scholarly journals Immune Responses in Perforin Deficient Mice

2021 ◽  
Author(s):  
◽  
Helen Mary Alys Simkins

<p>Dendritic cells (DC) play a pivotal role in the initiation of T cell responses and earlier studies have shown that their survival is important for the generation of effective immune responses. Cytotoxic T lymphocytes (CTL) and natural killer T (NKT) cells have been proposed to regulate the survival of antigen presenting DC through their ability to kill cells expressing specific antigen via secretion of perforin, a protein contained in cytotoxic granules. Perforin knockout (PKO) mice generate amplified immune responses to DC immunization, suggesting a link between defective cytotoxicity and increased T cell responses. The studies in this thesis used PKO mice and in vivo models of CD8+T cells and NKT cell immune responses to determine whether CTL and NKT cells eliminate DC in a perforin-dependent manner, and whether DC elimination is a mechanism to regulate T cell responses. During a primary influenza infection C57BL/6 and PKO mice generated a similar influenza specific CD8+ immune response. No significant difference in the percentage of influenza epitope PA224-233 specific T cells was observed between C57BL/6 and PKO mice during a secondary influenza infection, but PKO mice had a significantly reduced T cell response directed towards the dominant influenza epitope, NP366-374. The reduced T cell response in PKO mice was not due to differences in activation or differentiation status of specific T cells compared to C57BL/6 mice. Therefore, the extended DC survival in PKO after secondary influenza viral infection, recently reported by other authors, does not appear to correlate with increased expansion of virus specific CD8+T cells in infected mice. The role of NKT cells in DC elimination was assessed in vivo using the NKT cell ligand a-Galactosylceramide (a-GalCer). Injection of a-GalCer in C57BL/6 mice induced a dramatic decline in the number of splenic CD8+DC. A similar decrease in CD8+DC numbers was observed in PKO mice, suggesting that the mechanism of DC loss did not involve perforinmediated killing. In contrast, treatment with a TNF-a neutralizing antibody substantially reduced the decline in CD8+DC numbers. This reduction in splenic CD8+DC occurred as early as 15 hr after a-GalCer treatment, and did not affect generation of CD8+T cell responses or the ability of a-GalCer treatment to provide tumour protection. Taken together, these results suggest that multiple cells and mechanisms can regulate DC survival in vivo. CTL regulate DC survival in vivo in a perforin-dependent manner, but this does not necessarily affect the magnitude of the resulting immune responses. NKT cells also affect the survival of DC in vivo, but in a perforin-independent, cytokine-dependent manner. These findings provide additional knowledge about the in vivo involvement of perforin in regulating DC survival by CTL and NKT cells and the effects this has on T cell responses.</p>

2021 ◽  
Author(s):  
◽  
Helen Mary Alys Simkins

<p>Dendritic cells (DC) play a pivotal role in the initiation of T cell responses and earlier studies have shown that their survival is important for the generation of effective immune responses. Cytotoxic T lymphocytes (CTL) and natural killer T (NKT) cells have been proposed to regulate the survival of antigen presenting DC through their ability to kill cells expressing specific antigen via secretion of perforin, a protein contained in cytotoxic granules. Perforin knockout (PKO) mice generate amplified immune responses to DC immunization, suggesting a link between defective cytotoxicity and increased T cell responses. The studies in this thesis used PKO mice and in vivo models of CD8+T cells and NKT cell immune responses to determine whether CTL and NKT cells eliminate DC in a perforin-dependent manner, and whether DC elimination is a mechanism to regulate T cell responses. During a primary influenza infection C57BL/6 and PKO mice generated a similar influenza specific CD8+ immune response. No significant difference in the percentage of influenza epitope PA224-233 specific T cells was observed between C57BL/6 and PKO mice during a secondary influenza infection, but PKO mice had a significantly reduced T cell response directed towards the dominant influenza epitope, NP366-374. The reduced T cell response in PKO mice was not due to differences in activation or differentiation status of specific T cells compared to C57BL/6 mice. Therefore, the extended DC survival in PKO after secondary influenza viral infection, recently reported by other authors, does not appear to correlate with increased expansion of virus specific CD8+T cells in infected mice. The role of NKT cells in DC elimination was assessed in vivo using the NKT cell ligand a-Galactosylceramide (a-GalCer). Injection of a-GalCer in C57BL/6 mice induced a dramatic decline in the number of splenic CD8+DC. A similar decrease in CD8+DC numbers was observed in PKO mice, suggesting that the mechanism of DC loss did not involve perforinmediated killing. In contrast, treatment with a TNF-a neutralizing antibody substantially reduced the decline in CD8+DC numbers. This reduction in splenic CD8+DC occurred as early as 15 hr after a-GalCer treatment, and did not affect generation of CD8+T cell responses or the ability of a-GalCer treatment to provide tumour protection. Taken together, these results suggest that multiple cells and mechanisms can regulate DC survival in vivo. CTL regulate DC survival in vivo in a perforin-dependent manner, but this does not necessarily affect the magnitude of the resulting immune responses. NKT cells also affect the survival of DC in vivo, but in a perforin-independent, cytokine-dependent manner. These findings provide additional knowledge about the in vivo involvement of perforin in regulating DC survival by CTL and NKT cells and the effects this has on T cell responses.</p>


2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 21032-21032
Author(s):  
K. N. Heller ◽  
P. G. Steinherz ◽  
C. S. Portlock ◽  
C. Münz

21032 Background: Epstein-Barr virus (EBV) asymptomatically establishes persistent infections in more than 90% of the adult population. However, due to effective immune control, only a minority of infected carriers develops spontaneous EBV-associated lymphomas. Since EBV nuclear antigen-1 (EBNA1) is the only protein expressed in all proliferating EBV infected cells we hypothesize that EBNA1 specific immune response is critical in preventing EBV-positive lymphomas. Methods: After informed consent, peripheral blood from healthy volunteers and lymphoma patients (prior to therapy- no evidence of cytopenia) were stimulated (ex vivo) with overlapping peptides covering the immunogenic EBNA1 (aa400–641) sequence. Frequency of EBNA1-specific T-cells were assessed by intracellular cytokine staining and flow cytometric proliferation assays. Cytokine pattern, surface marker phenotype and functional reactivity against EBV specific and control antigens were analyzed. Results: Patient and volunteer immune responses to control antigens and other viruses were assessed and statistically indistinguishable. EBNA1 specific CD4+ T cell responses were detected among 18 of 20 healthy carriers, and among 10 of 16 patients with EBV-negative lymphoma (relative to healthy volunteers p=0.145 via paired student T test). None of the patients with EBV-positive lymphomas (n=8) had a detectable EBNA1-specific CD4+ T-cell response (p<0.003 relative to healthy volunteers and patients with EBV-negative lymphomas). Conclusions: Healthy volunteers and patients with EBV-negative lymphoma have statistically similar EBNA1-specific CD4+ T cell responses. Although patients with EBV-positive lymphoma have intact immune responses to common viruses and antigens, they selectively lack an EBNA1-specific CD4+ T cell response. An intact EBNA1 specific immune response among patients with EBV-negaitve lymphoma implies that lymphoma is not a cause of a selective immune deficiency. On the contrary, these findings suggest that EBNA1-specific CD4+ T cells are critical in the prevention of EBV mediated lymphomas, and a defect in EBNA1 specific immunity may leave EBV carriers suseptible to EBV-positive lymphomas. EBNA1- specific CD4+ T cell function may be a new target for therapies of EBV-associated malignancies. No significant financial relationships to disclose.


Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 552-552 ◽  
Author(s):  
Geoffrey L. Rogers ◽  
Roland W Herzog

Abstract CD8+ T cell responses to the adeno-associated virus (AAV) capsid have posed a significant barrier to transduction in clinical trials of AAV-mediated gene therapy for hemophilia B, as reactivation of a memory CTL response to the capsid is capable of eliminating transduced hepatocytes in the absence of immunosuppression. Recently, it has been suggested that innate immune responses induced by the toll-like receptor (TLR) pathway can influence the development of adaptive immune responses to AAV-mediated gene transfer. In particular, reports have implicated TLR2 (AAV capsid), TLR9 (AAV genome), and MyD88 (downstream signaling adaptor of both these TLRs). Herein, we have used a modified AAV2 with an insertion of the immunodominant MHC class I epitope of ovalbumin into the capsid (AAV2-SIINFEKL) to study the mechanism of CD8+ T cell responses to the AAV capsid. Using an H2-Kb-SIINFEKL tetramer reagent, we determined that anti-capsid CD8+ T cell responses depended on the TLR9-MyD88 pathway. While the frequency of circulating capsid-specific CD8+ T cells peaked around 7-10 days post-injection and subsided after about 21 days in wild type (WT) mice, tetramer-positive cells were not detected in TLR9-/- or MyD88-/- mice. The kinetics and magnitude of the response was unaltered in TLR2-/- mice. Mice deficient in STING, a downstream adaptor of multiple cytoplasmic DNA sensing pathways, also developed comparable capsid-specific CD8+ T cell frequencies to WT mice, suggesting that this is not a general effect of pattern recognition of DNA. Interestingly, the frequency of capsid-specific CD8+ T cells was not reduced in AP3-/- mice, which are deficient in type I IFN signaling downstream of TLR9. Adoptively transferred OVA-specific OT-1 T cells proliferated in WT but not TLR9-/- mice that received AAV2-SIINFEKL, confirming the importance of TLR9. The effect was antigen-specific, as OT-1 cells in WT mice that received AAV2 lacking SIINFEKL showed minimal proliferation comparable to TLR9-/- mice. In addition to pattern-recognition receptors, we also assessed the role of antigen-presenting cells in the CD8+ T cell response to capsid. The formation of capsid-specific CD8+ T cells was unaltered in mice that received gadolinium chloride to inactivate macrophages, or in B cell-deficient μMT mice. Depletion of B cells in WT mice prior to vector administration also failed to affect the anti-capsid CD8+ T cell response. However, transient depletion of dendritic cells (DCs) in CD11c-DTR mice resulted in a delayed development of capsid-specific CD8+ T cells. Seven days post-injection, DC-depleted mice had a significantly reduced frequency of tetramer-positive CD8+ T cells which recovered to normal by 10 days, likely due to the repopulation of DCs before the input capsid was completely cleared. Overall, our results show that TLR9 signaling, most likely in DCs, is required for the formation of de novo anti-capsid CD8+ T cell responses. Disclosures Herzog: Genzyme: AAV-FIX technology Patents & Royalties.


2021 ◽  
Author(s):  
◽  
Haley Ataera

<p>The adoptive transfer of activated dendritic cells (DC) loaded with tumour antigen or tumour specific T cells improves weak anti-tumour responses, however, without treatments to relieve suppression, these therapies will continue to fall short of their full potential. The aim of this thesis was to understand the role of hypoxia-induced increases in adenosine and of CD4+ CD25+ Foxp3+ regulatory T cells (Treg) in the suppression of anti-tumour immune responses and to design strategies to abrogate these mechanisms. These aims were investigated using the B16.OVA murine melanoma model because the OVA specific CD4+ (OTII) and CD8+ (OTI) T cell transgenic mice allowed detailed investigation of Ag specific T cell responses. Recent studies have shown that the inhibition of adenosine signalling in activated CD8+ T cells can improve the anti-tumour activity of these cells. To investigate these findings using the B16.OVA model, tumour-bearing mice were given activated OTI T cells and the adenosine receptor inhibitor caffeine. Caffeine treatment did not improve the anti-tumour response, possibly because this response was suppressed due to the increased frequency of myeloid derived suppressor cells observed in mice that received T cells. To determine whether the defective function of tumour infiltrating DC (TIDC) in tumours is due to suppression by Treg, mice were treated with the anti-CD25 monoclonal antibody PC61 to deplete Treg and challenged with tumours. PC61 treatment caused a delay in tumour growth but did not affect DC frequency, or expression of the DC activation markers CD40, CD86 and MHC II in tumours or lymph nodes. DC function was tested using in vitro and in vivo T cell proliferation assays and was found to be unaffected by PC61 treatment. Studies in RAG1-/- mice, which lack Treg, also showed no improvement in DC activation status or function. These results show that Treg do not suppress TIDC in the B16.OVA model. It is well known, however, that Treg suppress T cell responses and it has been suggested that Treg may mediate some of this suppression by using the perforin-granzyme pathway to cause T cell death. To investigate this possibility, naive, perforin sufficient OTI T cells were transferred into normal and perforin knockout (PKO) mice, with or without PC61 treatment. To stimulate an OTI T cell response, mice also received OVA-loaded DC. Depletion of both normal and PKO Treg resulted in decreased death and increased proliferation of the transferred cells, increased expression of IFN-y and TNF-a, and improved in vivo target cell killing by the transferred cells. These findings indicate that perforin expression by Treg is not required to suppress T cell responses or cause T cell death. In conclusion, the results of this thesis were consistent with the observation that there are multiple suppressive mechanisms in tumours and that there is substantial redundancy of these mechanisms. Depletion of Treg was found to improve the anti-tumour response, however, suppression of the DC was still evident, demonstrating that the neutralisation of a single suppressive mechanism may not be sufficient to treat aggressive, late stage cancers such as melanoma.</p>


eLife ◽  
2021 ◽  
Vol 10 ◽  
Author(s):  
Risa Ebina-Shibuya ◽  
Erin E West ◽  
Rosanne Spolski ◽  
Peng Li ◽  
Jangsuk Oh ◽  
...  

Thymic stromal lymphopoietin (TSLP) is a cytokine that acts directly on CD4+ T cells and dendritic cells to promote progression of asthma, atopic dermatitis, and allergic inflammation. However, a direct role for TSLP in CD8+ T-cell primary responses remains controversial and its role in memory CD8+ T cell responses to secondary viral infection is unknown. Here, we investigate the role of TSLP in both primary and recall responses in mice using two different viral systems. Interestingly, TSLP limited the primary CD8+ T-cell response to influenza but did not affect T cell function nor significantly alter the number of memory CD8+ T cells generated after influenza infection. However, TSLP inhibited memory CD8+ T-cell responses to secondary viral infection with influenza or acute systemic LCMV infection. These data reveal a previously unappreciated role for TSLP on recall CD8+ T-cell responses in response to viral infection, findings with potential translational implications.


2021 ◽  
Vol 9 (9) ◽  
pp. e002754
Author(s):  
Eva Bräunlein ◽  
Gaia Lupoli ◽  
Franziska Füchsl ◽  
Esam T Abualrous ◽  
Niklas de Andrade Krätzig ◽  
...  

BackgroundNeoantigens derived from somatic mutations correlate with therapeutic responses mediated by treatment with immune checkpoint inhibitors. Neoantigens are therefore highly attractive targets for the development of therapeutic approaches in personalized medicine, although many aspects of their quality and associated immune responses are not yet well understood. In a case study of metastatic malignant melanoma, we aimed to perform an in-depth characterization of neoantigens and respective T-cell responses in the context of immune checkpoint modulation.MethodsThree neoantigens, which we identified either by immunopeptidomics or in silico prediction, were investigated using binding affinity analyses and structural simulations. We isolated seven T-cell receptors (TCRs) from the patient’s immune repertoire recognizing these antigens. TCRs were compared in vitro by multiparametric analyses including functional avidity, multicytokine secretion, and cross-reactivity screenings. A xenograft mouse model served to study in vivo functionality of selected TCRs. We investigated the patient’s TCR repertoire in blood and different tumor-related tissues over 3 years using TCR beta deep sequencing.ResultsSelected mutated peptide ligands with proven immunogenicity showed similar binding affinities to the human leukocyte antigen complex and comparable disparity to their wild-type counterparts in molecular dynamic simulations. Nevertheless, isolated TCRs recognizing these antigens demonstrated distinct patterns in functionality and frequency. TCRs with lower functional avidity showed at least equal antitumor immune responses in vivo. Moreover, they occurred at high frequencies and particularly demonstrated long-term persistence within tumor tissues, lymph nodes and various blood samples associated with a reduced activation pattern on primary in vitro stimulation.ConclusionsWe performed a so far unique fine characterization of neoantigen-specific T-cell responses revealing defined reactivity patterns of neoantigen-specific TCRs. Our data highlight qualitative differences of these TCRs associated with function and longevity of respective T cells. Such features need to be considered for further optimization of neoantigen targeting including adoptive T-cell therapies using TCR-transgenic T cells.


2021 ◽  
Vol 12 ◽  
Author(s):  
Sergio Gil-Manso ◽  
Diego Carbonell ◽  
Luis López-Fernández ◽  
Iria Miguens ◽  
Roberto Alonso ◽  
...  

ObjectivesIn the context of the Covid-19 pandemic, the fast development of vaccines with efficacy of around 95% preventing Covid-19 illness provides a unique opportunity to reduce the mortality associated with the pandemic. However, in the absence of efficacious prophylactic medications and few treatments for this infection, the induction of a fast and robust protective immunity is required for effective disease control, not only to prevent the disease but also the infection and shedding/transmission. The objective of our study was to analyze the level of specific humoral and cellular T-cell responses against the spike protein of SARS-CoV-2 induced by two mRNA-based vaccines (BNT162b2 and mRNA-1273), but also how long it takes after vaccination to induce these protective humoral and cellular immune responses.MethodsWe studied in 40 healthy (not previously infected) volunteers vaccinated with BNT162b2 or mRNA-1273 vaccines the presence of spike-specific IgG antibodies and SARS-CoV-2-specific T cells at 3, 7 and 14 days after receiving the second dose of the vaccine. The specific T-cell response was analyzed stimulating fresh whole blood from vaccinated volunteers with SARS-CoV-2 peptides and measuring the release of cytokines secreted by T cells in response to SARS-CoV-2 stimulation.ResultsOur results indicate that the immunization capacity of both vaccines is comparable. However, although both BNT162b2 and mRNA-1273 vaccines can induce early B-cell and T-cell responses, these vaccine-mediated immune responses do not reach their maximum values until 14 days after completing the vaccination schedule.ConclusionThis refractory period in the induction of specific immunity observed after completing the vaccination could constitute a window of higher infection risk, which could explain some emerging cases of SARS-CoV-2 infection in vaccinated people.


2009 ◽  
Vol 83 (21) ◽  
pp. 10981-10992 ◽  
Author(s):  
Young-Hee Jin ◽  
Bongsu Kang ◽  
Byung S. Kim

ABSTRACT Theiler's murine encephalomyelitis virus (TMEV)-induced immune-mediated demyelinating disease in susceptible mouse strains has been extensively investigated as a relevant model for human multiple sclerosis. Previous investigations of antiviral T-cell responses focus on immune responses to viral capsid proteins, while virtually nothing is reported on immune responses to nonstructural proteins. In this study, we have identified noncapsid regions recognized by CD4+ T cells from TMEV-infected mice using an overlapping peptide library. Interestingly, a greater number of CD4+ T cells recognizing an epitope (3D21-36) of the 3D viral RNA polymerase, in contrast to capsid epitopes, were detected in the CNS of TMEV-infected SJL mice, whereas only a minor population of CD4+ T cells from infected C57BL/6 mice recognized this region. The effects of preimmunization and tolerization with these epitopes on the development of demyelinating disease indicated that capsid-specific CD4+ T cells are protective during the early stages of viral infection, whereas 3D21-36-specific CD4+ T cells exacerbate disease development. Therefore, protective versus pathogenic CD4+ T-cell responses directed to TMEV appear to be epitope dependent, and the differences in CD4+ T-cell responses to these epitopes between susceptible and resistant mice may play an important role in the resistance or susceptibility to virally induced demyelinating disease.


Blood ◽  
2010 ◽  
Vol 115 (3) ◽  
pp. 724-735 ◽  
Author(s):  
Tomomi Toubai ◽  
Chelsea Malter ◽  
Isao Tawara ◽  
Chen Liu ◽  
Evelyn Nieves ◽  
...  

Abstract Little is known about the role of active immunization in suppressing undesirable immune responses. Because CD8α+ dendritic cells (DCs) suppress certain immune responses, we tested the hypothesis that immunization of donors with host-derived CD8α+ DCs will reduce host-specific donor T-cell responses. BALB/c T cells from the animals that were immunized with B6 CD8α+ DCs demonstrated, in vitro and in vivo, significantly reduced proliferation and secretion of inflammatory cytokines but showed enhanced secretion of interleukin-10 (IL-10). The responses against third-party and model antigens were preserved demonstrating antigen specificity. The in vivo relevance was further demonstrated by the reduction on graft-versus-host disease (GVHD) in both a major histocompatibility complex–mismatched clinically relevant BALB/c → B6 model and major histocompatibility complex–matched, minor-mismatched C3H.SW → B6 model of GVHD. Immunization of the donors that were deficient in IL-10 (IL-10−/−) or with CD8α+ DCs from B6 class II (class II−/−) failed to reduce T-cell responses, demonstrating (1) a critical role for secretion of IL-10 by donor T cells and (2) a direct contact between the T cells and the CD8α+ DCs. Together, these data may represent a novel strategy for reducing GVHD and suggest a broad counterintuitive role for vaccination strategies in mitigating undesirable immune responses in an antigen-specific manner.


Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 3-3
Author(s):  
Ning Li ◽  
Thais Bertolini ◽  
Roland W Herzog

Adeno-associated viral (AAV) vectors are currently evaluated in multiple Phase III clinical trial for the treatment of hemophilia and neuromuscular disorders. A major concern is the potential for immune responses. Viral vectors are initially sensed by the innate immune system, which shapes subsequent adaptive immune responses. Particularly, toll-like receptors (TLRs) have been reported as major sensors of pathogens during innate immune response. TLRs recognize pathogen-associated molecular patterns (PAMPs). Our previous studies found that cross-priming of AAV capsid-specific CD8+ T cells depended on TLR9-MyD88 pathway. TLR9 is an endosomal DNA receptor that responds most potently to unmethylated CpG motifs as found in bacterial and viral DNA. Similarly, others documented TLR9-dependent CD8+ T cell responses against non-secreted transgene products such as LacZ and hemagglutinin upon muscle-directed AAV gene transfer. Similarly, we published that CD8+ T cell responses to a secreted ovalbumin (ova) transgene product were substantially reduced (although not entirely eliminated) upon muscle gene transfer in TLR9-deficient mice [J Innate Immun. 7:302-14]. For those studies, we had used a self-complementary scAAV genomes, which we found to more strongly activate TLR9 than conventional single-stranded ssAAV vectors. Here, we performed intramuscular injections of 3 doses of ssAAV1-CMV-ova vector (2X1010, 2X1011 and1X1012 vg) in wild-type (WT), TLR9-/-, or MYD88-/- C57BL/6 mice. Using MHC tetramer (H2-Kb -SIINFEKL), ova-specific CD8+ T cell frequencies were monitored in peripheral blood for up to 6 weeks. As expected from prior studies, TLR9-/- mice showed a substantially reduced response (1.2% tetramer+ of CD8) at the low dose when compared to WT (12% tetramer+ of CD8) animals (p&lt;0.0001, n=5/group). To our surprise, CD8+ T cell responses were similar in TLR9-/- and WT mice at the 2 higher doses. TLR9-/- mice displayed 16% and 3.3% tetramer+ of CD8 frequencies at the median and the high doses, respectively; which was comparable to WT mice, where 15% and 4.8% tetramer+ of CD8 frequencies were observed (n=5/group). Therefore, sensing of the AAV genome by TLR9 is more critical for the CD8+ T cell response to the secreted transgene product at lower vector doses (possibly related to the lower levels of transgene expression). Interestingly, transgene product-specific CD8+ T cell responses were much reduced in MyD88-/- mice, in which 0.2% and 1.7% tetramer+ of CD8 frequencies were found for low and median doses. Therefore, an alternative signaling pathway that includes the MyD88 adaptor molecule likely exists that is more critical than TLR9 above a certain level of expression. The reduced strength of the CD8+ T cell response seen at the highest vector dose compared to the medium dose may be explained by a transient increase in FoxP3+ Treg and in PD-1+ T cells that we observed 1 week after gene transfer and that was significantly greater at the highest vector dose. In related experiments, we performed intramuscular gene transfer using a ssAAV1-EF1a-FIX vector in hemophilia B mice (C3H/HeJ F9-/-, 1x1011 vg/mouse). Here, we used either a vector with native sequences or with an expression cassette that was entirely devoid of CpG motifs (and there stimulates TLR9 less effectively). CpG depletion did not have substantial effects on antibody formation against human FIX or the viral capsid. However, CD8+ T cell infiltrates in skeletal muscle were markedly reduced but not entirely eliminated when tissue sections were examined 1 month after gene transfer. In conclusion, TLR9 signaling is one important factor in the activation of transgene product-specific CD8+ T cells in AAV gene transfer, but other pathways exist that may be more critical depending on vector dose or levels of expression. Disclosures Herzog: Takeda Pharmaceuticals: Patents & Royalties.


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