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Introduction:
Evidence from a number of open-label, uncontrolled studies has suggested that rituximab may benefit patients with autoimmune diseases who are refractory to standard-of-care. The objective of this study was to evaluate the safety and clinical outcomes of rituximab in several standard-of-care-refractory autoimmune diseases (within rheumatology, nephrology, dermatology and neurology) other than rheumatoid arthritis or non-Hodgkin’s lymphoma in a real-life clinical setting.
Methods:
Patients who received rituximab having shown an inadequate response to standard-of-care had their safety and clinical outcomes data retrospectively analysed as part of the German Registry of Autoimmune Diseases. The main outcome measures were safety and clinical response, as judged at the discretion of the investigators.
Results:
A total of 370 patients (299 patient-years) with various autoimmune diseases (23.0% with systemic lupus erythematosus, 15.7% antineutrophil cytoplasmic antibody-associated granulomatous vasculitides, 15.1% multiple sclerosis and 10.0% pemphigus) from 42 centres received a mean dose of 2,440 mg of rituximab over a median (range) of 194 (180 to 1,407) days. The overall rate of serious infections was 5.3 per 100 patient-years during rituximab therapy. Opportunistic infections were infrequent across the whole study population, and mostly occurred in patients with systemic lupus erythematosus. There were 11 deaths (3.0% of patients) after rituximab treatment (mean 11.6 months after first infusion, range 0.8 to 31.3 months), with most of the deaths caused by infections. Overall (n = 293), 13.3% of patients showed no response, 45.1% showed a partial response and 41.6% showed a complete response. Responses were also reflected by reduced use of glucocorticoids and various immunosuppressives during rituximab therapy and follow-up compared with before rituximab. Rituximab generally had a positive effect on patient well-being (physician’s visual analogue scale; mean improvement from baseline of 12.1 mm)
Background: Since there is no standardized and effective treatment for advanced uveal melanoma (UM), the prognosis is dismal once metastases develop. Due to the availability of immune checkpoint blockade (ICB) in the real-world setting, the prognosis of metastatic UM has improved. However, it is unclear how the presence of hepatic and extrahepatic metastasis impacts the response and survival after ICB. Methods: A total of 178 patients with metastatic UM treated with ICB were included in this analysis. Patients were recruited from German skin cancer centers and the German national skin cancer registry (ADOReg). To investigate the impact of hepatic metastasis, two cohorts were compared: patients with liver metastasis only (cohort A, n = 55) versus those with both liver and extra-hepatic metastasis (cohort B, n = 123). Data were analyzed in both cohorts for response to treatment, progression-free survival (PFS), and overall survival (OS). The survival and progression probabilities were calculated with the Kaplan–Meier method. Log-rank tests, χ\(^2\) tests, and t-tests were performed to detect significant differences between both cohorts. Results: The median OS of the overall population was 16 months (95% CI 13.4–23.7) and the median PFS, 2.8 months (95% CI 2.5–3.0). The median OS was longer in cohort B than in cohort A (18.2 vs. 6.1 months; p = 0.071). The best objective response rate to dual ICB was 13.8% and to anti-PD-1 monotherapy 8.9% in the entire population. Patients with liver metastases only had a lower response to dual ICB, yet without significance (cohort A 8.7% vs. cohort B 16.7%; p = 0.45). Adverse events (AE) occurred in 41.6%. Severe AE were observed in 26.3% and evenly distributed between both cohorts. Conclusion: The survival of this large cohort of patients with advanced UM was more favorable than reported in previous benchmark studies. Patients with both hepatic and extrahepatic metastasis showed more favorable survival and higher response to dual ICB than those with hepatic metastasis only.
Die Cyclodextrin-modifizierte Kapillarelektrophorese (CE) ist eine wichtige chirale analytische Technik geworden, die zur HPLC und zur Gaschromatographie komplementär ist und sich deshalb für die Analyse der Abbauprodukte von Aspartam gut eignet. Ausgehend von diesen Abbauprodukten wurden im Arbeitskreis Scriba an der Universität Jena systematische Studien über die Trennung von Enantiomeren verschiedener Dipeptide mit einer Vielzahl von nativen und derivatisierten Cyclodextrinen bei verschiedenen pH-Werten durchgeführt. Bei der Trennung der Enantiomere von z. B. Ala-Phe oder Ala-Tyr mit beta-Cyclodextrin wurde eine Umkehr der Migrationsreihenfolge bei Erhöhung des Puffer-pH-Werts von 2,5 auf 3,5 festgestellt. Mit Heptakis-(6-sulfato)-beta-cyclodextrin (HS-beta-CD), Heptakis-(2,3-O-diacetyl)-beta-cyclodextrin (Diac-beta-CD) und Heptakis-(2,3-diacetyl-6-sulfato)-beta-cyclodextrin (HDAS-beta-CD) wurde diese Umkehr der Migrationsreihenfolge nicht beobachtet. Das Ziel der vorliegenden Arbeit war, den Mechanismus der Wechselwirkungen zwischen Cyclodextrinen und Aminosäuren bzw. Dipeptiden gründlich und umfassend zu untersuchen. Dabei ging es v. a. um die Untersuchung der Mechanismen der chiralen Erkennung durch Cyclodextrine, die mit Hilfe von verschiedensten Analysenmethoden, vor allem potentiometrische Titrationen und spektroskopische Methoden, wie der NMR-, UV- und CD-Spektroskopie durchgeführt werden sollten. Damit sollte auch die beobachtete Umkehr der Migrationsreihenfolge bei Erhöhung des pH-Wertes des Laufpuffers in der CE erklärt werden. Die potentiometrische Titrationsmethode lieferte sinnvolle Bindungskonstanten für Cyclodextrin-Einschlusskomplexe mit Aminosäuren. Eine Analyse der Struktur-Aktivitätsbeziehungen für Aminosäuren und Cyclodextrine ergab, dass ein gewisses Volumen der Aminosäure-Seitenkette und damit ein gutes Ausfüllen der Cyclodextrin-Kavität nötig ist, um den vollen Nutzen aus den hydrophoben Wechselwirkungen zwischen der Aminosäure-Seitenkette und der Cyclodextrin-Kavität zu ziehen. Eine Verlängerung des hydrophilen Restes, der aus der Kavität herausragt, wie bei den untersuchten Dipeptiden Ala-Phe und Ala-Tyr der Fall, führt zu der Möglichkeit der Ausbildung von Wasserstoff-Brücken mit den Hydroxylgruppen am breiteren Rand der Cyclodextrin-Kavität und damit zu einer stärkeren Bindung an das Cyclodextrin. Um den chiralen Erkennungsprozess von beta-CD und einigen seiner Derivate, nämlich HS-beta-CD, Diac-beta-CD und HDAS-beta-CD, zu verstehen, wurden NMR-Experimente durchgeführt, und zwar wurden „durch Komplexbildung induzierte Verschiebungen der chemischen Verschiebungen” (complexation induced chemical shifts, CICS) gemessen und mittels ROESY-Experimenten die Komplexgeometrie untersucht. Betrachtet man die CICS, die für die Paare Diac-beta-CD/Ala-Phe, HDAS-beta-CD/Ala-Phe, Diac-beta-CD/Ala-Tyr und HDAS-beta-CD/Ala-Tyr auftreten, dann zeigt sich, dass sie relativ klein sind und demnach auf eine eher schwache Wechselwirkung des jeweiligen Gastmoleküls mit dem Wirt hindeuten. Die CICS für beta-CD- und HS-beta-CD-Dipeptid-Komplexe bestätigten einen Einschluss des aromatischen Restes in die Cyclodextrin-Kavität. Es konnte gezeigt werden, dass bei pH 2.5 das DD-Enantiomer von Ala-Tyr tiefer in die Kavität von beta-CD eintaucht als das LL-Enantiomer. Außerdem ist bei pH 3.5 die Eintauchtiefe in die Kavität geringer als bei pH 2.5, was durch die Ergebnisse der ROESY-Experimente bestätigt werden konnte. Um einen besseren Einblick in die Bindungsmodi der Enantiomere von Ala-Phe und Ala-Tyr mit beta-CD bei unterschiedlichen pH-Werten zu erhalten, wurden Moleküldynamik-(MD-)-Simulationen durchgeführt. Die Simulationen wurden mit jedem Enantiomer von Ala-Phe und Ala-Tyr in jedem möglichen Protonierungszustand durchgeführt, d. h. Kation, Zwitterion und Anion. Zum ersten Mal wurden MD-Simulationen für eine größere Serie von unterschiedlichen Komplexen von Enantiomeren in verschiedenen Protonierungszuständen systematisch über den langen Zeitraum von 1 ns (=1000 ps) ausgeführt. Die Eintauchtiefe der untersuchten Dipeptide wurde mit Hilfe einer in die Cyclodextrin-Kavität eingepassten Ebene berechnet. Auf diese Weise konnten Informationen über das unterschiedliche Einschlussverhalten der untersuchten Dipeptide erhalten werden. Die angewendete Methode lässt sich leicht auf andere Wirt-Gast-Komplexe übertragen und erleichtert die Datenerfassung auch in anderen Fällen. Es konnte gezeigt werden, dass bei pH 2.5 das DD-Enantiomer von Ala-Phe tiefer in die Kavität von beta-Cyclodextrin eintaucht als das LL-Enantiomer, wohingegen bei pH 3.5 der umgekehrte Fall vorliegt. Betrachtet man das Dipeptid Ala-Tyr, dann dringt bei pH 2.5 das DD-Enantiomer tiefer ein, wohingegen keine klare Aussage über das Eindringverhalten der Enantiomere bei pH 3.5 gemacht werden kann. Die CICS und die Ergebnisse der Kapillarelektrophorese weisen jedoch auf ein tieferes Eindringen des LL-Enantiomers hin.
Background: Eosinophils appear to contribute to the efficacy of immunotherapy and their frequency was suggested as a predictive biomarker. Whether this observation could be transferred to patients treated with targeted therapy remains unknown. Methods: Blood and serum samples of healthy controls and 216 patients with advanced melanoma were prospectively and retrospectively collected. Freshly isolated eosinophils were phenotypically characterized by flow cytometry and co-cultured in vitro with melanoma cells to assess cytotoxicity. Soluble serum markers and peripheral blood counts were used for correlative studies. Results: Eosinophil-mediated cytotoxicity towards melanoma cells, as well as phenotypic characteristics, were similar when comparing healthy donors and patients. However, high relative pre-treatment eosinophil counts were significantly associated with response to MAPKi (p = 0.013). Eosinophil-mediated cytotoxicity towards melanoma cells is dose-dependent and requires proximity of eosinophils and their target in vitro. Treatment with targeted therapy in the presence of eosinophils results in an additive tumoricidal effect. Additionally, melanoma cells affected eosinophil phenotype upon co-culture. Conclusion: High pre-treatment eosinophil counts in advanced melanoma patients were associated with a significantly improved response to MAPKi. Functionally, eosinophils show potent cytotoxicity towards melanoma cells, which can be reinforced by MAPKi. Further studies are needed to unravel the molecular mechanisms of our observations.
Re-induction with immune checkpoint blockade (ICB) needs to be considered in many patients with uveal melanoma (UM) due to limited systemic treatment options. Here, we provide hitherto the first analysis of ICB re-induction in UM. A total of 177 patients with metastatic UM treated with ICB were included from German skin cancer centers and the German national skin cancer registry (ADOReg). To investigate the impact of ICB re-induction, two cohorts were compared: patients who received at least one ICB re-induction (cohort A, n = 52) versus those who received only one treatment line of ICB (cohort B, n = 125). In cohort A, a transient benefit of overall survival (OS) was observed at 6 and 12 months after the treatment start of ICB. There was no significant difference in OS between both groups (p = 0.1) with a median OS of 16.2 months (cohort A, 95% CI: 11.1–23.8) versus 9.4 months (cohort B, 95% CI: 6.1–14.9). Patients receiving re-induction of ICB (cohort A) had similar response rates compared to those receiving ICB once. Re-induction of ICB may yield a clinical benefit for a small subgroup of patients even after resistance or development of toxicities.
This evidence‐based clinical guideline provides consensus‐recommendations for the treatment and care of patients with primary antibody deficiencies (PADs). The guideline group comprised 20 clinical and scientific expert associations of the German, Swiss, and Austrian healthcare system and representatives of patients. Recommendations were based on results of a systematic literature search, data extraction, and evaluation of methodology and study quality in combination with the clinical expertise of the respective representatives. Consensus‐based recommendations were determined via nominal group technique. PADs are the largest clinically relevant group of primary immunodeficiencies. Most patients with PADs present with increased susceptibility to infections, however immune dysregulation, autoimmunity, and cancer affect a significant number of patients and may precede infections. This guideline therefore covers interdisciplinary clinical and therapeutic aspects of infectious (e.g., antibiotic prophylaxis, management of bronchiectasis) and non‐infectious manifestations (e.g., management of granulomatous disease, immune cytopenia). PADs are grouped into disease entities with definitive, probable, possible, or unlikely benefit of IgG‐replacement therapy. Summary and consensus‐recommendations are provided for treatment indication, dosing, routes of administration, and adverse events of IgG‐replacement therapy. Special aspects of concomitant impaired T‐cell function are highlighted as well as clinical data on selected monogenetic inborn errors of immunity formerly classified into PADs (APDS, CTLA‐4‐, and LRBA‐deficiency).