[Curative effect of percutaneous microwave ablation therapy on hepatocellular carcinoma survival: a 15-year real-world study]

Objective: To evaluate the long-term efficacy of percutaneous microwave ablation (MWA) therapy for hepatocellular carcinoma. Methods: 2054 cases with Barcelona Clinic Liver Cancer (BCLC) stage 0~B at the Fifth Medical Center of the Chinese People's Liberation Army General Hospital from January 2006 to September 2020 were retrospectively collected. All patients were followed up for at least 2 years. The primary endpoint of overall survival and secondary endpoints (tumor-related survival, disease-free survival, and postoperative complications) of patients treated with ultrasound-guided percutaneous MWA were analyzed. Kaplan-Meier method was used for stratified survival rate analysis. Fine-and-Gray competing risk model was used to analyze overall survival. Results: A total of 5 503 HCC nodules [mean tumor diameter (2.6±1.6) cm] underwent 3 908 MWAs between January 2006 and September 2020, with a median follow-up time of 45.6 (24.0 -79.2) months.The technical effectiveness rate of 5 375 tumor nodules was 97.5%. The overall survival rates at 5, 10, and 15-years were 61.6%, 38.8%, and 27.0%, respectively. The tumor-specific survival rates were 67.1%, 47.2%, and 37.7%, respectively. The free tumor survival rates were 25.8%, 15.7%, and 9.9%, respectively. The incidence rate of severe complications was 2.8% (108/3 908). Further analysis showed that the technical effectiveness and survival rate over the passing three time periods from January 2006-2010, 2011-2015, and 2016-September 2020 were significantly increased, with P < 0.001, especially for liver cancer 3.1~5.0 cm (P < 0.001). Conclusion: Microwave ablation therapy is a safe and effective method for BCLC stage 0-B, with significantly enhanced technical efficacy and survival rate over time.

A real-world experience of a prescribing policy for SGLT2-inhibitors in HFrEF in a Malaysian public tertiary cardiac centre

A prescribing policy for SGLT2-inhibitors was implemented in a local public tertiary cardiology centre in Sabah to improve access for heart failure (HF) patients. The study evaluated 169 HF patients with reduced ejection fraction (HFrEF) who met the policy criteria. After starting SGLT2- inhibitors, a significant proportion of patients experienced decreased NTproBNP levels, indicating a positive response. HF hospitalisation rates within 1 year were lower compared to the previous year. No adverse events were reported, suggesting that the treatment is safe. Findings demonstrates the benefits of implementing prescribing policies to enhance treatment accessibility and generate valuable real-world data at the local healthcare level..

Stability of enteroviruses on toys commonly found in kindergarten

Hand, foot, and mouth disease (HFMD) is a contagious childhood disease caused by enteroviruses including enterovirus A71 (EV-A71), coxsackievirus A6 (CV-A6) and CV-A16 transmitted via direct and indirect contact. Different types of toy surfaces can affect the stability of viruses. Understanding the stability of enteroviruses on toys provides insightful data for effective disinfection in kindergartens or homes. Porous (ethylene-vinyl acetate mat foam, paper, pinewood, polyester fabric, and squishy polyurethane foam) and non-porous (acrylonitrile butadiene styrene plastic and stainless-steel coin) surfaces were inoculated with EV-A71 at 4, 24, and 35°C, and coxsackieviruses at 24°C. Infectious enteroviruses were recovered and titred in median tissue culture infectious dose assay (TCID50). Atomic force microscopy (AFM) images were taken from surfaces to examine association of surface roughness with virus stability. Overall, infectious enteroviruses were persistent on all non-porous and porous surfaces. Virus persistence was longest at 4°C followed by 24°C and 35°C. EV-A71 half-lives ranged between 6.4-12.8 hours at 4°C, 2.4-6.7 hours at 24°C, and 0.13-2.7 hours at 35°C. At lower virus titres exposed to 24°C, half-lives of enteroviruses ranged from 0.1-1.4 hours. Surface roughness values from AFM suggested smooth surfaces of non-porous surfaces were associated with better virus stability. Temperature, enterovirus concentration, and type of surface affected persistence and stability of enteroviruses. Our findings suggest both porous and non-porous surfaces in kindergartens allow enterovirus persistence and should be frequently disinfected to curb HFMD outbreaks in kindergartens.

Patient-Specific Vascularized Tumor Model: Blocking TAM Recruitment with Multispecific Antibodies Targeting CCR2 and CSF-1R

Tumor-associated inflammation drives cancer progression and therapy resistance, with the infiltration of monocyte-derived tumor-associated macrophages (TAMs) associated with poor prognosis in diverse cancers. Targeting TAMs holds potential against solid tumors, but effective immunotherapies require testing on immunocompetent human models prior to clinical trials. Here, we develop an in vitro model of microvascular networks that incorporates tumor spheroids or patient tissues. By perfusing the vasculature with human monocytes, we investigate monocyte trafficking into the tumor and evaluate immunotherapies targeting the human tumor microenvironment. Our findings demonstrate that macrophages in vascularized breast and lung tumor models can enhance monocyte recruitment via TAM-produced CCL7 and CCL2, mediated by CSF-1R. Additionally, we assess a novel multispecific antibody targeting CCR2, CSF-1R, and neutralizing TGF-β, referred to as CSF1R/CCR2/TGF-β Ab, on monocytes and macrophages using our 3D models. This antibody repolarizes TAMs towards an anti-tumoral M1-like phenotype, reduces monocyte chemoattractant protein secretion, and effectively blocks monocyte migration. Finally, we show that the CSF1R/CCR2/TGF-β Ab inhibits monocyte recruitment in patient-specific vascularized tumor models. Overall, this vascularized tumor model offers valuable insights into monocyte recruitment and enables functional testing of innovative therapeutic antibodies targeting TAMs in the tumor microenvironment (TME).

The HERA (Hyper-response Risk Assessment) Delphi consensus for the management of hyper-responders in in vitro fertilization

PURPOSE

To provide agreed-upon guidelines on the management of a hyper-responsive patient undergoing ovarian stimulation (OS) METHODS: A literature search was performed regarding the management of hyper-response to OS for assisted reproductive technology. A scientific committee consisting of 4 experts discussed, amended, and selected the final statements. A priori, it was decided that consensus would be reached when ≥66% of the participants agreed, and ≤3 rounds would be used to obtain this consensus. A total of 28/31 experts responded (selected for global coverage), anonymous to each other.

RESULTS

A total of 26/28 statements reached consensus. The most relevant are summarized here. The target number of oocytes to be collected in a stimulation cycle for IVF in an anticipated hyper-responder is 15-19 (89.3% consensus). For a potential hyper-responder, it is preferable to achieve a hyper-response and freeze all than aim for a fresh transfer (71.4% consensus). GnRH agonists should be avoided for pituitary suppression in anticipated hyper-responders performing IVF (96.4% consensus). The preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder of average weight is 150 IU/day (82.1% consensus). ICoasting in order to decrease the risk of OHSS should not be used (89.7% consensus). Metformin should be added before/during ovarian stimulation to anticipated hyper-responders only if the patient has PCOS and is insulin resistant (82.1% consensus). In the case of a hyper-response, a dopaminergic agent should be used only if hCG will be used as a trigger (including dual/double trigger) with or without a fresh transfer (67.9% consensus). After using a GnRH agonist trigger due to a perceived risk of OHSS, luteal phase rescue with hCG and an attempt of a fresh transfer is discouraged regardless of the number of oocytes collected (72.4% consensus). The choice of the FET protocol is not influenced by the fact that the patient is a hyper-responder (82.8% consensus). In the cases of freeze all due to OHSS risk, a FET cycle can be performed in the immediate first menstrual cycle (92.9% consensus).

CONCLUSION

These guidelines for the management of hyper-response can be useful for tailoring patient care and for harmonizing future research.

BCA101 Is a Tumor-Targeted Bifunctional Fusion Antibody That Simultaneously Inhibits EGFR and TGFβ Signaling to Durably Suppress Tumor Growth

The EGFR and TGFβ signaling pathways are important mediators of tumorigenesis, and cross-talk between them contributes to cancer progression and drug resistance. Therapies capable of simultaneously targeting EGFR and TGFβ could help improve patient outcomes across various cancer types. Here, we developed BCA101, an anti-EGFR IgG1 mAb linked to an extracellular domain of human TGFβRII. The TGFβ "trap" fused to the light chain in BCA101 did not sterically interfere with its ability to bind EGFR, inhibit cell proliferation, or mediate antibody-dependent cellular cytotoxicity. Functional neutralization of TGFβ by BCA101 was demonstrated by several in vitro assays. BCA101 increased production of proinflammatory cytokines and key markers associated with T-cell and natural killer-cell activation, while suppressing VEGF secretion. In addition, BCA101 inhibited differentiation of naïve CD4+ T cells to inducible regulatory T cells (iTreg) more strongly than the anti-EGFR antibody cetuximab. BCA101 localized to tumor tissues in xenograft mouse models with comparable kinetics to cetuximab, both having better tumor tissue retention over TGFβ "trap." TGFβ in tumors was neutralized by approximately 90% in animals dosed with 10 mg/kg of BCA101 compared with 54% in animals dosed with equimolar TGFβRII-Fc. In patient-derived xenograft mouse models of head and neck squamous cell carcinoma, BCA101 showed durable response after dose cessation. The combination of BCA101 and anti-PD1 antibody improved tumor inhibition in both B16-hEGFR-expressing syngeneic mouse models and in humanized HuNOG-EXL mice bearing human PC-3 xenografts. Together, these results support the clinical development of BCA101 as a monotherapy and in combination with immune checkpoint therapy.

SIGNIFICANCE

The bifunctional mAb fusion design of BCA101 targets it to the tumor microenvironment where it inhibits EGFR and neutralizes TGFβ to induce immune activation and to suppress tumor growth.

The HERA (Hyper-response Risk Assessment) Delphi consensus definition of hyper-responders for in-vitro fertilization

PURPOSE

To provide an agreed upon definition of hyper-response for women undergoing ovarian stimulation (OS)?

METHODS

A literature search was performed regarding hyper-response to ovarian stimulation for assisted reproductive technology. A scientific committee consisting of 5 experts discussed, amended, and selected the final statements in the questionnaire for the first round of the Delphi consensus. The questionnaire was distributed to 31 experts, 22 of whom responded (with representation selected for global coverage), each anonymous to the others. A priori, it was decided that consensus would be reached when ≥ 66% of the participants agreed and ≤ 3 rounds would be used to obtain this consensus.

RESULTS

17/18 statements reached consensus. The most relevant are summarized here. (I) Definition of a hyper-response: Collection of ≥ 15 oocytes is characterized as a hyper-response (72.7% agreement). OHSS is not relevant for the definition of hyper-response if the number of collected oocytes is above a threshold (≥ 15) (77.3% agreement). The most important factor in defining a hyper-response during stimulation is the number of follicles ≥ 10 mm in mean diameter (86.4% agreement). (II) Risk factors for hyper-response: AMH values (95.5% agreement), AFC (95.5% agreement), patient's age (77.3% agreement) but not ovarian volume (72.7% agreement). In a patient without previous ovarian stimulation, the most important risk factor for a hyper-response is the antral follicular count (AFC) (68.2% agreement). In a patient without previous ovarian stimulation, when AMH and AFC are discordant, one suggesting a hyper-response and the other not, AFC is the more reliable marker (68.2% agreement). The lowest serum AMH value that would place one at risk for a hyper-response is ≥ 2 ng/ml (14.3 pmol/L) (72.7% agreement). The lowest AFC that would place one at risk for a hyper-response is ≥ 18 (81.8% agreement). Women with polycystic ovarian syndrome (PCOS) as per Rotterdam criteria are at a higher risk of hyper-response than women without PCOS with equivalent follicle counts and gonadotropin doses during ovarian stimulation for IVF (86.4% agreement). No consensus was reached regarding the number of growing follicles ≥ 10 mm that would define a hyper-response.

CONCLUSION

The definition of hyper-response and its risk factors can be useful for harmonizing research, improving understanding of the subject, and tailoring patient care.

Prevalence of COVID-19 among healthcare workers in the paediatric department: Estimates from a multicenter cross-sectional survey in Negeri Sembilan

INTRODUCTION

The COVID-19 pandemic has reached a phase where many have been infected at least once. Healthcare workers were not spared from being infected. This study aimed to determine the period prevalence of COVID-19 among the paediatric healthcare workers in Negeri Sembilan as the country transitioned into an endemic phase of the pandemic. Additionally, we investigate potential sociodemographic and occupational characteristics associated with SARS-CoV-2 infection among healthcare workers.

MATERIALS AND METHODS

A cross-sectional study was conducted among the healthcare workers in the paediatric department at three public specialist hospitals in Negeri Sembilan between 15 and 21 April 2022. Data were collected through a self-administered questionnaire.

RESULTS

Out of the 504 eligible healthcare workers, 493 participated in this study (response rate 97.8%). The overall prevalence of COVID-19 (11 March 2020-15 April 2022) among healthcare workers was 50.9%. The majority (80.1%) were infected during the Omicron wave two months before the survey. Household contacts accounted for 35.9% of infection sources. The proportion of non-doctors in the COVID-19-infected group was significantly higher compared to the non-infected group (74.1% vs 64.0%, p=0.016). The COVID-19-infected group had a higher proportion of schoolgoing children (44.6% vs 30.6%, p=0.001) and children who attended pre-school/sent to the babysitter (49.0% vs 24.4%, p<0.001). There were no significant differences between infection rates among the healthcare workers working in the tertiary hospital and the district hospitals. There were also no significant differences in the proportion of COVID-19- infected doctors and nurses when analysed by seniority.

CONCLUSION

Our study provided an estimate on the prevalence of COVID-19 among paediatric healthcare workers in Negeri Sembilan and the factors associated with infection, which captures the extent and magnitude of this pandemic on the state's paediatric department. Most infections resulted from household contact, with a higher proportion of infected healthcare workers having young children.

874 Development of BCA101, a bifunctional antibody capable of simultaneously disabling EGFR and TGFβ signaling, as novel single-agent immunotherapy

Background

Given the pleiotropic functions of transforming growth factor-beta (TGFβ), current approaches to targeting systemic TGFβ will likely lead to suboptimal clinical activity and/or undesirable effects. Epidermal growth factor receptor (EGFR) is one of the most extensively validated tumor-associated antigens. Bicara Therapeutics has developed a novel bifunctional fusion protein, composed of a monoclonal antibody against EGFR and an extracellular domain of human TGFβ receptor II (TGFβRII). We demonstrate BCA101 has the potential to improve anti-tumor response by leveraging the cooperativity between EGFR and TGFβ signaling pathways while restricting TGFβ neutralization to EGFR-expressing tissues.

Methods

Functional neutralization of TGFβ by BCA101 was demonstrated by several in vitro assays which assessed TGFβ-dependent epithelial to mesenchymal transition (EMT), cell invasion, inducible Treg differentiation, as well as allogeneic immune responses in tumor cell/immune cell coculture assays. In vivo, the anti-tumor efficacy of BCA101 was determined in tumor xenograft mouse models, using either human tumor cell lines or patient-derived tumor cells (PDX), as well as in a humanized mouse model.

Results

In vitro, we showed BCA101 is capable of simultaneously binding EGFR and TGFβ1 with a significantly higher affinity for EGFR. The incorporation of the TGFβRII ”trap” did not sterically interfere with the ability of BCA101 to bind EGFR, inhibit cell proliferation or mediate antibody-dependent cellular cytotoxicity (ADCC). Relative to cetuximab, BCA101 showed improved ability to reverse EMT and preserve ADCC activity. In tumor cell/immune cell co-culture assays, BCA101 increased production of proinflammatory cytokines associated with T and NK cell activation and suppressed VEGF release. Further, BCA101 inhibited differentiation of inducible Treg and displayed an immuno-potentiating profile in the BioMAP® TME model. In vivo, biodistribution studies showed that BCA101 localized to tumor tissues in xenograft mouse models, with comparable kinetics as cetuximab. TGFβ in tissues was neutralized to about 90% at 10 mg/kg of BCA101 while equimolar doses of TGFβRII receptor inhibited TGFβ in tumors by around 50%, confirming improved tumor localization with BCA101. In PDX models derived from head and neck cancer squamous cell carcinoma patients, BCA101 exerted sustained antitumor effect and delayed tumor growth compared to cetuximab. Finally, BCA101 improved the anti-tumor activity of PD1 blockade therapy in humanized HuNOG-EXL mice bearing PC-3 xenografts (figure 1).

Abstract 874 Figure 1

BCA101 shows superiority over cetuximab in animal models. (A) & (B). Patient derived xenograft (PDX) models. Patient derived tumors were engrafted into female NOG mice. Once tumor reached about 130 mm3, mice were randomized into control and test groups. Test group mice were treated with either BCA101 (A) or cetuximab (B), thrice a week (i.p), whereas control animals received placebo alone. Mice were treated for 27 days followed by a treatment-free phase until Day 79. Tumor volumes and mice weight were recorded twice a week. (C). BCA101 inhibits FaDu tumor xenograft growth (CDX) in vivo. Nude mice were implanted with FaDu cells on flanks. Once tumor reached about 100 mm3, mice were randomized (n=7) and treated with six doses of test compounds, BCA101 and cetuximab. Tumor volume and mice weight were recorded twice a week. (D). BCA101 and anti-PD1 combination studies in hu-NOG-EXL humanized animal model. PC-3 cells were implanted into flank of Hu-NOG-EXL humanized mice and randomized into control and test groups once tumors reached about 120 mm3. Test group mice were treated with cetuximab or BCA101, intraperitoneally for 6 doses. Anti-PD1 antibody (pembrolizumab) was administered intraperitoneally at a dose of 10 mg/kg with a dosage schedule of every fifth-day for 5 doses (Q5Dx5). Statistical analysis for panel (C) & (D) was performed using repeated measures two-way ANOVA followed by Bonferroni’s multiple comparison test. Significance was indicated by * = p value ≤0.05, ** = p value ≤0.01 and *** = p value ≤0.001. Tumor volumes are presented as Mean ± SEM.

Conclusions

These results support the clinical development of BCA101 as a targeted immunotherapy with the potential to induce improved anti-tumor response with a wider therapeutic window, either as a monotherapy or in combination with immune checkpoint blockade therapy.

Acknowledgements

We acknowledge Mazumdar Shaw Center for Translational Research for providing the human tissues used for the PDX studies. We thank Syngene International for conducting the PDX and humanized mice studies at their vivarium. We thank Dr. Sreesha Srinivasa for providing suggestions and feedback at the early stages of this project.

References

Bedi A, Chang X, Noonan K , Pham V, Bedi R, Fertig EJ, Considine M, Califano JA, Borrello I, Chung CH, Sidransky D, Ravi R. Inhibition of TGF-b enhances the in vivo antitumor efficacy of EGF receptor–targeted therapy. Mol Cancer Ther 2012;11:1–11.

Yegodayev KM, Novoplansky O, Golden A, Prasad M, Levin L, Jagadeeshan S, Zorea J, Dimitstein O, Joshua B-Z, Cohen L, Khrameeva E, Elkabets M. TGF-Beta-activated cancer-associated fibroblasts limit cetuximab efficacy in preclinical models of head and neck cancer. Cancers 2020;12:1–17.

Ethics Approval

Mice were maintained as per the regulations of Committee for the Purpose of Control and Supervision of Experiments on Animals (CPCSEA), Government of India and Association for Assessment and Accreditation of Laboratory Animal Care (AAALAC) guidelines. All animal experiments were approved by institutional ethical committee and performed under approved protocols. For PDX model, head and neck cancer patient samples were obtained from Mazumdar Shaw Medical Foundation, Bengaluru, India after appropriate approvals were obtained from institutional ethical committee: NHH/MEC-RC2016-404

P–533 Effects of sex chromosomal complement, XX, XO, or XY, on the transcriptome and development of mouse oocytes during follicular growth

Study question

How does the sex chromosome complement affect the transcriptome and development of oocytes during follicular growth in the mouse ovary?

Summary answer

Highly expressed X-linked genes adjust their transcript levels according to the X dosage. Y-linked genes affect the transcript levels of some X-linked and autosomal genes.

What is known already

Female mice carrying XO and XY chromosomes on the C57BL/6J (B6) genetic background are healthy but encounter subfertility and infertility, respectively. Our previous results have shown that the XY oocyte is defective in its cytoplasm; its replacement with that of an XX oocyte at the GV stage allows for production of healthy offspring after fertilization. Since transcription is shut down in the oocyte by the end of growth phase, the mRNAs and proteins necessary for meiotic progression and early embryonic development are accumulated during follicular growth.

Study design, size, duration

30 oocytes of 50–59 μm diameter were pooled for each genotype in biological triplicate and subjected to RNA-Sequencing. Total RNA extracted from 10–30 pooled oocytes of each size range and genotype in biological triplicate were subjected to qRT-PCR. All experiments were performed between 2019–2021.

Participants/materials, setting, methods

XY and XO females were generated by cross between B6 females with B6.YTIR and B6.XPafY males, respectively. Oocytes in the growth phase were collected at 8–18 days postpartum (dpp), whereas fully-grown oocytes were collected at 27–29 dpp after injection with equine chorionic gonadotropin. Oocytes of 50–59 μm diameter were subjected to RNA-Sequencing using a version of SmartSeq2, followed by DEG analyses. Transcript levels in the oocytes of various diameters were determined by qRT-PCR.

Main results and the role of chance

Chromatin configuration, mitochondrial distribution, and de novo transcription were largely comparable among the XX, XO, and XY oocytes smaller than 60 µm. Three way comparisons of RNA-Seq data in the oocytes of 50–59 μm revealed; (1) 13.8% of X-linked DEGs showed the transcript levels in correspond to the X chromosome dosage; (2) 9 genes on the Y short arm and 2 genes near the distal end of the Y long arm were highly expressed in XY oocytes; (3) transcript levels of X- or autosomal homologs were affected by the XY complement compared to XX and XO oocytes; and (4) 54 and 39 X-linked and autosomal genes show higher and lower transcript levels, respectively, in XY oocytes compared to XX and XO oocytes. The results of qRT-PCR of selected genes revealed distinct dynamic changes in transcript levels in the oocyte during follicular growth. Data of RNA-Seq were statistically analyzed using R Bioconductor limma package for differentially expressed genes having Benjamini-Hochberg adjusted P values lower than 0.01 and log2 fold change higher than 1. All data of qRT-PCR were statistically analyzed by one-way ANOVA followed by Tukey’s honestly significant difference (HSD) test.

Limitations, reasons for caution

In humans, most XO females die in utero and those who reach the term suffer from congenital abnormalities and infertility (Turner’s syndrome). However, the severer phenotype can be attributed to somatic cells with a greater number of genes that escape from X chromosome inactivation in humans than mice.

Wider implications of the findings: XO and XY mice provide animal models for investigating the consequence of X haplodeficiency in the female germline, independent of somatic defects. Furthermore, XY female mice provide a unique opportunity for examining whether and how Y-linked genes are transcribed outside the male germline.

Trial registration number

Not applicable

P–553 Women with molar pregnancies have a genetic susceptibility to aneuploid miscarriages

Study question

What causes non-molar miscarriages in women with one hydatidiform mole (HM)?

Summary answer

We found a higher rate of aneuploidies in the non-molar miscarriages of women with HM than in those from women with sporadic or recurrent miscarriages.

What is known already

Women with hydatidiform moles have higher rates of miscarriages and women with recurrent miscarriages have higher rates of moles than women from the general population.

Study design, size, duration

We retrieved archived formalin-fixed paraffin embedded tissues from non-molar miscarriages of patients with one HM and analyzed them for the presence of aneuploidies using single nucleotide polymorphism (SNP)-microarray. We next determined the meiotic origin of the aneuploidies by genotyping the aneuploid non-molar miscarriages along with the parental genomes using microsatellite markers.

Participants/materials, setting, methods

All participants and some of their partners provided written consent to participate in our study, agreed to a blood draw for genotyping analysis, and agreed for us to retrieve their molar and non-molar tissues from various histopathology laboratories for research purposes.

Main results and the role of chance

We demonstrate for the first time that patients with an HM and miscarriages are at higher risk for aneuploid miscarriages [83.3%, 95% confidence interval (CI): 0.653–0.944] than women with sporadic (51.5%, 95% CI: 50.3–52.7%, p value = 0.0003828) or recurrent miscarriages (43.8%, 95% CI: 40.7–47.0%, p value = 0.00002). Genotyping the aneuploid miscarriages and the parental genomes demonstrated that most of the aneuploidies originated from errors in maternal meiosis I or II.

Limitations, reasons for caution

We were able to retrieve only 30 non-molar miscarriages from women with one HM for analysis. Expanding such analysis to a larger and independent cohort of miscarriages from such patients will be important to validate our observations.

Wider implications of the findings: Our data suggest common genetic female germline defects predisposing to HM and aneuploid non-molar miscarriages in some patients.

Trial registration number

Not applicable

First-in-human phase I study of the bifunctional EGFR/TGF fusion protein BCA101 in patients with EGFR-driven advanced solid cancers

3074

Background: Therapeutic targeting of EGFR has demonstrated efficacy in common advanced malignancies such as colorectal cancer (CRC), squamous cell of the head and neck (SCCHN), and non-small cell lung cancer (NSCLC). TGFβ has pro-tumorigenic effects on migration, invasion and tumor-specific immunosuppression, which may enhance the oncogenic effects of activated EGFR. Inhibition of EGFR signaling can lead to TGFβ upregulation as a resistance mechanism. BCA101 is a bifunctional recombinant fusion protein consisting of a chimeric anti-EGFR antibody and an extracellular domain (ECD) of human TGFβRII which demonstrated anti-tumor activity in several preclinical models. Methods: Patients with EGFR-driven advanced solid cancers refractory to standard therapies received BCA101 at escalating doses from 64 mg to 1000 mg intravenously (IV) weekly across 6 dose levels using a 3+3 design to determine dose limiting toxicities (DLT, established within 21 days of initial dosing), maximum tolerated dose (MTD) and/or recommended dose (RD). Secondary endpoints include detailed pharmacokinetic (PK), pharmacodynamic (PD) studies in serial tumor and/or blood samples and assessment of anti-tumor activity. Results: As of 2/11/2021, 21 patients received single agent BCA101 at 64 (n = 3), 240 (n = 7), 500 (n = 2), 750 (n = 3), 800 (n = 3) or 1000 (n = 3) mg IV weekly, including patients with CRC (n = 6), SCCHN (n = 5) uveal melanoma (n = 2), ovarian cancer (n = 2), glioblastoma multiforme (n = 2), conjunctival melanoma, chordoma, pancreatic cancer and anal squamous cell carcinoma (all n = 1). These patients had 1-7 prior lines of antineoplastic therapy (median 4), including 3 patients with prior EGFR inhibitor exposure. Adverse events (AE) related to BCA101 observed in > 1 patient included grade (G) 1-2 rash (n = 9), G 1-2 lipase elevation (n = 2). G3 vitreous hemorrhage at the 240 mg dose level has been the only DLT. The MTD has not been reached and the RD will be based on safety, exposure and pending PD data. Saturation of the clearance was observed at doses above 500mg. Dose proportional increase in Cmax and AUC were observed with doses of 750-1000mg. Best RECISTv1.1 response was stable disease (SD) in 3/10 evaluable patients, with 1 patient on drug ≥4 months. Conclusions: BCA101 is well tolerated at biologically active doses. BCA101 is now being tested in combination with the PD-1 antibody pembrolizumab in patients with SCCHN and anal carcinoma. Clinical trial information: NCT04429542.

[Application of the Virtual Reality-Pattern Visual Evoked Potential in Forensic Visual Acuity Evaluation]

Abstract

Objective To explore a kind of visual evoked potential test equipment and method that is more suitable for the application of forensic clinical visual acuity evaluation. Methods Thirty-four volunteers （68 eyes） were selected, including 15 males and 19 females, aged between 20 and 40 years. Test lenses were placed before the tested eyes of volunteers to induce refractive myopia with insert method, and the diopter lenses were adjusted so that the visual acuity level of one eye of volunteers was above 0.8, and the visual acuity of the other eye was at moderate damage level （<0.3 and ≥0.1）. The tests were carried out under the binocular simultaneous asynchronous stimulation mode （hereinafter referred to as "binocular mode"） and monocular separate stimulation mode （hereinafter referred to as "monocular mode"） of virtual reality-pattern visual evoked potential （VR-PVEP）, and the amplitude of PVEP of volunteers under the two modes was compared at four spatial frequencies of 8×8, 16×16, 24×24 and 32×32. Results The differences in the amplitude of P100 wave between monocular and binocular modes at 8×8 spatial frequency had no statistical significance and the differences in amplitude of P100 wave between monocular and binocular modes at 16×16, 24×24, and 32×32 spatial frequencies had statistical significance （P<0.05）. The amplitude of the same eye in monocular mode was higher than that in binocular mode. Through correlation analysis, it was found that the amplitude of P100 wave in monocular mode was moderately correlated with amplitude of P100 wave in binocular mode. Conclusion In forensic identification practice, VR-PVEP is helpful for overcoming the disturbance of poor fixation, and to increase the reliability of PVEP evaluation results. It can greatly shorten the detection time of PVEP and improve work efficiency.

Laparoscopic splenic artery ligation in a patient with immune thrombocytopenia with intracranial haemorrhage (two clips that stopped a timebomb)

Intracranial haemorrhage (ICH) in a patient with relapse of idiopathic thrombocytopaenic purpura (ITP) can be lethal. The site of haemorrhage, compounded by low platelets in this disease, makes its management extremely challenging, especially when a neurosurgical procedure is warranted. We report a case report of an unconventional way of increasing platelet counts in ITP rapidly in an emergency setting.

Inhibition of IRF5 cellular activity with cell-penetrating peptides that target homodimerization

The transcription factor interferon regulatory factor 5 (IRF5) plays essential roles in pathogen-induced immunity downstream of Toll-, nucleotide-binding oligomerization domain-, and retinoic acid-inducible gene I-like receptors and is an autoimmune susceptibility gene. Normally, inactive in the cytoplasm, upon stimulation, IRF5 undergoes posttranslational modification(s), homodimerization, and nuclear translocation, where dimers mediate proinflammatory gene transcription. Here, we report the rational design of cell-penetrating peptides (CPPs) that disrupt IRF5 homodimerization. Biochemical and imaging analysis shows that IRF5-CPPs are cell permeable, noncytotoxic, and directly bind to endogenous IRF5. IRF5-CPPs were selective and afforded cell type- and species-specific inhibition. In plasmacytoid dendritic cells, inhibition of IRF5-mediated interferon-α production corresponded to a dose-dependent reduction in nuclear phosphorylated IRF5 [p(Ser⁴⁶²)IRF5], with no effect on pIRF5 levels. These data support that IRF5-CPPs function downstream of phosphorylation. Together, data support the utility of IRF5-CPPs as novel tools to probe IRF5 activation and function in disease.

Application of PRVEP Waveform Amplitude Ratio to Evaluate Visual Acuity and Its Forensic Significance

Abstract

Objective To research the correlation between the visual acuity ratio and pattern reversal visual evoked potential （PRVEP） P100 waveform amplitude ratio of both eyes. Methods Forty-seven volunteers were selected, and the visual chart visual acuity of both eyes was measured. The visual acuity ratio of the eye with poor vision to the eye with better vision was calculated by five grade notation method. The amplitudes of P100 waveforms of both eyes were recorded respectively by using black-and-white checkerboard PRVEP and chosing 1°, 15' stimulating visual angle, and the ratio of amplitudes between the two eyes was also calculated. SPSS 20.0 software was used to analyze the correlation between the visual acuity ratio and the ratio of P100 waveform amplitudes between the two eyes. Return test and linear regression analysis with the binocular ratio of P100 waveform amplitudes as the independent variable （x） and the binocular visual acuity ratio as the dependent variable （y） were made. Results There was a positive correlation between the binocular visual acuity ratio and the ratio of P100 waveform amplitudes under 15' stimulating visual angle （Pearson correlation coefficient was 0.62, P=0.000）. The fitting linear regression equation was y=0.090 x+0.846 （F=20.954, P=0.000）. There was no significant correlation between the binocular ratio of visual acuity and the binocular ratio of P100 waveform amplitudes under 1° stimulating visual angle （P>0.05）. Results of return test showed that there was no statistical significance in the difference between visual acuity estimated by equation and actual detected visual acuity. Conclusion In forensic appraisal of monocular injury, fitting linear regression equation of binocular visual acuity ratio and the binocular ratio of P100 waveform amplitudes under 15' stimulating visual angle, is helpful for visual acuity level estimation of the injured eye to some extent.

Progress on the Muscle Function Evaluation and Its Forensic Application

Accurate evaluation of muscle function helps to understand the recovery of muscle, bone, nervous system diseases or injuries, especially for muscle dysfunction caused by peripheral nerve injury. Therefore, the methods of muscle function evaluation have been the focus of researchers, with new methods having been constantly proposed. Muscle strength testing is an important part of muscle function evaluation. Besides hand muscle strength assessment, currently used muscle function assessments include simple instrumental test, isokinetic muscle test, electrophysiological test, etc. In addition, the application of needle electromyography, motor unit number estimation, motion unit index in muscle function evaluation has also been reported for several times. This paper reviews the research progress and practical application of these methods.

Assessment of the Original Height of L1~2 after Vertebral Compression Fracture

OBJECTIVES

To explore the assessment method of original height of L_1-2 after vertebral compression fracture and its application value in forensic clinical practice.

METHODS

A total of 154 normal thoracic and lumbar X-ray films were collected, and 140 cases were used as experimental group while 14 cases as validation group. The heights of anterior （Ha） and posterior （Hp） vertebral body of T₁₂-L₃ vertebrae in each X-ray image were measured. In the experimental group, the correlation analysis between Ha_L₁ and Ha_T₁₂, Hp_T₁₂, Hp_L₁, Ha_L₂ and Hp_L₂ was carried out, and regression equation was established via fitting. The correlation analysis between Ha_L₂ and Ha_L₁, Hp_L₁, Hp_L₂, Ha_L₃, Hp_L₃ was performed, and the regression equation was also established via fitting. The difference between the predicted and measured values of Ha_L₁ and Ha_L₂ in validation group was compared.

RESULTS

In the 140 normal subjects, Ha_L₁ （y₁） was well correlated with Ha_T₁₂ （x₁） and Ha_L₂（x₂）, and the multiple linear regression equation was y₁=2.545+0.423 x₁+0.486 x₂ （determining coefficient R²=0.712, P<0.05; F=169.206, P<0.05）. There was no significant difference between the predicted and actual measured values of Ha_L₁ in the validation group （ P>0.05）. HaL₂ （y₂） was well correlated with Ha_L₁ （x₃） and Ha_L₃ （x₄）, and the multiple linear regression equation was y₂=4.354+0.530 x₃+0.349 x₄ （determining coefficient R²=0.689, P<0.05; F=151.575, P<0.05）. There was no significant difference between the predicted and actual measured values of Ha_L₂ in the validation group （ P>0.05）.

CONCLUSIONS

It is more appropriate to evaluate the original height of L₁ or L₂ single vertebrae by comparing with the height of the anterior edge of the upper and lower adjacent vertebral bodies.

[Research Progress of the Effects of Monocular Visual Impairment on Binocular Vision]

Binocular vision refers to a progress of analysing and integrating the binocular visual signals into a whole and three-dimensional sensory perception by higher nerve centre. In this process, the interac- tion between the two eyes results in the changes of output signal, which is called binocular interaction. Through a series of subjective and objective experiments, it can be concluded that binocular interaction can be divided into three types： facilitation, summation and suppression, and the forms of binocular interaction in different visual states are different. In general, the visual signal is processed by binocular interaction, so that there are some differences between binocular vision and monocular vision. The extent of the difference can be affected by the damage of monocular vision and then affects the binocular vision. Thus, it is necessary for forensic scientists to further study the effects of the monocular visual impairment on visual function. Based on relevant data, this paper reviews the mechanism of the monocular visual impairment in binocular vision, the research methods and the application prospect in forensic science.

[Comparison of Measurement Methods of Exophthalmos and Its Forensic Significance]

OBJECTIVES

To compare the differences between Hertel exophthalmometry and CT on exophthalmos measurement, and explore its practical application value in forensic medicine.

METHODS

Fifty-six normal individuals without eye injuries or diseases were selected as the control group. The absolute values of exophthalmos were measured in the standardized CT image workstation. The difference of binocular exophthalmos was compared in normal group. Forty-seven cases with unilateral orbital fracture were divided into injured eye group and normal eye group according to the presence of binocular orbital fractures. The differences of the absolute values of eophthalmos from the same eye and the relative values of eophthalmos between two eyes for same person measured by Hertel exophthalmometry and CT were analyzed.

RESULTS

There was no statistical difference of exophthalmos between the normal eyes measured by CT method. In the normal eye group, the absolute value of exophthalmos measured by CT method was （16.66±5.41） mm, which was （16.16±4.45） mm when measured by the Hertel exophthalmometry method. There was no statistical difference between two groups （P>0.05）. In the injured eye group, there was statistical difference between the absolute values of exophthalmos measured by two measurement methods （ P<0.05）. There was no statistical difference of the relative values of exophthalmos between the injured eyes and the normal eyes by two measurement methods （P>0.05）.

CONCLUSIONS

CT method has a good consistency with Hertel exophthalmometry, which can be applied into the practice of medicolegal expertise.

Strained GaAs/InGaAs Core-Shell Nanowires for Photovoltaic Applications

We report on the successful growth of strained core-shell GaAs/InGaAs nanowires on Si (111) substrates by molecular beam epitaxy. The as-grown nanowires have a density in the order of 10(8) cm(-2), length between 3 and 3.5 μm, and diameter between 60 and 160 nm, depending on the shell growth duration. By applying a range of characterization techniques, we conclude that the In incorporation in the nanowires is on average significantly smaller than what is nominally expected based on two-dimensional growth calibrations and exhibits a gradient along the nanowire axis. On the other hand, the observation of sharp dot-like emission features in the micro-photoluminescence spectra of single nanowires in the 900-1000-nm spectral range highlights the co-existence of In-rich enclosures with In content locally exceeding 30 %.

Data for the crystal structure of APRIL-BAFF-BAFF heterotrimer

The TNF family ligands B cell activation factor (BAFF) and a proliferation-inducing ligand (APRIL) modulate B cell function by forming homotrimers and heterotrimers. To determine the structure of a heterotrimer of BAFF and APRIL, these ligands were expressed as a single chain protein in HEK 293 cells, purified by affinity and size exclusion chromatographies, and crystallized. Crystals belonging to the orthorhombic crystal system with a space group of C2221 diffracted to 2.43 Å. Initial structural solution was obtained by the molecular replacement method, and the structure was further refined to an R factor of 0.179 and free R factor of 0.234. The atomic coordinates and structure factors have been deposited into the Protein Data Bank (accession code 4ZCH).

Stoichiometry of Heteromeric BAFF and APRIL Cytokines Dictates Their Receptor Binding and Signaling Properties

The closely related TNF family ligands B cell activation factor (BAFF) and a proliferation-inducing ligand (APRIL) serve in the generation and maintenance of mature B-lymphocytes. Both BAFF and APRIL assemble as homotrimers that bind and activate several receptors that they partially share. However, heteromers of BAFF and APRIL that occur in patients with autoimmune diseases are incompletely characterized. The N and C termini of adjacent BAFF or APRIL monomers are spatially close and can be linked to create single-chain homo- or hetero-ligands of defined stoichiometry. Similar to APRIL, heteromers consisting of one BAFF and two APRILs (BAA) bind to the receptors B cell maturation antigen (BCMA), transmembrane activator and CAML interactor (TACI) but not to the BAFF receptor (BAFFR). Heteromers consisting of one APRIL and two BAFF (ABB) bind to TACI and BCMA and weakly to BAFFR in accordance with the analysis of the receptor interaction sites in the crystallographic structure of ABB. Receptor binding correlated with activity in reporter cell line assays specific for BAFFR, TACI, or BCMA. Single-chain BAFF (BBB) and to a lesser extent single-chain ABB, but not APRIL or single-chain BAA, rescued BAFFR-dependent B cell maturation in BAFF-deficient mice. In conclusion, BAFF-APRIL heteromers of different stoichiometries have distinct receptor-binding properties and activities. Based on the observation that heteromers are less active than BAFF, we speculate that their physiological role might be to down-regulate BAFF activity.

Combined inhibition of tumor necrosis factor α and interleukin-17 as a therapeutic opportunity in rheumatoid arthritis: development and characterization of a novel bispecific antibody

OBJECTIVE

Rheumatoid arthritis therapies that are based on inhibition of a single cytokine, e.g., tumor necrosis factor α (TNFα) or interleukin-6 (IL-6), produce clinically meaningful responses in only about half of the treated patients. This study was undertaken to investigate whether combined inhibition of TNFα and IL-17 has additive or synergistic effects in the suppression of mesenchymal cell activation in vitro and inflammation and tissue destruction in arthritis in vivo.

METHODS

Cultures of human fibroblast-like synoviocytes (FLS) were stimulated with TNFα, IL-17, or a combination of both. Single/combined neutralizing antibodies against TNFα and IL-17 were used to examine in vitro cytokine responses and in vivo development of arthritis and bone and cartilage destruction in TNFα-transgenic mice. Bispecific anti-TNFα/IL-17 antibodies were designed, and their potential to block cytokine responses in human FLS was tested.

RESULTS

TNFα and IL-17 had additive/synergistic effects in promoting production of IL-6, IL-8, and granulocyte colony-stimulating factor, as well as matrix metalloproteinases, in FLS. Bispecific anti-TNFα/IL-17 antibodies showed superior efficacy in blocking cytokine and chemokine responses in vitro. Furthermore, dual versus single inhibition of both cytokines using neutralizing antibodies was more effective in inhibiting the development of inflammation and bone and cartilage destruction in arthritic mice.

CONCLUSION

Combined blockade of TNFα and IL-17 was more effective than single blockade in inhibiting cytokine, chemokine, and matrix enzyme responses from human mesenchymal cells and in blocking tissue destruction associated with arthritis, and additionally showed a positive impact on rebalance of bone homeostasis. Bispecific anti-TNFα/IL-17 antibodies may have superior efficacy in the treatment of arthritis and may overcome the limited therapeutic responses obtained with single cytokine neutralization.

Tocilizumab, a humanized anti-IL-6R antibody, as an emerging therapeutic option for rheumatoid arthritis: molecular and cellular mechanistic insights

Pro-inflammatory cytokines play a major role in the initiation and maintenance of joint inflammation and destruction in rheumatoid arthritis (RA). The therapeutic success of biologics targeting tumour necrosis factor-alpha (TNF-α), interleukin-1 (IL-1) and interleukin (IL)-6 receptor (IL-6R) has broadened the treatment options for RA. These agents have potential overlapping and discriminating biologic effects, as well as different pharmacological features. Tocilizumab (TCZ) is a humanized monoclonal antibody that binds and neutralizes IL-6R, resulting in the inhibition of various IL-6-mediated biological activities, including inflammation-related, immunomodulatory and tissue/matrix remodelling effects. Randomized, double-blind, controlled phase III studies and a number of early clinical observational studies have shown that treatment with TCZ results in rapid and sustained improvement in the signs and symptoms of RA among different patient populations. These studies have established the efficacy and safety of TCZ. Here, we review the pleiotropic functions of IL-6 and how it impinges on many aspects of RA pathogenesis, and highlight the clinical experience to date with TCZ as an emerging new treatment option for RA.

B-cell antigen receptor signaling in chronic lymphocytic leukemia: therapeutic targets and translational opportunities

B-cell chronic lymphocytic leukemia (CLL) is characterized by clonally expanded and molecularly heterogeneous populations of B lymphocytes with impaired apoptotic mechanisms. This occurs as a result of multiple genetic and epigenetic abnormalities, including chromosomal aberrations and enhancer region hypomethylation, often impinging on intracellular signaling pathways that are essential to normal B-cell activation, proliferation, and survival. The B-cell antigen receptor (BCR) signaling is one such pathway usurped by malignant B cells, as exemplified by the early phase clinical success achieved by small-molecule agents targeting key players involved in the pathway. Such new targeted agents, including those that inhibit the function of Spleen tyrosine kinase (SYK), Bruton's tyrosine kinase (BTK), phosphatidylinositol 3-kinases (PI3K), and B-cell lymphoma 2 (BCL-2), along with the current standard therapy comprising chemo-immunotherapies with or without B-cell depleting biologic agent rituximab (anti-CD20 monoclonal antibody), should expand the armamentarium for CLL therapy. We review the therapeutic agents currently in clinical development which target different effectors of the malignant BCR signaling, and discuss their overlapping and discriminating translational opportunities in the context of CLL treatment.

Selective inhibition of spleen tyrosine kinase (SYK) with a novel orally bioavailable small molecule inhibitor, RO9021, impinges on various innate and adaptive immune responses: implications for SYK inhibitors in autoimmune disease therapy

Introduction

Spleen tyrosine kinase (SYK) is a key integrator of intracellular signals triggered by activated immunoreceptors, including Bcell receptors (BCR) and Fc receptors, which are important for the development and function of lymphoid cells. Given the clinical efficacy of Bcell depletion in the treatment of rheumatoid arthritis and multiple sclerosis, pharmacological modulation of Bcells using orally active small molecules that selectively target SYK presents an attractive alternative therapeutic strategy.

Methods

A SYK inhibitor was developed and assayed in various in vitro systems and in the mouse model of collagen-induced arthritis (mCIA).

Results

A novel ATP-competitive inhibitor of SYK, 6-[(1R,2S)-2-Amino-cyclohexylamino]-4-(5,6-dimethyl-pyridin-2-ylamino)-pyridazine-3-carboxylic acid amide, designated RO9021, with an adequate kinase selectivity profile and oral bioavailability, was developed. In addition to suppression of BCR signaling in human peripheral blood mononuclear cells (PBMC) and whole blood, FcγR signaling in human monocytes, and FcϵR signaling in human mast cells, RO9021 blocked osteoclastogenesis from mouse bone marrow macrophages in vitro. Interestingly, Toll-like Receptor (TLR) 9 signaling in human Bcells was inhibited by RO9021, resulting in decreased levels of plasmablasts, immunoglobulin (Ig) M and IgG upon B-cell differentiation. RO9021 also potently inhibited type I interferon production by human plasmacytoid dendritic cells (pDC) upon TLR9 activation. This effect is specific to TLR9 as RO9021 did not inhibit TLR4- or JAK-STAT-mediated signaling. Finally, oral administration of RO9021 inhibited arthritis progression in the mCIA model, with observable pharmacokinetics (PK)-pharmacodynamic (PD) correlation.

Conclusions

Inhibition of SYK kinase activity impinges on various innate and adaptive immune responses. RO9021 could serve as a starting point for the development of selective SYK inhibitors for the treatment of inflammation-related and autoimmune-related disorders.

Development of a pharmacodynamic assay based on PLCγ2 phosphorylation for quantifying spleen tyrosine kinase (SYK)-Bruton's tyrosine kinase (BTK) signaling

Spleen tyrosine kinase (SYK) and Bruton's tyrosine kinase (BTK) are key mediators in coupling cell surface receptors, such as the B-cell receptor (BCR), to downstream signaling events affecting diverse biological functions. There is therefore tremendous interest in the development of pharmacological inhibitors targeting the SYK-BTK axis for the treatment of inflammatory disorders and hematological malignancies. A good pharmacodynamic (PD) assay, ideally a blood-based assay that measures proximal events, is warranted for evaluation of such inhibitors. In platelets, collagen-induced activation of membrane glycoprotein GPVI is dependent on the SYK-BTK axis. Here, we report the development of a novel immunoassay that uses the dissociation-enhanced lanthanide fluorescent immunoassay (DELFIA) to measure GPVI-mediated phosphorylation of phospholipase C γ2 (PLCγ2), a direct substrate of SYK and BTK, in platelets. The assay was validated using SYK or BTK inhibitors and generated IC50 correlated with those from the BCR-induced B-cell activation assay. Furthermore, this assay showed good stability and uniformity over a period of 24 h in different donors. Interestingly, compound IC50 values using blood from patients with rheumatoid arthritis were slightly higher compared with those produced using samples from healthy donors. This novel platelet PLCγ2 phosphorylation-based immunoassay should serve as a promising PD assay for preclinical and clinical development of inhibitors targeting the SYK-BTK axis.

Targeting the SYK-BTK axis for the treatment of immunological and hematological disorders: recent progress and therapeutic perspectives

Spleen Tyrosine Kinase (SYK) and Bruton's Tyrosine Kinase (BTK) are non-receptor cytoplasmic tyrosine kinases that are primarily expressed in cells of hematopoietic lineage. Both are key mediators in coupling activated immunoreceptors to downstream signaling events that affect diverse biological functions, from cellular proliferation, differentiation and adhesion to innate and adaptive immune responses. As such, pharmacological inhibitors of SYK or BTK are being actively pursued as potential immunomodulatory agents for the treatment of autoimmune and inflammatory disorders. Deregulation of SYK or BTK activity has also been implicated in certain hematological malignancies. To date, from a clinical perspective, pharmacological inhibition of SYK activity has demonstrated encouraging efficacy in patients with rheumatoid arthritis (RA), while patients with relapsed or refractory chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) have benefited from covalent inhibitors of BTK in early clinical studies. Here, we review and discuss recent insights into the emerging role of the SYK-BTK axis in innate immune cell function as well as in the maintenance of survival and homing signals for tumor cell progression. The current progress on the clinical development of SYK and BTK inhibitors is also highlighted.

Bruton's Tyrosine Kinase mediates platelet receptor-induced generation of microparticles: a potential mechanism for amplification of inflammatory responses in rheumatoid arthritis synovial joints

Platelet microparticles (pMPs) are small membrane-coated vesicles that are released from the plasma membrane upon platelet activation. In the joint fluid of patients with rheumatoid arthritis, pMP can interact with and activate fibroblast-like synoviocytes (FLS), which are important effector cells that mediate both immune activation and joint destruction. The signaling process by which engagement of glycoprotein VI (GPVI), a surface glycoprotein receptor for collagen which is expressed on platelets, triggers pMP generation is poorly understood, but has been suggested to involve Spleen Tyrosine Kinase (SYK), best known as an upstream activator of Bruton's Tyrosine Kinase (BTK) in B cells. In this study, we showed that activation of human platelets triggered by convulxin or collagen, specific ligands for GPVI receptor, or alternatively by antibody-mediated cross-linking of another platelet receptor, C type lectin-like receptor 2 (CLEC2), resulted in phosphorylation of BTK and downstream effector, phospholipase Cγ2 (PLCγ2). A potent and selective BTK inhibitor, RN486, inhibited GPVI- or CLEC2-mediated PLCγ2 phosphorylation and pMP production in a dose-dependent manner. BTK is also an essential effector of B cell receptor (BCR)-induced B cell signaling. Consistent with the biology, the IC50s of BTK inhibitors with varying potencies in a BCR-dependent B cell activation marker assay correlated with those in the GPVI-mediated PLCγ2 phosphorylation. In a co-culture system consisting of human primary synovial FLS and activated human platelets, convulxin stimulation resulted in elevated production of pro-inflammatory cytokines, IL-6 and IL-8, an effect which was dose-dependently blocked by RN486. The effects are specific as RN486 abrogated platelet aggregation induced by GPVI ligands but not by other platelet surface receptor agonists. Taken together, our data further support the potential therapeutic utility of BTK inhibitors in RA therapy, by inhibiting GPVI-mediated platelet activation and thus subsequent amplification of inflammation driven by pMP-induced FLS cytokines production.

3-Amido pyrrolopyrazine JAK kinase inhibitors: development of a JAK3 vs JAK1 selective inhibitor and evaluation in cellular and in vivo models

The Janus kinases (JAKs) are involved in multiple signaling networks relevant to inflammatory diseases, and inhibition of one or more members of this class may modulate disease activity or progression. We optimized a new inhibitor scaffold, 3-amido-5-cyclopropylpyrrolopyrazines, to a potent example with reasonable kinome selectivity, including selectivity for JAK3 versus JAK1, and good biopharmaceutical properties. Evaluation of this analogue in cellular and in vivo models confirmed functional selectivity for modulation of a JAK3/JAK1-dependent IL-2 stimulated pathway over a JAK1/JAK2/Tyk2-dependent IL-6 stimulated pathway.

Development and comparison of a new personalized warfarin stable dose prediction algorithm in Chinese patients undergoing heart valve replacement

BACKGROUND

Pharmacogenetics-based algorithms would be especially desirable for patients undergoing heart valve replacement (HVR), who are particularly sensitive to warfarin during the initial treatment phase following surgery. We aimed to derive a warfarin dosing algorithm from data of Chinese patients undergoing HVR, and to compare it with previously published dosing algorithms as applied to our HVR patients.

METHODS

641 Chinese HVR patients on stable maintenance dose of warfarin were enrolled from a single clinic site. Data of 321 patients were used to derive a warfarin dosing algorithm using stepwise multiple linear regression analysis. Previously published algorithms were selected from Pubmed database for comparison. The performance of all the algorithms was characterized according to mean absolute error (MAE) and percentage of predicted doses falling within +/- 20% of clinically observed doses (percentage of ideal prediction) in the other 320 patients.

RESULTS

The newly developed algorithm included eight factors: VKORC1-1639G > A, CYP2C9*3, BSA, age, number of increasing INR drugs, smoking habit, preoperative stroke history and hypertension. Our algorithm accounted for 56.4% of variations in the inter-patient warfarin stable doses. All the algorithms showed better performance in a medium-dose (1.88-4.38 mg/day) and high-dose (> or = 4.38 mg/day) groupings than in a low-dose (< or = 1.88 mg/day) grouping. Compared with the 14 previously published algorithms, our algorithm had the lowest MAE (-0.07 mg/day) and the highest percentage of ideal prediction (62.8%) in the total validation cohort.

CONCLUSIONS

Our warfarin dosing algorithm is potentially useful for patients whose population profiles are similar to those of our patients.

Rhinoscleroma: a case series

Rhinoscleroma is a chronic, slowly progressive, inflammatory disease of the upper respiratory tract. It is associated with Klebsiella rhinoscleromatis infection. We present the clinical and pathological features of four patients diagnosed with rhinoscleroma at the National Skin Centre, Singapore between 1997 and 2010. All four patients presented with only cutaneous involvement, and the diagnosis was clinched via histological examination. The patients were treated with a combination of antibiotics. Two patients who were on follow-up at the time of this writing responded positively to the antibiotic treatment, while two were lost to follow-up. Rhinoscleroma is a diagnostic challenge, as it is an uncommon disease in Singapore and Malaysia. We highlight this condition to raise awareness of the disease in order to aid in early diagnosis of patients. Without treatment, this condition can result in significant complications, including involvement of the lower airways. Early diagnosis and appropriate treatment help to reduce morbidity.

Dietary compliance and its association with glycemic control among poorly controlled type 2 diabetic outpatients in Hospital Universiti Sains Malaysia

INTRODUCTION

Compliance with medical nutrition therapy is important to improve patient outcomes. The purpose of this study was to determine dietary compliance and its association with glycemic control among outpatients with poorly controlled type 2 diabetes mellitus (T2DM) in Hospital Universiti Sains Malaysia (HUSM).

METHODS

In this cross-sectional study, patients who had a glycosylated hemoglobin (HbA1c) level of at least 6.5%, after attending a diet counseling session at the Outpatient Dietetic Clinic, HUSM, were enrolled. Out of 150 diabetic patients reviewed between 2006 and 2008, 61 adults (32 men and 29 women) agreed to participate in this study. A questionnaire-based interview was used to collect socio-demographic, clinical and diabetes self-care data. The patient's dietary compliance rate was determined by the Summary of Diabetes Self-Care Activities (SDSCA) measure. Anthropometric and biological measurements were also taken.

RESULTS

Only 16.4% of the respondents adhered to the dietary regimen provided by dietitians. Among the 7 dietary self-care behaviours, item number 6 (eat lots of food high in dietary fibre such as vegetable or oats) had the highest compliant rate (54.1%); whereas item number 3 (eat five or more servings of fruits and vegetables per day) had the lowest compliant rate (23.0%). There was a significant association between gender (p = 0.037) and fasting blood sugar (FBS) (p = 0.007) with the compliance status.

CONCLUSION

Dietary non-compliance is still common among T2DM patients. Dietitians need to improve their skills and use more effective intervention approaches in providing dietary counseling to patients.

TBK1 directly engages Akt/PKB survival signaling to support oncogenic transformation

The innate immune-signaling kinase, TBK1, couples pathogen surveillance to induction of host defense mechanisms. Pathological activation of TBK1 in cancer can overcome programmed cell death cues, enabling cells to survive oncogenic stress. The mechanistic basis of TBK1 prosurvival signaling, however, has been enigmatic. Here, we show that TBK1 directly activates AKT by phosphorylation of the canonical activation loop and hydrophobic motif sites independently of PDK1 and mTORC2. Upon mitogen stimulation, triggering of the innate immune response, re-exposure to glucose, or oncogene activation, TBK1 is recruited to the exocyst, where it activates AKT. In cells lacking TBK1, insulin activates AKT normally, but AKT activation by exocyst-dependent mechanisms is impaired. Discovery and characterization of a 6-aminopyrazolopyrimidine derivative, as a selective low-nanomolar TBK1 inhibitor, indicates that this regulatory arm can be pharmacologically perturbed independently of canonical PI3K/PDK1 signaling. Thus, AKT is a direct TBK1 substrate that connects TBK1 to prosurvival signaling.

A unique biological in-vivo model to evaluate follicular development during in-vitro maturation treatment

The aim of this study was to identify the size in which the dominant follicle acquires the ability to produce a functional corpus luteum. This observational study includes 15 women with ovulatory cycles who underwent human chorionic gonadotrophin (HCG)-primed in-vitro maturation (IVM) treatments without embryo transfer. All patients received subcutaneous injection of HCG 10,000 IU 38 h prior to oocyte retrieval. Five to seven days following retrieval, serum concentrations of progesterone and oestradiol were measured along with ultrasound scan measuring the antral follicle count. Using receiver operating characteristic curves and the Youden index (J), this study clearly shows that the diameter of the dominant follicle at the time of the LH surge is a good predictor for its ability to form a progesterone-producing corpus luteum (area under the curve 0.94). These findings revealed that the dominant follicle develops the competence to form a corpus luteum, signified by the production of more than 10 nmol/l serum progesterone at 5-7 days from oocyte retrieval, as soon as it acquires a diameter of 10.5-12.0mm. In addition, a new cohort of viable antral follicles can be identified as early as 5-7 days following IVM oocyte retrieval.

Preservation of ovarian function by ovarian transposition prior to concurrent chemotherapy and pelvic radiation for cervical cancer. A case report and review of the literature

BACKGROUND

For over 45 years, ovarian transposition has been proposed for patients with cervical cancer to preserve ovarian function prior to pelvic radiation. We report a case of preservation of ovarian function and regular normal menstrual cycles after pelvic cisplatin-based chemoradiation and perform a literature review.

CASE

A 29-year-old female with cervical cancer underwent laparoscopic ovarian transposition prior to cisplatin-based chemoradiation. At 3-year follow-up after completion of her chemoradiation treatment indicated that she was still free of any disease. She is experiencing normal menstrual cycles at regular monthly intervals.

CONCLUSION

The present case shows that it is possible to retain ovarian function and menstrual cycles by ovarian transposition prior to pelvic chemoradiation. This provides an option for cervical cancer patients who desire preservation of ovarian function.

Chronic obstructive pulmonary disease and comorbidity: a review and consideration of pathophysiology

Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation that is not fully reversible, though a number of pulmonary phenotypes are recognized. These include small airways diseases, chronic bronchitis and bronchiectasis, as well as pulmonary emphysema, which can be further subdivided by the zone of the lung which it affects, and its radiological appearance. In addition COPD is associated with a number of comorbidities, which are found more frequently than would be expected by chance, even after controlling for common etiological factors (such as smoking or steroid use). These comorbid conditions may be responsible for some of the deterioration and de-conditioning seen in COPD, as well as a significant proportion of mortality, and should be sought and managed where clinically appropriate. This review examines the prevalence and clinical features of associated comorbid conditions, including atherosclerosis, cardiac failure, diabetes, osteoporosis, cachexia, gastro-esophageal reflux disease and depression. A brief consideration of their management in COPD is also given. In addition evidence for the concept of pulmonary overspill leading to systemic inflammation, the consequences of systemic inflammation, the possibility of accelerated aging, and of how these concepts could relate to shared genetic risk factors for both comorbidity and pulmonary aspects of COPD is discussed.

Modular "plug-and-play" capsules for multi-capsule environment in the gastrointestinal tract

The invention of wireless capsule endoscopy has opened new ways of diagnosing and treating diseases in the gastrointestinal tract. Current wireless capsules can perform simple operations such as imaging and data collection (like temperature, pressure, and pH) in the gastrointestinal tract. Researchers are now focusing on adding more sophisticated functions such as drug delivery, surgical clips/tags deployment, and tissue samples collection. The finite on-board power on these capsules is one of the factors that limits the functionalities of these wireless capsules. Thus multiple application-specific capsules would be needed to complete an endoscopic operation. This would give rise to a multi-capsule environment. Having a modular "plug-and-play" capsule design would facilitate doctors in configuring multiple application-specific capsules, e.g. tagging capsule, for use in the gastrointestinal tract. This multi-capsule environment also has the advantage of reducing power consumption through asymmetric multi-hop communication.

Protein kinase C isozymes as potential therapeutic targets in immune disorders

BACKGROUND

Members of the protein kinase C (PKC) family are key signalling mediators in immune responses, and pharmacological inhibition of PKCs may be useful for treating immune-mediated diseases.

OBJECTIVE

To review and discuss the insights gained so far into various PKC isozymes and the therapeutic potential and challenges of developing PKC inhibitors for immune disorder therapy.

METHODS

A literature review of the role of PKCs in immune cell signalling and recent studies describing immune functions associated with PKC isozyme deficiency in relevant mouse disease models, followed by specific case studies of current and potential therapeutic strategies targeting PKCs.

RESULTS/CONCLUSION

There is vast amount of data supporting PKC isozymes as attractive drug targets for certain immune disorders. Although the development of specific PKC isozyme inhibitors has been challenging, some progress has been made. It remains to be seen if broad-scale or isozyme-selective inhibition of PKC will have clinical efficacy.

Cryopreservation of ovarian tissue and in vitro matured oocytes in a female with mosaic Turner syndrome: Case Report

We report a novel approach of fertility preservation in a young woman with mosaic Turner syndrome. A 16-year-old female with 20% 45XO and 80% 46XX karyotype underwent laparoscopic ovarian wedge resection. Before performing ovarian tissue cryopreservation, all visible follicles on the ovarian surface were aspirated. We recovered 11 immature germinal vesicle stage oocytes, which were subjected to in vitro maturation (IVM). Eight oocytes that matured (73% maturation rate) were cryopreserved by vitrification. The combination of ovarian tissue cryobanking and immature oocyte collection from the tissue followed by IVM and vitrification of matured oocytes represent a promising approach of fertility preservation for young women with mosaic Turner syndrome.

Towards a truly biomimetic olfactory microsystem: an artificial olfactory mucosa

Today, the capability of the human olfactory system is still, in many ways, superior to that of the electronic nose. Although electronic noses are often compared with their biological counterpart, they neither mimic its neural architecture nor achieve its discriminating performance. Experimental studies on the mammalian olfactory system suggest that the nasal cavity, comprising of the mucous layer and the olfactory epithelium, performs a degree of chromatographic separation of complex mixtures. Thus receptor cells distributed beneath the mucous layer provide both spatial and temporal chemosensory information. Here we report on the development of an artificial olfactory microsystem that replicates this basic structure. This contains an integrated channel to emulate the nasal cavity and coated with a polymer to mimic the partitioning mucous layer, which is positioned directly over a sensor array. Our system employs an 80 element chemoresistive microsensor array with carbon black/polymer odour-sensitive films combined with a microfluidic package fabricated by micro-stereolithography. Results show that this biomimetic system generates both spatial and temporal odorant signals, with a temporal chemical retention period of up to 170 s. Data analysis has revealed improvements in its ability to discriminate between two simple odours and a set of complex odours. We believe such emulation of the olfactory system can lead to improved odour discrimination within the field of electronic noses.

Phosphorylation of hepatitis C virus NS5A nonstructural protein: a new paradigm for phosphorylation-dependent viral RNA replication?

The hepatitis C virus (HCV) nonstructural 5A (NS5A) phosphoprotein has been intensely studied due to its ability to subvert the host interferon-induced antiviral response. However, more recent studies suggest that it may also play an important regulatory role in HCV RNA replication as well as modulate host intracellular signaling pathways. Phosphorylation of NS5A appears to be a highly regulated process and several cellular protein kinases responsible for NS5A phosphorylation have been identified in vitro. Studies utilizing the HCV replicon cell culture system have suggested a provocative role for the differential phosphorylation of NS5A in the regulation of viral RNA replication through its association with the viral replication complex, including several host cell factors. Importantly, recent in vivo data linking loss of NS5A hyperphosphorylation to non-productive HCV replication in the chimpanzee model have provided high validation for targeting the cellular kinases involved, particularly the kinases responsible for NS5A phosphorylation, for antiviral therapeutic intervention. Understanding the process of NS5A phosphorylation and the definite identification of the culprit cellular protein kinase(s) will shed light on the mechanisms of HCV RNA replication and/or pathogenesis.

Emerging host cell targets for hepatitis C therapy

Chronic hepatitis C virus (HCV) infection is a major burden on humanity. The current HCV therapy has limited efficacy, and there is pressing need for new and more effective therapies. Host cell factors that are required for HCV infection, replication and/or pathogenesis represent potential therapeutic targets. Of particular interest are cellular receptors that mediate HCV entry, factors that facilitate HCV replication and assembly, and intracellular pathways involving lipid biosynthesis, oxidative stress and innate immune response. A crucial challenge now is to manipulate such cellular targets pharmacologically for chronic HCV treatment, without being limited by side effects.

Cytokine-Activated Natural Killer Cells Exert Direct Killing of Hepatoma Cells Harboring Hepatitis C Virus Replicons

Hepatitis C virus (HCV)-specific impairments in host immunity have been described at multiple levels of the innate and adaptive response, which may lead to viral persistence in the majority of infections. Understanding of HCV-associated immune defects could lead to novel therapeutic advances. Natural killer (NK) cells, the major effector cells of the innate immune system, are functionally impaired in chronic HCV infection. It has been suggested that this phenotype is a result of virus-specific defects in antigen-presenting cells (APCs) that regulate NK cell activity, as normal NK function is restored when they are stimulated ex vivo. In this study, we used human NK cell cytotoxicity assays to evaluate the activation-induced effects of NK cells on the HCV replicon-containing hepatic cells. We found that cytokine-activated NK cells were capable of inducing an HCV-associated, perforin/granzyme-dependent lysis of human hepatoma cells and that this required direct cellular contact and was independent of MHC class I expression levels. In contrast, on removal of cytokine stimulation, NK cells failed to exert any direct cytolytic effect on replicon targets. These findings suggest an important underlying mechanism by which NK cells control HCV infection and, with appropriate understanding of HCV-associated immune defects, could lead to novel therapeutic advances.

The last 10 amino acid residues beyond the hydrophobic motif are critical for the catalytic competence and function of protein kinase Calpha

The segment C-terminal to the hydrophobic motif at the V5 domain of protein kinase C (PKC) is the least conserved both in length and in amino acid identity among all PKC isozymes. By generating serial truncation mutants followed by biochemical and functional analyses, we show here that the very C terminus of PKCalpha is critical in conferring the full catalytic competence to the kinase and for transducing signals in cells. Deletion of one C-terminal amino acid residue caused the loss of approximately 60% of the catalytic activity of the mutant PKCalpha, whereas deletion of 10 C-terminal amino acid residues abrogated the catalytic activity of PKCalpha in immune complex kinase assays. The PKCalpha C-terminal truncation mutants were found to lose their ability to activate mitogen-activated protein kinase, to rescue apoptosis induced by the inhibition of endogenous PKC in COS cells, and to augment melatonin-stimulated neurite outgrowth. Furthermore, molecular dynamics simulations revealed that the deletion of 1 or 10 C-terminal residues results in the deformation of the V5 domain and the ATP-binding pocket, respectively. Finally, PKCalpha immunoprecipitated using an antibody against its C terminus had only marginal catalytic activity compared with that of the PKCalpha immunoprecipitated by an antibody against its N terminus. Therefore, the very C-terminal tail of PKCalpha is a novel determinant of the catalytic activity of PKC and a promising target for selective modulation of PKCalpha function. Molecules that bind preferentially to the very C terminus of distinct PKC isozymes and suppress their catalytic activity may constitute a new class of selective inhibitors of PKC.