Effectiveness of tixagevimab/cilgavimab (Evusheld) in antiCD20‑treated patients with multiple sclerosis and neuromyelitis optica spectrum disorder

BACKGROUND

AntiCD20 therapy, such as rituximab, ocrelizumab, or ofatumumab, effectively treats patients with multiple sclerosis (pwMS) or neuromyelitis optica spectrum disorder (pwNMOSD) but negatively affects the humoral immune response to COVID-19 vaccination. One strategy to protect these patients is using tixagevimab/cilgavimab (T/C) as pre-exposure prophylaxis. This study aimed to evaluate the effect of T/C on the incidence of COVID-19 in pwMS and pwNMOSD.

METHODS

Data in this observational cohort study were collected in two Czech MS centres through ReMuS registry between March 1, 2020 and December 31, 2022. Adult pwMS and pwNMOSD who were (1) treated with antiCD20 therapy at least six months before T/C administration, or at least from February 1, 2022 in the control group; (2) were already on antiCD20 therapy at the time of vaccination or COVID-19 infection; and (3) were on antiCD20 therapy at least 100 days after T/C, or at least 90 days after August 1, 2022 in the control group, were included. Analysis was performed using frequency-based (propensity score matching) and Bayesian statistical methods (informative and non-informative priors).

RESULTS

Using propensity score matching 1:1, 47 patients who received T/C (mean age 45.7 years, median disease duration 12.5 years) were matched with those who did not receive T/C (n = 341; mean age 46.6 years, median disease duration 11.4 years) based on age, MS/NMOSD duration, and number of vaccine doses. None of the T/C patients and three in the control matched group, developed COVID-19 between 10 and 100 days after receiving T/C, August 1, 2022, respectively. The frequency of COVID-19 was not significantly different between groups (p = 0.242). Due to the low number of patients, a Bayesian analysis was also added. Using a non-informative Bayesian prior, the median relative risk of COVID-19 after T/C was 7.6 % (95 % CrI 0.02-115.9 %). The posterior probability of risk difference lower than zero was 96.4 %. Using an informative prior (based on the registration study of Evusheld), the median relative risk of COVID-19 after T/C was 20.2 % (95 % CI 8.4-43.8 %). The posterior probability of the risk difference lower than zero was 100 %.

CONCLUSION

This work highlights the possible good efficacy of T/C in antiCD20-treated pwMS and pwNMSOD. Based on Bayesian analysis with an informative prior, the T/C group's risk of COVID-19 infection was approximately 20.2 % of the control group's risk. However, given the low frequency of COVID-19, the results of this pilot analysis must be interpreted with caution.

Simultaneous tonic and phasic REM sleep without atonia best predicts early phenoconversion to neurodegenerative disease in idiopathic REM sleep behavior disorder

Study Objectives

Rapid eye movement (REM) sleep without atonia (RWA) is the main polysomnographic feature of idiopathic REM sleep behavior disorder (iRBD) and is considered to be a promising biomarker predicting conversion to manifested synucleinopathy. Besides conventionally evaluated tonic, phasic and any RWA, we took into consideration also periods, when phasic and tonic RWA appeared simultaneously and we called this activity “mixed RWA.” The study aimed to evaluate different types of RWA, to reveal the most relevant biomarker to the conversion.

Methods

A total of 55 patients with confirmed iRBD were recruited with mean follow-up duration 2.3 ± 0.7 years. Scoring of RWA was based on Sleep Innsbruck Barcelona rules. Positive phenocoversion was ascertained according to standard diagnostic criteria during follow-up. Receiver operator characteristic analysis was applied to evaluate predictive performance of different RWA types.

Results

A total of nine patients (16%) developed neurodegenerative diseases. Yearly phenoconversion rate was 5.5%. Significantly higher amounts of mixed (p = 0.009), tonic (p = 0.020), and any RWA (p = 0.049) were found in converters. Optimal cutoffs differentiating the prediction were 16.4% (sensitivity 88.9; specificity 69.6) for tonic, 4.4% (sensitivity 88.9; specificity 60.9) for mixed, and 36.8% (sensitivity 77.8; specificity 65.2) for any RWA. With area under the curve (AUC) 0.778, mixed RWA has proven to be the best predictive test followed by tonic (AUC 0.749) and any (AUC 0.710).

Conclusions

Mixed, tonic and any RWA may serve as biomarkers predicting the conversion into neurodegenerative disease in iRBD. The best predictive value lies within mixed RWA, thus it should be considered as standard biomarker.

Thalamic Iron Differentiates Primary-Progressive and Relapsing-Remitting Multiple Sclerosis

BACKGROUND AND PURPOSE

Potential differences between primary progressive and relapsing remitting multiple sclerosis are the subject of ongoing controversial discussions. The aim of this work was to determine whether and how primary-progressive and relapsing-remitting multiple sclerosis subtypes differ regarding conventional MR imaging parameters, cerebral iron deposits, and their association with clinical status.

MATERIALS AND METHODS

We analyzed 24 patients with primary-progressive MS, 80 with relapsing-remitting MS, and 20 healthy controls with 1.5T MR imaging for assessment of the conventional quantitative parameters: T2 lesion load, T1 lesion load, brain parenchymal fraction, and corpus callosum volume. Quantitative susceptibility mapping was performed to estimate iron concentration in the deep gray matter.

RESULTS

Decreased susceptibility within the thalamus in relapsing-remitting MS compared with primary-progressive MS was the only significant MR imaging difference between these MS subtypes. In the relapsing-remitting MS subgroup, the Expanded Disability Status Scale score was positively associated with conventional parameters reflecting white matter lesions and brain atrophy and with iron in the putamen and caudate nucleus. A positive association with putaminal iron and the Expanded Disability Status Scale score was found in primary-progressive MS.

CONCLUSIONS

Susceptibility in the thalamus might provide additional support for the differentiation between primary-progressive and relapsing-remitting MS. That the Expanded Disability Status Scale score was associated with conventional MR imaging parameters and iron concentrations in several deep gray matter regions in relapsing-remitting MS, while only a weak association with putaminal iron was observed in primary-progressive MS suggests different driving forces of disability in these MS subtypes.

Diagnostic Efficiency of Serum and Urine Procathepsin B and Cathepsin B in Patients with Carcinoma of the Urinary Bladder

BACKGROUND

The aim of the study was to evaluate the diagnostic efficiency of cathepsins B (cathepsin B and procathepsin B) in patients with transient cell carcinoma of the urinary bladder.

METHODS

Serum and urine concentrations of cathepsin B and procathepsin B were measured by two commercially available enzymatic immunoassays in a group of 125 patients with bladder cell carcinoma without metastases and in a group of 72 healthy individuals. Concentrations in urine were adjusted to creatinine.

RESULTS

Concentrations of both cathepsin B and procathepsin B in serum and urine were significantly elevated in patients with bladder cell carcinoma (p < 0.0001 for U-procathepsin B, U-procathepsin B/creatinine, and U-cathepsin B/creatinine, p = 0.0001 for U-cathepsin B, p = 0.0002 for S-procathepsin B and p = 0.02 for S-cathepsin B). Comparison of all diagnostic efficiencies of cathepsin B and procathepsin B in serum and in urine showed the best diagnostic accuracy for procathepsin B in urine (AUC = 0.81 vs. 0.50). The ratio of U-procathepsin B/creatinine was also more efficient than the ratio of U-cathepsin B/creatinine (AUC = 0.81 vs. AUC = 0.70). The diagnostic efficiencies of both parameters in serum were low (S-procathepsin B: AUC = 0.50, S-cathepsin B: AUC = 0.60). U-procathepsin B and U-procathepsin B/creatinine ratio show significantly better diagnostic efficiency in patients with invasive bladder tumors than other parameters (S-procathepsin B, S-cathepsin B, U-cathepsin B and U-Cathepsin B/creatinine; U-procathepsin B: AUC = 0.82, U-procathepsin B/creatinine: AUC = 0.86, S-procathepsin B and cathepsin B: AUC = 0.51 - 0.68).

CONCLUSIONS

Procathepsin B concentration in urine is a valuable diagnostic marker in patients with bladder cell carcinoma.

Wilms tumor gene 1 (WT1), TP53, RAS/BRAF and KIT aberrations in testicular germ cell tumors

PURPOSE

Wilms tumor gene 1 (WT1), a zinc-finger transcription factor essential for testis development and function, along with other genes, was investigated for their role in the pathogenesis of testicular germ cell tumors (TGCT).

METHODS

In total, 284 TGCT and 100 control samples were investigated, including qPCR for WT1 expression and BRAF mutation, p53 immunohistochemistry detection, and massively parallel amplicon sequencing.

RESULTS

WT1 was significantly (p < 0.0001) under-expressed in TGCT, with an increased ratio of exon 5-lacking isoforms, reaching low levels in chemo-naïve relapsed TGCT patients vs. high levels in chemotherapy-pretreated relapsed patients. BRAF V600E mutation was identified in 1% of patients only. p53 protein was lowly expressed in TGCT metastases compared to the matched primary tumors. Of 9 selected TGCT-linked genes, RAS/BRAF and WT1 mutations were frequent while significant TP53 and KIT variants were not detected (p = 0.0003).

CONCLUSIONS

WT1 has been identified as a novel factor involved in TGCT pathogenesis, with a potential prognostic impact. Distinct biologic nature of the two types of relapses occurring in TGCT has been demonstrated. Differential mutation rate of the key TGCT-related genes has been documented.

Iron and Non-Iron-Related Characteristics of Multiple Sclerosis and Neuromyelitis Optica Lesions at 7T MRI

BACKGROUND AND PURPOSE

Characterization of iron deposition associated with demyelinating lesions of multiple sclerosis and neuromyelitis optica has not been well studied. Our aim was to investigate the potential of ultra-high-field MR imaging to distinguish MS from neuromyelitis optica and to characterize tissue injury associated with iron pathology within lesions.

MATERIALS AND METHODS

Twenty-one patients with MS and 21 patients with neuromyelitis optica underwent 7T high-resolution 2D-gradient-echo-T2* and 3D-susceptibility-weighted imaging. An in-house-developed algorithm was used to reconstruct quantitative susceptibility mapping from SWI. Lesions were classified as "iron-laden" if they demonstrated hypointensity on gradient-echo-T2*-weighted images and/or SWI and hyperintensity on quantitative susceptibility mapping. Lesions were considered "non-iron-laden" if they were hyperintense on gradient-echo-T2* and isointense or hyperintense on quantitative susceptibility mapping.

RESULTS

Of 21 patients with MS, 19 (90.5%) demonstrated at least 1 quantitative susceptibility mapping-hyperintense lesion, and 11/21 (52.4%) had iron-laden lesions. No quantitative susceptibility mapping-hyperintense or iron-laden lesions were observed in any patients with neuromyelitis optica. Iron-laden and non-iron-laden lesions could each be further characterized into 2 distinct patterns based on lesion signal and morphology on gradient-echo-T2*/SWI and quantitative susceptibility mapping. In MS, most lesions (n = 262, 75.9% of all lesions) were hyperintense on gradient-echo T2* and isointense on quantitative susceptibility mapping (pattern A), while a small minority (n = 26, 7.5% of all lesions) were hyperintense on both gradient-echo-T2* and quantitative susceptibility mapping (pattern B). Iron-laden lesions (n = 57, 16.5% of all lesions) were further classified as nodular (n = 22, 6.4%, pattern C) or ringlike (n = 35, 10.1%, pattern D).

CONCLUSIONS

Ultra-high-field MR imaging may be useful in distinguishing MS from neuromyelitis optica. Different patterns related to iron and noniron pathology may provide in vivo insight into the pathophysiology of lesions in MS.

The use of early postoperative prostate-specific antigen to stratify risk in patients with positive surgical margins after radical prostatectomy

BACKGROUND

It is well recognized that the presence of positive surgical margins (PSM) after radical prostatectomy (RP) adversely affects cancer specific outcomes and recent evidence from randomized trials supports the use of adjuvant radiotherapy in these cases. However, not all of the patients with PSM develop disease recurrence and the policy of adjuvant radiation could result in considerable over-treatment. We investigated the ability of early postoperative prostate specific antigen (PSA) and PSA decline rates to stratify the risk of disease progression during the first weeks after the surgery thereby allowing adequate time for planning eventual adjuvant therapy.

METHODS

We studied 116 consecutive patients with the finding of PSM after RP for localized prostate cancer between 2001 and 2012. No patients were treated with radiation or hormonal therapy. An intensive postoperative PSA monitoring using ultrasensitive assay started first at day 14 after the surgery, then at day 30, 60, 90 and 180, and subsequently in 3 monthly intervals. Biochemical recurrence (BCR) presented the failure of surgical treatment and it was defined as PSA ≥0.2 ng/ml. The ability of PSA decline parameters to predict BCR was assessed using Cox regression model and area under the curve (AUC) calculation.

RESULTS

Overall 55 (47%) patients experienced BCR during median follow-up of 31.4 months (range 6-69). Preoperative PSA, pathologic Gleason sum and pathologic grade failed to reveal any association with observation of BCR. Postoperative PSA levels achieved significant predictive accuracy already on day 30 (AUC 0.74). PSA >0.073 ng/ml at day 30 increased significantly the risk of BCR (HR 4.35, p < 0.001). Predictive accuracy was significantly exceeded on day 60 (AUC 0.84; p < 0.001), while further enhancements on day 90 (AUC 0.84) and 180 (AUC 0.91) were not significant.

CONCLUSIONS

The level of ultrasensitive PSA yields valuable information about the prostatectomy outcome already at the first month after the surgery and should aid risk stratification in patients with PSM. Patients not likely to experience subsequent disease progression may be spared the toxicity of immediate adjuvant radiotherapy.

Urine and serum cathepsin B concentrations in the transitional cell carcinoma of the bladder

BACKGROUND

It has been shown that expression and activity of lysosomal proteolytic enzymes (i.e., cathepsin B) correlate with tumor progression in various neoplasms. We investigate possible correlation of cathepsin B concentrations with grading and invasivity of tumorous bladder tissue.

METHOD

Cathepsin B concentrations in serum and urine were measured in 40 patients (29 men, 11 women, mean age 68 years) with transitional cell carcinoma (TCC) of the bladder without metastases and in control group of 64 healthy subjects (28 men, 36 women, mean age 55 years) using commercially available enzymatic immunoassay. Concentration of cathepsin B in urine was adjusted on creatinine. Urinary creatinine in all samples was measured by enzymatic creatinase method. Patients were divided into groups according to the grading (low grading: 18 patients, high grading: 22 patients) and invasivity of the carcinoma (nonmuscle-invasive tumors: 23 patients, invasive tumors: 17 patients).

RESULT

Concentrations of cathepsin B in urine were significantly elevated in patients than in control group (Median = 3.87 μg/L vs. 1.35 μg/L, P = 0.0002). Similarly, the ratio of U-cathepsin B/creatinine was significantly higher in patients (Median: 0.44 μg/mmol creatinine vs. 0.17 μg/mmol creatinine, P < 0.0001). U-cathepsin B may prove to be useful biomarker (area under the curve [AUC] = 0.72 and 0.73 for the U-cathepsin B/creatinine ratio, respectively). S-cathepsin B significantly correlated with grading of carcinoma (P = 0.02) and U-cathepsin B and U-cathepsin B/creatinine are positively associated with invasive tumors (P = 0.0001 and P = 0.002).

CONCLUSION

Cathepsin B concentrations correlate well with grading and invasivity of tumors and may have diagnostic value in investigation of bladder cell carcinoma. New index U-cathepsin B/Creatinine ratio is more appropriate biomarker to monitor TCC, than U-cathepsin B so far.

Positron emission tomography and clinical predictors of survival in primary extragonadal germ cell tumors

BACKGROUND

Primary extragonadal germ cell tumors (EGTs) are an uncommon malignancy -accounting for 2-4% of all germ cell neoplasms in adult males. Their prognosis is worse than that for testicular germ cell tumors because of their relative chemoresistance and frequent presentation with widely disseminated metastases. We have studied the role of fluorodeoxyglucose positron emission tomography (FDG-PET) for outcome prediction of patients with EGTs.

PATIENTS AND METHODS

We have retrospectively analysed 36 men with germ cell tumors originating in the mediastinum or the retroperitoneum. All patients were treated between 1994 and 2010. Negative result of testicular ultrasonographic examination and/or testicular biopsy was required for diagnosis of EGT. Platinum-based systemic therapy was used in all cases, and resectable residual tumor masses were removed surgically.

RESULTS

Overall survival at one and three years was 81% (95% confidence interval [CI]: 68-94%) and 55% (CI: 38-71%), respectively. None of the patients who had positive FDG-PET findings after first line chemotherapy survived at three years after diagnosis. In contrast, 69% and 20% of patients with positive tumor markers, and 90% and 67% of patients with negative tumor markers after first line chemotherapy survived at one and three years, respectively. Negative FDG-PET after completion of treatment was also a powerful predictor of long-term survival with 100% patients surviving three years and 89% surviving five years after diagnosis.

CONCLUSIONS

Negative FDG-PET after first-line chemotherapy or after the completion of systemic treatment and resection of residual tumor masses strongly predicts long-term event-free survival in patients with EGTs.

[Time perception in functional brain imaging]

BACKGROUND

Knowledge of physiological mechanisms underlying time perception is still rather limited. The aim of our study was to search for a 'time accumulator', i.e. the part of the brain where information on the duration of time is stored.

METHODS AND RESULTS

Nine healthy volunteers were given a time reproduction task during event-related fMRI. Subjects were instructed to retain the duration of the stimulus presented (presentation phase) and then to reproduce it by pressing a button (reproduction phase). Two different analyses were made: event-related (P < 0.05, FWR corrected) and parametric (BOLD signal increase/decrease during the presentation/reproduction phases correlated with the time intervals; P < 0.01, FDR corrected). When the event-related approach was employed, activation was noted bilaterally in the inferior prefrontal cortex (IPFC), supplementary motor area (SMA), precuneus and secondary visual cortex. On the right, there was activation in the dorsolateral prefrontal cortex (DLPFC), gyrus cinguli and inferior parietal lobule. On the left, the primary sensory-motor cortex was activated. While during the presentation phase the left DLPFC activity inversely correlated with the presented duration, a nearly identical area showed positive correlation in the reproduction phase.

CONCLUSIONS

The event-related analysis did not allow distinguishing the process of time perception from many cognitive processes running simultaneously. In turn, the parametric analysis was based on visualizing regions, in which the signal correlated with the varying duration of the time interval provided the level of attention, decision-making and the processes of behavioral response planning and execution were constant. Moreover, the right and left DLPFC seem to play different roles in time perception. While the left one is functioning as a "time accumulator", the right one is rather involved in the recognition of previously perceived intervals.

[Results of surgical treatment of benign prostatic hyperplasia]

The authors have evaluated the results of the BPH surgery in the computer study on 669 patients (out of them 181 after TVPE and 488 after TURP) operated on at the department of Urology, FN Motol during 1988-1992. The average age of the patients was 70.6 years. The occult cancer was found in 6.7%. The incidence of bladder stones rose with the age (in the 8th decade at the quarter of patients). The average weight of the resected tissue was 63.7 gms in TVPE and 16.7 gms in TURP and it rose with the age. The average surgery time 47.1 mins at TVPE and 50.8 mins at TURP did not change statistically. The average demand on the blood transfusion was higher at TVPE (440.1 mls) than at TURP (95.5 mls) and rose with the resected tissue. The death rate was 0.5% among all the patients included (TVPE 0, TURP 0.6%). All three patients after TURP died from myocardial infarction. In this thesis is evaluated the number of early and late complications (incl. the transient incontinence), which have occurred in five consecutive years. The total morbidity was 27.2% and the further surgery was necessary in 2.8% after TVPE and 5.7% after TURP respectively. The pre-surgery performance status was aggravated in 79.4% of patients. In spinal anesthesia was operated on in 84.2% (subarachnoidal 56.5% and epidural 27.7%) and in general anesthesia in only 15.8% of patients. The pre-surgery urinary infection was found in 38.7% and after operation in 29.3%. Out of the latter, 30% were nosocomials. This was in accordance with the higher rate of late complications after both types of operations.

[Subjective symptoms before and after prostate surgery. The International Symptom Scoring System, I-PSS]

In this thesis are evaluated the questionnaires of the I-PSS retrieved from 415 patients (TVPE 104, TURP 272, TUIP + PRP 25 and TUIP 14) operated on the BPH at the department of Urology, FN Motol, during 1988-1993. The average value of S in the whole group of patients was 18.9 in the pre-surgery period and 6.9 after surgery. Before the surgery, the prominent difficulties were recorded in 50.8% of patients (S = 20-35) and after surgery this number fell down to 7%. Without any major difficulties (S = 0-7) were 66.3% of patients after the surgery. The average value of L before and after surgery was 4.2 and 1.6 respectively. The quality of life after the surgery was perceived by the patients more convenient than should correspond to the symptom scoring value. The best results (both the average S and L) were recorded in patients after TVPE (S 5.1 and L 1.1), followed by TURP (S 7.4 and L 1.7), than TUIP + PRP (S 8.4 and L 2.1) and only TUIP alone closed scale (S 8.9 and L 2.4). The differences of postsurgery S and L are statistically significant (p < 0.05). The comparison between the subjective better performance and the quality of life, when taken from TVPE resp. TURP point of view, does not prove to be the statistical difference. The comparison between S changes after the standard operation (TVPE and TURP) and minor prostatic surgery (TUIP + PRP and TUIP) also does not occur as statistically significant. Only the quality of life (L changes) is recorded by the patients as significantly worse after the minor prostatic surgery (p < 0.05). The pre-surgery worst perceived symptoms are: weak stream, nycturia and polakisuria (questions Nr. 5.7 and 2). After the surgery, nycturia is the leading worst symptom.

[Sexual consequences of benign prostatic hyperplasia]

In this thesis are evaluated the sexual questionnaires retrieved from 412 patients (TVPE 101, TURP 272, TUIP + PRP 25, TUIP 14), who had been operated on during 1988-1993 for the BPH at the department of Urology, FN Motol. Before the surgery, 69.7% of patients were sexually active yet (28.6% regularly, 41% irregularly). Without sexual intercourse were 29.9% in the time of surgery and 2 patients (0.5% did not respond the questions. The sexual activity was rapidly declining in the 7th decade, in the 8th decade still 41% of the patient argued sexual activity prior to surgery. The libido remained unchanged in 62.9%, worsened in 24.3% and improved in 10.7%. The changes in libido was neither parallel to the aging nor the type of prostatic surgery. After the surgery, the intercourse was admitted only by 49.3% of patients. Without any intercourse remained 50%. The difference compared to the pre-surgery responds is statistically proved (p < 0.01). The erectile dysfunction seemed to be the main cause of sexual intercourse decline. The impotence margin after TVPE or TURP is not statistically significant. On the other hand, the reawakening of the sexual activity at the patients, who had already not experienced intercourse preoperatively, was recorded only in 6 cases (1.5%). The unchanged ejaculation after surgery argued 13.1% of patients, the weaker ejaculation was recorded in 21.6% of patients and ejaculation was completely absent in 62.4% (retrograde ejaculation). Between TVPE and TURP was no significant margin found. The ejaculation damage after minimal prostatic surgery (TUIP + PRP and TUIP alone) is significantly minor (p < 0.01) than after the standard prostatectomy (TVPE and TURP).