heading:"Gathering valuable insights from the patient’s perspective",
interviewtabid:"maxfirst",
cardtext:"",
quoteNachname:"Mundt",
quoteVorname:"Philip",
language:"de",
quote:"The statement that left the biggest impression for me was when Max was telling about a friend of his and fellow cystic fibrosis patient who caught a fungi infection which he now cannot get rid of anymore, showing how fast a seemingly little infection can change the life of a cystic fibrosis patient for the worse without any kind of warning.",
quote:"A friend of mine with cystic fibrosis recently got a fungal infection that he can't get rid of. His situation really struck me; it showed how quickly a seemingly minor issue can worsen a person's life, especially for someone like us. It’s a strong reminder of how fragile our health is and how fast things can change without warning.",
aimofcontact:[<p>When cystic fibrosis came up as a possible topic, we reached out to a teammate's friend Max in the hopes of getting insights into the needs of CF patients and current treatments to verify the need for further treatment options.
Since he was much more enthusiastic and open for discussion than we dared to hope, we extended our exchanges into the realms of the reality of life for CF patients, possible progressions, organizations and doctors in our area and his personal perspectives and values.
The interest in meeting him grew in the whole team and we invited him to one of our meetings. </p>],
<QaBoxq="Since you almost had to sue for your medication, do you know if there are any lawyers specializing in cases like this? "a="No, I don’t. "/>
<QaBoxq="Are most of the other patients you know in good health like you?"a="No. Another boy my age got a fungal infection and does not have long time left to live. "/>
heading:"Discussion on optimizing our pegRNA Design to improve precision in prime editing",
interviewtabid:"JPpegRNA",
cardtext:"",
language:"de",
quoteNachname:"Lenger",
quoteNachname:"Lenger, Teammember",
quoteVorname:"Malte",
quote:"The interview proved invaluable in gaining an initial understanding of the principles of pegRNA design and optimisation, particularly in the context of silent edits.",
aimofcontact:"The aim of the contact was to engage in a discussion about prime editing and pegRNAs, as the Jan-Phillip Gerhards had used these technologies in his internship. We sought to exchange ideas, gather insights, and explore potential improvements or strategies for our project, leveraging his experience with prime editing tools. His practical knowledge in this field was very valuable for refining our approach and ensuring we were aligned with the latest advancements and methodologies in prime editing. ",
insights:"During our discussion we gained valuable insights that had a significant impact on our project. One of the most important findings was the effectiveness of silent edits, which will enable us to make our PrimeGuide safer. Silent edits changes the sequence of bases in the DNA in such a way that the resulting protein remains unchanged, because the genetic code is redundant. This means that different codons can code for the same amino acid. By making silent edits in addition to correcting the CFTR gene, we can prevent the pegRNA from rebinding. We have also learned that the length of the primer binding site (PBS) plays a crucial role in determining optimal results and that it is recommended to keep the PBS temperature close to 37°C. Specifically, PBS lengths of 17nt (38.3°C) and 16nt (36.4°C) were found to be ideal options. For our planned set of 12 samples, it was recommended to use three different PBS lengths (differing by +/- 1nt from that close to 37°C) in combination with four RTTs to achieve the best result. Another important finding was the use of non-annotated regions with overhangs for cloning, which could give better results in our experiments. However, we also encountered concerns that circRNA, a covalently closed circular RNA molecule, might be sterically hindered by Cas9, which we need to investigate further. When discussing cloning overhangs, we learned that a base-pair length close to 60°C is optimal. However, the use of a 15nt PBS was not recommended as it has a lower temperature range which could affect performance. Although we still need to confirm the oligonucleotide delivery time, these findings will help us to refine our cloning strategy, optimise PBS selection and improve our overall approach to primer editing, especially in terms of the pegRNA design.",
implementation:"We incorporated the lessons learned from our discussions on prime editing and silent editing directly into our project by refining our approach to gene editing. Based on feedback about the optimal length of primer binding sequences (PBS) and RTTs, we adjusted the design of our pegRNAs to ensure greater precision and efficiency in our experiments. In particular, we learned that using PBS lengths close to 37°C melting temperatures (e.g. 16-17 nucleotides) increased stability, which led us to fine-tune these sequences for improved editing results. The concept of silent editing became an integral part of our safety strategy, allowing us to make changes to the DNA more precise. We also revised our cloning strategies by considering the appropriate overhang length, targeting a base pair length near the melting temperature of 60°C to improve cloning efficiency. We also reassessed the practicality of ordering shorter PBS sequences, concluding that lengths shorter than 15 nt were less advantageous due to reduced efficiency. By integrating these findings, we optimised our experimental workflow and made informed decisions about the tools and methods for our prime editing experiments. ",
insights:"The interview yielded valuable insights into the regular implementation of the therapy, the use of aids and the adaptation of exercises to the individual needs of the patients. It was notable that the therapy has improved considerably thanks to better medication and adapted exercises, with a concomitant increase in life expectancy for children affected by cystic fibrosis. Of particular interest was the emphasis on the importance of sport and exercise, which should not only be therapeutically effective, but also increase quality of life. ",
implementation:"The following statement by Katrin Westhoff had a particularly profound impact on our project: 'The more we know, the more opportunities we have.' We learned from the interview that the current medication is already helping many patients to a huge extent, but that there is still a significant opportunity for improvement. After all, successful gene therapy would markedly enhance the quality of life for those affected. The findings of this project will be disseminated to the relevant researchers in order to facilitate the rapid improvement of the quality of life of all cystic fibrosis patients, regardless of their mutation. ",
<li>A well-functioning treatment team is essential.</li>
</ol>,
<p>We have jointly weighed up the extent to which an early diagnosis is always an advantage, as some parents perceive an early diagnosis as an additional burden and would prefer to experience the first years of their child's life without constant medical intervention. Especially when there are cases in which patients only show a clear clinical picture at an advanced age. The psychological burden also lies with the children, who often experience medical trauma because they are involved in such intensive medical care from birth. Additionally, the treatment of cystic fibrosis is very expensive, and the costs are covered by health insurance companies to varying degrees. In some countries, such as the USA, Ukraine or Developing countries, many families cannot afford the necessary treatments. Dr Olariu drew our attention to another problem in the treatment of cystic fibrosis. Infections, especially with bacteria such as Pseudomonas spcc., are difficult to treat and often lead to long hospital stays. Max, our patients’ representative, who knows Dr. Olariu through his treatment, talked about his infections with Pseudomonas spcc., illustrating the reality of an invisible danger that determines a patient's everyday life. Strict hygiene measures are required to prevent infections, such as wearing face masks in hospital and careful handling of potential sources of infection. The clinics where cystic fibrosis patients are treated work closely with a multidisciplinary team of doctors, psychologists, physiotherapists and nutritionists to ensure that patients receive holistic care. At the same time, research is constantly being carried out and new therapeutic approaches developed, such as the use of nanoparticles to improve drug delivery. Former patients are also involved in research and provide valuable insights and advances. </p>,
<divclassName="flex flex-col">
<divclassName="min-w-full overflow-x-auto">
<divclassName="inline-block min-w-full py-4">
<divclassName="overflow-hidden p-2">
<tableclassName="text-center">
<theadclassName="bg-d">
<tr>
<td>Pros</td>
<td>Cons</td>
</tr>
</thead>
<tbody>
<tr>
<td><b>Timely Intervention:</b> Prevents severe organ damage and improves long-term outcomes.</td>
<td><b>Psychological Burden:</b> May cause stress for parents and children due to constant medical interventions.</td>
</tr>
<tr>
<td><b>Holistic Care:</b> Involves a multidisciplinary team for comprehensive patient support.</td>
<td><b>Cost Implications:</b> Treatments can be expensive, with varying insurance coverage, leaving many families unable to afford care</td>
</tr>
<tr>
<td><b>Access to Innovations: </b>Allows patients to benefit from advancements like nanoparticle drug delivery.</td>
<td><b>Infection Risks:</b> Patients still face risks from infections like <i>Pseudomonas spp.</i>, leading to potential hospitalizations.</td>
</tr>
<tr>
<td><b>Family Support: </b>Provides education and resources for effective management from the start.</td>
<td><b>Over-medicalization: </b>Continuous focus on treatment can overwhelm families, affecting the quality of early childhood experiences.</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>,
<ol>
<li>Pros of Early Diagnosis and Treatment</li></ol>,
<ol>
<li>Timely Intervention: Prevents severe organ damage and improves long-term outcomes.</li>
<li>Holistic Care: Involves a multidisciplinary team for comprehensive patient support.</li>
<li>Access to Innovations: Allows patients to benefit from advancements like nanoparticle drug delivery.</li>
<li>Family Support: Provides education and resources for effective management from the start.</li>
</ol>,
<ol>
<li>Cons of Early Diagnosis and Treatment</li></ol>,
<ol>
<li>Psychological Burden: May cause stress for parents and children due to constant medical interventions.</li>
<li>Cost Implications: Treatments can be expensive, with varying insurance coverage, leaving many families unable to afford care.</li>
<li>Infection Risks: Patients still face risks from infections like Pseudomonas spp., leading to potential hospitalizations.</li>
<li>Over-medicalization: Continuous focus on treatment can overwhelm families, affecting the quality of early childhood experiences.</li>
</ol>,
],
implementation:"In summary, our project greatly benefited from the conversation with Dr. Olariu. His insights into the complexities of cystic fibrosis treatment, particularly the significance of early diagnosis, were invaluable. Max’s personal experiences added a crucial human perspective, illustrating the medical and psychological challenges he faces, including infections with Pseudomonas spp. Dr. Olariu emphasized the importance of a multidisciplinary approach, involving not just medical professionals but also psychologists, physiotherapists, and nutritionists for holistic care. This discussion helped us appreciate the balance between timely interventions and the emotional burden on patients and their families, guiding us to develop a more empathetic understanding of living with cystic fibrosis. ",
<QaBoxq="What do you think about support groups or health retreats for CF patients?"a="Support groups are extremely important. Although we are a good medical team, advice from peers often resonates more with patients. We’ve organized two parents' evenings recently, where parents can exchange experiences and support each other. Unfortunately, we can’t invite the children themselves due to the risk of infection, but in rehabilitation settings, they can meet in germ-specific groups and benefit from shared experiences."/>
<QaBoxq="Is there a risk of antibiotic resistance with repeated treatments?"a="Yes, resistance is a concern, especially with repeated antibiotic treatments. However, there’s often a discrepancy between what we see in lab tests and the clinical outcomes. Even if a germ shows resistance on paper, many patients still respond well to treatment. We base our decisions more on clinical outcomes than lab results, changing antibiotics only if the patient’s condition doesn’t improve."/>
<QaBoxq="Are there any side effects to the medications?"a="Yes, all medications have potential side effects, though many of them are minor, like rashes or stomachaches. One serious side effect of some antibiotics is hearing damage, which can lead to lifelong hearing loss. This is why we closely monitor patients in the hospital when starting treatments. The newer therapies, like modulators, can cause liver stress, so we regularly check liver enzymes in the blood. However, severe side effects are rare, and the drugs are generally well tolerated."/>
aimofcontact:"The main objective of the contact was to learn from the discussion on issues related to cystic fibrosis (CF), gene therapy, health insurance processes and regulatory pathways. In particular, we wanted to understand the real-world challenges and technical aspects of gene editing, especially prime editing, as well as the complexities of approval and reimbursement of gene therapies for CF patients.",
insights:"The regulatory approval process, particularly by the European Medicines Agency (EMA) for advanced medical devices, has highlighted the bureaucratic hurdles that gene therapies must overcome. We learned that such therapies for cystic fibrosis have to navigate complex European and German regulatory systems. The discussion on the AMNOG process was crucial. We learnt that the additional benefit of a therapy is assessed for reimbursement by the statutory health insurance funds. We implemented this insight in our project by considering the long-term regulatory and economic effects as important milestones for therapy development. We also gained insight into how public and private health insurers may differ in their reimbursement of such therapies. Public insurers have stricter guidelines, while private insurers can be more flexible, but both require strict justification, especially for rare diseases such as cystic fibrosis. Information on newborn screening and genetic counselling covered by public health insurance was crucial to understanding how preventive measures for CF are managed. This underlines the importance of early intervention and diagnosis in our project. Atypical forms of CF, where health insurance companies do not cover treatment due to non-standardised test results, were identified as a key problem. This helped us to recognise the need for more adaptable insurance policies and clearer pathways for the treatment of atypical cases in our project plans. The debate about whether healthcare systems can afford the high costs of gene therapies highlighted an important issue in the current medical landscape. We have incorporated this insight into our project by discussing possible cost-effective alternatives and the need for thorough cost-benefit analysis in the development of treatments.",
implementation:"After the interview, we further tailored our project to focus on a simple delivery method. To gain an overview of the regulatory requirements and to better deliver the project, one of our team members attended a GxP course to ensure we met all the necessary standards. To deepen our knowledge of entrepreneurship, we conducted further interviews with start-ups and industrial companies, which gave us important insights into practical implementation. These steps ensure that our project is not only based on scientific research, but also takes into account the practical, regulatory and social aspects that are crucial to bringing new CF therapies to the market. We are currently developing strategies to successfully implement our ideas and the project in the future.",
<p>Chrissi takes modulators and will soon take a trip to a water park with some friends. Katrin teaches us that when the children do not breathe out properly, air stays in the lungs and causes hyperinflation – with which it is actually harder to float in water! After the manual drainage, Katrin gets all of us glasses with water and dish soap and straws. Blowing bubbles is a playful way to train how to properly breathe out by either trying to blow bubbles as long as possible or trying to make an existing bubble as big as possible!</p>
quote:"At first, our world fell apart. I still remember the conversation with the doctor. ",
aimofcontact:"We learned from our discussion with Max that cystic fibrosis (CF) has a profound impact on the whole family – not just the patient. In order to gain further insight into this subject, we sought to engage with the next of kin of CF patients. We were able to make contact with Julia through the self-help group of Mukviszidose EV, of which Max is a member. She subsequently reached out to us following Max's request for potential candidates for an interview with a patient group. She and her husband have a six-year-old daughter carrying the F508del mutation in the CFTR gene and a toddler without CF. ",
insights:"The interview with Julia shifted our focus to a new group of stakeholders: The patient’s support systems. Most people do not get genetically tested before having children and due to that, many people could get in the position of having a loved one with CF. We considered the societal impacts, such as the rising health care costs, which Nicole Friedlein emphasized during our interview. She explained how the long-term nature of treatment, frequent hospital visits, and the need for specialized medications place a significant financial burden on both patients and the health care system. This insight shaped our understanding of the broader economic challenges faced by families and institutions involved in managing chronic illnesses. Meanwhile, Julia brought attention to the psychological impact, stressing the emotional strain that accompanies not only the illness itself but also the financial pressures. She also showed us more perspectives on parenting of children with CF, than we heard before, and told us about the way from the first diagnosis to growing accustomed to and living with a child with CF. Julia also confirmed that most children will have no issue using an inhalative therapy like we envision our gene therapy to be and shone light onto the comparatively very good situation for CF patients in Germany. ",
implementation:"This interview helped us confirm the delivery method we planned to use as we were previously concerned how and if children would be able to use the inhalative therapy. Besides that, Julia gave us further insights into the emotional side of dealing with CF and we were able to discuss the situation for patients in Germany in comparison to other countries better in later interviews [Link Joshua]. ",
aimofcontact:[<p>We learned from our discussion with Max [Link Max] that cystic fibrosis (CF) has a profound impact on the whole family – not just the patient. In order to gain further insight into this subject, we sought to engage with the next of kin of CF patients.
We were able to make contact with Julia through the self-help group of Mukviszidose e.V. [Link https://www.muko.info/ ], of which Max is a member. She subsequently reached out to us following Max's request for potential candidates for an interview with a patient group.
She and her husband have a six-year-old daughter carrying the F508del mutation in the CFTR gene and a toddler without CF. </p>]
insights:[<p> The interview with Julia shifted our focus to a new group of stakeholders: The patient’s support systems. Most people do not get genetically tested before having children and due to that, many people could get in the position of having a loved one with CF.
We considered the societal impacts, such as the rising health care costs, which Nicole Friedlein emphasized during our interview. She explained how the long-term nature of treatment, frequent hospital visits, and the need for specialized medications place a significant
financial burden on both patients and the health care system. This insight shaped our understanding of the broader economic challenges faced by families and institutions involved in managing chronic illnesses. Meanwhile, Julia brought attention to the psychological impact,
stressing the emotional strain that accompanies not only the illness itself but also the financial pressures. She also showed us more perspectives on parenting of children with CF, than we heard before, and told us about the way from the first diagnosis to growing accustomed
to and living with a child with CF. Julia also confirmed that most children will have no issue using an inhalative therapy like we envision our gene therapy to be and shone light onto the comparatively very good situation for CF patients in Germany. </p>],
implementation:[<p> This interview helped us confirm the delivery method we planned to use as we were previously concerned how and if children would be able to use the inhalative therapy. Besides that, Julia gave us further insights into the emotional side of
dealing with CF and we were able to discuss the situation for patients in Germany in comparison to other countries better in later interviews [Link Joshua]. </p>],
interview:<>
<QaBoxq="Can you tell us a bit about your family? How old are your children and yourselves?"a="I’m 37, my husband is 44, and our daughter is six, turning seven soon. We also have a son who’s about a year and a half."/>
<QaBoxq="Does your son also have cystic fibrosis?"a="No, he doesn’t."/>
<QaBoxq="Does your daughter do physiotherapy?"a="Yes, once a week for about an hour. She’s been going since she was discharged from the hospital, and she has a close bond with her physiotherapist. They’ve been working together since she was a baby, and she goes by herself now."/>
<QaBoxq="Are there any restrictions for her in terms of physical activities?"a="No, not really. She does dancing once a week, physiotherapy, and she’s even done a swimming course without any problems."/>
<QaBoxq="How do you handle communicating about her illness?"a="We try not to make a big deal of it. When I looked for information, I found what we needed. There’s nothing we’ve really felt was missing."/>
(from the USA) and his family live in Thailand where he and his wife run a children’s home. Their daughter is the only child with CF.</p>,
<p>It is possible to learn more about Joshua and his family though the <ahref="https://thebonnellfoundation.org/cf-vests-worldwide/">
podcast of the Bonnel foundation</a>.</p>],
insights:"Joshua showed us just how dire the situation is for CF patients is in some regions. It was shocking to hear there is only one doctor knowledgeable about CF in Thailand and that many doctors dismiss the possibility of CF due to racial bias and misinformation. Additionally, we confirmed how much the accessibility of care depends on the healthcare system, as we already touched on during the interview with Nicole Friedlein [link]. On the parenting level, Joshua brought in many perspectives contrary to what we previously heard. In the interview with Max [Link], we learned he vehemently avoids ponding water while Joshua’s daughter is allowed to roam around with no such restrictions. Neither have chronic infections. ",
insights:[<p> Joshua showed us just how dire the situation is for CF patients is in some regions. It was shocking to hear there is only one doctor
knowledgeable about CF in Thailand and that many doctors dismiss the possibility of CF due to racial bias and misinformation. Additionally, we confirmed how much the accessibility
of care depends on the healthcare system, as we already touched on during the interview with Nicole Friedlein [link]. On the parenting level, Joshua brought in many perspectives contrary to what we previously heard. In the interview with Max [Link], we learned he vehemently avoids ponding water while Joshua’s daughter is allowed to roam around with no such restrictions. Neither have chronic infections.</p>],
implementation:[<p>The interview with Josh made us realize we too needed to look at the reason why we chose F508del. Did we, too, fall for bias?
Despite a change of target not being feasible anymore, we looked into it and traced back our steps that led to our decision. We did not find as much
information about other mutations when first researching cystic fibrosis, especially in the context of prime editing. Mattijs Bulceans's paper on
aimofcontact:"The aim of the interview was to get an answer to the question of whether we need an ethics vote for our project or not and to obtain guidelines for dealing with patient cells regarding ethical issues and data protection. ",
insights:"The discussion was very informative in terms of how we should approach this topic and focused primarily on the important factors that need to be considered when planning the handling of patient cells. These include which legal principles need to be observed, data protection, ethical considerations and, above all, detailed and specific information for the donor. It also made us look at the situation from many different angles and consider the risks of worst-case scenarios. Overall, this interview was very useful to us, and we were able to use the information we gained to develop a kind of guideline that allowed us to approach this sensitive topic, which was new to us, with a certain degree of confidence. ",
implementation:"Based on the knowledge we have gained, we have drawn up guidelines for our handling of the cells. We used this guide when handling the patient cells, to ensure they were handled in an ethically correct manner.",
