Report of the European Medicines Agency Conference on RNA-Based Medicines

RNA-based medicines have potential to treat a large variety of diseases, and research in the field is very dynamic. Proactively, The European Medicines Agency (EMA) organized a virtual conference on February 2, 2023 to promote the development of RNA-based medicines. The initiative addresses the goal of the EMA Regulatory Science Strategy to 2025 to "catalyse the integration of science and technology in medicines development." The conference focused on RNA technologies (excluding RNA vaccines) and involved different stakeholders, including representatives from academia, industry, regulatory authorities, and patient organizations. The conference comprised presentations and discussion sessions conducted by panels of subject matter experts. In this meeting report, we summarize the presentations and recap the main themes of the panel discussions.

Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing: A Cluster Randomized Clinical Trial

Importance

Statins reduce the risk of major adverse cardiovascular events, but less than one-half of individuals in America who meet guideline criteria for a statin are actively prescribed this medication.

Objective

To evaluate whether nudges to clinicians, patients, or both increase initiation of statin prescribing during primary care visits.

Design, Setting, and Participants

This cluster randomized clinical trial evaluated statin prescribing of 158 clinicians from 28 primary care practices including 4131 patients. The design included a 12-month preintervention period and a 6-month intervention period between October 19, 2019, and April 18, 2021.

Interventions

The usual care group received no interventions. The clinician nudge combined an active choice prompt in the electronic health record during the patient visit and monthly feedback on prescribing patterns compared with peers. The patient nudge was an interactive text message delivered 4 days before the visit. The combined nudge included the clinician and patient nudges.

Main Outcomes and Measures

The primary outcome was initiation of a statin prescription during the visit.

Results

The sample comprised 4131 patients with a mean (SD) age of 65.5 (10.5) years; 2120 (51.3%) were male; 1210 (29.3%) were Black, 106 (2.6%) were Hispanic, 2732 (66.1%) were White, and 83 (2.0%) were of other race or ethnicity, and 933 (22.6%) had atherosclerotic cardiovascular disease. In unadjusted analyses during the preintervention period, statins were prescribed to 5.6% of patients (105 of 1876) in the usual care group, 4.8% (97 of 2022) in the patient nudge group, 6.0% (104 of 1723) in the clinician nudge group, and 4.7% (82 of 1752) in the combined group. During the intervention, statins were prescribed to 7.3% of patients (75 of 1032) in the usual care group, 8.5% (100 of 1181) in the patient nudge group, 13.0% (128 of 981) in the clinician nudge arm, and 15.5% (145 of 937) in the combined group. In the main adjusted analyses relative to usual care, the clinician nudge significantly increased statin prescribing alone (5.5 percentage points; 95% CI, 3.4 to 7.8 percentage points; P = .01) and when combined with the patient nudge (7.2 percentage points; 95% CI, 5.1 to 9.1 percentage points; P = .001). The patient nudge alone did not change statin prescribing relative to usual care (0.9 percentage points; 95% CI, -0.8 to 2.5 percentage points; P = .32).

Conclusions and Relevance

Nudges to clinicians with and without a patient nudge significantly increased initiation of a statin prescription during primary care visits. The patient nudge alone was not effective.

Trial Registration

ClinicalTrials.gov Identifier: NCT04307472.

Follicular Lymphoma Treated with First-Line Immunochemotherapy: A Review of PET/CT in Patients Who Did Not Achieve a Complete Metabolic Response in the GALLIUM Study

Complete metabolic response (CMR) on PET/CT was the sole independent predictor of overall survival in the PET substudy of the phase III GALLIUM trial (NCT01332968) in first-line treatment of high-tumor-burden follicular lymphoma. The aim of this analysis was to further investigate the outcome of patients not achieving CMR. Methods: Two international experts rereviewed PET/CT scans from patients failing to achieve CMR assessed by the Independent Review Committee masked otherwise to committee results. Metabolic response category and Deauville score were assigned. Progression-free survival (PFS) was investigator-assessed with contrast-enhanced CT. Kaplan-Meier methodology was used to estimate landmark PFS and time to next treatment from end of induction by Deauville score. Patients who experienced CT-based progressive disease at the end of induction were excluded. Results: Fifty-four patients were reviewed. Six had CMR, 37 had a partial metabolic response, 2 had no metabolic response, and 9 had progressive metabolic disease. Patients were reassigned to CMR because ¹⁸F-FDG uptake was considered inflammatory (n = 2), was considered incidental neoplasia (n = 2), or was visually close to liver uptake but quantitatively lower (n = 2). There was a trend for shorter PFS and time to next treatment for patients with a Deauville score of 5 than a score of 4. High-grade mesenteric uptake at the end of induction was common, occurring in 20 patients with non-CMR, 14 of whom achieved CMR at all other sites. Only 3 of 14 (21%) patients with mesenteric uptake as the only site of disease experienced progression or death within 24 mo, whereas 4 of 6 patients (67%) with mesenteric and additional sites of ¹⁸F-FDG-avid disease experienced progression or death within 24 mo. All patients with early progression had measurable disease on contrast-enhanced CT at ¹⁸F-FDG-avid sites at the end of induction. Conclusion: After induction immunochemotherapy, CMR was assigned after reassessment in some patients, in whom increased ¹⁸F-FDG uptake was considered due to inflammation or incidental neoplasia rather than to lymphoma. Quantitative assessment to confirm the visual impression of residual uptake in lesions is suggested. Isolated mesenteric ¹⁸F-FDG uptake is likely a common false-positive finding at the end of induction and does not warrant changes in clinical management or disease surveillance unless there is measurable disease on contrast-enhanced CT or clinical suspicion of active disease.

Identifying Electronic Nicotine Delivery System Brands and Flavors on Instagram: Natural Language Processing Analysis

Background

Electronic nicotine delivery system (ENDS) brands, such as JUUL, used social media as a key component of their marketing strategy, which led to massive sales growth from 2015 to 2018. During this time, ENDS use rapidly increased among youths and young adults, with flavored products being particularly popular among these groups.

Objective

The aim of our study is to develop a named entity recognition (NER) model to identify potential emerging vaping brands and flavors from Instagram post text. NER is a natural language processing task for identifying specific types of words (entities) in text based on the characteristics of the entity and surrounding words.

Methods

NER models were trained on a labeled data set of 2272 Instagram posts coded for ENDS brands and flavors. We compared three types of NER models—conditional random fields, a residual convolutional neural network, and a fine-tuned distilled bidirectional encoder representations from transformers (FTDB) network—to identify brands and flavors in Instagram posts with key model outcomes of precision, recall, and F1 scores. We used data from Nielsen scanner sales and Wikipedia to create benchmark dictionaries to determine whether brands from established ENDS brand and flavor lists were mentioned in the Instagram posts in our sample. To prevent overfitting, we performed 5-fold cross-validation and reported the mean and SD of the model validation metrics across the folds.

Results

For brands, the residual convolutional neural network exhibited the highest mean precision (0.797, SD 0.084), and the FTDB exhibited the highest mean recall (0.869, SD 0.103). For flavors, the FTDB exhibited both the highest mean precision (0.860, SD 0.055) and recall (0.801, SD 0.091). All NER models outperformed the benchmark brand and flavor dictionary look-ups on mean precision, recall, and F1. Comparing between the benchmark brand lists, the larger Wikipedia list outperformed the Nielsen list in both precision and recall.

Conclusions

Our findings suggest that NER models correctly identified ENDS brands and flavors in Instagram posts at rates competitive with, or better than, others in the published literature. Brands identified during manual annotation showed little overlap with those in Nielsen scanner data, suggesting that NER models may capture emerging brands with limited sales and distribution. NER models address the challenges of manual brand identification and can be used to support future infodemiology and infoveillance studies. Brands identified on social media should be cross-validated with Nielsen and other data sources to differentiate emerging brands that have become established from those with limited sales and distribution.

A novel assistive therapy chair to improve trunk control during neurorehabilitation: Perceptions of physical therapists and patients

A prototype assistive therapy chair (T-Chair) that induces exercise stimuli to improve trunk control and standing and walking early after stroke has been developed. The aim of this study was to assess its usability in a rehabilitation setting. Eleven physical therapists (PTs) integrated the T-Chair into the therapy programs of 15 patients post stroke. Each patient performed on average four individual therapy sessions on the T-Chair under the PTs' supervision. Usability was assessed using questionnaires, therapy diaries and focus group interviews with PTs'. Among PTs', 64% had generally a positive view on the T-Chair. Physical therapists recognized the potential for unsupervised therapy. Generally, patients reacted positively and enjoyed training. The T-Chair has the potential to become an adequate training tool for patients with an intermediate trunk control after stroke. Further development and usability testing are required to provide a therapeutic device allowing for an intensive therapy early post stroke.

Relationships Between Iron Status, Cognitive Performance, and Smoking Cessation

Objectives

Smoking cessation research suggests that women are more likely than men to respond to financial incentives to quit smoking, despite having lower rates of smoking cessation overall. Animal models suggest that iron deficiency, which is more prevalent in women, may alter dopaminergic pathways involved in both reward processing and addiction. The present study examines the extent to which iron status impacts ability to quit smoking and performance on a battery of cognitive tasks, including tasks assessing learning and decision-making which depend on the integrity of the dopaminergic pathways.

Methods

Participants were recruited from a local smoking cessation clinic and followed for 6 months as they received counseling to quit smoking. Visits included a baseline appointment, as well as 1- and 6-month follow up visits. At each appointment, participants performed cognitive tests, including the serial reaction time task (SRT) and probabilistic selection task (PST), with concurrent EEG, then gave a small sample of blood. Smoking behavior was examined using time to relapse (TTR), which was the week (1–26) in which the participant relapsed, if relapse occurred. Iron status variables of interest were hemoglobin (Hb) and percentile of the NHANES III age- and race-adjusted distributions of serum ferritin (sFtP). Correlations examined the associations between iron status variables and reaction times (RTs) on the SRT and PST, choice behavior on PST, and TTR.

Results

TTR was positively related to sFtP (r = 0.79, P < .005). Regarding the cognitive measures, there was a nonlinear relationship between sFtP and RT for the SRT task: participants with sFtP at or below the 45th percentile had a negative relationship with RT, while those with sFtP above the 55th percentile had a positive one. Hb was negatively correlated with learning from negative consequences in the PST. In addition, RTs for high-conflict choices and correct responses had a nonlinear relationship with sFtP like that found with the SRT.

Conclusions

Variations in iron affect smoking cessation as well as cognitive performance. Being low in iron may represent an additional burden to a woman who attempts to quit smoking.

Funding Sources

TSET Health Promotion Research Center - Oklahoma Tobacco Settlement Endowment Trust (TSET; Grant # r21–02) and NCI Support Grant P30CA225520.

Your Brain Knows if You're Iron Deficient: Distinct Brain Dynamics in Iron Deficient vs. Sufficient Females in a Visual Category Learning Task

Objectives

The present study sought to determine the possibility of identifying someone as either iron deficient or sufficient based solely on brain activity, and, if possible, how quickly (based on processing time on a cognitive task) this could be done.

Methods

Both iron sufficient(IS) and iron deficient non-anemic (IDNA) females (mean age 21.1 y) learned two visual categorization tasks while concurrent EEG was acquired. Both tasks involved classifying gray-scale gabor patches on the basis of spatial frequency and orientation; one task used an easily-verbalized rule (rule-based, RB), the other required complex integration of the information (II). Moving windows (20 ms width) of EEG data from 100 electrodes were used to predict the participant's iron status using logistic regression; model form was determined using stepwise variable selection. The outcome variable was the area under the curve (AUC) of the receiver operating characteristic for the classification. We set a criterion of AUC ≥ 0.80 for successful classification performance.

Results

For both tasks, successful classification was possible before 200 ms of processing on the basis of fewer than 12 electrodes. Classification in the RB task suggested some early right lateralization in the selection of electrodes, which became more central as processing proceeded. Classification in the II task did not suggest lateralization, although there was some change to more central electrodes as processing proceeded. At each 20 ms time window, for each of the selected set of electrodes, a measure of neural efficiency was calculated as the ratio of the hazard function of the reaction time distribution and the global field power of the selected set of electrodes. This ratio can be interpreted as the amount of work accomplished per unit of energy expended. In all cases, neural efficiency for the IS females exceeded that for the IDNA females, suggesting that the efficiency with which neural energy is expended in cognitive work differs as a function of iron status.

Conclusions

Iron deficiency without anemia results in distinct patterns of brain activity early in processing that reflect reduced levels of neural efficiency, relative to females who are iron sufficient.

Funding Sources

OU Office of the Vice President for Research.

Estimated Ages of JUUL Twitter Followers

This social media analysis used a prediction model to estimate the ages of followers of @JUULvapor on Twitter.

Polatuzumab vedotin or pinatuzumab vedotin plus rituximab in patients with relapsed or refractory non-Hodgkin lymphoma: final results from a phase 2 randomised study (ROMULUS)

BACKGROUND

Antibody-drug conjugates (ADCs) polatuzumab vedotin (pola) and pinatuzumab vedotin (pina) showed clinical activity and tolerability in phase 1 trials. The aim of this multicentre, open-label, phase 2 study was to compare rituximab plus pola (R-pola) or pina (R-pina) in patients with relapsed or refractory diffuse large B-cell lymphoma and follicular lymphoma.

METHODS

In this phase 2 randomised study at 39 investigational sites in six countries, patients were randomly assigned (1:1), by use of a dynamic hierarchical randomisation scheme, to receive R-pola or R-pina (375 mg/m² rituximab plus 2·4 mg/kg ADCs) every 21 days until disease progression or unacceptable toxicity up to 1 year. Treatment allocations were not masked to the investigator, patients or sponsor after the patients were enrolled and randomly assigned. The primary objectives were safety and tolerability, and antitumour response. The study is registered with ClinicalTrials.gov, number NCT01691898, and is closed to accrual.

FINDINGS

81 patients with diffuse large B-cell lymphoma and 42 with follicular lymphoma were recruited between Sept 27, 2012, and Oct 10, 2013, and were assigned to treatment. 81 patients with diffuse large B-cell lymphoma and 41 patients with follicular lymphoma were eligible for analysis. Of the 42 patients with diffuse large B-cell lymphoma who received R-pina, 25 (60%, 95% CI 43-74) achieved an objective response and 11 (26%, 95% CI 14-42) achieved a complete response. Of the 39 patients in this cohort who received R-pola, 21 (54%, 95% CI 37-70) achieved an objective response, and eight (21%, 95% CI 9-36) achieved a complete response. Of the 21 patients in the follicular lymphoma cohort who received R-pina, 13 (62%, 95% CI 38-82) achieved an objective response, and one (5%, 95% CI 0·1-24) achieved a complete response. Of the 20 patients in this cohort who received R-pola, 14 (70%, 95% CI 46-88) achieved an objective response, and nine (45%, 95% CI 23-68) achieved a complete response. In the diffuse large B-cell lymphoma cohort, grade 3-5 adverse events occurred in 33 (79%) of 42 patients receiving R-pina (most common were neutropenia [29%] and hyperglycaemia [10%]; nine [21%] grade 5 adverse events, five of which were infection-related), and in 30 (77%) of 39 patients receiving R-pola (most common were neutropenia [23%], anaemia [8%] and diarrhoea [8%]; no grade 5 adverse events). In the follicular lymphoma cohort, grade 3-5 adverse events occurred in 13 (62%) of 21 patients receiving R-pina (most common were neutropenia [29%] and hyperglycaemia [14%]; no grade 5 adverse events) and in ten (50%) of 20 patients receiving R-pola (most common were neutropenia [15%] and diarrhoea [10%]; one grade 5 adverse event).

INTERPRETATION

R-pina and R-pola are potential treatment options in patients with relapsed or refractory diffuse large B-cell lymphoma and follicular lymphoma. Pola was selected by the study funder for further development in non-Hodgkin lymphoma, partly because of longer durations of response than pina, and an overall benefit-risk favouring R-pola.

FUNDING

F Hoffmann-La Roche.

Supplementing a survey with respondent Twitter data to measure e-cigarette information exposure

Social media data are increasingly used by researchers to gain insights on individuals' behaviors and opinions. Platforms like Twitter provide access to individuals' postings, networks of friends and followers, and the content to which they are exposed. This article presents the methods and results of an exploratory study to supplement survey data with respondents' Twitter postings, networks of Twitter friends and followers, and information to which they were exposed about e-cigarettes. Twitter use is important to consider in e-cigarette research and other topics influenced by online information sharing and exposure. Further, Twitter metadata provide direct measures of user's friends and followers as opposed to survey self-reports. We find that Twitter metadata provide similar information to survey questions on Twitter network size without inducing recall error or other measurement issues. Using sentiment coding and machine learning methods, we find Twitter can elucidate on topics difficult to measure via surveys such as online expressed opinions and network composition. We present and discuss models predicting whether respondents' tweet positively about e-cigarettes using survey and Twitter data, finding the combined data to provide broader measures than either source alone.

Obinutuzumab for the First-Line Treatment of Follicular Lymphoma

BACKGROUND

Rituximab-based immunochemotherapy has improved outcomes in patients with follicular lymphoma. Obinutuzumab is a glycoengineered type II anti-CD20 monoclonal antibody. We compared rituximab-based chemotherapy with obinutuzumab-based chemotherapy in patients with previously untreated advanced-stage follicular lymphoma.

METHODS

We randomly assigned patients to undergo induction treatment with obinutuzumab-based chemotherapy or rituximab-based chemotherapy. Patients with a response received maintenance treatment for up to 2 years with the same antibody that they had received in induction. The primary end point was investigator-assessed progression-free survival.

RESULTS

A total of 1202 patients with follicular lymphoma underwent randomization (601 patients in each group). After a median follow-up of 34.5 months (range, 0 to 54.5), a planned interim analysis showed that obinutuzumab-based chemotherapy resulted in a significantly lower risk of progression, relapse, or death than rituximab-based chemotherapy (estimated 3-year rate of progression-free survival, 80.0% vs. 73.3%; hazard ratio for progression, relapse, or death, 0.66; 95% confidence interval [CI], 0.51 to 0.85; P=0.001). Similar results were seen with regard to independently reviewed progression-free survival and other time-to-event end points. Response rates were similar in the two groups (88.5% in the obinutuzumab group and 86.9% in the rituximab group). Adverse events of grade 3 to 5 were more frequent in the obinutuzumab group than in the rituximab group (74.6% vs. 67.8%), as were serious adverse events (46.1% vs. 39.9%). The rates of adverse events resulting in death were similar in the two groups (4.0% in the obinutuzumab group and 3.4% in the rituximab group). The most common adverse events were infusion-related events that were considered by the investigators to be largely due to obinutuzumab in 353 of 595 patients (59.3%; 95% CI, 55.3 to 63.2) and to rituximab in 292 of 597 patients (48.9%; 95% CI, 44.9 to 52.9; P<0.001). Nausea and neutropenia were common. A total of 35 patients (5.8%) in the obinutuzumab group and 46 (7.7%) in the rituximab group died.

CONCLUSIONS

Obinutuzumab-based immunochemotherapy and maintenance therapy resulted in longer progression-free survival than rituximab-based therapy. High-grade adverse events were more common with obinutuzumab-based chemotherapy. (Funded by F. Hoffmann-La Roche; GALLIUM ClinicalTrials.gov number, NCT01332968 .).

Rituximab in B-Cell Hematologic Malignancies: A Review of 20 Years of Clinical Experience

Rituximab is a human/murine, chimeric anti-CD20 monoclonal antibody with established efficacy, and a favorable and well-defined safety profile in patients with various CD20-expressing lymphoid malignancies, including indolent and aggressive forms of B-cell non-Hodgkin lymphoma. Since its first approval 20 years ago, intravenously administered rituximab has revolutionized the treatment of B-cell malignancies and has become a standard component of care for follicular lymphoma, diffuse large B-cell lymphoma, chronic lymphocytic leukemia, and mantle cell lymphoma. For all of these diseases, clinical trials have demonstrated that rituximab not only prolongs the time to disease progression but also extends overall survival. Efficacy benefits have also been shown in patients with marginal zone lymphoma and in more aggressive diseases such as Burkitt lymphoma. Although the proven clinical efficacy and success of rituximab has led to the development of other anti-CD20 monoclonal antibodies in recent years (e.g., obinutuzumab, ofatumumab, veltuzumab, and ocrelizumab), rituximab is likely to maintain a position within the therapeutic armamentarium because it is well established with a long history of successful clinical use. Furthermore, a subcutaneous formulation of the drug has been approved both in the EU and in the USA for the treatment of B-cell malignancies. Using the wealth of data published on rituximab during the last two decades, we review the preclinical development of rituximab and the clinical experience gained in the treatment of hematologic B-cell malignancies, with a focus on the well-established intravenous route of administration. This article is a companion paper to A. Davies, et al., which is also published in this issue.

FUNDING

F. Hoffmann-La Roche Ltd., Basel, Switzerland.

Obinutuzumab or Rituximab Plus Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone in Previously Untreated Diffuse Large B-Cell Lymphoma

Purpose Rituximab (R) plus CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy is the standard of care in previously untreated diffuse large B-cell lymphoma (DLBCL). Obinutuzumab (G) is a glycoengineered, type II, anti-CD20 monoclonal antibody. GOYA was a randomized phase III study that compared G-CHOP with R-CHOP in patients with previously untreated advanced-stage DLBCL. Methods Patients (N = 1,418) were randomly assigned to receive eight 21-day cycles of G (n = 706) or R (n = 712), plus six or eight cycles of CHOP. Primary end point was investigator-assessed progression-free survival (PFS). Results After median observation of 29 months, the number of investigator-assessed PFS events was similar between G (201; 28.5%) and R (215; 30.2%), stratified hazard ratio was 0.92 (95% CI, 0.76 to 1.11; P = .39), and 3-year PFS rates were 70% and 67%, respectively. Secondary end points of independently reviewed PFS, other time-to-event end points, and tumor response rates were similar between arms. In exploratory subgroup analyses, patients with germinal-center B cell-like subtype had a better PFS than did patients with activated B cell-like subtype, irrespective of treatment. Frequencies of grade 3 to 5 adverse events (AEs; 73.7% v 64.7%, respectively) and serious AEs (42.6% v 37.6%, respectively) were higher with G-CHOP compared with R-CHOP. Fatal AE frequencies were 5.8% for G-CHOP and 4.3% for R-CHOP. The most common AEs were neutropenia (G-CHOP, 48.3%; R-CHOP, 40.7%), infusion-related reactions (G-CHOP, 36.1%; R-CHOP, 23.5%), nausea (G-CHOP, 29.4%; R-CHOP, 28.3%), and constipation (G-CHOP, 23.4%; R-CHOP, 24.5%). Conclusion G-CHOP did not improve PFS compared with R-CHOP in patients with previously untreated DLBCL. AEs reported with G were consistent with the known safety profile. Biomarker analyses may help define a future role for G in DLBCL.

Double Fortified Salt Intervention Improved Iron Intake But Not Energy and Other Nutrient Intakes in Female Tea Plantation Workers From West Bengal, India

BACKGROUND

Iron deficiency is a global public health concern and has implications on the health status of women in reproductive age.

OBJECTIVE

We hypothesized that improving iron intake with double fortified salt would improve food intake, resulting in higher energy, nutrient intakes, and weight indicators of female tea plantation workers.

METHODS

In this randomized double-masked study, the participants (n = 245) were assigned to receive salt double fortified with iron and iodine (DFS; treatment) or salt fortified with iodine (control) and followed for 7.5 to 9 months. Dietary intakes were measured at three time points, baseline, midpoint, and end line using (1) food frequency questionnaire, (2) 24-hour recall, and (3) weighed lunch intake. Anthropometric measures of height (cm), weight (kg), and mid-upper arm circumference (cm) were also recorded at three time points. Mixed-model repeated-measures approach was used to detect group differences across time.

RESULTS

Double fortified salt improved dietary iron intake in the treatment group compared to the control group ( P < .001). No other dietary or anthropometric differences could be attributed to treatment. Significant effect of time was observed in the intake frequency of major food groups and calcium, vitamin A and C ( P <.001 for all), suggesting an equal effect of seasonality in both the groups.

CONCLUSION

Addition of DFS in the diet improved dietary iron intake but did not affect the intake of energy, other nutrients, or nutritional status indicators. The improvement observed in the dietary iron intake demonstrates that fortification is an effective strategy to address iron deficiency in at-risk populations.

EEG fluctuations of wake and sleep in mild cognitive impairment

Amnestic Mild Cognitive Impairment (aMCI), a condition in which the memory functions of cognition are significantly impaired, is an established risk factor for Alzheimer's disease. Electroencephalography (EEG) is a tool capable of measuring the dynamics of the brain's neural networks, and is thus an important means in analysis and understanding of aMCI. In this proof-of-concept study, we compared the brain activation patterns of ten aMCI subjects with those of four healthy subjects during sleep by employing a 64-channel EEG data collection system. The power spectrum was analyzed to identify sleep stages, while spectral topography and source imaging techniques were employed to study the fluctuating patterns of the brain. Results of this study show an increase in activation power across all sleep stages in the delta and theta frequency bands alongside a decrease in alpha band activity for aMCI subjects. Source imaging analysis of the resting EEG identified default mode network, which becomes decoupled as sleep stages deepen. In the proof-of-concept study, our exploratory analysis demonstrated the feasibility of imaging dynamic network organization using EEG in aMCI.

Abstract P4-20-09: Diagnosing cognitive impairment (“chemo brain”) in breast cancer survivors

Background:

Cognitive complaints (“chemo brain”) are reported frequently after breast cancer treatment but little is known about its incidence and causes. Before we can intervene we need to be able to diagnose it properly. Mini Mental state examination (MMSE) can detect advanced Alzheimer's but won't help in detecting mild cognitive disturbances. We used Montreal Cognitive Assessment for Telephone (MoCA-T) and full scale Montreal Cognitive Assessment for Telephone (MoCA) to diagnose mild cognitive impairments in patients having normal MMSE.

Methods:

20 breast cancer survivors aged 50 years or older completed MoCA-T and MoCA, a year after they completed their treatment for breast cancer, describing the impact of their treatment regimen on their short term memory and ability to think and concentrate. On Day 5, they underwent a standardized laboratory protocol that assessed both behavioral and electroencephalographic (EEG) indicators of memory consolidation.

Results:

Patient characteristics:

20 postmenopausal breast cancer survivors aged 50 or above participated in the study a year after they completed their therapy. We are reporting preliminary results of 10 patients. Patients had stage I-III disease (stage I – One patient, Stage II – five patients, and stage III- four patients). All of them received various chemo regimens e.g. Cytoxan, methotrexate, 5-FU (CMF), Taxol, Trastuzumab (TH), Adriamycin (AC), taxotere, carboplatin (TCH). 8/10 patients received adjuvant radiation. 1/10 patient underwent reconstruction later. 7/10 patients received hormonal therapy with aromatase inhibitors.

Results of MoCA –T and MoCA:

MoCA-T, tests attention and concentration, executive functions, memory, language, conceptual thinking, calculations, and orientation. Possible scores range from 0-22 and scores &lt;18 indicate mild cognitive impairment. The MoCA has possible scores from 0-30 and a score &gt;26 is normal but &lt;19 is indicative of cognitive impairment.

5/10 patients had abnormal MoCA and 3/10 patients had impaired MoCA-T signifying that almost 50%patients develop mild cognitive impairment after breast cancer treatment. During memory consolidation, EEG contained less theta and frequent bursts of alpha waves which is commonly seen in patients with neuropathic pain and insomnia.

MoCA-T and MoCA results for the patientsPatient no.MoCA-TMoCAPtient 00817*23*Patient 0102126Patient 0111923*Patient 01216*27Patient 0132027Patient 01517*21*Patient 0161824*Patient 0172025*Patient 0191926Patient 0202129*presents affected patient

Conclusions:

The study signifies that mild cognitive impairment from breast cancer treatment (or “chemo brain”) was frequently reported and MoCA-T and MoCA tests were able to show even mild cognitive impairment in these patients. We are compiling our full data for EEG but the early results show that the patients had less theta but had frequent bursts of alpha waves, a pattern seen commonly in patients with insomnia and neuropathic pain. They retain fewer items and take more time responding to items as compared to normal people. We need more studies to diagnose and treat mild cognitive impairment (“chemo brain”) in breast survivors as most of these patients are still working and can be a valuable part of the community.

Citation Format: Razaq WA, Tanaka T, Carlson B, Wenger M, Friedman J, Benbrook D, Craft M. Diagnosing cognitive impairment (“chemo brain”) in breast cancer survivors [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-20-09.

Unexplained bleeding as primary clinical complaint in dogs infected with Angiostrongylus vasorum

INTRODUCTION

Unexplained bleeding was the primary clinical complaint in 15 dogs diagnosed with A. vasorum and was observed in the mouth, as external bleeding, as large subcutaneous hematoma, as hemoptysis, in the brain, post ovariectomy, as epistaxis, in the anterior ocular chamber and on a tracheal intubation tube. In 8 dogs the cause of bleeding initially was suspected to be a minor trauma or a surgical complication, and various surgical approaches had been undertaken to eliminate the problem. In only 3 dogs respiratory signs were observed before the bleeding prompted referral. The median time elapsed between the first recognized clinical signs attributed to A. vasorum until diagnosis was 2 weeks (range1 day to 4 months). Four dogs died, 3 on the day of admission and 1 dog 4 days after admission. Suspected causes of death were respiratory failure and cerebral hemorrhage in 2 dogs each. Four dogs had been pre-treated with NSAIDs; of these, 2 dogs developed severe hemoptysis (1 died), 1 dog developed brain hemorrhage (and died), and 1 dog developed a large subcutaneous hematoma with marked anemia. Bleeding at various sites may be the only recognized abnormality in A. vasorum infection. Without a high index of suspicion, the diagnosis and appropriate therapy may be delayed to the point of a fatal outcome. Tests of coagulation were quite variable and the cause of bleeding likely multifactorial.

Rationale for optimal obinutuzumab/GA101 dosing regimen in B-cell non-Hodgkin lymphoma

Obinutuzumab (GA101) is a type II, glycoengineered anti-CD20 monoclonal antibody for the treatment of hematologic malignancies. Obinutuzumab has mechanisms of action that are distinct from those of rituximab, potentially translating into improved clinical efficacy. We present the pharmacokinetic and clinical data from the phase I/II GAUGUIN and phase I GAUDI studies that were used to identify the obinutuzumab dose and regimen undergoing phase III assessment. In phase I (GAUGUIN and GAUDI), non-Hodgkin lymphoma patients received up to a maximum 9 fixed doses (obinutuzumab 50-2000 mg). In GAUGUIN phase II, patients received obinutuzumab 400/400 mg or 1600/800 mg [first dose day (D)1, D8, cycle (C) 1; second dose D1, C2-C8]. The influence of demographic factors on pharmacokinetics and drug exposure on tumor response and toxicity were analyzed using exploratory graphical analyses. Obinutuzumab serum concentrations with 1600/800 mg were compared with a 1000 mg fixed-dose regimen (D1, D8 and D15, C1; D1, C2-C8) using pharmacokinetic modeling simulations. Factors related to CD20-antigenic mass were more influential on obinutuzumab pharmacokinetics with 400/400 versus 1600/800 mg. Higher serum concentrations were observed with 1600/800 versus 400/400 mg, irrespective of CD20-antigenic mass. Tumor shrinkage was greater with 1600/800 versus 400/400 mg; there was no significant increase in adverse events. Fixed dose 1000 mg with an additional C1 infusion resulted in similar serum concentrations to 1600/800 mg in model-based analyses. The obinutuzumab 1000 mg fixed-dose regimen identified in this exploratory analysis was confirmed in a full covariate analysis of a larger dataset, and is undergoing phase III evaluation. GAUGUIN and GAUDI are registered at www.clinicaltrials.gov (clinicaltrials.gov identifier:00517530 and 00825149, respectively).

Developmental oestrogen exposure differentially modulates IGF-I and TNF-α expression levels in immune organs of Yersinia ruckeri-challenged young adult rainbow trout (Oncorhynchus mykiss)

Intensified aquaculture has strong impact on fish health by stress and infectious diseases and has stimulated the interest in the orchestration of cytokines and growth factors, particularly their influence by environmental factors, however, only scarce data are available on the GH/IGF-system, central physiological system for development and tissue shaping. Most recently, the capability of the host to cope with tissue damage has been postulated as critical for survival. Thus, the present study assessed the combined impacts of estrogens and bacterial infection on the insulin-like growth factors (IGF) and tumor-necrosis factor (TNF)-α. Juvenile rainbow trout were exposed to 2 different concentrations of 17β-estradiol (E2) and infected with Yersinia ruckeri. Gene expressions of IGF-I, IGF-II and TNF-α were measured in liver, head kidney and spleen and all 4 estrogen receptors (ERα1, ERα2, ERβ1 and ERβ2) known in rainbow trout were measured in liver. After 5 weeks of E2 treatment, hepatic up-regulation of ERα1 and ERα2, but down-regulation of ERß1 and ERß2 were observed in those groups receiving E2-enriched food. In liver, the results further indicate a suppressive effect of Yersinia-infection regardless of E2-treatment on day 3, but not of E2-treatment on IGF-I whilst TNF-α gene expression was not influenced by Yersinia-infection but was reduced after 5 weeks of E2-treatment. In spleen, the results show a stimulatory effect of Yersinia-infection, but not of E2-treatment on both, IGF-I and TNF-α gene expressions. In head kidney, E2 strongly suppressed both, IGF-I and TNF-α. To summarise, the treatment effects were tissue- and treatment-specific and point to a relevant role of IGF-I in infection.

Obinutuzumab plus chlorambucil in patients with CLL and coexisting conditions

BACKGROUND

The monoclonal anti-CD20 antibody rituximab, combined with chemotherapeutic agents, has been shown to prolong overall survival in physically fit patients with previously untreated chronic lymphocytic leukemia (CLL) but not in those with coexisting conditions. We investigated the benefit of the type 2, glycoengineered antibody obinutuzumab (also known as GA101) as compared with that of rituximab, each combined with chlorambucil, in patients with previously untreated CLL and coexisting conditions.

METHODS

We randomly assigned 781 patients with previously untreated CLL and a score higher than 6 on the Cumulative Illness Rating Scale (CIRS) (range, 0 to 56, with higher scores indicating worse health status) or an estimated creatinine clearance of 30 to 69 ml per minute to receive chlorambucil, obinutuzumab plus chlorambucil, or rituximab plus chlorambucil. The primary end point was investigator-assessed progression-free survival.

RESULTS

The patients had a median age of 73 years, creatinine clearance of 62 ml per minute, and CIRS score of 8 at baseline. Treatment with obinutuzumab-chlorambucil or rituximab-chlorambucil, as compared with chlorambucil monotherapy, increased response rates and prolonged progression-free survival (median progression-free survival, 26.7 months with obinutuzumab-chlorambucil vs. 11.1 months with chlorambucil alone; hazard ratio for progression or death, 0.18; 95% confidence interval [CI], 0.13 to 0.24; P<0.001; and 16.3 months with rituximab-chlorambucil vs. 11.1 months with chlorambucil alone; hazard ratio, 0.44; 95% CI, 0.34 to 0.57; P<0.001). Treatment with obinutuzumab-chlorambucil, as compared with chlorambucil alone, prolonged overall survival (hazard ratio for death, 0.41; 95% CI, 0.23 to 0.74; P=0.002). Treatment with obinutuzumab-chlorambucil, as compared with rituximab-chlorambucil, resulted in prolongation of progression-free survival (hazard ratio, 0.39; 95% CI, 0.31 to 0.49; P<0.001) and higher rates of complete response (20.7% vs. 7.0%) and molecular response. Infusion-related reactions and neutropenia were more common with obinutuzumab-chlorambucil than with rituximab-chlorambucil, but the risk of infection was not increased.

CONCLUSIONS

Combining an anti-CD20 antibody with chemotherapy improved outcomes in patients with CLL and coexisting conditions. In this patient population, obinutuzumab was superior to rituximab when each was combined with chlorambucil. (Funded by F. Hoffmann-La Roche; ClinicalTrials.gov number, NCT01010061.).

Evaluation of aldosterone concentrations in dogs with hypoadrenocorticism

BACKGROUND

Some dogs with primary hypoadrenocorticism (HA) have normal sodium and potassium concentrations, a phenomenon called atypical Addison's disease. The assumption that the zona glomerulosa and aldosterone secretion in these dogs are normal seems widely accepted; however, aldosterone measurements are missing in most published cases.

OBJECTIVES

To measure aldosterone in dogs with HA with and without electrolyte abnormalities and to determine the time point of aldosterone peak concentrations during ACTH stimulation.

ANIMALS

Seventy dogs with HA, 22 dogs with diseases mimicking HA, and 19 healthy dogs.

METHODS

Prospective study. Blood samples were taken before and 60 minutes after injection of 250 μg ACTH in all dogs. Additional blood samples were taken 15, 30, and 45 minutes after ACTH in 7 dogs with HA and in 22 with diseases mimicking HA.

RESULTS

Baseline and ACTH-stimulated aldosterone was significantly lower in dogs with HA than in the other groups. Aldosterone was low or undetectable in 67/70 dogs with HA independently of sodium and potassium levels. In 3 dogs, sodium/potassium concentrations were normal; in 1 dog, sodium was normal and potassium decreased. In all 4, ACTH-stimulated aldosterone concentrations were below the detection limit of the assay. Aldosterone concentrations were not different at 30, 45, or 60 minutes after ACTH administration.

CONCLUSION AND CLINICAL IMPORTANCE

Cortisol and aldosterone secretion is compromised in dogs with HA with and without electrolyte abnormalities. The term atypical Addison's disease, used for dogs with primary HA and normal electrolytes, must be reconsidered; other mechanisms allowing normal electrolyte balance without aldosterone should be evaluated in these dogs.

Obinutuzumab (GA101) in patients with relapsed/refractory indolent non-Hodgkin lymphoma: results from the phase II GAUGUIN study

PURPOSE

The phase II part of the phase I/II GAUGUIN study evaluated the efficacy and safety of two different doses of obinutuzumab (GA101), a type II, glycoengineered, humanized anti-CD20 monoclonal antibody, in patients with relapsed/refractory indolent non-Hodgkin lymphoma.

PATIENTS AND METHODS

Patients were randomly assigned to receive eight cycles of obinutuzumab (GA101) as a flat dose of 400 mg on days 1 and 8 of cycle 1 and also on day 1 of cycles 2 to 8 (400/400 mg) or 1,600 mg on days 1 and 8 of cycle 1 and 800 mg on day 1 of cycles 2 to 8 (1,600/800 mg).

RESULTS

Forty patients were enrolled, including 34 with follicular lymphoma; 38 of 40 patients had previously received rituximab and 22 of 40 were rituximab refractory. The overall response rate at the end of treatment was 55% (95% CI, 32% to 76%) in the 1,600/800-mg group (9% complete responders) and 17% (95% CI, 4% to 41%) in the 400/400-mg group (no complete responders). Five of 10 rituximab-refractory patients had an end-of-treatment response in the 1,600/800-mg group versus one of 12 in the 400/400-mg group. Median progression-free survival was 11.9 months in the 1,600/800-mg group (range, 1.8 to 33.9+ months) and 6.0 months in the 400/400-mg group (range, 1.0 to 33.9+ months). The most common adverse events were infusion-related reactions (IRRs) seen in 73% of patients, but only two patients had grade 3 to 4 IRRs (both in the 1,600/800-mg group). No IRRs were considered serious, and no patients withdrew for IRRs.

CONCLUSION

The 1,600/800-mg dose schedule of obinutuzumab (GA101) has encouraging activity with an acceptable safety profile in relapsed/refractory indolent non-Hodgkin lymphoma.