes mellitus (70%) and steroid use for COVID-19 disease (70%). After clinical, microbiological and radiological workup, final diagnosis of rhino-orbital CAM was made in most patients (68.6%). Systemic antifungals were started in the ED and urgent surgical debridement was planned.

CONCLUSION

COVID-19 infection along with its medical management have increased patient susceptibility to MM.

Diagnostic and Prognostic Utility of the Extracellular Vesicles Subpopulations Present in Pleural Effusion

Extracellular vesicles (EVs), comprising exosomes, microvesicles, and apoptotic bodies, are released by all cells into the extracellular matrix and body fluids, where they play important roles in intercellular communication and matrix remodeling in various pathological conditions. Malignant pleural mesothelioma (MPM) is a primary tumor of mesothelial origin, predominantly related to asbestos exposure. The detection of MPM at an early stage and distinguishing it from benign conditions and metastatic adenocarcinomas (AD) is sometimes challenging. Pleural effusion is often the first available biological material and an ideal source for characterizing diagnostic and prognostic factors. Specific proteins have previously been identified as diagnostic markers in effusion, but it is not currently known whether these are associated with vesicles or released in soluble form. Here, we study and characterize tumor heterogeneity and extracellular vesicle diversity in pleural effusion as diagnostic or prognostic markers for MPM. We analyzed extracellular vesicles and soluble proteins from 27 pleural effusions, which were collected and processed at the department of pathology and cytology at Karolinska University Hospital, representing three different patient groups, MPM (n = 9), benign (n = 6), and AD (n = 12). The vesicles were fractionated into apoptotic bodies, microvesicles, and exosomes by differential centrifugation and characterized by nanoparticle tracking analysis and Western blotting. Multiplex bead-based flow cytometry analysis showed that exosomal markers were expressed differently on EVs present in different fractions. Further characterization of exosomes by a multiplex immunoassay (Luminex) showed that all soluble proteins studied were also present in exosomes, though the ratio of protein concentration present in supernatant versus exosomes varied. The proportion of Angiopoietin-1 present in exosomes was generally higher in benign compared to malignant samples. The corresponding ratios of Mesothelin, Galectin-1, Osteopontin, and VEGF were higher in MPM effusions compared to those in the benign group. These findings demonstrate that relevant diagnostic markers can be recovered from exosomes.

Evaluation of the feasibility and accuracy of remote mobile app-based self-reported atrial fibrillation risk factor assessment in patients with atrial fibrillation: TeleCheck-AF results

Background

Previously, we introduced the TeleCheck-AF approach, which is an on-demand mobile health (mHealth) infrastructure incorporating mobile app-based heart rate and rhythm monitoring as well as mobile app-based self-reported atrial fibrillation (AF) risk factor assessment to allow comprehensive remote AF management through teleconsultation. Herein, we evaluated the feasibility and accuracy of remote mobile app-based self-reported AF risk factor assessment in AF patients.

Methods

In our University Medical Center, 545 patients were managed within the TeleCheck-AF project by an on-demand heart rate and rhythm mHealth infrastructure through teleconsultation. Patients were asked to fill in a short mobile app-based 10-item questionnaire related to AF risk factors. A reminder to complete the questionnaire automatically popped-up after the following four heart rate and rhythm recordings. Furthermore, patient's medical history was retrieved from the electronic health records (EHRs).

Results

Out of 545 patients, 542 (99.4%) patients (217 female, age 67 (59–72) years) completed the mobile app-based 10-item questionnaire and were included in this analysis. The number of patients with diabetes mellitus was similar in the EHRs and mobile app-based questionnaire (both 11.3%, p=1.000). There was no significant difference in the number of patients who had a medical history of transient ischemic attack (TIA)/cerebrovascular accident (CVA) and artery disease (coronary artery disease and peripheral artery disease) in the EHRs and mobile app-based questionnaire (11.4% vs 12.2%, p=0.608 and 14.8% vs 13.3%, p=0.366, respectively). Heart failure was more frequently reported in the mobile app-based questionnaire compared to the EHRs (33.4% vs 14.0%, p<0.001). A total of 260 (48.0%) patients had a diagnosis of hypertension verified in EHRs and only 239 (44.1%) patients reported hypertension in the mobile app-based questionnaire (p=0.044). There was no significant difference in number of patients with CHA2DS2-VASc-score ≥2 between the EHRs and mobile app-based questionnaire (64.2% vs 66.1%, p=0.275). The accuracy of mobile app-based assessment of diabetes mellitus was 85.4%, of TIA/CVA 78.9%, of artery disease 60.9%, of heart failure 78.8%, and of hypertension 89.3%.

Conclusion

Patient self-reported AF risk factors by a remote mobile app-based assessment is feasible and may be useful for future digital trials and comprehensive remote AF management through teleconsultation.

Funding Acknowledgement

Type of funding sources: None.

Delivery of Oligonucleotide Therapeutics: Chemical Modifications, Lipid Nanoparticles, and Extracellular Vesicles

Oligonucleotides (ONs) comprise a rapidly growing class of therapeutics. In recent years, the list of FDA-approved ON therapies has rapidly expanded. ONs are small (15-30 bp) nucleotide-based therapeutics which are capable of targeting DNA and RNA as well as other biomolecules. ONs can be subdivided into several classes based on their chemical modifications and on the mechanisms of their target interactions. Historically, the largest hindrance to the widespread usage of ON therapeutics has been their inability to effectively internalize into cells and escape from endosomes to reach their molecular targets in the cytosol or nucleus. While cell uptake has been improved, "endosomal escape" remains a significant problem. There are a range of approaches to overcome this, and in this review, we focus on three: altering the chemical structure of the ONs, formulating synthetic, lipid-based nanoparticles to encapsulate the ONs, or biologically loading the ONs into extracellular vesicles. This review provides a background to the design and mode of action of existing FDA-approved ONs. It presents the most common ON classifications and chemical modifications from a fundamental scientific perspective and provides a roadmap of the cellular uptake pathways by which ONs are trafficked. Finally, this review delves into each of the above-mentioned approaches to ON delivery, highlighting the scientific principles behind each and covering recent advances.

Amelioration of systemic inflammation via the display of two different decoy protein receptors on extracellular vesicles

Extracellular vesicles (EVs) can be functionalized to display specific protein receptors on their surface. However, surface-display technology typically labels only a small fraction of the EV population. Here, we show that the joint display of two different therapeutically relevant protein receptors on EVs can be optimized by systematically screening EV-loading protein moieties. We used cytokine-binding domains derived from tumour necrosis factor receptor 1 (TNFR1) and interleukin-6 signal transducer (IL-6ST), which can act as decoy receptors for the pro-inflammatory cytokines tumour necrosis factor alpha (TNF-α) and IL-6, respectively. We found that the genetic engineering of EV-producing cells to express oligomerized exosomal sorting domains and the N-terminal fragment of syntenin (a cytosolic adaptor of the single transmembrane domain protein syndecan) increased the display efficiency and inhibitory activity of TNFR1 and IL-6ST and facilitated their joint display on EVs. In mouse models of systemic inflammation, neuroinflammation and intestinal inflammation, EVs displaying the cytokine decoys ameliorated the disease phenotypes with higher efficacy as compared with clinically approved biopharmaceutical agents targeting the TNF-α and IL-6 pathways.

Safety and acute clinical outcomes of atrial fibrillation catheter ablation in octogenarians: a multicentre evaluation with a matched younger cohort

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Sven Knecht and the International Octogenarian AF ablation group

Background

Octogenarians are a fast-growing demographic with a high burden of atrial fibrillation (AF). There are limited data on procedural safety and acute outcomes of catheter ablation (CA) for AF in this group.

Purpose

Investigation of complications & outcomes in octogenarians undergoing CA for AF.

Methods

Data on all octogenarian patients who underwent AF ablation at nine European cardiology centres between 2013 and 2019 were retrospectively analysed and matched with control patients aged <80 years.  The characteristics used for matching were type of AF, type of procedure (de novo or redo), & the year of procedure.

Results

216 octogenarians (81.9 ± 1.9 years; 52.8% females) underwent an AF ablation procedure, and were matched with 216 patients aged <80 years (62.4 ± 9.5 years, 34.7% females), p <0.001 for both. The proportion of paroxysmal and persistent AF was 43.5% & 56.5% respectively in both groups, and 79.3% of the procedures were de novo. RF ablation made up 75.4% & 75.9% (p = 0.90) procedures in octogenarians and controls respectively.  17 complications occurred in 14 (7.9%) octogenarian patients and 11 in 11 (5.1%) patients in the younger matched cohort (p = 0.07). There were 4.2% & 1.9% major complications (p= 0.17) and 3.7% & 3.2% minor complications (p= 0.77) in the octogenarian & younger cohorts respectively. Complications in octogenarians consisted of groin complications (n = 6), pneumonia (n = 3), pericardial effusion (n = 2), phrenic nerve injury (n = 2), pulmonary oedema (n = 1), gastroparesis (n = 1), stroke (n = 1). Acute procedural success rates were 99.1% & 99.5% (p = 0.62) The complication rates were similar for RF; 6.0% vs 5.4% (p = 0.79) and Cryoballoon; 14.0% vs 4.1% (p = 0.09) in both octogenarians and younger cohort respectively.

Conclusion

In spite of significantly higher overall risk profile of octogenarians undergoing AF ablation, there is no difference in acute procedural success and complication rates as compared to younger patients Catheter ablation of AF in octogenerians Octogenarians n = 216 Matched Controls (aged < 80yrs) n = 216 P value Age (yrs), mean (SD)s 81.9 (1.9) 62.4(9.5) < 0.0001 Females, (%) 52.8 34.7 0.0002 CHA2DS2-VASc, mean (SD) 3.6 (1.2) 1.4 (1.3) < 0.0001 Mean LA size, mm 42.8 ± 8.3mm 45.8 ± 16.2 0.062 Impaired LV function, (%) 23.7 17.9 0.206 IHD, (%) 20.7 5.9 < 0.0001 Procedural time (mins), mean (sd) 150.6 (69.7) 148.9 (64.4) 0.914 All complications, n (%) 17 (7.9) 11 (5.1) 0.073

The TeleCheck-AF project on remote app-based management of atrial fibrillation during the COVID-19 pandemic: Patient experiences

Funding Acknowledgements

OnBehalf

Aims

Methods

Results

Conclusions

Ablation Index-guided 50W ablation for left atrial posterior wall isolation compared with lower powers: feasibility and lesion level analysis

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Groupe de Rythmologie de la Société Française de Rythmologie

Background 

Posterior Wall Isolation (PWI) is increasingly performed for Atrial Fibrillation (AF). The use of Ablation Index (AI)-guided 50W ablation for PWI has not been described, nor the interplay between ablation parameters at this power when compared to lower powers. 

Methods 

40 consecutive AF patients (26 males, 65.5 ± 10.0 years. 95% non-paroxysmal AF) underwent PWI following pulmonary vein isolation. A roof line and floor line were created with point-by-point ablation, targeting a contact force (CF) of 10-30g, AI 550-600 on the roof and 400-450 on the floor, and inter-tag distance of <6mm. 35-40W powers were used for the first 20 patients, and 50W used for the next 20. Generator impedance was monitored in real time for each lesion. Ablation inside the box was delivered in case of failure of first pass isolation (FPI). All VisiTags (n = 959) were analyzed retrospectively. 

Results 

PWI was successful in 19(95%) of the 35-40W group and in all 20 patients in the 50W group, with FPI seen in 8(40%) and 10(50%) respectively, p = 0.53. The mean CF and number of RF applications on the roof. floor and inside the box were similar between the two groups. Ablation time per lesion (10.4 [8.8-12.5]sec) and total ablation time per patient (3.84[3.34-4.66] min) were shorter in the 50W group as compared to 35-40W (13.0 [11.6-16.2] sec and 5.86 [4.23-7.73] min respectively), p < 0.005. The mean AI and Impedance Drop were larger in the 50W group (Table). There was no steam pop observed in any of the 959 radiofrequency applications. 

Conclusion 

Ablation Index guided 50W ablation has a very high success rate for posterior wall isolation with shorter ablation times and higher impedance drop compared to conventional powers. Steam pops may be avoidable by targeting CF < 30g, and by monitoring impedance in real-time. 50W Group(N = 458) 35-40W Group(N = 501) p-value Number of lesions (s, IQR)Roof lineFloor lineAdditional ablation inside box 21.5 [19.5-26.3]7.0 [5.8-9.0]13.0 [10.8-14.3]6.0 [6.0-6.8] 24.0 [20.8-29.5]8.0 [6.0-10.0]12.5 [10.8-14.0]5.5 [2.8-9.0] 0.330.180.850.59 Ablation Time per lesion (s, IQR)Roof lineFloor lineAdditional ablation inside box 10.4 [8.8-12.5]13.0 [10.9-16.0]9.9 [8.7-11.4]8.1 [6.9-9.0] 13.0 [11.6-16.2]14.5 [12.4-19.0]12.7 [11.4-15.9]11.8 [10.6-14.0] <0.005<0.005<0.005<0.005 Total RF Time (min, IQR)Roof lineFloor lineAdditional ablation inside box 3.84 [3.34-4.66]1.54 [1.15-1.90]2.06 [1.68-2.54]0.79 [0.65-1.07] 5.86 [4.23-7.73]1.98 [1.62-2.59]2.78 [2.28-3.25]1.07 [0.59-1.42] < 0.0050.0190.0090.50 Impedance Drop (ohms, IQR)Roof lineFloor lineAdditional ablation inside box 7.4 [5.2-10.3]8.7 [6.1-11.3]6.9 [5.0-10.1]7.1 [5.4-9.8] 6.9 [4.8-9.7]7.5 [5.1-10.0]6.0 [4.2-8.3]8.3 [5.8-10.9] 0.0070.04< 0.0050.17 Contact Force (g, IQR)Roof lineFloor lineAdditional ablation inside box 21.1 [14.5-30.3]23.9 [17.8-32.7]19.2 [13.2-25.3]25.5 [18.5-36.9] 21.2 [14.9-28.1]24.3 [17.2-30.3]19.0 [14.1-25.0]23.1 [16.9-31.7] 0.560.450.870.21 Ablation Index (IQR)Roof lineFloor lineAdditional ablation inside box 471 [441-519]560 [509-571]453 [436-475]461 [430-488] 461 [434-493]502 [466-541]446 [426-464]455 [434-478] < 0.005< 0.005< 0.0050.59 Lesion level analysis for Posterior Wall Isolation

Remote app-based management of atrial fibrillation during the COVID-19: The centre characteristics and experiences of the European TeleCheck-AF project

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

TeleCheck-AF Investigators

Aims

Herein we describe the characteristics, inclusion rates and experiences from participating centres in the European TeleCheck-AF project. TeleCheck-AF is a multicentre international project initiated to maintain care delivery for patients with atrial fibrillation (AF) during COVID-19 through teleconsultations supported by an on-demand photoplethysmography-based heart rate and rhythm monitoring app (FibriCheck®). 

Methods

Two surveys exploring centre characteristics (n = 25) and centre experiences (n = 23) were completed.

Results

Most centres were academic (64%) and specialized public cardiology/district hospitals (36%). Majority of centres had AF outpatient clinics (64%) and only 36% had AF ablation clinics. The time required to start patient inclusion and total number of included patients in the project was comparable for centres experienced (56%) or inexperienced in mHealth use. Within 28 weeks, 1930 AF patients were recruited, mainly for remote AF control (31% of patients) and AF ablation follow-up (42%). Average inclusion rate was highest during the lockdown restrictions and reached a steady state at a lower level after easing the restrictions (188 vs 52 weekly recruited patients). Majority (>80%) of the centres reported no problems during the implementation of the TeleCheck-AF approach. Centres agreed that the on-boarding process of their center in the TeleCheck-AF project was simple and access to the patients measurements via stand-alone cloud infrastructure was trouble-free and possible from the first day on. They also agreed that remote heart rate and rhythm assessment by the FibriCheck® app around teleconsulatation supported their medical decision making; that their patients responded positively to use FibriCheck® for seven days; and that they felt comfortable to interpret PPG recordings. 

Conclusions

Despite different health care settings and mHealth experiences, the TeleCheck-AF approach could be set up within an extremely short time and easily used in different European centres during COVID-19.

Assessing atrial fibrillation ablation priority during COVID-19 -does use of patient questionnaires help in stratification above physician assessment?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Catheter ablation for atrial fibrillation (AF) is largely offered for symptomatic relief. The ORBIT registry has shown that patients with a higher EHRA class and lower quality of life (QoL) scores (AFEQT score <65.7) are more likely to suffer emergency hospital admissions. To help prevent unplanned AF admissions and to best utilise the reduced capacity for elective work during the COVID-19 pandemic, it has become even more important to prioritise the most symptomatic AF patients for ablation. Purpose: To evaluate the accuracy of a subjective symptom-based clinician prioritisation schema compared to objective patient-completed quality of life (QoL) scores. Methods: In July 2020, all elective cases awaiting AF ablation at our institution were categorised by their cardiologist as either category 1 (C1-urgent), category 2 (C2–priority, procedure to be done during the ongoing COVID-19 pandemic) or category 3 (C3–routine, procedure may be delayed until post pandemic). This categorisation was based on review of clinic letters where EHRA AF symptom class or PROMS are not routinely recorded.  All patients in C2 and C3 were then posted an AF specific (AFEQT) and a generic (EQ5D) QoL questionnaire to complete. Physicians were blinded to patient responses on the QoL questionnaires. Results: Details of physician prioritisation and completed questionnaires were available for 85 patients (62 ± 10 years, PAF in 61%, males 66%). The 18 patients that had been categorised in C2 (priority) group were found to have a significantly lower AFEQT score (30.4, IQR 17.2-51.9) compared to the 67 patients classed in C3 (routine) group (56.5, IQR 32.1-74.1; p < 0.01)(Figure 1a). EQ5D scores also tended to be lower in the C2 patients (0.7, IQR 0.4-0.8) compared to C3 (0.8, IQR 0.6-0.9; p = 0.056) (Figure 1c). 16 (89%) patients in C2 had significant AF-related impact on QoL (as defined as AFEQT score <65.7) compared to 42 (63%) of patients in C3.  However, there was significant overlap between groups (Figure 1b). 4 patients in C3 had unplanned AF related hospital admissions while awaiting ablation, as compared to none in C2. The median AFEQT score of these 4 patients was 23.3, indicating that they were highly symptomatic despite being classified in C3 by their cardiologist. Conclusion : Physician assessments are moderately accurate in prioritising patients awaiting AF ablation. The addition of formal patient-completed QoL assessment such as with AFEQT, helps to identify the most symptomatic patients at risk of emergency hospital admission, and physicians should consider using these as part of routine assessment, especially during the COVID pandemic.

Abstract Figure 1

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Novel deep transfer learning model for COVID-19 patient detection using X-ray chest images

Around the world, more than 250 countries are affected by the COVID-19 pandemic, which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This outbreak can be controlled only by the diagnosis of the COVID-19 infection in early stages. It is found that the radiographic images are ideal for the fastest diagnosis of COVID-19 infection. This paper proposes an ensemble model which detects the COVID-19 infection in the early stage with the use of chest X-ray images. The transfer learning enables to reuse the pretrained models. The ensemble learning integrates various transfer learning models, i.e., EfficientNet, GoogLeNet, and XceptionNet, to design the proposed model. These models can categorize patients as COVID-19 (+), pneumonia (+), tuberculosis (+), or healthy. The proposed model enhances the classifier's generalization ability for both binary and multiclass COVID-19 datasets. Two popular datasets are used to evaluate the performance of the proposed ensemble model. The comparative analysis validates that the proposed model outperforms the state-of-art models in terms of various performance metrics.

Measurements of impurity ion temperature and velocity distributions via active charge-exchange recombination spectroscopy in C-2W

In TAE Technologies' C-2W experiment, electrode biasing is utilized for boundary control of a field-reversed configuration (FRC) plasma embedded in a magnetic mirror. Understanding the underlying physics associated with FRC rotation, stabilization, and heating is crucial for improving machine performance. Impurity ion rotation and temperature are sensitive to biasing effects, and measurements of these quantities can provide insight into important plasma dynamics and overall effectiveness of the biasing system. To this end, a charge-exchange recombination spectroscopy (ChERS) diagnostic was developed and deployed to measure local impurity ion temperature and velocity in the confinement vessel of C-2W. The system utilizes a new diagnostic neutral beam (40 keV, 8.5 A) and a fiber-coupled spectrometer with an image-intensified high-speed camera to measure beam-induced spectral line emission at multiple lines-of-sight. Design details and the first experimental results obtained with this new diagnostic are presented and discussed.