AAV-mediated gene transfer of a checkpoint inhibitor in combination with HER2-targeted CAR-NK cells as experimental therapy for glioblastoma.

Glioblastoma (GB) is the most common primary brain tumor, which is characterized by low immunogenicity of tumor cells and prevalent immunosuppression in the tumor microenvironment (TME). Targeted local combination immunotherapy is a promising strategy to overcome these obstacles. Here, we evaluated tumor-cell specific delivery of an anti-PD-1 immunoadhesin (aPD-1) via a targeted adeno-associated viral vector (AAV) as well as HER2-specific NK-92/5.28.z (anti-HER2.CAR/NK-92) cells as components for a combination immunotherapy. In co-culture experiments, target-activated anti-HER2.CAR/NK-92 cells modified surrounding tumor cells and bystander immune cells by triggering the release of inflammatory cytokines and upregulation of PD-L1. Tumor cell-specific delivery of aPD-1 was achieved by displaying a HER2-specific designed ankyrin repeat protein (DARPin) on the AAV surface. HER2-AAV mediated gene transfer into GB cells correlated with HER2 expression levels, without inducing anti-viral responses in transduced cells. Furthermore, AAV-transduction did not interfere with anti-HER2.CAR/NK-92 cell-mediated tumor cell lysis. After selective transduction of HER2+ cells, aPD-1 expression was detected at the mRNA and protein level. The aPD-1 immunoadhesin was secreted in a time-dependent manner, bound its target on PD-1-expressing cells and was able to re-activate T cells by efficiently disrupting the PD-1/PD-L1 axis. Moreover, high intratumoral and low systemic aPD-1 concentrations were achieved following local injection of HER2-AAV into orthotopic tumor grafts in vivo. aPD-1 was selectively produced in tumor tissue and could be detected up to 10 days after a single HER2-AAV injection. In subcutaneous GL261-HER2 and Tu2449-HER2 immunocompetent mouse models, administration of the combination therapy significantly prolonged survival, including complete tumor control in several animals in the GL261-HER2 model. In summary, local therapy with aPD-1 encoding HER2-AAVs in combination with anti-HER2.CAR/NK-92 cells may be a promising novel strategy for GB immunotherapy with the potential to enhance efficacy and reduce systemic side effects of immune-checkpoint inhibitors.

Group psychotherapy treatment of borderline personalities.

Borderline personalities have been treated in psychotherapy groups for over 40 years. This article elaborates some of the characteristics pertinent to the treatment of these patients. Combined treatment of group and individual therapy addresses the needs for object constancy, the integration of object and self representations, and the possibility of attachment to others. Collaboration with individual therapists in this process is essential and there are specific conditions that allow this to occur as well as guidelines to help them make referrals. Cotherapy can be especially beneficial if the cotherapy team is knowledgeable and experienced. The group therapist must have special training and supervision to conduct groups of such intensity and affectively laden content.

The nequipos' collusion with the patient's family of origin in analytic group psychotherapy.

When the analytic group is led by individuals paired for educational reasons, that is, by a supervisor and his or her student, the difficulty in conducting the group becomes magnified. Such teams are called nequipos and it is hypothesized that they will not function optimally until the latter phases of their development. The authors describe the mistakes they made as early phase nequipos in their treatment of one patient in group psychotherapy.

A comparison of open peritoneal lavage with modified closed peritoneal lavage in blunt abdominal trauma.

A randomized prospective study compared open peritoneal lavage using a peritoneal dialysis catheter with modified closed lavage using either the Lazarus-Nelson or Cook lavage catheter. The time required to perform the lavage, technical difficulties, complications, and accuracy were assessed in 63 adult victims of blunt abdominal trauma. The average time to perform lavage was 21.1 minutes for open lavage, 14.7 minutes for Lazarus-Nelson closed lavage, and 9.8 minutes for Cook closed lavage. The closed technique using the Cook catheter was significantly faster than open lavage. Technical difficulties were significantly less frequent with Cook catheter closed lavage than with Lazarus-Nelson catheter closed lavage. The overall complication rate was 1.8%, and the overall accuracy was 98.1%, without apparent difference among techniques. It is concluded that, when no contraindications to closed lavage exist, and when time is of importance, closed lavage with the Cook catheter is the preferred technique.

A multicenter validation of the prehospital index.

The prehospital index (PHI) is a triage-oriented trauma severity scoring system. This prospective multicenter validation of the PHI was undertaken in response to a favorable pilot study. We applied the PHI to 3,581 patients from 14 different institutions during the period from January 1985 to February 1986. The PHI was accurate in predicting the need for emergency life-saving surgery within four hours (P less than .0001) and mortality within 72 hours (P less than .0001) following traumatic injury. The curves were generated for PHI versus emergency surgery, mortality, surgery and mortality, injury severity score, and ICU admission rate. These data compare favorably with those from previously published, prospectively tested, triage-oriented trauma severity scoring systems.

Aortic compressor for aortic occlusion in hemorrhagic shock.

The aortic compressor is a device that allows rapid, simple, immediately reversible occlusion of the thoracic aorta, without the aortic dissection required to use an aortic cross-clamp. We evaluated the aortic compressor in a controlled study using a canine hemorrhagic shock model. Twelve mongrel dogs were exsanguinated to a mean arterial pressure (MAP) of 47 mm Hg and maintained at that level for 20 minutes. At that point, all animals had a left lateral thoracotomy. Six study animals had the thoracic aorta occluded at the diaphragm using the compressor. Five minutes after thoracotomy, with or without occlusion, the shed blood was reinfused. Application of the aortic compressor was the only variable. Use of the aortic compressor led to an immediate and statistically significant doubling of the study animals' MAP. The increased afterload of aortic occlusion did not impair cardiac output. The cardiac index of the study animals rose slightly, while that of the control animals fell. At the same time the compressor prevented blood flow to the abdominal aorta. If the canine model can be extrapolated to human application, then the aortic compressor would be expected to enhance perfusion of the heart and brain during hemorrhagic shock, prevent further arterial blood loss from intra-abdominal injury or ruptured abdominal aortic aneurysm, and preserve already diminished cardiac output. Because the aorta does not need to be dissected out to use the compressor, there is no risk of injury to nearby vascular structures.

Deoxyribonucleoside triphosphate pools in synchronized human cells infected with herpes simplex virus types 1 and 2.

Deoxyribonucleoside triphosphate pools in uninfected and herpes simplex virus type 1 (HSV-1)- and HSV-2-infected KB cells were analyzed to determine whether ribonucleotide reductase functions in vivo in the presence and absence of thymidine (TdR). Previously we showed that HSV-2 replication was inhibited in KB cells blocked in their capacity to synthesize DNA by TdR. HSV-1 replication was not inhibited under these conditions. Both HSV-1 and HSV-2 induced an altered ribonucleotide reductase resistant to dTTP inhibition. Thus, the block to HSV-2 replication apparently was not at the level of reductase. However, the in vitro activity of the enzyme does not necessarily correspond to intracellular conditions. In TdR-blocked HSV-2-infected cells, we found that, while dTTP levels remained high, dCTP concentrations increased. In contrast, KB cells blocked by TdR showed increased dTTP but decreased dCTP levels. We conclude that the HSV-2 enzyme is functional in vivo and that TdR inhibits viral replication by a mechanism other than depletion of dCTP. Infection of KB cells with HSV-1 or HSV-2 altered both dATP and dGTP levels in the presence or absence of TdR. Inhibition of viral replication was not explained by changes in these pools. We suggest that, during infection, HSV-1 induces a virus function(s) not related to reductase which is resistant to TdR, whereas the corresponding HSV-2 function is sensitive. Our evidence shows that the TdR-sensitive function is not in the pathways leading to deoxyribonucleoside triphosphate and may occur at the level of DNA replication.