BACKGROUND. After its introduction as standard-of-care for severe COVID-19, dexamethasone has been administered to a large number of patients globally. Detailed knowledge of its impact on the cellular and humoral immune response to SARS-CoV-2 remains scarce. METHODS. We included immunocompetent individuals with 1) mild COVID-19, 2) severe COVID-19 before introduction of dexamethasone treatment, and 3) severe COVID-19 infection treated with dexamethasone from prospective observational cohort studies at Charité-Universitätsmedizin Berlin, Germany. We analyzed SARS-CoV-2 spike-reactive T cells, spike-specific IgG titers as well as serum neutralizing activity against B.1.1.7, B.1.617.2 in samples ranging from two weeks to six months post infection. We also analyzed BA.2 neutralization in sera after booster immunization. RESULTS. Patients with severe COVID-19 and dexamethasone treatment had lower T cell and antibody responses to SARS-CoV-2 compared to patients without dexamethasone treatment in the early phase of disease, which converged in both groups before six months post infection and also post-immunization. Patients with mild COVID-19 had a comparatively lower T cell and antibody response than patients with severe disease, including a lower response to booster-immunization during convalescence. CONCLUSION. Dexamethasone treatment is associated with short-term reduction of T cell and antibody response in severe COVID-19 when compared to the non-treated group, but this difference evens out six months after infection. We confirm higher cellular and humoral immune responses in patients after severe versus mild COVID-19 infection and the concept of improved hybrid immunity upon immunization. TRIAL REGISTRATION.: n/aFunding: Berlin Institute of Health, German Federal Ministry of Education and German Federal Institute for Drugs and Medical Devices
Charlotte Thibeault, Lara Bardtke, Kanika Vanshylla, Veronica Cristianzano, Kirsten A. Eberhardt, Paula Stubbemann, David Hillus, Pinkus Tober-Lau, Parnika Mukherjee, Friederike Münn, Lena J Lippert, Elisa T. Helbig, Tilman Lingscheid, Fridolin Steinbeis, Mirja Mittermaier, Martin Witzenrath, Thomas Zoller, Florian Klein, Leif E. Sander, Florian Kurth
BACKGROUND. Fibrocytes are bone marrow-derived circulating cells that traffic to the injured lungs and contribute to fibrogenesis. The mTOR inhibitor, sirolimus, inhibits fibrocyte CXCR4 expression, reducing fibrocyte traffic and attenuating lung fibrosis in animal models. We sought to test the hypothesis that short-term treatment with sirolimus reduces the concentration of CXCR4+ circulating fibrocytes in patients with idiopathic pulmonary fibrosis (IPF). METHODS. We conducted a short-term randomised double-blind placebo-controlled crossoverpilot trial to assess the safety and tolerability of sirolimus in IPF. Subjects were randomly assigned to sirolimus or placebo for approximately 6 weeks, and after a 4 week washout, assigned to the alternate treatment. Toxicity, lung function, and the concentration of circulating fibrocytes were measured before and after each treatment. RESULTS. In the 28 study subjects, sirolimus resulted in a statistically significant 35% decline in the concentration of total fibrocytes, 34% decline in CXCR4+ fibrocytes, and 42% decline in fibrocytes expressing ɑ-smooth muscle actin, but no significant change in these populations occurred on placebo. Respiratory adverse events occurred more frequently during treatment with placebo than sirolimus; the incidence of adverse events and drug tolerability did not otherwise differ during therapy with drug and placebo. Lung function was unaffected by either treatment with the exception of a small decline in gas transfer during treatment with placebo. CONCLUSIONS. As compared with placebo, short-term treatment with sirolimus resulted inreduction of circulating fibrocyte concentrations in subjects with IPF with an acceptable safety profile. TRIAL REGISTRATION. clinicaltrials.gov identifier number NCT01462006 FUNDING. NIH R01HL098329 and American Heart Association 18TPA34170486
Diana C. Gomez Manjarres, Dierdre B. Axell-House, Divya C. Patel, John Odackal, Victor Yu, Marie D. Burdick, Borna Mehrad
BACKGROUND. Cellular stressors influence the development of clonal hematopoiesis (CH). We hypothesized that aging, environmental, inflammatory, and genotoxic stresses drive the emergence of CH in patients with severe lung disease undergoing lung transplantation. METHODS. We performed a cross-sectional cohort study of 85 patients with severe lung disease undergoing transplantation to characterize CH prevalence. We evaluated somatic variants using duplex error-corrected sequencing and germline variants using whole exome sequencing. We evaluated CH frequency and burden using chi-square and Poisson regression, associations with clinical and demographic variables using logistic regression, and associations with clinical outcomes using chi-square, logistic, and Cox regression. RESULTS. CH in DNA damage response (DDR) genes TP53, PPM1D, and ATM was observed at high frequency in transplant recipients compared to a control group of older adults [28% vs. 0%, aOR 12.9 (1.7-100.3), p=0.0002]. Age [OR 1.13 (1.03-1.25), p=0.014] and smoking history [OR 4.25 (1.02-17.82), p=0.048] were associated with CH in DDR genes. Germline variants causing predisposition to idiopathic pulmonary fibrosis, including telomere biology disorders and surfactant-related lung disease were identified but not associated with CH. DDR CH was associated with increased cytomegalovirus viremia compared to patients with no CH [OR 7.23 (1.95-26.8), p=0.009]] or non-DDR CH [OR 7.64 (1.77-32.89, p=0.012)], decreased lymphopenia (aHR 0.49 (0.27 – 0.90), p=0.021) and mycophenolate discontinuation [aOR 3.8 (1.3-12.9), p=0.031]. CONCLUSION. In patients with severe lung disease requiring lung transplantation, CH due to somatic variants in PPM1D, TP53 or ATM is highly prevalent and associated with post-transplant outcomes including cytomegalovirus activation and mycophenolate intolerance. FUNDING. NIH/NHLBI K01HL155231 (LKT), R25HL105400 (LKT), Foundation for Barnes-Jewish Hospital (LKT), Evans MDS Center at Washington University (KAO, MJW), ASH Scholar Award (KAO), NIH K12CA167540 (KAO), NIH P01AI116501 (AEG, DK), NIH R01HL094601 (AEG), and NIH P01CA101937 (DCL).
Laneshia K. Tague, Karolyn A. Oetjen, Anirudh Mahadev, Matthew J. Walter, Hephzibah Anthony, Daniel Kreisel, Daniel C. Link, Andrew E. Gelman
BACKGROUND Chronic kidney disease (CKD) is characterized by chronic overactivation of the sympathetic nervous system (SNS), which increases the risk of cardiovascular (CV) disease and mortality. SNS overactivity increases CV risk by multiple mechanisms, including vascular stiffness. We tested the hypothesis that aerobic exercise training would reduce resting SNS activity and vascular stiffness in patients with CKD.METHODS In this randomized controlled trial, sedentary older adults with CKD underwent 12 weeks of exercise (cycling, n = 32) or stretching (an active control group, n = 26). Exercise and stretching interventions were performed 20–45 minutes/session at 3 days/week and were matched for duration. Primary endpoints include resting muscle sympathetic nerve activity (MSNA) via microneurography, arterial stiffness by central pulse wave velocity (PWV), and aortic wave reflection by augmentation index (AIx).RESULTS There was a significant group × time interaction in MSNA and AIx with no change in the exercise group but with an increase in the stretching group after 12 weeks. The magnitude of change in MSNA was inversely associated with baseline MSNA in the exercise group. There was no change in PWV in either group over the study period.CONCLUSION Our data demonstrate that 12 weeks of cycling exercise has beneficial neurovascular effects in patients with CKD. Specifically, exercise training safely and effectively ameliorated the increase in MSNA and AIx observed over time in the control group. This sympathoinhibitory effect of exercise training showed greater magnitude in patients with CKD with higher resting MSNA.TRIAL REGISTRATION ClinicalTrials.gov, NCT02947750.FUNDING NIH R01HL135183; NIH R61AT10457; NIH NCATS KL2TR002381; and NIH T32 DK00756; NIH F32HL147547; and VA Merit I01CX001065.
Jinhee Jeong, Justin D. Sprick, Dana R. DaCosta, Kevin Mammino, Joe R. Nocera, Jeanie Park
BACKGROUND. Major depressive disorder (MDD) can benefit from novel interventions and personalization. Deep transcranial magnetic stimulation (Deep TMS) targeting the lateral prefrontal cortex (LPFC) using the H1 Coil, was FDA-cleared for treatment of MDD, however recent preliminary data indicate that targeting medial prefrontal cortex (MPFC) using the H7 Coil might induce as good or even better outcomes. Here we explored whether Deep TMS targeting the MPFC is non-inferior to targeting LPFC, and whether electrophysiological or clinical markers for patient selection can be identified. METHODS. The present prospective multicenter randomized study enrolled 169 MDD patients who failed antidepressant treatments in the current episode. Patients were randomized to receive 24 Deep TMS sessions over 6 weeks, using either the H1 Coil or the H7 Coil. The primary efficacy endpoint was the change from baseline to week 6 in the Hamilton-Depression-Rating-Scores. RESULTS. Clinical efficacy and safety profiles were similar and not significantly different between groups, with response rates of 60.9% for the H1 Coil and 64.2% for the H7 Coil. Moreover, brain activity measured by EEG during the first treatment session correlated with clinical outcomes in a coil-specific manner, and a cluster of baseline clinical symptoms was found to potentially distinguish between patients who can benefit from each Deep TMS target. CONCLUSION. This study provides a new treatment option for MDD, using the H7 Coil, and initial guidance to differentiate between patients likely to respond to LPFC versus MPFC stimulation targets, which require further validation studies. TRIAL REGISTRATION. ClinicalTrials.gov NCT03012724. FUNDING. Brainsway Ltd.
Abraham Zangen, Samuel Zibman, Aron Tendler, Noam Barnea-Ygael, Uri Alyagon, Daniel M. Blumberger, Geoffrey Grammer, Hadar Shalev, Tatiana Gulevsky, Tanya Vapnik, Alexander Bystritsky, Igor Filipčić, David Feifel, Ahava Stein, Frederic Deutsch, Yiftach Roth, Mark S. George
BACKGROUND Adverse drug reactions are unpredictable immunologic events presenting frequent challenges to clinical management. Systemically administered cholecalciferol (vitamin D3) has immunomodulatory properties. In this randomized, double-blinded, placebo-controlled interventional trial of healthy human adults, we investigated the clinical and molecular immunomodulatory effects of a single high dose of oral vitamin D3 on an experimentally induced chemical rash.METHODS Skin inflammation was induced with topical nitrogen mustard (NM) in 28 participants. Participant-specific inflammatory responses to NM alone were characterized using clinical measures, serum studies, and skin tissue analysis over the next week. All participants underwent repeat NM exposure to the opposite arm and then received placebo or 200,000 IU cholecalciferol intervention. The complete rash reaction was followed by multi-omic analysis, clinical measures, and serum studies over 6 weeks.RESULTS Cholecalciferol mitigated acute inflammation in all participants and achieved 6 weeks of durable responses. Integrative analysis of skin and blood identified an unexpected divergence in response severity to NM, corroborated by systemic neutrophilia and significant histopathologic and clinical differences. Multi-omic and pathway analyses revealed a 3-biomarker signature (CCL20, CCL2, CXCL8) unique to exaggerated responders that is suppressed by cholecalciferol and implicates IL-17 signaling involvement.CONCLUSION High-dose systemic cholecalciferol may be an effective treatment for severe reactions to topical chemotherapy. Our findings have broad implications for cholecalciferol as an antiinflammatory intervention against the development of exaggerated immune responses.TRIAL REGISTRATION clinicaltrials.gov (NCT02968446).FUNDING NIH and National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS; grants U01AR064144, U01AR071168, P30 AR075049, U54 AR079795, and P30 AR039750 (CWRU)).
Madison K. Ernst, Spencer T. Evans, Jose-Marc Techner, Robert M. Rothbaum, Luisa F. Christensen, Ummiye Venus Onay, Dauren Biyashev, Michael M. Demczuk, Cuong V. Nguyen, Kord S. Honda, Thomas S. McCormick, Lam C. Tsoi, Johann E. Gudjonsson, Kevin D. Cooper, Kurt Q. Lu
BACKGROUND. Immune checkpoint blockade is an emerging treatment for T cell non-Hodgkin lymphoma (T-NHL), but some T-NHL patients have experienced hyperprogression with undetermined mechanisms upon anti-PD-1 therapy. METHODS. Single-cell RNA sequencing, whole-genome sequencing, whole-exome sequencing, and functional assays were performed on primary malignant T cells from a patient with advanced cutaneous T cell lymphoma, who experienced hyperprogression upon anti-PD-1 treatment. RESULTS. The patient was enrolled in a clinical trial of anti-PD-1 therapy and experienced disease hyperprogression. Single-cell RNA sequencing revealed that PD-1 blockade elicited a remarkable activation and proliferation of the CD4+ malignant T cells, which showed functional PD-1 expression and an exhausted status. Further analyses identified somatic amplification of PRKCQ in the malignant T cells. PRKCQ encodes PKCθ, a key player in the T cell activation/NF-kB pathway. PRKCQ amplification led to high expressions of PKCθ and p-PKCθ (T538) on the malignant T cells, resulting in an oncogenic activation of the T cell receptor (TCR) signaling pathway. PD-1 blockade in this patient released this signaling, de-repressed the proliferation of malignant T cells, and resulted in disease hyperprogression. CONCLUSIONS. Our study provides real-world clinical evidence that PD-1 acts as a tumor suppressor for malignant T cells with oncogenic TCR activation. TRIAL REGISTRATION. ClinicalTrials.gov (NCT03809767). FUNDING. The National Natural Science Foundation of China (81922058), the National Science Fund for Distinguished Young Scholars (T2125002), the National Science and Technology Major Project (2019YFC1315702), the National Youth Top-Notch Talent Support Program (283812), and the Peking University Clinical Medicine plus X Youth Project (PKU2019LCXQ012).
Yumei Gao, Simeng Hu, Ruoyan Li, Shanzhao Jin, Fengjie Liu, Xiangjun Liu, Yingyi Li, Yicen Yan, Weiping Liu, Jifang Gong, Shuxia Yang, Ping Tu, Lin Shen, Fan Bai, Yang Wang
BACKGROUND. To minimize COVID-19 pandemic burden and spread, 3-dose vaccination campaigns commenced worldwide. Since patients who are pregnant are at increased risk for severe disease, they were recently included in that policy, despite the lack of available evidence regarding the impact of a third boosting dose during pregnancy, underscoring the urgent need for relevant data. We aimed to characterize the effect of the third boosting dose of mRNA Pfizer BNT162b2 vaccine in pregnancy.METHODS. We performed a prospective cohort study of anti–SARS-CoV-2 antibody titers (n = 213) upon delivery in maternal and cord blood of naive fully vaccinated parturients who received a third dose (n = 86) as compared with 2-dose recipients (n = 127).RESULTS. We found a robust surge in maternal and cord blood levels of anti–SARS-CoV-2 titers at the time of delivery, when comparing pregnancies in which the mother received a third boosting dose with 2-dose recipients. The effect of the third boosting dose remained significant when controlling for the trimester of last exposure, suggesting additive immunity extends beyond that obtained after the second dose. Milder side effects were reported following the third dose, as compared with the second vaccine dose, among the fully vaccinated group.CONCLUSION. The third boosting dose of mRNA Pfizer BNT162b2 vaccine augmented maternal and neonatal immunity with mild side effects. These data provide evidence to bolster clinical and public health guidance, reassure patients, and increase vaccine uptake among patients who are pregnant.FUNDING. Israel Science Foundation KillCorona grant 3777/19; Research grant from the “Ofek” Program of the Hadassah Medical Center.
Adva Cahen-Peretz, Lilah Tsaitlin-Mor, Hadas Allouche Kam, Racheli Frenkel, Maor Kabessa, Sarah M. Cohen, Michal Lipschuetz, Esther Oiknine-Djian, Sapir Lianski, Debra Goldman-Wohl, Asnat Walfisch, Michal Kovo, Michal Neeman, Dana G. Wolf, Simcha Yagel, Ofer Beharier
BACKGROUND. Chronotherapy is a drug intervention at specific times of the day to optimize efficacy and minimize adverse effects. Its value in hematologic malignancy remains to be explored, in particular in adult patients. METHODS. We performed chronotherapeutic analysis using two cohorts of diffuse large B cell lymphoma (DLBCL) patients undergoing chemotherapy with a dichotomized schedule (morning or afternoon). The effect of a morning or afternoon schedule of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) on survival and drug tolerability were evaluated in a survival cohort (n = 210) and an adverse event cohort (n = 129), respectively. Analysis of ~14,000 healthy subjects was followed to identify the circadian variation in hematologic parameters. RESULTS. Both progression-free survival (PFS) and overall survival (OS) of female, but not male, patients were significantly shorter when patients received chemotherapy mostly in the morning (PFS hazard ratio [HR] 0.357; P = 0.033 and OS HR 0.141; P = 0.032). The dose intensity was reduced in female patients treated in the morning (cyclophosphamide 10%; P = 0.002, doxorubicin 8%; P = 0.002 and rituximab 7%; P = 0.003). This was mainly attributable to infection and neutropenic fever: female patients treated in the morning suffered from a higher incidence of infections (16.7% vs 2.4%) and febrile neutropenia (20.8% vs 9.8%) as compared to those treated in the afternoon. The sex-specific chronotherapeutic effects can be explained by the larger daily fluctuation of circulating leukocytes and neutrophils in females than in males. CONCLUSIONS. In female DLBCL patients, R-CHOP treatment in the afternoon can reduce the toxicity while it improves the efficacy and the survival outcome.
Dae Wook Kim, Ja Min Byun, Jeong-Ok Lee, Jae Kyoung Kim, Youngil Koh
BACKGROUND Primary Sjögren’s syndrome (pSS) is characterized by B cell hyperactivity and elevated B-lymphocyte stimulator (BLyS). Anti-BLyS treatment (e.g., belimumab) increases peripheral memory B cells; decreases naive, activated, and plasma B cell subsets; and increases stringency on B cell selection during reconstitution. Anti-CD20 therapeutics (e.g., rituximab) bind and deplete CD20-expressing B cells in circulation but are less effective in depleting tissue-resident CD20+ B cells. Combined, these 2 mechanisms may achieve synergistic effects.METHODS This 68-week, phase II, double-blind study (GSK study 201842) randomized 86 adult patients with active pSS to 1 of 4 arms: placebo, s.c. belimumab, i.v. rituximab, or sequential belimumab + rituximab.RESULTS Overall, 60 patients completed treatment and follow-up until week 68. The incidence of adverse events (AEs) and drug-related AEs was similar across groups. Infections/infestations were the most common AEs, and no serious infections of special interest occurred. Near-complete depletion of minor salivary gland CD20+ B cells and a greater and more sustained depletion of peripheral CD19+ B cells were observed with belimumab + rituximab versus monotherapies. With belimumab + rituximab, reconstitution of peripheral B cells occurred, but it was delayed compared with rituximab. At week 68, mean (± standard error) total EULAR Sjögren’s syndrome disease activity index scores decreased from 11.0 (1.17) at baseline to 5.0 (1.27) for belimumab + rituximab and 10.4 (1.36) to 8.6 (1.57) for placebo.CONCLUSION The safety profile of belimumab + rituximab in pSS was consistent with the monotherapies. Belimumab + rituximab induced enhanced salivary gland B cell depletion relative to the monotherapies, potentially leading to improved clinical outcomes.TRIAL REGISTRATION ClinicalTrials.gov NCT02631538.FUNDING Funding was provided by GSK.
Xavier Mariette, Francesca Barone, Chiara Baldini, Hendrika Bootsma, Kenneth L. Clark, Salvatore De Vita, David H. Gardner, Robert B. Henderson, Michael Herdman, Karoline Lerang, Prafull Mistry, Raj Punwaney, Raphaele Seror, John Stone, Paul L.A. van Daele, André van Maurik, Nicolas Wisniacki, David A. Roth, Paul Peter Tak
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