Use of serial ultrasound to identify periods of fetal growth restriction in relation to neonatal anthropometry.

The developmental origins of the health and disease hypothesis suggests that fetal growth restriction (FGR) is a risk factor for several chronic diseases of adulthood. However, most supporting studies use birth weight as a proxy measure of FGR. To examine the relationship between birth weight and FGR, the present study used serial prenatal ultrasound to identify periods of FGR during gestation, and related these periods to birth size and shape. The data in this study included serial prenatal ultrasounds performed on 1,349 high-risk Scandinavian women enrolled in the National Institute of Child Health and Human Development Study of Successive Small for Gestational Age Births. Fetal growth velocity between ultrasounds was used to identify periods of isolated FGR, and these were studied in relation to anthropometry at birth. FGR was identified in 184 subjects. A control group of 384 subjects without FGR was also identified. Infants with first-trimester FGR (n = 20) had the highest birth weight, ponderal index, and subscapular skinfold thickness. Infants with second-trimester FGR (n = 37) had the highest arm fat percentage. Infants with early third-trimester FGR (n = 55) had the lowest mean birth weight and ponderal index. When infant gender, gestational age, maternal body mass index, and smoking were controlled, birth weight was predicted only by third-trimester FGR (not first- or second-trimester FGR), and arm fat percent was predicted only by second-trimester FGR. These results suggest that birth weight is not a valid indicator of FGR occurring before the third trimester. Body composition may be a more sensitive marker of early FGR.     

Engineered IL13 variants direct specificity of IL13Rα2-targeted CAR T cell therapy

IL13Rα2 is an attractive target due to its overexpression in a variety of cancers and rare expression in healthy tissue, motivating expansion of interleukin 13 (IL13)–based chimeric antigen receptor (CAR) T cell therapy from glioblastoma into systemic malignancies. IL13Rα1, the other binding partner of IL13, is ubiquitously expressed in healthy tissue, raising concerns about the therapeutic window of systemic administration. IL13 mutants with diminished binding affinity to IL13Rα1 were previously generated by structure-guided protein engineering. In this study, two such variants, termed C4 and D7, are characterized for their ability to mediate IL13Rα2-specific response as binding domains for CAR T cells. Despite IL13Rα1 and IL13Rα2 sharing similar binding interfaces on IL13, mutations to IL13 that decrease binding affinity for IL13Rα1 did not drastically change binding affinity for IL13Rα2. Micromolar affinity to IL13Rα1 was sufficient to pacify IL13-mutein CAR T cells in the presence of IL13Rα1-overexpressing cells in vitro. Interestingly, effector activity of D7 CAR T cells, but not C4 CAR T cells, was demonstrated when cocultured with IL13Rα1/IL4Rα-coexpressing cancer cells. While low-affinity interactions with IL13Rα1 did not result in observable toxicities in mice, in vivo biodistribution studies demonstrated that C4 and D7 CAR T cells were better able to traffic away from IL13Rα1+ lung tissue than were wild-type (WT) CAR T cells. These results demonstrate the utility of structure-guided engineering of ligand-based binding domains with appropriate selectivity while validating IL13-mutein CARs with improved selectivity for application to systemic IL13Rα2-expressing malignancies.

Chimeric antigen receptor (CAR)–engineered T cells have invigorated the field of cancer immunotherapy with their proven ability to treat CD19⁺ malignancies in the clinic (1–4) and continuing progress in solid tumors (5, 6). The synthetic CAR imparts T cells with the ability to recognize antigen independent of peptide presentation by major histocompatibility complexes. This antigen recognition is most often mediated by single-chain variable fragments derived from monoclonal antibodies. As an alternative, naturally occurring ligands or receptors have been used for CAR antigen recognition (7), including interleukin 13 (IL13) (8–10), a proliferation-inducing ligand (APRIL) (11), NKG2D (12), NKp44 (13), and CD27 (14). By leveraging natural binding interactions, these molecules can mediate CAR antigen recognition with minimal additional engineering (8, 14), are fully human in sequence and thus carry potentially lower immunogenicity than other classes of engineered antigen binding domains, and can potentially target multiple cancer biomarkers (11–13). However, the ability to target multiple receptors can also be disadvantageous when binding partners are not implicated in disease.IL13 is one prominent example of a naturally occurring ligand that has been used for CAR antigen recognition (8–10). IL13 interacts strongly with the high-affinity receptor IL13Rα2 (15), which is a versatile therapeutic target due to its rare expression in normal tissue (16) and overexpression in many human cancers, including glioblastoma (GBM) (17), pancreatic ductal adenocarcinoma (18), melanoma (19), ovarian carcinoma (20), clear cell renal cell carcinoma (21), breast cancer (22), and lung cancer (23). A second IL13 receptor family member, IL13Rα1, interacts with IL13 with lower affinity (15) and is ubiquitously expressed in healthy tissue (16). Additionally, IL4Rα can stabilize the IL13Rα1-IL13 complex (15) to mediate signaling through the JAK/STAT6 pathway (24). This receptor pair is coexpressed in pulmonary and other normal tissues (25). Despite this wide expression of IL13 binding partners in healthy tissue, an IL13 ligand–based CAR has shown safety in humans during clinical trials with locoregional central nervous system delivery in GBM (5, 26), suggesting that toxicity from on-target/off-disease binding is not problematic in this context. However, for the treatment of systemic disease, the wide expression of IL13 binding partners outside of the diseased tissue could act as a sink for IL13-based therapy, resulting in safety concerns and possibly impeding trafficking to the disease site. Previous work in the field has attempted to address this problem by generating CARs derived from IL13 variants containing mutations to direct binding away from IL13Rα1/IL4Rα. Mutations at E12 have yielded improved selectivity for IL13Rα2 over IL13Rα1 (8, 9), albeit with the E12Y mutation still allowing measurable recognition of IL13Rα1 in the context of both recombinant antigen and antigen-expressing cancer cells (9). The addition of both E12K and R109K mutations into an IL13-based CAR also showed attenuated, but not abolished, recognition of IL13Rα1-expressing cancer cells relative to IL13Rα2-expressing cancer cells (10). While these examples are encouraging, additional protein engineering is warranted to develop an IL13Rα2-specific IL13 mutant.Structure-based protein engineering and directed evolution approaches offer opportunities to modify the affinity and specificity of binding interactions (27, 28). In this approach, structural information is used to identify residues that contribute to binding interactions, combinatorial libraries are developed through designed or random mutation at the identified residues, and high-throughput in vitro methods are employed to screen for the desired function. Previous applications of this method in the context of cytokines have led to the development of a panel of IL13 mutants with a 6-log affinity range for IL13Rα1 to study the interplay of binding affinity and signal transduction (29), engineering of an orthogonal interleukin 2 (IL2) cytokine-receptor complex system that does not act with the native cytokine or receptor (30), and the development of transforming growth factor beta (TGFβ)-based inhibitors (31), among other examples.Here, we describe the development of IL13-mutein CARs with improved selectivity for IL13Rα2 relative to IL13Rα1 and study their activity in IL13Rα1-expressing, IL13Rα2-expressing, and IL13Rα1/IL4Rα-coexpressing contexts. Prior knowledge of the structures of the IL13 complexes with IL13Rα2 and IL13Rα1/IL4Rα (15) informed the design of an IL13-mutein library that was screened using yeast surface display for diminished binding to IL13Rα1 (29). Characterization of hits yielded two promising candidates, termed C4 and D7, with markedly improved selectivity for IL13Rα2, as shown by affinity characterization. These IL13 muteins were then built into CAR constructs for functional comparison to CARs derived from IL13 wild-type (WT) and IL13 with the E12Y mutation. In vitro and in vivo functional characterization of C4 and D7 IL13-mutein CAR T cells showed decreased activation, degranulation, cytokine release, and cytolytic activity compared to WT and E12Y CAR T cells in the presence of IL13Rα1-expressing cancer cells. Interestingly, C4, but not D7, showed attenuated cytotoxicity relative to WT against IL13Rα1/IL4Rα-coexpressing cancer cells in vitro and in vivo. Conversely, all of the IL13-mutein CAR T cells exhibited similar cytolytic killing of IL13Rα2 targets in vitro and in vivo. Collectively, this work provides insight into the interplay of binding affinity and selectivity in CAR T cell activity and validates IL13-mutein CARs with improved recognition profiles for targeting IL13Rα2-expressing malignancies. Application of these CARs could expand the therapeutic window for systemic administration of IL13Rα2-targeted therapy for a variety of cancers.     

Rare occurrence of fatal Candida haemulonii peritonitis in a diabetic CAPD patient

A 68-year-old diabetic chronic kidney disease patient on continuous ambulatory peritoneal dialysis for two years developed Candida haemulonii peritonitis without any predisposing factors. There is no effective treatment for this fungus. A peritoneal biopsy showed morphological changes of acute inflammation and chronicity.     

Case Report: Severe Hypercalcemia Mimicking St-Segment Elevation Myocardial Infarction

The identification of ST-segment elevation on the electrocardiogram is an integral part of decision making in patients who present with suspected ischemia. Unfortunately, ST-segment elevation is nonspecific and may be caused by noncardiac causes such as electrolyte abnormalities. We present a case of ST-segment elevation secondary to hypercalcemia in a patient with metastatic cancer.     

Comparative analysis of different methods used for molecular characterization of Burkholderia cepacia complex isolated from noncystic fibrosis conditions

PurposeBurkholderia is a Gram-negative opportunistic bacterium capable of causing severe nosocomial infections. The aim of this study was to characterize Burkholderia cepacia complex and to compare different molecular methods used in its characterization.MethodsIn this study, 45 isolates of Burkholderia cepacia complex (Bcc) isolated from clinical cases were subjected to RAPD (Random amplified polymorphic DNA), recA-RFLP (Restriction fragment length polymorphism), 16SrDNA-RFLP, whole-cell protein analysis, recA DNA sequencing and biofilm assay.ResultsOf the 45 isolates tested, 97.7% were sensitive to ceftazidime, 82.2% were sensitive to Cotrimoxazole, 73.3% were sensitive to meropenem, 55.5% were sensitive to minocycline and 42.2% were sensitive to levofloxacin. Majority of the isolates harbored all the tested virulence genes except bpeA and cblA. The RAPD generated 11 groups (R1-R11), recA-RFLP 10 groups (A1-A10), 16SrRNA-RFLP 5 groups (S1–S5) and SDS-PAGE (Sodium Dodecyl Sulphate-Polyacrylamide gel electrophoresis) whole cell protein analysis revealed 12 groups (C1–C12). recA sequencing revealed that most of the isolates belonging to the genomovar III Burkholderia cenocepacia. Though all the methods are found to be efficient in differentiating Burkholderia spp., recA-RFLP was highly discriminatory at 96% similarity value. The study also identified a new strain Burkholderia pseudomultivorans for the first time in the country. Further, recA sequencing could identify the strains to species level. Majority of the multidrug-resistant strains also showed moderate to strong biofilm-forming ability, which further contributes to the virulence characteristics of the pathogens.ConclusionsThe study highlights the importance of combination of molecular methods to characterize Burkholderia cepacia complex. Molecular typing of these human pathogens yields important information for the clinicians in order to initiate the most appropriate therapy in the case of severe infections and to implement preventive measures for the effective control of transmission of Burkholderia spp.     

Efficacy of an eConsult service to cure hepatitis C in primary care

In 2016, an eConsult service was developed within a safety net health system to expand access to hepatitis C (HCV) treatment in the primary care setting. The eConsult system provides individualized treatment recommendations from specially trained primary care pharmacists and primary care physicians to primary care providers with less experience in the rapidly changing treatment of HCV. Since its launch, this service has had a large impact in expanding care to a largely homeless and low-income urban population within our health system. We now aim to evaluate its efficacy in curing HCV. In this retrospective cohort study, we describe rates of sustained virologic response 12 weeks after treatment completion (SVR12) for those who received primary care-based HCV treatment through the eConsult system with those who were treated in primary care independent of an eConsult from 2017 to 2019. We found there was no significant difference in the proportion of patients who achieved SVR12 between the two groups. Overall, >90% of patients who received treatment achieved SVR12. Approximately 40% of patients treated for HCV received an eConsult, suggesting utility of the eConsult in expanding access and coordinating treatment for patients within our network.     

Aromatase inhibitors associated osteonecrosis of jaw: signal refining to identify pseudo safety signals

International Journal of Clinical Pharmacy - Background Signal generation through data mining algorithms is an innovative and emerging field in pharmacovigilance. Early detection of safety signals...