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Decisions to withdraw life sustaining treatment in the ICU are common, but there is little information about how treatment should be withdrawn. A pilot study showed that doctors withdraw life sustaining treatment in different ways even in identical cases. This variation can cause stress for ICU staff and relatives.  Our study investigated the decisions of doctors working in ICUs in Sweden regarding the withdrawal of life sustaining treatment for two fictitious patients. There was variation in if and how drug treatments should be withdrawn, as well as how ventilatory support should be withdrawn. Less experienced doctors tended to choose to prolong the dying process by weaning, even if it is unclear if that is preferable for the staff or for relatives.  Our study could be used in discussions in ICUs to try to understand how individual doctors make decisions about withdrawing life sustaining treatment.

Cancer immunotherapy remains limited by poor antigenicity and a regulatory tumor microenvironment (TME). Here, we create "onion-like" multi-lamellar RNA lipid particle aggregates (LPAs) to substantially enhance the payload packaging and immunogenicity of tumor mRNA antigens. Unlike current mRNA vaccine designs that rely on payload packaging into nanoparticle cores for Toll-like receptor engagement in immune cells, systemically administered RNA-LPAs activate RIG-I in stromal cells, eliciting massive cytokine/chemokine response and dendritic cell/lymphocyte trafficking that provokes cancer immunogenicity and mediates rejection of both early- and late-stage murine tumor models. In client-owned canines with terminal gliomas, RNA-LPAs improved survivorship and reprogrammed the TME, which became "hot" within days of a single infusion. In a first-in-human trial, RNA-LPAs elicited rapid cytokine/chemokine release, immune activation/trafficking, tissue-confirmed pseudoprogression, and glioma-specific immune responses in glioblastoma patients. These data support RNA-LPAs as a new technology that simultaneously reprograms the TME while eliciting rapid and enduring cancer immunotherapy., Competing Interests: Declaration of interests D.A.M. holds ownership interest in iOncologi, Inc. E.J.S is a paid consultant for Siren Biotechnology. The manuscript discusses patented technologies from H.R.M.-G., P.C., S.Q., J.M., A.P.G., J.H., W.G.S., M.R., D.A.M., and E.J.S. Patented technologies are under option to license by iOncologi, Inc., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Messenger RNA (mRNA) has emerged as a remarkable tool for COVID-19 prevention but its use for induction of therapeutic cancer immunotherapy remains limited by poor antigenicity and a regulatory tumor microenvironment (TME). Herein, we develop a facile approach for substantially enhancing immunogenicity of tumor-derived mRNA in lipid-particle (LP) delivery systems. By using mRNA as a molecular bridge with ultrapure liposomes and foregoing helper lipids, we promote the formation of 'onion-like' multi-lamellar RNA-LP aggregates (LPA). Intravenous administration of RNA-LPAs mimics infectious emboli and elicits massive DC/T cell mobilization into lymphoid tissues provoking cancer immunogenicity and mediating rejection of both early and late-stage murine tumor models. Unlike current mRNA vaccine designs that rely on payload packaging into nanoparticle cores for toll-like receptor engagement, RNA-LPAs stimulate intracellular pathogen recognition receptors (RIG-I) and reprogram the TME thus enabling therapeutic T cell activity. RNA-LPAs were safe in acute/chronic murine GLP toxicology studies and immunologically active in client-owned canines with terminal gliomas. In an early phase first-in-human trial for patients with glioblastoma, we show that RNA-LPAs encoding for tumor-associated antigens elicit rapid induction of pro-inflammatory cytokines, mobilization/activation of monocytes and lymphocytes, and expansion of antigen-specific T cell immunity. These data support the use of RNA-LPAs as novel tools to elicit and sustain immune responses against poorly immunogenic tumors.

Although doctor-led RAT has advantages, serial processing (triage - investigation - treatment) still predominates in UK EDs. We have designed a RAT decision-support app to assist ED nurses to select investigations and treatments at initial patient assessment and aid acuity scoring., Methods: Test nurses accompanied triage ('control') nurses in an observational study of 529 adult patients. Investigations, treatments and procedures, selected using the app, were compared with those selected later by ED clinicians. Acuities set by both nurses were re-evaluated blind by a consultant panel., Results: Data capture and decision making using RAT-support took a median of 1.43 min (IQR 1.13-2.07). Odds ratios are reported for matching of test versus control investigation and treatment orders. The ability to predict, within minutes, control investigations which were ordered at median of 50 min (IQR 21-99) is encouraging. Median times to order treatments (analgesia 88 min, IV antibiotics 112 min) were also reduced. Acuity scores versus the consultant panel gave weighted kappa of 0.54 (CI 0.48-0.61) for study nurses and for controls 0.45 (CI 0.36-0.53)., Conclusions: We conclude that nurse-led RAT for use in initial assessment is feasible given decision support. We also identified improvements required for the app., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

Pompe disease is a neuromuscular disease caused by a deficiency of the lysosomal enzyme acid alpha-glucosidase leading to lysosomal and cytoplasmic glycogen accumulation in neurons and striated muscle. In the decade since availability of first-generation enzyme replacement therapy (ERT) a better understanding of the clinical spectrum of disease has emerged. The most severe form of early onset disease is typically identified with symptoms in the first year of life, known as infantile-onset Pompe disease (IOPD). Infants are described at floppy babies with cardiac hypertrophy in the first few months of life. A milder form with late onset (LOPD) of symptoms is mostly free of cardiac involvement with slower rate of progression. Glycogen accumulation in the CNS and skeletal muscle is observed in both IOPD and LOPD. In both circumstances, multi-system disease (principally motoneuron and myopathy) leads to progressive weakness with associated respiratory and feeding difficulty. In IOPD the untreated natural history leads to cardiorespiratory failure and death in the first year of life. In the current era of ERT clinical outcomes are improved, yet, many patients have an incomplete response and a substantial unmet need remains. Since the neurological manifestations of the disease are not amenable to peripheral enzyme replacement, we set out to better understand the pathophysiology and potential for treatment of disease manifestations using adeno-associated virus (AAV)-mediated gene transfer, with the first clinical gene therapy studies initiated by our group in 2006. This review focuses on the preclinical studies and clinical study findings which are pertinent to the development of a comprehensive gene therapy strategy for both IOPD and LOPD. Given the advent of newborn screening, a significant focus of our recent work has been to establish the basis for repeat administration of AAV vectors to enhance neuromuscular therapeutic efficacy over the life span., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Intubation and admission to ICU are vital stages in the management of unconscious patients. Treatment records for all patients who died within 5 days of admission to Södersjukhuset during 2015 were obtained. Patients with GCS <9 in the ER were selected. It was noted if the patients had been intubated, had done a CT brain scan and if they had been admitted to ICU. They were divided into one of three diagnosis groups: cardiac arrest, intracerebral hemorrhage/stroke or other. 48 of 51 cardiac arrest patients were intubated and transferred to ICU. Only 17 of 46 ICH/stroke patients were intubated, and 22 ICH/stroke patients did a CT brain scan with an unprotected airway. Possible organ donors were more difficult to detect in the cardiac arrest group (6 of 14 possible) compared with the ICH/stroke group (12 of 14 possible). Our analysis shows that improvements need to be made in the airway management of unconscious patients who have suffered an ICH or stroke, and that identification of possible organ donors amongst victims of cardiac arrest also needs to be improved.

Recombinant adeno-associated vectors based on serotype 9 (rAAV9) have demonstrated highly effective gene transfer in multiple animal models of muscular dystrophies and other neurological indications. Current limitations in vector production and purification have hampered widespread implementation of clinical candidate vectors, particularly when systemic administration is considered. In this study, we describe a complete herpes simplex virus (HSV)-based production and purification process capable of generating greater than 1 × 10(14) rAAV9 vector genomes per 10-layer CellSTACK of HEK 293 producer cells, or greater than 1 × 10(5) vector genome per cell, in a final, fully purified product. This represents a 5- to 10-fold increase over transfection-based methods. In addition, rAAV vectors produced by this method demonstrated improved biological characteristics when compared to transfection-based production, including increased infectivity as shown by higher transducing unit-to-vector genome ratios and decreased total capsid protein amounts, shown by lower empty-to-full ratios. Together, this data establishes a significant improvement in both rAAV9 yields and vector quality. Further, the method can be readily adapted to large-scale good laboratory practice (GLP) and good manufacturing practice (GMP) production of rAAV9 vectors to enable preclinical and clinical studies and provide a platform to build on toward late-phases and commercial production.

A recombinant serotype 9 adeno-associated virus (rAAV9) vector carrying a transgene that expresses codon-optimized human acid alpha-glucosidase (hGAA, or GAA) driven by a human desmin (DES) promoter (i.e., rAAV9-DES-hGAA) has been generated as a clinical candidate vector for Pompe disease. The rAAV9-DES-hGAA vector is being developed as a treatment for both early- and late-onset Pompe disease, in which patients lack sufficient lysosomal alpha-glucosidase leading to glycogen accumulation. In young patients, the therapy may need to be readministered after a period of time to maintain therapeutic levels of GAA. Administration of AAV-based gene therapies is commonly associated with the production of neutralizing antibodies that may reduce the effectiveness of the vector, especially if readministration is required. Previous studies have demonstrated the ability of rAAV9-DES-hGAA to correct cardiac and skeletal muscle pathology in Gaa(-/-) mice, an animal model of Pompe disease. This article describes the IND-enabling preclinical studies supporting the program for a phase I/II clinical trial in adult patients with Pompe. These studies were designed to evaluate the toxicology, biodistribution, and potential for readministration of rAAV9-DES-hGAA injected intramuscularly into the tibialis anterior muscle using an immune modulation strategy developed for this study. In the proposed clinical study, six adult participants with late-onset Pompe disease will be enrolled. The goal of the immune modulation strategy is to ablate B-cells before the initial exposure of the study agent in one leg and the subsequent exposure of the same vector to the contralateral leg four months after initial dosing. The dosing of the active agent is accompanied by a control injection of excipient dosing in the contralateral leg to allow for blinding and randomization of dosing, which may also strengthen the evidence generated from gene therapy studies in the future. Patients will act as their own controls. Repeated measures, at baseline and during the three months following each dosing will assess the safety, biochemical, and functional impact of the vector.