Muscle-specific, liver-detargeted adeno-associated virus gene therapy rescues Pompe phenotype in adult and neonate Gaa-/- mice.

Pompe disease (PD) is a neuromuscular disorder caused by acid α-glucosidase (GAA) deficiency. Reduced GAA activity leads to pathological glycogen accumulation in cardiac and skeletal muscles responsible for severe heart impairment, respiratory defects, and muscle weakness. Enzyme replacement therapy with recombinant human GAA (rhGAA) is the standard-of-care treatment for PD, however, its efficacy is limited due to poor uptake in muscle and the development of an immune response. Multiple clinical trials are ongoing in PD with adeno-associated virus (AAV) vectors based on liver- and muscle-targeting. Current gene therapy approaches are limited by liver proliferation, poor muscle targeting, and the potential immune response to the hGAA transgene. To generate a treatment tailored to infantile-onset PD, we took advantage of a novel AAV capsid able to increase skeletal muscle targeting compared to AAV9 while reducing liver overload. When combined with a liver-muscle tandem promoter (LiMP), and despite the extensive liver-detargeting, this vector had a limited immune response to the hGAA transgene. This combination of capsid and promoter with improved muscle expression and specificity allowed for glycogen clearance in cardiac and skeletal muscles of Gaa-/- adult mice. In neonate Gaa-/- , complete rescue of glycogen content and muscle strength was observed 6 months after AAV vector injection. Our work highlights the importance of residual liver expression to control the immune response toward a potentially immunogenic transgene expressed in muscle. In conclusion, the demonstration of the efficacy of a muscle-specific AAV capsid-promoter combination for the full rescue of PD manifestation in both neonate and adult Gaa-/- provides a potential therapeutic avenue for the infantile-onset form of this devastating disease.

Induction of tumor-specific CTL responses using the C-terminal fragment of Viral protein R as cell penetrating peptide.

The discovery of tumor-associated antigens recognized by T lymphocytes opens the possibility of vaccinating cancer patients with defined antigens. However, one of the major limitation of peptide-based vaccines is the low immunogenicity of antigenic peptides. Interestingly, if these epitopes are directly delivered into the cytoplasm of antigen presenting cells, they can be efficiently presented via the direct MHC class I presentation pathway. To improve antigen entry, one promising approach is the use of cell penetrating peptides (CPPs). However, most studies use a covalent binding of the CPP with the antigen. In the present study, we focused on the C-terminal domain of Vpr which was previously demonstrated to efficiently deliver plasmid DNA into cells. We provide evidence that the peptides Vpr55-91 and Vpr55-82 possess the capacity of delivering proteins and epitopes into cell lines as well as into human primary dendritic cells, without the necessicity for a chemical linkage. Moreover, immunization of HLA-A2 transgenic mice with Vpr55-91 as the sole adjuvant is able to induce antigen-specific cytotoxic T lymphocytes against multiple tumor epitopes.

A lentiviral vector encoding the human Wiskott-Aldrich syndrome protein corrects immune and cytoskeletal defects in WASP knockout mice.

Wiskott-Aldrich syndrome (WAS) is an immune deficiency with thrombopenia resulting from mutations in the WASP gene. This gene normally encodes the Wiskott-Aldrich syndrome protein (WASP), a major cytoskeletal regulator expressed in hematopoietic cells. Gene therapy is a promising option for the treatment of WAS, requiring that clinically applicable WASP gene transfer vectors demonstrate efficacy in preclinical studies. Here, we describe a self-inactivating HIV-1-derived lentiviral vector encoding human WASP and show that it effectively transduced bone marrow progenitor cells of WASP knockout (WKO) mice. Transplantation of these transduced cells into lethally irradiated WKO recipients led to stable expression of WASP and correction of immune, inflammatory and cytoskeletal defects. Splenic T-cell proliferation was restored, podosomes were reinstated on bone-marrow-derived dendritic cells and colon inflammation was reduced. This shows for the first time (a) that cytoskeletal defects can be corrected in WKO mice, (b) that human WASP is biologically active in mice and (c) that a lentiviral vector is effective to express human WASP in vivo over several months. These data support further development of such lentiviral vectors for the gene therapy of WAS.

HLA-A*0201-restricted cytolytic responses to the rtTA transactivator dominant and cryptic epitopes compromise transgene expression induced by the tetracycline on system.

The tetracycline-controlled transcription system (Tet-on) is widely used to regulate gene expression in mammalian cells. In gene therapy applications, immune responses to Tet-on proteins such as the rtTA transcription factor have been reported, raising concerns about their occurrence in humans. To monitor the HLA class I cytolytic responses against Tet-on regulators, we characterized the immunogenic CD8+ epitopes within rtTA and tTS regulators using HLA-A*0201 class I transgenic mice. Epitope prediction programs, HLA-A*0201 binding assays, and peptide immunization were used to select a set of immunogenic peptides within rtTA and tTS sequences. To identify further the rejection epitopes, we expressed Tet-on protein components in vivo and found a single dominant rtTA186 CTL epitope in the rtTA tetracycline repressor domain. Target cells expressing rtTA were susceptible to CTL lysis, and rtTA expression compromised muscle transgene engraftment. To reduce the occurrence of immune responses to rtTA protein, we mutated the dominant rtTA186 epitope and found that this leads to the appearance of subdominant epitopes. As a result, we think that an epitope modification strategy is not applicable to blunt the immune response in this model. Moreover, the identification of HLA-A*0201 rtTA epitopes allowed us to demonstrate here that the delivery of the Tet-on system with weakly immunogenic rAAV vectors does not trigger primary CTL responses in mice, in contrast to DNA transfer. Altogether, the existence of HLA-A*0201 rtTA epitopes may lead to the occurrence of immune responses depending on vectors and local inflammation in gene therapy applications involving rtTA-based regulatory systems.

Identification of HER-2/neu immunogenic epitopes presented by renal cell carcinoma and other human epithelial tumors.

HER-2/neu is a tumor-associated antigen overexpressed in a large variety of human tumors. Eight HER-2/neu peptides displaying HLA-A*0201 anchoring motifs were selected and tested for their binding affinity to HLA-A*0201 and their capacity to elicit cytotoxic T lymphocyte (CTL) responses in both HLA-A*0201 transgenic mice and in HLA-A*0201(+) healthy donors. Two high-affinity (p5 and p48) and one intermediate-affinity (p1023) peptides triggered CTL responses in both transgenic mice and humans, comparable to those observed for the well-known HER2/neu dominant peptide p369. CTL induced in transgenic mice lysed HLA-A*0201(+) RMA cells infected with recombinant HER-2/neu but not cells infected with wild-type vaccinia virus. Human CTL lysed HLA-A*0201(+) HER-2/neu(+) tumor cells of different origins (breast, colon, lung and renal cancer) irrespective of the expression levels of HER-2/neu. Importantly, primed CTL specific for these epitopes were detected in freshly isolated tumor-infiltrating lymphocytes from three renal cell carcinoma patients. Therefore, the HER-2/neu peptides p5, p48 and p1023 may be good candidates for immunotherapy of a broad spectrum of tumors, including renal cell carcinoma.

A skin surgery fable.

A fable is presented to inform the reader of the existence of a valuable, but under-utilized educational resource that might be utilized in the teaching of dermatologic surgery.

[Anchoring cytokines to cancer cells using diphtheria toxin: better than immunotherapy by gene transfer?]. / Ancrer des cytokines aux cellules cancéreuses à l'aide de la toxine diphtérique: mieux que l'immunothérapie par transfert de gène?

Many cytokines are able to stimulate the antitumor immune response. However, in order to avoid the toxic effects due to systemic injection, it is necessary to concentrate the cytokines in the tumor microenvironment. Current methods, based on the transfer of cytokine genes into tumor cells, still suffer drawbacks. We describe an alternative approach using recombinant cytokines genetically conjugated to a membrane anchor derived from diphtheria toxin. Interleukin-2 anchored to lymphoma and melanoma cells remained displayed on their surface and were not internalized. Injection of these cell preparations to mice led to an immune response able to prevent or slow tumor growth following tumor challenge.

A general strategy to enhance immunogenicity of low-affinity HLA-A2. 1-associated peptides: implication in the identification of cryptic tumor epitopes.

Low-affinity MHC class I-associated cryptic epitopes derived from self proteins overexpressed in a wide variety of human tumors or derived from antigens of viruses exhibiting a high mutation rate, could be interesting candidates for tumor and virus immunotherapy, respectively. However, identification of low-affinity MHC-associated epitopes comes up against their poor immunogenicity. Here we describe an approach that enhances immunogenicity of nonimmunogenic low-affinity HLA-A2.1-binding peptides. It consists of modifying their sequence by introducing a tyrosine in the first position (P1Y). P1Y substitution enhances affinity of HLA-A2.1-associated peptides without altering their antigenic specificity. In fact, P1Y variants of ten nonimmunogenic low-affinity peptides exhibited a 2.3- to 55-fold higher binding affinity and/or stabilized the HLA-A2.1 for at least 2 h more than the corresponding native peptides. More importantly, P1Y variants efficiently triggered in vivo native peptide-specific CTL which also recognized the corresponding naturally processed epitope. The possibility for generating CTL against any low-affinity HLA-A2.1-associated peptide provides us with the necessary tool for the identification of cryptic tumor and virus epitopes which could be used for peptide-based immunotherapy.

Clinical and genetic heterogeneity in familial focal segmental glomerulosclerosis. International Collaborative Group for the Study of Familial Focal Segmental Glomerulosclerosis.

BACKGROUND: Familial forms of focal segmental glomerulosclerosis (FFSGS) that exhibit autosomal dominant or recessive patterns of inheritance have been described. The genetic basis of these hereditary forms of FSGS is unknown. One recent study of a kindred from Oklahoma with an autosomal dominant form of FSGS linked this disease to a region of chromosome 19q. In addition, polymorphisms in a gene in this region on chromosome 19q13 have been linked to congenital nephrotic syndrome of the Finnish type. We have ascertained and characterized a large family with autosomal dominant FFSGS (Duke 6530). METHODS: Families were compared for clinical and genetic heterogeneity. To test for linkage of our family to this portion of chromosome 19, genomic DNA was isolated from 102 family members, and polymerase chain reaction was performed using eight microsatellite markers that spanned the area of interest on chromosome 19. Data were evaluated using two-point linkage analysis, multipoint analysis, and an admixture test. RESULTS: Linkage was excluded at a distance of +/- 5 to 10 CM for all markers tested with two-point log10 of the odds of linkage (LOD) scores and from an approximate 60 CM interval in this area of chromosome 19q via multipoint analysis. CONCLUSIONS: FSGS has been called the "final common pathway" of glomerular injury, as it is a frequent pathological manifestation with diverse etiologies. This diversity likely correlates with the genetic heterogeneity that we have established. Thus, our data demonstrate that there are at least two genes responsible for this disease, and there is genetic as well as clinical heterogeneity in autosomal dominant FSGS.

Patient satisfaction with time spent with their physician.

BACKGROUND: We examined the variables related to patient satisfaction with the time spent with their family physician during the office visit. METHODS: Research nurses directly observed consecutive patient visits to 138 family physicians in 84 practices. Analyses examined sequential models of the association of patient and physician characteristics, visit type and length, and time use during visits, with patients' satisfaction with the amount of time spent with their physician. RESULTS: Among 2315 visit by adult patients returning questionnaires, patient satisfaction with the time spent with their physician was high and strongly linked to longer visits (P < 001). After controlling for visit duration, greater patient satisfaction with time spent was associated with older patient age, white race, better perceived health status, visits for well care, and visits with a greater proportion of the visit spent chatting. The physician's discussion of test results or findings from the physical examination was associated with greater satisfaction with time spent for visits longer than 15 minutes, but with less satisfaction with time spent for shorter visits. CONCLUSIONS: Physicians can enhance patient satisfaction with the amount of time spent during an office visit by spending a small proportion of time chatting about nonmedical topics, and by allowing sufficient time for exchange with the patient is feedback is necessary.

Gonadal steroidogenesis in vitro from juvenile alligators obtained from contaminated or control lakes.

The ubiquitous distribution of many contaminants and the nonlethal, multigenerational effects of such contaminants on reproductive, endocrine, and immune systems have led to concerns that wildlife worldwide are affected. Although the causal agents and effects are known for some species, the underlying physiological mechanisms associated with contaminant-induced reproductive modifications are still poorly understood and require extensive research. We describe a study examining the steroidogenic activity of gonads removed from juvenile alligators (Alligator mississippiensis) obtained from contaminated or control lakes in central Florida. Synthesis of estradiol-17 beta (E2) was significantly different when ovaries from the contaminated and control lakes were compared in vitro. Additionally, testes from males obtained from the contaminated lake. Lake Apopka, synthesized significantly higher concentrations of E2 when compared to testes obtained from control males. In contrast, testosterone (T) synthesis from all testes examined in this study displayed a normal pattern and produced concentrations greater than that observed from ovaries obtained from either lake. Interestingly, the pattern of gonadal steroidogenesis differs from previously reported plasma concentrations of these hormones obtained from the same individuals. We suggest that the differences between the in vivo and in vitro patterns are due to modifications in the hepatic degradation of plasma sex steroid hormones.

The vertical wedge biopsy.

A biopsy technique is described that has been used in my clinical practice thousands of times. This very simple, cost-effective technique employs only one surgical tool, the scalpel blade, and permits a biopsy to be taken with sufficient tissue for histologic analysis. In that there is no disruption of a tumor margin, it permits the physician to make a diagnosis and not limit his or her choice of therapeutic modalities. Again, I wish to stress that appropriate selection of lesions is a critical point of this technique. It is unacceptable for lesions suspected to be malignant melanoma or for dermatoses that may have a deep component.

Cooperative frozen section surgery.

Utilization of the office setting for frozen section evaluation of tumor removal in the treatment of skin cancer is of considerable value. The impact of such surgery includes (1) enhanced quality of surgery by reducing the possibility of incomplete removal of tumor, (2) decreased financial cost to the patient when compared to hospital treatment, (3) better utilization of the doctor's time and facilities, (4) decreased disruption in the life of the patient and his family in terms of time off from work, surgery schedule flexibility, and a decrease in patient anxiety.

On history-taking before surgery.

History-taking is discussed with particular reference to cutaneous surgery. Systematic questioning with regard to general health, established and potential allergies, medicaments currently being taken, and miscellaneous relevant matters is important to the planning, execution, and outcome of surgical procedures.