The role of foetal assessment by ultrasound at 11-13+6 weeks of gestation

Background: The prevalence of congenital anomalies has been increasing over the years, and it is estimated that every year 1 in 33 infants are affected by some sort of congenital anomaly. At 12 weeks of intrauterine gestation, most of the major foetal structures complete their development and also proper delineation of the foetal anatomy is possible by the time of routine NT scan at 11-13+6 weeks. Methods: This was a prospective study of 110 cases who underwent a first trimester 11-13+6 weeks scan for congenital foetal abnormalities. The eligibility criteria for selection of cases were first trimester pregnancy between the 11-13+6 weeks gestation and CRL between 45 mm and 84 mm. Results: The study found that the detection rate of foetus abnormalities was 15.4% in mothers over 35 years old. Total 2.7% of the present study population were detected to be high risk for trisomy 21. All the 110 cases in present study were followed up till delivery/ termination. MTP was performed in 8.1% cases with lethal anomalies and in 1 cases of structural anomaly with missed abortion, D and E was done. 91% delivered live and healthy babies. There was no intrauterine foetal death or still born in present study. Conclusions: Ultrasound at 11-13+6 weeks must be mandatory, not only for the detection of major foetal anomalies but also for diagnosis of multiple pregnancy and abnormal pregnancy like missed abortion, molar pregnancy and ectopic pregnancy

BET Bromodomain Inhibitors Which Permit Treg Function Enable a Combinatorial Strategy to Suppress GVHD in Pre-clinical Allogeneic HSCT

A recent approach for limiting production of pro-inflammatory cytokines has been to target bromodomain and extra-terminal (BET) proteins. These epigenetic readers of histone acetylation regulate transcription of genes involved in inflammation, cardiovascular disease, and cancer. Development of BET inhibitors (BETi) has generated enormous interest for their therapeutic potential. Because inflammatory signals and donor T cells promote graft-versus-host disease (GVHD), regulating both pathways could be effective to abrogate this disorder. The objective of the present study was to identify a BETi which did not interfere in vivo with CD4+FoxP3+ regulatory T cell (Treg) expansion and function to utilize together with Tregs following allogeneic hematopoietic stem cell transplantation (aHSCT) to ameliorate GVHD. We have reported that Tregs can be markedly expanded and selectively activated with increased functional capacity by targeting TNFRSF25 and CD25 with TL1A-Ig and low dose IL-2, respectively. Here, mice were treated over 7 days (TL1A-Ig + IL-2) together with BETi. We found that the BETi EP11313 did not decrease frequency/numbers or phenotype of expanded Tregs as well as effector molecules, such as IL-10 and TGF-β. However, BETi JQ1 interfered with Treg expansion and altered subset distribution and phenotype. Notably, in Treg expanded mice, EP11313 diminished tnfa and ifng but not il-2 RNA levels. Remarkably, Treg pSTAT5 expression was not affected by EP11313 supporting the notion that Treg IL-2 signaling remained intact. MHC-mismatched aHSCT (B6 → BALB/c) was performed using in vivo expanded donor Tregs with or without EP11313 short-term treatment in the recipient. Early post-transplant, improvement in the splenic and LN CD4/CD8 ratio along with fewer effector cells and high Treg levels in aHSCT recipients treated with expanded Tregs + EP11313 was detected. Interestingly, this group exhibited a significant diminution of GVHD clinical score with less skin and ocular involvement. Finally, using low numbers of highly purified expanded Tregs, improved clinical GVHD scores were observed in EP11313 treated recipients. In total, we conclude that use of this novel combinatorial strategy can suppress pre-clinical GVHD and posit, in vivo EP11313 treatment might be useful combined with Treg expansion therapy for treatment of diseases involving inflammatory responses

A Single Institution Experience of Bortezomib for Gvhd in a Pediatric HSCT Population

Background Graft vs Host Disease (GVHD) is a common but revered complication after allogenic hematopoietic stem cell transplants (HSCT). Corticosteroids are the first-line therapy for GVHD, yet a consensus is lacking for second-line therapy in patients who experience worsening of symptoms when doses are reduced after initial response (steroid dependent), or who progress despite optimum steroid therapy (steroid refractory) GVHD. Bortezomib is a first-generation reversible proteasome inhibitor that inhibits T cells and prevents activation of dendritic cells that mediate antigen presentation and cytokine transcription. Though promising in adult clinical trials, there is a paucity of data on children less than 18 years for the prevention and treatment of GVHD. We hereby report on a single institutional case-series of bortezomib in pediatric HSCT treatment of GVHD. Results Our first case, a 7 year old male with history of acute myeloid leukemia, developed stage 1 acute gastrointestinal GVHD 23 days post-HSCT, and stage 4 skin GVHD beginning 39 days post-HSCT. His skin GVHD failed multiple attempts to wean off steroids, hence the addition of bortezomib at 364 days post-HSCT, receiving weekly doses for 30 weeks ranging from 0.5 mg/m2 to 1.0 mg/m2. This allowed us to wean him off prednisone and discontinue all immune suppression without additional flares. Our second case, a 4 year old male, presented with acute stage 4 skin and stage 2 liver GVHD 108 days and 341 post-HSCT, respectively. Bortezomib was started for the skin GVHD after unable to wean him off steroids. He received a total of 15 doses administered weekly and ranging from 0.4 to 0.87 mg/m2. While on bortezomib his skin GVHD resolved allowing discontinuation of steroids and other immune-suppressive agents. He later developed liver GVHD, which was not responsive to bortezomib. Our third case, a 1 year old female, presented with steroid-dependent acute skin GVHD 177 days post-HSCT. She responded remarkably to steroids but experienced multiple flares of skin GVHD any time the steroid dose was reduced below 1 mg/kg/day. After multiple attempts employing different combinations of immunosuppressive regimens, bortezomib was started. She showed initial response to bortezomib at doses ranging from 0.1 mg to 1.3/m2 mg but was unable to be completely weaned off steroids. Our fourth case, a 19 year old male with lung GVHD who was on long-term steroids, received bortezomib after failing steroid dose reduction when combined with sirolimus and extra-corporeal photopheresis. He received weekly doses of bortezomib for 12 weeks, ranging from 0.2 mg to 1.3/m2 mg, that permitted a successful wean off steroids. However, he later died from pulmonary GVHD. Conclusion We hereby report, based on these cases that bortezomib is a safe option for adjuvant GVHD therapy in children after HSCT. It resulted in successful discontinuation of steroids in two of the three patients with skin GVHD. Well-designed studies of GVHD management with bortezomib in pediatrics are necessary to elucidate this initial finding. We plan to explore this further in a multi-center trial. OffLabel Disclosure: Bortezomib is off label - FDA indications are for treatment of multiple melanoma and second line mantel cell lymphom

Identification of a BET Bromodomain Inhibitor That Enables Treg Function: A Combinatorial Strategy to Inhibit GVHD

Targeting bromodomain and extra-terminal (BET) proteins has recently provided a useful approach for limiting production of pro-inflammatory cytokines. These epigenetic readers regulate transcription of genes involved in inflammation and cancer. Development of BET inhibitors (BETi) has generated significant interest for their therapeutic potential. Because inflammatory signals and donor T cells promote graft-versus-host disease (GVHD), regulating both pathways could be beneficial for abrogating this disorder. The objective of the present study was to identify a BETi which did not interfere with expansion / function of CD4+FoxP3+ regulatory T cells (Treg) in vivo to enable their combined application following aHSCT to ameliorate GVHD. We have reported that Tregs can be markedly expanded with increased functional capacity by targeting TNFRSF25 and CD25 with TL1A-Ig and low dose IL-2, respectively (Wolf, et al 2017; Copsel et al. 2018). Here, mice were concomitantly treated over 7 days with TL1A-Ig+IL-2 together with BETi. We found that the BETi EP11313 did not decrease frequency/numbers or phenotype of expanded Tregs (Figure 1) as well as effector molecules (IL-10 and TGF-β). However, BETi JQ1 interfered with Treg proliferation and altered their phenotype. Notably, in Treg expanded mice, EP11313 diminished tnfa and ifng but not il-2 RNA levels. Phospho-STAT5 expression in Tregs was not affected by EP11313 supporting the notion that Treg IL-2 signaling remained intact. MHC-mismatched aHSCT (B6→BALB/c) was performed using in vivo expanded donor Tregs in the presence or absence of EP11313 short-term treatment in the recipient. Early post-transplant, improvement in the splenic and LN CD4/CD8 ratio along with fewer effector cells and high Treg levels in aHSCT recipients treated with expanded Tregs+EP11313 was detected. Interestingly, this group exhibited a significant diminution of GVHD clinical score early post-transplant with less skin involvement. Moreover, following transplant of low numbers of highly purified expanded Tregs, improved clinical GVHD scores were observed in EP11313 treated recipients (Figure 2). In total, we conclude that use of this novel combinatorial strategy can suppress pre-clinical GVHD. We propose that because BETi have demonstrated the ability to kill tumor cells, these compounds may provide additional anti-tumor activity together with GVL following allogeneic HSCT

BET Bromodomain Inhibitors Which Permit Treg Function Enable a Combinatorial Strategy to Suppress GVHD in Pre-clinical Allogeneic HSCT

A recent approach for limiting production of pro-inflammatory cytokines has been to target bromodomain and extra-terminal (BET) proteins. These epigenetic readers of histone acetylation regulate transcription of genes involved in inflammation, cardiovascular disease, and cancer. Development of BET inhibitors (BETi) has generated enormous interest for their therapeutic potential. Because inflammatory signals and donor T cells promote graft-versus-host disease (GVHD), regulating both pathways could be effective to abrogate this disorder. The objective of the present study was to identify a BETi which did not interfere with CD4 FoxP3 regulatory T cell (Treg) expansion and function to utilize together with Tregs following allogeneic hematopoietic stem cell transplantation (aHSCT) to ameliorate GVHD. We have reported that Tregs can be markedly expanded and selectively activated with increased functional capacity by targeting TNFRSF25 and CD25 with TL1A-Ig and low dose IL-2, respectively. Here, mice were treated over 7 days (TL1A-Ig + IL-2) together with BETi. We found that the BETi EP11313 did not decrease frequency/numbers or phenotype of expanded Tregs as well as effector molecules, such as IL-10 and TGF-β. However, BETi JQ1 interfered with Treg expansion and altered subset distribution and phenotype. Notably, in Treg expanded mice, EP11313 diminished tnfa and ifng but not il-2 RNA levels. Remarkably, Treg pSTAT5 expression was not affected by EP11313 supporting the notion that Treg IL-2 signaling remained intact. MHC-mismatched aHSCT (B6 → BALB/c) was performed using expanded donor Tregs with or without EP11313 short-term treatment in the recipient. Early post-transplant, improvement in the splenic and LN CD4/CD8 ratio along with fewer effector cells and high Treg levels in aHSCT recipients treated with expanded Tregs + EP11313 was detected. Interestingly, this group exhibited a significant diminution of GVHD clinical score with less skin and ocular involvement. Finally, using low numbers of highly purified expanded Tregs, improved clinical GVHD scores were observed in EP11313 treated recipients. In total, we conclude that use of this novel combinatorial strategy can suppress pre-clinical GVHD and posit, EP11313 treatment might be useful combined with Treg expansion therapy for treatment of diseases involving inflammatory responses

BET Bromodomain Inhibitors Which Permit Treg Function Enable a Combinatorial Strategy to Suppress GVHD in Pre-clinical Allogeneic HSCT

A recent approach for limiting production of pro-inflammatory cytokines has been to target bromodomain and extra-terminal (BET) proteins. These epigenetic readers of histone acetylation regulate transcription of genes involved in inflammation, cardiovascular disease, and cancer. Development of BET inhibitors (BETi) has generated enormous interest for their therapeutic potential. Because inflammatory signals and donor T cells promote graft-versus-host disease (GVHD), regulating both pathways could be effective to abrogate this disorder. The objective of the present study was to identify a BETi which did not interfere in vivo with CD4+FoxP3+ regulatory T cell (Treg) expansion and function to utilize together with Tregs following allogeneic hematopoietic stem cell transplantation (aHSCT) to ameliorate GVHD. We have reported that Tregs can be markedly expanded and selectively activated with increased functional capacity by targeting TNFRSF25 and CD25 with TL1A-Ig and low dose IL-2, respectively. Here, mice were treated over 7 days (TL1A-Ig + IL-2) together with BETi. We found that the BETi EP11313 did not decrease frequency/numbers or phenotype of expanded Tregs as well as effector molecules, such as IL-10 and TGF-β. However, BETi JQ1 interfered with Treg expansion and altered subset distribution and phenotype. Notably, in Treg expanded mice, EP11313 diminished tnfa and ifng but not il-2 RNA levels. Remarkably, Treg pSTAT5 expression was not affected by EP11313 supporting the notion that Treg IL-2 signaling remained intact. MHC-mismatched aHSCT (B6 → BALB/c) was performed using in vivo expanded donor Tregs with or without EP11313 short-term treatment in the recipient. Early post-transplant, improvement in the splenic and LN CD4/CD8 ratio along with fewer effector cells and high Treg levels in aHSCT recipients treated with expanded Tregs + EP11313 was detected. Interestingly, this group exhibited a significant diminution of GVHD clinical score with less skin and ocular involvement. Finally, using low numbers of highly purified expanded Tregs, improved clinical GVHD scores were observed in EP11313 treated recipients. In total, we conclude that use of this novel combinatorial strategy can suppress pre-clinical GVHD and posit, in vivo EP11313 treatment might be useful combined with Treg expansion therapy for treatment of diseases involving inflammatory responses

Comparison of diagnoses of early-onset sepsis associated with use of Sepsis Risk Calculator versus NICE CG149: a prospective, population-wide cohort study in London, UK, 2020–2021

Objective We sought to compare the incidence of early-onset sepsis (EOS) in infants ≥34 weeks’ gestation identified >24 hours after birth, in hospitals using the Kaiser Permanente Sepsis Risk Calculator (SRC) with hospitals using the National Institute for Health and Care Excellence (NICE) guidance.Design and setting Prospective observational population-wide cohort study involving all 26 hospitals with neonatal units colocated with maternity services across London (10 using SRC, 16 using NICE).Participants All live births ≥34 weeks’ gestation between September 2020 and August 2021.Outcome measures EOS was defined as isolation of a bacterial pathogen in the blood or cerebrospinal fluid (CSF) culture from birth to 7 days of age. We evaluated the incidence of EOS identified by culture obtained >24 hours to 7 days after birth. We also evaluated the rate empiric antibiotics were commenced >24 hours to 7 days after birth, for a duration of ≥5 days, with negative blood or CSF cultures.Results Of 99 683 live births, 42 952 (43%) were born in SRC hospitals and 56 731 (57%) in NICE hospitals. The overall incidence of EOS (<72 hours) was 0.64/1000 live births. The incidence of EOS identified >24 hours was 2.3/100 000 (n=1) for SRC vs 7.1/100 000 (n=4) for NICE (OR 0.5, 95% CI (0.1 to 2.7)). This corresponded to (1/20) 5% (SRC) vs (4/45) 8.9% (NICE) of EOS cases (χ=0.3, p=0.59). Empiric antibiotics were commenced >24 hours to 7 days after birth in 4.4/1000 (n=187) for SRC vs 2.9/1000 (n=158) for NICE (OR 1.5, 95% CI (1.2 to 1.9)). 3111 (7%) infants received antibiotics in the first 24 hours in SRC hospitals vs 8428 (15%) in NICE hospitals.Conclusion There was no significant difference in the incidence of EOS identified >24 hours after birth between SRC and NICE hospitals. SRC use was associated with 50% fewer infants receiving antibiotics in the first 24 hours of life