Switching CAR T cells on and off: a novel modular platform for retargeting of T cells to AML blasts.

The adoptive transfer of CD19-specific chimeric antigen receptor engineered T cells (CAR T cells) resulted in encouraging clinical trials in indolent B-cell malignancies. However, they also show the limitations of this fascinating technology: CAR T cells can lead to even life-threatening off-tumor, on-target side effects if CAR T cells crossreact with healthy tissues. Here, we describe a novel modular universal CAR platform technology termed UniCAR that reduces the risk of on-target side effects by a rapid and reversible control of CAR T-cell reactivity. The UniCAR system consists of two components: (1) a CAR for an inert manipulation of T cells and (2) specific targeting modules (TMs) for redirecting UniCAR T cells in an individualized time- and target-dependent manner. UniCAR T cells can be armed against different tumor targets simply by replacement of the respective TM for (1) targeting more than one antigen simultaneously or subsequently to enhance efficacy and (2) reducing the risk for development of antigen-loss tumor variants under treatment. Here we provide 'proof of concept' for retargeting of UniCAR T cells to CD33- and/or CD123-positive acute myeloid leukemia blasts in vitro and in vivo.

Bispecific antibody releasing-mesenchymal stromal cell machinery for retargeting T cells towards acute myeloid leukemia blasts.

Bispecific antibodies (bsAbs) engaging T cells are emerging as a promising immunotherapeutic tool for the treatment of hematologic malignancies. Because their low molecular mass, bsAbs have short half-lives. To achieve clinical responses, they have to be infused into patients continously, for a long period of time. As a valid alternative we examined the use of mesenchymal stromal cells (MSCs) as autonomous cellular machines for the constant production of a recently described, fully humanized anti-CD33-anti-CD3 bsAb, which is capable of redirecting human T cells against CD33-expressing leukemic cells. The immortalized human MSC line SCP-1 was genetically modified into expressing bsAb at sufficient amounts to redirect T cells efficiently against CD33 presenting target cells, both in vitro and in an immunodeficient mouse model. Moreover, T cells of patients suffering from acute myeloid leukemia (AML) in blast crisis eliminated autologous leukemic cells in the presence of the bsAb secreting MSCs over time. The immune response against AML cells could be enhanced further by providing T cells an additional co-stimulus via the CD137-CD137 ligand axis through CD137L expression on MSCs. This study demonstrates that MSCs have the potential to be used as cellular production machines for bsAb-based tumor immunotherapy in the future.

Endoscopic sinus surgery using intraoperative computed tomography imaging for updating a three-dimensional navigation system.

OBJECTIVES: The use of three-dimensional navigation systems provides information on the structures surrounding the field of operation and thereby reduces the risk of iatrogenic damage. The computed tomography (CT) data conventionally used are provided by preoperative scanning procedures, which means that tissue changes coming about during surgery are not seen on the screen. An intraoperative CT scanning procedure being able to update the CT data could provide a solution. STUDY DESIGN: Endoscopic sinus operations using an intraoperative CT updating the three-dimensional navigation system were performed on six persons to find out, whether the above is true. METHODS: Different parameters, advantages, and disadvantages in the cases of these six patients were compared with a group of 22 patients who underwent conventional endoscopic sinus surgery with different three-dimensional navigation systems without updating the CT data set. RESULTS: The intraoperative CT for updating the three-dimensional navigation system provides useful information for the surgeon. CONCLUSION: Balancing its advantages against its disadvantages, the updating of the CT data set with intraoperative CT cannot be recommended for conventional standard endoscopic sinus surgery.

No evidence for leptin as an independent associate of blood pressure in childhood and juvenile obesity.

We studied whether leptin is an independent associate of blood pressure in obese children and adolescence. 102 obese children (48 girls, age: 11.6 +/- 2.22 yr; body mass index [BMI]: 27.45 +/- 4.4; blood pressure: 122.5 +/- 11.1/64.7 +/- 10.6 mm Hg and 54 boys, age: 11.5 +/- 2.4 yr; BMI: 27.6 +/- 4.4; blood pressure: 122.5 +/- 13.2/60.9 +/- 8.1 mm Hg [mean +/- SD]) were investigated. Serum leptin and insulin were measured by RIA; glucose was determined enzymatically. Fat mass (FM) was calculated by bioelectrical impedance. Leptin was higher in girls than in boys (p=0.018) but no significant gender differences were found with respect to indices of adiposity and systolic blood pressure (SBP). Children were divided into three groups, according to pubertal stage (Group 1: prepubertal, 32 boys/13 girls; Group 2: pubertal, 17 boys/25 girls; Group 3: late/postpubertal, 5 boys/10 girls). SBP and DBP correlated with body weight in the whole group (r=0.49, p<0.0001, and r=0.27, p=0.004). In Group 1, BMI showed the highest correlation to SBP; in Group 3 no indices of adiposity were related to SBP. In no case was leptin significantly associated with SBP after adjustment for adiposity. In Group 2, glucose was significantly associated with SBP after adjustment for body weight. In Group 3, however, no correlations were found between SBP, DBP and metabolic characteristics, perhaps due to small sample size. Stepwise multiple regression revealed that body weight and glucose contributed to the variation in SBP in the whole group (R2=0.31, p<0.0001). Insulin accounted for almost 8% of the variation in DBP (R2=0.08, p=0.0034). Body weight contributed significantly to SBP in boys (R2=0.39, p<0.0001) and girls (R2=0.24, p< 0.001). The results imply that body weight contributes independently to the variation in blood pressure. Glucose and insulin contribute to mean blood pressure to some extent, but our data do not support the assumption that leptin per se serves as an independent predictor of blood pressure in obese children and adolescents.

No relationship between leptin and cortisol in obese children and adolescents.

Recent findings have shown that leptin downregulates the steroid producing system in the adrenal. We studied the interactions of leptin, insulin and cortisol in obese children and adolescents at different stages of maturation. In 44 boys (age 11+/-3.1 yr, body mass index [BMI] 29+/-5.3 [mean +/- SD]) and 35 girls (age 11.4+/-2.6 yr, BMI 29+/-4.3), blood levels of leptin, insulin, cortisol, and glucose were determined. Fat mass (FM) was calculated by bioelectrical impedance. No significant differences were found between boys and girls with respect to humoral and anthropometric characteristics. When children were divided according to maturation stage (prepubertal, pubertal, and late/postpubertal) insulin was higher in the more mature groups (p<0.01) and leptin was higher in the pubertal group (p=0.03). In the prepubertal and pubertal groups, the expected positive relationship between adiposity and leptin was found although the magnitude of this association decreased with maturity. In none of the groups studied was cortisol significantly correlated to leptin. Insulin (p=0.03) and glucose (p=0.01) were positively associated with cortisol in the prepubertal group after adjustment for adiposity. However, in the pubertal group an inverse correlation was found between insulin and cortisol (p=0.03), and between insulin and glucose after control for adiposity. In the late/ postpubertal group, no significant correlations were found between estimates of adiposity and humoral parameters even after adjustment for gender. Stepwise multiple regression failed to detect a significant influence of cortisol to explain the variation in leptin, and vice versa. BMI contributed to the variation in leptin (adj. R2 =0.275, p<0.0001), and glucose added 5% to the variation in cortisol (p=0.03). The results do not confirm the inverse association between leptin and cortisol found in adults. Although BMI reflects levels of leptin, it is likely that several other factors in conjunction with fatness modulate the relationship with leptin. Whether leptin per se exerts an influence on the hypothalamic-adrenal-adipo axis remains to be investigated in longitudinal studies.

Central projections from singular parts of the vestibular labyrinth in the guinea pig.

Primary afferent projections from singular parts of the vestibular labyrinth were studied in the guinea pig. The posterior ampullary nerve, the common trunk of the anterior and lateral ampullary nerves, as well as fibers innervating the macula sacculi or the macula utriculi were traced with crystals of horseradish peroxidase (HRP) lyophilisate. Posterior, as well as anterior and lateral ampullary fibers were found to project extensively to the superior vestibular nucleus, but also reached the other main vestibular nuclei. Saccular fibers projected mainly to the lateral parts of the lateral vestibular nucleus and to the adjoining descending and superior vestibular nuclei as well as to group y. Modest projections could be followed to the medial vestibular nucleus. Furthermore, a distinct saccular projection to the cochlear nuclei was evident. Utricular projections reached the four main vestibular nuclei with a denser accumulation of fibers within ventral parts of the lateral, descending and superior vestibular nuclei.

Comparison of six three-dimensional navigation systems during sinus surgery.

Three-dimensional (3D) navigation systems are routinely used in the fields of endoscopic skull base surgery, neurosurgery, maxillo-facial and endoscopic sinus surgery. The use of such systems is associated with the following advantages: a better 3D orientation: a more confident surgeon; a more precise surgical approach; and a reduced operation time. Six different brands of 3D navigation system were compared in order to find out if there are major differences in performance and whether the considerable financial investment required to purchase such a system would be justified by a noticeable improvement in surgical interventions and a realization of the above expectations. The 3D navigation systems were tested by performing endoscopic sinus surgery on 26 patients suffering from chronic sinusitis. The system accuracy, the confidence of the surgeon, the time of anaesthesia, the cost, the number of personnel required (and their skills), and the technical resources were compared. No major differences in performance of the different brands of 3D navigation system were noticed. All of the systems showed high, but varying, system precision, the surgeons felt more confident and the time of anaesthesia was prolonged by 5-15 min. A well-trained operating staff is required. Assuming that the initial costs are excluded and that data transfer occurs automatically, personnel costs and the extra time required still have to be considered.

Experiences in intraoperative computer-aided navigation in ENT sinus surgery with the Aesculap navigation system.

Five patients with chronic sinus pathology and an indication for sinus surgery were selected. For intraoperative navigation, we used Surgical Planning and Orientation Computer Systems (SPOCS) Aesculap navigation software (ISG Technologies, Mississauga, Ontario, Canada) and surgical instruments fitted with light-emitting diodes. Navigation procedures are described in detail in the article. The system's precision was measured by pointing at anatomical landmarks. The accuracy was measured as the distance in millimeters between the bony structures of the computed tomographic (CT) scan on screen and the cross-hair of the pointer tip displayed on the screen. Another parameter of the system's accuracy was calculated by the system itself as the root mean square error in millimeters between the markers' position as registered and their position in the CT data set. Axial 3/3/1-mm spiral CT provided sufficient resolution, and data transfer via optical disk was practicable. Positioning of the navigation equipment required some experience, and the registration of the patient's head position also needed attention, as the markers have to be pointed at precisely. During the operation, the position of the head-tracking system on the patient's head must remain unchanged to ensure a correct navigation display. The main advantage of the computed navigation system was the constant orientation provided during the sinus surgical procedure. Borders and critical anatomical structures could be identified in the corresponding CT data set, thus enabling the surgeon to decide on subsequent procedures. Use of the navigation system was found to increase the operation time by about 1 h, resulting in additional time under anesthesia. We found the SPOCS Aesculap computed navigation system to be an established technical aid, ready for use in ENT sinus surgery. In the cases reported here, a precision between 1 and 3 mm was obtained.

Acupuncture in gonarthrotic pain--"Bachmann's knee program".

In a retrospective study 35 patients with gonarthrotic pain were treated with acupuncture at the outpatient unit of the Department of Anaesthesia and Intensive Care in the University of Vienna. The subjective effectiveness of the treatment using a standard method on the knee demonstrated that patients reported an explicit improvement of their ailments. Therefore, we can unreservedly recommend this program, which was only augmented through additive "locus dolendi" treatment if indicated.

Beneficial effect of acupuncture on adult patients with asthma bronchiale.

In a retrospective study 17 patients with long-standing history of asthma bronchiale were treated with acupuncture at the outpatient unit of the Department of Anaesthesia and Intensive Care in the University Hospital of Vienna. The subjective effectiveness of the treatment was determined using a standard questionnaire, which was sent to the patients' homes half a year after starting acupuncture treatment. Over 70% of our patients reported a significant improvement of their ailments after ten weeks of treatment as well as half a year after starting acupuncture.

Costimulation improves the killing capability of T cells redirected to tumor cells expressing low levels of CD33: description of a novel modular targeting system.

Owing to their clinical success, there is growing interest in novel bispecific antibodies (bsAbs) for retargeting of T cells to tumor cells including for the treatment of acute myeloid leukemia (AML). One potential target for retargeting of T cells to AML blasts is the surface molecule CD33. Here we describe a novel modular targeting platform that consists of a universal effector module (EM) and individual target modules (TMs). Both modules can form an immune complex via a peptide epitope. The resulting targeting complex can functionally replace a conventional bsAb. By fusion of a costimulatory domain (for example, the extracellular CD137 ligand domain) to the TM, the targeting complex can even provide a costimulatory signal to the redirected T cells at their side of interaction with the tumor cell. Furthermore, we observed that an efficient killing of tumor cells expressing low levels of the tumor target CD33 becomes critical at low effector-to-target cell ratios but can be improved by costimulation via CD137 using our novel targeting system.

Neurofibroma of the auriculotemporal nerve.

Despite the extensive branching of the trigeminal nerve, solitary neurofibromas along its branches are a rare finding. We report our management of a neurofibroma of the right auriculotemporal nerve in a 46-year-old women. A chain of small nodules palpable in the right postauricular region was associated with increasing pain radiating into the postauricular and temporoparietal regions of her head. Magnetic resonance imaging and computed tomography showed several small ovoid lesions extending from the postauricular region to the infratemporal fossa. The lesions were removed surgically. The facial nerve adhered to the dorsal side of the largest nodule, but this could be removed without sequelae. The auriculotemporal nerve was identified as the nerve of origin and was removed together with the lesions. Histopathological examination was consistent with a neurofibroma with early plexiform cell formations. Clinical findings are discussed.

[Epidemiology of malignant neoplasms of the respiratory and upper digestive tract in Austria]. / Zur Epidemiologie bösartiger Neubildungen des Atmungs- und oberen Verdauungstraktes in Ostösterreich.

Between 1981 and 1985 the incidence of malignant tumours of the buccal cavity and mesopharynx, the larynx and hypopharynx and of the oesophagus in males was higher in the mainly rural Burgenland and Lower Austria than in Vienna. In lung tumours a slight urban-rural gradient tended to level out (Tables 1-4). In women, the cancer incidence on all locations showed an urban-rural gradient, steeper in the buccal cavity and mesopharynx, in the larynx and hypopharynx and in the oesophagus than in lung tumours (Tables 1-4). Cancer incidence in the nasal and paranasal cavities, middle ear, epipharynx, salivary glands and lips was low. Sex ratios, lips excepted, were lower than in other sites studied (Tab. 6). In Eastern Austria the mortality of malignant neoplasms of the mouth and pharynx in males increased steadily from 1960 to 1987. In laryngeal and oesophageal cancer no persistent trend was discernible. The lung cancer mortality decreased from the mid-seventies onwards (Figs. 1-2). In women, the lung cancer mortality increased continuously, and for some years now also that of the mouth and pharynx. Cancer of the oesophagus decreased, and laryngeal cancer mortality showed nearly constant rates (Figs. 5-6).

[The double mask]. / Die Doppelmaske.

While the consequences of occupational exposure to anesthetic gases and volatile agents on morbidity in operating room staff are controversial (survey in Swiss investigations show a distinct correlation with subjective complaints, e.g. tiredness and headache on the day of exposure (Table 1). In Sweden, rigorous control of occupational exposure to anesthetic gases has prompted development of various scavenging systems, among which the double mask (Fig. 1) is the latest and most advanced. During mask anesthesia, escaping anesthetic gases are evacuated at the point of leakage via a thin slot between a flexible silicone inner mask and a rigid plastic outer mask. A small plate in the mask produces turbulence in the otherwise laminar flow of anesthetic gases, thus reducing the speed of gas leakage. A silicone chamber is mounted on the mask and connected to a fan, requiring a flow of 35 m3/h for optimal function. This chamber does, however, also associate the system with two practical problems: the system with its evacuation tube is heavier to hold than conventional masks, and it is associated with increased dead-space that is only partly minimized by a modification of the Y-connector. While the handling is largely a matter of routine and the weight of the system is minimized when the evacuation tube is arranged to draw slightly upward, the increased dead space may reduce the practicality of the double mask in infants.

Comparison of different 3D navigation systems by a clinical "user".

Three-dimensional navigation systems are routinely used in endoscopic skull base surgery, neurosurgery, maxillo-facial and endoscopic sinus surgery. Their precision can, however, change in the course of one experiment. We have compared five different 3D navigation systems and discuss here possible reasons for the limits of system precision. A plexiglass cube on which test points were marked served as a test-model. Two well-trained system users measured the distances between the test points in each of the five systems. The results were compared with reference data provided by the NUMEREX device at the Technical University of Vienna. The accuracy data shown by all these 3D navigation systems ranged from 0.0 mm to 6.67 mm. The accuracy data of a system calculated in advance did not always correspond with the system precision on the screen. The system precision in the center of the cube was higher than on its surface, which made us conclude that the angle between the tracker system and the pointing device touching the test point may be critical for system precision. Applying an automatic registration step did not result in greater system precision. Slice thickness and the angle of the pointing device seem to be responsible for system precision.

[Changes in the age of illness onset in cancer of the hypopharynx and larynx since 1960. The epidemiologic context in Austria]. / Anderungen des Erkrankungsalters der Karzinome des Hypopharynx und des Larynx seit 1960. Der epidemiologische Kontext in Ostösterreich.

Between 1960 and 1987, 1567 laryngeal and hypopharyngeal carcinomas were diagnosed at the First ENT Clinic of Vienna University. Patients under 50 years of age increased steadily in number and proportion. Three subgroups of carcinomas were considered: glottic (including subglottic), supraglottic and hypopharyngeal. A total of 1442 cases could be studied in detail. In the supraglottic and hypopharyngeal groups the proportion under 50 years of age rose significantly, whereas in the glottic cases no significant trend is discernible. The subgroups were standardized in 10-year age groups to the population of eastern Austria. The incidence was constant in females. In males two opposite trends were found: in glottic tumours the proportion of middle-aged patients shows a slight decrease, whereas older age groups show a significant decrease. In hypopharyngeal carcinoma, younger age groups show a highly significant increase and the older age groups a slight decrease. Supraglottic carcinoma was intermediate: in younger age groups, a slight increase was found compared with a marked decrease in older ages. The age-specific regional mortality showed a pattern similar to that of the supraglottic and hypopharyngeal tumours seen at our clinic. The alcohol and tobacco consumption of all male patients between 1977 and 1983 was reviewed. Heavy smoking was about equally frequent for all tumour sites. High alcohol intake was more frequent in supraglottic and hypopharyngeal than in glottic tumours, and more frequent in younger than in older patients. Tobacco smoke acts as a carcinogen in the long run, and this effect can be enhanced by heavy drinking.(ABSTRACT TRUNCATED AT 250 WORDS)

[Incidence and age at onset of cancers of the mouth and oropharynx since 1960. The epidemiologic context in East Austria]. / Häufigkeit und Erkrankungsalter der Karzinome der Mundhöhle und des Mesopharynx seit 1960. Der epidemiologische Kontext in Ostösterreich.

Between 1960 and 1987, a total of 709 carcinomas of the floor of the mouth, tongue and oropharynx (BOPC) were diagnosed at the first ENT Clinic of the University of Vienna (555 men, 154 women). Patients under 50 years of age increased steadily in number of proportion. Age-specific rates in men based on the actual population of eastern Austria showed a highly significant increase in younger patients and a slight decrease in older patients. Crude regional mortality increased considerably in men during the whole period, and in women since 1982. The evolution of age-specific mortality in men was similar to that of the incidence at our clinic. In women the increase affected all ages. The rate of tobacco and alcohol consumption of male patients between 1977 and 1983 was compared with that of patients with chronic otitis and hypopharyngeal carcinoma. Smoking and drinking rates were substantially higher in the BOPC group than in the otitis group, and their distribution differed from that of the hypopharyngeal cancer group: heavy consumption of both tobacco and alcohol was equally frequent, but smoking rates were lower and heavy drinking more frequent in the BOPC group. High consumption in BOPC patients was more common in patients under 60 years of age. The increasing incidence of the disease and the shift to younger patients may be linked with the alcohol component within the field of influence of combined tobacco and alcohol abuse.