First-in-human study of a pharmacological duodenal exclusion therapy shows reduced postprandial glucose and insulin and increased bile acid and gut hormone concentrations

AIMS

To address the need for noninvasive alternatives to metabolic surgery or duodenal exclusion devices for the management of type 2 diabetes (T2D) and obesity by developing an orally administered therapeutic polymer, GLY-200, designed to bind to and enhance the barrier function of mucus in the gastrointestinal tract to establish duodenal exclusion noninvasively.

MATERIALS AND METHODS

A Phase 1, randomized, double-blind, placebo-controlled, single- (SAD) and multiple-ascending-dose (MAD) healthy volunteer study was conducted. In the SAD arm, four cohorts received a single dose of 0.5 g up to 6.0 g GLY-200 or placebo, while in the MAD arm, four cohorts received 5 days of twice-daily or three-times-daily dosing (total daily dose 2.0 g up to 6.0 g GLY-200 or placebo). Assessments included safety and tolerability (primary) and exploratory pharmacodynamics, including serum glucose, insulin, bile acids and gut hormones.

RESULTS

No safety signals were observed; tolerability signals were limited to mild to moderate dose-dependent gastrointestinal events. In the MAD arm (Day 5), reductions in glucose and insulin and increases in bile acids, glucagon-like peptide-1, peptide YY and glicentin, were observed following a nonstandardized meal in subjects receiving twice-daily dosing of 2.0 g GLY-200 (N = 9) versus those receiving placebo (N = 8).

CONCLUSIONS

GLY-200 is safe and generally well tolerated at doses of ≤2.0 g twice daily. Pharmacodynamic results mimic the biomarker signature observed after Roux-en-Y gastric bypass and duodenal exclusion devices, indicating a pharmacological effect in the proximal small intestine. This study represents the first clinical demonstration that duodenal exclusion can be achieved with an oral drug and supports further development of GLY-200 for the treatment of obesity and/or T2D.

Clinical performance of a multimodal screening blood test for advanced adenomas and CRC in an average-risk cohort of 1,038 participants

75

Background: The National Polyp Study and 2021 USPSTF CRC-update highlight that the detection and removal of precancerous advanced adenomas (AA) prevents colorectal cancer (CRC), decreases mortality, and leads to higher cost savings than early cancer detection. Performance of a multimodal blood-based test for the detection of CRC and AA that integrates sensitive and accurate detection of circulating gastrointestinal epithelial cells and somatic oncologic variants as well as SEER data of the impact of sex and age is described. Methods: The prospective study included average-risk, asymptomatic screening subjects from 18 geographically dispersed US colonoscopy centers with blood drawn before colonoscopy. Monte Carlo cross-validation (MCCV) methods were used to evaluate the robustness of test performance through 2000 iterations of independent training and validation using bootstrap resampling with stratification to balance patient histopathology, age, and gender. Results include point estimates, confidence intervals, and distributions of sensitivity and specificity to detect AA and CRC. Results: The study cohort (53.2% female; mean age 56.7 yrs.) consisted of 1,038 subjects (White 65.1%; Black 8.5%; Hispanic 24.8%; Asian 1.7%); of which 954 (92%) were asymptomatic, average-risk screening subjects without age enrichment (including 11 CRC and 93 AA) and 84 (8%) were enriched case-control (65 CRC and 19 AA) subjects. The algorithm derives a test score from 0 (low risk) to 100 (high risk) as a quantitative measure of AA and CRC risk. A pre-defined cut point of 47.2 yields a test specificity > 90%, and 92.1% and 54.5% sensitivity for the detection of CRC and AA, respectively. Estimated sensitivities and selected Clopper-Pearson (Exact) 95% confidence intervals based on validation results from MCCV are presented. A split analysis shows for the 954 intended-use, asymptomatic, average-risk screening subjects, the sensitivity for CRC and AA are 100% and 55.9%. Conclusions: A multi-site, prospective, average-risk CRC screening study using a multimodal assay had high sensitivity and specificity for AA and CRC. The quantitative correlation of test scores with disease pathology indicates that the modes of the assay interrogate the primary underlying pathophysiology of disease. The results demonstrate the potential of this novel test to meet the clinically unmet need for a noninvasive strategy for CRC screening and prevention that detects CRC and AA. Clinical trial information: NCT05127096 . [Table: see text]

Evaluation of differential contribution of a circulating epithelial cell signal component in a multimodal colorectal neoplasia assay

e15527

Background: Multimodal diagnostic classifiers survey signals from multiple biological compartments and provide iterative, independent and interactive information. Detection of both CRC and AA is critical for noninvasive colorectal screening to improve overall survival and prevent the 2.5-5% annual transition of AA to CRC. FirstSight integrates clinically validated somatic variants from cfDNA and circulating epithelial cells (CECs) adjusting for age and sex. CECs provide information from both intrinsic factors of the adenoma and extrinsic factors such as adenoma microenvironment which facilitates early systemic entry. We sought to assess differential information from CEC signals for the detection of colorectal cancer and/or advanced adenoma (AA). Methods: Blood samples and colonoscopy pathology results were obtained from 438 asymptomatic screening subjects enriched for CRC/AA obtained from 15 US medical centers. The cohort included 18 CRCs and 64 AAs. Somatic variants from cfDNA were identified using NGS and qPCR. CECs were captured by the CellMax biomimetic platform (CMx) using high-avidity EpCAM antibody embedded in the CMx biochip and confirmed with immunostaining (DAPI: nucleus, CK20: epithelial cell and CD45: WBC). CMx platform’s AI/ML analyses of CEC images quantify stain intensities and cellular features. CEC derived signal GM1was evaluated for its predictive capability beyond somatic variants from cfDNA. Results: Genetic or epigenetic variants were not detected in 52% (33/64) of AA cases, limiting the sensitivity of these markers for early disease. However, distinct CEC signals have been identified that aid in the detection of subjects with CRC or AA, or conversely subjects with negative colonoscopies or non-advanced adenomas (nAA). Among them, a novel feature (referred to as GM1) derived from CEC signals was able to differentiate with statistical significance AA from negative/non-neoplastic findings or nAAs in study subjects with negative results in corresponding somatic variants from cfDNA (p < 0.0001). While targeted somatic variants from cfDNA performed well on CRC (17/18), they provided no predictive information for detection of AA for the 353 subjects which were negative for variants, GM1 provided 100.0% (33/33) sensitivity at 35.1% (112/319) specificity, showing its ability to rule out AA with high negative predictive value. Conclusions: Somatic variant detection modes of the First Sight multi-modal assay have high sensitivity for CRC and modest sensitivity for AA. We demonstrate that CEC signal GM1 of FirstSight provides significant independent information for the detection of CRC and AA beyond somatic variants from cfDNA. Additional CEC signals may further improve the sensitivity and specificity for detection of early-stage colorectal neoplasia. The GM1 CEC signal marker will need to be validated further in future studies.

Development and clinical validation of a blood test for early detection of colorectal adenomas and cancer

50

Background: Many of the 50,000 annual colorectal cancer (CRC) deaths can be attributed to 1/3 eligible Americans not following screening guidelines or approximately 1/2 of the population not adherent to the follow-up post-polypectomy guidelines. The new understanding of the natural history and shared etiology of adenomas and CRC inform integration of clinically relevant biomarkers. The two objectives of CRC screening and surveillance are early detection to improve survival and prevention of CRC through removal of adenomas using colonoscopy. Adenomas account for 98% of actionable colonoscopies. Stool tests have low sensitivity for advanced adenomas (AA, 24-42%). Methods: A prospective, blinded study was conducted at the VA Palo Alto Health Care System. Patients had blood drawn prior to colonoscopy. The test analyzes two biomarkers: circulating gastrointestinal epithelial cells and somatic mutations of cell-free DNA. The probability of advanced neoplasia was obtained by ordinal/nominal logistic regression methods together with SEER-incidence rate and prior history of AA on a training set of 346 subjects. The cutpoint for the quantitative score was fixed and the remaining 112 subjects were tested. Results: Interim results for 458 patients with no prior diagnosis of colorectal cancer (CRC) are presented. The cohort included both screening (239) and surveillance (219) subjects. Indications for colonoscopy were 86% asymptomatic and 14% with symptoms or positive-FIT. Balanced distribution of roughly 3/4th subjects in each disease category were randomly selected for training and algorithm development and the remaining 1/4th subjects were used for validation. A cutpoint was selected to obtain a test specificity (non-neoplastic finding or negative colonoscopy) of 90% resulting in a sensitivity of 100% and 80.0% for detection of CRC and advanced neoplasia (AN = CRC+AA), respectively, on the training subjects. The area under the ROC curve is 0.91. Validation using the fixed cutpoint and 112 test subjects achieved 91.4% specificity and 100% and 75.0% sensitivity for CRC and AN. Conclusions: This blood test has high sensitivity for colorectal advanced neoplasia while retaining high specificity. The quantitative nature of the score has the potential to enable stratification of patients for screening or post-polypectomy surveillance colonoscopy. [Table: see text]

Exploring a New Management Option for Patients With Refractory Ascites: The PeriLeve Device

Cirrhosis of the liver is often accompanied by refractory ascites, a condition characterized by fluid buildup in the peritoneal cavity that does not respond to diuretics or recurs shortly after therapeutic paracentesis. There are several management strategies in practice including large-volume paracentesis, transjugular intrahepatic portosystemic shunts, peritoneovenous shunting, and liver transplant. However, each of these options come with limitations such as high cost, poor efficacy, and increased risk of complications. This article explores a new management strategy with a novel biopowered shunt, the PeriLeve device, that moves fluid from the peritoneal cavity to the urinary bladder using natural changes in intra-abdominal pressure (IAP). By doing so, PeriLeve shifts the current paradigm of care from the hospital to the home which reduces costs to healthcare providers and patients while improving quality of life. The basic design of the pump consists of two check (i.e., one-way) valves on either side of a fluid filled cavity which is separated from an air cavity by an elastomeric membrane. This article presents benchtop testing results of a prototype PeriLeve pump. The performance of the pump was analyzed along six parameters: change in intra-abdominal pressure, valve opening pressure, membrane thickness, membrane stiffness, membrane surface area, and air cavity volume. Initial results indicate that, with future optimizations, the pump can ultimately move a clinically significant volume of fluid.

A sensitive and quantitative multimodal blood test for the detection of colorectal adenomas and cancer: Correlation with size and number of polyps

1555

Background: Colonoscopic polypectomy is the primary reason for declining colorectal cancer incidence and mortality. Epidemiological evidence has ordered the timing and risk of pre-cancerous adenomas, localized and invasive cancer along a 7-10 year continuum. The increased size and number of index polyps are correlated with an increased probability of progression to cancer and informs surveillance colonoscopies. Methods: A single-center, IRB-approved, prospective, blinded study was conducted at the VA Palo Alto Health Care System. Results for 354 patients with no prior diagnosis of CRC who were scheduled for colonoscopy are presented. Indications for colonoscopy were 86% asymptomatic and 14% with symptoms or positive-FIT. Patients had blood drawn immediately prior to colonoscopy. The test analyzes three biomarkers: circulating gastrointestinal epithelial cells (CEC), validated somatic mutations, and methylation (SEPTIN9) of cell-free DNA and uses incident risk to calculate a CMx Score, scaled from 0 to 100. Multivariate regression methods were used to assess the degree of association between the pre-defined CMx Scores and polyp sizes and number, adjusting for both DNA mutation and DNA methylation status. Results: There is a significant association between CMx Scores and polyp size (F value = 5.80, p-value = 0.017). DNA mutation (F value = 1.29, p-value = 0.263) and methylation status (F value = 0.34, p-value = 0.560) were non-significant. Similarly, there is a significant association between CMx Scores and number of polyps (F value = 23.71, p-value < 0.0001). Again, DNA mutation (F value = 1.57, p-value = 0.210) and methylation status (F value = 1.34, p-value = 0.248) were non-significant. These results suggest that CMx Scores, which incorporate CEC, are providing predictive information of polyp sizes and number above and beyond DNA mutation and methylation status alone. Conclusions: A novel noninvasive multimodal blood-based assay that analyzes cell-free DNA for somatic mutations and methylation, CEC and integrates SEER incidence risk is significantly associated with polyp size and number. The opportunity to track progression and potentially inform colonoscopy interval is notable. [Table: see text]

Circulating tumor cell count from a blood sample for colorectal cancer (CRC) prevention: A 627-patient prospective study

485

Background: Up to 25% of patients with adenomas progress to having colorectal cancer. If detected early, adenomas can be removed with a diagnostic colonoscopy procedure, preventing cancer. Invasive colonoscopy is the only screening method with the sensitivity to accurately detect adenomas, but has a low compliance rate of 38% for screening. Available non-invasive tests (including stool-based multi-analyte tests) have very limited sensitivity for adenomas. Hence, there is an unmet need for a non-invasive test for adenoma detection. Methods: IRB-approved prospective study was conducted in 627 subjects 50 years or older- recommended for routine CRC screening- 405 subjects had adenoma or CRC, confirmed by colonoscopy with tumor biopsy. Two mL peripheral blood was processed using the CellMax biomimetic platform (CMx), which uses a microfluidic biochip to enumerate circulating tumor cells (CTCs). Nominal logistic regression was used to assess performance while proportional odds logistic regression and Cuzick’s trend test were used to determine association of CTC counts with cancer stage. Results: An increase in CTC count was significantly correlated with an increase in disease burden (Cuzick’s Test p-value < 0.0001). Furthermore, there was a significant association between CTC counts and stages of adenoma-carcinoma progression (Likelihood ratio p-value < 0.0001). The CTC enumeration was able to differentiate between healthy and diseased patients (adenoma + cancer). Conclusions: To the best of our knowledge, these are the first reported results for a blood test that has high accuracy for adenoma detection, and truly enables colorectal cancer prevention. This test can be administered in the primary care setting and drive high compliance.[Table: see text]

Abstract 3635: CTC and ctDNA profiling to detect 6 NCCN-guideline recommended classes of alterations for immunotherapy and targeted therapy selection using sample from a single blood draw

Introduction The availability of targeted and immunotherapies has provided NSCLC patients with more effective treatment options. However, this has resulted in an increase in the number and modality of tests required for treatment selection. Given 30-50% of advanced lung cancer patients have insufficient or unavailable tissue for comprehensive genomic profiling, there is a need for a non-invasive assay that can accurately detect all guideline-recommended markers for NSCLC treatment selection. To meet this need, we have developed a blood test that detects six classes of alterations (SNV, Indels, Rearrangements, CNA, Microsatellite Instability and PD-L1 expression) for therapy selection.

Methods & Results Three tubes of blood from a routine blood draw were sent to our CLIA-certified and/or CAP accredited lab for analysis. PD-L1 expression was evaluated in circulating tumor cells (CTCs) utilizing two different assays; (i) Immunofluorescence (IF) antibody staining, (ii) mRNA qPCR. CTCs were captured on the CMxTM CTC Platform coated with lipid bilayer and antibodies to EpCAM. PD-L1 expression results were highly correlated between IF and qPCR assays in ten solid tumor cell lines (lung, breast, prostate and colorectal cancer) spiked into whole blood to mimic the actual patient CTC capture process. In an ongoing study on clinical samples from NSCLC patients (N=20), we observed greater than 90% concordance between tissue (IHC by 22C3 PD-L1 clone) and blood (CTC IF and mRNA assays). A proprietary Single Molecule Sequencing (SMSEQTM) NGS assay was performed on plasma in order to detect 5 classes of genomic alterations (SNV, Indels, Rearrangements, CNA, MSI) from ctDNA. This assay was validated in accordance with the latest ACMG and AMP guidelines to accurately detect variants at low mutant allele fraction (.1% for SNVs and Indels, 1% for rearrangements and 5 copies for CNA) with high sensitivity and specificity. MSI status was determined by assessing nucleotide repeat sequences in five standard markers (BAT-25, BAT-26, MONO-27, NR-21, NR-24), and was detectable down to a MAF of 1%. In an ongoing study on clinical samples from NSCLC patients (N=20), we observed high concordance of MSI status between tissue (immunohistochemistry for dMMR/MSI status) and blood (ctDNA SMSEQ assay).

Conclusion Tissue insufficiency and procurement challenges are the primary reasons why ~90% of patients diagnosed with advanced NSCLC are not comprehensively tested per NCCN-guidelines in the community setting where most cancer is treated, leading to suboptimal treatment selection. An accurate blood test that detects all 6 NCCN-recommended markers for immunotherapy and targeted therapy selection has the potential to significantly improve adherence to NCCN testing guidelines and enable optimal treatment selection.

Citation Format: Huangpin B. Hsieh, Jen-chia Wu, Feng-Ming Lin, Julian Lucas, Alex Atkins, Pratyush Gupta, Hung-Jen Shao, Yen-Lin Chen, Wen-Jie Huang, Chia-Hsun Hsieh, Ruey Kuen Hsieh, Kuo-Wei Chen, Ming-Hong Yen, Mana Javey, Shih-En Chang, Twinkal Marfatia, Drew Watson, Mahul Amin, Ashish Nimgaonkar, Oscar Segurado, Rui Mei. CTC and ctDNA profiling to detect 6 NCCN-guideline recommended classes of alterations for immunotherapy and targeted therapy selection using sample from a single blood draw [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3635.

Prospective clinical study of circulating tumor cells for colorectal cancer screening

556

Background: Colorectal cancer (CRC) is among the most preventable cancers when precancerous lesions are detected at an early stage. Current screening methods for CRC require bowel prep or stool-based testing that are inconvenient, resulting in low compliance. Stool based tests have limited sensitivity for the detection of precancerous lesions. We have conducted a prospective clinical study over a period of > 3 years to assess a novel assay to detect and enumerate circulating tumor cells (CTCs) in a blood sample for early CRC detection. Methods: A single-center, IRB-approved, prospective and blinded clinical study was conducted in 620 subjects including 438 with adenoma, polyps or stage I-IV CRC and 182 healthy controls. For each subject, 2mL peripheral whole blood collected through a routine blood draw was processed using the CellMax biomimetic platform (CMx). The CMx test is a proprietary microfluidic biochip that minimizes non-specific binding and accurately enumerates CTCs. A multivariate analysis was performed to assess the clinical performance characteristics of the CMx test. Results: Disease status was evaluated by a standard clinical protocol which included colonoscopy and biopsy results. Probability of CRC risk was assessed by an age-adjusted regression model which correlated CTCs to clinical status. The CMx test’s overall accuracy was 88% for all stages of colorectal illness, including precancerous lesions. Conclusions: The study has demonstrated high accuracy for the detection of CRC using a novel CTC assay. It is the first study to show high sensitivity in the detection of precancerous colorectal lesions. The simple blood draw required can be easily integrated into a patient’s routine physical, increasing test compliance.[Table: see text]

Precision Bariatrics: Toward a New Paradigm of Personalized Devices in Obesity Therapeutics

The prevalence and complexity of obesity and its associated metabolic complications highlight the importance of building a rigorous investigative framework for the development of novel weight loss therapies. Device-based interventions in particular constitute a market poised for rapid expansion in the coming years. Optimizing outcomes for this new class of therapies requires attention to an evolving taxonomy of subdivisions within the broader obesity phenotype and a means for stratifying patients toward maximally effective interventions. Extant bariatric devices implicitly prioritize anatomic variables as surrogates for physiology, a somewhat arbitrary assumption that merits empiric validation. Utilizing the governing principles of systems biology and recent innovations in clinical trial design, a robust and precise research infrastructure can and should be developed to more effectively mitigate this contemporary epidemic.

Primary endoscopic therapies for obesity and metabolic diseases

PURPOSE OF REVIEW

Endoscopic approaches to obesity may help fulfill the unmet need of over half the US adult population who would benefit from therapy for obesity but are not receiving it. Endoluminal approaches have the potential to be more efficacious than antiobesity medications and have a lower risk-cost profile compared with bariatric surgery. This review outlines the current state of primary endoscopic weight loss and metabolic therapies and sheds light on the challenges faced toward making endoscopic bariatric therapies 'ready for prime time'.

RECENT FINDINGS

Endoscopic approaches to obesity are being increasingly modeled on the proposed mechanisms contributing to the benefits of bariatric surgery.Therapies targeted at the stomach induce weight loss with only a proportional benefit to underlying metabolic disorders.Therapies targeting the proximal small bowel appear to modulate various neurohormonal pathways resulting in an improvement in metabolic profile in excess to that accounted for by weight loss itself.

SUMMARY

Rigorous scientific assessment of endoscopic approaches to obesity is necessary to allow its integration into the treatment algorithm of obesity. The endoscopic armamentarium against obesity continues to evolve with the endoscopist poised to be a key player in the management of this disease.

VIDEO ABSTRACT

http://links.lww.com/COG/A12.

Prediction of mortality in an Indian intensive care unit. Comparison between APACHE II and artificial neural networks

OBJECTIVE

To compare hospital outcome prediction using an artificial neural network model, built on an Indian data set, with the APACHE II (Acute Physiology and Chronic Health Evaluation II) logistic regression model.

DESIGN

Analysis of a database containing prospectively collected data.

SETTING

Medical-neurological ICU of a university hospital in Mumbai, India.

SUBJECTS

Two thousand sixty-two consecutive admissions between 1996 and 1998.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

The 22 variables used to obtain day-1 APACHE II score and risk of death were recorded. Data from 1,962 patients were used to train the neural network using a back-propagation algorithm. Data from the remaining 1,000 patients were used for testing this model and comparing it with APACHE II. There were 337 deaths in these 1,000 patients; APACHE II predicted 246 deaths while the neural network predicted 336 deaths. Calibration, assessed by the Hosmer-Lemeshow statistic, was better with the neural network (H=22.4) than with APACHE II (H=123.5) and so was discrimination (area under receiver operating characteristic curve =0.87 versus 0.77, p=0.002). Analysis of information gain due to each of the 22 variables revealed that the neural network could predict outcome using only 15 variables. A new model using these 15 variables predicted 335 deaths, had calibration (H=27.7) and discrimination (area under receiver operating characteristic curve =0.88) which was comparable to the 22-variable model (p=0.87) and superior to the APACHE II equation (p<0.001).

CONCLUSION

Artificial neural networks, trained on Indian patient data, used fewer variables and yet outperformed the APACHE II system in predicting hospital outcome.

Reproducibility of gene expression across generations of Affymetrix microarrays

BACKGROUND

The development of large-scale gene expression profiling technologies is rapidly changing the norms of biological investigation. But the rapid pace of change itself presents challenges. Commercial microarrays are regularly modified to incorporate new genes and improved target sequences. Although the ability to compare datasets across generations is crucial for any long-term research project, to date no means to allow such comparisons have been developed. In this study the reproducibility of gene expression levels across two generations of Affymetrix GeneChips (HuGeneFL and HG-U95A) was measured.

RESULTS

Correlation coefficients were computed for gene expression values across chip generations based on different measures of similarity. Comparing the absolute calls assigned to the individual probe sets across the generations found them to be largely unchanged.

CONCLUSION

We show that experimental replicates are highly reproducible, but that reproducibility across generations depends on the degree of similarity of the probe sets and the expression level of the corresponding transcript.