Etiologies and predictors of mortality in an all-comer population of patients with non-ischemic heart failure

BACKGROUND

Despite progress in diagnosis and therapy of heart failure (HF), etiology and risk stratification remain elusive in many patients.

METHODS

The My Biopsy HF Study (German clinical trials register number: DRKS22178) is a retrospective monocentric study investigating an all-comer population of patients with unexplained HF based on a thorough workup including endomyocardial biopsy (EMB).

RESULTS

655 patients (70.9% men, median age 55 [45/66] years) with non-ischemic, non-valvular HF were included in the analyses. 489 patients were diagnosed with HF with reduced ejection fraction (HFrEF), 52 patients with HF with mildly reduced ejection fraction (HFmrEF) and 114 patients with HF with preserved ejection fraction (HFpEF). After a median follow-up of 4.6 (2.5/6.6) years, 94 deaths were enumerated (HFrEF: 68; HFmrEF: 8; HFpEF: 18), equating to mortality rates of 3.3% and 11.6% for patients with HFrEF, 7.7% and 15.4% for patients with HFmrEF and 5.3% and 11.4% for patients with HFpEF after 1 and 5 years, respectively. In EMB, we detected a variety of putative etiologies of HF, including incidental cardiac amyloidosis (CA, 5.8%). In multivariate logistic regression analysis adjusting for age, sex and comorbidities only CA, age and NYHA functional class III + IV remained independently associated with all-cause mortality (CA: HRperui 3.13, 95% CI 1.5-6.51; p = 0.002).

CONCLUSIONS

In an all-comer population of patients presenting with HF of unknown etiology, incidental finding of CA stands out to be independently associated with all-cause mortality. Our findings suggest that prospective trials would be helpful to test the added value of a systematic and holistic work-up of HF of unknown etiology.

Production of recombinant vesicular stomatitis virus-based vectors by tangential flow depth filtration

Cell culture-based production of vector-based vaccines and virotherapeutics is of increasing interest. The vectors used not only retain their ability to infect cells but also induce robust immune responses. Using two recombinant vesicular stomatitis virus (rVSV)-based constructs, we performed a proof-of-concept study regarding an integrated closed single-use perfusion system that allows continuous virus harvesting and clarification. Using suspension BHK-21 cells and a fusogenic oncolytic hybrid of vesicular stomatitis virus and Newcastle disease virus (rVSV-NDV), a modified alternating tangential flow device (mATF) or tangential flow depth filtration (TFDF) systems were used for cell retention. As the hollow fibers of the former are characterized by a large internal lumen (0.75 mm; pore size 0.65 μm), membrane blocking by the multi-nucleated syncytia formed during infection could be prevented. However, virus particles were completely retained. In contrast, the TFDF filter unit (lumen 3.15 mm, pore size 2-5 μm) allowed not only to achieve high viable cell concentrations (VCC, 16.4-20.6×106 cells/mL) but also continuous vector harvesting and clarification. Compared to an optimized batch process, 11-fold higher infectious virus titers were obtained in the clarified permeate (maximum 7.5×109 TCID50/mL). Using HEK293-SF cells and a rVSV vector expressing a green fluorescent protein, perfusion cultivations resulted in a maximum VCC of 11.3×106 cells/mL and infectious virus titers up to 7.1×1010 TCID50/mL in the permeate. Not only continuous harvesting but also clarification was possible. Although the cell-specific virus yield decreased relative to a batch process established as a control, an increased space-time yield was obtained. KEY POINTS: • Viral vector production using a TFDF perfusion system resulted in a 460% increase in space-time yield • Use of a TFDF system allowed continuous virus harvesting and clarification • TFDF perfusion system has great potential towards the establishment of an intensified vector production.

Characterization of a quail suspension cell line for production of a fusogenic oncolytic virus

The development of efficient processes for the production of oncolytic viruses (OV) plays a crucial role regarding the clinical success of virotherapy. Although many different OV platforms are currently under investigation, manufacturing of such viruses still mainly relies on static adherent cell cultures, which bear many challenges, particularly for fusogenic OVs. Availability of GMP-compliant continuous cell lines is limited, further complicating the development of commercially viable products. BHK21, AGE1. CR and HEK293 cells were previously identified as possible cell substrates for the recombinant vesicular stomatitis virus (rVSV)-based fusogenic OV, rVSV-NDV. Now, another promising cell substrate was identified, the CCX.E10 cell line, developed by Nuvonis Technologies. This suspension cell line is considered non-GMO as no foreign genes or viral sequences were used for its development. The CCX.E10 cells were thus thoroughly investigated as a potential candidate for OV production. Cell growth in the chemically defined medium in suspension resulted in concentrations up to 8.9 × 106 cells/mL with a doubling time of 26.6 h in batch mode. Cultivation and production of rVSV-NDV, was demonstrated successfully for various cultivation systems (ambr15, shake flask, stirred tank reactor, and orbitally shaken bioreactor) at vessel scales ranging from 15 mL to 10 L. High infectious virus titers of up to 4.2 × 108 TCID50 /mL were reached in orbitally shaken bioreactors and stirred tank reactors in batch mode, respectively. Our results suggest that CCX.E10 cells are a very promising option for industrial production of OVs, particularly for fusogenic VSV-based constructs.

Process intensification strategies toward cell culture-based high-yield production of a fusogenic oncolytic virus

We present a proof-of-concept study for production of a recombinant vesicular stomatitis virus (rVSV)-based fusogenic oncolytic virus (OV), rVSV-Newcastle disease virus (NDV), at high cell densities (HCD). Based on comprehensive experiments in 1 L stirred tank reactors (STRs) in batch mode, first optimization studies at HCD were carried out in semi-perfusion in small-scale cultivations using shake flasks. Further, a perfusion process was established using an acoustic settler for cell retention. Growth, production yields, and process-related impurities were evaluated for three candidate cell lines (AGE1.CR, BHK-21, HEK293SF)infected at densities ranging from 15 to 30 × 106  cells/mL. The acoustic settler allowed continuous harvesting of rVSV-NDV with high cell retention efficiencies (above 97%) and infectious virus titers (up to 2.4 × 109  TCID50 /mL), more than 4-100 times higher than for optimized batch processes. No decrease in cell-specific virus yield (CSVY) was observed at HCD, regardless of the cell substrate. Taking into account the accumulated number of virions both from the harvest and bioreactor, a 15-30 fold increased volumetric virus productivity for AGE1.CR and HEK293SF was obtained compared to batch processes performed at the same scale. In contrast to all previous findings, formation of syncytia was observed at HCD for the suspension cells BHK 21 and HEK293SF. Oncolytic potency was not affected compared to production in batch mode. Overall, our study describes promising options for the establishment of perfusion processes for efficient large-scale manufacturing of fusogenic rVSV-NDV at HCD for all three candidate cell lines.

Cell-line screening and process development for a fusogenic oncolytic virus in small-scale suspension cultures

Abstract

Oncolytic viruses (OVs) represent a novel class of immunotherapeutics under development for the treatment of cancers. OVs that express a cognate or transgenic fusion protein is particularly promising as their enhanced intratumoral spread via syncytia formation can be a potent mechanism for tumor lysis and induction of antitumor immune responses. Rapid and efficient fusion of infected cells results in cell death before high titers are reached. Although this is an attractive safety feature, it also presents unique challenges for large-scale clinical-grade manufacture of OVs. Here we evaluate the use of four different suspension cell lines for the production of a novel fusogenic hybrid of vesicular stomatitis virus and Newcastle disease virus (rVSV-NDV). The candidate cell lines were screened for growth, metabolism, and virus productivity. Permissivity was evaluated based on extracellular infectious virus titers and cell-specific virus yields (CSVYs). For additional process optimizations, virus adaptation and multiplicity of infection (MOI) screenings were performed and confirmed in a 1 L bioreactor. BHK-21 and HEK293SF cells infected at concentrations of 2 × 10⁶ cells/mL were identified as promising candidates for rVSV-NDV production, leading to infectious titers of 3.0 × 10⁸ TCID₅₀/mL and 7.5 × 10⁷ TCID₅₀/mL, and CSVYs of 153 and 9, respectively. Compared to the AGE1.CR.pIX reference produced in adherent cultures, oncolytic potency was not affected by production in suspension cultures and possibly even increased in cultures of HEK293SF and AGE1.CR.pIX. Our study describes promising suspension cell-based processes for efficient large-scale manufacturing of rVSV-NDV.

Key points

• Cell contact-dependent oncolytic virus (OV) replicates in suspension cells.

• Oncolytic potency is not encompassed during suspension cultivation.

• Media composition, cell line, and MOI are critical process parameters for OV production.

• The designed process is scalable and shows great promise for manufacturing clinical-grade material.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00253-022-12027-5.

A high cell density perfusion process for Modified Vaccinia virus Ankara production: Process integration with inline DNA digestion and cost analysis

By integrating continuous cell cultures with continuous purification methods, process yields and product quality attributes have been improved over the last 10 years for recombinant protein production. However, for the production of viral vectors such as Modified Vaccinia virus Ankara (MVA), no such studies have been reported although there is an increasing need to meet the requirements for a rising number of clinical trials against infectious or neoplastic diseases. Here, we present for the first time a scalable suspension cell (AGE1.CR.pIX cells) culture-based perfusion process in bioreactors integrating continuous virus harvesting through an acoustic settler with semi-continuous chromatographic purification. This allowed obtaining purified MVA particles with a space-time yield more than 600% higher for the integrated perfusion process (1.05 × 10¹¹ TCID₅₀ /L_bioreactor /day) compared to the integrated batch process. Without further optimization, purification by membrane-based steric exclusion chromatography resulted in an overall product recovery of 50.5%. To decrease the level of host cell DNA before chromatography, a novel inline continuous DNA digestion step was integrated into the process train. A detailed cost analysis comparing integrated production in batch versus production in perfusion mode showed that the cost per dose for MVA was reduced by nearly one-third using this intensified small-scale process.

Increased C reactive protein, cardiac troponin I and GLS are associated with myocardial inflammation in patients with non-ischemic heart failure

Inflammatory cardiomyopathy diagnosed by endomyocardial biopsy (EMB) is common in non-ischemic heart failure (HF) and might be associated with adverse outcome. We aimed to identify markers predicting myocardial inflammation in HF. We screened 517 patients with symptomatic non-ischemic HF who underwent EMB; 397 patients (median age 54 [IQR 43/64], 28.7% females) were included in this study. 230 patients were diagnosed with myocardial inflammation, defined as ≥ 7.0 CD3⁺ lymphocytes/mm² and/or ≥ 35.0 Mac1 macrophages/mm² and were compared to 167 inflammation negative patients. Patients with myocardial inflammation were more often smokers (52.4% vs. 39.8%, p = 0.013) and had higher C-reactive protein (CRP) levels (5.4 mg/dl vs. 3.7 mg/dl, p = 0.003). In logistic regression models CRP ≥ 8.15 mg/dl (OR 1.985 [95%CI 1.160–3.397]; p = 0.012) and Troponin I (TnI) ≥ 136.5 pg/ml (OR 3.011 [1.215–7.464]; p = 0.017) were independently associated with myocardial inflammation, whereas no association was found for elevated brain natriuretic peptide (OR 1.811 [0.873–3.757]; p = 0.111). In prognostic performance calculation the highest positive predictive value (90%) was detected for the combination of Global longitudinal strain (GLS) ≥ -13.95% and TnI ≥ 136.5 pg/ml (0.90 (0.74–0.96)). Elevated CRP, TnI and GLS in combination with TnI can be useful to detect myocardial inflammation. Smoking seems to predispose for myocardial inflammation.

e-Health-based management of patients receiving oral anticoagulation therapy: results from the observational thrombEVAL study

Essentials e-Health based health care by an expert centre may advance management of oral anticoagulation. Outcome of patients was compared between an e-health based coagulation service and regular care. Patients in the coagulation service cohort experienced a significantly better clinical outcome. Lower risk for adverse events was related to anticoagulation-specific and non-specific outcome.

SUMMARY

Background Management of oral anticoagulation (OAC) therapy is essential to minimize adverse events in patients receiving vitamin K-antagonists (VKAs). Data on the effect of e-health-based anticoagulation management systems on the clinical outcome of OAC patients are limited. Objectives To compare the clinical outcome of OAC patients managed by an e-health-based coagulation service (CS) with that of patients receiving regular medical care (RMC). Methods The prospective multicenter cohort study thrombEVAL (NCT01809015) comprised 1558 individuals receiving RMC and 760 individuals managed by a CS. Independent study monitoring and adjudication of endpoints by an independent review panel were implemented. Results The primary study endpoint (composite of thromboembolism, clinically relevant bleeding and death) occurred in 15.7 per 100 patient-years (py) with RMC and in 7.0 per 100 py with the CS (rate ratio [RR], 2.3; 95% confidence interval [CI], 1.7-3.1). Rates for major and clinically relevant bleeding were higher with RMC than with the CS: 6.8 vs. 2.6 and 10.1 vs. 3.6 per 100 py, respectively. Thromboembolic events showed an RR of 1.5 (95% CI, 0.8-2.6) comparing RMC with the CS. Hospitalization (RR, 2.6; 95% CI, 2.3-3.0) and all-cause mortality (RR, 4.6; 95% CI, 2.8-7.7) were markedly more frequent with RMC. In Cox regression analysis with adjustment for age, sex, cardiovascular risk factors, comorbidities, treatment characteristics and sociodemographic status, hazard ratios (HR) for the primary endpoint (HR, 2.2; 95% CI, 1.5-3.4), clinically relevant bleeding (HR, 3.1; 95% CI, 1.7-5.5), hospitalization (HR, 2.2; 95% CI, 1.8-2.8) and all-cause mortality (HR, 5.6; 95% CI, 2.9-11.0) favored CS treatment. Conclusions In this study, e-health-based management of OAC therapy was associated with a lower frequency of OAC-specific and non-specific adverse events.

The mental number line and the human angular gyrus

To investigate the hemispheric organization of a language-independent spatial representation of number magnitude in the human brain we applied focal repetitive transcranial magnetic stimulation (rTMS) to the right or left angular gyrus while subjects performed a number comparison task with numbers between 31 and 99. Repetitive TMS over the angular gyrus disrupted performance of a visuospatial search task, and rTMS at the same site disrupted organization of the putative "number line." In some cases the pattern of disruption caused by angular gyrus rTMS suggested that this area normally mediates a spatial representation of number. The effect of angular gyrus rTMS on the number line task was specific. rTMS had no disruptive effect when delivered over another parietal region, the supramarginal gyrus, in either the left or the right hemisphere.

[Aggression, inanimate objects and fantasy of invulnerability]

Some highly aggressive children prefer to symbolize and express their inner experiences by toys, which represent "things" and not living creatures. The special function of this preference represents a defense structure of deanimation after traumatization. It implicates the phantasy, that inanimated objects are not part of the vivid dialogue and can "survive" every attack. Thus in the transferential relationship the deanimation can slowly be reanimated by borrowing the undestroyable aspects of a thing in combination with the suffering feelings of the therapist.

Vehicle-Dependent Biotin Liberation and Penetration into Human Skin

The presence of a sufficient quantity of a drug in the epidermis is a necessary prerequisite for influencing epidermal proliferation and differentiation processes. With the aim of obtaining a high concentration of a potential active agent (biotin) at the target area after topical application, the influence of the vehicle on biotin release and penetration was investigated. Liberation studies (multi-layer membrane model) showed that over 50% of the biotin in an oil-in-water (O/W) emulsion (64.8 ± 1.9%) and a micro-emulsion (ME, 54.5 ± 2.4%) is released within 300 min, whereas the degree of release from a water-in-oil emulsion does not exceed 16%. For this latter vehicle, the influence of a controlled drug release on the penetration processes in human skin (Franz cell) results in the penetration of only small quantities of the drug into the skin layers (into the horny layer 7.9 ± 2.6%, living epidermis 0.11 ± 0.06%, dermis 0.38 ± 0.31% within 300 min). The application of an O/W emulsion or an ME appears to be more favourable. Both vehicles lead to not only a large reservoir in the horny layer (O/W 26.5 ± 3.5%, ME 26.0 ± 0.8% within 300 min) of the skin but also important epidermal and dermal concentrations (living epidermis: O/W 2.0 ± 0.9%, ME 0.3 ± 0.2%; dermis: O/W 3.4 ± 1.3%, ME 1.6 ± 0.8% within 300 min). The time-dependent concentration profiles in the skin layers suggest that the use of an ME produces an immediate effect, whereas the application of an O/W emulsion results in a delayed and/or long-term effect.

Application of capillary zone electrophoresis for analyzing biotin in pharmaceutical formulations--a comparative study

The detection limit and reproducibility of capillary zone electrophoresis (CZE) measurement of biotin were compared to those of a spectrophotometric method and those of the determination of the sulphur content by combustion of the biotin sample followed by coulometric titration of the formed SO2. Drug analysis showed that all three methods gave consistent results and were suitable for the determination of biotin. CZE was found to be the best method for the determination of pharmaceutical formulations containing biotin because of its high separation efficiency, short analysis time, ease of instrumentation and sample preconditioning, and good precision.

[Various mechanisms of disorders of carbohydrate metabolism in myocardial infarct]

A group of 112 patients with acute myocardial infarction was studied. Methods for determining the content of immunoreactive insulin, uric acid, triglycerides, and sugar in blood on a fasting stomach and under conditions of carbohydrate load in dynamics were used. The data obtained show that patients, mainly those with uncomplicated myocardial infarction, are marked by relative insulin insufficiency as well as by a high level of triglycerides and uric acid in the acute period of the disease. The causal relationship between hyperuricemia, hypertriglyceridemia, and carbohydrate metabolism disorders is discussed.

[Nuclear medicine diagnosis of pulmonary embolism (author's transl)]

Pulmonary embolism is an emergency situation. The earlier therapy begins, the more effective it will be. This, however, asks for immediate diagnosis. At present the most effective method of diagnosing and localizing pulmonary embolism is perfusion scintiscan of the lung. It should be completed by chest radiography to exclude peripheral infiltration and/or central lung cancer. Generally, these two procedures ensure optimal diagnosis. In case of additional disease of the pleura, mediastinum and lung parenchyma, further measures may be necessary: especially in chronic obstructive lung disease ventilation perfusion ratio and outwash of xenon might be helpful. Scintiscan of the lung is suited for early diagnosis as well as for follow-up examinations. Only if thrombectomy is planned, pulmonary angiography should be preferred. Scintiscan of the lung with marked particle suspensions ensures a minimum of complications. There is only one incident in 10,000 examinations. According to Quinn (1964) and Felix (1971) pulmonary scintiscan might be harmful in patients with right heart failure. We made no such observation in 4000 cases.

[Tracer kinetic studies of the cholesterol metabolism in patients with hypercholesterolemia]

For the examination of the cholesterol metabolism in patients with normal and increased serum cholesterol the 3H-cholesterol was used. The tracer-kinetic investigation programme consisted of the examination of the serum for free and esterified cholesterol as well as the separation in VLDL-, LDL- AND HDL-fractions. The establishment of the content of radioactivity of the individual samples was carried out in the LSC-nitrobeta 1210. Specific activity-time-curves were established and fitted according to a mathematical programme. The most essential findings of the evaluation of these curves resulted in a clearly changed turnover of the LDL-fraction. Possible causes for the disturbed LDL-turnover were discussed.

[Replacement of the trigonum vesicae by silicone rubber in mini pigs (author's transl)]

Prostheses of the trigonum vesicae made of silicone rubber and covered with a textile layer were implanted in 18 mini pigs. Investigations were done in two series: in the first the prostheses were covered on the outside with a narrow woven textile layer, in the second with Dacron-velour. While the narrow woven textile-lined prostheses were rejected into the urinary bladder after a short period, the Dacron-velour-lined prostheses remained well attached to the bladder wall.