Systematic review with meta-analysis: effectiveness of anti-inflammatory therapy in immune checkpoint inhibitor-induced enterocolitis

Background: Immune checkpoint inhibitors have revolutionised cancer treatment, but at the cost of off-target immune-mediated organ damage. This includes checkpoint inhibitor-induced enterocolitis which frequently requires hospitalisation and may be life-threatening. Empirical treatment typically includes corticosteroids and infliximab, although, no large-scale studies have confirmed their effectiveness. Aim: To investigate the effectiveness of anti-inflammatory therapy in checkpoint inhibitor-induced enterocolitis. Methods: We performed a systematic review and meta-analysis of studies reporting clinical outcomes of checkpoint inhibitor-induced enterocolitis in adult cancer patients treated with anti-inflammatory agents. We searched Medline, EMBASE, and the Cochrane library through April and extracted the proportion of patients responding to anti-inflammatory therapy. Variation in effect size was studied using a randomeffects meta-regression analysis, with checkpoint inhibitor agent and tumour type as the variables. Results: Data were pooled from 1210 treated patients across 39 studies. Corticosteroids were effective in 59% (95% CI 54- 65) of patients, with response significantly more favourable in patients treated with anti-PD-1/L1 monotherapy, compared with anti-CTLA-4 containing regimens (78%, 95% CI 69-85 vs 56 %, 95% CI 49-63, P = 0.003), and more favourable in lung cancer patients compared with melanoma patients (88%, 95% CI 62-97 vs 55%, 95% CI 47-63, P = 0.04). Infliximab was effective in 81% (95% CI 73-87) of patients, and vedolizumab in 85% (95% CI 60-96). Conclusion: Corticosteroids, infliximab and vedolizumab, are effective in the treatment of checkpoint inhibitor‐induced enterocolitis. Checkpoint inhibitor regimen and cancer type were significant moderators in response to corticosteroid therapy

Immune checkpoint inhibitor-induced colitis is mediated by polyfunctional lymphocytes and is dependent on the IL23/IFNg axis

Immune checkpoint inhibitors (CPIs) have revolutionised cancer treatment, with previously untreatable disease now amenable to potential cure. Combination regimens of anti-CTLA-4 and anti-PD-1 show enhanced efficacy but are prone to off-target immune-mediated tissue injury, particularly at the barrier surfaces. CPI-induced colitis is a common and serious complication. To probe the impact of immune checkpoints on intestinal homeostasis, mice were challenged with combination anti-CTLA-4/anti-PD-1 immunotherapy and manipulation of the intestinal microbiota. Colonic immune responses were profiled using bulk and single-cell RNA-sequencing and flow cytometry. CPI-colitis was dependent on the composition of the intestinal microbiota and was characterized by remodelling of mucosal lymphocytes with induction of polyfunctional lymphocyte responses characterized by increased expression of interferon-γ (IFNγ), other pro-inflammatory cytokines/chemokines (Il22, Il17a Ccl3, Ccl4 and Ccl9), cytotoxicity molecules (Gzmb, Gzma, Prf1, Nkg7) and the chemokine receptor Cxcr6. In comparison with mucosal lymphocytes in the steady state, polyfunctional lymphocytes from both CD4+ and CD8+ lineages upregulated costimulatory molecules and checkpoint molecules in CPI-colitis, indicating that these cells are tightly regulated. CPI-colitis was attenuated following depletion of effector lymphocytes or following blockade of the IL23/IFNγ axis. This study provides new mechanistic insights into CPI-colitis, identifying polyfunctional, cytotoxic lymphocytes as key mediators of disease. Therapeutic targeting of their effector response or regulatory networks, including the IL23/IFNγ axis likely holds the key to preventing and reversing CPI-colitis

Oral beclomethasone dipropionate is an effective treatment for immune checkpoint inhibitor induced colitis.

INTRODUCTION: Systemic corticosteroids are the mainstay of treatment for immune checkpoint inhibitor induced (CPI) colitis but are associated with complications including life-threatening infection. The topically acting oral corticosteroid beclomethasone dipropionate (BD) is an effective treatment for mild to moderate flares of ulcerative colitis, and has fewer side effects than systemic corticosteroids. We hypothesized that BD would be an effective treatment for CPI-induced colitis. METHODS: We performed a retrospective analysis of all patients who started BD for CPI-induced colitis at three UK cancer centers between November 2017 and October 2020. All patients underwent endoscopic assessment and biopsy. The initial regimen of BD was 5 mg once daily for 28 days. Data were collected from electronic patient records. Clinical outcomes were assessed at 28 days after initiation of treatment. RESULTS: Twenty-two patients (14 male) with a median age of 64 (range 45-84) with CPI-induced colitis were treated with BD. At baseline, the median number of loose stools in a 24-hour period was six (common terminology criteria for adverse events, CTCAE grade diarrhea=2). Thirteen patients (59%) were dependent on systemic corticosteroids prior to starting BD. Baseline sigmoidoscopy showed moderate inflammation (Mayo Endoscopic Score (MES) = 2) in two patients (9%), mild inflammation (MES=1) in nine patients (41%) and normal findings (MES=0) in eleven patients (50%). Twenty patients (91%) had histopathological features of inflammation. All 22 patients (100%) had a clinical response to BD and 21 (95%) achieved clinical remission with a return to baseline stool frequency (CTCAE diarrhea=0). Ten patients (45%) had symptomatic relapse on cessation of BD, half within 7 days of stopping. All patients recaptured response on restarting BD. No adverse events were reported in patients treated with BD. CONCLUSIONS: Topical BD represents an appealing alternative option to systemic immunosuppressive treatments to treat colonic inflammation. In this study, BD was effective and safe at inducing remission in CPI-induced colitis, which was refractory to systemic corticosteroids. Further randomized studies are needed to confirm these findings and determine the optimum dosing regimen

The gut microbiota and metabolome are associated with diminished COVID-19 vaccine-induced antibody responses in immunosuppressed inflammatory bowel disease patients

Background: Patients with inflammatory bowel disease (IBD) treated with anti-TNF therapy exhibit attenuated humoral immune responses to vaccination against SARS-CoV-2. The gut microbiota and its functional metabolic output, which are perturbed in IBD, play an important role in shaping host immune responses. We explored whether the gut microbiota and metabolome could explain variation in anti-SARS-CoV-2 vaccination responses in immunosuppressed IBD patients. Methods: Faecal and serum samples were prospectively collected from infliximab-treated patients with IBD in the CLARITY-IBD study undergoing vaccination against SARS-CoV-2. Antibody responses were measured following two doses of either ChAdOx1 nCoV-19 or BNT162b2 vaccine. Patients were classified as having responses above or below the geometric mean of the wider CLARITY-IBD cohort. 16S rRNA gene amplicon sequencing, nuclear magnetic resonance (NMR) spectroscopy and bile acid profiling with ultra-high-performance liquid chromatography mass spectrometry (UHPLC-MS) were performed on faecal samples. Univariate, multivariable and correlation analyses were performed to determine gut microbial and metabolomic predictors of response to vaccination. Findings: Forty-three infliximab-treated patients with IBD were recruited (30 Crohn's disease, 12 ulcerative colitis, 1 IBD-unclassified; 26 with concomitant thiopurine therapy). Eight patients had evidence of prior SARS-CoV-2 infection. Seventeen patients (39.5%) had a serological response below the geometric mean. Gut microbiota diversity was lower in below average responders (p = 0.037). Bilophila abundance was associated with better serological response, while Streptococcus was associated with poorer response. The faecal metabolome was distinct between above and below average responders (OPLS-DA R2X 0.25, R2Y 0.26, Q2 0.15; CV-ANOVA p = 0.038). Trimethylamine, isobutyrate and omega-muricholic acid were associated with better response, while succinate, phenylalanine, taurolithocholate and taurodeoxycholate were associated with poorer response. Interpretation: Our data suggest that there is an association between the gut microbiota and variable serological response to vaccination against SARS-CoV-2 in immunocompromised patients. Microbial metabolites including trimethylamine may be important in mitigating anti-TNF-induced attenuation of the immune response. Funding: JLA is the recipient of an NIHR Academic Clinical Lectureship (CL-2019-21-502), funded by Imperial College London and The Joyce and Norman Freed Charitable Trust. BHM is the recipient of an NIHR Academic Clinical Lectureship (CL-2019-21-002). The Division of Digestive Diseases at Imperial College London receives financial and infrastructure support from the NIHR Imperial Biomedical Research Centre (BRC) based at Imperial College Healthcare NHS Trust and Imperial College London. Metabolomics studies were performed at the MRC-NIHR National Phenome Centre at Imperial College London; this work was supported by the Medical Research Council (MRC), the National Institute of Health Research (NIHR) (grant number MC_PC_12025) and infrastructure support was provided by the NIHR Imperial Biomedical Research Centre (BRC). The NIHR Exeter Clinical Research Facility is a partnership between the University of Exeter Medical School College of Medicine and Health, and Royal Devon and Exeter NHS Foundation Trust. This project is supported by the National Institute for Health Research (NIHR) Exeter Clinical Research Facility. The views expressed are those of the authors and not necessarily those of the NIHR or the UK Department of Health and Social Care

CRISPR-enhanced human adipocyte \u27browning\u27 as cell therapy for metabolic disease [preprint]

Obesity and type 2 diabetes (T2D) are associated with poor tissue responses to insulin [1,2], disturbances in glucose and lipid fluxes [3-5] and comorbidities including steatohepatitis [6] and cardiovascular disease [7,8]. Despite extensive efforts at prevention and treatment [9,10], diabetes afflicts over 400 million people worldwide [11]. Whole body metabolism is regulated by adipose tissue depots [12-14], which include both lipid-storing white adipocytes and less abundant \u27brown\u27 and \u27brite/beige\u27 adipocytes that express thermogenic uncoupling protein UCP1 and secrete factors favorable to metabolic health [15-18]. Application of clustered regularly interspaced short palindromic repeats (CRISPR) gene editing [19,20] to enhance \u27browning\u27 of white adipose tissue is an attractive therapeutic approach to T2D. However, the problems of cell-selective delivery, immunogenicity of CRISPR reagents and long term stability of the modified adipocytes are formidable. To overcome these issues, we developed methods that deliver complexes of SpyCas9 protein and sgRNA ex vivo to disrupt the thermogenesis suppressor gene NRIP1 [21,22] with near 100% efficiency in human or mouse adipocytes. NRIP1 gene disruption at discrete loci strongly ablated NRIP1 protein and upregulated expression of UCP1 and beneficial secreted factors, while residual Cas9 protein and sgRNA were rapidly degraded. Implantation of the CRISPR-enhanced human or mouse brown-like adipocytes into high fat diet fed mice decreased adiposity and liver triglycerides while enhancing glucose tolerance compared to mice implanted with unmodified adipocytes. These findings advance a therapeutic strategy to improve metabolic homeostasis through CRISPR-based genetic modification of human adipocytes without exposure of the recipient to immunogenic Cas9 or delivery vectors

COVID-19 vaccine-induced antibody and T cell responses in immunosuppressed patients with inflammatory bowel disease after the third vaccine dose

Background: COVID-19 vaccine-induced antibody responses are reduced in patients with inflammatory bowel disease (IBD) taking infliximab or tofacitinib after two vaccine doses. We sought to determine whether immunosuppressive treatments were associated with reduced antibody and T cell responses after a third vaccine dose. Methods: 352 adults (72 healthy controls and 280 IBD) from the prospectively recruited study cohort were sampled 28-49 days after a third dose of SARS-CoV-2 vaccine. IBD medications studied included thiopurines (n=65), infliximab (n=46), thiopurine/infliximab combination therapy (n=49), ustekinumab (n=44), vedolizumab (n=50) or tofacitinib (n=26). SARS-CoV-2 spike antibody binding and T cell responses were measured. Findings: Geometric mean [geometric SD] anti-S1 RBD antibody concentrations increased in all study groups following a third dose of vaccine, but were significantly lower in patients treated with infliximab (2736.8 U/mL [4.3]; P<0.0001), infliximab and thiopurine combination (1818.3 U/mL [6.7]; P<0.0001) and tofacitinib (8071.5 U/mL [3.1]; P=0.0018) compared to controls (16774.2 U/ml [2.6]). There were no significant differences in anti-S1 RBD antibody concentrations between control subjects and thiopurine (12019.7 U/mL [2.2]; P=0.099), ustekinumab (11089.3 U/mL [2.8]; P=0.060), nor vedolizumab treated patients (13564.9 U/mL [2.4]; P=0.27). In multivariable modelling, lower anti-S1 RBD antibody concentrations were independently associated with infliximab (Geometric mean ratio 0.15, 95% CI 0.11-0.21, P<0.0001), tofacitinib (0.52, 95% CI 0.31-0.87, P=0.012) and thiopurine (0.69, 95% CI 0.51-0.95, P=0.021), but not with ustekinumab (0.64, 95% CI 0.39-1.06, P=0.083), or vedolizumab (0.84, 95% CI 0.54-1.30, P=0.43). Previous SARS-CoV-2 infection (1.58, 95% CI 1.22-2.05, P=0.00056) and older age (0.88, 95% CI 0.80-0.97, P=0.0073) were independently associated with higher and lower anti-S1 antibody concentrations respectively. However, antigen specific T cell responses were similar in IBD patients in all treatment groups studied, except for recipients of tofacitinib without evidence of previous infection, where T cell responses were significantly reduced relative to healthy controls (p=0.021). Interpretation: A third dose of COVID-19 vaccine induced a boost in antibody binding in immunosuppressed patients with IBD, but these responses were reduced in patients taking infliximab, infliximab/thiopurine combination and tofacitinib therapy. Tofacitinib was also associated with reduced T cell responses. These findings support continued prioritisation of immunosuppressed groups for further booster dosing, particularly those on Janus Kinase (JAK) inhibitors who have attenuation of both serological and cell-mediated vaccine-induced immunity. Funding: Financial support was provided as a Research Grant by Pfizer Ltd

Pathology of immune-mediated tissue lesions following treatment with immune checkpoint inhibitors.

Immune check point inhibitor (CPI) therapy has revolutionized treatment paradigms for several cancers, but at the cost of triggering a diverse spectrum of immune-mediated injury to non-cancer tissues. The complex biology of these toxicities remains incompletely understood, partly because tissue acquisition from affected areas can be challenging to retrieve, thus hindering development of targeted therapy. Here, we review the literature describing pathology of immune-mediated tissue lesions including gastrointestinal, skin, rheumatic, pulmonary, cardiac, renal and hepatic lesions and highlight key immunological insights

STATISTICAL ESTIMATION OF PRODUCTION FUNCTIONS AND AGRICULTURAL COSTS AND MEASURES OF PRODUCTIVITY EFFICIENCY OF WATER USERS' ASSOCIATIONS OF DIFFERENT IRRIGATION SYSTEMS IN AL-BEHEIRA GOVERNORATE

Egypt suffers from future risks due to lack of water especially in the downstream countries, Egypt and Sudan, which depend on the Nile water almost entirely and the upstream countries are moving to raise problems with Egypt and erect dams and pressure on Egypt to achieve the greatest economic benefit possible to prevent Egypt from horizontal agricultural expansion. Egypt is the largest and most dependent country on Nile water, with almost no rainfall. Groundwater is not renewable. Thus, the Nile water accounts for about 97% of Egypt's water resources and the share of the Egyptians is 55.5 billion m3, this quantity of water is insufficient to the needs of the population, and in order to maintain Egypt's per capita water, it needs about 80 billion m3, which means a deficit of 25 billion m3 and stability of Egypt's share of the Nile water under current local, regional and global conditions, and development of the appropriate strategy to alleviate the conflict with the basin countries Nile River so the study aimed to compare production efficiency and the economics of the irrigation systems used in the province of the lake through the study of water user associations in agriculture under the different irrigation patterns within water users association and outside association to rationalize the use of water and raising awareness to increase productivity. The results of the estimation indicated that the economic efficiency indicators of the maize and potato crop farmers in the sample of the field study show the preference of the use of the production function in the logarithmic formula to the different variables affecting the productivity of the crops according to the irrigation systems within the water user associations The results showed that the total production elasticity of maize crop was about 0.720, 0.530, 0.348 for sprinkler & drop, developed irrigation, and padded flooding systems, while the value of (R2) was about 0.76 , 0.60, 0.63  for irrigation systems respectively, The results showed that the total productivity of the potato crop was 1.127, 1.16, 1.318, for sprinkler & drop, developed irrigation, and padded flooding systems respectively, while the value of (R2) was about 0.76, 0.62, 0.70 for irrigation systems respectively. The relationship between the total costs and quantity produced of maize, which showed that the quadratic formula is the best formulas for the data, and the equations show that there is a statistically significant positive relationship between the total costs and production of maize in Behera Governorate. In the estimation of the optimal production volume, which reduces the costs is estimated at about 18.7, 22.1, 23.9 ardab/feddan, for sprinkler & drop, developed irrigation, and padded flooding systems respectively. In the estimation of the production volume which maximizes profit, the results showed that this volume was not reached, 29.1, 36.1, 31.9 ardab/feddan, for sprinkler & drop, developed irrigation, and padded flooding systems respectively. Calculating cost elasticity, it reached about 1.19, 0.804, 0.719, for sprinkler & drop, developed irrigation, and padded flooding systems respectively. In order to determine the optimal production volume of the potato crop, which reduces the costs, so make average cost equal marginal costs, estimated  at 12.539, 11.377, 11.064 tons/fed, for sprinkler & drop, developed irrigation, and padded flooding systems respectively. The size of production of potato that maximizes profit was about 42,500, 33.350, 25.600 tons/fed, for sprinkler & drop, developed irrigation, and padded flooding systems respectively. Calculating the cost elasticity of the potato, it turned out that it was about 0.93, 0.804, 0.719 for sprinkler & drop, developed irrigation, and padded flooding systems respectively. Production efficiency measures are (7), the study of the efficiency of production of maize crop for members of water associations in the sample of the study in Behera Governorate. It was found that the members of the water users association of developed irrigation for in the feddan productivity of maize was exceeded, which was estimated at 23.01 ardab/feddan, while it reached about 19.05, 22.1 ardab/feddan for sprinkler & drop, and flooding systems respectively. Increase the total revenues of the members of water user associations to developed irrigation system for the maize crop, estimated at 8744.7 pounds/feddan while it reached about 7239, 8402.2 pounds/fed for members of the water associations that use sprinkler & drop, and flooding systems respectively.   Increase in return of maize crop for members of water associations users of developed irrigation system, which amounted to about 3529.3 pounds while estimated at about 2204.8, 3270.1 pounds for members of water use associations for sprinkler & drop, and flooding systems respectively. Increase in the profitability of the pound for water use associations of developed irrigation system, which amounted to about 0.677 pounds, the ratio of the total return on the costs of the members of water use associations to flooding irrigation and developed irrigation, estimated at 2.03, 2.07 while estimated at 1.71 sprinkler irrigation, members of water user associations of the developed irrigation system was  exceeded, where the return of cubic meter of water reached about 3.53 pounds, and the productivity of the cubic meter of water for the members of the water user associations showed that the irrigation system of sprinkling and drip was about 5.6 for maize crop. The members of water use associations of for sprinkler & drop irrigation in the potato productivity was exceeded, estimated at 11.250 tons/fed, increase the total income of The members of water use associations of irrigation sprinkling and drip of potato crop, estimated at about 33750 pounds/ fed, shows the increase yield of potato crop members of links irrigation sprinkler system, where reached about 11300 pound. Increase in the profitability of the pound for the members of sprinkler irrigation system, it was about LE 0.5. The members of the water users association of the sprinkler and drip irrigation system, was exceeded, where the return of the use of cubic meters of water was about 18.9 pounds. Showing the return of the use of cubic meters of water for the members of water users association for sprinkling irrigation system, which amounted to about 5.6, The cultivation of maize, and potatoes in the water users' associations was exceeded compared to the different irrigation system in all the centers in the study sample. The second scenario aims beside minimizing the water needs of cropping pattern, increasing export crop areas such as onions, peanuts, potatoes, tomatoes and other vegetables as much as possible, assuming situation stability of foreign trade.  The results of the analysis of the statistical models in the second scenario showed that the total quantity of irrigation water available for the cropping pattern was about 41.483 billion m3, while 38,471, 38.912, 38.803 billion m3 were used for the statistical models respectively, indicating that the required water quantities decreased by 3.013, 2.572, 2.681 billion m3, with a change rate of about 7.26, 6.20, 6.46%, for statistical models, respectively. The net return of the water unit for the actual cropping pattern was about 1.634 LE/m3, while it reached about 1.773, 1.830, 1.833 LE/m3 for the statistical models respectively, which shows the increase in the net return of water unit by 0.139, 0.197, 0.199 LE/m3, with a change rate of about 8.53, 12.04, 12.21%, for statistical models respectively.  Crop rotations can be applied to the new lands using water savings including (wheat and maize), with an area ranging from 2048 to 2399 thousand feddans, and including (wheat and summer and nili vegetables), with an area ranging from 2941 to 3444 thousand acres, also including (maize, winter and nili vegetables), with an area ranging from 3432 to 4021 thousand feddans. With regard to the impact of reducing the area of water crops to water gap which reached about 20.9 billion m3, it decreased by about 2.879, 2.758, 2.800 billion m3, which make water gap decreased to about 18.02, 18.14, 18.10 billion m3, with change rate of about 3.77, 3.61, 3.66%, for statistical models respectively, while the results of the second scenario show decreased of about 3.013, 2.572, 2.681 billion m3, which make water gap decreased to about 17.89, 18.33, 18.22 billion m3, with change rate of about 3.94, 3.37 and 3.51% for statistical models respectively. The research recommends the following points: 1. Reduce the areas of rice, sugar cane and alfalfa to save a quantity of water ranging between 2.572 - 3.013 billion m3 of land within the valley. 2. Using of water savings resulting from reducing the areas of water crops to expand the cultivation of new land with strategic and monetary crops. 3. Sugar beet area can be expanded at least to the extent that it covers the shortage of sugar production caused by reducing the sugar cane area, then taking into account and study the effects resulting from that. 4. Modification of cropping patern structure to be in accordance with the local, regional, environmental situations that may affect current and future water availability

Topical beclometasone dipropionate in the management of immune checkpoint inhibitor-induced microscopic colitis

Immune checkpoint inhibitors (ICPis) have revolutionised survival outcomes for cancer patients by bolstering anti-tumour immunity. However, immune activation also occurs in non-cancer tissue, and a significant proportion of patients develop immune-mediated colitis, which can be fatal if not promptly recognised and managed. Diagnosis is often made by inflammation observed during lower gastrointestinal endoscopy. Little is known about microscopic inflammation (histological findings of inflammation in the absence of overt mucosal injury). Management strategies beyond the use of systemic corticosteroids, which incur a high burden of deleterious side effects, have not been extensively explored. We describe the cases of two cancer patients with ICPi-induced colitis who had isolated histoloigical features of colitis in the absence of macroscopic disease. Sustained clinical and histological remission was induced with the topical steroid preparation, beclometasone dipropionate (Clipper), with no adverse effects