Pre-hospital ECPR in an Australian metropolitan setting: a single-arm feasibility assessment-The CPR, pre-hospital ECPR and early reperfusion (CHEER3) study

INTRODUCTION

Survival from refractory out of hospital cardiac arrest (OHCA) without timely return of spontaneous circulation (ROSC) utilising conventional advanced cardiac life support (ACLS) therapies is dismal. CHEER3 was a safety and feasibility study of pre-hospital deployed extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) for refractory OHCA in metropolitan Australia.

METHODS

This was a single jurisdiction, single-arm feasibility study. Physicians, with pre-existing ECMO expertise, responded to witnessed OHCA, age < 65 yrs, within 30 min driving-time, using an ECMO equipped rapid response vehicle. If pre-hospital ECPR was undertaken, patients were transported to hospital for investigations and therapies including emergent coronary catheterisation, and standard intensive care (ICU) therapy until either cardiac and neurological recovery or palliation occurred. Analyses were descriptive.

RESULTS

From February 2020 to May 2023, over 117 days, the team responded to 709 "potential cardiac arrest" emergency calls. 358 were confirmed OHCA. Time from emergency call to scene arrival was 27 min (15-37 min). 10 patients fulfilled the pre-defined inclusion criteria and all were successfully cannulated on scene. Time from emergency call to ECMO initiation was 50 min (35-62 min). Time from decision to ECMO support was 16 min (11-26 min). CPR duration was 46 min (32-62 min). All 10 patients were transferred to hospital for investigations and therapy. 4 patients (40%) survived to hospital discharge neurologically intact (CPC 1/2).

CONCLUSION

Pre-hospital ECPR was feasible, using an experienced ECMO team from a single-centre. Overall survival was promising in this highly selected group. Further prospective studies are now warranted.

Prediction of Response to Immune Checkpoint Blockade in Patients with Metastatic Colorectal Cancer with Microsatellite Instability

BACKGROUND

Mismatch repair deficient (dMMR) tumors displaying microsatellite instability (MSI) represent a paradigm for the success of immune checkpoint inhibitor (ICI)-based immunotherapy, particularly in patients with metastatic colorectal cancer (mCRC). However, a proportion of patients with dMMR/MSI mCRC exhibit resistance to ICI. Identification of tools predicting MSI mCRC patient response to ICI are required for the design of future strategies further improving this therapy.

PATIENTS AND METHODS

We combined high-throughput DNA and RNA sequencing of tumors from 116 patients with MSI mCRC treated with anti-PD-1 +/- anti-CTLA-4 of the NIPICOL phase II trial (C1, NCT03350126, discovery set) and the IMMUNOMSI prospective cohort (C2, validation set). The DNA/RNA predictors whose status was significantly associated with ICI status of response in C1 were subsequently validated in C2. Primary endpoint was iPFS (progression-free survival by iRECIST).

RESULTS

Analyses showed no impact of previously suggested DNA/RNA indicators of resistance to ICI, e.g., MSISensor score, tumor mutational burden, or specific cellular and molecular tumoral contingents. By contrast, iPFS under ICI was shown in C1 and C2 to depend both on a multiplex MSI signature involving the mutations of 19 microsatellites (HR_C2 = 3.63; 95% CI [1.65-7.99] ; p = 1.4x10^-3) and the expression of a set of 182 RNA markers with a non-epithelial TGFB-related desmoplastic orientation (HR_C2 = 1.75 ; 95% CI [1.03-2.98] ; p = 0.035). Both DNA and RNA signatures were independently predictive of iPFS.

CONCLUSIONS

iPFS in patients with MSI mCRC can be predicted by simply analyzing the mutational status of DNA microsatellite-containing genes in epithelial tumor cells together with nonepithelial TGFB-related desmoplastic RNA markers.

POS0520 ASSOCIATION BETWEEN BASELINE STATIN TREATMENT AND MAJOR ADVERSE CARDIOVASCULAR EVENTS IN PATIENTS WITH RHEUMATOID ARTHRITIS: A POST HOC ANALYSIS OF ORAL SURVEILLANCE

Background

ORAL Surveillance (NCT02092467) was a post-authorisation safety study of tofacitinib vs tumour necrosis factor inhibitors (TNFi) in patients (pts) with rheumatoid arthritis (RA) aged ≥50 years (yrs) with ≥1 additional cardiovascular (CV) risk factor and an inadequate response to methotrexate (MTX). Statins are used to treat coronary artery disease (CAD) and are recommended by the American College of Cardiology/American Heart Association (ACC/AHA) for the management of pts at risk of atherosclerotic CV disease (ASCVD),1 such as those with ≥7.5% 10-yr risk of major adverse CV events (MACE) or diabetes mellitus.

Objectives

To examine the association between baseline (BL) statin use and MACE in ORAL Surveillance.

Methods

Pts with RA on stable MTX were randomised 1:1:1 to receive tofacitinib 5 or 10 mg twice daily (BID) or TNFi (adalimumab 40 mg every 2 weeks or etanercept 50 mg once weekly). Pts were stratified post hoc by BL statin use (yes/no). Pts were further categorised by history of CAD (HxCAD), BL CV risk score per ACC/AHA guidelines1 (for pts without HxCAD; 10-yr risk of MACE per the ASCVD-pooled cohort equations risk calculator2 with a 1.5 multiplier applied3), and separately by BL diabetes status. CV risk score/BL diabetes status categories were: high (≥20%)/HxCAD (yes), intermediate (≥7.5–<20%) or low-borderline (<7.5%), and diabetes status (yes). For the overall population and each treatment group, risk of MACE was compared between BL statin use (yes vs no) via Cox analyses for each CV risk category and diabetes status (yes). Incidence rates (IRs; pts with first events/100 pt-yrs) and hazard ratios (HRs; BL statin use: yes vs no) were evaluated for adjudicated MACE.

Results

Of 4362 pts (tofacitinib 5 mg BID, n=1455; tofacitinib 10 mg BID, n=1456; TNFi, n=1451), 497 had a HxCAD, and 3813 without a HxCAD had CV risk scores determined; 789 had BL diabetes. Overall, 1020 (23.4%) pts reported BL statin use. Across CV risk score categories for all treatment groups, <50% of pts received statins at BL, with statin use highest in the high/HxCAD category pts (35.7–40.6%) and pts with diabetes (35.7–44.2%) (Table 1). Across categories, no interpretable associations between BL statin use and MACE were found. However, in the overall population, MACE IRs were lower in pts with vs without BL statin use in the high/HxCAD category, and in pts with diabetes (Figure 1). In pts receiving tofacitinib 5 mg BID and TNFi, MACE IRs were lower in pts with vs without BL statin use across all categories (Figure 1).

Table 1.

Proportion of pts receiving statins at BL, by CV risk category and presence of diabetes

n/N (%)OverallTofacitinibTofacitinibTNFi5 mg BID10 mg BIDHigh (≥20%)/HxCAD525/1370 (38.3)168/435 (38.6)193/475 (40.6)164/460 (35.7)Intermediate (≥7.5–<20%)302/1511 (20.0)110/490 (22.4)94/516 (18.2)98/505 (19.4)Low-borderline (<7.5%)178/1429 (12.5)66/513 (12.9)57/446 (12.8)55/470 (11.7)Diabetes (yes)320/789 (40.6)111/251 (44.2)114/272 (41.9)95/266 (35.7)

N, number of pts in each category; n, number of pts receiving BL statins

Conclusion

In this post hoc analysis of data from ORAL Surveillance, most pts did not receive BL statin treatment. This suggests suboptimal CV risk management, particularly in pts at high risk of CV events. There was no interpretable association between BL statin use and MACE. However, pts in the higher risk categories, particularly those receiving tofacitinib 5 mg BID, had lower MACE IRs with vs without BL statin use. This analysis did not take into account initiation or dose adjustment of statin treatment during the study, and had low yrs of exposure in some categories.

References

[1]Arnett et al. J Am Coll Cardiol 2019; 74: e177-232.

[2]American College of Cardiology, American Heart Association. ASCVD risk estimator. https://tools.acc.org/ldl/ascvd_risk_estimator/index.html#!/calulate/estimator/.

[3]Agca et al. Ann Rheum Dis 2017; 76: 17-28.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Lauren Hogarth, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Jon T Giles Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Genentech, Gilead Sciences and UCB, Grant/research support from: Pfizer Inc, Christina Charles-Schoeman Consultant of: AbbVie, Gilead Sciences, Pfizer Inc and Sanofi-Regeneron, Grant/research support from: AbbVie, Bristol-Myers Squibb and Pfizer Inc, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead Sciences, MSD, Pfizer Inc and Roche, Grant/research support from: Pfizer Inc, Roche and UCB, Maxime Dougados Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, Zoltán Szekanecz Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Paid instructor for: AbbVie, Eli Lilly, Gedeon Richter, Novartis, Pfizer Inc and Roche, Consultant of: AbbVie, Eli Lily, Novartis, Pfizer Inc, Roche and Sanofi, Steven R. Ytterberg Consultant of: Corbus Pharmaceuticals, Kezar Life Sciences and Pfizer Inc, Gary G Koch Shareholder of: IQVIA, Grant/research support from: AbbVie, Acceleron, Amgen, Arena, AstraZeneca, Cytokinetics, Eli Lilly, Gilead Scienes, GlaxoSmithKline, Huya Bioscience International, Johnson & Johnson, Landos Biopharma, Merck, Momentum, Novartis, Otsuka, Pfizer Inc, Sanofi and vTv Therapeutics, Employee of: University of North Carolina at Chapel Hill, Joseph Wu Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Cunshan Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Kenneth Kwok Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sujatha Menon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Yan Chen Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Teoman Yusuf Cesur Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose L. Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer SLU, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Annette Diehl Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Deepak L Bhatt Grant/research support from: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Lexicon, Lilly, Medtronic, MyoKardia, Novo Nordisk, Owkin, Pfizer Inc, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic and The Medicines Company.

POS0296 INTEGRATED SAFETY ANALYSIS OF TOFACITINIB IN ANKYLOSING SPONDYLITIS CLINICAL TRIALS

Background

Tofacitinib is an oral JAK inhibitor for the treatment of adults with ankylosing spondylitis (AS).

Objectives

To describe the tofacitinib safety profile from an integrated analysis of randomised controlled trials (RCTs) in patients (pts) with active AS.

Methods

Pooled data from Phase (P)2 (NCT01786668) and P3 (NCT03502616) RCTs in pts with AS were analysed in 3 cohorts (Table 1): the 16-Week (Wk) placebo (PBO)-controlled cohort (pts receiving tofacitinib 5 mg twice daily [BID] or PBO from Wks 0–12 [P2 RCT] or Wks 0–16 [P3 RCT]), the 48-Wk all tofacitinib 5 mg BID cohort and the 48-Wk all tofacitinib cohort (pts receiving ≥1 dose of tofacitinib 2, 5 or 10 mg BID), including pts receiving tofacitinib from Wks 0–12 (P2 RCT) or Wks 0–48 (P3 RCT). Pts receiving tofacitinib 5 mg BID were included in the 16-Wk PBO-controlled cohort and both 48-Wk tofacitinib cohorts. Adverse event (AE)/AEs of special interest incidence rates (IRs; pts with events/100 pt-yrs) were reported based on a 28-day risk period (time of first to last study drug dose +28 days). Baseline (BL) cardiovascular (CV) risk was calculated post hoc by the atherosclerotic CV disease (ASCVD)-pooled cohort equations calculator for pts without history of coronary artery disease (48-Wk tofacitinib cohorts).

Results

At BL, most pts (>76%) in the 48-Wk tofacitinib cohorts had <5% (low) 10-yr ASCVD risk (Figure 1). The most common treatment-emergent AEs were nasopharyngitis/upper respiratory tract infection. Serious AE IRs were higher with tofacitinib 5 mg BID vs PBO in the 16-Wk PBO-controlled cohort, and similar in the 48-Wk tofacitinib cohorts (Table 1). Discontinuation due to AEs was similar between groups in the 16-Wk PBO-controlled cohort and between the 48-Wk tofacitinib cohorts (Table 1). One pt receiving tofacitinib 5 mg BID (included in the 16-Wk PBO-controlled and both 48-Wk tofacitinib cohorts) had a serious infection (SI; meningitis; Table 1). No SIs with PBO. Herpes zoster (HZ; all non-serious) occurred in the 48-Wk all tofacitinib 5 mg BID (5 pts [1.6%]) and 48-Wk all tofacitinib cohorts (7 pts [1.7%]; Table 1) only. Most cases involved a single dermatome, but 1 pt (tofacitinib 10 mg BID) had HZ involving 2 adjacent dermatomes. Across cohorts, there were no deaths or adjudicated opportunistic infections (OIs), OIs excluding tuberculosis (TB), TB, malignancies excluding non-melanoma skin cancer (NMSC), NMSC, major adverse CV events, thromboembolic events, gastrointestinal perforation or interstitial lung disease. Uveitis was reported in 1 (0.5%), 3 (1.6%), 4 (1.3%) and 6 (1.4%) pts in the tofacitinib 5 mg BID, PBO, 48-Wk all tofacitinib 5 mg BID and 48-Wk all tofacitinib groups, respectively; all but 1 pt (tofacitinib 2 mg BID) had history of uveitis. Psoriasis occurred in 1 (0.5%) pt (PBO) with history of psoriasis. There were no AEs of inflammatory bowel disease.

Table 1.

AEs and AEs of special interest

16-Wk PBO-controlled cohort48-Wk tofacitinib cohortsTofacitinib 5 mg BID N=185PBO N=18748-Wk all tofacitinib 5 mg BID N=31648-Wk all tofacitinib N=420AE, n (%), IR [95% CI per 100 pt-yrs]Serious AE3 (1.6) 5.28 [0.00, 11.25]2 (1.1) 3.56 [0.00, 8.49]8 (2.5) 3.49 [1.51, 6.87]9 (2.1) 3.45 [1.58, 6.55]Discontinuation due to AEs4 (2.2) 7.04 [0.14, 13.94]4 (2.1) 7.10 [0.14, 14.05]11 (3.5) 4.77 [2.38, 8.54]12 (2.9) 4.58 [2.37, 8.00]SI1 (0.5) 1.77 [0.00, 5.89]0 0.00 [0.00, 3.31]1 (0.3) 0.43 [0.01, 2.41]1 (0.2) 0.38 [0.01, 2.12]HZ0 0.00 [0.00, 3.28]0 0.00 [0.00, 3.31]5 (1.6) 2.18 [0.71, 5.08]7 (1.7) 2.68 [1.08, 5.53]All-cause mortality0 0.00 [0.00, 3.28]0 0.00 [0.00, 3.31]0 0.00 [0.00, 1.59]0 0.00 [0.00, 1.40]Malignancies excluding NMSC0 0.00 [0.00, 3.28]0 0.00 [0.00, 3.31]0 0.00 [0.00, 1.59]0 0.00 [0.00, 1.40]Major adverse CV event0 0.00 [0.00, 3.28]0 0.00 [0.00, 3.31]0 0.00 [0.00, 1.59]0 0.00 [0.00, 1.40]Venous thromboembolism0 0.00 [0.00, 3.28]0 0.00 [0.00, 3.31]0 0.00 [0.00, 1.59]0 0.00 [0.00, 1.40]

CI, confidence interval; n, number of pts with event within 28-day risk period

Conclusion

Tofacitinib 5 mg BID was well tolerated over 48 Wks in pts with AS, and safety was consistent with the established safety profile of tofacitinib.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Jennifer Arnold, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Atul Deodhar Consultant of: AbbVie, Amgen, Aurinia, Boehringer Ingelheim, Bristol-Myers Squibb, Celegene, Eli Lilly, GlaxoSmithKline, Janssen, MoonLake, Novartis, Pfizer Inc and UCB, Grant/research support from: AbbVie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer Inc and UCB, Servet Akar Speakers bureau: AbbVie, Amgen, Eli Lilly, MSD, Novartis, Pfizer Inc and UCB, Consultant of: AbbVie, Amgen, Eli Lilly, MSD, Novartis, Pfizer Inc and UCB, Grant/research support from: Pfizer Inc, Jeffrey Curtis Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, CorEvitas, LLC (formerly Corrona, LLC), Eli Lilly, Janssen, Myriad, Pfizer Inc, Radius, Roche and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, CorEvitas, LLC (formerly Corrona, LLC), Eli Lilly, Janssen, Myriad, Pfizer Inc, Radius, Roche and UCB, Bassel Zorkany Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eva, Eli Lilly, Hekma, Janssen, MSD, New Bridge, Novartis, Pfizer Inc, Roche, Sanofi-Aventis and Servier, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Eva, Eli Lilly, Hekma, Janssen, MSD, New Bridge, Novartis, Pfizer Inc, Roche, Sanofi-Aventis and Servier, Marina Magrey Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer Inc and UCB, Grant/research support from: AbbVie and UCB, Cunshan Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Joseph Wu Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Solomon B Makgoeng Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Ivana Vranic Shareholder of: Pfizer Inc, Employee of: Pfizer Ltd, Sujatha Menon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Dona Fleishaker Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Annette Diehl Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Lara Fallon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Robert B.M. Landewé Consultant of: AbbVie, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Galapagos NV, Novartis, Pfizer Inc and UCB

A Novel Mobile Platform Enhances Motivation and Satisfaction of Academic Teachers

With rising numbers of students, shorter hospital stays and increasing workload of academic teachers, teaching time have become a scarce resource. Thus, optimal preparation by teachers is key for good clinical teaching. Though a lot of teaching duties are performed by residents in Germany, they are not likely to have been educated in didactic techniques. We developed and evaluated a mobile teaching application using the “Learning Toolbox (LTB)” platform (Raycom BV, Utrecht, Netherlands) that was offered to academic teachers for preparation and support during curricular courses at our medical school. Courses were part of the curricula in Anaesthesiology, Emergency Medicine, and Orthopaedic and Trauma Surgery, and course length could vary up to 40 h per week. Information provided by the novel platform included logistic information, learning objectives, and curricula for the individual courses. A basic tutorial on didactic techniques, suggestions for providing feedback and for enhancing students’ participation was also part of the platform.

After one semester, interviews with teachers indicated an increase in overall satisfaction. Residents appreciated didactic aids and content provided for preparation, leading to higher motivation and self-confidence. The more experienced teachers were particularly satisfied with easy access to scheduling, teaching assignments and daily planning. The app increased teachers’ satisfaction with their performance and enabled better integration of teaching in the daily schedule.

AB0248 INFLUENZA ADVERSE EVENTS IN PATIENTS WITH RHEUMATOID ARTHRITIS IN THE TOFACITINIB CLINICAL PROGRAMME

Background:

Patients (pts) with rheumatoid arthritis (RA) have an increased susceptibility to seasonal influenza and its complications.1 In light of the COVID-19 pandemic, there is a need to better understand acute respiratory viral RNA infections, such as influenza, in pts with RA.

Objectives:

To present a comprehensive summary of data on influenza adverse events (AEs) occurring in the tofacitinib RA clinical programme.

Methods:

Influenza AEs were evaluated in pts with RA from 21 Phase (P)1–3b/4 trials and two open-label, long-term extension (LTE) studies from 2005–2019. These were analysed as two cohorts: P2–3b/4 cohort (pts who received tofacitinib 5 or 10 mg twice daily [BID] as monotherapy or with conventional synthetic [cs]DMARDs, adalimumab, methotrexate or placebo, in P2–3b/4 controlled studies) and Overall cohort (pts who received ≥1 tofacitinib dose, as monotherapy or with csDMARDs, in P1–3b/4 and LTE studies; data were summarised by average tofacitinib dose [average tofacitinib 5 or 10 mg BID based on average total daily dose of <15 or ≥15 mg, respectively]). Incidence rates (IRs; unique pts with events/100 pt-years of exposure; censored at day of first event or up to last dose +28 days) were evaluated for influenza AEs, influenza complication AEs, influenza-like illness (all composites of several MedDRA preferred/verbatim terms) and overall influenza AEs (composite of all preferred/verbatim terms included under influenza AEs, influenza complication AEs and influenza-like illness). In the Overall cohort, the incidence of serious non-influenza AEs within 28 days of the start of an overall influenza AE and time taken to resolution of overall influenza AEs by action taken were summarised descriptively.

Results:

In total, 7964 pts were included; 517 (6.5%) pts reported overall influenza AEs, three of which occurred outside the risk period. In the P2–3b/4 cohort (N=6690), IRs for influenza AEs, influenza-like illness and overall influenza AEs generally appeared similar across treatment arms (Figure 1a). In the Overall cohort, IRs for influenza AEs and influenza-like illness were similar between tofacitinib doses (Figure 1b), and IRs for overall influenza AEs were similar between tofacitinib doses and pt age groups (Figure 1c). No influenza complication AEs (eg pneumonia/encephalitis influenzal) were reported in either cohort. Among pts with overall influenza AEs, nine (1.7%) had serious overall influenza AEs (average tofacitinib 5 mg BID, n=6; average tofacitinib 10 mg BID, n=3). Of these pts, eight (1.5%) were hospitalised (average tofacitinib 5 mg BID, n=6; average tofacitinib 10 mg BID, n=2) and two (0.4%) died (average tofacitinib 5 mg BID, n=1; average tofacitinib 10 mg BID, n=1). Both deaths occurred in pts with H1N1 Influenza A. Twelve (2.3%) pts had a serious non-influenza AE within 28 days of the start of the overall influenza AE (average tofacitinib 5 mg BID, n=6; average tofacitinib 10 mg BID, n=6). The most common serious non-influenza AEs (one event each in average tofacitinib 5 and 10 mg BID groups) were acute respiratory distress syndrome and pneumonia. In most pts with overall influenza AEs, no change to tofacitinib treatment was made (70.2%, n=363) or treatment was stopped temporarily (28.2%, n=146) for a mean duration of 11.0 days. The mean number of days to resolution of overall influenza AEs was numerically similar, ranging from 10.4–11.8 days across tofacitinib doses, irrespective of these actions.

Conclusion:

This post hoc analysis of influenza AEs across the tofacitinib RA clinical programme, over 14–15 influenza seasons, showed generally similar rates between treatment groups, and between tofacitinib doses and pt age groups. Limitations include varying exposure across treatment arms in the P2–3b/4 cohort. Most influenza AEs were non-serious (98.3%), and were not associated with changes to tofacitinib treatment.

References:

[1]Blumentals et al. BMC Musculoskelet Disord 2012; 13: 158.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Kirsten Woollcott, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

Kevin Winthrop Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead Sciences, Pfizer Inc, Roche, UCB, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Dan Henrohn Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Hyejin Jo Consultant of: Pfizer Inc, Employee of: Syneos Health, Sara Marsal Shareholder of: IMIDomics, Consultant of: AbbVie, Celgene, Galapagos, Gilead Sciences, Pfizer Inc, Sandoz, Sanofi, Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Jansen-Cilag, MSD, Novartis, Pfizer Inc, Roche, Sandoz, Sanofi, UCB, María Galindo-Izquierdo Grant/research support from: AbbVie, Eli Lilly, GSK, Janssen-Cilag, Annette Diehl Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Andrea Shapiro Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Stanley B. Cohen Consultant of: AbbVie, Eli Lilly, Genentech, Gilead Sciences, Pfizer Inc, Grant/research support from: AbbVie, Eli Lilly, Genentech, Gilead Sciences, Pfizer Inc

POS0651 CLINICAL AND FUNCTIONAL RESPONSE TO TOFACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: PROBABILITY PLOT ANALYSIS OF RESULTS FROM A 48-WEEK PHASE 3b/4 METHOTREXATE WITHDRAWAL STUDY

Background:

The Phase 3b/4 study ORAL Shift (NCT02831855) demonstrated sustained efficacy/safety of tofacitinib modified-release 11 mg QD following MTX withdrawal, that was non-inferior to continued tofacitinib + MTX use, in patients (pts) with moderate to severe RA who achieved LDA with tofacitinib + MTX at Week (W)24.1

Objectives:

To assess differences and similarities in clinical/functional responses in pts receiving tofacitinib ± MTX in ORAL Shift.

Methods:

In ORAL Shift, pts received open-label tofacitinib + MTX to W24; at W24, pts who achieved CDAI LDA were randomised to receive tofacitinib + MTX or tofacitinib + placebo (PBO) from W24–48. In this post hoc analysis, clinical efficacy endpoints were ACR-N (minimum % change from baseline [BL; Δ] at W48 achieved by each pt in 3 efficacy measures), ΔDAS28-4(ESR), and DAS28-4(ESR) remission/LDA (scores ≤3.2) and moderate/high disease activity (scores >3.2). Functional efficacy endpoints were ΔHAQ-DI and HAQ-DI clinically relevant functional progression (CRFP) status at W48, defined as failure to achieve improvement in HAQ-DI ≥ minimum clinically important difference (MCID; ≥0.22 decrease from BL in HAQ-DI). Thus, CRFP was defined as <0.22 decrease, no change or increase from BL in HAQ-DI at W48. All efficacy endpoints were summarised descriptively. Cumulative probability plots of ACR-N and ΔHAQ-DI were produced. Median of mean CRP values from BL–W24 and >W24–48 were assessed by response subgroups.

Results:

266 pts receiving tofacitinib + MTX and 264 pts receiving tofacitinib + PBO in W24–48 were included. At W48: mean ACR-N was numerically greater with tofacitinib + MTX vs tofacitinib + PBO (60.8 vs 53.1); mean decrease in HAQ-DI was generally similar between groups (-0.71 vs -0.67); mean decrease in DAS28-4(ESR) was numerically greater with tofacitinib + MTX vs tofacitinib + PBO (-2.95 vs -2.68). The differences/similarities between groups in ACR-N and ΔHAQ-DI were also seen in cumulative probability plots (Figure 1). CRFP rates were numerically lower with tofacitinib + MTX (18.7%) vs tofacitinib + PBO (23.5%), and in pts with remission/LDA (tofacitinib + MTX, 12.1%; tofacitinib + PBO, 16.8%) vs moderate/high disease activity (tofacitinib + MTX, 26.2%; tofacitinib + PBO, 30.8%). Median of mean CRP over time was generally numerically lower in pts with CRFP vs non-CRFP and DAS28-4(ESR)-defined remission/LDA vs moderate/high disease activity; and in those receiving tofacitinib + PBO vs tofacitinib + MTX, irrespective of CRFP or DAS28-4(ESR) disease status (Table 1).

Table 1.

Median of mean CRPa up to W48 by response subgroups

Tofacitinib 11 mg QD + MTXTofacitinib 11 mg QD + PBOMean CRP,amedian (IQR) [n]>BL–W24>W24–48>BL–W24>W24–48HAQ-DI CRFP2.84 (1.15–7.30)2.30 (0.82–4.75)1.45 (0.77–4.42)2.28 (0.53–7.28)[45][46][56][56]HAQ-DI non-CRFP2.81 (1.09–6.19)2.91 (1.19–5.84)2.26 (0.98–4.63)2.47 (1.13–5.53)[195][195][176][178]DAS28-4(ESR) remission/LDA2.48 (1.05–4.95)2.46 (1.07–4.76)1.70 (0.89–4.14)1.95 (0.81–3.82)[126][127][115][117]DAS28-4(ESR) moderate/high disease activity3.56 (1.17–7.13)3.58 (1.36–8.33)2.60 (0.87–5.16)2.68 (1.34–8.23)[107][107][115][115]

aMean CRP was calculated as the average CRP value during each time period (>BL–W24 or >W24–48)

CRP, C-reactive protein; DAS28-4(ESR), Disease Activity Score in 28 joints, erythrocyte sedimentation rate; HAQ-DI, Health Assessment Questionnaire-Disability Index; IQR, interquartile range; LDA, low disease activity; MTX, methotrexate; n, number of pts meeting assessment criteria; QD, once daily

Conclusion:

Although clinical/functional responses were generally similar between treatment groups, numerical improvements were seen for some efficacy endpoints with tofacitinib + MTX vs tofacitinib + PBO. A numerically higher CRFP rate may be associated with higher DAS28-4(ESR) disease activity. CRP changes up to W48 may not trend with CRFP status.

References:

[1]Cohen et al. Lancet Rheumatol 2019; 1: E23-34.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Anthony G McCluskey, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

Stanley B. Cohen Consultant of: AbbVie, Eli Lilly, Genentech, Gilead Sciences, Pfizer Inc, Grant/research support from: AbbVie, Eli Lilly, Genentech, Gilead Sciences, Pfizer Inc, Yi-Hsing Chen Grant/research support from: Bristol-Myers Squibb, GlaxoSmithKline, Pfizer Inc, Naonobu Sugiyama Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose Luis Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Annette Diehl Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Tatjana Lukic Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jerome Paulissen Consultant of: Pfizer Inc, Haiyun Fan Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Tomohiro Hirose Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Edward Keystone Speakers bureau: AbbVie, Amgen, F. Hoffman-La Roche, Janssen, Merck, Novartis, Pfizer Inc, Sanofi Genzyme, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celltrion, Eli Lilly, F. Hoffman-La Roche, Gilead Sciences, Janssen, Merck, Myriad Autoimmune, Pfizer Inc, Sandoz, Sanofi Genzyme, Samsung Bioepsis, Grant/research support from: Amgen, Merck, Pfizer Inc, PuraPharm

POS0650 PREDICTORS OF DURABLE CLINICAL RESPONSE TO TOFACITINIB 11 MG ONCE DAILY WITH OR WITHOUT METHOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS: POST HOC ANALYSIS OF DATA FROM A PHASE 3b/4 METHOTREXATE WITHDRAWAL STUDY

Background:

ORAL Shift, a global Phase 3b/4 non-inferiority study, demonstrated sustained efficacy and safety of tofacitinib modified-release (MR) 11 mg once daily (QD) following methotrexate (MTX) withdrawal in patients with rheumatoid arthritis (RA) who achieved Clinical Disease Activity Index (CDAI) low disease activity (LDA) after treatment with tofacitinib + MTX.1

Objectives:

To assess predictors of durable clinical response in patients receiving tofacitinib MR 11 mg QD in ORAL Shift.

Methods:

ORAL Shift (NCT02831855) enrolled patients aged ≥18 years with moderate to severe RA and an inadequate response to MTX. Patients received open-label tofacitinib MR 11 mg QD + MTX for 24 weeks. Patients achieving LDA (CDAI score ≤10) at Week (W)24 entered the 24-week double-blind MTX withdrawal phase and were randomised 1:1 to receive tofacitinib MR 11 mg QD + placebo (tofacitinib monotherapy; ie blinded MTX withdrawal) or continue tofacitinib + MTX. In this post hoc analysis of randomised patients, we assessed predictors of durable response (maintenance of response from W24–48) per CDAI LDA and remission (CDAI score ≤2.8) criteria. All covariates were initially assessed for significance in a univariate logistic regression. Highly correlated covariates were reviewed to assess which would be removed prior to modelling in a multivariable logistic regression. Remaining significant (p≤0.10) covariates in the univariate regression were selected in the model using a stepwise selection process with p≤0.15 entry and p≤0.05 stay criteria. From the final model, estimated odds ratios (ORs) with 95% confidence intervals (CIs) are presented.

Results:

In the double-blind phase of ORAL Shift, durable CDAI LDA and remission rates were: 66.2% and 14.7%, respectively, with tofacitinib + MTX (N=266); and 55.3% and 11.0%, respectively, with tofacitinib + placebo (N=264) (Table 1). In the multivariable analysis, five patient covariates significantly predicted durable CDAI LDA (Figure 1; discussed hereafter). Each unit increase in CDAI score at W24 reduced the likelihood of maintaining CDAI LDA by 22.0%. Each unit increase in C-reactive protein (CRP) at W24 increased the likelihood of maintaining CDAI LDA by 4.0%; this may have been due to imbalanced CRP levels at W24 (randomisation) between treatment groups (Figure 1, footnote c). The odds of durable CDAI LDA were 53.0% lower in the US vs Europe and 61.0% lower in the US vs ‘other’ regions. Each unit increase in baseline Health Assessment Questionnaire-Disability Index (HAQ-DI) score reduced the odds of durable CDAI LDA by 34.0%. Patients receiving tofacitinib + MTX had 66.0% greater odds of durable CDAI LDA vs patients receiving tofacitinib + placebo. CDAI at W24 was the only significant predictor of durable CDAI remission in the multivariable analysis: OR (95% CI) 0.32 (0.24, 0.43); p<0.0001. Each unit increase in CDAI score at W24 reduced the odds of durable CDAI remission by 68.0%.

Table 1.

Durable CDAI LDA and remissiona in patients receiving tofacitinib MR 11 mg QD with MTX or placebo in the double-blind phase of ORAL Shift

Tofacitinib + MTX(N=266)Tofacitinib + placebo(N=264)Durable CDAI LDA, n (%)176 (66.2)146 (55.3)Durable CDAI remission, n (%)39 (14.7)29 (11.0)

aDurable CDAI LDA or remission was defined as achievement of LDA (CDAI score ≤10) or remission (CDAI score ≤2.8), respectively, at W24–48

N, number of patients in each group; n, number of patients achieving outcome

Conclusion:

This post hoc analysis of data from ORAL Shift found that CDAI and CRP at W24, geographic region, baseline HAQ-DI and treatment could be predictors for durable CDAI LDA. As these findings were limited to patients who achieved CDAI LDA at W24 with tofacitinib MR 11 mg QD + MTX, additional data in the general patient population need to be investigated.

References:

[1]Cohen et al. Lancet Rheumatol 2019; 1: E23-34.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Sarah Piggott, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

Kunihiro Yamaoka Speakers bureau: Actelion, Astellas, Chugai, Eisai, Eli Lilly, GlaxoSmithKline, Janssen, Mitsubishi Tanabe, Nippon Shinyaku, Pfizer Inc, Takeda, Consultant of: Actelion, Astellas, Chugai, Eisai, Eli Lilly, GlaxoSmithKline, Janssen, Mitsubishi Tanabe, Nippon Shinyaku, Pfizer Inc, Takeda, Stanley B. Cohen Consultant of: AbbVie, Eli Lilly, Genentech, Gilead Sciences, Pfizer Inc, Grant/research support from: AbbVie, Eli Lilly, Genentech, Gilead Sciences, Pfizer Inc, Naonobu Sugiyama Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Harry Shi Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose Luis Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Annette Diehl Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Josef S. Smolen Consultant of: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead Sciences, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Roche, Samsung, Sanofi, Grant/research support from: AbbVie and AstraZeneca

POS0086 ANALYSIS OF DISEASE ACTIVITY MEASURES IN THE CONTEXT OF A METHOTREXATE WITHDRAWAL STUDY AMONG PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH TOFACITINIB 11 MG ONCE DAILY + METHOTREXATE: POST HOC ANALYSIS OF DATA FROM ORAL SHIFT

Background:

The Phase 3b/4 study ORAL Shift demonstrated sustained efficacy and safety of tofacitinib modified-release (MR) 11 mg once daily (QD) following methotrexate (MTX) withdrawal that was non-inferior to continued tofacitinib + MTX use (per DAS28-4[ESR]), in patients (pts) with rheumatoid arthritis (RA) who achieved CDAI-defined low disease activity (LDA) with tofacitinib + MTX at Week (W)24.1

Objectives:

To assess the performance of alternative disease activity measures at W24 (randomisation) and W48 (study endpoint) in ORAL Shift.

Methods:

ORAL Shift (NCT02831855) enrolled pts aged ≥18 years with moderate to severe RA and an inadequate response to MTX. Pts received open-label tofacitinib MR 11 mg QD + MTX for 24 weeks. Achievement of CDAI LDA (≤10) at W24 was set as the criteria for entry to the 24-week double-blind MTX withdrawal phase, with pts randomised 1:1 to receive tofacitinib MR 11 mg QD + placebo (PBO) (ie blinded MTX withdrawal) or continue tofacitinib + MTX. In this post hoc analysis, efficacy analyses were performed in 8 subgroups defined by achievement of various disease activity criteria at W24: DAS28-4(ESR) remission (<2.6) or LDA (≤3.2); DAS28-4(CRP) <2.6 or ≤3.2; RAPID3 remission (≤3) or LDA (≤6); CDAI remission (≤2.8); and SDAI remission (≤3.3). For each subgroup, the proportion of pts who achieved the corresponding disease activity criterion at W48 was calculated, with a 95% confidence interval (CI) estimated using the normal approximation to the binomial distribution. The change (Δ) from W24 to W48 in least squares (LS) mean DAS28-4(ESR) and DAS28-4(CRP) was also calculated in each subgroup, with a 95% CI for the difference between treatment groups estimated using a mixed model with repeated measures. Nominal p values were calculated and are presented with no formal statistical hypothesis testing formulated.

Results:

Overall, 694 pts entered the open-label phase of ORAL Shift, and 530 were randomised and received treatment in the double-blind phase; 264 and 266 pts received tofacitinib + PBO and tofacitinib + MTX, respectively (Figure 1a). Considering those pts who were randomised and treated, the proportion of pts achieving each disease activity criterion at W24 varied, but was similar between treatments within each subgroup (Figure 1a). Among pts who met each disease activity criterion at W24, generally the majority of pts in both treatment groups also met the same criterion at W48 (Figure 1b). Numerically more pts receiving tofacitinib + MTX vs tofacitinib + PBO continued to meet the corresponding criterion at W48. Regardless of the disease activity criterion met at W24, differences between treatment groups in LS mean ΔDAS28-4(ESR) (Figure 1c) and ΔDAS28-4(CRP) (data not shown) from W24 to W48 favoured tofacitinib + MTX vs tofacitinib + PBO.

Conclusion:

This post hoc analysis of data from pts randomised and treated in ORAL Shift demonstrated that, regardless of the disease activity state criterion met at W24, generally a majority of pts receiving tofacitinib maintained achievement of the corresponding disease activity criterion at W48, with or without continued MTX. Differences between treatment groups in LS mean ΔDAS28-4(ESR) from W24 to W48, as defined by achievement of LDA or remission with a variety of disease activity measures, were less than a change of 1.2, which is considered to be the threshold for a minimal clinically important improvement.2

References:

[1]Cohen et al. Lancet Rheumatol 2019; 1: E23-34.

[2]Ward et al. Ann Rheum Dis 2015; 74: 1691-1696.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Gemma Turner, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

Roy Fleischmann Speakers bureau: Pfizer Inc, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celltrion, Eli Lilly, GlaxoSmithKline, Janssen, Novartis, Pfizer Inc, Sanofi-Aventis, UCB, Grant/research support from: AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Celltrion, Eli Lilly, Genentech, GlaxoSmithKline, Janssen, Novartis, Pfizer Inc, Samumed, Sanofi-Aventis, UCB, VORSO, Boulos Haraoui Speakers bureau: Amgen, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Eli Lilly, Merck, Pfizer Inc, UCB, Grant/research support from: AbbVie, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead, MSD, Pfizer Inc, Roche, Sanofi, Grant/research support from: Pfizer Inc, Roche, UCB, David Gold Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Gosford Sawyerr Consultant of: Pfizer Inc, Employee of: Syneos Health Inc, Harry Shi Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Annette Diehl Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Kristen Lee Shareholder of: Pfizer Inc, Employee of: Pfizer Inc.

Effect of bypass kinase pathways on acquired CDK4/6 inhibitor resistance

379

Background: Cyclin Dependent Kinase-4/6 (CDK4/6) kinase inhibitors have shown clinical benefit in treatment of solid tumor types, including breast cancer. However, resistance is common, and the underpinning mechanisms of action are not well understood. Given the dependence of CDK4/6 inhibitors on retinoblastoma tumor suppressor (RB) function for activity, this class of agents may be particularly effective in tumor types for which RB loss is infrequent or occurs late in tumor progression. Methods: Here, models of acquired palbociclib resistance were generated in early stage, RB positive cancers, wherein it was shown acquired palbociclib resistance resulted in cross-resistance to other CDK4/6 inhibitors under clinical testing. Results: Cells showing acquired resistance exhibited aggressive in vitro and in vivo phenotypes without genetic loss of RB or RB pathway members, including enhanced proliferative capacity, migratory potential, and characteristics of epithelial to mesenchymal transition. Further analyses through integration of RNA sequencing and phospho-proteomics identified activation of the MAPK signaling pathway as a mediator of CDK4/6 inhibitor resistance, capable of bypassing CDK4/6 activity. However, this altered kinase dependence resulted in sensitization to MEK inhibitors, suggestive of new clinical opportunities in CDK4/6 resistant tumors. Conclusions: In sum, the studies herein not only identify activation of the MAPK pathway as capable of bypassing the CDK4/6 requirement and promoting aggressive tumor characteristics, but nominate MEK inhibitors as potential mechanisms to treat or prevent CDK4/6 inhibitor resistance.

Preventing involuntary admissions: special needs for distinct patient groups

BACKGROUND

Coercive measures in psychiatry are a controversial topic and raise ethical, legal and clinical issues. Involuntary admission of patients is a long-lasting problem and indicates a problematic pathway to care situations within the community, largely because personal freedom is fundamentally covered by the UN declaration of human rights and the German constitution.

METHODS

In this study, a survey on a large and comprehensive population of psychiatric in-patients in the eastern part of North Rhine-Westphalia, Germany, was carried out for the years 2004-2009, including 230.678 treatment cases. The data were collected from the dataset transferred to health insurance automatically, which, since 2004 is available in an electronic form. In addition, a wide variety of information on treatment, sociodemographic and illness-related factors were collected and analysed. Data were collected retrospectively and analyses were calculated using statistical software (IBM SPSS Statistics 19.0^®). Quantitative data are presented as mean and standard deviation. Due to the unequal group sizes, group differences were calculated by means of Chi-square tests or independent sample t tests. A Bonferroni correction was applied to control for multiple comparisons.

RESULTS

We found an over-representation of involuntary admissions in young men (<21 years) suffering from schizophrenia and in female patients aged over 60 with a diagnosis of dementia. Most of our results are concordant with the previous literature. Also admission in hours out of regular out-patient services elevated the risk.

CONCLUSION

The main conclusion from these findings is a need for a fortification of ambulatory treatment offers, e.g. sociopsychiatric services or ward round at home for early diagnosis and intervention. Further prospective studyies are needed.

Abstract 1254: Mitochondrial SOD2 regulates EMT and cancer stem cell-like cell populations

Epithelial-mesenchymal transition (EMT) is involved in cancer cell invasion, metastasis and treatment failure. EMT may promote conversion of a subset of cancer cells defined by low expression of CD44 (CD44L) to those with high expression of CD44 (CD44H), the latter associated with increased malignant properties of cancer cells. Triggered by a variety of stimuli such as transforming growth factor (TGF)-β, hypoxia and chemoradiation, EMT may be activated in cancer cells via stress-induced reactive oxygen species (ROS) in the tumor microenvironment. Excessive ROS may cause cell death or senescence; however, cells undergoing EMT may require a physiological level of ROS. It remains elusive as to how cellular antioxidant capabilities may influence EMT. Mitochondrial superoxide dismutase 2 (SOD2) is frequently overexpressed in oral and esophageal cancers. Here, we investigated mechanisms of SOD2 transcriptional regulation in EMT as well as the functional role of this antioxidant in EMT. Using well-characterized genetically engineered oral and esophageal human epithelial cell lines coupled with RNA interference (RNAi) and flow cytometric approaches, we find that TGF-β stimulates EMT, resulting in conversion of CD44L to CD44H cells, the latter of which display SOD2 upregulation. SOD2 induction in transformed cells was concurrent with suppression of TGF-β-mediated induction of both ROS and senescence. SOD2 gene expression appeared to be transcriptionally regulated by NF-κB and ZEB2, but not ZEB1. Moreover, SOD2-mediated antioxidant activity may restrict conversion of CD44L cells to CD44H cells at the early stages of EMT. In aggregate, this study provides novel mechanistic insights into the dynamic expression of SOD2 during EMT and delineates a functional role for SOD2 in EMT, influencing distinct CD44L and CD44H subsets of cancer cells that have been implicated in oral and esophageal tumor biology.

Note: This abstract was not presented at the meeting.

Citation Format: Kelly A. Whelan, Hideaki Kinugasa, Koji Tanaka, Satish Srinivasan, Manti Guha, Daret St. Clair, Andres Klein-Szanto, Narayan Avadhani, Alan Diehl, Anil Rustgi, Hiroshi Nakagawa. Mitochondrial SOD2 regulates EMT and cancer stem cell-like cell populations. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1254. doi:10.1158/1538-7445.AM2015-1254

[Epidemiological study on the dimension of vitamin D deficiency in North Germany]

BACKGROUND AND PURPOSE

In North Germany, the recommended exposure to sunlight of 30 minutes per day to produce sufficient vitamin D is hardly achieved, in particular due to weather conditions. Moreover, lifestyle and working habits also contribute to this problem. The aim of our study was therefore to investigate the prevalence of the vitamin D deficiency in North Germany.

METHODS

For this purpose, 25-hydroxy vitamin D levels of over 98,000 people from North Germany during the time period 2008-2011 were retrospectively analysed based on age, gender and season. 25-vitamin D status was divided into sufficient (> 75 nmol/l) and insufficient (50 to 75 nmol/l) supply as well as vitamin D deficiency (< 50 to 25 nmol/l) and severe vitamin D deficiency (< 25 nmol/l).

RESULTS

An undersupply of vitamin D was evident in all age groups analysed both in women and men in North Germany. Overall, vitamin D deficiency was particularly present during the months with less sunlight: more than 30 % of the people analysed showed a severe vitamin D deficiency in the months January to April. The study also showed that 25-vitamin D tests were almost evenly distributed over the individual months of the whole year and that this analysis was requested more frequently in elderly than in younger people. However, a severe vitamin D deficiency could also be detected in 25 % of the people analysed in the adolescent and young adult age group.

CONCLUSION

Based on these results, it can be recommended to test 25-vitamin D levels once a year during the months January to April to detect a severe deficiency and to early initiate preventive supplementation.

Ion fluxes through nanopores and transmembrane channels

We introduce an implicit solvent Molecular Dynamics approach for calculating ionic fluxes through narrow nanopores and transmembrane channels. The method relies on a dual-control-volume grand-canonical molecular dynamics (DCV-GCMD) simulation and the analytical solution for the electrostatic potential inside a cylindrical nanopore recently obtained by Levin [Europhys. Lett. 76, 163 (2006)]. The theory is used to calculate the ionic fluxes through an artificial transmembrane channel which mimics the antibacterial gramicidin A channel. Both current-voltage and current-concentration relations are calculated under various experimental conditions. We show that our results are comparable to the characteristics associated to the gramicidin A pore, especially the existence of two binding sites inside the pore and the observed saturation in the current-concentration profiles.

Photoelectric stimulation of defined ear points (Smokex-Pro method) as an aid for smoking cessation: a prospective observational 2-year study with 156 smokers in a primary care setting

BACKGROUND

Smokex-Pro is a smoking cessation method using a protocol of a standardized consultation and computer-assisted photoelectric stimulation of defined regions in the ear and face.

METHODS

We prospectively enrolled 156 consecutive adult smokers (81 males, 75 females; mean age 43.8 years; body mass index 25.5; daily cigarettes 24.7; Fagerström Test for Nicotine Dependence 5; 30 smoking years). The primary end point was the self-reported continuous abstinence rate.

RESULTS

Participants completed on average only 32% of recommended visits. A total of 76.7% stopped smoking for more than 7 days. Moreover, 53.4% remained free of smoking for more than 90 days. Long-term abstinence rates were 49.3% (1 year) and 47.95% (2 years). Treatment-related side effects were observed in 24.5% of participants. Side effects were mild and resolved within hours.

CONCLUSION

The Smokex-Pro method appears to be an effective aid for smoking cessation. The treatment was well tolerated and showed only mild and temporary side effects. The average cost of treatment is typically less than EUR 90; the total treatment time is typically 60-90 min. These factors make it an attractive alternative compared to traditional smoking cessation methods. Controlled clinical trials will be needed to confirm the results of this study and refine the treatment for maximum efficacy.

Cyclin D1b in human breast carcinoma and coexpression with cyclin D1a is associated with poor outcome

BACKGROUND/AIM

Cyclin D1 is a mediator of cell-cycle control that is frequently overexpressed in primary ductal breast carcinomas, but its role is controversial. A polymorphism in the CCND1 gene, G870A, results in an aberrantly spliced protein (cyclin D1b) lacking the Thr-286 phosphorylation site necessary for nuclear export. Studies of murine fibroblasts have shown that although overexpression of canonical cyclin D1 (cyclin D1a) alone is not sufficient to drive malignant transformation, expression of nuclear cyclin D1b is oncogenic. Our objectives were to determine whether cyclin D1b is expressed in human breast carcinomas and to characterize the relationship of this protein to both cyclin D1a and clinical outcome in breast cancer patients.

PATIENTS AND METHODS

We performed a prospective cohort study of women with early-stage breast cancer and analyzed cyclin D1a and D1b expression in primary breast tumor sections. Expression was tested for correlation with other breast cancer prognostic factors and clinical outcome, including recurrence or death.

RESULTS

A total of 118 patients were included in this analysis, with a median follow-up of 44 months. Cyclin D1b was expressed in 26% of tumors and cyclin D1a was overexpressed in 27%; co-expression occurred in 4%. Cyclin D1a and/or D1b expression were not significantly associated with estrogen or progesterone receptor negativity, Her2 overexpression, young age, lymph node positivity, high tumor grade, nor large tumor size. The risk of recurrence was higher in those co-expressing D1a and D1b compared to the expression of either alone (relative risk=5.3, 95% confidence interval 1.27 to 22.1, p=0.02). The hazard ratio for those with co-expression compared with those without was 6.05 (p=0.04).

CONCLUSION

Expression of cyclin D1b occurs in primary human breast carcinomas and its coexpression with cyclin D1a may be a marker for increased recurrence risk, independently of other factors.

[Anterior shoulder instability--the current situation]

AIM

The aim of the study was to survey the current state of the conservative and operative treatment of anterior shoulder instability and its rehabilitation in German hospitals.

METHODS

A previously evaluated online questionnaire was sent out to all German hospitals with orthopaedic or trauma surgery departments. The Federal Statistical Office's hospital list was the basis for the selection of hospitals. The questions referred to the year 2007. The survey, including 3 reminders, was conducted over 3 months. The questionnaire consisted of 6 response categories: always (100%), almost always (99-81%), predominantly (80-51%), rarely (50-21%), almost never (20-1%) and never (0%).

RESULTS

The response rate was 41% and 67% of these had carried out shoulder stabilisations. In total, 99.2% of the 67% were evaluable. The proportion of shoulder surgery was 8.4% of the total number of operations. Shoulder stabilisations represented 10.6% of these operations. A specialised shoulder department existed in 22.9%. Conservative treatment was carried out with an immobilisation of the arm "predominantly", "almost always" and "always" for internal rotation in 70.8% and in 23.4% for external rotation. The shoulders were "predominantly", "almost always" and "always" stabilised in an arthroscopic technique in 68.2% and in an open one in 31.8% of the clinics. With 92.9%, the Bankart repair was the most common operation. Shoulder instability was principally treated with the arthroscopic technique, regardless of the care level and department and is considered the best surgical technique. Physiotherapy was prescribed "always" and "almost always" in 99.3%. The rate of reluxation after conservative treatment was estimated at 35.5%, after operative open anterior shoulder stabilisation at 9.1% and after arthroscopic shoulder stabilization at 10.6%. Nevertheless, 49.4% of respondents expected the best results after arthroscopic treatment. Participants, who mainly applied the arthroscopic technique, expected a lower rate of reluxation in comparison to other techniques (p<0.001).

CONCLUSION

The operative shoulder stabilisation is most frequently carried out as arthroscopic Bankart repair. A standardised, subsequent treatment is well established.

Rivastigmine reduces tobacco craving in alcohol-dependent smokers

INTRODUCTION

Although alcohol-dependent smokers represent an important group for applying smoking interventions, a sufficient pharmacotherapy has not been established in this high-risk group so far.

METHODS

In order to examine the effect of the acetylcholinesterase inhibitor rivastigmine on tobacco dependence, we performed a 12-week, randomized, placebo-controlled trial. 26 alcohol-dependent smokers were randomized to rivastigmine 6 mg/day (n=14) or placebo (n=12). Assessments on addictive behavior included carbon monoxide (CO), severity of tobacco dependence (FTND), daily smoked cigarettes (diaries), and craving for tobacco (QSU) and alcohol (AUQ).

RESULTS

ANOVA revealed a significant treatment-by-time interaction for tobacco consumption and tobacco craving (each p<0.0001). The rivastigmine group showed a decrease in daily smoked cigarettes (-30%), in exhaled carbon monoxide (-32%) and in tobacco craving (-18%) whereas controls did not show significant changes. ANCOVA revealed rivastigmine effects to be more prominent in smokers suffering from more severe tobacco dependence. None of the patients developed an alcohol relapse or an increase in alcohol craving.

DISCUSSION

Our preliminary data indicate an effect of rivastigmine on tobacco craving and consumption. This pilot study encourages further investigation of acetylcholinesterase-inhibitors as a promising treatment approach regarding tobacco dependence.

Is Varenicline Able to Prevent Smoking Cessation Induced Affective Symptoms?

The selective alpha4-beta2 nicotinic acetylcholine receptor (nAChR) partial agonist varenicline has been shown to be effective in the treatment of tobacco dependence by counteracting withdrawal symptoms and reducing smoking reward. However, the need to test safety, especially in smokers with varying co-morbidities and risk patterns is highlighted. There are some publications reporting exacerbation of psychiatric symptoms in subjects with pre-existing psychiatric disorders associated with varenicline treatment.

This case-report describes a patient whose several smoking cessation attempts led to enduring nicotine-related symptoms such as depression and suicidal tendencies. All further cessation attempts under medical control with nicotine patches, bupropion and psychotherapy failed. At lest reducing her daily dose by one cigarette already led to suicidal thoughts. We took her into inpatient treatment and started an uptitration with varenicline. Unlike earlier attempts there were no complications during the detoxication and depressive symptoms improved clearly.

Affective symptoms like depression are known to develop during nicotine cessation. The improving of affective symptoms in this case might be a result of the partial agonistic effects of varenicline.

Effect of monovalent salt on the conformation of polyelectrolyte-surfactant complexes

We study the conformation of polyelectrolyte-surfactant complexes in the presence of monovalent salt. A simple model for the formation of these structures is presented in the framework of the Debye-Hückel-Bjerrum-Manning and Flory theories, with the hydrophobic interactions between the hydrocarbon tails of surfactant molecules treated in the spirit of van der Waals theory as an effective attraction. The extension of the polyelectrolyte-surfactant complexes is analyzed as a function of the salt concentration and a discrete conformational transition between a compact globule and an elongated coil is found, in agreement with experimental results for the unfolding transition of a DNA-cationic surfactant complex.

Does the Degree of Smoking Effect the Severity of Tardive Dyskinesia?

Background:

Tardive dyskinesia (TD) is a movement disorder observed in a chronic neuroleptic treatment. Smoking is presumed to increase the prevalence of TD. the question of a cause-effect-relationship between smoking and TD, however, remains to be answered. Purpose of this study was to examine the correlation between the degree of smoking and the severity of TD with respect to differences caused by medication.

Methods:

We examined 60 patients suffering from schizophrenia and TD. We compared a clozapine-treated group with a group treated with typical neuroleptics. Movement disorders were assessed using the Abnormal-Involuntary-Movement-Scale and the technical device Digital-Image-Processing providing rater independent information on perioral movements.

Results:

We found a strong correlation (.80< r< .90, always p< .0001) between degree of smoking and severity of TD. Repeated measurements revealed a positive correlation between changes in cigarette consumption and changes of the severity of TD (p< .0001). Analyses of covariance indicated a significant group-effect with a lower severity of TD in the clozapine-group compared to the typical-neuroleptics-group (p=.010). Interaction-analyses indicated a higher impact of smoking on the severity of TD in the typical-neuroleptics-group compared to the clozapine-group (p=.033) (Diehl et al., 2008).

Conclusion:

Concerning a possible cause-effect-relationship between smoking and TD, smoking is more of a general health-hazard than neuroleptic exposure in terms of TD.

[Smoking reduction during inpatient alcohol detoxification: a controlled clinical pilot trial]

Health care professionals tend to advise alcohol dependent patients to quit tobacco consumption only after longer periods of alcohol abstinence. This recommendation reflects concerns that smoking intervention programs may adversely interfere with the outcome of ongoing alcohol detoxification and rehabilitation treatment. However, the issue of appropriate time windows for initiating changes of smoking behaviour in alcoholic patients is still in need of empirical evaluation. Thus the aim of the present study is to investigate whether alcohol dependent smokers may be able to reduce cigarette consumption very early during alcohol detoxification and rehabilitation treatment. We performed a non-randomized controlled clinical pilot trial with 56 female and male alcohol dependent smokers in an inpatient setting providing a 3-weeks alcohol detoxification program. 28 individuals received a smoking reduction program consisting of a 6-sessions approach in a group format following behavioural principles. For the control group of 28 individuals the program was not available. Tobacco consumption was assessed daily by staff members. Alcohol dependent patients participating in the smoking reduction program reduced their daily cigarette consumption rates significantly, whereas the control group showed a tendency to increase tobacco consumption. According to the tentative findings of this pilot study early smoking interventions already during alcohol detoxification appear to be a feasible approach.

[Pharmacology of disulfiram - an update]

Recently, we have been observing an increase in prescription of Disulfiram requiring medical knowledge concerning the overall effects, side effects and drug interactions of this substance. In the following report, we give an overview about the pharmacology and the side effects of Disulfiram. As an example we demonstrate a case, in which an acute neurological deficit was misjudged as a side effect of Disulfiram. Furthermore, the potential of Disulfiram as a promising treatment in addiction medicine will be discussed.

Nikotinabhängigkeit als komorbide Störung bei Alkoholabhängigkeit - Epidemiologie, Ätiologie und Therapie

There is a high association between alcohol and nicotine dependence. Compared to one particular dependence, associated nicotine and alcohol dependence are more severe and the course is more unfavourable for each dependence. This also applies to the sequels of dependence regarding physical health and cognitive functions. Possible biological causes for this high comorbidity are 1) an additive rewarding effect by combined consumption, 2) substance interaction with an impact on receptor activation and metabolism which results in reduction of adverse acute alcohol effects, and 3) a combined genetic disposition for both addictions. From a psychological point of view the association of both acts of use is learned. There is no evidence for the commonly presumed fundamental lack of interest, motivation, and ability for smoking cessation in alcohol dependent patients. The outcome of smoking cessation programs, however, is less successful compared to smokers without alcohol problems. Respective studies have used the common therapeutic strategies for nicotine addiction. Specifically adapted strategies for patients with a dual dependence are required.

Improved hematopoietic stem cell engraftment following ex vivo expansion of murine marrow cells with SCF and Flt3L

BACKGROUND

In vitro incubation of murine BM cells with IL-3, IL-6, IL-11 and SCF induces expansion of HPC but fails to preserve 'engraftability' in comparison with normal untreated marrow cells. We studied how culturing marrow cells for 48 and 72 h with a combination of the cytokines SCF and Flt3L influences cell expansion and engraftability.

METHODS

Competitive repopulation of lethally irradiated C57BL/6 mice was used to examine engraftability of ex vivo cytokine-expanded Ptprc chimeric BM. A methylcellulose in vitro assay was used to determine the expansion of substitute progenitors.

RESULTS

Both cytokine combinations successfully expanded progenitor populations when assayed in methylcellulose culture in vitro. After 72 h, the colony numbers of the expansion cultures increased 61% with IL-3, IL-6, IL-11 and SCF stimulation and 96% with SCF and Flt3L stimulation. Engraftment of competitively transplanted cells, cultured with IL-3, IL-6, IL-11 and SCF, consistently dropped to levels below 16%. However, 48 h culture with SCF and Flt3L resulted in 53.5+/-1.6% engraftment at 17 days and 64+/-3.7% engraftment at 19 weeks post-transplantation. Extending the cytokine exposure to 72 h resulted in 70+/-4.4% short-term engraftment at 17 days, and 64+/-2.4% engraftment at 19 weeks post-transplantation.

DISCUSSION

The data demonstrate the ability of SCF and Flt3L cytokine-stimulated BM cells to maintain short- and long-term engraftability. We conclude that these cytokines play a crucial role in maintaining engraftment of hematopoietic progenitors.

Flexible polyelectrolyte conformation in the presence of oppositely charged surfactants

Conformational behavior of flexible polyelectrolytes in the presence of monovalent cationic surfactants is examined. A simple model is presented for the formation of polyelectrolyte-surfactant complexes in salt-free solutions in the framework of the Debye-Hückel-Bjerrum-Manning and Flory theories, including explicitly the hydrophobic interactions between the associated surfactant molecules on the polyelectrolyte. The distribution of complexes is calculated as a function of the surfactant concentration and a discrete conformational transition between an elongated coil and a compact globule was found, in agreement with experimental observations.

Galantamine reduces smoking in alcohol-dependent patients: a randomized, placebo-controlled trial

INTRODUCTION

The high morbidity and mortality caused by smoking highlights the importance of investigating new strategies for smoking cessation or reduction. Galantamine is an acetylcholinesterase inhibitor that increases the effect of acetylcholine (ACh). The nicotinic ACh receptor is activated via positive allosteric modulation (APL).

METHODS

We investigated whether galantamine reduces smoking by performing a 24-week randomized, placebo-controlled, multicentric clinical trial in recently detoxified alcohol-dependent patients. We included all study subjects irrespective of an intention or motivation to abstain from nicotine. Specific treatment for cessation or reduction of smoking was not provided. Smoking behavior was assessed by means of patients' diaries. The nicotine metabolite cotinine was measured to verify the number of smoked cigarettes as documented in the patient's diary.

RESULTS

114 randomized smokers received galantamine (n = 56) or placebo (n = 58) for 12 weeks. Follow-up examinations were terminated after an additional 12 weeks without treatment. Smoking behavior did not differ between both groups at baseline. After treatment, the intention-to-treat analysis revealed significant differences with a 20% lower cumulative number of smoked cigarettes and a 15% lower number of smoking days in the galantamine group compared to placebo. The average number of smoked cigarettes per smoking day as well as the cotinine values decreased about 10%. Cotinine values showed a positive correlation with the number of documented cigarettes, validating the patients' diaries.

CONCLUSION

Our tentative data indicate that galantamine reduces smoking behavior even without any additional specific intervention. We suggest introducing the term "substitution therapy" into the treatment of smoking. This result could open up a new treatment approach for groups of patients which usually have a low motivation for change.

Beschaffung psychotroper Substanzen über das Internet

Several national institutions are registering a significant increase in sales of prescription and illegal drugs from internet pharmacies. Psychoactive drugs are preferred; the clients are particularly young. Considering the current amount of data available, the extent and relevance to addiction medicine remain unclear. In the following report we present the case of a patient from our outpatient department who has suffered from an opioid dependency for several years and has been using a Spanish internet pharmacy to purchase tramadol without prescription.

Quetiapine in relapse prevention in alcoholics suffering from craving and affective symptoms: a case series

PURPOSE

Quetiapine is a novel antipsychotic, which is efficacious in the treatment of positive and negative symptoms in schizophrenia. Research has shown that atypical antipsychotic also reduce the craving and consumption for stimulants and alcohol. Due to Quetiapine's particulars and the promising receptor profile concerning addiction medicine, we set out to examine the tolerability and efficacy concerning relapse prevention of withdrawn alcoholics suffering from craving and affective symptoms.

SUBJECTS AND METHODS

Our case observations attempted to evaluate nine alcoholics after withdrawal suffering from persisting craving, sleep disorder, excitement, depressive symptoms or anxiety symptoms. The patients were treated with quetiapine as relapse prevention and we followed them up in our outpatient clinic.

RESULTS

Eight out of nine patients were abstinent under quetiapine over a period of 2-7 months. One of these patients relapsed after he stopped taking the preparation at his own initiative after 10 weeks. The ninth patient stopped taking the preparation immediately because of swollen nasal mucosae. All target symptoms disappeared in the patients after an average of (mean+/-S.D.) 24.5+/-18.1 days. The overall tolerability was considered to be very good; however, initial sleepiness appeared in four patients.

CONCLUSION

Although uncontrolled case observations can only be interpreted with caution quetiapine seems to deserve further investigation and may hold the potential for preventing alcohol relapse in alcoholics suffering from additional above-mentioned symptoms.

[Carbamazepine intoxication. Complication of alcohol detoxification with combined carbamazepine and tiapride]

The advantages of alcohol detoxification treatment with combined carbamazepine and tiapride compared to benzodiazepines or clomethiazole is a lower level of sedation and lack of addictive potential. We report a case of carbamazepine intoxication with serum levels up to 19 mg/l in an otherwise healthy 45-year-old alcohol-dependent male after treatment with 600 mg carbamazepine and 600 mg tiapride per day. Medication was discontinued immediately and a purgative was administered. We were able to combat the intoxication but the assumed good tolerance of the combined treatment with carbamazepine and tiapride for alcohol detoxification still has to be proven.

Pharmakologische Rückfallprävention bei Alkohol- und Tabakabhängigkeit

A better understanding of the neurobiological substrates of alcohol and tobacco dependence has been accompanied by the increasing role of pharmacological relapse prevention. In alcohol dependence, substances which are able to block or ameliorate alcohol craving improve the maintenance of abstinence in combination with psychosocial treatment. In particular, the N-methyl-D-aspartate receptor antagonist acamprosate and the opiate receptor antagonist naltrexone have been shown to be effective in numerous trials. Administration starts immediately after detoxification and should last for 12 months. This treatment, however, is not a replacement for the psychosocial treatment of the alcohol dependence. Compared with placebo treatment, approximately twice as many patients remain abstinent under acamprosate 1 year after the end of treatment. The most widely studied and used pharmacotherapy for the treatment of tobacco dependence is nicotine containing medications. Nicotine replacement therapies (patch, gum, tablet, inhaler) have been shown to reduce tobacco craving and enhance abstinence. The only non-nicotine medication that has been approved in Germany is the antidepressant bupropion. Current studies identify particularly suitable subgroups of patients responding to more individualized pharmacological relapse prevention. A specific application of these substances will optimise the outcome for alcohol and tobacco dependent patients.

Galantamine: a cholinergic patch in the treatment of alcoholism: a randomized, placebo-controlled trial

OBJECTIVES

The involvement of the central cholinergic system in alcohol abuse behavior is well known. It is possible that the reinforcing effects of ethanol are partially mediated by nicotinic receptors, which modulate neurotransmitter release. It was demonstrated that the application of a cholinesterase inhibitor reduces alcohol consumption in alcohol-preferring rats. This suggests that galantamine (GAL), a cholinesterase inhibitor, could be effective when seeking to prolong abstinence in recently detoxified alcoholics. This study represents the first reported clinical trial of a cholinergic drug in alcohol-relapse prevention.

PATIENTS AND METHODS

We investigated the efficacy and safety of GAL by conducting a 24-week randomized, placebo-controlled, multicentric clinical trial on 149 recently detoxified alcoholics. Survival analyses (Kaplan-Meier) were performed to reveal evidence of prolonged abstinence periods in patients who received GAL.

RESULTS

Our findings did not support our hypothesis. GAL did not extend the time to first severe relapse. However, additional post hoc analyses suggest that relapsed patients treated with GAL consume less ethanol per drinking day than patients treated with placebo.

CONCLUSIONS

GAL seems to be ineffective when used in relapse prevention of detoxified alcoholics. It is possible that alcohol needs to be "on board" for GAL to be beneficial. This could explain why our post hoc analysis showed that GAL possibly reduces the alcohol consumption of relapsers. If confirmed, GAL could play a role in the reduction of harmful alcohol use and at-risk consumption.

Scheme-Based Benzodiazepine Detoxification with Oxcarbazepine

We attempted to evaluate the tolerability and efficacy of the antiepileptic drug oxcarbazepine in benzodiazepine detoxification, by observing several cases. Detoxification followed a predefined dosage scheme. All patients detoxified with oxcarbazepine completed the withdrawal successfully, without withdrawal symptoms. The administration of oxcarbazepine according to the scheme proved to be tolerable. The dosage was sufficient. Though uncontrolled case observations must be interpreted with caution, oxcarbazepine appears to be a promising drug in inpatient benzodiazepine withdrawal. It should be examined in further randomized placebo-controlled studies including long-term follow-ups.

Neuroimaging of gender differences in alcohol dependence: are women more vulnerable?

BACKGROUND

Alcoholic brain damage has been demonstrated in numerous studies using neuropathology and brain imaging techniques. However, gender differences were addressed only in a few studies. Recent research has shown that development, course, and consequences of alcohol dependence may differ between female and male patients. Our investigation was built upon earlier research where we hypothesized that women develop alcoholic brain damage more readily than men do. To further compare the impact of alcohol dependence between men and women, we examined brain atrophy in female and male alcoholics by means of computed tomography (CT).

METHODS

The study group consisted of a total of 158 subjects (76 women: 42 patients, 34 healthy controls; 82 age-matched men: 34 patients, 48 healthy controls). All patients had a DSM-IV and ICD-10 diagnosis of alcohol dependence. CT with digital volumetry was performed twice in patients (at the beginning and end of the 6-week inpatient treatment program) and once in controls.

RESULTS

Patients of both genders had consumed alcohol very heavily. Although the average alcohol consumption in the year before the study was significantly lower in female alcoholics, this gender difference disappeared when controlled for weight. However, women had a significantly shorter duration of alcohol dependence. Despite this fact, both genders developed brain atrophy to a comparable extent. Brain atrophy was reversible in part after 6 weeks of treatment; it did not reach the level in the control groups.

CONCLUSIONS

Gender-specific differences in the onset of alcohol dependence were confirmed. This is in line with the telescoping effect, where a later onset and a more rapid development of dependence in women were described. Under the assumption of a gradual development of consequential organ damage, brain atrophy seems to develop faster in women. As shown in other organs (i.e., heart, muscle, liver), this may confirm a higher vulnerability to alcohol among women.

Olanzapine versus flupenthixol in the treatment of inpatients with schizophrenia: a randomized double-blind trial

OBJECTIVE

The atypical antipsychotic olanzapine has extensively been compared with haloperidol, whereas studies vs. other (conventional) neuroleptics are scarce. This exploratory double-blind 4-week study was designed to compare the efficacy and the safety of olanzapine (OLA) and flupenthixol (FLU) which have recently been considered as a "partially atypical" antipsychotics.

METHODS

Twenty-eight inpatients with schizophrenia (DSM-IV) were randomly assigned for treatment with OLA (N = 15, 5-20 mg/d) or FLU (N = 13, 5-20 mg/d). The Brief Psychiatric Rating Scale (BPRS) and the Negative Symptoms Rating Scale (NSRS), plus the Patient Global Impression (PGI) and Clinical Global Impression (CGI) scales, were used to assess the efficacy of both compounds; safety was determined by using the Simpson Angus Scale (SAS) and the Abnormal Involuntary Movement Scale (AIMS) and by assessing treatment-emergent adverse events. Non-parametric statistics were applied.

RESULTS

BPRS and NSRS scores improved in both groups (exploratory tests; all p < or = 0.02). Similar results were observed for CGI-Severity, CGI- and PGI-Improvement. There were no significant group differences. Responder rates (at least 40 % decrease in BPRS total) were 9/13 OLA patients (69 %) and 9/12 FLU patients (75 %). EPS events were reported only in the FLU group (p < 0.01); FLU patients needed significantly more anticholinergic medication. Weight gain was higher in OLA patients (p < 0.01). Overall, fewer patients with adverse events were observed in the OLA group (p = 0.04). No significant changes were noted on SAS and AIMS scores.

CONCLUSION

Findings from this study suggest that overall and negative symptomatology improved in both treatment groups, while the safety and tolerability profiles differed for both substances.