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Cynata Therapeutics (ASX:CYP) receives R&D tax incentive refund of more than $1.8M – The Market Herald

January 7th, 2020 12:52 pm

Cynata Therapeutics (CYP) has received a research and development tax incentive refund of $1,891,795 for the 2018-2019 financial year.

This tax incentive refund increases the company's cash position which stood at $9.2 million at the end of the September quarter.

It also enables further resources to be invested towards Cynata's phase 2 clinical trial programs for the critical limb ischemia (CLI) (reduced blood flow) and osteoarthritis products.

This will be alongside the anticipated phase 2 trial for CYP-001 in graft-versus-host disease which will be conducted by Fujifilm.

CLI is an advanced stage of peripheral artery disease which is the narrowing of the arteries in the limbs, typically in the lower legs.

It results from severely impaired blood flow which can cause pain, tissue damage, and gangrene.

Around 25 per cent of CLI patients who are unable to undergo surgery to remove the affected area, often an amputation, will die within a year of diagnosis.

Cynata' Cymerus mesenchymal stem cells (MSCs) have been successfully tested in a mouse model of CLI.

Muscles on the ischaemic leg were injected with Cymerus MSCs or a control.

Over a four-week follow-up period, the return of blood flow was measured and in animals treated with Cymerus MSCs blood flow in the injured limb was significantly higher at every point compared to the control.

MSCs are an adult stem cell found in a wide range of human tissues including bone marrow, fat tissue and placenta.

They are multi-potent which means they can produce more than one type of cell, for example they can differentiate into cartilage cells, bone cells and fat cells.

MSCs have been shown to ease regeneration and effects on the immune system without relying on engraftment (when the transplanted cells start to grow and make healthy cells).

The research and development tax incentive is an important Australian Government program that encourages companies to engage in research and development benefiting Australia by providing a tax offset for eligible activities.

Cynata's share price is up a steady 4.82 per cent with shares trading for $1.20 apiece at 3:29 pm AEDT.

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Cynata Therapeutics (ASX:CYP) receives R&D tax incentive refund of more than $1.8M - The Market Herald

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Dead bodies are revealing the secrets of how cancer kills – Wired.co.uk

January 7th, 2020 12:51 pm

At the Francis Crick Institute in central London, Andrew Rowan is labelling test tubes filled with chunks of human brain. The pieces are brown and spongy-looking, as if they would be springy to the touch; the rest of the brain sits to his right, in a large, smoking polystyrene box of dry ice. On a shelf above him is a row of food blenders. There is a curious smell in the laboratory not entirely unpleasant, but the kind one chooses not to ask about.

Rowan is excited. This particular brain is fresh from an autopsy conducted the previous week, and the donor a man in his 60s was found to have unforeseen tumours in his lower abdomen. We were prompted that the case would be mainly brain disease, so we were surprised at the extent of it elsewhere, Rowan says. Hopefully it will give us some clues.

As a senior research scientist at the institutes Cancer Evolution and Genome Instability Laboratory, Rowan has handled his fair share of human tissue to the extent that he can tell by eye which of his dissected samples are cancerous and which are not. (Theyre often different in colour, morphology, appearance.) When he has finished organising these 100 samples of brain some are set in liquid paraffin so they can be studied at room temperature, others kept frozen for longer-term study he will select the best quality ones for genetic sequencing. As for the rest of the patients organs, thats where the blenders come in.

We're making a slurry soup of matter, he says. We will then conduct something called deep sequencing we try and make sure we are picking up the total number of [genetic] mutations from that sample. All tumour tissue that is left over is collected for this, as we want to make sure nothing gets wasted. Tools used for liquidising the tissue before it is sequenced can only be used once owing to the risk of contamination, so Rowan gets his homogenisers (standard food blenders) for cheap from Argos.

It sounds macabre, but its important research. Rowan is one of a team of experts working on a new study into the way tumours spread. The Posthumous Evaluation of Advanced Cancer Environment (PEACE) study is an ongoing project, funded by Cancer Research UK, that follows a simple premise: terminally ill cancer patients agree to donate their body to science after they die, allowing researchers to perform autopsies to collect their blood and tissue for testing.

Until recently, scientists working in labs such as this one have relied upon cancer tissue taken from surgically removed biopsies a small section of disease taken from one site while the patient is alive. But the scope for experimentation with these samples is limited, and reveals very little about the wider ecosystem of the disease inside a patients body. Thanks to the volunteers signed up to PEACE, the team is now able to access entire, fresh organs from multiple sites in a patients body. It is the only study like it in the world, and the researchers believe the discoveries made from it could be revolutionary both in furthering scientific understanding of cancer, and in the continuing quest to find a cure.

Dr Andrew Rowan in the Francis Crick freezer farm, where tissue is stored at -80C

Sebastian Nevols

Some of the first recorded human autopsies are thought to have taken place in Egypt around 300 BCE, and throughout history medics, artists, philosophers and legal authorities have all taken inspiration or evidence from human and animal dissections. But while post-mortems remain relatively common, and are a legal requirement in many countries when a death is unexpected or suspicious, there has been a steep decline in hospital autopsies for research purposes over the past few decades. This is in part due to a misconception that, given the advances of modern technology, such apparently medieval practices are no longer useful. It is also a subject that makes many people squeamish including, PEACE co-ordinators suggest, doctors and clinicians.

When we were medical students, we used to go to the mortuary frequently to understand why patients died of that particular disease, says Charles Swanton, one of the Cricks leading cancer geneticists. Now, I think there is a sort of view that we dont need to know that it's not terribly important and its not going to tell us very much.

As group leader of the Cancer Evolution and Genome Instability Lab, Swanton first broached the idea for PEACE during a conversation with his colleague, Mariam Jamal-Hanjani, in 2014. I remember he walked into the lab late one night when I was still working and said You should set up a patient autopsy, Jamal-Hanjani recalls. Id only just joined his lab and I thought Thats a bit controversial. But hed planted the seed, and we just kept it going from there.

It took several more conversations for the pair to convince their colleagues, but by November 2016 they had managed to gather the resources and ethical approval required for the study. For decades, science and medicine had been waiting to be invigorated with new technologies, Swanton says. Probably part of the reason why nobody's been terribly interested in studying death is because, until recently, we've lacked the means to probe it.

One in two people will develop cancer in their lifetime, according to figures from Cancer Research UK. And while research has advanced in leaps and bounds in terms of finding drugs and improving our understanding of the disease, doctors still dont know the answer to one of the biggest questions: why do patients die? There is some degree of complacency, says Jamal-Hanjani. If a patient's got lung cancer or any type of cancer and then they die clinicians will presume that they have died of their cancer. But thats really a failure on our part.

In patients with cancer, there are some obvious reasons, Swanton says. Organ failure comes into it, [or] if you've got a brain metastasis patients can develop blood clots. But there are many other, much more subtle causes of death we know next to nothing about.

One interesting finding to come out of the PEACE study already is that the degree of cancer cells found within patients at death can vary by several million, demonstrating how some peoples bodies can live much longer than others when faced with tumour spread. A lung cancer patient, for example, may have a tumour containing between 100 and 300 million tumour cells at the point of diagnosis. By the time they die, that figure may have reached one trillion.

But what we are finding is that some patients really don't have much of the disease in their body at all, and so we really don't know how they die, says Swanton. There may be complex metabolic syndromes going on, it could be immune failure we just don't know. And we hope that PEACE can start to illuminate some of these questions.

A sample of metastatic bone tissue

Sebastian Nevols

With so much money being pumped into cancer research (Cancer Research UK alone had an income exceeding 670 million in 2018-19), one common question researchers face is why we havent found a cure. While cancer drugs often work for months, and sometimes years, drug resistance is the norm rather than the exception, Swanton says. Although there are thousands of treatments in development, the prospect of a one-stop drug that could help all cancer patients is a particular challenge, he says, because of the way cancer cells evolve.

In many living organisms, evolution happens in a linear pattern. For instance, a mutation will form in a cell that becomes replicated several times until all the cells contain the same mutation. If that were the case with tumour cells, one could imagine it would be possible to wipe out the entire tumour with a single drug because every cell in every tumour would essentially be the same. But we now know that these tumours aren't developing in a linear fashion at all they are evolving in a branch manner, Swanton says. While some cells contain mutations number one and two, others will have one, four and five; and others could have mutations one, six and seven the evolution of the cells becomes increasingly unpredictable and complex. This, he says, is a major reason why the drugs we use in the clinical setting fail.

The PEACE project is trying a new approach, by looking at the wider human biology, beyond a specific tumour site hence the need for access to the full human system. In our diagnostic practice we tend to get a biopsy from one metastatic site [an area to which a tumour has spread] it's very rare that we ever get more, says Swanton. But if you could sample a lung and a brain and an adrenal gland and the liver you could start to understand how the tumour cells start to react within the local environment. Because you cannot understand evolution unless you understand the species in this case cancer but also the environment in which it's evolving.

Through PEACE, Swanton and his team hope to develop their understanding of how and why tumours spread through the body, and attempt to find genetic patterns that might help explain cancer progression. A major purpose of the study is to collect enough material from autopsies to create a longstanding database of samples, which can hopefully be used in cancer research for decades to come.

The study is already producing results. In one paper, published in the journal Nature last year, the team looked at a patient with lung cancer. Analysing samples from different sites in the body to which the cancer had spread, they were able to identify genetic abnormalities. They then retrospectively analysed blood samples collected prior to the patients death, and detected the same genetic abnormalities. This showed us that blood could be used as a predictor of genetic changes that may be involved in cancer progression and metastasis, Jamal-Hanjani explains.

Another study, published in Cell, looked at two patients with kidney cancer one who died six months after diagnosis and another who died 17 years after diagnosis. Again, researchers analysed samples from different sites in the body. They identified distinct evolutionary patterns in each patients cancer progression, indicating that the genetic pattern in which a cancer evolves and spreads may offer clues to an individuals clinical outcome.

This means scientists may one day be able to predict a patients experience with a particular type of cancer based on their genes. It could help doctors accurately prescribe drugs they know are more likely to benefit the patient, and stop wasting time on those that wont eventually tailoring each persons treatment plan to their genetic make-up. We know that the environment in which a cancer grows plays a crucial role in its behaviour and progression or regression, Jamal-Hanjani says. Its by knowing how this genetic landscape changes in time, and how it leads to increasing disease burden, that we can understand better why drugs dont work and why patients eventually die from their disease.

Oncologist Mariam Jamal-Hajani, co-leader of the PEACE project

Sebastian Nevols

The PEACE researchers work usually starts with a phone call. Sometimes this comes with forewarning: the patient is unwell, it wont be long now. Other times, the death is more sudden: at home in the middle of the night, or in another hospital, and the team must make arrangements for autopsy as soon as possible.

As co-leader of the project, it is Jamal-Hanjanis task to make this happen. If I learn of a patients death, the next 24 hours are mayhem, she says. My team is communicating throughout the night. We'll be sending emails even at midnight saying: Where are we going to collect tissue from tomorrow? What did the last scan show? Have we got a slot with the mortuary? Have we found an undertaker?

For the autopsy to go ahead, the researchers must first secure copies of the patients consent form and death certificate. Jamal-Hanjani must also make sure there is no-one contesting the cause of death if there is, it will complicate matters, although a coronary post-mortem can take place alongside the autopsy. She aims to strike a balance between practical concerns booking a slot in the mortuary, bringing together the required staff and a sense of duty to the patients and their family. We try not to delay the process because families want it to happen fast, she says. The study is not suitable for some people from Jewish or Muslim backgrounds, since their religion may require a rapid burial. But sometimes we've been able to accommodate for that.

Once permission has been secured, a team of clinicians, research assistants and mortuary technicians meets to gather the equipment needed: liquid nitrogen to freeze fresh tissue samples at -80C, chemicals to preserve tissue into blocks, a dissection kit and medical packaging. The process itself can be brutally physical. Chests are cracked open to access lungs. Organs are removed in blocks, often the lungs and heart combined. A pathologist removes a kidney, slices it. The next person in line dissects it a little more. Another person puts it in the liquid nitrogen tank, and someone else labels it. The system is an exacting and precise conveyor belt, from the point of death to the moment the samples are brought back to the lab, with every piece barcoded and tracked.

Well-preserved tissue can last for many years often for as long as a study has ethical approval and so the researchers hope to build up a bank of good-quality samples to use in future work as well.

In the mortuary, the noise from the 24-hour flurry of emails, phone calls and planning comes to an abrupt stop. The mood is sombre, respectful. Theres no laughter, there's no discussion, says Jamal-Hajani. We just know that this is what our patient wanted, and we all get on with our business. The researchers are looking for evidence of tumour spread, so major tumour sites will be collected, but, unlike any kind of surgery when the patient is alive, the team will also collect some healthy tissue from surrounding regions for the purposes of comparison.

Everything else is replaced as it was inside the body, and the patient is sewn back up. Attention to detail and duty of care take priority; even in cases where the donors skull must be opened for access to the brain, pathologists will make their incision at the back of the patients neck, so that once the procedure is over no scarring can be seen.

People have asked me, What kind of scars will I have, what colour stitching will you use? says Jamal-Hanjani. She tells them that the stitching is subcutaneous under the skin and uses flesh-coloured thread. If its not a cremation, families sometimes haven't had time to view the body, and they'll do it after an autopsy, so we'll try to minimise any incisions, she explains. But beyond this, she takes such care because she believes the team is so privileged. Some patients say, When I'm dead, I'm dead I don't care what you do with my body. But for me, that respect and dignity that we try to maintain when patients are alive that's got to follow through even after death.

Human tissue, fixed for pathology analysis

Sebastian Nevols

The first person Jamal-Hanjani recruited to the PEACE study was 19 years old. A Cambridge University undergraduate studying politics, philosophy and economics, she was at the top of her class and had a bright future. But cancer is not one to discriminate, and, despite her youth, intelligence and ambitions, she died within 18 months.

That first conversation really stayed with me, Jamal-Hanjani remembers. She was so bright, so interested in what we were doing. She asked real specific questions. She wanted to know what would happen to her eyes. Would her body be scarred, would there be bruising? She cared about the research, but also what her family would be left with.

Approaching a patient about signing up to the study can be difficult. In the case of this young woman, I told her that donating herself to medical science could help us to learn why some patients develop drug resistance and why, in her case, we didnt have any treatment options that would work for her, Jamal-Hanjani says. I made it clear that she wouldnt benefit from any of this herself.

In the end, the team never did get to fulfil the students wish and go through with her autopsy. At that time, the project leader was heavily pregnant, and the study was in its early stages and had few resources. But the patient had also got married shortly before her death, and the sense was that her husband was not comfortable with the agreement. It was bittersweet, Jamal-Hanjani says. I really do feel strongly that we must try to keep the patients living wish. I couldnt do that for her, but I feel comfortable that I respected the wishes of her family whom she loved.

More than this, Jamal-Hanjani says the student gave her the push she needed in those early stages of the project. She taught me that there are patients out there who want to selflessly give like this because they want to help research, because they know thats how other patients might benefit in the future, she says. Before then, I had patients come to me and ask if there was anything they could do for instance, donate their organs after death. With her, it was the first time I could say: Heres a study you could be involved in. I have something for you. We may not have collected samples from her, but at that point in my life she really motivated me to make it happen for others.

A box of slides containing slices of preserved human tissue

Sebastian Nevols

Usually, a patient is approached to join the study by Jamal-Hanjani or a fellow clinician, but sometimes individuals get in touch themselves after hearing about it through their doctor or online. To date, the project has recruited around 190 patients across the UK and completed more than 100 autopsies. Initially starting as a collaboration between the Francis Crick Institute and the nearby University College Hospital, the programme has expanded to include ten sites across Britain, including Glasgow, Sheffield, Southampton and Birmingham. The study is potentially open to anyone with tumours that have spread, but Jamal-Hanjani is cautious about who she recruits, and has turned people down if there is a chance their tissue would not be useful for the study.

On the flipside, there have been cases where patients are included who have not had the chance to personally consent while alive. The study was set up with doctors and scientists, but also really heavy and ongoing input from patient advocacy groups, she explains. The feedback we had was that patients still want to be part of this study but maybe they're physically not well enough to come and give consent. At a certain point, a patient may have given power of attorney to a close relative so a family might give consent on the patient's behalf. Jamal-Hanjani admits it is difficult to that sort of patient down.

Every funded research project has targets. On paper, PEACEs aim is to perform 500 research autopsies in five years. In reality, it is not on track. It's rather ambitious because, logistically, this study has been a nightmare, says Jamal-Hanjani. These patients can die anywhere. At home, in a hospice, in another hospital. They can be hours away from where we perform the autopsies. We don't always know when a patient has died, simply that interaction with the family's relatives after death can be incredibly difficult for us and for them.

Theres also the issue of funding. PEACE was originally promised 5 million from Cancer Research UK spread over five years, but this was unexpectedly dropped to 4 million. According to Jamal-Hanjani, the amount is only enough to cover the basic infrastructure for the setup of the study any analysis of samples relies on additional funding. The current round of financial backing ends in October 2021, and the team is desperately hoping to keep going for another five years beyond that. It's a horrible thought that weve got fixed funding for a certain number of autopsies, says Swanton. It's a terribly cold measure.

More than that, of course, the future of PEACE will depend on the continued willingness of volunteers to participate. Patients have been our greatest advocate here, not doctors or lawyers, says Swanton. It's been patients who have really wanted this to happen. And theyve been incredible with their generosity in enabling us to do this. We really owe everything to them.

Thomas Filson, a cancer patient who has signed up to the PEACE trial, with his dog, Petal

Sebastian Nevols

The discoveries coming out of PEACE are too late to help Thomas Filson, but the decision to donate his body to the study was a no-brainer nonetheless. Why? Well youve just seen two reasons why, he says, indicating the two small boys scampering around him. Its a warm day, and the 70-year-old is sitting in an armchair at the home he shares with his wife, Lynn, in Ashford, Surrey. The boys two of his four grandchildren are making a convincing case for ice-cream. Thomas is stoic, a straight-talking former carpenter with a star dangling unexpectedly from his left earlobe (his daughters belly button ring, he explains just because she didnt think Id dare). On his wrists are piles of multicoloured woven bracelets and charity bands. He very much embraces life but doesnt take it too seriously certainly not since his diagnosis six years ago.

Thomas was just half a year from retirement when he was diagnosed with lung cancer. Then, as if to demonstrate how unfair life can be, Lynn's breast cancer was identified. She has since made a full recovery, but spent the first few months of Thomass diagnosis sick from her own chemotherapy.

From a lifetime of smoking and working with wood, Thomas says his lungs have had a fairly stressful time with dust and muck and everything. They told me at 50 I had to stop smoking because I'd kill myself. Then of course, years later, life comes and surprises you.

Like several PEACE recruits, Thomas was already signed up to a different cancer research trial run through the Crick called TRACERx, which studies the biopsies of tumours surgically removed from living patients. Being part of active research appeals to him, so he was an ideal candidate for researchers to bring up the subject of autopsy. I've been a carpenter all my life dirt's dirt, isnt it? he says. I've got a fairly rounded view of life and death. I'm a Christian, don't get me wrong, but I think of myself as just another ant, running over this planet destroying it. So I said Yes, let's go for it because there is no cure for this type of cancer, what have I got to lose? Let's give something back.

Behind Thomass upbeat demeanour is a man whose body is increasingly weak. He can no longer walk very far, and his skin has suffered since his last round of immunotherapy drugs. But every morning, he takes out his deaf Staffordshire bull terrier out to the waterfront near his house. The two of them will sit, sometimes for a couple of hours, and give space to their thoughts. I don't get emotional because I think I'm going to die, but sometimes I get a bit frustrated because I can't do what I want to do, he says. I very rarely get depressed, because I think my life has been good. But it's easy to die; its harder for your family or your partner.

For Lynn, the road ahead will no doubt be difficult. But she agrees Thomas is making the right choice. Tom and I we're at the stage now where if I woke up tomorrow and he was gone, I couldn't grieve, because I've done my grieving, she says. People will probably look at me and think What a hard woman. But they haven't lived with him with the knowledge that he's going to die. And I think hes absolutely doing the right thing.

To spend time with both patients such as Thomas and the researchers behind the PEACE study, is to see the strong, mutual respect. Ultimately, it is this human level of understanding and the shared experiences of how cancer affects a family that drives the study.

Im not daft enough to think my body will be the breakthrough, says Thomas. It will take many more volunteers before that happens. But both he and Lynn take courage from the hope that his death may ultimately help people. Lynn says she thinks taking part in the research has helped Thomas, too.

I don't get down, Thomas nods. Not really. I think what keeps me so buoyant is the fact that I have given myself to research and to PEACE, and to know that it's not all in vain. I'm not dying in vain.

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For Kaus, getting back on court is next step in recovery – Mankato Free Press

January 7th, 2020 12:50 pm

Justin Kaus has officiated thousands of basketball games in the last couple of decades, but on Friday night, in the locker room a few minutes before taking the court at Fitzgerald Gym, his resting heart rate was a rapid 118 beats per minute.

Its been a long time since Ive been that nervous and had that much adrenaline for a (junior-varsity) game, Kaus said, gathering with friends later Friday night to celebrate the way basketball officials often do on the weekend. It was awesome.

Kaus returned to the basketball court Friday for the first time since early February, having battled a form of leukemia that halted his professional and athletic career and nearly took his life.

It was great, he said, flexing some stiff muscles and joints. The interaction with coaches, talking with fans, interacting with the players ... you forget how much fun and rewarding that it.

It was more than 14 months since Kaus, 44, went to the clinic, feeling run down and with little energy or strength. He was diagnosed with a sinus infection, but two weeks passed, with stronger antibiotics, and he wasnt feeling any better.

He scheduled a visit to another doctor, who put him through a more extensive examination. He had blood drawn, and, as he was driving home, his doctor called and told him to get to the emergency room.

His hemoglobin level was dangerously low, and Kaus was taken by ambulance to the hospital in Rochester.

I went from thinking I had a sinus infection to having blood cancer in about 6 hours, Kaus said.

Thus began the yearlong process of trying to survive a diagnosis of primary myelofibrosis, a treatable form of leukemia. He continued his normal routine of work and officiating basketball games for a couple of months, trying not to get too worn down.

By February, after finding a couple of perfect donors for a bone-marrow transplant, the treatment became more rigorous and dangerous.

There was a round of chemotherapy in mid-February, followed by a stem cell transplant on Feb. 28. He was told to expect at least 100 days in the hospital, but that time more than doubled when he had to have his spleen removed in March. He developed an infection that required the removal of most of his colon, forcing a lifesaving surgery on May 25.

The doctor told me that if I didnt have my colon removed, it would likely burst, Kaus said. At that point, there would have been nothing more they could do for me.

There were a few weeks during the summer that he cant remember. At one point, he shut off his cell phone after staring at it one day, not sure what he was supposed to do with it. His friends stayed in touch through an online diary, written by his girlfriend, Delight Simpson.

In May, hundreds of Kaus friends gathered for a fundraiser, collecting thousands of dollars to help him with his monthly bills and extra expenses and exchanging hope for Kaus.

I cant thank people enough, he said, getting momentarily choked up with emotion. The support Ive received from my family, my work family, my basketball family has been unbelievable.

Kaus said that since that surgery, his recovery has been rapid and remarkable. Its about what he had originally been told had he not had any complications. Hes had more than 100 blood transfusions, and ironically, he now goes in a couple of times each month to have some blood removed.

After what Ive been through, its hard to watch them just throw that blood away, he said.

He weighed 153 pounds when the treatments began but slipped to 98 pounds. Hes worked hard to get his weight back to near normal, and hes done of lot of rehab work to regain strength. He was unable to lift 2 pounds at his most dire times. He still sees a doctor a couple of times each month, but those visits have become less frequent.

Until recently, he had to rely on Simpson, his daughter, Taylor, and his mom, Sally, to get around, but now hes driving again.

When he started rehab, he couldnt lift 10 pounds on the single-leg press, but hes now up to 125. Hes always been active, participating in sports, and his conditioning has slowly returned.

It felt so good to see him there, said Ben Kaus, Justins cousin and officiating partner on Friday. There was such a shock factor (a year ago) when we found out about his condition, and it took a while to sink in. For a while, we didnt know if Justin was going to be around much longer.

But at one of the visits, when it didnt look very good, he told us that he was going to make it. His positive attitude is what made the difference. Justin has always been like a big brother to me, and its great to have him back.

On Feb. 28, which will be one year from the stem-cell transplant, Kaus will have a checkup to see if the cancer is gone or he needs more treatment. Hell also know shortly after that if he needs to continue with colostomy and ileostomy bags or he can have surgery to reattach his colon to the digestive tract.

Until then, hes going to continue to increase his work hours and officiate basketball as much as his body can tolerate. He wanted to get that first assignment out of the way to see how he felt, then he can plan the next couple of months. Being on the court is as much of a mental triumph as a physical milestone.

In August, I had pretty much written off this season, he said. In early December, it was my 40th physical therapy session in Mankato, my physical therapist suggested that I talk with some coach and go to a scrimmage to simulate basketball movements.

Its the coolest thing to be back on the court, he said. Ive gotten so many messages and words of encouragement and support from the start to this point. This was another step in getting back to normal, and its something Ive worked hard for.

Its never been about me, but the camaraderie being around other officials and telling stories and talking about the games has been very therapeutic. We dont have to (officiate basketball games). We do it because we still enjoy the games and we want to give something back. I hope the coaches, the players, the fans appreciate what we do, but in the end, all that matters is were spending time in the gym, around a game that we love.

Follow Chad Courrier on Twitter @ChadCourrier.

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For Kaus, getting back on court is next step in recovery - Mankato Free Press

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Wearable monitoring technology helps nurses avoid waking sleep-deprived patients – ABC News

January 7th, 2020 12:50 pm

Updated January 06, 2020 08:30:20

Since being diagnosed with Hodgkin's lymphoma 18 months ago, Aliona Grytsenko has spent much of her time in and out of hospital.

When the 22-year-old architecture student developed an infection after having a stem cell transplant, she had to be woken every hour to have her vital signs checked.

"It made it really hard to sleep and rest in the midst of having fevers and going through the treatment and side effects themselves. It's really difficult to manage that when you're so sleep-deprived," Ms Grytsenko said.

Registered nurse and researcher Elise Button has worked in cancer and palliative care for 10 years and said waking people up was one of the worst parts of the job.

"We routinely wake people up every four hours if they're more unwell we wake them up every hour or 15 minutes to do vital sign monitoring to make sure they're safe," Dr Button said.

"The sicker they are, the more we wake them up."

But new technology being trialled at the 20-bed Kilcoy Hospital, north-west of Brisbane, may put an end to what has been one of nurses' core responsibilities taking and recording vital signs.

Patients are being fitted with wearable body sensors that will automatically record their temperature, heart rate, oxygen levels and blood pressure.

Dr Button said it was a potential game-changer in nursing care.

"It gives us more time to focus on all the other roles that a nurse does that are important particularly communicating with people, sitting down and talking to them, while we know they're being safely monitored," Dr Button said.

"This allows people who are unwell to get sleep and rest, with peace of mind that they're being safely monitored."

The Metro North Hospital and Health Service's Adam Scott is overseeing the trial and says the feedback so far has been positive.

"Patients have commented they no longer have to be woken through the night. They can sleep through the process," Professor Scott said.

The wireless monitoring technology has been in development for a decade, but it is the first time in the world it has been put to the test by an entire hospital.

It could also help save hospital bottom lines.

"We have a growing level and burden of chronic disease, we have higher life expectancies and higher community expectations on how healthcare is provided," Professor Scott said.

"We know we have to move towards a value-based healthcare approach to better provide services and care for our patients."

The Australian distributor for the wireless monitoring device, Wearable Health Tech, estimates there are more than 100 million patient observations performed each year in Australia.

Company spokesman Ben Magid said the system not only gave time back to staff to spend on patient care, but improved patient safety through continuous monitoring.

"If patients do start to go downhill, staff are alerted so they can intervene sooner and prevent adverse events and complications from developing," Mr Magid said.

If the trial goes well, the technology could be used more widely, allowing patients to recover at home, while still being monitored by hospital staff.

Ms Grytsenko said it would have given her peace of mind.

"In the first few weeks after the stem cell transplant you don't know how you're going, you don't know, is that bad enough that I should call someone and ask or is it OK?'' Ms Grytsenko said.

Professor Scott said he believed it could also revolutionise rural medicine.

"We could have a command centre located in a metropolitan city where the specialist staff are sitting supervising and looking after and viewing patients that are located in a rural facility," Professor Scott said.

The trial will run until June.

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First posted January 06, 2020 06:56:17

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Merck’s KEYTRUDA (pembrolizumab) in Combination with Chemotherapy Significantly Improved Progression-Free Survival Compared to Chemotherapy Alone as…

January 6th, 2020 4:46 pm

KENILWORTH, N.J.--(BUSINESS WIRE)--Merck (NYSE: MRK), known as MSD outside the United States and Canada, today announced that the Phase 3 KEYNOTE-604 trial investigating KEYTRUDA, Mercks anti-PD-1 therapy, in combination with chemotherapy met one of its dual primary endpoints of progression-free survival (PFS) in the first-line treatment of patients with extensive stage small cell lung cancer (ES-SCLC). In the study, treatment with KEYTRUDA in combination with chemotherapy (etoposide plus cisplatin or carboplatin) resulted in a statistically significant improvement in PFS compared to chemotherapy alone (HR=0.75 [95% CI, 0.61-0.91]), which was observed at a prior interim analysis. At the final analysis of the study, there was also an improvement in overall survival (OS) for patients treated with KEYTRUDA in combination with chemotherapy compared to chemotherapy alone; however, these OS results did not meet statistical significance per the pre-specified statistical plan (HR=0.80 [95% CI, 0.64-0.98]). The safety profile of KEYTRUDA in this trial was consistent with that observed in previously reported studies. Results will be presented at an upcoming medical meeting and discussed with regulatory authorities.

Results of KEYNOTE-604 demonstrated the potential of KEYTRUDA, in combination with chemotherapy, to improve outcomes for patients newly diagnosed with extensive stage small cell lung cancer, a highly aggressive malignancy, said Dr. Roy Baynes, senior vice president and head of global clinical development, chief medical officer, Merck Research Laboratories. We sincerely thank the patients and investigators for their participation in this study and are committed to helping patients who face difficult-to-treat types of lung cancer.

In addition to KEYTRUDAs five current indications in lung cancer, Merck is continuing to study KEYTRUDA across multiple settings and stages of lung cancer through a broad clinical program, which is comprised of more than 10,000 patients enrolled or expected to be enrolled across 20 Merck-sponsored clinical studies.

About KEYNOTE-604

KEYNOTE-604 is a randomized, double-blind, placebo-controlled Phase 3 trial (ClinicalTrials.gov, NCT03066778) investigating KEYTRUDA in combination with chemotherapy compared to chemotherapy alone in patients with newly diagnosed ES-SCLC. The dual primary endpoints were OS and PFS. Secondary endpoints included objective response rate (ORR), duration of response (DOR), safety and quality of life (QoL). The study enrolled 453 patients who were randomized to receive either:

About Lung Cancer

Lung cancer, which forms in the tissues of the lungs, usually within cells lining the air passages, is the leading cause of cancer death worldwide. Each year, more people die of lung cancer than die of colon and breast cancers combined. The two main types of lung cancer are non-small cell and small cell. Non-small cell lung cancer (NSCLC) is the most common type of lung cancer, accounting for about 85% of all cases. Small cell lung cancer (SCLC) accounts for about 10 to 15% of all lung cancers. The five-year survival rate for patients diagnosed in the U.S. with any stage of SCLC is estimated to be 6%.

About KEYTRUDA (pembrolizumab) Injection, 100mg

KEYTRUDA is an anti-PD-1 therapy that works by increasing the ability of the bodys immune system to help detect and fight tumor cells. KEYTRUDA is a humanized monoclonal antibody that blocks the interaction between PD-1 and its ligands, PD-L1 and PD-L2, thereby activating T lymphocytes which may affect both tumor cells and healthy cells.

Merck has the industrys largest immuno-oncology clinical research program. There are currently more than 1,000 trials studying KEYTRUDA across a wide variety of cancers and treatment settings. The KEYTRUDA clinical program seeks to understand the role of KEYTRUDA across cancers and the factors that may predict a patients likelihood of benefitting from treatment with KEYTRUDA, including exploring several different biomarkers.

Selected KEYTRUDA (pembrolizumab) Indications

Melanoma

KEYTRUDA is indicated for the treatment of patients with unresectable or metastatic melanoma.

KEYTRUDA is indicated for the adjuvant treatment of patients with melanoma with involvement of lymph node(s) following complete resection.

Non-Small Cell Lung Cancer

KEYTRUDA, in combination with pemetrexed and platinum chemotherapy, is indicated for the first-line treatment of patients with metastatic nonsquamous non-small cell lung cancer (NSCLC), with no EGFR or ALK genomic tumor aberrations.

KEYTRUDA, in combination with carboplatin and either paclitaxel or paclitaxel protein-bound, is indicated for the first-line treatment of patients with metastatic squamous NSCLC.

KEYTRUDA, as a single agent, is indicated for the first-line treatment of patients with NSCLC expressing PD-L1 [tumor proportion score (TPS) 1%] as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations, and is stage III where patients are not candidates for surgical resection or definitive chemoradiation, or metastatic.

KEYTRUDA, as a single agent, is indicated for the treatment of patients with metastatic NSCLC whose tumors express PD-L1 (TPS 1%) as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving KEYTRUDA.

Small Cell Lung Cancer

KEYTRUDA is indicated for the treatment of patients with metastatic small cell lung cancer (SCLC) with disease progression on or after platinum-based chemotherapy and at least one other prior line of therapy. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

Head and Neck Squamous Cell Cancer

KEYTRUDA, in combination with platinum and fluorouracil (FU), is indicated for the first-line treatment of patients with metastatic or with unresectable, recurrent head and neck squamous cell carcinoma (HNSCC).

KEYTRUDA, as a single agent, is indicated for the first-line treatment of patients with metastatic or with unresectable, recurrent HNSCC whose tumors express PD-L1 [combined positive score (CPS) 1] as determined by an FDA-approved test.

KEYTRUDA, as a single agent, is indicated for the treatment of patients with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) with disease progression on or after platinum-containing chemotherapy.

Classical Hodgkin Lymphoma

KEYTRUDA is indicated for the treatment of adult and pediatric patients with refractory classical Hodgkin lymphoma (cHL), or who have relapsed after 3 or more prior lines of therapy. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.

Primary Mediastinal Large B-Cell Lymphoma

KEYTRUDA is indicated for the treatment of adult and pediatric patients with refractory primary mediastinal large B-cell lymphoma (PMBCL), or who have relapsed after 2 or more prior lines of therapy. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials. KEYTRUDA is not recommended for treatment of patients with PMBCL who require urgent cytoreductive therapy.

Urothelial Carcinoma

KEYTRUDA is indicated for the treatment of patients with locally advanced or metastatic urothelial carcinoma (mUC) who are not eligible for cisplatin-containing chemotherapy and whose tumors express PD-L1 [combined positive score (CPS) 10] as determined by an FDA-approved test, or in patients who are not eligible for any platinum-containing chemotherapy regardless of PD-L1 status. This indication is approved under accelerated approval based on tumor response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

KEYTRUDA is indicated for the treatment of patients with locally advanced or metastatic urothelial carcinoma (mUC) who have disease progression during or following platinum-containing chemotherapy or within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy.

Microsatellite Instability-High (MSI-H) Cancer

KEYTRUDA is indicated for the treatment of adult and pediatric patients with unresectable or metastatic microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR)

This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials. The safety and effectiveness of KEYTRUDA in pediatric patients with MSI-H central nervous system cancers have not been established.

Gastric Cancer

KEYTRUDA is indicated for the treatment of patients with recurrent locally advanced or metastatic gastric or gastroesophageal junction (GEJ) adenocarcinoma whose tumors express PD-L1 (CPS 1) as determined by an FDA-approved test, with disease progression on or after two or more prior lines of therapy including fluoropyrimidine- and platinum-containing chemotherapy and if appropriate, HER2/neu-targeted therapy. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.

Esophageal Cancer

KEYTRUDA is indicated for the treatment of patients with recurrent locally advanced or metastatic squamous cell carcinoma of the esophagus whose tumors express PD-L1 (CPS 10) as determined by an FDA-approved test, with disease progression after one or more prior lines of systemic therapy.

Cervical Cancer

KEYTRUDA is indicated for the treatment of patients with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy whose tumors express PD-L1 (CPS 1) as determined by an FDA-approved test. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.

Hepatocellular Carcinoma

KEYTRUDA is indicated for the treatment of patients with hepatocellular carcinoma (HCC) who have been previously treated with sorafenib. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.

Merkel Cell Carcinoma

KEYTRUDA is indicated for the treatment of adult and pediatric patients with recurrent locally advanced or metastatic Merkel cell carcinoma (MCC). This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.

Renal Cell Carcinoma

KEYTRUDA, in combination with axitinib, is indicated for the first-line treatment of patients with advanced renal cell carcinoma (RCC).

Selected Important Safety Information for KEYTRUDA

Immune-Mediated Pneumonitis

KEYTRUDA can cause immune-mediated pneumonitis, including fatal cases. Pneumonitis occurred in 3.4% (94/2799) of patients with various cancers receiving KEYTRUDA, including Grade 1 (0.8%), 2 (1.3%), 3 (0.9%), 4 (0.3%), and 5 (0.1%). Pneumonitis occurred in 8.2% (65/790) of NSCLC patients receiving KEYTRUDA as a single agent, including Grades 3-4 in 3.2% of patients, and occurred more frequently in patients with a history of prior thoracic radiation (17%) compared to those without (7.7%). Pneumonitis occurred in 6% (18/300) of HNSCC patients receiving KEYTRUDA as a single agent, including Grades 3-5 in 1.6% of patients, and occurred in 5.4% (15/276) of patients receiving KEYTRUDA in combination with platinum and FU as first-line therapy for advanced disease, including Grades 3-5 in 1.5% of patients.

Monitor patients for signs and symptoms of pneumonitis. Evaluate suspected pneumonitis with radiographic imaging. Administer corticosteroids for Grade 2 or greater pneumonitis. Withhold KEYTRUDA for Grade 2; permanently discontinue KEYTRUDA for Grade 3 or 4 or recurrent Grade 2 pneumonitis.

Immune-Mediated Colitis

KEYTRUDA can cause immune-mediated colitis. Colitis occurred in 1.7% (48/2799) of patients receiving KEYTRUDA, including Grade 2 (0.4%), 3 (1.1%), and 4 (<0.1%). Monitor patients for signs and symptoms of colitis. Administer corticosteroids for Grade 2 or greater colitis. Withhold KEYTRUDA for Grade 2 or 3; permanently discontinue KEYTRUDA for Grade 4 colitis.

Immune-Mediated Hepatitis (KEYTRUDA) and Hepatotoxicity (KEYTRUDA in Combination With Axitinib)

Immune-Mediated Hepatitis

KEYTRUDA can cause immune-mediated hepatitis. Hepatitis occurred in 0.7% (19/2799) of patients receiving KEYTRUDA, including Grade 2 (0.1%), 3 (0.4%), and 4 (<0.1%). Monitor patients for changes in liver function. Administer corticosteroids for Grade 2 or greater hepatitis and, based on severity of liver enzyme elevations, withhold or discontinue KEYTRUDA.

Hepatotoxicity in Combination With Axitinib

KEYTRUDA in combination with axitinib can cause hepatic toxicity with higher than expected frequencies of Grades 3 and 4 ALT and AST elevations compared to KEYTRUDA alone. With the combination of KEYTRUDA and axitinib, Grades 3 and 4 increased ALT (20%) and increased AST (13%) were seen. Monitor liver enzymes before initiation of and periodically throughout treatment. Consider more frequent monitoring of liver enzymes as compared to when the drugs are administered as single agents. For elevated liver enzymes, interrupt KEYTRUDA and axitinib, and consider administering corticosteroids as needed.

Immune-Mediated Endocrinopathies

KEYTRUDA can cause hypophysitis, thyroid disorders, and type 1 diabetes mellitus. Hypophysitis occurred in 0.6% (17/2799) of patients, including Grade 2 (0.2%), 3 (0.3%), and 4 (<0.1%). Hypothyroidism occurred in 8.5% (237/2799) of patients, including Grade 2 (6.2%) and 3 (0.1%). The incidence of new or worsening hypothyroidism was higher in 1185 patients with HNSCC (16%) receiving KEYTRUDA, as a single agent or in combination with platinum and FU, including Grade 3 (0.3%) hypothyroidism. Hyperthyroidism occurred in 3.4% (96/2799) of patients, including Grade 2 (0.8%) and 3 (0.1%), and thyroiditis occurred in 0.6% (16/2799) of patients, including Grade 2 (0.3%). Type 1 diabetes mellitus, including diabetic ketoacidosis, occurred in 0.2% (6/2799) of patients.

Monitor patients for signs and symptoms of hypophysitis (including hypopituitarism and adrenal insufficiency), thyroid function (prior to and periodically during treatment), and hyperglycemia. For hypophysitis, administer corticosteroids and hormone replacement as clinically indicated. Withhold KEYTRUDA for Grade 2 and withhold or discontinue for Grade 3 or 4 hypophysitis. Administer hormone replacement for hypothyroidism and manage hyperthyroidism with thionamides and beta-blockers as appropriate. Withhold or discontinue KEYTRUDA for Grade 3 or 4 hyperthyroidism. Administer insulin for type 1 diabetes, and withhold KEYTRUDA and administer antihyperglycemics in patients with severe hyperglycemia.

Immune-Mediated Nephritis and Renal Dysfunction

KEYTRUDA can cause immune-mediated nephritis. Nephritis occurred in 0.3% (9/2799) of patients receiving KEYTRUDA, including Grade 2 (0.1%), 3 (0.1%), and 4 (<0.1%) nephritis. Nephritis occurred in 1.7% (7/405) of patients receiving KEYTRUDA in combination with pemetrexed and platinum chemotherapy. Monitor patients for changes in renal function. Administer corticosteroids for Grade 2 or greater nephritis. Withhold KEYTRUDA for Grade 2; permanently discontinue for Grade 3 or 4 nephritis.

Immune-Mediated Skin Reactions

Immune-mediated rashes, including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) (some cases with fatal outcome), exfoliative dermatitis, and bullous pemphigoid, can occur. Monitor patients for suspected severe skin reactions and based on the severity of the adverse reaction, withhold or permanently discontinue KEYTRUDA and administer corticosteroids. For signs or symptoms of SJS or TEN, withhold KEYTRUDA and refer the patient for specialized care for assessment and treatment. If SJS or TEN is confirmed, permanently discontinue KEYTRUDA.

Other Immune-Mediated Adverse Reactions

Immune-mediated adverse reactions, which may be severe or fatal, can occur in any organ system or tissue in patients receiving KEYTRUDA and may also occur after discontinuation of treatment. For suspected immune-mediated adverse reactions, ensure adequate evaluation to confirm etiology or exclude other causes. Based on the severity of the adverse reaction, withhold KEYTRUDA and administer corticosteroids. Upon improvement to Grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month. Based on limited data from clinical studies in patients whose immune-related adverse reactions could not be controlled with corticosteroid use, administration of other systemic immunosuppressants can be considered. Resume KEYTRUDA when the adverse reaction remains at Grade 1 or less following corticosteroid taper. Permanently discontinue KEYTRUDA for any Grade 3 immune-mediated adverse reaction that recurs and for any life-threatening immune-mediated adverse reaction.

The following clinically significant immune-mediated adverse reactions occurred in less than 1% (unless otherwise indicated) of 2799 patients: arthritis (1.5%), uveitis, myositis, Guillain-Barr syndrome, myasthenia gravis, vasculitis, pancreatitis, hemolytic anemia, sarcoidosis, and encephalitis. In addition, myelitis and myocarditis were reported in other clinical trials, including classical Hodgkin lymphoma, and postmarketing use.

Treatment with KEYTRUDA may increase the risk of rejection in solid organ transplant recipients. Consider the benefit of treatment vs the risk of possible organ rejection in these patients.

Infusion-Related Reactions

KEYTRUDA can cause severe or life-threatening infusion-related reactions, including hypersensitivity and anaphylaxis, which have been reported in 0.2% (6/2799) of patients. Monitor patients for signs and symptoms of infusion-related reactions. For Grade 3 or 4 reactions, stop infusion and permanently discontinue KEYTRUDA.

Complications of Allogeneic Hematopoietic Stem Cell Transplantation (HSCT)

Immune-mediated complications, including fatal events, occurred in patients who underwent allogeneic HSCT after treatment with KEYTRUDA. Of 23 patients with cHL who proceeded to allogeneic HSCT after KEYTRUDA, 6 (26%) developed graft-versus-host disease (GVHD) (1 fatal case) and 2 (9%) developed severe hepatic veno-occlusive disease (VOD) after reduced-intensity conditioning (1 fatal case). Cases of fatal hyperacute GVHD after allogeneic HSCT have also been reported in patients with lymphoma who received a PD-1 receptorblocking antibody before transplantation. Follow patients closely for early evidence of transplant-related complications such as hyperacute graft-versus-host disease (GVHD), Grade 3 to 4 acute GVHD, steroid-requiring febrile syndrome, hepatic veno-occlusive disease (VOD), and other immune-mediated adverse reactions.

In patients with a history of allogeneic HSCT, acute GVHD (including fatal GVHD) has been reported after treatment with KEYTRUDA. Patients who experienced GVHD after their transplant procedure may be at increased risk for GVHD after KEYTRUDA. Consider the benefit of KEYTRUDA vs the risk of GVHD in these patients.

Increased Mortality in Patients With Multiple Myeloma

In trials in patients with multiple myeloma, the addition of KEYTRUDA to a thalidomide analogue plus dexamethasone resulted in increased mortality. Treatment of these patients with a PD-1 or PD-L1 blocking antibody in this combination is not recommended outside of controlled trials.

Embryofetal Toxicity

Based on its mechanism of action, KEYTRUDA can cause fetal harm when administered to a pregnant woman. Advise women of this potential risk. In females of reproductive potential, verify pregnancy status prior to initiating KEYTRUDA and advise them to use effective contraception during treatment and for 4 months after the last dose.

Adverse Reactions

In KEYNOTE-006, KEYTRUDA was discontinued due to adverse reactions in 9% of 555 patients with advanced melanoma; adverse reactions leading to permanent discontinuation in more than one patient were colitis (1.4%), autoimmune hepatitis (0.7%), allergic reaction (0.4%), polyneuropathy (0.4%), and cardiac failure (0.4%). The most common adverse reactions (20%) with KEYTRUDA were fatigue (28%), diarrhea (26%), rash (24%), and nausea (21%).

In KEYNOTE-002, KEYTRUDA was permanently discontinued due to adverse reactions in 12% of 357 patients with advanced melanoma; the most common (1%) were general physical health deterioration (1%), asthenia (1%), dyspnea (1%), pneumonitis (1%), and generalized edema (1%). The most common adverse reactions were fatigue (43%), pruritus (28%), rash (24%), constipation (22%), nausea (22%), diarrhea (20%), and decreased appetite (20%).

In KEYNOTE-054, KEYTRUDA was permanently discontinued due to adverse reactions in 14% of 509 patients; the most common (1%) were pneumonitis (1.4%), colitis (1.2%), and diarrhea (1%). Serious adverse reactions occurred in 25% of patients receiving KEYTRUDA. The most common adverse reaction (20%) with KEYTRUDA was diarrhea (28%).

In KEYNOTE-189, when KEYTRUDA was administered with pemetrexed and platinum chemotherapy in metastatic nonsquamous NSCLC, KEYTRUDA was discontinued due to adverse reactions in 20% of 405 patients. The most common adverse reactions resulting in permanent discontinuation of KEYTRUDA were pneumonitis (3%) and acute kidney injury (2%). The most common adverse reactions (20%) with KEYTRUDA were nausea (56%), fatigue (56%), constipation (35%), diarrhea (31%), decreased appetite (28%), rash (25%), vomiting (24%), cough (21%), dyspnea (21%), and pyrexia (20%).

In KEYNOTE-407, when KEYTRUDA was administered with carboplatin and either paclitaxel or paclitaxel protein-bound in metastatic squamous NSCLC, KEYTRUDA was discontinued due to adverse reactions in 15% of 101 patients. The most frequent serious adverse reactions reported in at least 2% of patients were febrile neutropenia, pneumonia, and urinary tract infection. Adverse reactions observed in KEYNOTE-407 were similar to those observed in KEYNOTE-189 with the exception that increased incidences of alopecia (47% vs 36%) and peripheral neuropathy (31% vs 25%) were observed in the KEYTRUDA and chemotherapy arm compared to the placebo and chemotherapy arm in KEYNOTE-407.

In KEYNOTE-042, KEYTRUDA was discontinued due to adverse reactions in 19% of 636 patients; the most common were pneumonitis (3%), death due to unknown cause (1.6%), and pneumonia (1.4%). The most frequent serious adverse reactions reported in at least 2% of patients were pneumonia (7%), pneumonitis (3.9%), pulmonary embolism (2.4%), and pleural effusion (2.2%). The most common adverse reaction (20%) was fatigue (25%).

In KEYNOTE-010, KEYTRUDA monotherapy was discontinued due to adverse reactions in 8% of 682 patients with metastatic NSCLC; the most common was pneumonitis (1.8%). The most common adverse reactions (20%) were decreased appetite (25%), fatigue (25%), dyspnea (23%), and nausea (20%).

Adverse reactions occurring in patients with SCLC were similar to those occurring in patients with other solid tumors who received KEYTRUDA as a single agent.

In KEYNOTE-048, KEYTRUDA monotherapy was discontinued due to adverse events in 12% of 300 patients with HNSCC; the most common adverse reactions leading to permanent discontinuation were sepsis (1.7%) and pneumonia (1.3%). The most common adverse reactions (20%) were fatigue (33%), constipation (20%), and rash (20%).

In KEYNOTE-048, when KEYTRUDA was administered in combination with platinum (cisplatin or carboplatin) and FU chemotherapy, KEYTRUDA was discontinued due to adverse reactions in 16% of 276 patients with HNSCC. The most common adverse reactions resulting in permanent discontinuation of KEYTRUDA were pneumonia (2.5%), pneumonitis (1.8%), and septic shock (1.4%). The most common adverse reactions (20%) were nausea (51%), fatigue (49%), constipation (37%), vomiting (32%), mucosal inflammation (31%), diarrhea (29%), decreased appetite (29%), stomatitis (26%), and cough (22%).

In KEYNOTE-012, KEYTRUDA was discontinued due to adverse reactions in 17% of 192 patients with HNSCC. Serious adverse reactions occurred in 45% of patients. The most frequent serious adverse reactions reported in at least 2% of patients were pneumonia, dyspnea, confusional state, vomiting, pleural effusion, and respiratory failure. The most common adverse reactions (20%) were fatigue, decreased appetite, and dyspnea. Adverse reactions occurring in patients with HNSCC were generally similar to those occurring in patients with melanoma or NSCLC who received KEYTRUDA as a monotherapy, with the exception of increased incidences of facial edema and new or worsening hypothyroidism.

In KEYNOTE-087, KEYTRUDA was discontinued due to adverse reactions in 5% of 210 patients with cHL. Serious adverse reactions occurred in 16% of patients; those 1% included pneumonia, pneumonitis, pyrexia, dyspnea, GVHD, and herpes zoster. Two patients died from causes other than disease progression; 1 from GVHD after subsequent allogeneic HSCT and 1 from septic shock. The most common adverse reactions (20%) were fatigue (26%), pyrexia (24%), cough (24%), musculoskeletal pain (21%), diarrhea (20%), and rash (20%).

In KEYNOTE-170, KEYTRUDA was discontinued due to adverse reactions in 8% of 53 patients with PMBCL. Serious adverse reactions occurred in 26% of patients and included arrhythmia (4%), cardiac tamponade (2%), myocardial infarction (2%), pericardial effusion (2%), and pericarditis (2%). Six (11%) patients died within 30 days of start of treatment. The most common adverse reactions (20%) were musculoskeletal pain (30%), upper respiratory tract infection and pyrexia (28% each), cough (26%), fatigue (23%), and dyspnea (21%).

In KEYNOTE-052, KEYTRUDA was discontinued due to adverse reactions in 11% of 370 patients with locally advanced or metastatic urothelial carcinoma. Serious adverse reactions occurred in 42% of patients; those 2% were urinary tract infection, hematuria, acute kidney injury, pneumonia, and urosepsis. The most common adverse reactions (20%) were fatigue (38%), musculoskeletal pain (24%), decreased appetite (22%), constipation (21%), rash (21%), and diarrhea (20%).

In KEYNOTE-045, KEYTRUDA was discontinued due to adverse reactions in 8% of 266 patients with locally advanced or metastatic urothelial carcinoma. The most common adverse reaction resulting in permanent discontinuation of KEYTRUDA was pneumonitis (1.9%). Serious adverse reactions occurred in 39% of KEYTRUDA-treated patients; those 2% were urinary tract infection, pneumonia, anemia, and pneumonitis. The most common adverse reactions (20%) in patients who received KEYTRUDA were fatigue (38%), musculoskeletal pain (32%), pruritus (23%), decreased appetite (21%), nausea (21%), and rash (20%).

Adverse reactions occurring in patients with gastric cancer were similar to those occurring in patients with melanoma or NSCLC who received KEYTRUDA as a monotherapy.

Adverse reactions occurring in patients with esophageal cancer were similar to those occurring in patients with melanoma or NSCLC who received KEYTRUDA as a monotherapy.

In KEYNOTE-158, KEYTRUDA was discontinued due to adverse reactions in 8% of 98 patients with recurrent or metastatic cervical cancer. Serious adverse reactions occurred in 39% of patients receiving KEYTRUDA; the most frequent included anemia (7%), fistula, hemorrhage, and infections [except urinary tract infections] (4.1% each). The most common adverse reactions (20%) were fatigue (43%), musculoskeletal pain (27%), diarrhea (23%), pain and abdominal pain (22% each), and decreased appetite (21%).

Adverse reactions occurring in patients with hepatocellular carcinoma (HCC) were generally similar to those in patients with melanoma or NSCLC who received KEYTRUDA as a monotherapy, with the exception of increased incidences of ascites (8% Grades 34) and immune-mediated hepatitis (2.9%). Laboratory abnormalities (Grades 34) that occurred at a higher incidence were elevated AST (20%), ALT (9%), and hyperbilirubinemia (10%).

Among the 50 patients with MCC enrolled in study KEYNOTE-017, adverse reactions occurring in patients with MCC were generally similar to those occurring in patients with melanoma or NSCLC who received KEYTRUDA as a monotherapy. Laboratory abnormalities (Grades 34) that occurred at a higher incidence were elevated AST (11%) and hyperglycemia (19%).

In KEYNOTE-426, when KEYTRUDA was administered in combination with axitinib, fatal adverse reactions occurred in 3.3% of 429 patients. Serious adverse reactions occurred in 40% of patients, the most frequent (1%) were hepatotoxicity (7%), diarrhea (4.2%), acute kidney injury (2.3%), dehydration (1%), and pneumonitis (1%). Permanent discontinuation due to an adverse reaction occurred in 31% of patients; KEYTRUDA only (13%), axitinib only (13%), and the combination (8%); the most common were hepatotoxicity (13%), diarrhea/colitis (1.9%), acute kidney injury (1.6%), and cerebrovascular accident (1.2%). The most common adverse reactions (20%) were diarrhea (56%), fatigue/asthenia (52%), hypertension (48%), hepatotoxicity (39%), hypothyroidism (35%), decreased appetite (30%), palmar-plantar erythrodysesthesia (28%), nausea (28%), stomatitis/mucosal inflammation (27%), dysphonia (25%), rash (25%), cough (21%), and constipation (21%).

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Merck's KEYTRUDA (pembrolizumab) in Combination with Chemotherapy Significantly Improved Progression-Free Survival Compared to Chemotherapy Alone as...

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Want Glowing Skin and a Healthy Immune System This Winter? Institute This 1 House Hack Immediately – Inc.

January 6th, 2020 4:45 pm

Nobody likes being sick. Skipping work can be fun sometimes, but when you're miserable, it's hard to enjoy it. And if you're an entrepreneur or freelancer who isn't salaried, you simply can't afford it.

You need to do everything you can to stay healthy, especially during flu season. And while ingesting vitamin C is a good bet, there's another hack you should take advantage of immediately, due to its sheer multitude of advantages.

If you live in a heated house or apartment, the air in your home is dry. Really dry. This is a problem for a variety of reasons, the most salient being that a2013 study showed that in a low-humidity environment, 70-77 percent of flu viruses can transmit themselves through coughs. When humidity levels were boosted to 43 percent or higher, the transmission number fell to just 14 percent.

In the words of study researcher John Noti of the CDC's National Institute for Occupational Safety and Health, at high humidity levels "the [flu] virus just falls apart."

In short,if you want to protect yourself and your family from cold and flu season this year, you need a humidifier. Where? In your bedroom, where you spend crucial resting hours.

Here are a few other advantages to using a humidifier:

1. It softens your skin

Dry air saps the moisture from your skin, which you already know leads to noticeably dry skin and flaking. But did you know that this dryness also accelerates the aging process?A humidifier gives your skin that precious moisture back, which keeps you looking your best.

2. It promotes quicker healing

Say do end up succumbing to a cold or flu--using a humidifier helps you get better faster. Why? Because when you keep your nasal passages and throat moist, it reduces coughing and sneezing, which helps you recover quicker.

3. It gives your sinuses a break

Winter air dries out your sinuses--you're already familiar with that annoying, tight feeling you get in your nose when it's cold out. But dry sinuses are more than just uncomfortable--they leave you more vulnerable to bacteria and viruses. A humidifier keeps your sinuses healthy and happy, which keeps you the same.

4. It lowers your heating bill

Ever feel like when it's more humid out, it's hotter? It's true--moist air feels warmer. When you add moisture to the air in your home, it'll feel warmer, so you'll be able to lower the thermostat and save money on your heating bill.

5. It reduces electric shocks

If you feel likestatic electricity is worse in the winter, you're right. The dry air increases your chances of that painful snap when you touch a doorknob after moving over carpet. Add moisture back into the air and you'll be shockedby how much better this issue gets.

6. It protects your wood furniture

Dry air is bad for wood furniture, moldings and doors--it can cause the wood to split and crack. A humidifier helps preserve the integrity of the wood, maintaining your valuable pieces.

7. Better sleep

If you or your partner snores, a humidifier can help, since snoring often worsens when the person has a dry throat or sinuses. Plus, moist air in your bedroom will make the room warmer and more comfortable overall, which promotes restful sleep.

Ready to take the plunge? There are a few things to keep in mind. First, you'll need to regularly clean your humidifier (about once a week). If you don't, the humidifier itself can turn into a source of bacteria and mold.

Second, it's best to use distilled or de-mineralized water in your humidifier. Depending on where you live, your tap is likely to have minerals in it that will generate buildup in your machine (which then promotes the growth of bacteria).

It's easy tomake distilled water from tap water at home, for free. Useit in your humidifier and you'll have to clean it less often.

Third, if your humidifier has a filter, be sure to change it regularly. Same idea--you don't want bacteria to grow in there.

Finally, don't go overboard and turnyour bedroom into thetropics--too much humidity is just as bad as too little. Pick up a hygrometer to measure the humidity level in your room (they cost less than $8). According to the study, the ideal humidity level is 40-50 percent.

Then breathe deeply and be proud. You're taking good care of yourself.

The opinions expressed here by Inc.com columnists are their own, not those of Inc.com.

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Targeting the Immune System Could Prevent Neuropathic Pain – Technology Networks

January 6th, 2020 4:45 pm

An unpleasant tingling in the hands and feet, numbness, furry and burning sensations these symptoms may indicate a neuropathy, a disease of the nervous system. If the pain persists for several months, it is referred to as chronic pain. By then, it is very difficult to treat, and the available drugs often have serious side effects. Researchers at the Translational Medicine and Pharmacology TMP branch of the Fraunhofer Institute for Molecular Biology and Applied Ecology IME have found a way to prevent the development of neuropathic pain early on.

Around five million people in Germany suffer from neuropathic pain, which is the result of damage to the peripheral or central nervous system. Its causes are numerous and diverse. Neuropathic pain can occur after an operation, such as bypass surgery, or an accident, for instance when the spinal cord has been injured. Phantom pain, which many patients experience following an amputation, is also a neuropathic, mechanically induced pain.

A change in skin sensitivity is typical for neuropathic pain. Stimuli such as cold, heat or touches are felt more intensely or hardly at all. The situation becomes problematic when the pain takes on a life of its own and becomes chronic, as this has a major adverse effect on the patients quality of life.

The development of neuropathic, trauma-induced pain that often occurs following an operation or accident should be prevented at as early a stage as possible, because once neuropathic pain has developed, treatment has only a limited effect and the relevant drugs have strong side effects.

When immune cells become the enemy

This is where the researchers at the Frankfurt-based Fraunhofer IME began their approach. They are researching alternative therapies for the early treatment of neuropathic pain. They conducted tests in which they were able to show that various lipids that act as signaling molecules and are produced when an injury occurs control the inflammatory responses in the damaged nerves. The nerves sound the alarm and release lipids to signal to the immune system that an injury has occurred and the cause must be eliminated, says Prof. Klaus Scholich, group manager for biomedical analytics and imaging at Fraunhofer IME.

In the case of neuropathic pain, the immune cells that were lured to the site of the injury soon become the enemy, interacting with the nerves in a way that results in permanent inflammation in the affected areas. The neuropathic pain can no longer subside and becomes chronic. We can significantly reduce the pain by blocking signaling pathways that attract immune cells. One way to do this is by using painkillers such as ibuprofen and diclofenac. Administered at an early stage, these drugs can stop the production of prostaglandin E2, a lipid that plays a key role in trauma-induced pain because it both sensitizes the nerves and activates the immune system.

Prostaglandin E2 also binds the EP3 receptor. Neurons that express this receptor produce the signaling molecule CCL2, which in turn contributes significantly to pain development because it constantly lures new immune cells to the injured nerves and, as the IME researchers discovered in their studies, is itself involved in amplifying pain perception. We were able to shed light on the subsequent mechanisms that promote the genesis of neuropathic pain by means of inflammatory responses, explains Scholich.

The EP3 receptor recognizes the prostaglandin E2. By switching off the EP3, thus inhibiting CCL2 release, pain genesis can now be significantly reduced. The CCL2 could be intercepted with specific therapeutic antibodies, which are used for chronic pain when conventional drugs such as ibuprofen no longer work. The disadvantage of this approach is that antibodies have to be injected. Since most patients find this unpleasant, Scholich and his colleagues are researching alternative agents that can be administered orally.

This article has been republished from the following materials. Note: material may have been edited for length and content. For further information, please contact the cited source.

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Injecting the flu vaccine into a tumor gets the immune system to attack it – Ars Technica

January 6th, 2020 4:45 pm

picture alliance/Getty Images

A number of years back, there was a great deal of excitement about using viruses to target cancer. A number of viruses explode the cells that they've infected in order to spread to new ones. Engineering those viruses so that they could only grow in cancer cells would seem to provide a way of selectively killing these cells. And some preliminary tests were promising, showing massive tumors nearly disappearing.

But the results were inconsistent, and there were complications. The immune system would respond to the virus, limiting our ability to use it more than once. And some of the tumor killing seemed to be the result of the immune system, rather than the virus.

Now, some researchers have focused on the immune response, inducing it at the site of the tumor. And they do so by a remarkably simple method: injecting the tumor with the flu vaccine. As a bonus, the mice it was tested on were successfully immunized, too.

This is one of those ideas that seems nuts but had so many earlier results pointing toward it working that it was really just a matter of time before someone tried it. To understand it, you have to overcome the idea that the immune system is always diffuse, composed of cells that wander the blood stream. Instead, immune cells organize at the sites of infections (or tumors), where they communicate with each other to both organize an attack and limit that attack so that healthy tissue isn't also targeted.

From this perspective, the immune system's inability to eliminate tumor cells isn't only the product of their similarities to healthy cells. It's also the product of the signaling networks that help restrain the immune system to prevent it from attacking normal cells. A number of recently developed drugs help release this self-imposed limit, winning their developers Nobel Prizes in the process. These drugs convert a "cold" immune response, dominated by signaling that shuts things down, into a "hot" one that is able to attack a tumor.

But not everyone has a response to these drugs, raising the question of whether there are other ways to activate the immune system at the site of a tumor. One potential option is simply the things that normally rev up the immune system: infectious agents. The immune response to cancer-targeting viruses mentioned above would provide an indication that this does occur. Others have targeted a variety of pathogens to the sites of tumors and found that this increases the immune response to the tumor as well.

To check whether something similar might be happening in humans, the researchers identified over 30,000 people being treated for lung cancer and found those who also received an influenza diagnosis. You might expect that the combination of the flu and cancer would be very difficult for those patients, but instead, they had lower mortality than the patients who didn't get the flu.

For more detailed tests, the researchers moved to mice, using melanoma cells that can form tumors when transplanted into the lungs of the mice. These model systems often respond to treatments that don't end up working in humans, so the results have to be treated with appropriate caution. Still, they can be a valuable way of understanding the biology of the immune response here.

The use of melanoma cells is informative, as these cells cannot be infected by the influenza virus. So this system also provides a test of whether the tumor cells themselves have to be infected in order to increase the immune response to them. Apparently they do not. Having an active influenza virus infection reduced the ability of the melanoma cells to establish themselves in the lung. The effect isn't limited to the location of the infection, though, as tumors in the lung that wasn't infected were also inhibited. The effects were similar when breast cancer cells were placed into the lung, as well.

All of this is consistent with the immune stimulation provided by a pathogen. The stimulation causes a general activation of the immune system that releases it from limits on its activity that prevent it from attacking tumor cells. But does it require an actual infection? To find out, the researchers used a flu virus that had been inactivated by heat treatment. Normally, heat treating a virus is used to create a control for an effect that needs an active virus. But here, it turned out to be another experiment, as the heat-treated virus was also able to work just as effectively as the live virus.

This isn't entirely surprising, given that inactive viruses are often used as vaccines and thus clearly can stimulate the immune system. But that, in turn, suggested another experiment: would vaccines actually work? To find out, the researchers obtained this year's flu vaccine and injected it into the sites of tumors. Not only was tumor growth slowed, but the mice ended up immune to the flu virus.

Oddly, this wasn't true for every flu vaccine. Some vaccines contain chemicals that enhance the immune system's memory, promoting the formation of a long-term response to pathogens (called adjuvants). When a vaccine containing one of these chemicals was used, the immune system wasn't stimulated to limit the tumors' growth.

This suggests that it's less a matter of stimulating the immune system and more an issue of triggering it to attack immediately. But this is one of the things that will need to be sorted out with further study. The location of the stimulation will also need to be sorted out, too. Here, stimulation in one lung increases activity in both. But injection into muscles didn't work at all, and earlier work by some of the same team had indicated a heavy infection outside the lungs enhanced tumor growth by diverting immune cells elsewhere.

But the story does fit in well with the general consensus that the immune system can be a powerful tool against cancer, provided it can be mobilized properly. And, in at least some cases, a flu vaccine just might do the trick.

PNAS, 2019. DOI: 10.1073/pnas.1904022116 (About DOIs).

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Investigating the Immune System’s Connection to Blood Clots | University of Michigan – Michigan Medicine

January 6th, 2020 4:45 pm

Serious infections increase the risk of life-threatening conditions such as deep vein thrombosis (DVT), a blood clot that can form in deep veins, and pulmonary embolisms (PE), a condition where an artery in the lung becomes blocked by a blood clot. These conditions affect 1 in 1000 adults and lead to approximately 200,000-300,000 deaths per year.

In an effort to better understand blood clots, Andrea Obi, M.D., a vascular surgeon and investigator at Michigan Medicines Frankel Cardiovascular Center, is exploring the condition further through new research in her lab.

Her team is establishing a link between infection, thrombosis and changes in the bone marrow programming of immune cells and working on understanding the interplay between the immune system and thrombosis to help identify new, non-blood thinning techniques for preventing and treating DVT in the future.

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Obi, also the winner of the 2019 Wylie award from Vascular Cures, takes a deeper dive into her work here with questions from the Michigan Health Lab:

Whats the focus of your research?

My research focuses on the intersection between innate immunity and the coagulation system, specifically evaluating the role immune cells play in forming and breaking down blood clots in the venous system.

What sparked your interest in this?

My current work, like many surgeons, was the result of observing human suffering. During the 2009-2010 H1N1 influenza outbreak, I spent much time in the surgical intensive care unit caring for young individuals, some in their 20s and 30s, with severe pulmonary disease requiring advanced life support. We noticed that a large number of these patients developed severe venous clotting, leading to a very high mortality. Blood thinners helped us decrease the risk of death but led to a host of other bleeding complications for these ill patients.

When I had a chance to review data from large population studies, it became evident that DVT was associated with all types of infections to varying degrees, and the risk persisted over the course of the persons next year of life, even if he or she made a rapid recovery.

What discoveries has your team already made?

So far weve discovered that even with a remote infection, such as a pneumonia, the endothelium (inner lining of the blood vessel) in a remote location changes the proteins expressed on the cell surface and talks to circulating leukocytes differently.

How will patients benefit from this research?

My hope is that by using both animal models and human tissue we can identify some of the changes that occur in innate immune cell memory that predisposes individuals to form a DVT after suffering from an infection.

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In recent years, the pharmacology for a wide range of diseases such as rheumatoid arthritis, psoriasis, and melanoma have been transformed by the ability to target the immune system. Despite the fact that its never been tried in DVT, doesnt mean that it is impossible, rather that we just dont understand enough about the crosstalk between the immune system and coagulation (blood clotting) system to identify a protein or molecule that we can manipulate to change the course of human disease.

I hope that in the course of my work and in my lifetime we can make a discovery that decreases the need for dangerous blood thinning medication and improves the lives of individuals who are at high risk or whom have suffered from a DVT.

Read more from Dr. Obi about her research goals and progress in this blog post from the Michigan Medicine Department of Surgery.

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How to Keep Your Immune System Strong During Winter – The Free Press of the University of Southern Maine

January 6th, 2020 4:45 pm

The importance of a healthy immune system cant be overstatedespecially during the cold winter months. Common colds and the full-on flu are at their worst throughout the winter, so youll want to do whatever you can to boost your immune system and stay as healthy as possible. Follow this guide onhow to keep your immune system strong during winterto avoid untimely sickness.

Stress can do all kinds of terrible and negative things to your body. If your stress levels are through the roof, take a moment to find a release for relaxation. Without stress to weigh your body down, it can focus on building your immune system and keeping you at tip-top shape to face the harsh winter.

Drinking enough water is crucial to supporting your immune health; a healthy body requires eight cups of water a day. Unfortunately, many people dont like the way water tastes and consider it an unfulfilling drink. As a result, they dont drink itor they dont drink enough of it. One way to combat these issues is to jazz up plain water with some additional goodness. Heat up water and add lemonsfora delicious and nutritious wayto increase your H2O intake.

Vitamin C and zinc are common ingredients in many over-the-counter medicines because they help prevent and fight sicknesses. You dont have to rely on medicine, though. Many common foods contain vitamin C, zinc, or both: potatoes, broccoli, chicken, and tomatoes are some of the most popular items. Simply increasing your daily intake of these essentials can slowly and surely build extra immune system health and strength.

As you sleep, your body slows down and recharges. Consequently, your immune system can heal from the many battles it fought over the course of your day. While there are some exceptions to this rule, most of us need at least eight hours of sleep at nightthis give our bodies enough time to fully recover. Enough sleep is equally as important during the spring and summer seasons, too, as it gives your body time to fend off any germs it encountered during the day.

Exercise helps your body maintain health and can even contribute to building a stronger immune system. If youd like to go to the gym, thats great! However, even though exercise helps boost your immune systemand the gym is a wonderful place to exercisegyms are home to many different types of germs. Here are a few ways you can avoid germs before, during, and after your work out.

The winter is chilly, and keeping your body warm will help your immune system avoid fights and become stronger. Wear a hat when outdoors, as most of your bodys heat actually escapes through the top of the head. You should also wear a coat, proper footwear, gloves, and a scarf.

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Tips to protect yourself from getting the flu – CBS46 News Atlanta

January 6th, 2020 4:45 pm

'); $("#expandable-weather-block .modal-body #mrd-alert"+ alertCount).append(""+val.title+""); // if (window.location.hostname == "www.kmov.com" || window.location.hostname == "www.kctv5.com" || window.location.hostname == "www.azfamily.com" || window.location.hostname == "www.kptv.com" || window.location.hostname == "www.fox5vegas.com" || window.location.hostname == "www.wfsb.com") { if (val.poly != "" && val.polyimg != "") { $("#expandable-weather-block .modal-body #mrd-alert"+ alertCount).append('"+val.ihtml+""); $("#expandable-weather-block .weather-index-alerts").show(); $("#expandable-weather-block .modal-body h2").css({"font-family":"'Fira Sans', sans-serif", "font-weight":"500", "padding-bottom":"10px"}); $("#expandable-weather-block .modal-body p").css({"font-size":"14px", "line-height":"24px"}); $("#expandable-weather-block .modal-body span.wxalertnum").css({"float":"left", "width":"40px", "height":"40px", "color":"#ffffff", "line-height":"40px", "background-color":"#888888", "border-radius":"40px", "text-align":"center", "margin-right":"12px"}); $("#expandable-weather-block .modal-body b").css("font-size", "18px"); $("#expandable-weather-block .modal-body li").css({"font-size":"14px", "line-height":"18px", "margin-bottom":"10px"}); $("#expandable-weather-block .modal-body ul").css({"margin-bottom":"24px"}); $("#expandable-weather-block .modal-body pre").css({"margin-bottom":"24px"}); $("#expandable-weather-block .modal-body img").css({"width":"100%", "margin-bottom":"20px", "borderWidth":"1px", "border-style":"solid", "border-color":"#aaaaaa"}); $("#expandable-weather-block .modal-body #mrd-alert"+ alertCount).css({"borderWidth":"0", "border-bottom-width":"1px", "border-style":"dashed", "border-color":"#aaaaaa", "padding-bottom":"10px", "margin-bottom":"40px"}); }); } function parseAlertJSON(json) { console.log(json); alertCount = 0; if (Object.keys(json.alerts).length > 0) { $("#mrd-wx-alerts .modal-body ").empty(); } $.each(json.alerts, function(key, val) { alertCount++; $("#mrd-wx-alerts .alert_count").text(alertCount); $("#mrd-wx-alerts .modal-body ").append(''); $("#mrd-wx-alerts .modal-body #mrd-alert"+ alertCount).append(""+val.title+""); // if (window.location.hostname == "www.kmov.com" || window.location.hostname == "www.kctv5.com" || window.location.hostname == "www.azfamily.com" || window.location.hostname == "www.kptv.com" || window.location.hostname == "www.fox5vegas.com" || window.location.hostname == "www.wfsb.com") { if (val.poly != "" && val.polyimg != "") { $("#mrd-wx-alerts .modal-body #mrd-alert"+ alertCount).append(''); } else if (val.fips != "" && val.fipsimg != "") { // $("#mrd-wx-alerts .modal-body #mrd-alert"+ alertCount).append(''); } // } //val.instr = val.instr.replace(/[W_]+/g," "); $("#mrd-wx-alerts .modal-body #mrd-alert"+ alertCount).append(val.dhtml+"

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HOOKIPA’s Gilead Sciences Collaboration for HIV and HBV Therapeutic Vaccines Advancing Towards Clinical Entry – Associated Press

January 6th, 2020 4:45 pm

NEW YORK and VIENNA, Austria, Jan. 06, 2020 (GLOBE NEWSWIRE) -- HOOKIPA Pharma Inc. (NASDAQ: HOOK, HOOKIPA), a company developing a new class of immunotherapeutics targeting infectious diseases and cancers based on its proprietary arenavirus platform, today announced that HOOKIPA has made strong progress in its collaboration with Gilead for novel arenavirus-based therapeutics intended to support functional cures for chronic Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infections.

HOOKIPA and Gilead Sciences designed and tested multiple arenaviral vectors expressing HIV and HBV immunogens, optimizing each for potential preclinical immunogenicity, safety and manufacturability. In 2019, HOOKIPA earned multiple Gilead milestone payments for the delivery of research vectors and advancing the programs closer to clinical studies. On the basis of promising preclinical data, Gilead has committed to preparations to advance the HBV and HIV vectors toward development, with the HBV development decision triggering an additional milestone payment to HOOKIPA. To enable the development activities and expanded research programs, Gilead has agreed to reserve manufacturing capacity and expanded the HOOKIPA resources allocated to the Gilead collaboration.

About HOOKIPA

HOOKIPA Pharma Inc. (NASDAQ: HOOK) is a clinical stage biopharmaceutical company developing a new class of immunotherapeutics, targeting infectious diseases and cancers based on its proprietary arenavirus platform that is designed to reprogram the bodys immune system.

HOOKIPAs proprietary arenavirus-based technologies, VaxWave*, a replication-deficient viral vector, and TheraT*, a replication-attenuated viral vector, are designed to induce robust antigen specific CD8+ T cells and pathogen-neutralizing antibodies. Both technologies are designed to allow for repeat administration to augment and refresh immune responses. TheraT has the potential to induce CD8+ T cell response levels previously not achieved by other immuno-therapy approaches. HOOKIPAs off-the-shelf viral vectors target dendritic cells in vivo to activate the immune system.

HOOKIPAs VaxWave-based prophylactic Cytomegalovirus vaccine candidate is currently in a Phase 2 clinical trial in patients awaiting kidney transplantation from living Cytomegalovirus-positive donors. To expand its infectious disease portfolio, HOOKIPA has entered into a collaboration and licensing agreement with Gilead Sciences, Inc. to jointly research and develop functional cures for HIV and Hepatitis B infections.

In addition, HOOKIPA is building a proprietary immuno-oncology pipeline by targeting virally mediated cancer antigens, self-antigens and next-generation antigens. The TheraT based lead oncology product candidates, HB-201 and HB-202, are in development for the treatment of Human Papilloma Virus16-positive cancers. The Phase 1/2 clinical trial for HB-201 was initiated in December 2019. The HB-202 IND filing is intended for the first half of 2020.

Find out more about HOOKIPA online at http://www.hookipapharma.com.

*Registered in Europe; Pending in the US.

HOOKIPA Forward Looking StatementsCertain statements set forth in this press release constitute forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995, as amended. Forward-looking statements can be identified by terms such as believes, expects, plans, potential, would or similar expressions and the negative of those terms. Such forward-looking statements involve substantial risks and uncertainties that could cause HOOKIPAs research and clinical development programs, future results, performance or achievements to differ significantly from those expressed or implied by the forward-looking statements. Such risks and uncertainties include, among others, the uncertainties inherent in the drug development process, including HOOKIPAs programs early stage of development, the process of designing and conducting preclinical and clinical trials, the regulatory approval processes, the timing of regulatory filings, the challenges associated with manufacturing drug products, HOOKIPAs ability to successfully establish, protect and defend its intellectual property and other matters that could affect the sufficiency of existing cash to fund operations and HOOKIPAs ability to achieve the milestones under the agreement with Gilead. HOOKIPA undertakes no obligation to update or revise any forward-looking statements. For a further description of the risks and uncertainties that could cause actual results to differ from those expressed in these forward-looking statements, as well as risks relating to the business of the company in general, see HOOKIPAs quarterly report on Form 10-Q for the quarter ended September 30, 2019 which is available on the Security and Exchange Commissions website at http://www.sec.gov and HOOKIPAs website at http://www.hookipapharma.com.

Investors and others should note that we announce material financial information to our investors using our investor relations website ( https://ir.hookipapharma.com/ ), SEC filings, press releases, public conference calls and webcasts. We use these channels, as well as social media, to communicate with our members and the public about our company, our services and other issues. It is possible that the information we post on social media could be deemed to be material information. Therefore, we encourage investors, the media, and others interested in our company to review the information we post on the U.S. social media channels listed on our investor relations website.

For further information, please contact:

Media Investors Nina Waibel Matt Beck Senior Director - Communications Executive Director Investor Relations Nina.Waibel@HookipaPharma.com Matthew.Beck@HookipaPharma.com Media enquiries Ashley Tapp Instinctif Partners Hookipa@Instinctif.com +44 (0)20 7457 2020

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Trabectedin Targets Leukemic Cells and Restores Immune Cell Function in Models of Chronic Lymphocytic Leukemia – Cancer Therapy Advisor

January 6th, 2020 4:45 pm

The marine-derived compound trabectedin depletes both human primary leukemic cells and myeloid-derived suppressor cells, according to a new study published in Cancer Immunology Research.1 The researchers think their findings could lead to a new therapy that targets both leukemic cells and the protumor microenvironment, repairing the immune dysfunction that is characteristic of chronic lymphocytic leukemia (CLL).

CLLis characterized by lymphocyte accumulation in the blood, bone marrow, andlymphoid tissues.2 Recent advances in CLL therapy have come fromfinding and targeting the appropriate molecular pathways of the disease,explained Kanti R. Rai, MD, a professor of medicine and molecular medicine atthe Donald and Barbara Zucker School of Medicine at Hofstra/Northwell whowasnt involved in the study. Dr Rai said that, for instance, the Brutontyrosine kinase inhibitor ibrutinib binds to the receptor and affects B-cellreceptorsignaling. Another drug, venetoclax, an antagonist to BCL2, can effectivelyinduce apoptosis in CLL cells. However, treatment of this disease remainschallenging due to its immunosuppressive nature. If we [are] to attain a cure,newer compounds have to be identified which have a different mechanism ofcontrolling CLL, he said.

Patientswith CLL have dysfunctional T cells, noted Maria Teresa Bertilaccio, PhD, whois an assistant professor in the department of experimental therapeutics at TheUniversity of Texas MD Anderson Cancer Center in Houston, and the correspondingauthor of the study. Patients [with CLL] have immunosuppression features, sothey might develop an infection because their immune system is not working,she told Cancer Therapy Advisor. Our approach is not only to eradicateleukemia, but also to rearm the immune system to give patients a better qualityof life.

Trabectedintargets tumor-associated macrophages (TAMs); TAMs are thought to support CLLgrowth. A previous study by the Bertilaccio group showed that depleting TAMs byblocking CSF1R signaling reprograms the tumor microenvironment toward anantitumor phenotype.3 This led them to hypothesize that trabectedincould simultaneously target both leukemic cells and nonmalignant cells in thetumor microenvironment.

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Yisheng Biopharma and Tavotek Biotherapeutics Announce Strategic Research Alliance for Development of YS-ON-001/002 and Tavo-301/303 Combination…

January 6th, 2020 4:45 pm

GAITHERSBURG, Md. andAMBLER, Pa., Jan. 6, 2020 /PRNewswire/ --Yisheng Biopharma Co., Ltd.("Yisheng Biopharma"), a biopharmaceutical company focusing on research, development, manufacturing, sales and marketing of immunological biologics and vaccines, and Tavotek Biotherapeutics, a biotech company focusing on novel multi-specific antibodies in immuno-oncology and autoimmune diseases, announced today that the companies have entered into a strategic research alliance and collaborate in the development involving their lead assets in oncology. The objective of the alliance is to co-develop a combination therapy of YS-ON-001/002 and Tavo-301/303 for cancer treatment. The two companies are also in discussions regarding additional research and development collaborations beyond oncology.

"We are excited to collaborate with Tavotek, which has a rich pipeline of multi-specific antibodies and advanced technology platforms in oncology and other therapeutic areas," commentedDr. David Shao, President and Chief Executive Officer of Yisheng Biopharma. "As potent agonists of TLR3, MDA5 and RIG-I pathways, YS-ON-001 and YS-ON-002 have demonstrated promising effects in activating the innate and adaptive immune systems and modulating the tumor microenvironment, and YS-ON-001 has shown an excellent safety profile with clinical data to date. By combining YS-ON-001/002 with multi-specific antibodies directed against tumors, we are well positioned in developing a first-in-class immunotherapy with potentially higher response rates. We look forward to working with the Tavotek team to explore the potential synergy of YS-ON-001/002 and Tavo-301/303."

"The collaboration with Yisheng aligns with Tavotek's mission to develop life-changing therapies for patients with significant unmet medical need," saidDr. Mann Fung, Chief Executive Officer of Tavotek. "Current immuno-oncology approaches such as PD1/PDL1 antibody achieve only approximately 20 to 30 percent response rates in clinical settings. A majority of cancer patients still are not seeing a benefit from current therapies. We believe a combination regimen of YS-ON-001/002 with multi-specific IO antibodies, such as Tavo-301/303, will have beneficial impact on cancer care."

YS-ON-001 and YS-ON-002areimmunotherapeutic productsbased on the TLR3/RIG-I/MDA-5 signaling pathways of PIKA immunomodulating technology. They arecapable of both reducing the immunosuppressive effect of tumor microenvironment and enhancing the anti-tumor function of the immune system to tumor cells. YS-ON-001 is currently in clinical development in China and Singapore, and has received orphan drug designations from the U.S. FDA for treatment of pancreatic and liver cancers. The product has been approved in Cambodia for the treatment of advanced solid tumors. YS-ON-002 is a clinical candidate ready for IND submission. YS-ON-001/002 can be an integral immunotherapy component with standard of oncology care, such as chemotherapies, targeted therapies and checkpoint inhibitors or with emerging immunotherapies for additive or synergistic treatment benefits.

Tavo-301/303 is a series of novel multi-specific antibody-based Immuno-Oncology assets that was developed using Tavotek's proprietary TavoSelect Platform. Novel protein engineering employing TavoSelect technology generates multi-specific biologics with optimal molecular profiles for targeting multiple relevant epitopes simultaneously to manage difficult-to-treat solid tumors. These biologics modulate the immunosuppressive pathway by multiple mechanisms of action to promote anti-tumor response and efficacy. The TavoSelec technology also provides biologic molecules with favorable pharmacokinetic profiles and stable formats for ease of development and manufacturing.

About Yisheng Biopharma Co., Ltd.

Yisheng Biopharma is a fully integrated biopharmaceutical company with a global footprint that is discovering, developing and commercializing innovative biotherapeutics for cancer and infectious disease using its novel PIKA immunomodulating technology. PIKA technology augments both innate and adaptive immune responses through the TLR3, RIG-I and MDA5 pathways. Products in clinical development include YS-ON-001 for the treatment of advanced solid tumors, YS-HBV-001 hepatitis B vaccine, and the PIKA rabies vaccine for accelerated protection against rabies infection. The Company has two marketed products in China and South Asia market. Yisheng Biopharma is headquartered in Beijing and has approximately 500 employees in China, U.S., Singapore and other countries in Asia. For more information on Yisheng, please visit http://www.yishengbio.com.

About PIKA Technology

Proprietary PIKA technology originated from research in a class of well-defined synthetic dsRNA molecules. Endosomal dsRNA can be recognized by TLR3 while cytosolic dsRNA can be sensed by the RIG-I-like receptor family which include RIG-I and MDA-5. Through TLR3, RIG-I and MDA-5 signaling, PIKA technology can induce prompt production of interferon, cytokines, chemokines and costimulatory factors. The antiviral and antitumor effects of interferon have been well established. Production of type I interferon upon PIKA administration facilitates antigen cross-presentation by dendritic cells and augments CD4+ T-cell, CD8+ T-cell and natural killer cell responses, which makes PIKA-based therapeutics suitable for both antiviral and antitumor applications.

About Tavotek

Tavotek is a biopharmaceutical company focused on discovering, acquiring, developing, and commercializing therapeutic medicines for patients suffering from debilitating diseases with significant unmet medical need. Tavotek has a rich pipeline of product candidates in various stages of development, focused on cancers, autoimmune conditions, and infectious diseases. For more information, please visit http://www.tavotek.com

About TavoSelectPlatform

The TavoSelect Platform offers highly diversified human antibody sequences that can be utilized in different formats: VHH, scFv, IgG, multi-specific antibodies, fusion proteins, and the engineering of host defense cell surface receptors.TavoSelect of leads emphasize creative screening procedures, NGS analyses, and utilization of proprietary AI software to capture and optimize the best candidates rapidly.The efficiency of the TavoSelect Platform generates novel diverse therapeutic biologic molecules and medical diagnostics for patients.

Yisheng Contact:

Solebury TroutRich Allan (media)Tel: +1 646-378-2958Email: rallan@soleburytrout.com

Bob Ai (investors)Tel +1 646-378-2926Email: bai@soleburytrout.com

Tavotek Contact:

Wei Zhang, Investors and MediaTel: +1 267-405-9426Email: info@tavotek.com

View original content:http://www.prnewswire.com/news-releases/yisheng-biopharma-and-tavotek-biotherapeutics-announce-strategic-research-alliance-for-development-of-ys-on-001002-and-tavo-301303-combination-therapy-for-cancer-treatment-300980756.html

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Forty Seven: Early Indications Suggest Magrolimab Could Be A Winner – Seeking Alpha

January 6th, 2020 4:45 pm

Investment Thesis

Forty Seven (FTSV) management must be pleased with the progress they made in December '19.

First of all, early results from clinical trials of the company's flagship drug magrolimab were positive. In a trial evaluating magrolimab in combination with azacitidine for the treatment of myelodysplastic syndrome ("MDS") and acute myeloid leukaemia ("AML"), Complete Response ("CR") rates of 50% and Overall Response Rates ("ORR") of 92% were observed in untreated patients with higher risk MDS.

In Patients with Untreated AML who are ineligible for induction chemotherapy CR and ORR rates were 55% and 64% respectively. Furthermore, the combination of magrolimab and azacitidine was well tolerated, meaning the treatment may be safe for fragile, sicker and older patients.

The strong results appeared to take the market by surprise and Forty Seven's share price accelerated immediately. The stock gained 84% on 28x average volume in a single day to reach $39 and continued its ascent to reach an all-time high of over $44 (price at the time of writing is a little lower at just over $38).

Secondly, after releasing the results Forty Seven management wisely decided to issue a public offering of 5.59m shares at $35 per share, successfully raising $195.6m. (Source: Bloomberg). Given that the last fundraising, in July of last year, raised $86m at an offer price of just $8, the latest raise must be a cause of satisfaction. It is also a clear indication that investors are starting to see Forty Seven and magrolimab as the frontrunner amongst a plethora of biotechs focused on CD-47 directed therapies, in my view.

The company reported cash, cash equivalent and short-term investments of $166.7m on its Q319 earnings call which includes proceeds from the July raise and a $15.7m upfront licence payment from a collaboration with Ono Pharmaceuticals (Source: Globenewswire) which will see the Japanese firm develop, market and commercialise magrolimab across Japan and the ASEAN region.

Management stated this funding would be sufficient for Forty Seven to support its operations - which include up to ten clinical trials of magrolimab plus pre-clinical trials of anti-SIRPa antibody FSI 189 and anti-cKIT antibody FSI-174 - through to the first quarter of 2021.

Factor in December's raise and we can see that Forty Seven is now in a strong position to pursue and meet its stated goal of being the first company to release an approved therapy targeting the CD47 checkpoint of the innate immune system.

This being biotech, there are many reasons why Forty Seven's best efforts may fall short of winning approval for commercialisation from the FDA. Magrolimab is still in the early stages of being tested and its good results to date will count for nothing should Phase II or III trials reveal safety concerns or a failure to meet the primary endpoint.

Forty Seven does not have a strong pipeline to fall back on should magrolimab ultimately fail to secure commercialisation, meaning investing at this time comes with a high chance of making a loss.

A rival company could produce a CD47-directed treatment that proves to be more effective in which case Fifty Seven will struggle to sell magrolimab even if it is approved. Clinical tests could go on for longer than expected requiring further funding and there is no guarantee the company will be able to raise enough cash. Or, an alternative therapy, such as gene editing or RNAi could outperform all other treatments, rendering the company's development efforts fruitless.

Despite these concerns, however, if I were to pick a CD47 focused immunology company to back today, it would be Forty Seven. With no current concerns on the funding front and with such impressive early trial results from its lead candidate the near-term future certainly looks bright.

There are further reasons for optimism. The company owns exclusive rights to magrolimab which means should the drug be approved Forty Seven will retain the bulk of the profits from its sale. If results continue to impress Forty Seven represents an attractive acquisition target for a big pharma firm. And perhaps most importantly, besides MDS and AML magrolimab has the potential to be approved for numerous indications. Non Hodgkin's Lymphoma, for example, as well as ovarian cancer, colorectal cancer and bladder cancer.

In other words, magrolimab has blockbuster potential, and therefore, despite the obvious risks - one bad trial result could decimate the current share price - in my view Forty Seven should be carefully considered as an investment due to its upside potential. There has not been a new treatment available for Myelodysplastic syndromes ("MDS") in over a decade. Some investors may feel the rewards on offer for a successful treatment are significant enough to justify the risks.

Forty Seven was founded in 2014 in Menlo Park, California by a group of Stanford scientists, most notably Irv Weissman. Weissman played an instrumental role in identifying and developing CD47 as a potential cancer treatment.

Forty Seven went public in June 2018. The company raised $112m at a price of $16 giving it a valuation just shy of $480m. Today, thanks to the recent share price gain, Forty Seven's market cap stands at over $1.5bn.

Forty Seven's lead drug candidate magrolimab is an anti-CD47 antibody formerly known as 5f9. 5f9 has the ability to "switch off" the "don't eat me" signalling pathway used by cancerous cells to avoid detection by macrophages.

Macrophages are the innate immune system's first line of defence against abnormal cells. CD47 is expressed by healthy cells as a means of sending a "don't eat me" signal to macrophages, thereby exempting themselves from a process known as phagocytosis whereby a macrophage consumes abnormal cells to protect the body.

Nearly all cancerous cells over-express CD47 as a means of disguising themselves against macrophages to avoid being swallowed up and eliminated. The "don't eat me" message is sent when the cancerous cell binds to a receptor on macrophages known as SIRP-alpha.

Weissman's research at Stanford demonstrated three things. That blocking the "don't eat me" signalling pathway leads to elimination of many types of tumours and increases a patient's chances of survival. That boosting "eat me" signals found on cancer cells using therapeutic antibodies can work in conjunction with blocking CD47. And that, besides phagocytosis, macrophages activate tumor specific antigens that can activate T-cells against the cancerous cells, meaning that blocking CD47 can also work in conjunction with T-cell based therapies. (Source: FTSV Fundraising prospectus Dec '19)

FTSV 3-fold strategy. Source: FTSV Website

This has led directly to Forty Seven's three pronged development strategy. Monotherapy, e.g. facilitating phagocytosis, synergizing with other tumor targeting antibodies and T-cell activation, and using pro-phagocytic signals on tumor cells in conjunction with chemotherapy.

5F9 is a humanized IgG4 subclass monoclonal antibody that Forty Seven say is designed to combine with a proprietary dosing regimen to help overcome the toxicity limitations of rival anti-CD47 therapies developed by other companies.

Besides 5F9 / magrolimab, Forty Seven are also advancing FSI-189, an anti-SIRPa antibody, and FSI-174, an anti-cKIT antibody. FSI-189 is expected to enter solid-tumor trials this year, whilst cKIT - an antibody targeting stem cell growth factor inhibitors and issuing an "eat me signal" - may prove effective in treating leukemia, melanoma and gastrointestinal stroma tumors.

Forty Seven has 6 clinical trials of magrolimab ongoing that have progressed beyond the pre-clinical stage.

The trial that has produced the most positive results to date (referred to in the introduction of this article) is evaluating magrolimab both as a monotherapy and in conjunction with azacitidine as a treatment for MDS and AML in patients with haemotological malignancies.

Trial investigator David Sallman, M.D., H Lee Moffit Cancer Center and Research Institute had this to say on the publication of the encouraging early data:

The data that continue to emerge from this clinical trial are incredibly exciting, suggesting that the combination of magrolimab and azacitidine may offer the first new therapeutic regimen in over a decade, with the potential to induce meaningful and lasting responses in patients with higher-risk disease. Importantly, these results also support magrolimabs tolerability profile, further differentiating it as a safe treatment that may be used even in more fragile, sicker, and older patients.

Forty Seven have subsequently entered discussions with the FDA with regard to initiating a registration-enabling program with the goal of securing accelerated approval, and also hope to submit a biologics license application ("BLA") in Q421.

MDS is regarded by Forty Seven management as one of its most important treatment targets given its high incidence in the US (as illustrated in the chart below) and due to the paucity of treatment options available to patients.

Source: FTSV Investor Presentation Dec '19

Research suggests that 75% of MDS patients receive only supportive care with the only other options: chemotherapy drugs Vidaza (the brand name version of azacitidine), revlimid and Dacogen, or allogeneic stem cell therapy, being ineffective.

As we can also see from the above chart, diffuse large B-cell lymphoma ("DLBCL") represents another target for Forty Seven and it is the subject of a second planned clinical trial of magrolimab, this time in conjunction with rituximab, a monoclonal antibody that targets a protein known as CD20.

The trial will enrol 100 patients who have failed at least two prior lines of therapy, and will begin, management say, in Q120 with the earliest interim efficacy data slated to be made available in Q420. On the Q319 earnings call Forty Seven CEO Mark McCamish stated his desire to advance into earlier lines of treatment as early as possible referring to a "substantial unmet need" in treatment of DLBCL.

McCamish also updated investors and analysts concerning the phase 1b solid tumor trials. Results from both magrolimab combined with avelumab to treat patients with brain cancer, and in combination with cetuximab in patients with colo-rectal cancer will be made available in meetings scheduled for Q120 with abstracts of early data having already been submitted.

McCamish also announced a collaboration with gene therapy specialists Bluebird Bio. Forty Seven intend to leverage Bluebird's LentiGlobin platform to evaluate FSI-174 and move forward the cKIT program with a focus on pretransplantation and avoiding the need for chemotherapy or radiation toxicities or secondary malignancies when performing stem cell transplants.

Targeting blood-forming stem cells that express cKIT with FSI-174 releases macrophages to clear the steam cells, and, used in conjunction with magrolimab could, McCamish says:

massively expand the number of patients eligible for transplantation and therefore enable many more people to benefit from the curative potential transplantation.

During Q3 Forty Seven had an R&D spend of $27.1m - up from $18m in Q318, ascribed to the advancement of clinical trials and contract manufacturing costs for the proposed BLA.

In total, the company made a loss of $15.1m, down from $21.7m the previous year. In the first nine months of 2019 losses totalled $61.2m. As mentioned previously, Forty Seven should have more than enough funding to complete its trials and submit the BLA without having to dilute investors further - but it would be wise not to rule anything out. One failed trial could set the whole process back by years. (Source: FTSV 10Q Submission Q319).

There is no doubt that Forty Seven faces stiff competition. Amongst the companies competing in the CD47 antibody space are Surf therapeutics (SURF), Trillium Therapeutics (TRIL), Celgene (CELG), China based biotech Innovent Biologics, and Netherlands Based Aurigene and Synthon. (Source: PM Live)

All are worth studying in more detail and both SURF and TRIL represent a far cheaper investment opportunity, with shares priced at just $1.94 and $1.26 respectively. Neither have experienced a "Forty Seven moment", delivering outstanding results from early stage trials, but the price of Trillium recently spiked as Morgan Stanley reported a 5% holding. (Source: Benzinga)

For my money, however, Forty Seven is the frontrunner, and although it is priced at a premium to some of its rivals, there are good reasons for this, as I have discussed above. Another reason Forty Seven is at a competitive advantage is the 187+ patents it owns protecting magrolimab and FSI-189.

Additionally, although it was painful at the time, in 2018 Forty Seven agreed to make $47m of milestone payments to Synthon to secure non-exclusive rights to several CD-47- and SIRPa- directed antibodies, including rituximab. Other companies will need to make similar agreements if they want to develop their drugs with the same freedom that Forty Seven now has. Further analysis can be found in this informative recent SA article.

The average analyst price target for Forty Seven at time of writing is $39.25 (Source: Nasdaq) with a high of $48 and a low of $35 with the majority of analysts issuing "buy" ratings for the stock.

In my view, provided trial results remain positive, each new development can move the share price higher. Given the size of the addressable market (the global market for MDS treatment alone is set to reach $2.4bn by 2022, at a CAGR of 9.7% according to research from Grand View) and the urgent need for new and better treatments for diseases such as NHL, MDS, AML and DLBCL, the potential upside here is substantial.

If Forty Seven were to perform as well as, for example, gene-silencing treatment developer Arrowhead (ARWR) has done in 2019, buoyed by positive data, the share price could easily double as Arrowhead's has done. That is a big "if", however.

Biotech investing is inherently risky and it is all too easy to get sucked into a "next big thing" such as CD47 antibodies. In Forty Seven's case, however, the exciting premise is backed by years of research and real clinical data. Importantly, the FDA has issued Forty Seven with accelerated approval status both for magrolimab as a treatment for MDS, AML and DLBCL, as well as follicular lymphoma.

The company has treated over 190 relapsed or refractory cancer patients with magrolimab and will shortly enter a pivotal phase III trial, ENHANCE, enrolling 90 new patients to evaluate the combination of azacitidine and magrolimab together, plus it has the BLA scheduled for submission before the end of 2021.

The management team are experienced with big pharma backgrounds including Abbott Laboratories, Amgen, Genentech, Gilead, Janssen Global Services, LLC, PDL Biopharma, Inc. and Sandoz Inc.

Furthermore, Forty Seven has agreed collaborations with big pharma companies Merck and Genentech, a subsidiary of the Roche group to explore opportunities within ovarian and bladder cancer.

On balance, I think there are enough positive signals to make Forty Seven are worthwhile, if speculative investment.

Disclosure: I/we have no positions in any stocks mentioned, and no plans to initiate any positions within the next 72 hours. I wrote this article myself, and it expresses my own opinions. I am not receiving compensation for it (other than from Seeking Alpha). I have no business relationship with any company whose stock is mentioned in this article.

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Forty Seven: Early Indications Suggest Magrolimab Could Be A Winner - Seeking Alpha

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Inflammation is body’s response to a threat – NewmarketToday.ca

January 6th, 2020 4:45 pm

Hi Nonie,I consistently follow your articles and I havea follow-up question about a recent article. You state, Systemic inflammation can almost always be traced back at least in good part to malnutrition or toxicity related to dietary imbalances. Inflammation is an issue I deal with as I have Lupus, arthritis and sinusitis. Could you elaborate further on areas of malnutrition that contribute to inflammation? Would you also be more specific in regards to toxicity? What should I be looking for or doing to fix these two possible issues? And lastly, is there anywhere you can recommend to have a reliable food intolerance test?Thanks,Confused

Dear Confused,

Thank you for your question, and for reading regularly.With your specific conditions Lupus, arthritis (RA?), and sinusitis you do need to address inflammation on a systemic level. Each of these conditions is inherently inflammatory in nature. Doing so will be the cornerstone to improving your health.

Yours is a very complex health picture and obviously outside of the scope of my column to address fully, but holistic treatment should include addressing gut dysbiosis and permeability, which is certainly a factor in your inflammation. Ill try to unpack this a bit, as it relates to toxins and malnutrition. But first I want to clarify the meaning of malnutrition.

The root mal means disordered (Latin) or badly (le francais). We tend to take malnutrition to mean a lack of proper nutrition from not getting enough to eat. But it can also mean a lack of nutrition from not eating enough of the right things or from not getting adequate nutrients from the food one does eat. I will explain how this is relevant.

Healthy intestines dont just absorb nutrients and channel waste, their mucosa and structure also act as a barrier to pathogens and an informant to the immune system. When theres permeability in this barrier (think of it as tiny holes or gaps in a tube shaped, tightly woven screen covered in little finger like projections) food, various toxins, and microorganisms weve been exposed to escape or leak into the bloodstream to circulate. This is not supposed to happen in a healthy body!

In a healthy body, only beneficial, fully digested nutrients are given entry into the bloodstream by specific transport molecules via approved pathways to strategic sites where they are unloaded and used for specific manufacturing purposes. And all the dangerous things are locked inside the tube and swept along to be excreted. So foreign molecules (even nutrients) arent supposed to get into our bloodstream indiscriminately.

But our bodies are wonderfully designed! Our immune systems are set up to tag antigens on the surface of all potentially harmful substances that get into our bloodstream, creating antibodies to them forevermore so once we have come into contact with an offender, we are more quickly able to identify and remove it in the future. Antibodies are a signal to obliterate: a sort of seek and destroy function, if you will. Toxins, viruses, fungi, bacteria, chemicals, drugs, foreign debris, and proteins all have surface antigens that identify them.

So do many of our own cells, it turns out. But with an immune system that is functioning at normal levels, these are clearly recognized.

In a healthy body the antigens are limited and of a specific duration under normal circumstances (a flu virus, for example), after which the body recuperates and the immune response dies down. But, in the case of a leaky gut, the invaders are continual every time anything is passing through the gut there is a slow leak of antigens from various sources. The immune system goes to work tagging them all as a threat - even proteins we need for survival because they are escaping in an unrecognized form. Now theyre seen as offenders and a food reaction (sensitivity) is borne. Of course, the response is system-wide because the gaps allow these antigens directly into the bloodstream to circulate around.

Now, the immune system response doesnt stop there. Its super sophisticated.It has a backup to that backup, called inflammation. When the body gets the memo that the seek-and-destroy mission isnt doing the job and there are still circulating offenders getting in like gangbusters, it mounts an inflammatory response that is sort of like a system lockdown.

Inflammation can be localized when a tissue is damaged, for example, and we get swelling, heat, redness, and pain as chemicals are released to bring blood to the area to facilitate healing and clean up. Or inflammation can be non-specific and systemic, depending on the perceived threat.

Systemic inflammation looks like this:

Seek and destroy botched it again.Not surprising. Snort. Okay, lets get this done right. Initiate operation overkill.Heat or fever - lets torch these guys.Mucous - lets trap these guys.Tissue swelling - lets lock these guys in.Call in the Mr. Ts. (T-cells) - lets attack these guys.Okay, but were running low on energy.Right. Shut down the brain and draw all the energy reserves.

For someone with Lupus, these symptoms will sound very familiar.

The current medical paradigm is that systemic inflammation is a response in the body that doesnt understand there is no threat a spontaneously overactive or delusional immune system, if you will. In this paradigm its recognized that people with chronic systemic inflammation are more likely to develop autoimmune disease, although its not really understood how. Its perceived that the body just randomly attacks its own tissues. And these people, in turn, develop multiple chemical and food sensitivities, by unknown mechanisms.

But what if the leaky gut sets all this in motion? When antigens are appearing several times a day the immune system naturally goes on high alert. This isnt a dysfunctional immune system its a smart one. And when it does this, it has to become hypervigilant in attacking antigens. Since the bodys cells have their own antigens, its easy to see how they could get accidentally tagged in sites where thereis a perceived threat.

When quality control in any factory isdealing with threeor four timesthe normal maximum capacity, there are mistakes. And in this factory, tags are a forever thing. Any food with any protein component that escapes into the bloodstream via this mechanism would also be tagged and become something the body reacts to. Ditto chemicals. When this is happening daily, of course the backup inflammatory system is going to kick in to try to protect against the perceived invasion.

BOOM! Continual systemic inflammation with multiple food and chemical intolerances and an immune system on overdrive that is now busy attacking not only outside offenders, but itself. This is a holistic understanding of autoimmune disease. And it all starts in the gut.

And leaky gut is often linked to gluten intolerance. With your symptom set I feel safe saying its likely that youre gluten intolerant, if not celiac. I would recommend testing for celiac immediately. If that does not return a positive test, I would recommend non-celiac gluten sensitivity testing. You can get antibody, saliva and blood testing, but they are not always accurate in the absence of symptomatology and a knowledgeable practitioner. Its still new territory. I prefer my food intolerance test, antibody testing, and intestinal permeability testing, working collaboratively with your physician. In complex cases its always best to have a collaborative approach if you can.

Why do I feel you are gluten intolerant? Gluten, in particular, damages the gut lining in sensitive individuals. It burns the microvilli and causes gaps in the junctions of the intestinal lining. Remember, these gaps are how antigens leak into the bloodstream to initiate and fuel the immune system mayhem.

Undiagnosed non-celiac gluten sensitivity has been shown to masquerade as Lupus.

As for toxins, mycotoxins (molds), parasites, candida, bacteria from root canals, heavy metals, synthetic fragrances, chemical cleaners, chemical body care products, and environmental toxins should all be considered and eliminated. These can precipitate the problem or just add to it. Remember, if there are regular antigens the immune system mayhem starts. Regular antigens can come from a food intolerance (gluten), from environmental toxins (mould), from endogenous toxins (bacterial imbalance or candida), or from any number of sources. So if you are gluten intolerant, that is also acting as a toxin.

The person with an autoimmune disease will, as a result of all this, have an overburdened liver because it is trying to deal with all these toxins -and this means any subsequent toxin will have an exaggerated impact compared to the impact they would have on a healthy host. Something as benign as perfume can even trigger migraines or seizures in such people. Their livers just cant handle any more! Discerning and eliminating these toxins can make a big impact on the burden of the body. Removing common toxins like sugar, alcohol, drugs, cigarettes, and processed foods are also imperative for managing symptoms and discomfort.

It may be helpful to think of toxicity as anything that adds to the burden of the body. It only makes sense that if the burden is increased chronically, the body is going to need copious nutrients to do that work. Unfortunately, when we are chronically ill the first thing to go is often our diet. We eat convenience food instead of quality, nutrient dense foods. These foods are full of toxic chemicals and additives. Too, many healthy molecules are mistakenly tagged as toxins (above). The body struggles in the presence of so many substances to protect itself from and is overwhelmed by the burden of it.

But how does malnutrition play in? When the digestive system cant contain nutrients in the lumen until they are properly broken down and delivered via appropriate pathways, deficiencies develop. At the same time, the body requires more nutrients than normal to sustain its protective detail. These deficiencies, in turn, make it difficult for tissues (like the damaged gut tissue) to self repair. This happens even when a person is eating well - because the food is not being absorbed properly. This is why I say malnutrition plays a large role.

As such, I believe healing the gut and adding strategic supplements to a nutrient dense, easy to digest diet that identifies and avoids or rotates intolerances is essential in starting to address chronic inflammation and autoimmunity.

I hope this helps clarify the role of inflammation, toxicity, and deficiency, particular to your concerns, and of food intolerances. I hope it gives you some clear actions you can take to start to improve your health. If you want further guidance you can come see me in my clinic. I offer comprehensive testing for food intolerances and gut biome health, which would tell us a lot about the state of your digestive system to create a strategic plan. At the very least, I hope you are less confused.

As always, if readers have their own questions I encourage them to write to me at nonienutritionista@gmail.com. For more health news, recipes, and nutrition related events in the community, readers can go to my website at nonienutritonista.com and sign up for the newsletter. Its nutritionist certified and 100 per cent gluten and sugar free!

Namaste!Nonie Nutritionista

Nonie De Long is a registered orthomolecular nutritionist with a clinic in Bradford West Gwillimbury, where she offers holistic, integrative health care for physical and mental health issues. Check out her website here.

Do you have a question about health and wellness? Emailnonienutritionista@gmail.com

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Inflammation is body's response to a threat - NewmarketToday.ca

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Magenta Therapeutics to Present at the 38th Annual J.P. Morgan Healthcare Conference on Wednesday, January 15th in San Francisco – Business Wire

January 6th, 2020 4:45 pm

CAMBRIDGE, Mass.--(BUSINESS WIRE)--Magenta Therapeutics (NASDAQ: MGTA), a clinical-stage biotechnology company developing novel medicines to bring the curative power of immune reset to more patients, today announced that the company is scheduled to present at the 38th Annual J.P. Morgan Healthcare Conference in San Francisco on Wednesday, January 15th, 2020 at 11:30 a.m. PT (2:30 p.m. ET), immediately followed by a Q&A session.

A live webcast of the presentation and Q&A session can be accessed on the Magenta Therapeutics website at https://investor.magentatx.com/events-and-presentations. The webcast replay will be available for 90 days following the event.

About Magenta Therapeutics

Magenta Therapeutics is a clinical-stage biotechnology company developing medicines to bring the curative power of immune system reset through stem cell transplant to more patients with autoimmune diseases, genetic diseases and blood cancers. Magenta is combining leadership in stem cell biology and biotherapeutics development with clinical and regulatory expertise, a unique business model and broad networks in the stem cell transplant world to revolutionize immune reset for more patients.

Magenta is based in Cambridge, Mass. For more information, please visit http://www.magentatx.com.

Follow Magenta on Twitter: @magentatx.

Forward-Looking Statement

This press release may contain forward-looking statements and information within the meaning of The Private Securities Litigation Reform Act of 1995 and other federal securities laws. The use of words such as may, will, could, should, expects, intends, plans, anticipates, believes, estimates, predicts, projects, seeks, endeavor, potential, continue or the negative of such words or other similar expressions can be used to identify forward-looking statements. The express or implied forward-looking statements included in this press release are only predictions and are subject to a number of risks, uncertainties and assumptions, including, without limitation risks set forth under the caption Risk Factors in Magentas Registration Statement on Form S-1, as updated by Magentas most recent Quarterly Report on Form 10-Q and its other filings with the Securities and Exchange Commission. In light of these risks, uncertainties and assumptions, the forward-looking events and circumstances discussed in this press release may not occur and actual results could differ materially and adversely from those anticipated or implied in the forward-looking statements. You should not rely upon forward-looking statements as predictions of future events. Although Magenta believes that the expectations reflected in the forward-looking statements are reasonable, it cannot guarantee that the future results, levels of activity, performance or events and circumstances reflected in the forward-looking statements will be achieved or occur. Moreover, except as required by law, neither Magenta nor any other person assumes responsibility for the accuracy and completeness of the forward-looking statements included in this press release. Any forward-looking statement included in this press release speaks only as of the date on which it was made. We undertake no obligation to publicly update or revise any forward-looking statement, whether as a result of new information, future events or otherwise, except as required by law.

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Magenta Therapeutics to Present at the 38th Annual J.P. Morgan Healthcare Conference on Wednesday, January 15th in San Francisco - Business Wire

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Cellectis: An Expert Review on Allogeneic CAR-T for Cancer Published in Nature Reviews Drug Discovery – Yahoo Finance

January 6th, 2020 4:45 pm

Cellectis and World Experts Review New Avenue of Allogeneic CAR T-cells, Optimization and Promises in Oncology

Cellectis (Paris:ALCLS) (NASDAQ:CLLS) (Euronext Growth:ALCLS; Nasdaq:CLLS), a biopharmaceutical company focused on developing immunotherapies based on gene-edited allogeneic CAR T-cells (UCART), announced today the publication of a review in Nature Reviews Drug Discovery by Prof. Stphane Depil1*, Dr. Philippe Duchateau2, Prof. Stephan Grupp3, Prof. Ghulam Mufti4 and Dr. Laurent Poirot2. The authors review the opportunities and challenges presented by universal allogeneic CAR T-cell therapies.

One of the most promising approaches in cancer treatment is chimeric antigen receptor (CAR) T-cell therapy, in which part of the bodys own immunological defendors, T-cells, are redirected against cancerous cells after being engineered to express CARs. Since their initial development in the early 90s, CAR T-cells have evolved through several generations. The use of autologous (patient-derived) CAR T-cells has proven to be successful in treating people with certain blood cancers such as B-cell malignancies. However, autologous CAR T-cell therapy is not suitable for all patients, and it often requires a long and expensive manufacturing process since each treatment must be made individually for each patient.

Cellectis was the first company to develop and test an allogeneic CAR T-cell therapy in patients, where T-cells are derived from healthy donors. This gives rise to off-the-shelf product candidates which aim to be suitable for many patients as opposed to only a single person.

"We realized early on that refined gene-editing techniques were what was needed to take an allogeneic approach to CAR T-cell therapy," said Dr. Laurent Poirot, VP, Immunology Division, Cellectis. "Despite the complexity of this approach, we decided to follow this route because we are confident that it can provide the most impact for a maximum number of people living with severe cancers. This comprehensive review underlines just how much this technology has evolved in very little time. It also gives us exciting areas to explore as we continue to improve our product candidates."

One of the major challenges in the allogeneic approach involves mitigating the risk of graft-versus-host-disease (GvHD) a medical complication that can present itself in people that have received tissues or cells from another person. The review examines aspects of this challenge and helps weigh the pros and cons associated with the different methods used to create allogeneic CAR T-cells. It also outlines some of the gene-editing work that Cellectis has done in this area along with complementary approaches being taken by others in the field, such as using cells other than conventional T-cells, also known as alpha beta T-cells.

"Our immune system, including our T-cells, is incredibly sophisticated. We know that T-cells can now be retasked to successfully fight cancer. There are amazing approaches to gene editing that are driving progress towards the most safe and efficacious versions of allogeneic products. It is exciting to see these approaches applied to off the shelf CAR T-cell products," said Prof. Stephan Grupp, Chief of Cell Therapy and Transplant Section at the Childrens Hospital of Philadelphia, Professor of Pediatrics at the Perelman School of Medicine, and a member of Cellectis Clinical Advisory Board. "Im looking forward to seeing emerging clinical data as well as even newer approaches, as Cellectis expertise in gene-editing technology continues to transform CAR-T."

Off-the-shelf allogeneic CAR T cells: new development and current challenges

Stphane Depil1*, Philippe Duchateau2, Stephan Grupp3, Ghulam Mufti4, Laurent Poirot2

1Formerly Cellectis, now Centre Lon Brard and Centre de Recherche en Cancrologie de Lyon, 28 rue Laennec, 69008 Lyon, France2Cellectis, 8 rue de la Croix Jarry, 75013, Paris, France3Childrens Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd Philadelphia, PA 10104, USA4Kings College London and Kings College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom

About CellectisCellectis is developing the first of its kind allogeneic approach for CAR-T therapies, pioneering the concept of off-the-shelf and ready-to-use gene-edited CAR-T cells to treat patients. As a clinical-stage biopharmaceutical company with over 20 years of expertise in gene editing, we are developing game-changer product candidates in immune-oncology. Utilizing TALEN, our gene editing technology, and PulseAgile, our pioneering electroporation system, we are harnessing the power of the immune system to target and eradicate cancer cells.

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As part of our commitment to a cure, Cellectis remains dedicated to its goal of providing life-saving UCART product candidates to address unmet need for multiple cancers including B-cell acute lymphoblastic leukemia (B-ALL), non-Hodgkin lymphoma (NHL) and multiple myeloma (MM). Cellectis is listed on the Nasdaq (ticker: CLLS) and on Euronext Growth (ticker: ALCLS).

Cellectis headquarters are in Paris, France, with additional locations in New York, New York and Raleigh, North Carolina. For more information, visit http://www.cellectis.com.

Follow Cellectis on social media: @Cellectis, LinkedIn and YouTube.

TALEN is a registered trademark owned by Cellectis.

DisclaimerThis press release contains "forward-looking" statements that are based on our managements current expectations and assumptions and on information currently available to management. Forward-looking statements involve known and unknown risks, uncertainties and other factors that may cause our actual results, performance or achievements to be materially different from any future results, performance or achievements expressed or implied by the forward-looking statements. Further information on the risk factors that may affect company business and financial performance is included in Cellectis Annual Report on Form 20-F and the financial report (including the management report) for the year ended December 31, 2018 and subsequent filings Cellectis makes with the Securities Exchange Commission from time to time. Except as required by law, we assume no obligation to update these forward-looking statements publicly, or to update the reasons why actual results could differ materially from those anticipated in the forward-looking statements, even if new information becomes available in the future.

View source version on businesswire.com: https://www.businesswire.com/news/home/20200106005969/en/

Contacts

Media:Jennifer Moore, VP of Communications, 917-580-1088, media@cellectis.comCaitlin Kasunich, KCSA Strategic Communications, 212-896-1241, ckasunich@kcsa.com

IR:Simon Harnest, VP of Corporate Strategy and Finance, 646-385-9008, simon.harnest@cellectis.com

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Cellectis: An Expert Review on Allogeneic CAR-T for Cancer Published in Nature Reviews Drug Discovery - Yahoo Finance

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Human T cell response to CD1a and contact dermatitis allergens in botanical extracts and commercial skin care products – Science

January 6th, 2020 4:45 pm

Oily skin allergens hole up inside CD1a

Contact dermatitis induced by allergens in personal care products is a common cause of skin rashes, but the molecular mechanisms leading to T cell activation are poorly understood. Nicolai et al. tested known contact allergens for their ability to boost IFN- production by human T cells autoreactive to the CD1a antigen presentation molecule. Several hydrophobic chemicals came up as hits, including farnesol, a compound often used as a fragrance. Structural analysis of CD1a-farnesol complexes revealed that farnesol is buried deep within CD1as antigen-binding cleft beyond the reach of T cell receptor chains. These findings suggest that several hydrophobic contact allergens elicit T cellmediated hypersensitivity reactions through displacement of self-lipids normally bound to CD1a, thereby exposing T cellstimulatory surface regions of CD1a that are normally hidden.

During industrialization, humans have been exposed to increasing numbers of foreign chemicals. Failure of the immune system to tolerate drugs, cosmetics, and other skin products causes allergic contact dermatitis, a T cellmediated disease with rising prevalence. Models of T cell response emphasize T cell receptor (TCR) contact with peptide-MHC complexes, but this model cannot readily explain activation by most contact dermatitis allergens, which are nonpeptidic molecules. We tested whether CD1a, an abundant MHC Ilike protein in human skin, mediates contact allergen recognition. Using CD1a-autoreactive human T cell clones to screen clinically important allergens present in skin patch testing kits, we identified responses to balsam of Peru, a tree oil widely used in cosmetics and toothpaste. Additional purification identified benzyl benzoate and benzyl cinnamate as antigenic compounds within balsam of Peru. Screening of structurally related compounds revealed additional stimulants of CD1a-restricted T cells, including farnesol and coenzyme Q2. Certain general chemical features controlled response: small size, extreme hydrophobicity, and chemical constraint from rings and unsaturations. Unlike lipid antigens that protrude to form epitopes and contact TCRs, the small size of farnesol allows sequestration deeply within CD1a, where it displaces self-lipids and unmasks the CD1a surface. These studies identify molecular connections between CD1a and hypersensitivity to consumer products, defining a mechanism that could plausibly explain the many known T cell responses to oily substances.

The human immune system evolved to respond to foreign microbial antigens but must also tolerate foreign compounds present in the environment, such as plants and foods. Over the past two centuries, industrialization has introduced the widespread use of chemical extraction techniques and synthetic chemistry methods. Industrial development has greatly increased the range of synthetic or purified botanical compounds to which humans are commonly exposed through pollution or the intentional use of drugs, fragrances, cosmetics, and other consumer products, especially those applied at high concentrations directly on the skin. Accordingly, the incidence of contact dermatitis has risen, especially in industrialized countries (1). Lifetime incidence currently exceeds 50%, making contact dermatitis the most common occupational skin disease (2). The essential pathophysiological feature of contact dermatitis is the allergen-specific nature of immune hypersensitivity reactions. Diagnosis relies on identifying the specific allergens to which a patient was exposed. Physicians measure local skin inflammation to a grid network of allergen patches applied to the skin as a diagnostic test. The mainstay of treatment is avoidance of exposure to named allergens.

Considerable evidence documents a role for T cells in contact dermatitis, which is caused by delayed-type hypersensitivity reactions. Gell and Coombs (3) defined type IV reactions as delayed-type hypersensitivity because they appear after 72 hours. Type IV reactions are T cell mediated and are worsened after repeated exposure to allergens. During the sensitization phase, naive T cells are activated in a process that involves Langerhans cells and dermal dendritic cells (2). In the elicitation phase, T cells cause inflammatory manifestations in the skin. Biologists views of T cell response are strongly influenced by the known mechanisms by which T cell receptors (TCRs) recognize peptide antigens bound to major histocompatibility complex I (MHC I) and MHC II proteins (46). Yet, most known contact allergens are nonpeptidic small molecules, cations, or metals that are typically delivered to skin as drugs, oils, cosmetics, skin creams, or fragrances (1, 2). Thus, the chemical nature of contact allergens does not match the chemical structures of most antigens commonly recognized within the TCR-peptideMHC axis.

This apparent disconnect, which represents a core question regarding the origin of delayed-type hypersensitivity, might be explained if MHC proteins use atypical binding interactions to display nonpeptidic antigens to TCRs. For example, the antiretroviral drug abacavir binds within the human leucocyte antigen (HLA)B*57:01 groove to alter the seating of self-peptides, creating neo-self epitopes (7). Similarly, the MHC class II protein encoded by HLA-DP2 can bind beryllium, thereby plausibly altering the MHC-peptide complex shape to enable binding of an autoreactive TCR (8). Here, autoimmune response to nonpeptidic compounds still involves peptides in some way and is linked to a specific HLA allomorph that uses a defined structural mechanism. A second general model is that nonpeptidic allergens form covalent bonds with peptides in vivo. Such haptenation reactions might create hybrid molecules with peptide-based MHC binding moieties and TCR epitopes formed from the haptenizing drug or chemical. This concept derived from Landsteiners landmark studies with 2,4-dinitrophenols (9) and evolved into broader predictions that drugs could haptenate peptides or innate receptors (10). Some evidence indicates that drugs can generate immune hypersensitivity reactions via haptenation. For example, sulfamethoxazole, lidocaine, penicillins, lamotrigine, carbamazepine, p-phenylenediamine, or gadolinium can bind peptides, MHC proteins, or TCRs (1116). Although the haptenation hypothesis is broadly taught to physicians, the extent to which it accounts for the larger spectrum of contact allergens remains unknown (17).

Both of these models derive from the premise that T cell responses are mediated by MHC-encoded proteins and emphasize atypical modes of peptide presentation. Putting aside this premise, we tested a straightforward model whereby drugs and other nonpeptidic contact allergens are presented by a system that evolved to present nonpeptidic antigens to T cells (18). CD1 proteins are MHC Ilike molecules that fold to form an antigen binding cleft composed of two pockets, A and F, which are larger and more hydrophobic than the clefts present in MHC I and MHC II proteins (19, 20). Most published studies of human CD1 proteins (CD1a, CD1b, CD1c, and CD1d) emphasize display of amphipathic membrane phospholipids and sphingolipids. The alkyl chains bind within and fill up the cleft of CD1, and the polar head groups, composed of carbohydrates or phosphate esters, protrude through a small portal (F portal) to lie on the outer surface of CD1, where they are presented to TCRs (21).

Whereas most known CD1-presented antigens are amphipathic lipids, some evidence suggests that CD1 proteins mediate recognition of nonlipidic, drug-like molecules. For example, CD1d mediates T cell response to phenyl pentamethyldihydrobenzofuran sulfonates (PPBFs) (22), and chemically reactive small molecules can influence CD1-restricted T cell response by an unknown mechanism that might involve induced lipid autoantigen synthesis (23). PPBFs lack aliphatic hydrocarbon chains that define lipids, and they are instead ringed, sulfated small molecules that chemically resemble allergenic drugs, such as sulfonamide antibiotics and furosemide. However, PPBF antigens are much smaller than the known volume of CD1d cleft. Unlike amphipathic lipids, they lack a defined lipid anchor and hydrophilic head group (22), raising questions about how PPBFs could bind within CD1d and yet protrude in some way for TCR contact.

Among human CD1 isoforms, we focused on CD1a because it is abundantly expressed on epidermal Langerhans cells and dermal dendritic cells, which are implicated in contact dermatitis (24). In addition, CD1a-autoreactive T cells home to the skin, and polyclonal autoreactive T cells derived from blood and skin show higher responses to CD1a as compared with other CD1 proteins (25, 26). In addition, surface CD1a proteins can rapidly capture extracellular antigens using mechanisms that do not require complex mechanisms of antigen processing within the endosomal network (27, 28). Recently, transfer of the human CD1a gene into mice (29) was found to augment intradermal T cell responses to the natural, plant-derived compound, urushiol (30). Actual CD1a-mediated T cell responses to commonly used drugs or contact allergens in consumer goods are, to our knowledge, unknown.

As a screen for the most common and clinically important contact dermatitis antigens, we tested for human T cell response to compounds embedded in the thin-layer rapid use epicutaneous (T.R.U.E.) test (or Truetest), which is broadly used in dermatology and allergy clinics to screen patients for contact dermatitis allergens that are most commonly encountered in medical practice. This approach identified a human T cell response to a tree oilderived contact allergen known as balsam of Peru. Larger-scale screens defined the general chemical requirements for a T cell response to oily substances and discovered additional contact allergens presented by CD1a, including farnesol. The crystal structure of the CD1a-farnesol complex and study of the self-lipids bound to CD1a provided evidence for a molecular mechanism for recognition of a contact allergen, explaining how small antigens sequestered fully within CD1a can lead to T cell responses through the absence of interference with CD1a-TCR contact.

To determine whether CD1a can present contact allergens to T cells, we initially used the CD1a-restricted T cell line known as BC2 for testing response to the T.R.U.E. test panel 1 (Truetest 1) (fig. S1). BC2 is a T cell line derived from peripheral blood T cells of a blood bank donor and has previously been shown to be activated by CD1a loaded with small hydrophobic self-lipids (31). Normally, the Truetest panel consists of compounds arrayed on sterile matrix, which is placed on patient skin. Localized erythema occurring in vivo on skin 2 to 5 days after exposure is considered a positive test, allowing allergen identification based on position in the grid. For testing in vitro, individual allergen patches and untreated patch matrix (control patch) were cut apart with sterile technique. Patches were soaked in media and removed (soaking method) or inserted into wells to contact (contact method) CD1a-transfected K562 (K562-CD1a) antigen-presenting cells (APCs). We saw a modest response to K562-CD1a in the absence of added patch material using interferon- (IFN-) enzyme-linked immunosorbent assay (ELISA), as expected on the basis of the known CD1a autoreactivity of the BC2 T cell line (fig. S1A).

Compared with the control patch, most of the antigen-containing patches, including nickel, potassium dichromate, colophony, lanolin, and paraben, showed no effect. A combination of molecules known as fragrance mix 1 showed slight suppression of cytokine release, consistent with toxicity to cells (fig. S1A). Cobalt, neomycin, and ethylenediamine dihydrochloride showed small increases in IFN- at some doses tested but not reproducibly in subsequent assays. In contrast, balsam of Peru showed a significant response above background (fig. S1A), which also repeated in subsequent assays (fig. S1B and Fig. 1A). Response to balsam of Peru was not seen with patch soaking (fig. S1B), indicating that the stimulatory factor(s) was not physically released from the patch. Overall, the screen suggested a T cell response to balsam of Peru embedded in Truetest patches, leading to focused studies of this natural botanical extract.

(A to E) T cell lines with CD1a autoreactivity (BC2 and Bgp) or foreign antigen reactivity (CD8-2) were tested for activation to lipids using IFN- ELISA in cellular assays with CD1a-transfected K562 cells (K562-CD1a) or mock-transfected K562 cells (K562-mock) (A, B, and E) or on streptavidin plates coated with biotinylated CD1 proteins (C and D). Data are representative of three or more experiments each with the mean of triplicate measurements shown with SD. The significance of lipid concentration on IFN- release was tested by one-way ANOVA (A and C). Relevant pairwise comparisons were tested using Welchs t test (B). Post hoc comparison of marginal means after adjustment by the Sidak method was used to group treatments at the specified significance level after a significant result by two-way ANOVA (D). Post hoc comparison by least squares means after adjustment by the Sidak method was used to group treatments with nonoverlapping marginal means and 95% confidence levels into a, b, or c at the specified significance level after a significant result by two-way ANOVA (E). IgG, immunoglobulin G.

Balsam of Peru is a resin from the South American tree Myroxylon balsamum, which has a vanilla scent and is used as a fragrance and flavor in many personal care products such as skin creams and toothpaste. Balsam of Peru is a common contact allergen seen in medical practice, where it causes severe skin rash in allergic individuals (32, 33). We tested balsam of Peru extract and oily substances derived therefrom, which is known as balsam of Peru oil. Both preparations are commonly used in consumer products. BC2 T cells were activated by both preparations, establishing a T cell dose response to a common botanical extract used in consumer goods (Fig. 1A).

Given the unusual chemical nature of oily substances found in Balsam of Peru oil, we considered candidate mechanisms of T cell activation other than antigen display by CD1a. In theory, compounds might undergo peptide haptenation reactions for presentation by MHC proteins, but this possibility was less favored because K562 cells express very low or undetectable MHC I and MHC II (25). Oily mixtures might influence cellular lipid production (23) or contain mitogens that cross-link CD3 complexes or broadly activate lymphocytes via TCR-independent mechanisms (34). To determine the cellular and molecular mechanisms of T cell stimulation, we measured T cell activation by K562 APCs and by biotinylated CD1a proteins bound to avidin-coated plates. As assessed with anti-CD1a blocking antibodies and K562 cells lacking CD1a, CD1a was required for the BC2 response to crude balsam of Peru and oils derived therefrom (Fig. 1, B and C). Treating plate-bound CD1a protein with balsam of Peru was sufficient to activate the BC2 response, albeit at higher doses than with antigen in the presence of CD1a-expressing cells (Fig. 1C). Thus, APCs facilitate some aspects of T cell response, but clear activation in APC-free systems ruled out that antigen processing is required. As a specificity control, BC2 did not respond to a structurally unrelated lipid, sphingomyelin, which is a known ligand for CD1a (Fig. 1D) (35). These results were most consistent with CD1a forming complexes with some molecule in these antigen preparations. Further specificity controls showed that balsam of Peru preparations did not activate a CD1a-restricted T cell clone, CD8-2, that recognizes CD1a presenting a mycobacterial antigen (Fig. 1D) (18, 36). This finding, along with the absolute requirement for CD1a in all recognition events, strongly indicated that these substances are not mitogens. However, both balsam of Peru and balsam of Peru oil did activate another CD1a-autoreactive T cell line, Bgp (31). This indicates that balsam of Peru response was not limited to the BC2 T cell line (Fig. 1E).

Next, we sought to pinpoint chemical structures of the antigenic substances. Balsam of Peru is a complex botanical extract, with the most abundant components previously reported to be benzyl cinnamate and benzyl benzoate (37). Silica thin-layer chromatography (TLC) showed that crude balsam of Peru contained hydrophilic compounds that remained near the origin, as well as two dark spots that comigrate with synthetic benzyl benzoate and benzyl cinnamate standards (Fig. 2A). As expected, oils extracted from balsam of Peru lacked the hydrophilic compounds that adhered at the origin. Balsam of Peru oil generated one dark spot that comigrated with benzyl benzoate. More sensitive methods of positive-mode nanoelectrospray ionization mass spectrometry (MS) (Fig. 2B) detected sodium adducts [M+Na]+ of benzyl cinnamate [mass/charge ratio (m/z) 261.3] and benzyl benzoate (m/z 235.3) in both preparations. The signal for benzyl benzoate was ~10-fold stronger than for benzyl cinnamate in balsam of Peru oil. Thus, benzyl cinnamate was present in both preparations, but its concentration was below the threshold of detection by TLC.

(A) Normal-phase silica TLC plate resolves balsam of Peru oil (BPO), crude balsam of Peru (BP), synthetic benzyl cinnamate (BC), and synthetic benzyl benzoate (BB). (B) Structures of benzyl cinnamate and benzyl benzoate are shown with the expected mass of sodium adducts [M+Na]+, which were detected in positive-mode nanoelectrospray ionization MS. (C to E) T cell clones that are autoreactive to CD1a (BC2) or foreign antigen (CD8-2) were tested for response to antigens (g/ml) or SM (sphingomy) by IFN- ELISA in cellular (E) or CD1a-coated plate (C and D) assays. Data are representative of three or more experiments, each shown as the mean of triplicate samples SD. The significance of lipid concentration on IFN- release was tested by one-way ANOVA (C). The significance of benzyl cinnamate and benzyl benzoate concentration on IFN- release and of the effects of CD1b or CD8-2 T cells were tested by two-way ANOVA (D and E).

False-positive results from trace contaminants in natural preparations occur, so we tested whether benzyl benzoate and benzyl cinnamate, provided as purified synthetic molecules, activated CD1a-restricted T cells. We observed T cell activation in response to both synthetic molecules, and the response was dependent on precoating the plate with CD1a. We observed a stronger and more potent response to benzyl cinnamate (Fig. 2C), which was then used for further mechanistic studies. Detailed testing of BC2 and CD8-2 activation by benzyl cinnamate confirmed the dose dependence, CD1a dependence, and TCR specificity of the T cell response to benzyl cinnamate (Fig. 2D). Sphingomyelin, a known CD1a ligand (31), which has a bulky polar head group, did not activate T cells. Responses to benzyl cinnamate were seen in two T cell lines, BC2 and Bgp (31). Benzyl cinnamate and benzyl benzoate were efficiently presented by plate-bound CD1a proteins after a short coincubation, demonstrating the lack of a cellular processing requirement (Fig. 2, C and D). These findings are most consistent with the formation of CD1abenzyl cinnamate complexes as the target of T cell response. Thus, tree oils that are known to act as potent contact hypersensitivity agents also function as T cell stimulants that act via CD1a.

The dual benzyl rings present in benzyl cinnamate and benzyl benzoate (Fig. 2B) are chemically different from the alkyl chains present in most CD1-presented antigens. However, they are notably similar to the dually ringed structure present in the unusual nonlipidic antigen presented by CD1d known as PPBF (22). All three nonlipidic T cell stimulants are smaller (212 to 345 Da) than most previously known CD1-presented lipid antigens (~700 to 1500 Da) (21). Prior CD1-lipid structures (21) established a widely accepted mechanism whereby the acyl chains rest inside the hydrophobic clefts of CD1 proteins, so that hydrophilic head groups protrude outside CD1 and form epitopes that specifically contact TCRs (Fig. 3A) (38). In contrast, the antigenic tree oils identified here lack any identifiable polar group that could function as a TCR epitope (Fig. 3B). Further, the size of the carbon skeletons of benzyl benzoate and benzyl cinnamate (C14 to C16) are substantially smaller than other CD1 antigens (C20 to C40) and the estimated capacity of the CD1a cleft (~C36) (19, 39, 40). Because tree oils are apparently too small to fill the CD1a cleft we hypothesized that they might not form TCR epitopes and so function outside the main CD1 antigen display paradigm. For example, interactions within the CD1a cleft might alter the shape of CD1-lipid complexes from the inside (41). Alternatively, similar to recent studies of CD1a (31, 35) and CD1c (42), tree oils might displace endogenous lipids, whose large head groups interfere with TCR contact with CD1a. This emerging model is known as the absence of interference because carried lipids do not contact TCRs directly but instead bind CD1 in a manner that allows direct contact between CD1 and the TCR (31, 35).

(A) Using PC as an example, CD1 ligands are often composed of head groups and lipid anchors, but (B) recently identified CD1a presented antigens are oils. (C) BC2 T cells were tested for cytokine release in response to small hydrophobic molecules pulsed on plate-bound CD1a pretreated with acidic citrate buffer to strip ligands (31). Tested compounds are classified into groups based on the presence of branched-chain unsaturated lipids structurally related to squalene, (D) ringed lipids structurally related to benzyl cinnamate, or (E) molecules that show branched, polyunsaturated, and ringed structures, such as coenzyme Q2. Results of triplicate analyses are shown as means SD with each compound tested two or more times. Post hoc comparison by marginal means of the interaction term between lipid and concentration after adjustment by the Sidak method was used to group treatments by nonoverlapping 95% confidence levels at the specified significance level after a significant result by two-way ANOVA. (F) The size of all tested antigens is shown on the basis of the number of carbon atoms (C) or mass [atomic mass units (u)], as compared with the volume of the CD1a cleft, which has been measured at 1650 3, and can accommodate ~36 methylene units (C36) (19, 40). (G) Purified T cells (CD4 and CD4+) were incubated overnight with plate-bound CD1a, either mock treated or pretreated with the indicated antigens (50 g/ml). Real-time PCR of IFN- mRNA relative to -actin.*P < 0.05, two-sided Students t test, antigen-treated compared with mock-treated CD1a.

The approach to testing chemical features was guided by the observation that squalene, benzyl benzoate, and benzyl cinnamate have ringed or unsaturated structures that chemically constrain molecules, rendering them bulky and rigid. Using tree oils and skin oils as lead compounds (Fig. 3B) to generate a larger test panel (Fig. 3, C to E, and fig. S2), we surveyed 29 structurally related molecules that differed in size, saturation, branching patterns, or ringed structures. Fifteen compounds, including examples among branched (Fig. 3C), ringed (Fig. 3, D and E), and saturated or unsaturated fatty acyl compounds (fig. S2), were recognized. This moderately promiscuous pattern was markedly different from T cell responses to glycolipids such as -galactosyl ceramide or glucose monomycolate, where altering a single stereocenter on the carbohydrate epitope abolished recognition (43, 44). However, not every oily substance was sufficient to activate T cells.

Considering the particular chemical structures that control response, squalene is a C30 polyunsaturated branched-chain lipid antigen (Fig. 3B) (31). We found cross-reactivity to structurally related C20 geranylgeraniol and C23 geranylgeranylactone, as well as C15 farnesol, but not smaller geraniol-based compounds (Fig. 3C). The farnesol response is notable because it is also a contact allergen in Truetest panel 2 (45) (Fig. 1) and so represents another link between contact allergens and CD1a antigens. Further, considering molecules with branched and ringed structures related to benzyl cinnamate, we identified a new antigen, coenzyme Q2 (Fig. 3D). Although coenzyme Q2 has not been described as a contact allergen, idebenone, which has an identical head group (2,3-dimethoxy, 5-methyl, 1,4-benzoquinone) but a less hydrophobic lipid tail, composed of a 10-carbon alkyl chain with a hydroxyl group, is a well-known skin allergen (4648). In addition, in our CD1a plate assays, idebenone stimulated a dose-dependent T cell response, supporting a link between coenzyme Q2related structures and contact allergens (fig. S3). Vitamin E, a known skin allergen, did not induce a response in this BC2-based screening. However, this does not exclude the existence of CD1a-restricted T cells to this hydrophobic compound within a polyclonal T cell repertoire.

The identification of a strong stimulatory response to coenzyme Q2 prompted screening of coenzyme Q length analogs, finding optimal response to coenzyme Q2 but not larger or smaller chain length analogs (Fig. 3, D and E). Last, comparison of 12 fatty acyl analogs consistently showed stronger response when the normally charged carboxylate group was capped by a methyl, alkyl, or other structure to generate a nonpolar molecule (fig. S2). A weak effect was seen in some cases, where potency was increased by cis unsaturation.

In summary, compared with highly flexible lipids with saturated alkyl chains, an unsaturated, ringed, or branched structure correlated with higher response. However, very highly constrained or bulky structures, such as vitamin A, vitamin D, and vitamin E, were not recognized. Considering molecular size, response was optimal with compounds (222 to 410 Da, C15 to C30) that were near the middle of the size range tested (154 to 862 Da, C9 to C59) (Fig. 3F). These optima were considerably smaller than known CD1 antigens (~700 to 1500 Da). Even the largest stimulatory compound, squalene (C30, 410 Da), was substantially smaller than the predicted number of methylene units (~C36) that would fill the CD1a cleft (1650 3) (19, 40). Unlike molecules that form antigenic epitopes for TCRs, no single molecular variant could be assigned as essential for T cell activation.

Last, to determine whether the identified link between CD1a and contact allergens is generalizable to polyclonal T cells and among genetically unrelated human donors, we screened purified polyclonal T cells (CD4+ and CD4) from blood bank donors and determined their response to plate-bound CD1a preloaded with either farnesol or coenzyme Q2. As also seen in clinical evaluation of contact dermatitis patients, not all patients responded to every antigen, but we observed polyclonal responses to both antigens in two or more subjects using sensitive real-time quantitative polymerase chain reaction (qPCR) testing of IFN- response (Fig. 3G). Responses were seen in the CD4+ T cell fractions but were stronger in the CD4 T cell fraction (Fig. 3G). This suggests that the normal T cell repertoire contains T cells that respond to CD1acontact allergen complexes. Similarly, in a different set of donors, T cell responses were detected to benzyl cinnamateloaded CD1a (fig. S4). Together, these results support the broader relevance of these CD1a allergens beyond the specificity of two T cell lines.

Farnesol is a common additive to cosmetics and skin creams, where its use requires precaution labeling, based on its recognized role as a contact allergen (45). Farnesol testing is routine in clinical practice, where it is present in the fragrance mix 2 in Truetest patches. Farnesol can also be tested as a pure compound, generating responses in ~1% of people with suspected contact dermatitis (45). After the screen identified a farnesol response (Fig. 3C), we observed reproducible and dose-dependent response for BC2 in the CD1a-coated plate assay (Fig. 4A). Thus, farnesol was unlikely to be modified before recognition and was likely recognized by the BC2 TCR as a CD1a-farnesol complex.

(A) IFN- release by BC2 T cells in response to CD1a-coated plates treated with farnesol was measured. Asterisk (*) indicates that the significance of lipid concentration on IFN- release was assessed by marginal means with adjustment by the Sidak method after a significant result by ANOVA, treating experiments 1 and 2 as blocks. At the highest concentration of farnesol in both experiments, nonoverlapping 95% confidence intervals were observed at P < 0.001. (B) Affinity measurements (KD) by SPR in response to the recombinant BC2 TCR binding biotinylated CD1a directly isolated from cells (CD1a-endo), CD1a pretreated with farnesol (CD1a-farnesol), or CD1a treated with buffer (CD1a-mock). Positive-mode HPLC-MS analysis of a farnesol standard (C) and eluents from farnesol-treated CD1a (D) demonstrated ions that matched the expected mass (m/z 205.195) of an indicated dehydration product with a retention time of 2.9 min. (E and F) Lipid eluents from CD1a-endo and CD1a-farnesol were analyzed by positive normal-phase HPLC-QToF-MS. Ion chromatograms were generated at the nominal mass values of DAG, PC, SM, and PI, which are shown as CX:Y, where X is the number of methylene units in the combined lipid chains, and Y is the total number of unsaturations. (G) Compound identifications were based on the unknown matching of the retention time and mass of standards. Further, one compound in the PC, SM, and PI families (shown in color) underwent collision-induced dissociation MS analysis to generate the indicated diagnostic fragments. RU, resonance units.

To test this hypothesis, we loaded farnesol onto biotinylated CD1a monomers, generated fluorescent tetramers, and stained the BC2 T cell line and a control line. In several attempts with differing protocols, we failed to detect staining with CD1a-farnesol tetramers above background levels seen with farnesol-treated CD1b tetramers (fig. S5). Turning to surface plasmon resonance (SPR), we produced the BC2 TCR heterodimer in vitro and measured its binding to untreated CD1a carrying mixed endogenous lipids (CD1a-endo), CD1a that was treated with media (CD1a-mock), and CD1a treated with farnesol (CD1a-farnesol) after coupling to SPR chips. The BC2 TCR bound to all three complexes with low but measurable binding affinities for CD1a-endo [dissociation constant (KD) = 123 M], CD1a-mock (KD = 144 M), and CD1a-farnesol (KD = 123 M) (Fig. 4B). SPR is known to be more sensitive than tetramer staining (49), so the relatively low affinity interactions likely explained the absent tetramer staining. Yet, interactions are still in the physiological range, demonstrating direct binding between the BC2 TCR and CD1a. However, the cross-reactivity of the BC2 TCR to three forms of CD1a left unclear the role of farnesol or other carried lipids in mediating CD1a-TCR interactions.

A recently proposed but unproven hypothesis is small hydrophobic lipids could fully sequester within CD1a (31, 50), displacing larger endogenous self-lipids that cover TCR epitopes on the outer surface of CD1a. Therefore, we undertook direct biochemical analysis of CD1a-lipid complexes formed in vitro with detergents and stimulatory substances, analyzing elutable lipids using high-performance liquid chromatographymass spectrometry (HPLC-MS). First, we addressed the trivial possibility that the lack of effect of farnesol treatment on TCR binding to CD1a resulted from the lack of farnesol loading onto CD1a. Analysis of eluents from farnesol-treated CD1a monomers was initially inconclusive because farnesol is a nonpolar alcohol and does not readily adduct the cations or anions needed for MS detection. However, building on the fortuitous detection of a positively charged dehydration fragment [M-H2O + H]+ generated in the MS source (31), we could reliably detect the equivalent product (C15H25+; m/z 205.196) from a farnesol standard. Subsequently, we detected strong signal for this product from farnesol-treated CD1a proteins but not CD1a-endo, directly documenting farnesol in CD1a complexes (Fig. 4D).

Further, the HPLC-MSbased platform allowed broader analysis of the lipid ligands carried in CD1a-endo and CD1a-farnesol complexes. Similar to prior reports (31, 35), we could detect many ions in CD1a-endo eluents, which were self-lipids captured during protein expression in cells. Focusing on specific classes of lipids, including neutral lipids, phospholipids, and sphingolipids, we could identify many self-ligands. CD1a-endo complexes carried at least three molecular species of diacylglycerol (DAG), six phosphatidylcholine (PC), six sphingomyelin (SM), and two phosphatidylinositol (PI) species. Initially, these identifications were based on the expected early (DAG) or later (PI, PC, and SM) retention time, as well as match of the detected m/z value with the expected mass of these ligands (Fig. 4, E to F). For one lead compound in each class, we confirmed the identification using collision-induced dissociation MS, which demonstrated the characteristic phosphocholine, phosphoinositol, sphingolipid, or DAG fragments (Fig. 4G).

Elution analysis of farnesol-treated CD1a directly demonstrated farnesol loading (Fig. 4D). The comparison of CD1a-endo and CD1a-farnesol eluents showed complete or nearly complete suppression of ion chromatogram signals corresponding to all the 17 tested self-lipids (Fig. 4E, blue). Although the conditions used to load farnesol in vitro are not the same as those in immunological assays, these findings suggest high occupancy of CD1a proteins by farnesol and that farnesol and self-lipids are not simultaneously bound. Together, these data support a simple model for the cross-reactivity, where the TCR binds CD1a carrying either farnesol or certain self-lipids that permit recognition. Treatment of CD1a with farnesol displaces lipids with hydrophilic head groups to generate more homogeneously liganded CD1a proteins (Fig. 4, D and E).

To determine the structural basis of farnesol response, we solved the CD1a-farnesol crystal structure at 2.2- resolution (table S1). The electron density for the bound farnesol and surrounding CD1a residues were unambiguous (fig. S6), allowing determination of the position and orientation of farnesol within the cleft (Fig. 5, A and B). Unlike covalent binding of vitamin B metabolites to major histocompatibility complex class Irelated protein (MR1) (51) and the predictions of haptenation models, we find no evidence for haptenation of CD1a residues by farnesol.

(A) Overview of the binary crystal structure of CD1a (gray)farnesol (purple)/2m (cyan). (B) Molecular interactions of farnesol (purple) with the hydrophobic residues within CD1a binding cleft (gray surface). The side chains of the residues within a 4- distance from the lipid are shown. A diagram of trans,trans-farnesol with carbon numbering is shown. The A pole formed by V12-F70 interaction in the context of oleic acidbound CD1a pocket [Protein Data Bank (PDB) ID: 4X6D] is highlighted in the inset. (C to E) Superimposition of CD1a bound to farnesol and SM [PDB ID: 4X6F (35)] (C), lipopeptide [PDB ID: 1XZ0 (40)] (D), and urushiol [PDB ID: 5J1A (30)] (E).

Instead, the notable finding is that farnesol is deeply sequestered within the CD1a cleft, where it is fully inaccessible to TCRs. Most known amphipathic membrane lipids, such as sulfatide or SM (19), occupy nearly all of the CD1a cleft and then extend their head groups through a portal (F portal) onto the external surface of CD1a (Fig. 5C). In contrast, farnesol occupies only 36% of the cleft. Accordingly, this relatively small ligand could have been seated in many ways within the larger cavity or potentially bound with lipid:CD1 stoichiometry of 2:1 or 3:1 (52). Instead, a preferred seating and orientation of a single molecule is observed at the junction of the A and F pockets. Unlike CD1b structures in which two lipids bind simultaneously within the cleft (53, 54), electron density corresponding to a second lipid or spacer in the cleft was not observed (Fig. 5, A and B). This finding agreed with elution experiments showing substantial exclusion of the measured self-lipids from CD1a complexes (Fig. 4E). Together, the biochemical and structural data indicated that farnesol itself was sufficient to stabilize a partially occupied CD1a cleft.

In previously solved CD1a structures in complex with oleic acid (35) or an acyl peptide (40), the flexible fatty acyl chains take a C-shaped conformation around the margin of the curved A pocket (Fig. 5D) (19, 35, 40). These lipids encircle a vertical structure known as the A pole, which is formed by an interaction of Phe70 and Val12, located in the ceiling and floor of the A pocket, respectively (Fig. 5B, inset) (19, 35, 40). The semirigid and branched structure of farnesol does not allow the C-shaped peripheral conformation seen with other lipids and instead lies in the center of the A pocket, disrupting the A pole. The orientation of farnesol is discernible: The terminal methyl and hydroxyl groups point toward the A and F pocket, respectively (Fig. 5B). The polar hydroxyl group is situated nearer the solvent-exposed F portal of CD1a with ~15% of its surface water exposed. Farnesol made van der Waals contacts with Phe10, Trp14, Phe70, Val98, Leu161, Leu162, and Phe169 from CD1a (Fig. 5B and table S2). Here, Trp14 stacked against the unsaturated hydrocarbons C12 and C14 of farnesol, further stabilizing the bound lipid within the cleft. The same Trp14 residue maintains hydrophobic contacts with sphingosine and acyl chain moieties in the CD1a-SM and CD1a-sulfatide structures (19), respectively. Collectively, this positioning mechanism appears to be driven by unsaturations in farnesol, which limit its ability to bend and provide van der Waals interactions with the inner surface of CD1a.

Parallels in the positioning of CD1a-urushiol and CD1a-farnesol (Fig. 5E) highlight how the positioning of bulky and constrained lipids differs from the seating of acyl chaincontaining ligands (Fig. 5D). Although farnesol and urushiol are not located in the same position, they are both situated near the junction of the A and F pockets (Fig. 5E) and do not take the deep and curved positioning at the rim of the A toroid (Fig. 5D). Whereas oleate and acyl peptide wrap around the intact A pole [Fig. 5B (inset) and D], farnesol and urushiol complexes show a marked repositioning of Phe70, which disrupts the A pole (Fig. 5, B and E). Urushiol extends substantially into the F-pocket so that it approaches the F portal of CD1a. It is unknown whether TCRs contact urushiol, but the molecule is adjacent to the surface portal (30), and TCRs can contact lipids located just within the portal (55). In contrast, farnesol is ~8 more deeply positioned, so that it is unequivocally separated from the F portal and the TCR contact surface (Fig. 5E).

Overall, the structure-activity relationships (Fig. 3) indicated that many small, hydrophobic, bulky lipids from consumer goods are recognized by T cells. The biochemical (Fig. 4) and structural (Fig. 5) analyses of CD1a-lipid complexes demonstrate that farnesols small size and unsaturated structure allow it to interact specifically, but not covalently, within CD1a. This binding interaction stabilizes the CD1a cleft and positions farnesol out of the reach of the TCR, largely or fully displacing lipids that normally emerge to the outer surface of CD1a (19, 35, 40).

In 1963, Gell and Coombs (3) classified human diseaserelated immune manifestations into four types of hypersensitivity reactions. Despite the early development and descriptive nature of this scheme, the classification system is still widely taught in clinical immunology and medicine. Type I, II, and III reactions are rapid and mediated by B cells, whereas the delayed type IV response is mediated by T cells. Our study sought molecular mechanisms underpinning type IV hypersensitivity to the most common contact dermatitis allergens in consumer products. Our data provide specific molecular connections between CD1a-reactive T cells and four structurally related contact dermatitis allergens: benzyl benzoate, benzyl cinnamate, farnesol, and coenzyme Qrelated compounds. Whereas haptens (9), drugs (7), or cations (8) can influence MHC-peptide display, here, we detail a straightforward mechanism for T cell activation by small molecules that noncovalently bind CD1a.

In the MHC and CD1 systems, the most common recognition mechanism involves TCR cocontact with an epitope on the carried peptide or lipid and the antigen-presenting molecule (21, 5658). Here, we show evidence that the key active components of balsam of Peru and farnesol activate T cells by binding to CD1a without cellular processing. However, both the structural and biochemical data strongly point to a new model of recognition that does not involve TCR contact with epitopes present on the stimulatory small molecules. Antigenic tree oils, PPBF, farnesol, coenzyme Q2, and the other 14 oily stimulants identified here all lack carbohydrate, phosphate, or peptidic groups that normally serve as TCR epitopes. We show that the BC2 TCR can cross-react among at least 16 stimulatory compounds, which do not share any single chemical structure that would be a candidate cross-reactive epitope. More conclusively, farnesol resides deeply within the CD1a cleft, essentially ruling out direct contact with the TCR. Sequestration of molecules of a small size could be a general mechanism of their recognition, because all of the stimulatory molecules are smaller than the CD1a cleft (21, 40, 57).

Prior studies of CD1-lipid complexes have emphasized head group positioning, where the seating of amphipathic lipids in the cleft is guided by carbohydrates or charged moieties that interact near the F portal. Alkyl chains have a bland repetitive structure and have been described as sliding within CD1 allowing diversely positioning in the groove (54, 59). On the basis of this concept, we expected that the small hydrophobic ligands studied here might slide freely or adopt multiple positions in the CD1a cleft. Also, because many of the lipids have a molecular size that is less than half the volume of the CD1a cleft, they might have bound in pairs or together with spacer lipids (52, 53, 60, 61). However, farnesol shows one defined position in the CD1a groove. Both MS and crystallographic analysis failed to detect cobinding spacer lipids, indicating that partial occupancy by one small lipid is sufficient to stabilize the CD1a cleft.

Comparison of CD1a-farnesol with previously solved CD1a-lipid structures provides insight into the roles of steric hindrance and interior pocket remodeling. CD1a-oleate (35), CD1amycobactin-like lipopeptide (40), CD1a-sulfatide (19), and CD1a-SM (35) complexes involve lipids with flexible alkyl chains. These alkyl chains insert deeply into CD1a by curling along the outer wall of the A pocket and wrapping around the A pole to insert fully within the cleft (40). In contrast, farnesol is chemically hindered and bulky, on the basis of polyunsaturation and methyl branching. The rigid and bulky moiety in urushiol derives from a substituted catechol ring. These two molecules cannot curl to trace the outer wall of the A pocket and so do not penetrate deeply, and both sit in a central position within the A pocket that prevents the A pole from forming. Farnesol is anchored in a specific position by a series of van der Waals interactions with named pocket residues formed by its polyunsaturated and branched structure. Although the roles of benzyl rings in benzyl benzoate and benzyl cinnamate are not studied structurally, they also constrain the chemical structure in ways that are also expected to prevent the side wall curvature (19, 35, 40). More generally, many of the stimulatory lipids identified here and in a recent study (31)including farnesol, squalene, geranylgeraniol, geranylgeranylacetone, and coenzyme Q2are polyunsaturated or branched isoprenoid lipids that could plausibly anchor in CD1a by similar mechanisms.

Lipid antigen binding wholly within CD1a could trigger T cell responses by remodeling the three-dimensional structure of CD1a, as previously reported for CD1d (62, 63), CD1b (54), and CD1c (41, 64). However, comparing CD1a-farnesol with all CD1a-lipid structures solved to date (19, 35, 40) does not demonstrate a broad or obvious change in CD1a conformation. Also, binding of the BC2 TCR to both CD1a-farnesol and CD1a-endo points away from this explanation. Instead, biochemical analysis of CD1a-endo complexes and the CD1a-farnesol structure both indicate that farnesol displaces endogenous ligands from the cleft. Whereas farnesol can be considered a headless ligand, some amphipathic self-lipid ligands in CD1a-endo structures have head groups composed of phosphates or sugars that normally cover the exposed surface of CD1a (35). In the case of the SM, it blocks autoreactive T cells by interfering with TCR contact with CD1a (31, 35). Our experimental observations rule in key aspects of the absence of interference model, where activating substances are sequestered within the CD1a cleft, so that recognition occurs by ejecting self-lipids and freeing up epitopes on the surface of CD1a itself.

As contrasted with MHC I and MHC II, where peptides are broadly exposed over the lateral dimension of the platform, human CD1 proteins have a large roof-like structure above their clefts and a small antigen exit portal at the margin of the platform (65). This creates a potentially large, ligand-free TCR contact surface on CD1 proteins. Evidence for the predominant contact of TCRs with the surface of CD1 proteins in preference to carried lipids, including the extreme case in which TCRs contact CD1 only, is becoming a central theme in CD1 research (65). Recent studies have shown direct TCR contact with the unliganded surface of CD1a and CD1c by autoreactive clones and polyclonal T cells (31, 35, 42). Thus, the stimulatory compounds identified here, which are small and internally sequestered, provide a molecular link to polyclonal autoreactive T cell responses, which are specific for the surface of CD1 rather than the carried lipid.

The presence of CD1a in all individuals prompts the question of why allergic contact dermatitis does not universally develop in everyone. However, interindividual differences that may play a role include permeability of the skin barrier (66), dose and number of chemical exposures to allergens, regulatory T cell activity (6769), and interindividual differences in T cell repertoires. Prior studies show that there is interindividual variability in the frequency of CD1a-restricted T cells in the blood and skin of healthy individuals and differences in CD1a-autoreactive response rates in skin (25, 66, 70, 71). Increased CD1a-restricted T cells responses were observed in allergic individuals and those with inflammatory skin disease (66, 70, 72), which may be a factor in susceptibility to development of CD1a-mediated allergic contact dermatitis in certain individuals. Consistent with these known patterns of antigen response, our small study of 11 humans demonstrates differing patterns of polyclonal response in each individual rather than a universal response to one antigen, which might be expected from an innate receptor.

Overall, the molecular analysis of tree oils and isoprenoid lipids presented in this manuscript invites focused consideration of the role of CD1a in T cellmediated skin diseases. In this new view, the pattern of high-density CD1a on the Langerhans cell network present throughout the skin could mediate responses to oils naturally produced within the skin or oils that contact the skin through application of commercial skin products containing botanical extracts, synthetic lipids, or oils. Other immunogenic oils used in human patients or for experimental biology include the adjuvant MF-59 (squalene) and incomplete Freunds adjuvant (mineral oil). These immunogens, as well as drug-like small molecules resembling PPBF or sulfonamide antibiotics, could plausibly act through the CD1 system.

The goal of this study was to determine whether known contact allergens can bind to CD1a and stimulate a CD1a-dependent T cell response. This study involved in vitro T cell assays using both CD1a-restricted T cell lines and polyclonal purified T cells from healthy blood bank donors. For T cell recognition, either cell-based assays using CD1a-expressing APCs or CD1a plate assays using recombinant plate-bound CD1a were performed. Cytokine release was measured by ELISA, and/or cytokine transcription was measured by real-time qPCR. Complex lipid mixtures, such as balsam of Peru, were purified by TLC and analyzed by nanoelectrospray ionization MS. Lipid eluents from CD1a, after displacement by contact allergens, were analyzed by positive normal-phase HPLC-quadrupole time-of-flight (QToF)MS. Structural insights into CD1a complexed with the contact allergen farnesol were obtained by x-ray crystallography.

T.R.U.E. Test panel 1 (Truetest 1) is a patch test routinely used in clinic to diagnose contact dermatitis in response to the most common allergens (SmartPractice, Phoenix, AZ). The system consists of surgical tape (5.2 cm by 13.0 cm) that is embedded with antigen patches of 0.81 cm2 with each coated with a polyester film that contains uniformly dispersed specific allergen. Using sterile technique, individual allergen patches were cut and placed directly in the assay wells containing ~106 APCs and 1 ml of T cell media in 24-well plates (contact method) or first extracted by soaking patch in 1 ml of media (2 hours, 37C), followed by removing the patch and transferring 100 l of media to T cell assays. Antigen dose was normalized to square millimeters of patch exposure. Antigens or extracts were cocultured with 50,000 CD1a- or mock-transfected K562 cells (25) and a CD1a-dependent T cell line in a 96-well plate. Activation was measured by IFN- ELISA (Thermo Fisher Scientific).

Balsam of Peru, balsam of Peru oil, benzyl cinnamate, and benzyl benzoate or other isolated antigens were dried in clean glass, subjected to water bath sonication in T cell media for 120 s, cultured with 50,000 CD1a- or mock-transfected K562 cells for 3 hours at 37C, and then cocultured with 50,000 to 200,000 cells per well of an autoreactive T cell line (BC2 or Bgp) (31) or foreign antigen reactive T cells (CD8-2) (18) for 24 hours at 37C in 96-well plates as previously described (31). Activation was measured using IFN- ELISA (Thermo Fisher Scientific). For blocking experiments, CD1a-transfected K562 cells were preincubated for 1 hour at 37C with CD1a-blocking antibody (OKT-6) or isotype-matched control immunoglobulin G (P3) (10 g/ml) before the addition of T cells. For plate assays, 96-well streptavidin plates (Thermo Fisher Scientific) were incubated for 24 hours at room temperature with biotinylated CD1a or CD1b protein [10 g/ml; National Institutes of Health (NIH) Tetramer Core Facility] and anti-CD11a (2.5 g/ml) in phosphate-buffered saline (PBS) (pH 7.4) as previously described (31). For the acid-stripping protocol (Figs. 4 and 5A and fig. S2), after 24 hours of coating with protein, plates were washed three times with PBS, followed by washing twice with citrate buffer at pH 3.4 for 10 min, followed by three washes in PBS before the addition of lipid antigens (30). Peripheral blood mononuclear cells (PBMC) were isolated from buffycoats obtained from the New York Blood Center, as approved by the Institutional Review Board of Columbia University Irving Medical Center. Polyclonal T cell assays were performed using FACS (fluorescence-activated cell sorting)sorted T cells from PBMCs (CD4 and CD4+) and CD1a-coated 96-well plates as described above. Plate-coated CD1a was either treated with buffer only (0.05% CHAPS in PBS) or lipid antigens sonicated in buffer and incubated overnight at 37C. Plates were washed three times, and then purified T cells were added to the wells and incubated overnight at 37C. RNA was extracted using RNeasy (Qiagen), and first-strand complementary DNA synthesis was performed using iScript (Bio-Rad).

Balsam of Peru (W211613), balsam of Peru oil (W211710), benzyl cinnamate (234214), benzyl benzoate (B9550), geranylgeraniol (G3278), farnesol (277541), geranylgeranyl acetone (G5048), geraniol (163333), squalene (S3626), geranyl acetone (250716), vitamin K1 (V3501), vitamin K2 (V9378), vitamin A (R7632), vitamin E (T3251), vitamin D3 (C9756), coenzyme Q2 (C8081), coenzyme Q0 (D9150), coenzyme Q4 (C2470), coenzyme Q6 (C9504), coenzyme Q10 (C9538), palmitoleic acid (P9417), methyl palmitoleate (P9667), cis-11-hexadecenal (249084), palmityl acetate (P0260), palmitoleyl alcohol (P1547), lauryl palmitoleate (P1642), oleamide (O2136), palmitoyl ethanolamide (P0359), tetradecanoic acid ethylamide (R425567), N-oleoyl glycin (O9762), N,N-dimethyl tetradecanamide (S347388), and 1-dodecyl-2-pyrrolidinone (335673) were obtained from Sigma-Aldrich (St. Louis, MO). Coenzyme Q1 (270-294-M002) was obtained from Alexis Biochemicals.

Silica-coated glass TLC plates (10 cm by 20 cm; Scientific Adsorbents Incorporated) were precleared in chloroform-methanol-water (60:30:6, v/v/v). Samples (10 to 20 g) were developed with a solvent system-hexane/diethyl ether/acetic acid (70/30/1, v/v/v). For visualization, plates were sprayed with a solution of 3% (w/v) of cupric acetate in 8% (v/v) phosphoric acid, followed by heating for 20 to 30 min at 150C.

Methanol solution (2 g/ml) was prepared for each reagent, and then, 10 l was loaded onto a glass nanospray tip for positive-mode electrospray ionization MS performed on an LXQ (Thermo Scientific), two-dimensional ion trap mass spectrometer. The spray voltage and capillary temperature were set to 0.8 kV and 200C.

CD1a-endo (200 g) and CD1a-farnesol (200 g) were transferred to 15-ml glass tubes and treated with chloroform, methanol, and water for lipid extraction according to the method of Bligh and Dyer (73). The lipid-containing organic solvent layer was separated from the top aqueous layer by centrifugation at 850g for 10 min. For HPLC-MS analysis, the samples were normalized on the basis of the input proteins (20 M), and 20 l of eluent was injected to an Agilent 6530 Accurate-Mass Q-TOF spectrometer equipped with a 1260 series HPLC system using a normal-phase Inertsil diol column (150 mm by 2.1 mm, 3 m; GL Sciences) with a guard column (10 mm by 3 mm, 3 m; GL Sciences), running at 0.15 ml/min according to a published method (74).

The glycoprotein CD1a was expressed in human embryonic kidney (HEK) 293S GnTI cells and purified as previously described (35). After an endoglycosidase H (New England BioLabs) and thrombin treatment, the purified CD1a was first loaded with the ganglioside GD3 (GD3) (Avanti) that was dissolved in a solution containing 2.5% dimethyl sulfoxide (DMSO) and 0.5% tyloxapol (Sigma-Aldrich). CD1a was first incubated overnight with GD3 at room temperature at a molar ratio of 1:8. The CD1a sample loaded with GD3 was further purified using ion exchange chromatography (MonoQ 10/100 GL, GE Healthcare). Trans,trans-farnesol (Sigma-Aldrich) was dissolved in a solution containing 2.5% DMSO and 0.5% tyloxapol (Sigma-Aldrich). The CD1a-GD3 sample was then incubated overnight with farnesol at a 1:100 molar ratio and at room temperature. A subsequent ion exchange chromatography (MonoQ 10/100 GL) was performed to remove the excess of farnesol, CD1a-GD3, and tyloxapol.

The BC2 TCR was produced using a previously described method (31). Briefly, individual and chains of the TCR, with an engineered disulfide bond between the TCR and TCR constant domains were expressed in BL21 Escherichia coli cells as inclusion bodies and solubilized in 8 M urea buffer containing 10 mM tris-HCl (pH 8), 0.5 mM Na-EDTA, and 1 mM dithiothreitol. The TCR was then refolded in buffer that was composed of 5 M urea, 100 mM tris-HCl (pH 8), 2 mM Na-EDTA, 400 mM l-Arg-HCl, 0.5 mM oxidized glutathione, and 5 mM reduced glutathione. The refolded solution was dialyzed twice against 10 mM tris-HCl (pH 8.0) overnight. The dialyzed samples were then purified through DEAE cellulose, size exclusion, and anion exchange HiTrap Q chromatography approaches. The quality and purity of the samples were analyzed via SDSpolyacrylamide gel electrophoresis.

Seeds obtained from previous binary CD1a antigen crystals (30) were used to grow crystals of the CD1a-farnesol binary complex in 20 to 25% polyethylene glycol 1500/10% dl-Malic acid, MES monohydrate, Tris (MMT) buffer (pH 5 to 6). The crystals were flash-frozen, and data were collected at the MX2 beamline (Australian Synchrotron) to a resolution of 2.2 . All the data were processed with the program XDS (75) and were scaled with SCALA from the CCP4 programs suite (76). Upon successful phasing by molecular replacement using the program PHASER (77) and the CD1a-urushiol structure as the search model (30), the farnesol electron density was evident in the unbiased electron density maps in addition to some very weak residual density. An initial run of rigid body refinement was performed using phenix.refine (78). Iterative model improvement was performed using with the program COOT (79) and phenix.refine. The final refinement led to an R/R-free (%) of 20/25. The quality of the structure was confirmed at the Research Collaboratory for Structural Bioinformatics Protein Data Bank Data Validation and Deposition Services website. All presentations of molecular graphics were created with UCSF Chimera (80).

Biotinylated CD1a-endogenous lipids derived from HEK293 cells was incubated overnight with 30-fold molar excess of farnesol solubilized in 2.5% DMSO/0.5% tyloxapol (CD1a-farnesol) or with solvent only (CD1a-mock). The sample was coupled onto research-grade streptavidin-coated chips to a mass concentration of ~3000 resonance units. Increasing concentrations of the BC2 TCR (0 to 200 M) were injected over all flow cells for 30 s at a rate of 5 l/min on a Biacore 3000 in 10 mM tris-HCl (pH 8) and 150 mM NaCl buffer. The final response was calculated by subtraction of the response for CD1a-endogenous minus a flow cell containing an unrelated protein. The data were fitted to a 1:1 Langmuir binding model using BIAevaluation version 3.1 software (Biacore AB) and the equilibrium data analyzed using Prism program for biostatistics, curve fitting, and scientific graphing (GraphPad).

All statistical analyses were performed in R (www.R-project.org/). Pairwise t tests, analysis of variance (ANOVA) post hoc testing, and adjustments of P values for multiple hypothesis testing used base R and the package emmeans (https://CRAN.R-project.org/package=emmeans). Dose-response analyses used the package drc to fit log normal or logistic curves to the data and to test fitted models against simplified, pooled models (81). R code is available on request.

immunology.sciencemag.org/cgi/content/full/5/43/eaax5430/DC1

Fig. S1. Screening human T cells for responses to known contact allergens.

Fig. S2. CD1a-dependent T cell response to small hydrophobic molecules.

Fig. S3. Idebenone is recognized by CD1a-restricted T cell line BC2.

Fig. S4. CD1a-dependent polyclonal T cell responses to contact allergens.

Fig. S5. CD1a tetramer staining of CD1a-autoreactive T cell line.

Fig. S6. Electron density for farnesol in CD1a-farnesol binary complex.

Table S1. Supporting data CD1a-farnesol binary complex.

Table S2. Van der Waals bonds between CD1a and farnesol.

Table S3. Raw data sets for main figures (Excel spreadsheet).

Acknowledgments: We thank A. G. Kasmar, M. C. Castells, and P. Brennan for advice or critical comments on the manuscript. We thank the staff at the Australian Synchrotron for assistance with data collection and the NIH Tetramer Core Facility for recombinant biotinylated CD1 protein. Funding: S.N. was supported by an NIH training grant (T32 AI007306) and is currently employed by HealthPartners, St. Paul, Minnesota. A.d.J. is supported by a K01 award from the NIH (K01 AR068475) and an Irving Scholarship from the Irving Institute for Clinical and Translational Research at Columbia University. D.B.M. is supported by the NIH (R01 AR048632) and the Wellcome Trust Collaborative Award. This work was supported by the National Health and Medical Research Council of Australia (NHMRC) and the Australian Research Council (ARC) (CE140100011). J.L.N. is supported by an ARC Future Fellowship (FT160100074); J.R. is supported by an Australian ARC Laureate Fellowship and the Wellcome Trust Collaborative Award. Research reported in this publication was performed in the CCTI Flow Cytometry Core, supported, in part, by the Office of the Director, NIH under award S10OD020056. Author contributions: The indicated individuals carried out project oversight and direction (A.d.J., D.B.M., and J.R.); T cell assays (S.N., T.-Y.C., E.A.B., R.N.C., I.V.R., G.C.M., and A.d.J.); protein chemistry, structure, and SPR (M.W. and J.L.N.); and manuscript preparation (S.N., A.d.J., D.B.M., and J.R.) with input from all authors. Competing interests: The authors declare that they have no competing interests. Data and materials availability: Reagents are available to qualified scientists subject to the limitation that cells from primary T cell lines can be limited in number. The data and refined coordinates for the CD1a-farnesol structure were deposited in the Protein Data Bank under accession code 6NUX. All other data needed to evaluate the conclusions in the paper are present in the paper or the Supplementary Materials.

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Human T cell response to CD1a and contact dermatitis allergens in botanical extracts and commercial skin care products - Science

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Recession proofing the supply chain – Supply Chain Digital – The Procurement & Supply Chain Platform

January 6th, 2020 4:45 pm

Many organisations have enjoyed unquestionable success during the recent economic expansion, including higher margins, product portfolio expansion and a renaissance in talent acquisition, with millions of new jobs created over the past several years. However, signals from multiple sources point to a coming recession within the next 18 to 24 months. A recent Grant Thornton survey of more than 250 C-level executives and business owners found more than three-quarters of respondents expect a recession to occur within the next two years, with the potential to impact a number of critical supply chain attributes, including physical infrastructure planning, new-equipment procurement and critical research and development investments.Faced with these potential challenges, many organizations are embracing the pathway to recession preparedness by adopting a number of strategies designed to preserve recent performance gains and minimize supply chain disruptions.

Organisations can prepare for the uncertain times ahead by adopting a recession mitigation framework that targets the most high-risk supply base, process and delivery capabilities. With such a framework in place, they can quickly develop what can be termed a ready-for-deployment supply chain immune system to minimize any disruptions and preserve the competitive advantage of their supply chain. While some leaders are resigned to acceptance of inevitable recessionary effects, savvy, proactive executives can translate the noise of a recession into actionable, deployment-ready mitigation strategies to capture the highest level of supply chain resilience and agility possible.

Identifying the signs of recession

While knowledge of an impending recession is important, paying close attention and preparing for the potential impact on your operation is mission critical. Grant Thorntons survey found that nearly three in 10 (29%) respondents have a supply chain resiliency strategy in place. The balance of respondents, 71%, are in various stages of considering, planning or implementing such a strategy.

Based on our research, Grant Thornton has identified seven key recession indicators which, when combined, can provide a useful framework to assess your risk preparedness for a possible economic slowdown. These indicators, when viewed across the enterprise, can also inform your supply chain mitigation strategies:

Global dashboard deterioration outside of normal control limits (e.g. growing inventories, demand drop)

Supply partner financial issues including market contraction and growing backlogs

Internal and trading partner budget contractions and budget freezes

Diminishing margin capture against long-term forecasts

Talent pool shrinkage across core functions due to functional budget issues

Cross-functional continuous improvement investment shrinkage and funding shortfalls

Shrinking cross-functional cooperation and synchronization (local survival focus)

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Taken together, these seven indicators should prompt a number of introspective questions regarding an organizations supply chain health, including:

Could diminishing supply partner financial performance potentially transition from periodic issue management to a quantifiable supply risk?

Will our promised market-known business process improvements lapse because of internal funding choke-holds?

Can talent attrition become a highly visible concern to key customers?

When will my growing inventory pipeline reach the critical stage of unbudgeted obsolescence, disposal and excess storage costs?

While each question individually poses a tactical risk with (hopefully) only a localized performance impact, the effects of multiple scenarios in parallel pose significant risks to supply chain flexibility, adaptability and ultimately profitability. For those executives who see the signs of a recession as an opportunity to further refine and strengthen their existing supply chains, there are several practical strategies leaders can rapidly deploy as part of an offensive recessionary response.

Building up organisational supply chain immunity

Organisations have a clear opportunity to benefit from a supply chain recession preparedness framework designed to address the seven indicators outlined across the end-to-end supply chain value stream. Holistically evaluating the complete supply chain value stream, an effective supply chain immunity assessment should catalog the most significant supply chain risks, including the magnitude of the possible fallout of each identified risk along with the individual risk trigger point. Armed with priority risks and their associated trigger points, the assessment must then translate into ready-for-deployment mitigation strategies to lessen quantified recessionary impacts, preserve competitive advantages, and lessen market fears. Once in place, the immune system can provide the tailwinds to preserve market confidence and sound financial footing. Key aspects of a successful immune system include:

Contingency SKU rationalization planning to drive out unnecessary cost and complexity when laser focus on higher-margin products become a true recessionary lifeboat

Highly targeted supply contract temporary modifications, including advanced buys for high-risk components, tighter backlog management and improved risk-sharing across the relationship

Customer segmentation refinement to pre-select and plan for service level adjustments should supply constraints become a reality

Cross-functional preparedness to harness available enterprise-wide cerebral horsepower and prevent isolated, siloed recession response plans (e.g. expand the power of S&OP as a functional integrator)

Advanced automation efforts prior to major recessionary impacts to better prepare for, and ethically manage, labor reallocations

Close coordination with strategic suppliers to improve transparency to core supplier cost drivers and appropriately share recessionary concerns and deploy a partnership approach to proactively manage down costs where possible

Ultimately, the assessment, along with the adoption of targeted risk mitigation strategies, can proactively reduce an organizations overall recession risk profile and the magnitude of any possible disruption. Known and documented risks, proactive mitigation strategies and deployment-ready action plans are the necessary resilience tools for the next recession. Long before competitors are scrambling to adapt, proactive business leaders can take the steps necessary today to set their organisations on the right path. Theyll face down a coming recession with confidence, greater precision and highly ethical responses to challenging supply chain design and resourcing questions.

By Bob Hawkey, Director, Operations Transformation, Advisory Services, Grant Thornton LLP

For more information on all topics for Procurement, Supply Chain & Logistics - please take a look at the latest edition ofSupply Chain Digital magazine.

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