Introdução: Nos últimos vinte anos, estudos clínicos e experimentais demonstraram que as variações do ambiente materno (como o estresse precoce) associado à deficiência nutricional podem influenciar na saúde do indivíduo. Objetivo clínico: Determinar o impacto da interação entre o consumo alimentar das gestantes com o crescimento intrauterino em uma coorte de nascimentos. Objetivo experimental: Avaliar se o estresse neonatal, como a separação materna, interage com a deficiência nutricional de ácidos graxos (AG) poliinsaturados ômega-3 ao longo da vida em aspectos metabólicos em ratos adultos. Metodologia clínica: Trata-se de uma coorte envolvendo o recrutamento de nascimentos ocorridos nos hospitais de Porto Alegre, Rio Grande do Sul, Brasil. Mães de diferentes históricos clínicos (hipertensão-GHAS, diabetes-GDM, tabagismo-GTAB, crianças com restrição de crescimento intrauterino por razão idiopática-GRCIU e controles-GCON) foram convidadas a participar 24 horas após o nascimento da criança. Foram utilizadas as variáveis da entrevista do pós-parto (sociodemográficas e antropométricas das mães e dos recém-nascidos-RNs) e domiciliar aos 7 dias de vida da criança (questionário de frequência alimentar). A coorte está em andamento para outros acompanhamentos (15 dias e 1, 3 e 6 meses de vida da criança). O tamanho da amostra final constitui-se de, no mínimo, 20 pares mãe-RNs por grupo e 150 indivíduos no total. Metodologia experimental: Os filhotes de ratos foram randomizados em: Grupo Separação Materna (GSM) e Grupo Não-Manipulado (GNM), sendo filhotes separados removidos de suas mães durante 3 horas diárias do dia 1º ao 10º pós-natal (DPN) e colocados em incubadora a 32ºC. No DPN 35, os machos foram subdivididos em dois grupos de acordo com dieta adequada ou deficiente em AG poliinsaturados ômega-3, nas subsequentes 15 semanas de vida. O peso corporal e o consumo alimentar dos ratos eram mensurados semanalmente e ao final do tratamento as amostras de tecidos foram coletadas. Resultados clínicos: Entre Setembro de 2011 a Julho de 2013, 255 puérperas foram elegíveis para o estudo, sendo que 218 (14,5%) aceitaram participar e 182 (16,5%) apresentavam dados completos para análise. Ao comparar-se as puérperas elegíveis com as recusas (n=37) não houve diferenças significativas entre qualquer variável, entretanto, as puérperas do seguimento apresentaram média de idade superior em relação às perdas (p=0,010). O GHAS apresentou média de idade superior em relação ao GTAB e GRCIU (p=0,007), já o GRCIU apresentou peso pré-gestacional inferior em comparação ao GDM (p=0,022) e GHAS (p=0,003). Apenas o GHAS apresentou peso pré-gestacional e ganho de peso gestacional superior ao GCON (p=0,002; p=0,018). Os valores de peso ao nascer do GRCIU foram inferiores em comparação aos demais grupos e o peso ao nascer do GDM foi superior ao GTAB (p<0,001). O comprimento ao nascer do GRCIU foi diferente de todos os outros (p<0,001), exceto o GHAS. A média do perímetro cefálico do GRCIU foi significativamente diferente dos demais grupos (p<0,001). Não houve diferença entre o consumo de macronutrientes e o perfil de AG entre as mães dos diferentes grupos. Todavia, o consumo do AG 20:4 n-6 foi maior no GHAS e a razão n-6/n-3 menor no GDM em relação ao GCON. Observou-se que não houve associação entre o consumo alimentar das gestantes e o peso ao nascer. Resultados experimental: Ratos do GSM apresentaram consumo alimentar maior (p=0,047) e ganharam mais peso (p=0,012), porém, o conteúdo de neuropeptídeo Y não variou entre os grupos. Ratos do GSM também apresentaram maior deposição de gordura abdominal (p<0,001) e triglicerídeos plasmáticos (p=0,018), quando comparados ao GNM. Interação entre estresse neonatal e deficiência de AG poliinsaturados ômega-3 foi encontrada com insulina plasmática (p=0,033), índice de HOMA (p=0,049), leptina (p=0,01) e expressão de PEPCK hepática (p=0,05), no qual a vulnerabilidade metabólica no GSM foi agravada com a dieta inadequada em AG poliinsaturados ômega-3. Houve associações entre alterações específicas no perfil de AG periféricos (p<0,05). Conclusões: Assim, os achados clínicos sugerem que, a curto prazo, o consumo de AG das gestantes não influenciou o peso ao nascer dos RNs entre os diferentes ambientes intrauterinos, porém o GHAS possuiu maior consumo de AA e o GDM menor relação n-6/n-3. Os achados experimentais sugerem que as variações no ambiente neonatal interagem, a longo prazo, com a deficiência dietética de n-3 PUFAs, alterando a vulnerabilidade metabólica de ratos adultos. / Introduction: In the last twenty years, clinical and experimental studies have shown that perinatal events (how early stress) associated with nutritional deficiency may influence in the individual health. Clinical objective: To assess the impact of interaction between the food consumption with the infant intrauterine growth in the birth cohort. Experimental objective: To assess whether an early stressful event such as maternal separation interacts with the nutritional availability of Omega-3 polyunsaturated fatty acids during the life course on metabolic aspects. Clinical methods: This is a cohort involving the recruitment of births in hospitals in Porto Alegre, Rio Grande do Sul, Brazil. Mothers from different clinical backgrounds (hypertensive-GHAS, diabetics-GDM, smokers-GTAB, having an intrauterine growth restriction for idiopathic reasons-GIUGR, and controls-GCON) were be invited twentyfour hours after the child birth. It was used data in postpartum interview (economic, social and anthropometric measures) and in home visit interview at 7 days of life (food frequency questionnaire). The cohort is ongoing and there are still the interviews: 15 days and 1, 3 and 6 month of life. The sample size consists in 20 mother-child pairs per group and 150 pairs in total. Experimental methods: Litters rats were randomized into: maternal separated group (GMS) and non-handled group (GNH). The GMS was removed from their dam for 3 hours per day on days 1º to 10º postnatal (PND) and put in an incubator at 32ºC. On PND 35, males were subdivided into two groups diets that were adequate or deficient in n-3 PUFAs, and this intervention was applied during the subsequent 15 weeks. Animal’s body weight and food consumption were measured weekly, and at the end of the treatment samples of tissues were collected. Clinical results: From September 2011 to July 2013, 255 postpartum women were eligible, 218 (14.5%) agreed to participate and 182 (16.5%) had complete data for analysis. Comparing with the women eligible, refusals (n=37) have no significant differences between the variables, however, these mothers showed more average age (p=0.010) than lost. The GHAS had a mean age higher than the GTAB and GIUGR (p=0,007). The GRCIU presented prepregnancy weight lower compared to GDM (p=0,022) and GHAS (p=0.003). Only GHAS presented prepregnancy weigh and gestational weight gain above the GCON (p=0.002; p=0.018). The values of GRCIU birth weight were lower compared to the other groups and the birth weight of GDM was higher than GTAB (p<0.001). The birth length of GRCIU was different from all others (p<0.001), except in GHAS. The average of GIUGR head circumference was significantly different from the other groups (p<0.001). There was no statistically significant difference between macronutrient intake and fatty acid profile (AG) among mothers of different groups. However, consumption AG 20:4 n-6 was higher in GHAS and the ratio of n-6/n-3 is lower in GDM compared GCON. We observed no association between dietary intake of pregnant women and birth weight. Experimental results: MS was associated with increased food intake (p=0.047) and weight gain (p=0.012), but no differences were found in the NPY hypothalamic content between the groups. MS rats had also increased deposition of abdominal fat (p<0.001) and plasma triglycerides (p=0.018) when compared to the GNH. Interactions between early life stress and n-3 PUFAs deficiency were found in plasma insulin (p=0.033), HOMA index (p=0.049), leptin (p=0.010) and liver PEPCK expression (p=0.05), in which the metabolic vulnerability in the GMS was aggravated by the n-3 PUFAs deficient diet exposure. This was associated with specific alterations in the peripheral fatty acid profile (p<0.05). Conclusions: Thus, the clinical findings suggest that in the short term, AG consumption pregnant women did not influence intrauterine growth of children from different intrauterine environments, but the GHAS have more consumption of AA and GDM lower ratio n-6/n-3. Experimental findings suggest interacts variations in neonatal environment in the long term, with n-3 PUFAs deficient diet exposure, increasing the metabolic vulnerability in adult rats.

Magister Public Health - MPH / A qualitative descriptive study approach was used to gather the required information. The sample for this study was drawn from an existing group of volunteers who participated in the vaccine trial at Mbeya Medical Research Centre in 2006-2007. A purposive sampling method was used to select respondents because they had had experience of being participants in a HIV vaccine trial. Twenty audio recorded in-depth interviews were conducted. The interviews were conducted at the clinic during their routine follow up visits. An open ended interview guideline was used to guide the discussion to elicit the required information from the respondents. The data was transcribed, translated and then analyzed by both content and thematic approach. Ethical procedures were observed, including getting permission from the local ethical committee in Mbeya region and participants were given an informed consent form to read and sign before starting the interview. / South Africa

La législation relative à la recherche biomédicale est fondée historiquement sur le principe selon lequel la recherche et le soin constituent deux activités distinctes. Perçu comme le garant éthique de tout encadrement normatif de la recherche, ce principe a conduit en France à la création d’un cadre juridique spécifique pour les pratiques médicales expérimentales. En pratique cependant, un protocole de recherche biomédicale est souvent constitué d’actes de recherche intriqués avec les interventions du soin. La distinction entre les pratiques médicales et les interventions expérimentales peut être brouillée par l’objet de la recherche (le soin courant), par la méthodologie employée (l’évaluation en conditions réelles) ou encore par le faible niveau de l’intervention ajoutée par le protocole. Tant les dispositifs juridiques passés que les modèles présents occultent cette évidence en invoquant la séparation du soin et de la recherche. Pourtant la coexistence du soin avec la recherche a créé des tensions que le cadre juridique actuel ne peut résoudre. Il est manifeste que ces dernières n'ont été évacuées en rien par la création de deux régimes juridiques distincts, l'un relatif au soin et l'autre relatif à larecherche biomédicale. De plus, la séparation nette au plan normatif entre les deux activités a empêché l’indispensable réflexion sur l’articulation entre les obligations qui relèvent de la relation médicale et celles qui sont liées à la recherche, telle l'obligation d'assurer la continuité des soins. Le législateur, soucieux de garantir cette frontière, ne traite pas spécifiquement de ces questions. Il est dès lors essentiel de déterminer avec précision le contenu et l’étendue des obligations de soigner ainsi que de mieux encadrer le « soin courant » et le « standard de soin» dans le contexte de la recherche biomédicale. Dans ces conditions, le paradigme juridique centré sur la distinction soin-recherche a-t-il encore un sens? / A biomedical research protocol includes both medical and research interventions. Since its origins, the legal framework has ignored this evidence under the pretext that research and care are two distinct activities. That is why it is all the more essential to determine the nature and the scope of the duty of care and the standard of care used in the context of biomedical research. In parallel, there is a need to distinguish, from a regulatory perspective, this "standard of care" from any equivalent notions used in the context of usual care.

In the US, the incidence and mortality rates of hepatocellular carcinoma (HCC) are alarmingly increasing since no effective therapy is available for the advanced disease. Activation of IGF signaling is a major oncogenic event in diverse cancers, including HCC. Insulin-like growth factor binding protein-7 (IGFBP7) inhibits IGF signaling by binding to IGF-1 receptor (IGF-1R) and functions as a potential tumor suppressor for hepatocellular carcinoma (HCC). IGFBP7 abrogates tumors by inducing cancer-specific senescence and apoptosis and inhibiting angiogenesis. We now document that Igfbp7 knockout (Igfbp7-/- ) mouse shows constitutive activation of IGF signaling, presents with pro-inflammatory and immunosuppressive microenvironment, and develops spontaneous tumors in lungs and liver and markedly accelerated carcinogen-induced HCC. Loss of Igfbp7 resulted in increased proliferation and decreased senescence in hepatocytes and mouse embryonic fibroblasts that could be blocked by an IGF-1 receptor inhibitor. A significant inhibition of genes regulating immune surveillance was observed in Igfbp7-/- livers which was associated with marked inhibition in antigen cross presentation by Igfbp7-/- dendritic cells. IGFBP7 overexpression inhibited growth of HCC cells in syngeneic immune competent mice, which could be abolished by depletion of CD4+ or CD8+ T lymphocytes. Our studies unravel modulation of immune response as a novel component of pleiotropic mechanisms by which IGFBP7 suppresses HCC. Even though HCC has an immunosuppressive milieu, immune targeted therapies are beginning to demonstrate significant objective responses in clinical trials. IGFBP7 might be an effective anti-HCC therapeutic by directly inhibiting cancer cells and stimulating an anti-tumor immune response.

Abstract Purpose: The purpose of this project was to evaluate outcomes of an existing inpatient tobacco cessation counseling program with 30-day follow-up among recently admitted tobacco-dependent patients who were tobacco-dependent. Background/Significance: Tobacco use is considered the number one most preventable cause of disease, disability, and death in the United States. Despite associated dangers, approximately 21% Americans currently smoke. This has led to increased hospital admissions and chronic disease management, costing the United States approximately $96 billion per year. Decades of research and evidence-based clinical practice guidelines substantiate that inpatient tobacco cessation counseling has the potential to improve quit rates post-hospital discharge. Method: This quality improvement project utilized existing hospital data containing demographic and medical information about patients and tobacco use behaviors. The goal was to answer the question: Does the provision of a tobacco cessation program initiated during hospitalization for persons who are tobacco-dependent (a) increase quit attempts or (b) reduce tobacco consumption? The electronic medical record was queried for data related to: demographics, insurance type, and diagnosis. Data related to smoking status and the intervention was extracted from a paper chart maintained by the certified tobacco treatment specialist. Results: Out of 176 tobacco-dependent patients admitted to the hospital, 100 (57%) indicated an intention to quit (at admission time) while only 40 (23%) reported having quit within 30 days post discharge (McNemar Test, p=0.000, n=176). The mean number of cigarettes smoked per day dropped from 19 cigarettes on admission to 13 cigarettes post discharge. [t (158)=6.7476, p=0.000]. Conclusions: This quality improvement project showed that although an inpatient smoking cessation program did not improve quit rates, it did significantly improve reduction in tobacco consumption.

GM2 gangliosidoses are a family of lysosomal storage disorders that include both Tay-Sachs and Sandhoff diseases. These disorders result from deficiencies in the lysosomal enzyme β-N-acetylhexosaminidase (HexA). Impairment of HexA leads to accumulation of its substrate, GM2 ganglioside, in cells resulting in cellular dysfunction and death. There is currently no treatment for GM2 gangliosidoses. Patients primarily present with neurological dysfunction and degeneration. Here we developed a central nervous system gene therapy through direct injection that leads to long-term survival in the Sandhoff disease mouse model. We deliver an equal mixture of AAVrh8 vectors that encode for the two subunits (α and β) of HexA into the thalami and lateral ventricle. This strategy has also been shown to be safe and effective in treating the cat model of Sandhoff disease. We tested the feasibility and safety of this therapy in non-human primates, which unexpectedly lead to neurotoxicity in the thalami. We hypothesized that toxicity was due to high overexpression of HexA, which dose reduction of vector could not compensate for. In order to maintain AAV dose, and therefore widespread HexA distribution in the brain, six new vector designs were screened for toxicity in nude mice. The top three vectors that showed reduction of HexA expression with low toxicity were chosen and tested for safety in non-human primates. A final formulation was chosen from the primate screen that showed overexpression of HexA with minimal to no toxicity. Therapeutic efficacy studies were performed in Sandhoff disease mice to define the minimum effective dose.

Vitiligo is an autoimmune disease in which CD8+ T cells selectively destroy melanocytes, leading to a patchy, disfiguring depigmentation of the skin. Our group and others have highlighted the central role of IFN-γ-dependent chemokines in the progression of disease; however, IFN-γ is also reported to have pleiotropic effects on melanocyte biology. We examined whether IFN-γ has a direct role in melanocyte killing. We tested the T-cell effector functions IFN-γ, Fas ligand and perforin by deleting them from autoreactive T cells used to induce vitiligo in mice. We found that disease incidence, disease severity and T cell accumulation in the skin was reduced in mice receiving adoptive transfer of either IFN-γ deficient or Fas ligand deficient gp100-specific T cells; however, perforin was dispensable and led to increased disease scores and T cell accumulation. To determine how melanocytes are affected by IFN-γ signaling during vitiligo, we performed single-cell RNA-sequencing on suction blister biopsies obtained from vitiligo and healthy subjects. We discovered that integrin expression and TGFb2 signaling was decreased only in lesional melanocyte transcriptomes. Moreover, melanocytes appear to participate in their own demise by increasing HLA expression and recruiting effector cells through the chemotactic ligand CCL18. The loss of melanocyte retention factors may explain their clean disappearance from the skin during keratinocyte turnover. Taken together, we believe IFN-γ production by autoreactive T cells in the skin leads to clean loss of melanocytes by downregulation of melanocyte retention factors and by increasing their potential to be detected by effector cells during vitiligo.

The thesis consists of an introduction and two papers. In the introduction a brief historical survey of empirical investigations into the effectiveness of medicinal interventions is given. Also, the main ideas of the EBM (evidence-based medicine) movement are presented. Both included papers can be viewed as investigations into the reasonableness of EBM and its hierarchies of evidence. Paper I: Typically, in a clinical trial patients with specified symptoms are given either of two or more predetermined treatments. Health endpoints in these groups are then compared using statistical methods. Concerns have been raised, not least from adherents of so-called alternative medicine, that clinical trials do not offer reliable evidence for some types of treatment, in particular for highly individualized treatments, for example traditional homeopathy. It is argued that such concerns are unfounded. There are two minimal conditions related to the nature of the treatments that must be fulfilled for evaluability in a clinical trial, namely (1) the proper distinction of the two treatment groups and (2) the elimination of confounding variables or variations. These are delineated, and a few misunderstandings are corrected. It is concluded that the conditions do not preclude the testing of alternative medicine, whether individualized or not. Paper II: Traditionally, mechanistic reasoning has been assigned a negligible role in standard EBM literature, although some recent authors have argued for an upgrading. Even so, mechanistic reasoning that has received attention has almost exclusively been positive -- both in an epistemic sense of claiming that there is a mechanistic chain and in a health-related sense of there being claimed benefits for the patient. Negative mechanistic reasoning has been neglected, both in the epistemic and in the health-related sense. I distinguish three main types of negative mechanistic reasoning and subsume them under a new definition of mechanistic reasoning in the context of assessing medical interventions. Although this definition is wider than a previous suggestion in the literature, there are still other instances of reasoning that concern mechanisms but do not (and should not) count as mechanistic reasoning. One of the three distinguished types, which is negative only in the health-related sense, has a corresponding positive counterpart, whereas the other two, which are epistemically negative, do not have such counterparts, at least not that are particularly interesting as evidence. Accounting for negative mechanistic reasoning in EBM is therefore partly different from accounting for positive mechanistic reasoning. Each negative type corresponds to a range of evidential strengths, and it is argued that there are differences with respect to the typical strengths. The variety of negative mechanistic reasoning should be acknowledged in EBM, and presents a serious challenge to proponents of so-called medical hierarchies of evidence. / <p>QC 20150413</p>

Introduction: Genetic rearrangements in Ewing sarcoma, prostate, and leukemia cells result in activation of oncogenic ETS transcription factor fusions. Mithramycin (MTM) has been identified as an inhibitor of EWS-FLI1 transcription factor, a gene fusion product responsible for oncogenesis in Ewing sarcoma. Despite preclinical success, a phase I/II clinical trial testing MTM therapy in refractory Ewing sarcoma was terminated. Liver and blood toxicities resulted in dose de-escalation and sub-therapeutic exposures. However, the promise of selectively targeting oncogenic ETS transcription factors like EWS-FLI1 prompted us to undertake the discovery of more selective, less toxic analogues of MTM. MTM is a potent inhibitor of ubiquitous SP1 transcription factor, likely inducing non-specific toxicity. In collaboration with two medicinal chemistry groups, two semi-synthetic efforts were implemented to develop novel analogues of MTM. The first effort utilized the biosynthetic product mithramycin SA (MTMSA) to modify C3-side chain. The second effort utilized an oxime linker directly formed on MTM’s C3-side chain (MTM-oxime; MTMox). Here I present the pharmacological assessment of over 75 novel MTM analogues towards selectively targeting oncogenic ETS transcription factors, like EWS-FLI1, over ubiquitous transcription factors, like SP1. Methods: Novel MTM analogues were evaluated for selective cytotoxicity against ETS fusion-dependent cell lines. Selectively cytotoxic analogues were evaluated for inhibitory effects on several gene promoters in TC-32 reporter cell lines, a Ewing sarcoma cell line dependent on EWS-FLI1, transfected with luciferase reporter vector. Cloned reporter vectors incorporated NR0B1 (EWS-FLI1 binding), β-actin (SP1 binding) and CMV (non-specific) gene promoters. Furthermore, gene (mRNA) and protein expression changes of EWS-FLI1 and SP1, as well as regulated target genes, namely NR0B1, VEGFA and BCL-2 were evaluated with MTM analogue treatments. The MTM analogues with most selective activity in vitro were administered to mice by intravenous bolus dose for pharmacokinetic analysis. The MTM analogues with highest systemic exposure from each semi-synthetic effort, namely MTMSA-Trp-A10 and MTMox-24, were further evaluated. Metabolic stabilities in whole blood, plasma, and tumor cell matrices, and across multiple species were compared with MTM. Moreover, intrinsic hepatic clearances were estimated using mouse liver microsomes. Tumor and liver distributions were estimated in tumor bearing mice. Additionally, the effect of organic anionic transporter polypeptides (OATP) on distribution of MTM was investigated. Maximum tolerated doses were evaluated for lead MTM analogues, having both selective activities in vitro and high systemic exposure, compared to MTM. Complete blood cell counts and plasma alanine aminotransferase activity were measured to evaluate dose-dependent blood and liver toxicities, respectively. ETS fusion-dependent and non-dependent cell lines were implanted subcutaneously into immunocompromised mice for efficacy studies. Average tumor volumes and survival were tracked for mice receiving treatment, compared to MTM and vehicle treatment. Results: Evaluation of MTM analogues from both semi-synthetic efforts revealed that conjugation of MTM C3-side chain with tryptophan (Trp) and/or phenylalanine (Phe) improved selective cytotoxicity against ETS fusion-dependent cell lines. This was highlighted by MTMSA-Trp-A2 (also refer to as MTMSA-Phe-Trp) and MTMSA-Trp-A10 (also refer to as MTMSA-Trp-Trp), with selective indices of 19.1 and 15.6, respectively, compared to MTM (1.5). Similarly, MTMox-23 (also refer to as MTMox-Phe-Trp) and MTMox-20 (also refer to as MTMox-Trp) had selectivity indices of 4.6 and 4.5, respectively. These selectively cytotoxic MTM analogues inhibited EWS-FLI1-mediated transcription 10-fold more effectively than both non-specific CMV-mediated and SP1-mediated (via β-actin promoter) transcription in TC-32 reporter cell lines. Moreover, gene (mRNA) and protein expression of EWS-FLI1 and regulated gene, NR0B1, were inhibited with MTM analogue treatment (GI50, 6-hour) in TC-32 cells. Similarly, SP1 and target genes, VEGFA and BCL-2, gene (mRNA) and protein expressions were also inhibited with MTM analogue treatment (GI50, 6-hour) in TC-32 cells. Conjugation of Trp and/or Phe to C3-side chain of MTM increased systemic exposure in vivo. Most impressively, the addition of two Trp residues, namely MTMSA-Trp-A10 and MTMox-24 (also refer to as MTMox-Trp-Trp), resulted in systemic exposure increases of 218- and 42-fold, respectively, after intravenous (IV) bolus dose. Metabolically, tryptophan/phenylalanine conjugated MTM analogues are liable to esterase activity on carboxy-methyl functional group. Very rapid de-methylation in biological matrix was observed with MTMox-24, compared to MTMSA-Trp-A10, suggesting a regiospecific effect. However, esterase activity was limited to rodent matrices and demethylation occurred at significantly diminished rates in non-human primate and human plasma. MTM analogues were not susceptible to p450-mediated metabolism, with negligible loss in mouse liver microsome assay compared to verapamil control. MTM (1mg/kg) and MTMox-24 (6mg/kg) were detected in subcutaneously implanted (flank) LL2 tumors and liver homogenates after IV bolus dose. Interestingly, MTMSA-Trp-A10 (2mg/kg) was not. Despite a 3-fold increase in systemic exposure with rifampin oral pretreatment, an OATP inhibitor, exposure of MTM was unaffected in Oatp knockout mouse model. Exposure of MTM in liver tissue was 8.4-fold higher compared to tumor tissue with low tissue clearance. This agrees with the lack of metabolism observed in liver microsomes and may provide a mechanism for clinically observed liver toxicity. MTMSATrp-A10 had a single maximum tolerated dose (MTD) of 0.75mg/kg, compared to 1mg/kg for MTM, administered by IV bolus. In contrast, MTM-oxime analogues (MTMox-20, -23, -24 and -25) had single maximum tolerated doses of 20 – 25mg/kg. These increased tolerances are the result of additive differences in whole blood stability, cytotoxicity and systemic exposure. At a dose of 0.75mg/kg, administered every 3 days, MTMSA-Trp-A10 did not result in an efficacious result in tumor xenograft studies. These studies remain under further investigation, but the result may indicate high plasma protein binding of MTMSA-Trp-A10 and lack of free fraction available within tumor. The most selective MTM-oxime analogue in vitro, MTMox-23, significantly inhibited TC-32 (EWS-FLI1+) tumor xenograft growth (p=0.0025, day 16, one-way ANOVA multiple comparisons test) compared to MTM (p=0.1174, day 16) and extending survival for 17 days out of 48 days on study (p=0.0003, Log Rank (Mantel-Cox) single comparison test) with treatment at MTD every 3 days, compared to vehicle. Additionally, the MTM-oxime analogue with highest systemic exposure, MTMox-24, also significantly inhibited TC-32 (EWS-FLI1+) tumor xenograft growth (p=0.0003, day 21, one-way ANOVA multiple comparisons test) compared to MTM (p=0.032, day 21) and extending survival for 12 days out of 37 days on study (p=0.0004, Log Rank (Mantel-Cox) single comparison test) with treatment, compared to vehicle. Conclusion: These studies in whole highlight the importance of exposure (pharmacokinetics; PK), toxicity and efficacy (pharmacodynamics; PD) relationships. The cytotoxicity and high systemic exposure of MTMSA-Trp-A10 directly contributes to its lower tolerated dose. However, despite a similar tolerated dose to MTM, systemic exposure remains 163-fold higher at the MTD. High systemic exposure may be attributed to high plasma protein binding, but also reduces the exposure of free MTMSA-Trp-A10 within the tumor tissue, which drives the efficacious response. In contrast, the less cytotoxic and rapidly de-methylated MTM-oxime analogues allow for 25-fold higher tolerances in mice. This unique metabolism and clearance may prevent exposures required to induced systemic blood and liver toxicities induced by MTM. Moreover, at these highly tolerated doses, the initial systemic exposure at MTD is highest among analogues tested, which resulted in an efficacious response with MTMox-23 and MTMox-24 treatment in tumor xenograft models. It remains to be determined if these PK/PD relationships can be reproduced in additional animal models, including human, without inducing toxicity. Nonetheless, these initial studies in mice demonstrate that a more selective, more tolerated analogue of MTM has potential for clinical success in treating ETS fusion-dependent tumors.

Acute Respiratory Distress Syndrome (ARDS) is common in COVID-19 patients and is associated with high mortality. The aim of this observational study was to describe patients’ characteristics and outcome, identifying potential risk factors for in-hospital mortality and for developing Long-COVID symptoms. This retrospective study included all patients with COVID-19 associated ARDS (cARDS) in the period from March 2020 to March 2021 who were invasively ventilated at the intensive care unit (ICU) of the University Hospital Dresden, Germany. Between October 2021 and December 2021 patients discharged alive (at minimum 6 months after hospital discharge—midterm survival) were contacted and interviewed about persistent symptoms possibly associated with COVID-19 as well as the quality of their lives using the EQ-5D-5L-questionnaire. Long-COVID was defined as the occurrence of one of the symptoms at least 6 months after discharge. Risk factors for mortality were assessed with Cox regression models and risk factors for developing Long-COVID symptoms by using relative risk (RR) regression. 184 Patients were included in this study (male: n = 134 (73%), median age 67 (range 25–92). All patients were diagnosed with ARDS according to the Berlin Definition. 89% of patients (n = 164) had severe ARDS (Horovitz-index < 100 mmHg). In 27% (n = 49) extracorporeal membrane oxygenation was necessary to maintain gas exchange. The median length of in-hospital stay was 19 days (range 1–60). ICU mortality was 51%, hospital mortality 59%. Midterm survival (median 11 months) was 83% (n = 55) and 78% (n = 43) of these patients presented Long-COVID symptoms with fatigue as the most common symptom (70%). Extreme obesity (BMI > 40 kg/m2) was the strongest predictor for in-hospital mortality (hazard ratio: 3.147, confidence interval 1.000–9.897) and for developing Long-COVID symptoms (RR 1.61, confidence interval 1.26–2.06). In-hospital mortality in severe cARDS patients was high, but > 80% of patients discharged alive survived the midterm observation period. Nonetheless, most patients developed Long-COVID symptoms. Extreme obesity with BMI > 40 kg/m2 was identified as independent risk factor for in-hospital mortality and for developing Long-COVID symptoms.