The CD40 agonist HERA-CD40L results in enhanced activation of antigen presenting cells, promoting an anti-tumor effect alone and in combination with radiotherapy

Introduction

The ability to modulate and enhance the anti-tumor immune responses is critical in developing novel therapies in cancer. The Tumor Necrosis Factor (TNF) Receptor Super Family (TNFRSF) are potentially excellent targets for modulation which result in specific anti-tumor immune responses. CD40 is a member of the TNFRSF and several clinical therapies are under development. CD40 signaling plays a pivotal role in regulating the immune system from B cell responses to myeloid cell driven activation of T cells. The CD40 signaling axis is well characterized and here we compare next generation HERA-Ligands to conventional monoclonal antibody based immune modulation for the treatment of cancer.

Methods & results

HERA-CD40L is a novel molecule that targets CD40 mediated signal transduction and demonstrates a clear mode of action in generating an activated receptor complex via recruitment of TRAFs, cIAP1, and HOIP, leading to TRAF2 phosphorylation and ultimately resulting in the enhanced activation of key inflammatory/survival pathway and transcription factors such asNFkB, AKT, p38, ERK1/2, JNK, and STAT1 in dendritic cells. Furthermore, HERA-CD40L demonstrated a strong modulation of the tumor microenvironment (TME) via the increase in intratumoral CD8+ T cells and the functional switch from pro-tumor macrophages (TAMs) to anti-tumor macrophages that together results in a significant reduction of tumor growth in a CT26 mouse model. Furthermore, radiotherapy which may have an immunosuppressive modulation of the TME, was shown to have an immunostimulatory effect in combination with HERA-CD40L. Radiotherapy in combination with HERA-CD40L treatment resulted in an increase in detected intratumoral CD4+/8+ T cells compared to RT alone and, additionally, the repolarization of TAMs was also observed, resulting in an inhibition of tumor growth in a TRAMP-C1 mouse model.

Discussion

Taken together, HERA-CD40L resulted in activating signal transduction mechanisms in dendritic cells, resulting in an increase in intratumoral T cells and manipulation of the TME to be pro-inflammatory, repolarizing M2 macrophages to M1, enhancing tumor control.

Abstract 1587: Generation and characterization of novel bispecific molecules combining single-chain-CD40L with anti-CEA, anti-CD95L or anti-PD-L1 targeting moieties

CD40 ligand is a member of the TNF superfamily (TNF-SF) and a key regulator of the immune system. Its cognate receptor CD40 is expressed on antigen-presenting cells and on many tumor types, and has emerged as an attractive target for immunological cancer treatment. We developed HERA-CD40L, a construct composed of a trivalent single-chain CD40L-receptor-binding-domain (scCD40L-RBD) linked to a silenced human IgG1-Fc-domain thereby generating a hexavalent molecule. We showed previously that HERA-CD40L mimics the natural ligand, thereby inducing potent agonistic activity which is independent of FcγR mediated crosslinking and superior to anti-CD40 benchmark antibodies. For combinatorial cancer immunotherapy we have created bispecific molecules by combining the HERA-CD40L scaffold with antibody derived domains targeting different classes of tumor associated antigens. These bispecific fusion proteins combine the potent co-stimulatory CD40-agonist with either direct tumor-cell targeting and/or additional immunomodulatory activities in the tumor microenvironment. To evaluate the different fusion protein formats, the tumor associated antigens CEA, PD-L1 and CD95L were chosen as model-targets. In addition to the hexavalent targeted HERA-CD40L, trivalent targeted fusion proteins, employing the scCD40L-RBD as building block, were created as well. All engineering prototypes were produced in CHO-S cells and purified, resulting in highly pure non-aggregating protein lots as demonstrated by SDS-PAGE and HPLC-SEC. Functional binding to their respective targets was shown by ELISA and to proof biological in vitro activity luciferase reporter gene assays were employed. The basic underlying immunological processes have been investigated in vitro. The trivalent CD40L, the trivalent CD40L-bispecifics anti-CD95L-scCD40L-RBD and anti-CEA-scCD40L-RBD as well as anti-CD40, anti-PD-L1 or anti-CD95L antibodies did not activate human monocytes, even if the antibodies were co-administered with trivalent CD40L. In contrast, the hexavalent HERA-CD40L, the hexavalent bifunctional CD40L-constructs and the trivalent anti-PD-L1-scCD40L-RBD-construct induced strong activation/maturation of the monocytes as indicated by CD83, CD86, HLA-DR upregulation which was accompanied by increased chemokine receptor (CD54, CCR7) and PD-L1 expression. When co-cultured with CD3 positive T cells, these pre-activated monocytes led to subsequent activation of CD4 as well as CD8 positive T cells, indicated by increased expression of CD25, CD69 and CD54. This clearly shows that the close proximity of anti-PD-L1 and trivalent CD40L within one molecule makes a huge difference for biological activity. Hence, these novel bispecific constructs are a promising therapeutic approach to promote anti-tumor immune responses.

Citation Format: Matthias Schroeder, Katharina Billian-Frey, Jaromir Sykora, Mauricio Redondo-Mueller, Karl Heinonen, Jamie Frankish, Christian Gieffers, Meinolf Thiemann, Oliver Hill. Generation and characterization of novel bispecific molecules combining single-chain-CD40L with anti-CEA, anti-CD95L or anti-PD-L1 targeting moieties [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1587.

Abstract 4460: Novel bispecific molecules combining HERA-CD40L with anti-CEA or with anti-PD-L1 for targeting

CD40 ligand is a member of the TNF superfamily and a key regulator of the immune system. Its cognate receptor CD40 is expressed on antigen-presenting cells and on many tumor types, and has emerged as an attractive target for immunological cancer treatment. We have shown previously, that hexavalent HERA-CD40L is a potent CD40 agonist which is clearly superior over anti-CD40 benchmark antibodies and able to establish single agent anti-tumor immune responses both in vitro and in vivo. Since this compound qualifies as an ideal candidate for combinatorial cancer treatments we have created bispecific molecules by adding antibody derived targeting domains to the HERA-CD40L scaffold. These bispecific fusion proteins combine the potent co-stimulatory CD40-agonist with additional functionalities to enable tumor targeting and/or additional immuno-modulatory activities. To evaluate the different fusion protein formats in principle, the tumor associated antigens CEA and PD-L1 were chosen as targets. In addition to the hexavalent targeted HERA-CD40L, trivalent targeted fusion proteins employing the single-chain CD40L (scCD40L) as building block were created. Anti-CEA-HERA-CD40L, anti-CEA-trivalent scCD40L, anti-PD-L1-HERA-CD40L and anti-PD-L1-trivalent scCD40L were produced in CHO-S cells and purified resulting in highly pure non-aggregating protein lots as demonstrated by SDS-PAGE and HPLC-SEC. ELISA assays confirmed the specific binding to their targets - CD40 and CEA or CD40 and PD-L1, respectively. Employing a CD40 Luciferase reporter gene assay, hexavalent anti-CEA-HERA-CD40L showed a strong agonistic activity which was clearly superior to the anti-CEA-trivalent scCD40L- construct. Similarly, hexavalent anti-PD-L1-HERA-CD40L showed a strong agonistic activity in this assay which also was clearly superior to the anti-PD-L1-trivalent scCD40L construct. A PD-1/PD-L1 Luciferase reporter gene assay assessing the cellular activity of compounds interfering with PD-1/PD-L1 binding showed a clear activity for anti-PD-L1-HERA-CD40L. As expected for an assay assessing antagonistic activities, the activity of hexavalent anti-PD-L1-HERA-CD40L was in the same range as a reference anti-PD-L1 antibody and the anti-PD-L1-trimeric scCD40L- construct. Based on the in vitro data presented, the bispecific molecules combining HERA-CD40L with tumor targeting (anti-CEA) or with a checkpoint-blockade inhibitor (anti-PD-L1) are promising therapeutic approaches to promote anti-tumor immune responses.

Citation Format: Meinolf Thiemann, Katharina Billian-Frey, Matthias Schröder, Christian Merz, Jaromir Sykora, David M. Richards, Mauricio Redondo Müller, Julian P. Sefrin, Karl Heinonen, Christian Gieffers, Oliver Hill. Novel bispecific molecules combining HERA-CD40L with anti-CEA or with anti-PD-L1 for targeting [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4460.

Abstract 1076: Hexavalent HERA-CD40L induces a productive T cell-mediated anti-tumor immune response and shows superior activity in comparison to benchmark CD40 agonistic antibodies

TNF Receptor Superfamily members (TNF-R-SF), including CD40, are key regulators of the immune system and have been immunotherapeutic targets for over 20 years. CD40 signaling serves as an important co-stimulatory signal for antigen-presenting cells (APC). For the induction of a CD40 driven anti-tumor immune response multiple approaches, - most of them antibody based - are currently under investigation. However, the structural necessity of trimerization within the TNF-R-SF, defines bivalent antibodies generally as unfeasible inducers of signaling events within this protein family. To overcome the known inadequacies of antibodies, we developed HERA-CD40L, composed of two trivalent CD40L-receptor-binding domains, fused to a silenced human IgG1 Fc-domain. This hexavalent CD40 agonist mimics the natural ligand and enables efficient receptor clustering and superior signaling. HERA-CD40L treatment increased the pro-inflammatory state of all CD40-expressing cells examined. It promoted the licensing of dendritic cells (DC), macrophages, B cells and other APC. Comparison to benchmark antibodies revealed that HERA-CD40L elicited a stronger and more rapid activation of NFκB signaling in primary B cells. HERA-CD40L treatment, but not clinical benchmark antibodies triggered immediate NFκB, MAPK, PI3K and STAT-1 signaling in primary monocyte-derived immature DC. As a result, HERA-CD40L induced upregulation of activation markers and co-stimulatory molecules in B cells and DC. Using SEC fractionation followed by a CD40 reporter assay, we could furthermore demonstrate that the activity of a clinical benchmark antibody derived exclusively from antibody aggregates. In vitro HERA-CD40L treatment converted immature phagocytic macrophages into mature/professional APC and induced repolarization of M2- to M1-like macrophages. These findings were confirmed in vivo using a mouse surrogate (mmHERA-CD40L). Upon treatment of MC38-CEA and CT26wt syngeneic mouse models, we observed single agent anti-tumor efficacy. In the CT26wt model, mmHERA-CD40L treatment converted cold into hot tumors by increasing T cell infiltration. Furthermore, mmHERA-CD40L induced a strong dose dependent decrease of tumor associated pro-tumorigenic M2-macrophages indicating a profound reorganization of the tumor microenvironment. Both in vitro (human) and in vivo (mouse), HERA-CD40L increased antigen-specific immune system activation without affecting the non-specific immune cells. These data, together with pilot PD/safety results, demonstrate that the activity of HERA-CD40L is both potent and safe. In conclusion, HERA-CD40L is a potent agonist able to show single agent anti-tumor activity. The biological activity is distinct from and superior to clinical benchmark “agonistic” antibodies. HERA-CD40L has a well-defined mechanism of action, does not depend on Fc gamma receptor-mediated crosslinking and hence functions as a true agonist.

Citation Format: Christian Gieffers, David M. Richards, Jaromir Sykora, Christian Merz, Julian P. Sefrin, Katharina Billian-Frey, Karl Heinonen, Mauricio Redondo Müller, Matthias Schröder, Meinolf Thiemann, Oliver Hill. Hexavalent HERA-CD40L induces a productive T cell-mediated anti-tumor immune response and shows superior activity in comparison to benchmark CD40 agonistic antibodies [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1076.

HERA-GITRL activates T cells and promotes anti-tumor efficacy independent of FcγR-binding functionality

Background

Glucocorticoid-induced TNFR-related protein (TNFRSF18, GITR, CD357), expressed by T cells, and its ligand (TNFSF18, GITRL), expressed by myeloid populations, provide co-stimulatory signals that boost T cell activity. Due to the important role that GITR plays in regulating immune functions, agonistic stimulation of GITR is a promising therapeutic concept. Multiple strategies to induce GITR signaling have been investigated. The limited clinical efficacy of antibody-based GITR agonists results from structural and functional characteristics of antibodies that are unsuitable for stimulating the well-defined trimeric members of the TNFRSF.

Methods

To overcome limitations of antibody-based TNFRSF agonists, we have developed HERA-GITRL, a fully human hexavalent TNF receptor agonist (HERA) targeting GITR and mimicking the natural signaling concept. HERA-GITRL is composed of a trivalent but single-chain GITRL-receptor-binding-domain (scGITRL-RBD) unit fused to an IgG1 derived silenced Fc-domain serving as dimerization scaffold. A specific mouse surrogate, mmHERA-GITRL, was also generated to examine in vivo activity in respective mouse tumor models.

Results

For functional characterization of HERA-GITRL in vitro, human immune cells were isolated from healthy-donor blood and stimulated with anti-CD3 antibody in the presence of HERA-GITRL. Consistently, HERA-GITRL increased the activity of T cells, including proliferation and differentiation, even in the presence of regulatory T cells.

In line with these findings, mmHERA-GITRL enhanced antigen-specific clonal expansion of both CD4+ (OT-II) and CD8+ (OT-I) T cells in vivo while having no effect on non-specific T cells. In addition, mmHERA-GITRL showed single-agent anti-tumor activity in two subcutaneous syngeneic colon cancer models (CT26wt and MC38-CEA). Importantly, this activity is independent of its FcγR-binding functionality, as both mmHERA-GITRL with a functional Fc- and a silenced Fc-domain showed similar tumor growth inhibition.

Finally, in a direct in vitro comparison to a bivalent clinical benchmark anti-GITR antibody and a trivalent GITRL, only the hexavalent HERA-GITRL showed full biological activity independent of additional crosslinking.

Conclusion

In this manuscript, we describe the development of HERA-GITRL, a true GITR agonist with a clearly defined mechanism of action. By clustering six receptor chains in a spatially well-defined manner, HERA-GITRL induces potent agonistic activity without being dependent on additional FcγR-mediated crosslinking.

Electronic supplementary material

The online version of this article (10.1186/s40425-019-0671-4) contains supplementary material, which is available to authorized users.

Abstract 5015: HERA-CD40L a hexavalent CD40 agonist induces T cell mediated anti-tumor immune response and shows superior activity in direct comparison to benchmark agonistic antibodies

CD40 ligand is a member of the TNF superfamily (TNF-SF) and a key regulator of the immune system. Its cognate receptor CD40 is expressed on antigen-presenting cells and on many tumor types, and has emerged as an attractive target for immunological cancer treatment.

Effective signaling for CD40/CD40L depends on the formation of a defined ligand/receptor complex triggered by interaction of a trimeric CD40L with three CD40 receptor chains allowing correct assembly of intracellular signaling complexes and respective signal transduction. Trimerization is a hallmark of the TNF-SF and has pivotal implications for the generation of respective TNFR-SF agonists in particular. However, ignoring the underlying trimeric structural concept bivalent antibodies are still the main agonistic biotherapeutic development candidates to address TNFR-SF members including CD40. Such bivalent antibodies are inherently associated with limited agonistic activity that requires Fc/FcγR interactions or potentially show increased toxicity caused by super-clustering of endogenous ligand receptor pairs.

To overcome the inadequacies of antibodies, we have developed HERA-CD40L composed of three receptor binding domains in a single chain arrangement, linked to an Fc-silenced human IgG1 thereby generating a hexavalent molecule. HERA-CD40L mimics the natural ligand, induces potent agonistic activity and, importantly, does not require FcγR mediated crosslinking. Comparison of HERA-CD40L to anti-CD40 benchmark antibodies (including CP-870,893) revealed superiority for HERA-CD40L in all assays tested. (i) In contrast to antibodies, HERA-CD40L showed strong activation of NFkB signaling upon treatment of B cells. (ii) HERA-CD40L treatment, but not clinical benchmark antibodies, converts immature phagocytic macrophages into mature/professional APCs and promoted differentiation towards the M1 spectrum macrophages. (iii) Furthermore, HERA-CD40L treated PBMCs stimulate potent allogeneic anti-tumor T cell response that was not detectable for CD40-antibodies.

In vivo, a murine surrogate of HERA-CD40L stimulated clonal expansion of OT-I specific murine CD8+ T cells without affecting non-specific immune cells. In the syngeneic CT26wt mouse model mHERA-CD40L treatment converts cold into hot tumors by increasing infiltration of CD8+ and CD4+ T cells. In addition mHERA-CD40L showed single agent anti-tumor activity in the CD40-negative syngeneic MC38-CEA mouse model, suggesting an involvement of the immune system in controlling tumor growth.

In summary HERA-CD40L is a potent agonist able to establish single agent anti-tumor immune responses. Comparison to bivalent benchmark antibodies showed superior biological activity of HERA-CD40L and qualifies this molecule as an ideal candidate for combinatorial cancer treatments.

Citation Format: Christian Gieffers, Jaromir Sykora, Christian Merz, Mauricio Redondo Müller, David M. Richards, Julian Sefrin, Katharina Billian-Frey, Karl Heinonen, Viola Marschall, Matthias Schröder, Harald Fricke, Meinolf Thiemann, Hill Oliver. HERA-CD40L a hexavalent CD40 agonist induces T cell mediated anti-tumor immune response and shows superior activity in direct comparison to benchmark agonistic antibodies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5015.

Abstract 4845: HERA-CD27L, a true CD27 agonist, is a hexavalent CD27 ligand that enhances T cell activation and induces potent anti-tumor immunity

Agonistic stimulation of TNFRSF members like CD27 is a promising strategy to boost anti-tumor responses. Although antibodies are effective inhibitors of signaling, they have shown minimal agonistic activity due to their limited binding domains, flexibility and the toxicity mediated by Fc/FcγR interactions. TNFRSF signaling is a structurally well-defined event that takes place during cell contact. The trimeric-trivalent TNFSF-receptor binding domain (TNFSF-RBD) on the conducting cell and the resulting multi-trimer-based receptor clustering on the receiving cell are essential for signaling. In contrast to antibodies, HERA-CD27L mimics the natural ligand and induces potent activity. In order to understand the activity of HERA-CD27L, human T cells were stimulated in the presence of HERA-CD27L, the trimeric CD27L or a clinical benchmark anti-CD27 antibody. In all assays, treatment with the hexavalent HERA-CD27L significantly boosted T cell activation, proliferation and differentiation. Furthermore, the hexavalent molecule was always superior to the trimeric CD27L and bivalent antibody. In fact, treatment with the anti-CD27 antibody resulted in significantly weaker proliferation compared to anti-CD3 antibody alone. To understand early events, we tested CD27 signaling using a reporter cell assay. Treatment with HERA-CD27L and CD27L resulted in high and intermediate, respectively, reporter activity. In contrast, the anti-CD27 antibody failed to show any signaling activity across a wide range of concentrations. Since most T cells express CD27, there is potential for non-specific T cell activation. This was examined by comparing OVA-specific and non-specific T cells in the same environment using the CD8+ “OT-I” T cell adoptive transfer mouse model. Following a single dose of HERA-CD27L, serial blood samples showed a significant and HERA-CD27L dose-dependent clonal expansion of OT-I T cells. OT-I T cells expressed high levels of activation markers, while the endogenous T cells failed to show any response. The potent single-agent anti-tumor efficacy of the hexavalent HERA-CD27L was demonstrated in two different mouse models. With CT26wt, HERA-CD27L also showed superior activity compared to anti-PD-1 antibody. Furthermore, combination of HERA-CD27L and anti-PD-1 antibody showed additive effects. Finally, early treatment with HERA-CD27L significantly increased overall survival, from 19 to 41 days, and tumor-free animals still alive at the end of the study were protected from tumor re-challenge. Various strategies have been proposed for targeting CD27 for cancer therapy. As we have shown here, the hexavalent HERA-CD27L has superior activity compared to bivalent antibodies. Altogether, HERA-CD27L shows single-agent anti-tumor efficacy, is well tolerated by multiple relevant species and the lead candidate is currently ready for GMP cell line development.

Citation Format: Julian P. Sefrin, David M. Richards, Katharina Billian-Frey, Karl Heinonen, Viola Marschall, Christian Merz, Mauricio Redondo Müller, Matthias Schröder, Jaromir Sykora, Meinolf Thiemann, Harald Fricke, Christian Gieffers, Oliver Hill. HERA-CD27L, a true CD27 agonist, is a hexavalent CD27 ligand that enhances T cell activation and induces potent anti-tumor immunity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4845.

A Single-Chain-Based Hexavalent CD27 Agonist Enhances T Cell Activation and Induces Anti-Tumor Immunity

Tumor necrosis factor receptor superfamily member 7 (TNFRSF7, CD27), expressed primarily by T cells, and its ligand CD27L (TNFSF7, CD70) provide co-stimulatory signals that boost T cell activation, differentiation, and survival. Agonistic stimulation of CD27 is therefore a promising therapeutic concept in immuno-oncology intended to boost and sustain T cell driven anti-tumor responses. Endogenous TNFSF/TNFRSF-based signal transmission is a structurally well-defined event that takes place during cell-to-cell-based contacts. It is well-established that the trimeric-trivalent TNFSF-receptor binding domain (TNFSF-RBD) exposed by the conducting cell and the resulting multi-trimer-based receptor clustering on the receiving cell are essential for agonistic signaling. Therefore, we have developed HERA-CD27L, a novel hexavalent TNF receptor agonist (HERA) targeting CD27 and mimicking the natural signaling concept. HERA-CD27L is composed of a trivalent but single-chain CD27L-receptor-binding-domain (scCD27L-RBD) fused to an IgG1 derived silenced Fc-domain serving as dimerization scaffold. The hexavalent agonist significantly boosted antigen-specific T cell responses while having no effect on non-specific T cells and was superior over stabilized recombinant trivalent CD27L. In addition, HERA-CD27L demonstrated potent single-agent anti-tumor efficacy in two different syngeneic tumor models, MC38-CEA and CT26wt. Furthermore, the combination of HERA-CD27L and an anti-PD-1 antibody showed additive anti-tumor effects highlighting the importance of both T cell activation and checkpoint inhibition in anti-tumor immunity. In this manuscript, we describe the development of HERA-CD27L, a true CD27 agonist with a clearly defined forward-signaling mechanism of action.

Abstract 3754: The novel hexavalent human CD137/4-1BB agonist HERA-CD137L promotes anti-cancer immunity by activating CD8 T cells while regulatory T cells are not affected

CD137/4-1BB is an inducible costimulatory receptor mainly expressed on immune cells following activation. Binding of the cognate ligand CD137L/4-1BBL leads to receptor trimerization and activation of signaling cascades involved in expansion and survival of T cells and myeloid cells as well as memory formation and protection against autoimmunity. Apogenix´ HERA technology is based on trivalent single-chain molecular mimics of the TNF-SF receptor binding domains fused to a silenced human IgG1-Fc-domain which serves exclusively as a dimerization scaffold. This results in hexavalent agonists replicating the natural receptor binding mode. Due to their inherent high receptor clustering capacity, HERA compounds are true agonists and their biological activity is, in contrast to bivalent anti-TNFR-SF antibodies, independent of FcR-mediated crosslinking events. HERA-CD137L was produced in CHO-S cells and purified resulting in highly pure non-aggregating protein lots. PK studies in mice demonstrated a terminal half-life of 75 hours indicating excellent in vivo stability. To study the effects on immune cells in vitro, T cells were isolated from healthy-donor buffy coats and stimulated with anti-CD3 antibody alone or in combination with HERA-CD137L. Using multicolor flow cytometry, we confirmed that expression of CD137 increased on CD8+ T cells following stimulation with anti-CD3 antibody. In accord with upregulation of the activation markers CD25 and CD69 and the memory marker CD45RO, treatment with HERA-CD137L enhanced proliferation of both CD4+ and CD8+ T cells, as determined by CFSE analysis. Intracellular accumulation of IFN-γ, TNF-α, Granzyme B and Perforin upon CD137 ligation was observed in CD8+ but not CD4+ T cells. HERA-CD137L treatment of THP-1 monocytes co-cultured with primary T cells also increased their cytotoxic activity against multiple tumor cell lines, including colorectal and mammary, as shown in a real-time live cell analysis (RTCA) assay. Primary human monocytes express low levels of CD137 and differentiation to macrophages in vitro did not increase expression. However, pro-inflammatory cytokines such as TNF-α and the chemokine CCL4 were secreted after stimulation with HERA-CD137L. RTCA assays further demonstrated enhanced antigen-specific killing of MDA-MB231 tumor cells by HERA-CD137L treated T cells. HERA-CD137L conveys its activity through effector T cell proliferation while regulatory T (Treg) cell proliferation or production of anti-inflammatory cytokines are not altered in Treg cell cultures. In contrast, HERA-CD137L prevented Treg-mediated suppression of effector T cells. Based on the in vitro data presented, HERA-CD137L is a promising candidate to promote anti-tumor immune responses either as single agent or in combination with other IO-compounds.

Citation Format: Meinolf Thiemann, Jaromir Sykora, David M. Richards, Christian Merz, Viola Marschall, Mauricio Redondo Mueller, Julian P. Sefrin, Karl Heinonen, Harald Fricke, Christian Gieffers, Oliver Hill. The novel hexavalent human CD137/4-1BB agonist HERA-CD137L promotes anti-cancer immunity by activating CD8 T cells while regulatory T cells are not affected [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3754.

Abstract 630: Novel hexavalent HVEM agonist HERA-LIGHT promotes T cell activation and expansion

The tumor necrosis factor superfamily (TNFSF) member LIGHT (TNFSF14) plays an important role in regulating the activity of immune cells, especially T cells. Several studies have shown that engagement of HVEM (herpesvirus entry mediator), one of the known receptors of LIGHT, can deliver a co-stimulatory signal to support T cell activation and expansion and promote tumor clearance. The HERA technology platform developed by Apogenix generates fully human hexavalent TNFSF fusion proteins that mimic the natural receptor binding mode in order to co-stimulate T cells. HERA ligands are pure agonists whose signaling capacity does not rely on secondary Fcγ-receptor crosslinking. Here we report the in vitro and in vivo properties of a novel HERA-LIGHT construct. Similar to all HERA fusion proteins, HERA-LIGHT has been engineered as a perfect molecular mimic of the natural ligand with high clustering capacity for the cognate receptor. The core unit consists of a single chain polypeptide comprising the three minimal LIGHT-subsequences necessary for folding into a functional trivalent receptor binding domain (RBD). By fusing a silenced IgG1 Fc-domain as a dimerization scaffold to the C-terminus of the RBD we generated HERA-LIGHT, a hexavalent fusion protein. HERA-LIGHT was expressed in CHO suspension cells followed by a lab-scale purification process including AFC- and SEC-based polishing, resulting in homogenous, aggregate-free protein lots. HERA-LIGHT was proven to bind both the human and murine HVEM receptor, as determined by ELISA. Qualitative analytics revealed excellent stability following heat- and pH-stress as well as freeze-thaw cycles. Analyzing serum samples from a PK study in CD1-mice, the terminal half-life of the compound was 36.5 hours. This short half-life, relative to antibodies, allows for fast-in/fast-out dynamics essential for improving combination therapy and reducing serious side effects associated with immune system overstimulation. In order to test biological activity, T cells were isolated by magnetic sorting from human PBMCs and treated with HERA-LIGHT in vitro. Flow cytometric analysis revealed that HERA-LIGHT enhanced activation and proliferation of naïve effector T cells (Teff) following stimulation with anti-CD3 antibody, as determined by CFSE dilution. Importantly, co-stimulation with HERA-LIGHT prevented regulatory T cell (Treg)-mediated suppression of Teff proliferation. In vivo, treatment with a murine surrogate of HERA-LIGHT resulted in significant tumor growth inhibition in a pilot study using the syngeneic CT-26 colorectal cancer model.In summary, the unique hexavalent design of HERA-LIGHT mediates efficient co-stimulation of Teff even in the presence of Treg cells and independent of secondary crosslinking events. Being true agonists, all HERA molecules are unique from current antibody-based concepts rendering them attractive candidates for cancer immunotherapy.

Citation Format: Julian P. Sefrin, David M. Richards, Jaromir Sykora, Meinolf Thiemann, Christian Merz, Viola Marschall, Mauricio Redondo Müller, Karl Heinonen, Harald Fricke, Christian Gieffers, Oliver Hill. Novel hexavalent HVEM agonist HERA-LIGHT promotes T cell activation and expansion [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 630.

Abstract 4963: Novel hexavalent GITR agonists stimulate T cells and enhance memory formation

Introduction: The co-stimulatory receptor GITR plays an important role in initiating the immune response in the lymph nodes and in maintaining the immune response in the tumor tissue. Binding of GITR to its natural ligand directly leads to increased anti-tumor T cell activation and their survival. It also reduces the suppressive abilities of Treg cells, further increasing the anti-tumor immune response. The HERA-technology developed by Apogenix targets the TNF-receptor superfamily and generates fully human hexavalent fusion proteins with high clustering capacity for the cognate receptor. Hexavalent HERA-ligands are pure agonists whose signaling capacity is independent of secondary Fcγ-receptor crosslinking. Here we report in vitro and in vivo properties of novel hexavalent HERA-GITRL constructs.

Experimental procedures: For the assessment of in vivo stability, serum samples from a PK study with three HERA-GITRL constructs in CD1-mice were analyzed with respect to their drug levels employing a specific ELISA assay. For functional characterization of HERA-GITRL in vitro, immune cells were isolated from healthy-donor blood samples and profiled by multicolor flow cytometry (MC-FC). Subsequently, immune cells were cultured in growth media containing different HERA-GITRL constructs and anti-CD3. Changes in activation and memory markers on T cells (e.g. CD25, CD69, CD45RA, CD45RO), their proliferation rate (CFSE assay) and the intracellular staining of cytokines (e.g. TNF-α and IFN-γ) was assessed by MC-FC.

Results: Minor modifications led to three HERA-GITRL drug candidates with unique pharmacokinetic properties / in vivo stability as explored in mice. Terminal half-life was between 61.7 and 200.6 hours. Stimulation of pan T cells as well as naïve CD4+ T-lymphocytes by anti-CD3 was further augmented by HERA-GITRL as demonstrated by CD69 and CD25 expression. This effect was accompanied by an increased proliferation and an increased memory formation. Furthermore, we observed an increased level of intracellular TNF-α and IFN-γ in naïve CD4+ T-lymphocytes incubated with anti-CD3 that could be further raised by the addition of HERA-GITRL.

Conclusion: HERA-GITRL demonstrate excellent in vivo stability. Their ability to enhance proliferation and activation of naïve CD4+ T cells and to induce memory formation render them as attractive candidates for immunotherapeutic treatments of cancer.

Citation Format: Meinolf Thiemann, Christian Gieffers, David M. Richards, Christian Merz, Karl Heinonen, Mauricio Redondo Mueller, Viola Marschall, Jaromir Sykora, Harald Fricke, Oliver Hill. Novel hexavalent GITR agonists stimulate T cells and enhance memory formation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4963. doi:10.1158/1538-7445.AM2017-4963

Childhood cognitive ability and body composition in adulthood

Background:

Childhood cognitive ability has been identified as a novel risk factor for adulthood overweight and obesity as assessed by adult body mass index (BMI). BMI does not, however, distinguish fat-free and metabolically harmful fat tissue. Hence, we examined the associations between childhood cognitive abilities and body fat percentage (BF%) in young adulthood.

Methods:

Participants of the Arvo Ylppö Longitudinal Study (n=816) underwent tests of general reasoning, visuomotor integration, verbal competence and language comprehension (M=100; s.d.=15) at the age of 56 months. At the age of 25 years, they underwent a clinical examination, including measurements of BF% by the InBody 3.0 eight-polar tactile electrode system, weight and height from which BMI (kg m⁻²) was calculated and waist circumference (cm).

Results:

After adjustments for sex, age and BMI-for-age s.d. score at 56 months, lower general reasoning and visuomotor integration in childhood predicted higher BMI (kg m⁻²) increase per s.d. unit decrease in cognitive ability (−0.32, 95% confidence interval −0.60,−0.05; −0.45, −0.75,−0.14, respectively) and waist circumference (cm) increase per s.d. unit decrease in cognitive ability (−0.84, −1.56,−0.11; −1.07,−1.88,−0.26, respectively) in adulthood. In addition, lower visuomotor integration predicted higher BF% per s.d. unit decrease in cognitive ability (−0.62,−1.14,−0.09). Associations between general reasoning and BMI/waist were attenuated when adjusted for smoking, alcohol consumption, intake of fruits and vegetables and physical activity in adulthood, and all associations, except for visuomotor integration and BMI, were attenuated when adjusted for parental and/or own attained education and/or birth weight.

Conclusions:

Of the measured childhood cognitive abilities, only lower visuomotor integration was associated with BF% in adulthood. This challenges the view that cognitive ability, at least when measured in early childhood, poses a risk for adiposity in adulthood, as characterized by higher BF%.

Common mental disorders in young adults born late-preterm

BACKGROUND

Results of adulthood mental health of those born late-preterm (34 + 0-36 + 6 weeks + days of gestation) are mixed and based on national registers. We examined if late-preterm birth was associated with a higher risk for common mental disorders in young adulthood when using a diagnostic interview, and if this risk decreased as gestational age increased.

METHOD

A total of 800 young adults (mean = 25.3, s.d. = 0.62 years), born 1985-1986, participated in a follow-up of the Arvo Ylppö Longitudinal Study. Common mental disorders (mood, anxiety and substance use disorders) during the past 12 months were defined using the Composite International Diagnostic Interview (Munich version). Gestational age was extracted from hospital birth records and categorized into early-preterm (<34 + 0, n = 37), late-preterm (34 + 0-36 + 6, n = 106), term (37 + 0-41 + 6, n = 617) and post-term (⩾42 + 0, n = 40).

RESULTS

Those born late-preterm and at term were at a similar risk for any common mental disorder [odds ratio (OR) 1.11, 95% confidence interval (CI) 0.67-1.84], for mood (OR 1.11, 95% CI 0.54-2.25), anxiety (OR 1.00, 95% CI 0.40-2.50) and substance use (OR 1.31, 95% CI 0.74-2.32) disorders, and co-morbidity of these disorders (p = 0.38). While the mental disorder risk decreased significantly as gestational age increased, the trend was driven by a higher risk in those born early-preterm.

CONCLUSIONS

Using a cohort born during the advanced neonatal and early childhood care, we found that not all individuals born preterm are at risk for common mental disorders in young adulthood - those born late-preterm are not, while those born early-preterm are at a higher risk. Available resources for prevention and intervention should be targeted towards the preterm group born the earliest.

Late preterm birth, post-term birth, and abnormal fetal growth as risk factors for severe mental disorders from early to late adulthood

BACKGROUND

Late preterm births constitute the majority of preterm births. However, most evidence suggesting that preterm birth predicts the risk of mental disorders comes from studies on earlier preterm births. We examined if late preterm birth predicts the risks of severe mental disorders from early to late adulthood. We also studied whether adulthood mental disorders are associated with post-term birth or with being born small (SGA) or large (LGA) for gestational age, which have been previously associated with psychopathology risk in younger ages.

METHOD

Of 12 597 Helsinki Birth Cohort Study participants, born 1934-1944, 664 were born late preterm, 1221 post-term, 287 SGA, and 301 LGA. The diagnoses of mental disorders were identified from national hospital discharge and cause of death registers from 1969 to 2010. In total, 1660 (13.2%) participants had severe mental disorders.

RESULTS

Individuals born late preterm did not differ from term-born individuals in their risk of any severe mental disorder. However, men born late preterm had a significantly increased risk of suicide. Post-term birth predicted significantly increased risks of any mental disorder in general and particularly of substance use and anxiety disorders. Individuals born SGA had significantly increased risks of any mental and substance use disorders. Women born LGA had an increased risk of psychotic disorders.

CONCLUSIONS

Although men born late preterm had an increased suicide risk, late preterm birth did not exert widespread effects on adult psychopathology. In contrast, the risks of severe mental disorders across adulthood were increased among individuals born SGA and individuals born post-term.

Neurocognitive abilities in young adults with very low birth weight

OBJECTIVE

Although severely preterm birth has been associated with impaired neurocognitive abilities in children, follow-up studies in adulthood are scarce. We set out to study whether adults born with very low birth weight (VLBW) (<1,500 g), either small for gestational age (SGA) (birth weight ≤-2 SD) or appropriate for gestational age (AGA), differ in a range of neurocognitive abilities and academic performance from adults born at term and not SGA.

METHODS

As part of the Helsinki Study of Very Low Birth Weight Adults, 103 VLBW (37 SGA) and 105 term-born control adults (mean age 25.0, range 21.4-29.7 years) without major neurosensory impairments participated in the follow-up study in 2007-2008. The test battery included measures of general cognitive ability as well as executive functioning and related abilities. Academic performance was self-reported.

RESULTS

With adjustment for sex and age, the VLBW group scored lower or performed slower than the control group in some indices of all tests (these mean differences ranged from 0.3 to 0.5 SD units, p ≤ 0.03) and they had received remedial education at school more frequently; however, no differences existed in self-reported academic performance. The differences were evident in both VLBW-SGA and VLBW-AGA groups. Further covariate adjustments for parental education, current head circumference, and head circumference at birth and, in tests of executive functioning and related abilities, adjustment for IQ estimate had minor effects on the results.

CONCLUSIONS

In comparison with control adults, VLBW adults scored lower on several neurocognitive tests. Poorer neurocognitive performance is associated with VLBW irrespective of the intrauterine growth pattern.

Prenatal growth, postnatal growth and trait anxiety in late adulthood - the Helsinki Birth Cohort Study

OBJECTIVE

Trait anxiety may predispose to anxiety disorders and cardiovascular events. We tested whether prenatal growth or postnatal growth from birth to 11 years of age and in adulthood predict trait anxiety in late adulthood.

METHOD

Women (n = 951) and men (n = 753) reported trait anxiety using the Spielberger Trait Anxiety Scale at an average age of 63.4 years and growth was estimated from records.

RESULTS

Higher trait anxiety was predicted by smaller body size at birth, in infancy and in adulthood. Moreover, faster growth particularly from seven to 11 years of age and slower growth between 11 and 63 years predicted higher trait anxiety.

CONCLUSION

We found a pattern of pre- and postnatal growth that predisposed to higher trait anxiety in late adulthood. This pattern resembles that found to increase the risk of cardiovascular events and, thus, points to a shared common origin in a suboptimal prenatal and childhood developmental milieu.

Childhood socioeconomic status modifies the association between intellectual abilities at age 20 and mortality in later life

Background

People who score poorly in intellectual ability tests have shorter life expectancy. A study was undertaken to determine whether this association is different in people from different socioeconomic backgrounds.

Methods

The mortality of 2786 men born in Helsinki, Finland during 1934–1944 who, as military conscripts, underwent a standardised intellectual ability test comprising verbal, visuospatial and arithmetic reasoning subtests was studied. Mortality data came from the Finnish Death Register.

Results

Comparing men in the lowest and highest test score quartiles, HRs for all-cause mortality were 1.9 (95% CI 1.4 to 2.5) for verbal reasoning, 2.2 (95% CI 1.6 to 3.0) for visuospatial reasoning and 1.9 (95% CI 1.4 to 2.5) for arithmetic reasoning, corresponding to 2.6, 3.4 and 2.6 excess years of life lost, respectively. Associations were similar for cardiovascular and non-cardiovascular mortality. Intellectual ability scores were stronger predictors in men who grew up in middle-class families. Compared with middle-class men in the highest quartile of the visuospatial reasoning score, middle-class men in the lowest quartile lost 6.5 years of life while men from families of manual workers in the highest quartile lost 2.8 years and men in the lowest quartile lost 5.6 years.

Conclusions

High intellectual ability in men aged 20 protects them from mortality in later life. This effect is stronger in men who grew up in middle-class families than in those who grew up in manual worker families. This finding suggests that early life conditions that are unfavourable to the development of cognitive abilities negate the life expectancy benefits of being born into a more affluent family.

Neonatal ventilation with inhaled nitric oxide vs. ventilatory support without inhaled nitric oxide for infants with severe respiratory failure born at or near term: the INNOVO multicentre randomised controlled trial

BACKGROUND

Evidence from European centres to support the use of nitric oxide (NO) in mature newborns with evidence of severe respiratory failure is sparse.

METHODS

Infants of >33 weeks' gestation, <28 days old, and with severe respiratory failure requiring ventilatory support were randomised to receive or not to receive inhaled NO (iNO). The study was not blinded.

RESULTS

Sixty infants were recruited (29 allocated iNO, 31 no iNO) from 15 neonatal units in the UK, Finland, Belgium and the Republic of Ireland. 15/60 recruited babies died, and 8.1% of the survivors (4/45) were classified as severely disabled at 1 year. There was no statistically significant difference between the randomised groups in terms of the primary outcome of death or severe disability by the corrected age of 1 year (relative risk = 0.96 (95% confidence interval = 0.46-2.03); p = 0.86) (Fisher's exact p = 1.00). The costs of NO were outweighed by reduced extra corporeal membrane oxygenation costs in the iNO group. The mean total hospitalisation costs were lower in the iNO group, although the mean difference (1,697 pounds) was not statistically significant (95% confidence interval = -14,472 to 11,478).

CONCLUSIONS

The results complement those of previous studies that suggest NO is cost-effective and reduces the need for extra corporeal membrane oxygenation in this group of babies. Overall survival rates compare unfavourably with results of US trials.

Small body size at birth and behavioural symptoms of ADHD in children aged five to six years

BACKGROUND

Behavioural disorders with a neurodevelopmental background, such as attention deficit hyperactivity disorder (ADHD), have been associated with a non-optimal foetal environment, reflected in small body size at birth. However, the evidence stems from highly selected groups with birth outcomes biased towards the extreme low end of the distribution in birth weight. Whether a similar association exists among the normal range of term birth is unclear.

METHODS

The ADHD Rating Scale was filled in by the biological mothers and fathers of children aged five to six years who were born healthy at term. Information on weight (kg), height (cm), head circumference (cm), and gestational age at birth were obtained from hospital records, and the ponderal index (kg/m3), a commonly used measure of thinness, and head circumference-to-length ratio were calculated.

RESULTS

Behavioural symptoms of ADHD were predicted by a lower ponderal index, a smaller head circumference, and a smaller head circumference-to-length ratio (beta's: -.12 to -.14, p's < .05). Adjustments for length of gestation, mother's age, tobacco and alcohol use during pregnancy, pre-pregnancy body mass index (BMI), or parity, the monthly gross income of the family, child's BMI at the age of five to six years or gender did not change the associations.

CONCLUSION

These results suggest that physiological adaptation in utero, indicated by small body size at birth, within term gestational range may increase the susceptibility to behavioural symptoms of ADHD.

A Review of Video Exposure Monitoring as an Occupational Hygiene Tool

This study reviews use of video exposure monitoring (VEM, also known as PIMEX) as an occupational hygiene tool since its inception in the mid-1980s. VEM involves the combination of real-time monitoring instruments, usually for gases/vapours and dust, with video of the worker's activities. VEM is an established method used by practitioners in different countries. The technical aspects of these VEM systems are described, then applications of VEM are discussed, focussing on task analysis, training (risk communication), encouraging worker participation in and motivation for improvements in the workplace environment and occupational hygiene research. The experiences from these applications are used to illustrate how exposure visualization with video can act as a catalyst, initiating a change process in the workplace. Finally, the role of VEM as a workplace improvement tool, now and in the future, is discussed.

Effects of gestational age and prenatal and perinatal events on the coagulation status in premature infants

OBJECTIVE

To study prospectively the effects of prematurity and perinatal events on the coagulation status of premature infants.

PATIENTS AND MAIN OUTCOME MEASURES

Blood samples from premature infants born before 37 gestational weeks were taken for analysis of coagulation factors II, V, VII, and X and platelet count.

RESULTS

A total of 125 premature infants, 71 boys, were studied at the median postnatal age of 40 minutes (range 12-100). The lowest median activities of coagulation factors II, V, VII, and X and the platelet count were observed, as expected, in infants (n = 21) born at 24-27 weeks gestation. Twin B (n = 14) had lower median activities of coagulation factors II, V, VII, and X than twin A. Infants with evidence of mild asphyxia (Apgar score at 5 minutes < 7 or cord pH < 7.26) had significantly (p < 0.05) lower levels of coagulation factors II, V, VII, and X and platelet counts than infants without asphyxia. Infants who were small for gestational age (SGA) had significantly (p < 0.05) lower levels of coagulation factors V and VII and platelet counts than infants of appropriate size for gestational age. Other prenatal and perinatal variables examined (sex, maternal hypertension and/or pre-eclampsia, antenatal steroid use, mode of delivery, Apgar scores) did not show any significant associations with coagulation status, which may be explained by the small number of infants studied.

CONCLUSIONS

The data strongly suggest that there are distinct differences in specific coagulation tests in different patient populations, which could assist in the identification of extremely preterm, SGA, or asphyxiated preterm infants who may be susceptible to haemorrhagic problems perinatally.

Efficacy of intramammary treatment with procaine penicillin G vs. procaine penicillin G plus neomycin in bovine clinical mastitis caused by penicillin-susceptible, gram-positive bacteria--a double blind field study

The efficacy of intramammary treatments containing procaine penicillin G alone (treatment A) or a combination of procaine penicillin G and neomycin (treatment B) was compared in treating clinical bovine mastitis caused by gram-positive bacteria susceptible in vitro to penicillin G. Both treatments were supplemented with a single intramuscular injection of procaine penicillin G on the first day of treatment. The study was carried out using a double blind design on commercial dairy farms in Southern Finland. A total of 56 quarters were treated with treatment A and 61 with treatment B. The cure rates for both treatments were equal, which suggests that the use of the penicillin G-aminoglycoside combination does not increase the efficacy of the treatment over that achieved by using penicillin G alone in bovine clinical mastitis caused by penicillin-susceptible, gram-positive bacteria.

Multiple complete remissions in a patient with acute myeloid leukemia (M4eo) with low-dose cytosine arabinoside and all-trans retinoic acid

A 54-year-old female with acute myeloid leukemia (AML) (FAB M4eo) was treated at second relapse with a combination of low-dose cytosine arabinoside (LDAraC) (20 mg b.i.d. subcutaneously) and all-trans retinoic acid (ATRA) (45 mg/m2/d orally) on days 1-10. The patient achieved a complete hematological remission after the first cycle and was consolidated with three similar cycles at four-week intervals. Subsequently, the patient relapsed several times. Altogether seven complete hematological remissions including some cytogenetic remissions were induced with the same regimen. The patient survived 81 months after the start with LDAraC-ATRA regimen. This low-toxicity regimen may be useful in some patients with poor-risk AML.

A national two year follow up study of extremely low birthweight infants born in 1996-1997

OBJECTIVE

To study neurodevelopmental outcome in a two year cohort of extremely low birthweight (ELBW) infants at 18 months corrected age, to compare the development of the ELBW infant subcohort with that of control children, and to find risk factors associated with unfavourable outcome.

STUDY DESIGN

All 211 surviving ELBW infants (birth weight < 1000 g) born in Finland in 1996-1997 were included in a national survey. The ELBW infants (n = 78) who were born and followed in Helsinki University Hospital belonged to a regional subcohort and were compared with a control group of 75 full term infants. A national follow up programme included neurological, speech, vision, and hearing assessments at 18 months of corrected age. Bayley infant scale assessment was performed on the subcohort and their controls at 24 months of age. Risk factors for unfavourable outcome were estimated using logistic and linear regression models.

RESULTS

The prevalence of cerebral palsy was 11%, of all motor impairments 24%, of ophthalmic abnormalities 23%, and of speech delay 42%. No impairment was found in 42% of children, and 18% were classified as severely impaired. The prevalence of ophthalmic abnormalities decreased with increasing birth weight and gestational age, but the prevalence of other impairments did not. In the subcohort, a positive correlation was found between the date of birth and Bayley scores.

CONCLUSION

Ophthalmic abnormalities decreased with increasing birth weight and gestational age, but no other outcome differences were found between birthweight groups or in surviving ELBW infants born at 22-26 weeks gestation. The prognosis in the regional subcohort seemed to improve during the short study period, but this needs to be confirmed.

Knowledge, assessment and management of pain related to nursing procedures used with premature babies: questionnaire study for caregivers

The aim of the study was to discover how much Finnish nursing staff know about the pain experienced by premature babies and about pain assessment. The types of helping methods used by caregivers in the nursing of premature babies were also studied. A semistructured questionnaire was sent in autumn 1995 to all registered nurses, practical children's nurses and medical laboratory technologists who take heel blood samples (n = 280) working in paediatric intensive care units in all Finnish university hospitals. The response rate was 70.4%. The structured questions were processed quantitatively at Kuopio University with the SPSS/PC+ data processing program (SPSS, Chicago, IL, USA), and the open questions were processed using quantitative content analysis. The results indicate that the respondents have rather extensive knowledge about the pain experienced by premature babies, pain assessment, pain management and about nursing and helping methods. Pain was assessed mostly on the basis of behaviour and physiological changes, and only infrequently on the basis of biochemical changes. The respondents described the helping methods they use in considerable detail. The most common was to increase the baby's feeling of security. The answers to the open questions revealed that the actions used by the respondents in pain assessment and pain management were not completely consistent with their knowledge. The results demonstrate that caregivers do not use their knowledge adequately in their pain management practices. Future studies should observe the three groups of caregivers in order to discover how they treat premature babies' pain.

BAALC, the human member of a novel mammalian neuroectoderm gene lineage, is implicated in hematopoiesis and acute leukemia

The molecular basis of human leukemia is heterogeneous. Cytogenetic findings are increasingly associated with molecular abnormalities, some of which are being understood at the functional level. Specific therapies can be developed based on such knowledge. To search for new genes in the acute leukemias, we performed a representational difference analysis. We describe a human gene in chromosome 8q22.3, BAALC (brain and acute leukemia, cytoplasmic), that is highly conserved among mammals but evidently absent from lower organisms. We characterized BAALC on the genomic level and investigated its expression pattern in human and mouse, as well as its complex splicing behavior. In vitro studies of the protein showing its subcellular localization suggest a function in the cytoskeleton network. Two isoforms are specifically expressed in neuroectoderm-derived tissues, but not in tumors or cancer cell lines of nonneural tissue origin. We show that blasts from a subset of patients with acute leukemia greatly overexpress eight different BAALC transcripts, resulting in five protein isoforms. Among patients with acute myeloid leukemia, those overexpressing BAALC show distinctly poor prognosis, pointing to a key role of the BAALC products in leukemia. Our data suggest that BAALC is a gene implicated in both neuroectodermal and hematopoietic cell functions.

Chronic lung disease of the newborn is not associated with Ureaplasma urealyticum

To clarify the association of Ureaplasma urealyticum infection with chronic lung disease of the newborn 145 preterm infants less than 34 weeks of gestation were examined. The infants were enrolled during two separate periods. The presence of U. urealyticum was studied by obtaining endotracheal culture samples and blood samples; if either of these samples grew the organism, the child was regarded as having U. urealyticum infection. Infection with U. urealyticum was detected in 33%, and chronic lung disease (defined as the need for oxygen, and typical chest radiograph at 28 days of age) in 43% of infants. The development of chronic lung disease was not associated with the presence of U. urealyticum. Our results suggest only a minor indirect role for U. urealyticum in the development of chronic lung disease of the newborn.

Clinical importance of cytogenetics in acute myeloid leukaemia

Acquired chromosome aberrations are present in the marrow of most patients with acute myeloid leukaemia (AML) at diagnosis. Cytogenetically, AML is a very heterogeneous disease with over 160 structural chromosome abnormalities observed recurrently to date. Molecular dissection of many reciprocal translocations and inversions has resulted in cloning of the genes involved in leukaemogenesis. Some recurrent aberrations and the resulting gene rearrangements, namely inv(16)/t(16;16) and CBFbeta- MYH11, t(8;21) and CBFA2-CBFA2T1, t(15;17) and PML-RARalpha, and rearrangements of band 11q23 and the MLL gene, are now used to help define distinct disease entities within AML in the new World Health Organization classification of haematological malignancies. Moreover, cytogenetic abnormalities, whether molecularly characterized or not, are among the most important, independent prognostic factors in AML, and are being used in the management of AML patients. This review presents current information on chromosome abnormalities in AML, and on associations between karyotype and clinical characteristics and outcome of AML patients.

Comparison between low- and standard-dose ACTH tests in premature infants at risk for chronic lung disease

In order to find a sensitive method to evaluate adrenocortical function in premature infants, we compared low- (0.5 microg/1.73 m(2)) and standard-dose (250 microg/1.73 m(2)) adrenocorticotropin tests (LD- and SD-ACTH) in 12 very-low-birth-weight infants before and 2 days after the end of dexamethasone therapy (duration 9-14 days) for chronic lung disease. Basal serum cortisol levels were inappropriately low in several infants already before dexamethasone therapy (median 190, range 60-357 nmol/l). The 95% confidence intervals of mean serum cortisol levels at 20 min were equal in LD- and SD-ACTH, while at 60 min, the low-dose gave a clearly lower response than the standard-dose test. The LD-ACTH can be used in premature infants as in older children and adults, but the criteria for adrenocortical insufficiency need to be defined.

A national short-term follow-Up study of extremely low birth weight infants born in Finland in 1996-1997

OBJECTIVES

The aims of this prospective nationwide investigation were to establish the birth rate, mortality, and morbidity of extremely low birth weight (ELBW) infants in Finland in 1996-1997, and to analyze risk factors associated with poor outcome.

PARTICIPANTS AND METHODS

The study population included all stillborn and live-born ELBW infants (birth weight: <1000 g; gestational age: at least 22 gestational weeks [GWs]), born in Finland between January 1, 1996 and December 31, 1997. Surviving infants were followed until discharge or to the age corresponding with 40 GWs. National ELBW infant register data with 101 prenatal and postnatal variables were used to calculate the mortality and morbidity rates. A total of 32 variables were included in risk factor analysis. The risk factors for death and intraventricular hemorrhage (IVH) of the live-born infants as well as for retinopathy of prematurity (ROP) and oxygen dependency of the surviving infants were analyzed using logistic regression models.

RESULTS

A total of 529 ELBW infants (.4% of all newborn infants) were born during the 2-year study. The perinatal mortality of ELBW infants was 55% and accounted for 39% of all perinatal deaths. Of all ELBW infants, 34% were stillborn, 21% died on days 0 through 6, and 3% on days 7 though 28. Neonatal mortality was 38% and postneonatal mortality was 2%. Of the infants who were alive at the age of 4 days, 88% survived. In infants surviving >12 hours, the overall incidence of respiratory distress syndrome (RDS) was 76%; of blood culture-positive septicemia, 22%; of IVH grades II through IV, 20%; and of necrotizing enterocolitis (NEC) with bowel perforation, 9%. The rate of IVH grades II through IV and NEC with bowel perforation decreased with increasing gestational age, but the incidence of RDS did not differ significantly between GWs 24 to 29. A total of 5 infants (2%) needed a shunt operation because of posthemorrhagic ventricular dilatation. Two hundred eleven ELBW infants (40% of all and 60% of live-born infants) survived until discharge or to the age corresponding with 40 GWs. The oxygen dependency rate at the age corresponding to 36 GWs was 39%, and 9% had ROP stage III-V. Neurological status was considered completely normal in 74% of the surviving infants. The proportions of infants born at 22 to 23, 24 to 25, 26 to 27, and 28 to 29 GWs with at least one disability (ROP, oxygen dependency, or abnormal neurological status) at the age corresponding to 36 GWs were 100%, 62%, 51%, and 45%, respectively. Birth weight <600 g and gestational age <25 GWs were the independent risks for death and short-term disability. The primary risk factor for IVH grades II through IV was RDS. Low 5-minute Apgar scores predicted poor prognosis, ie, death or IVH, and antenatal steroid treatment to mothers with threatening premature labor seemed to protect infants against these. Some differences were found in the mortality rates between the 5 university hospital districts: neonatal mortality was significantly lower (25% vs 44%) in one university hospital area and notably higher (53% vs 34%) in another area. Furthermore, significant differences were also found in morbidity, ie, oxygen dependency and ROP rates. Differences in perinatal (79% vs 45%) and neonatal (59% vs 32%) mortality rates were found between secondary and tertiary level hospitals.

CONCLUSION

Our study shows that even with modern perinatal technology and care, intrauterine and early deaths of ELBW infants are common. The outcome of infants born at 22 to 23 GWs was unfavorable, but the prognosis improved rapidly with increasing maturity. The clear regional and hospital level differences detected in survival rates and in short-term outcome of ELBW infants emphasizes that the mortality and morbidity rates should be continuously followed and that differences should be evaluated in perinatal audit procedures. (ABSTRACT TRUNCATED)

Prognostic value of cytogenetic findings in adults with acute myeloid leukemia

The majority of adults diagnosed with acute myeloid leukemia (AML) display acquired cytogenetic aberrations at presentation. Numerous recurring chromosomal abnormalities have been and continue to be identified in AML. In many instances, genes altered by these aberrations have been cloned, providing insights into the mechanisms of leukemogenesis and paving the way to designing novel therapeutic strategies that target specific genetic abnormalities in leukemic blasts. Moreover, karyotypic abnormalities, whether molecularly characterized or not, are among the most important independent prognostic factors in AML and are being used in the clinical management of AML patients. In this review, we present an overview of major cytogenetic findings in AML and discuss associations between karyotype and clinical outcome of adults with AML.

Antepartum findings in fetal protein C deficiency

A pregnancy with fetal homozygous protein C deficiency was complicated in the third trimester by fetal ventriculomegaly, intraorbital thrombosis and placental infarcts, which could be imaged by combined use of ultrasonography and MRI.

Effects of prematurity, intrauterine growth status, and early dexamethasone treatment on postnatal bone mineralisation

AIM

To examine the hypothesis that, apart from prematurity, intrauterine growth status (expressed as gestational age specific birth weight standard deviation scores), neonatal factors, and duration of dexamethasone treatment influence bone mineralisation in early infancy.

METHODS

In this prospective study, groups consisted of 15 preterm small for gestational age infants (SGA group) and 43 preterm appropriate for gestational age infants (AGA group). A reference group contained 17 term infants. Body size is known to affect bone mineral content (BMC), therefore postnatal bone mineralisation was measured when the study infants and controls had attained a similar body size. Bone mineral density (BMD) and BMC were determined by dual energy x ray absorptiometer of the lumbar spine (L2-L4).

RESULTS

Both preterm groups had significantly lower BMC and BMD than the weight matched term reference group, but no difference was found in BMC and BMD between preterm SGA and AGA infants. In stepwise regression analysis, bone area, duration of dexamethasone treatment, weight at examination, and weight gain per week were the most significant factors, explaining 54% of the variance of the BMC values.

CONCLUSION

In particular, weight at examination, prematurity, and possibly dexamethasone treatment, but not intrauterine growth status, affect postnatal bone mineralisation.

Factors affecting the work of an occupational health nurse

Society, economies, work-life and work are undergoing changes that will have global impact on occupational health services (OHS) and the work of occupational health nurses (OHNs) during the next 5-10 years. These changes will bring new challenges to both occupational health services and representatives of specialist groups within those services. The changes will require new ways of working, work methods, performance monitoring, and evaluation of impacts. These developments will also call for changes in the education of occupational health nurses.

Determinants of bronchial responsiveness at school age in prematurely born children

The bronchial challenge test using isocapnic hyperventilation of cold air (IHCA) was used to evaluate bronchial responsiveness in 63 offspring of multiple pregnancies when they were 8-15 years old. At birth, 27 (43%) children had had intrauterine growth retardation (IUGR, birth weight <-2 SD, or birth weight difference between twin pairs >1.3 SD). The median birth weight was 2,050 g (range, 800-3, 150), and the median gestational age was 35 weeks (range, 28-38). None of the children had asthma or suffered from asthma-like symptoms. In the interpretation of the IHCA test, a fall of 9% or more in the forced expiratory volume in 1 sec (FEV(1)) was considered as abnormal, and these children were classified as "cold air responders." The number of responders was 16 (25%); their baseline FEV(1)/forced vital capacity ratio (FEV(1)/FVC) and forced expiratory flow between 25-75% FVC (FEF(25-75)), but not FEV(1) were significantly lower than the corresponding values in nonresponders. No differences were found in perinatal or neonatal factors between responders or nonresponders. Eight (30%) of the 27 IUGR and 8 (22%) of the 36 appropriate for gestational age (AGA) children were IHCA responders. In particular, IUGR was not correlated with maximal FEV(1) falls following the IHCA test. Respiratory infections after the neonatal period were equally common in IUGR and AGA children; but infections were associated with subsequent IHCA responsiveness. Adenoidectomy, tonsillectomy, and/or myringotomy had been performed significantly more often in the responders than in the nonresponders. At least one of the above invasive procedures had been performed in 20 (32%) of the children; this group was termed the "ENT (ear, nose, throat) surgery group." Fifty-six percent of the responders, but only 26% of the nonresponders, belonged to the ENT surgery group (P = 0.02). We conclude that intrauterine growth retardation or prematurity is not associated with abnormal cold air responsiveness in the IHCA test.

Comparative genomic hybridization and conventional cytogenetic analyses in childhood acute myeloid leukemia

Comparative genomic hybridization (CGH) analysis was performed on bone marrow specimens from 19 children with acute myeloid leukemia (AML) at diagnosis. The results of CGH were compared to those of conventional cytogenetic analysis. The most common CGH aberrations were gains of whole chromosomes 6 and 8, both of which appeared three times. Two losses were seen twice; losses of whole chromosomes 7 and X. The CGH findings were concordant with the results of conventional karyotyping. CGH did not add new information to the karyotypes. Since no high-level amplification was found among the samples and standard karyotyping was highly successful, we do not advocate routine use of CGH in the diagnostic evaluation of childhood AML.