Clinical decision-making on spinal cord injury-associated pneumonia: a nationwide survey in Germany

Study design: Survey study. Objectives: Spinal cord injury (SCI)-associated pneumonia (SCI-AP) is associated with poor functional recovery and a major cause of death after SCI. Better tackling SCI-AP requires a common understanding on how SCI-AP is defined. This survey examines clinical algorithms relevant for diagnosis and treatment of SCI-AP. Setting: All departments for SCI-care in Germany. Methods: The clinical decision-making on SCI-AP and the utility of the Centers for Disease Control and Prevention (CDC) criteria for diagnosis of ‘clinically defined pneumonia’ were assessed by means of a standardized questionnaire including eight case vignettes of suspected SCI-AP. The diagnostic decisions based on the case information were analysed using classification and regression trees (CART). Results: The majority of responding departments were aware of the CDC-criteria (88%). In the clinical vignettes, 38–81% of the departments diagnosed SCI-AP in accordance with the CDC-criteria and 7–41% diagnosed SCI-AP in deviation from the CDC-criteria. The diagnostic agreement was not associated with the availability of standard operating procedures for SCI-AP management in the departments. CART analysis identified radiological findings, fever, and worsened gas exchange as most important for the decision on SCI-AP. Frequently requested supplementary diagnostics were microbiological analyses, C-reactive protein, and procalcitonin. For empirical antibiotic therapy, the departments used (acyl-)aminopenicillins/β-lactamase inhibitors, cephalosporins, or combinations of (acyl-)aminopenicillins/β-lactamase inhibitors with fluoroquinolones or carbapenems. Conclusions: This survey reveals a diagnostic ambiguity regarding SCI-AP despite the awareness of CDC-criteria and established SOPs. Heterogeneous clinical practice is encouraging the development of disease-specific guidelines for diagnosis and management of SCI-AP

CD62L as target receptor for specific gene delivery into less differentiated human T lymphocytes

Chimeric antigen receptor (CAR)-expressing T cells are a complex and heterogeneous gene therapy product with variable phenotype compositions. A higher proportion of less differentiated CAR T cells is usually associated with improved antitumoral function and persistence. We describe in this study a novel receptor-targeted lentiviral vector (LV) named 62L-LV that preferentially transduces less differentiated T cells marked by the L-selectin receptor CD62L, with transduction rates of up to 70% of CD4+ and 50% of CD8+ primary T cells. Remarkably, higher amounts of less differentiated T cells are transduced and preserved upon long-term cultivation using 62L-LV compared to VSV-LV. Interestingly, shed CD62L neither altered the binding of 62L-LV particles to T cells nor impacted their transduction. The incubation of 2 days of activated T lymphocytes with 62L-LV or VSV-LV for only 24 hours was sufficient to generate CAR T cells that controlled tumor growth in a leukemia tumor mouse model. The data proved that potent CAR T cells can be generated by short-term ex vivo exposure of primary cells to LVs. As a first vector type that preferentially transduces less differentiated T lymphocytes, 62L-LV has the potential to circumvent cumbersome selections of T cell subtypes and offers substantial shortening of the CAR T cell manufacturing process

protocol of a prospective, longitudinal study

Background Natural killer (NK) cells comprise the main components of lymphocyte-mediated nonspecific immunity. Through their effector function they play a crucial role combating bacterial and viral challenges. They are also thought to be key contributors to the systemic spinal cord injury-induced immune-deficiency syndrome (SCI-IDS). SCI-IDS increases susceptibility to infection and extends to the post-acute and chronic phases after SCI. Methods and design The prospective study of NK cell function after traumatic SCI was carried out in two centers in Berlin, Germany. SCI patients and control patients with neurologically silent vertebral fracture also undergoing surgical stabilization were enrolled. Furthermore healthy controls were included to provide reference data. The NK cell function was assessed at 7 (5–9) days, 14 days (11–28) days, and 10 (8–12) weeks post-trauma. Clinical documentation included the American Spinal Injury Association (ASIA) impairment scale (AIS), neurological level of injury, infection status, concomitant injury, and medications. The primary endpoint of the study is CD107a expression by NK cells (cytotoxicity marker) 8–12 weeks following SCI. Secondary endpoints are the NK cell’s TNF-α and IFN-γ production by the NK cells 8–12 weeks following SCI. Discussion The protocol of this study was developed to investigate the hypotheses whether i) SCI impairs NK cell function throughout the post-acute and sub-acute phases after SCI and ii) the degree of impairment relates to lesion height and severity. A deeper understanding of the SCI-IDS is crucial to enable strategies for prevention of infections, which are associated with poor neurological outcome and elevated mortality. Trial registration DRKS00009855

The spinal cord injury-induced immune deficiency syndrome: results of the SCIentinel study

Infections are prevalent after spinal cord injury (SCI), constitute the main cause of death and are a rehabilitation confounder associated with impaired recovery. We hypothesize that SCI causes an acquired lesion-dependent (neurogenic) immune suppression as an underlying mechanism to facilitate infections. The international prospective multicentre cohort study (SCIentinel; protocol registration DRKS00000122; n = 111 patients) was designed to distinguish neurogenic from general trauma-related effects on the immune system. Therefore, SCI patient groups differing by neurological level, i.e. high SCI [thoracic (Th)4 or higher]; low SCI (Th5 or lower) and severity (complete SCI; incomplete SCI), were compared with a reference group of vertebral fracture (VF) patients without SCI. The primary outcome was quantitative monocytic Human Leukocyte Antigen-DR expression (mHLA-DR, synonym MHC II), a validated marker for immune suppression in critically ill patients associated with infection susceptibility. mHLA-DR was assessed from Day 1 to 10 weeks after injury by applying standardized flow cytometry procedures. Secondary outcomes were leucocyte subpopulation counts, serum immunoglobulin levels and clinically defined infections. Linear mixed models with multiple imputation were applied to evaluate group differences of logarithmic-transformed parameters. Mean quantitative mHLA-DR [ln (antibodies/cell)] levels at the primary end point 84 h after injury indicated an immune suppressive state below the normative values of 9.62 in all groups, which further differed in its dimension by neurological level: high SCI [8.95 (98.3% confidence interval, CI: 8.63; 9.26), n = 41], low SCI [9.05 (98.3% CI: 8.73; 9.36), n = 29], and VF without SCI [9.25 (98.3% CI: 8.97; 9.53), n = 41, P = 0.003]. Post hoc analysis accounting for SCI severity revealed the strongest mHLA-DR decrease [8.79 (95% CI: 8.50; 9.08)] in the complete, high SCI group, further demonstrating delayed mHLA-DR recovery [9.08 (95% CI: 8.82; 9.38)] and showing a difference from the VF controls of -0.43 (95% CI: -0.66; -0.20) at 14 days. Complete, high SCI patients also revealed constantly lower serum immunoglobulin G [-0.27 (95% CI: -0.45; -0.10)] and immunoglobulin A [-0.25 (95% CI: -0.49; -0.01)] levels [ln (g/l × 1000)] up to 10 weeks after injury. Low mHLA-DR levels in the range of borderline immunoparalysis (below 9.21) were positively associated with the occurrence and earlier onset of infections, which is consistent with results from studies on stroke or major surgery. Spinal cord injured patients can acquire a secondary, neurogenic immune deficiency syndrome characterized by reduced mHLA-DR expression and relative hypogammaglobulinaemia (combined cellular and humoral immune deficiency). mHLA-DR expression provides a basis to stratify infection-risk in patients with SCI

Digitale Erschließung und Sicherung von aktuellen archäologischen Befunden

Bei Projekten zur Digitalisierung in Geisteswissenschaften ist heute die Realisierung größerer, überregionaler und über das World Wide Web abfragbarer Lösungen erforderlich. Die Beiträge dieses Bandes wurden auf der Tagung des Staatsarchivs Hamburg und des Zentrums "Geisteswissenschaften in der digitalen Welt" an der Universität Hamburg am 10. und 11. April 2006 gehalten. Sie leisten einen interdisziplinären Beitrag zur erforderlichen Standardisierung dieser Angebote, die erst den dringend notwendigen Austausch erleichtern und die gemeinsame Nutzung strukturierter Daten ermöglichen kann.Today, digitization projects in the Humanities require the implementation of larger, supraregional solutions. The contributions in this volume were presented at the conference of the Hamburg State Archives and the Center for the Humanities in the Digital World at the University of Hamburg on April 10 and 11, 2006. They make an interdisciplinary contribution to the required standardisation of corresponding services which can only facilitate the urgently needed exchange of information and make it possible to share structured data

Efficient gene silencing in tumor tissue using replication-competent retroviral vectors

RNA interference (RNAi) has become a powerful technology in cancer and biomedical drug research. While the mechanism of RNAi activity is well understood, particularly the in vivo delivery still remains a matter of improvement. Non-viral transfer systems mediate only transient activity which requires multiple transfections for long-term observations. Therefore, viral vector systems were developed that confer stable integration of shRNA into the cellular genome. Especially for preclinical studies in vivo, a RNAi transfer system is preferred that efficiently distributes RNAi to all target cells (e.g. tumor cells) upon systemic application. However, current viral vectors are replication-deficient which limits their use in vivo. It was hypothesized that long term suppression and efficient delivery can be combined when replication-competent retroviral vectors are used as delivery vehicle. Previously, it was shown in vitro that the murine leukemia virus (MLV) accepts the insertion of shRNA expression cassettes. This system was further developed in the present thesis to a second generation system by flanking the shRNA with sequences derived from an endogenous microRNA (miR30). shRNAs designed to mimick endogenous RNA triggers perturbe the host cell to a lower extent and are more potent in their silencing activity than conventional shRNAs. Initial studies on the orientation of the shRNAmir expression cassette in the virus genome revealed that one orientation (5’-3’) showed genetic stability, but for the other orientation a deletion in the promoter sequence was observed. The activity of the 5’-3’ virus construct was monitored by silencing marker genes on the fibrosarcoma cell line HT1080 which stably expressed either eGFP or luciferase. Using marker gene-specific MLV-shRNAmir, eGFP was suppressed by MLV-shGFP to 20% compared to control virus whereas luciferase silencing was more efficient with a reduction to less than 10% by MLV-shLuc. Remarkably, silencing kinetics were dependent on the virus dose used for infection. Moreover, when all cells were successfully infected, the maximum extent of gene silencing was achieved irrespective of the virus dose applied. In contrast, control virus with an unspecific shRNAmir had no influence on marker gene expression. The potential of this system for cancer research was demonstrated by using a MMP14-specific shRNAmir virus construct (MLV-shMMP14). MMP14 is known to contribute to tumor growth and to the formation of metastasis through, for example, proteolytic cleavage of proMMP2 to its active form. Active MMP2 is a tumor specific protease capable of efficiently degrading components of the extracellular matrix. In MLV-shMMP14-infected cells, MMP14 was suppressed on mRNA as well as on protein level shown by qRT-PCR and western blotting. As a consequence, proMMP2 activation and invasion activity were reduced in vitro. In vivo, subcutaneous tumor growth of preinfected cells in SCID mice was decreased to 30%. To demonstrate sufficient RNAi delivery after systemic application, MLV-shLuc was intravenously injected into SCID mice bearing subcutaneous, luciferase expressing HT1080 tumors (HT1080-Luc). Robust in vivo actvity was shown 20 days after virus injection, when luciferase expression in tumor tissue was suppressed to 17% compared to control virus infected animals. Furthermore, to show activity also for disseminated tumor tissue a metastasis model with HT1080-Luc was successfully established. There was a clear tendency of MLV-shLuc mediated suppression as seen with non-invasive bioluminescent in vivo imaging. Hence, a second generation RNAi transfer system was successfully established which is based on replication-competent retroviral vectors. This system supports long-term suppression, strong silencing activity and extented delivery to tumor cells in vitro and in vivo. This combination of features is unique in the field of RNAi transfer systems allowing gene function studies of tumor biology in an unprecedented way.Durch RNAinterferenz (RNAi) läßt sich die Expression eines beliebigen Gens spezifisch unterdrücken. Dafür müssen in das Zytoplasma kurze, doppelsträngige RNA Moleküle (siRNA bzw. shRNA) eingebracht werden, die teilweise komplementäre Sequenzen zu dem Zielgen aufweisen. Um siRNAs mit einer hohen Effizienz und Kopienzahl in die Zielzelle einzubringen, wurden Transfersysteme unterschiedlicher Art entwickelt. Nicht-virale Transfersysteme können nur einen transienten Effekt auslösen - ein Umstand, der für Langzeitstudien eine mehrfache Transfektion bedingt. Zur Lösung dieses Problems wurden retrovirale Vektorsysteme entwickelt, die durch Integration der shRNA-Expressionskassette in das zelluläre Genom eine stabile Unterdrückung eines Zielgens erreichen können. Insbesondere für präklinische Studien in vivo ist jedoch ein System mit erhöhter Transferrate wünschenswert, um in möglichst vielen Zielzellen einen RNAi-Effekt zu bewirken. Sliva et al. konnten zeigen, dass das Murine Leukämie Virus (MLV) theoretisch diese Anforderung erfüllt. Dafür wurde eine shRNA-Expressionskassette in das Virusgenom eingefügt und in vitro ein RNAi-Effekt nachgewiesen. In der vorliegenden Arbeit wurde dieses System nun durch die Verwendung von microRNA-adaptierten shRNAs (shRNAmir) verbessert. In mehreren Publikationen wurde bestätigt, dass shRNAs, die endogenen microRNAs nachempfunden sind, eine höhere Effizienz und niedrigere Toxizität aufweisen. Zunächst wurde die für die genetische Stabilität optimale Orientierung der shRNAmir-Expressionskassette bestimmt. Das Konstrukt in reverser Orientierung wies eine Deletion in der shRNAmir Promotersequenz auf, die wahrscheinlich durch Interferenz mit dem 5’LTR Promoter entstanden ist. Mit dem genetisch stabilen Viruskonstrukt wurden Experimente zur Reduktion der Expression von Markergenen durchgeführt, um die Effizienz der RNAi-Aktivität leicht zu quantifizieren. Dafür wurden humane Fibrosarkom (HT1080) Zellen infiziert, die eGFP oder Luziferase stabil exprimieren. Mit eGFP- und Luziferase-spezifischen shRNAmir-Expressionskassetten konnte nach Infektion eine Herunterregulation von eGFP auf etwa 20 % und für Luziferase auf unter 10% beobachtet werden. Das Kontrollvirus, das eine unspezifische shRNAmir kodiert, hatte keinen Einfluss auf die Expression beider Markerproteine. Die Kinetik mit der die Markerproteine herrunterreguliert wurden, war abhängig von der Virusdosis. Die Virusdosis hatte aber keinen Einfluß auf die Stärke des RNAi-Effekts, der nach Infektion aller Zellen festgestellt werden konnte. Dieses Ergebnis entspricht der Erwartung an ein replikatives Transfersystems, das je nach applizierter Virusdosis unterschiedlich schnell RNAi in der Zellkultur ausbreitet und induziert. Die Anwendbarkeit dieses RNAi-Transfersystems auch für endogene Gene wurde mit MMP14-spezifischen shRNAmirs gezeigt. Nach Infektion von HT1080 Zellen mit den entsprechenden Viren in HT1080 Zellen konnte eine verringerte Menge an MMP14 mRNA und Protein nachgewiesen werden. Dies konnte funktionell durch eine verringerte Menge an intermediärem MMP2 und durch eine reduzierte Invasivität bestätigt werden. Zudem war die Fähigkeit dieser Zellen subkutane Tumore zu bilden stark eingeschränkt. Um die Anwendbarkeit dieses Systems für in vivo Applikationen zu zeigen, wurde in Mäuse, die Luziferase-exprimierenden Tumoren trugen, MLV-shLuc oder das Kontrollvirus systemisch appliziert. 21 Tage nach Virusgabe konnte in den Tumoren von MLV-shLuc infizierten Mäusen eine Abnahme der Luziferaseaktivität auf 15 % nachgewiesen werden. Auch in Mäusen, die systemisch applizierte Tumorzellen erhielten, konnte eine Tendenz von RNAi-vermittelter Luziferase-Reduktion beobachtet werden. Damit wurde in dieser Arbeit ein neuartiges RNAi-Transfersystem geschaffen, das in der Lage ist, auch in vivo einen starken und lang andauernden RNAi-Effekt auszulösen. Die Einzigartigkeit besteht in der Kombination von shRNAmir und Replikations-kompetenten Retroviren. Dadurch konnte eine erweiterte Transferrate von shRNAmir in Tumorzellen erreicht werden, so dass nun Genfunktionsstudien mit sehr hoher Aussagekraft möglich sind

Adapter-Mediated Transduction with Lentiviral Vectors: A Novel Tool for Cell-Type-Specific Gene Transfer

Selective gene delivery to a cell type of interest utilizing targeted lentiviral vectors (LVs) is an efficient and safe strategy for cell and gene therapy applications, including chimeric antigen receptor (CAR)-T cell therapy. LVs pseudotyped with measles virus envelope proteins (MV-LVs) have been retargeted by ablating binding to natural receptors while fusing to a single-chain antibody specific for the antigen of choice. However, the broad application of MV-LVs is hampered by the laborious LV engineering required for every new target. Here, we report the first versatile targeting system for MV-LVs that solely requires mixing with biotinylated adapter molecules to enable selective gene transfer. The analysis of the selectivity in mixed cell populations revealed transduction efficiencies below the detection limit in the absence of an adapter and up to 5000-fold on-to-off-target ratios. Flexibility was confirmed by transducing cell lines and primary cells applying seven different adapter specificities in total. Furthermore, adapter mixtures were applied to generate CAR-T cells with varying CD4/CD8-ratios in a single transduction step. In summary, a selective and flexible targeting system was established that may serve to improve the safety and efficacy of cellular therapies. Compatibility with a wide range of readily available biotinylated molecules provides an ideal technology for a variety of applications

Evaluation of an Injectable Biphasic Calcium Sulfate/Hydroxyapatite Cement for the Augmentation of Fenestrated Pedicle Screws in Osteoporotic Vertebrae : A Biomechanical Cadaver Study

Cement augmentation of pedicle screws is one of the most promising approaches to enhance the anchoring of screws in the osteoporotic spine. To date, there is no ideal cement for pedicle screw augmentation. The purpose of this study was to investigate whether an injectable, bioactive, and degradable calcium sulfate/hydroxyapatite (CaS/HA) cement could increase the maximum pull-out force of pedicle screws in osteoporotic vertebrae. Herein, 17 osteoporotic thoracic and lumbar vertebrae were obtained from a single fresh-frozen human cadaver and instrumented with fenestrated pedicle screws. The right screw in each vertebra was augmented with CaS/HA cement and the un-augmented left side served as a paired control. The cement distribution, interdigitation ability, and cement leakage were evaluated using radiographs. Furthermore, pull-out testing was used to evaluate the immediate mechanical effect of CaS/HA augmentation on the pedicle screws. The CaS/HA cement presented good distribution and interdigitation ability without leakage into the spinal canal. Augmentation significantly enhanced the maximum pull-out force of the pedicle screw in which the augmented side was 39.0% higher than the pedicle-screw-alone side. Therefore, the novel biodegradable biphasic CaS/HA cement could be a promising material for pedicle screw augmentation in the osteoporotic spine