Role of Thioredoxin System in Regulating Cellular Redox Status in Alzheimer's Disease

Alzheimer's disease (AD) is the most common form of dementia and a public health problem. It exhibits significant oxidative stress and redox alterations. The antioxidant enzyme systems defend the cellular environment from oxidative stress. One of the redox systems is the thioredoxin system (TS), which exerts decisive control over the cellular redox environment. We aimed to review the protective effects of TS, which include thioredoxin (Trx), thioredoxin reductase (TrxR), and NADPH. In the following, we discussed the physiological functioning and the role of the TS in maintaining the cellular redox-homeostasis in the AD-damaged brain. Trx protects the cellular environment from oxidative stress, while TrxR is crucial for the cellular detoxification of reactive oxygen species in the brain. However, TS dysregulation increases the susceptibility to cellular death. The changes in Trx and TrxR levels are significantly associated with AD progression. Though the data from human, animal, and cellular models support the neuroprotective role of TS in the brain of AD patients, the translational potential of these findings to clinical settings is not yet applied. This review summarizes the current knowledge on the emerging role of the TrxR-Trx system in AD.

Use of Advanced Flexible Modeling Approaches for Survival Extrapolation from Early Follow-up Data in two Nivolumab Trials in Advanced NSCLC with Extended Follow-up

OBJECTIVES

Immuno-oncology (IO) therapies are often associated with delayed responses that are deep and durable, manifesting as long-term survival benefits in patients with metastatic cancer. Complex hazard functions arising from IO treatments may limit the accuracy of extrapolations from standard parametric models (SPMs). We evaluated the ability of flexible parametric models (FPMs) to improve survival extrapolations using data from 2 trials involving patients with non-small-cell lung cancer (NSCLC).

METHODS

Our analyses used consecutive database locks (DBLs) at 2-, 3-, and 5-y minimum follow-up from trials evaluating nivolumab versus docetaxel in patients with pretreated metastatic squamous (CheckMate-017) and nonsquamous (CheckMate-057) NSCLC. For each DBL, SPMs, as well as 3 FPMs-landmark response models (LRMs), mixture cure models (MCMs), and Bayesian multiparameter evidence synthesis (B-MPES)-were estimated on nivolumab overall survival (OS). The performance of each parametric model was assessed by comparing milestone restricted mean survival times (RMSTs) and survival probabilities with results obtained from externally validated SPMs.

RESULTS

For the 2- and 3-y DBLs of both trials, all models tended to underestimate 5-y OS. Predictions from nonvalidated SPMs fitted to the 2-y DBLs were highly unreliable, whereas extrapolations from FPMs were much more consistent between models fitted to successive DBLs. For CheckMate-017, in which an apparent survival plateau emerges in the 3-y DBL, MCMs fitted to this DBL estimated 5-y OS most accurately (11.6% v. 12.3% observed), and long-term predictions were similar to those from the 5-y validated SPM (20-y RMST: 30.2 v. 30.5 mo). For CheckMate-057, where there is no clear evidence of a survival plateau in the early DBLs, only B-MPES was able to accurately predict 5-y OS (14.1% v. 14.0% observed [3-y DBL]).

CONCLUSIONS

We demonstrate that the use of FPMs for modeling OS in NSCLC patients from early follow-up data can yield accurate estimates for RMST observed with longer follow-up and provide similar long-term extrapolations to externally validated SPMs based on later data cuts. B-MPES generated reasonable predictions even when fitted to the 2-y DBLs of the studies, whereas MCMs were more reliant on longer-term data to estimate a plateau and therefore performed better from 3 y. Generally, LRM extrapolations were less reliable than those from alternative FPMs and validated SPMs but remained superior to nonvalidated SPMs. Our work demonstrates the potential benefits of using advanced parametric models that incorporate external data sources, such as B-MPES and MCMs, to allow for accurate evaluation of treatment clinical and cost-effectiveness from trial data with limited follow-up.

HIGHLIGHTS

Flexible advanced parametric modeling methods can provide improved survival extrapolations for immuno-oncology cost-effectiveness in health technology assessments from early clinical trial data that better anticipate extended follow-up.Advantages include leveraging additional observable trial data, the systematic integration of external data, and more detailed modeling of underlying processes.Bayesian multiparameter evidence synthesis performed particularly well, with well-matched external data.Mixture cure models also performed well but may require relatively longer follow-up to identify an emergent plateau, depending on the specific setting.Landmark response models offered marginal benefits in this scenario and may require greater numbers in each response group and/or increased follow-up to support improved extrapolation within each subgroup.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

P3729The left atrial appendage closure by surgery-2 randomized trial

Background

Since the left atrium appendage (LAA) is the predilection site for clot formation in patients with atrial fibrillation (AF), closure of the LAA during surgery (LAACS) is often performed but not yet demonstrated to protect against stroke. The recent LAACS trial found that LAA closure protected from strokes and silent brain damages on a moderate (n=187) number of patients. However, results based solely on strokes and cerebral transitory ischemic attacks (TIA) was not significant (18% events in the control group compared to 6% in patients where LAA was closed (p=0.07). Furthermore, incomplete closure of the LAA is of concern, with an increased relative risk for stroke (10–25%).

Purpose

Determine if LAA closure added to planned open heart surgery protects against post-operative major stroke and minor stroke.

Methods

Adults scheduled for open-heart surgery who sign informed consent will be included regardless of known AF, provided LAA closure is not previously planned. LAACS-2 is an open, parallel, international multi-center study where patients will be randomized to closure of the LAA (with clip or staple), in addition to planned open-heart surgery. The LAA will remain open in the control group. Randomization will be stratified according to ongoing or expected use of anti-coagulant medication following surgery and classified as coronary artery bypass surgery (CABG) alone, mitral valve surgery or other. The primary endpoint is stroke or TIA occurring over at least two years following surgery. Secondary endpoints are: Total mortality and a combination of stroke, TIA or image of recent cerebral infarction in clinical settings demonstrated post-operatively, until the end follow-up. Occurrence of AF during follow-up will be assessed with prolonged (up to several weeks) monitoring with a three-lead compact sensor.

Studies on percutaneous coronary intervention and CABG, estimate a 3.7% pooled incidence of stroke in the first three years following coronary by-pass operations. Using these estimates and those from the previous LAACS study (3.2% strokes on patients with closed LAA vs 11.3% in the control group, p=0.07), we estimate that LAA closure can be demonstrated to protect from strokes, with a significance level of 0.05 and a 90% power, including 1200–1400 patients in an event-driven study. Expecting a cross-over of 10–20%, we plan to enroll 2000 adults. According to the a priori power-calculations, the LAACS-2 trial is powered: 1) to determine if randomization to closure of the LAA in conjunction with planned open-heart surgery, protects patients from post-operative clinical strokes; and 2) if there is an increased thrombogenic effect of incomplete closure or excessive pouch, since such harm can be identified by including between 359 and 1455 patients.

Perspective

If the LAACS procedure in conjunction with planned open-heart surgery protects against future stroke it should be included in future guidelines.

Acknowledgement/Funding

Innovation Fund Denmark; NovoNordisk Foundation; Ib Mogens Christiansen; Bispebjerg-Frederiksberg Research Fund

The relationship between childhood adversities and dissociation in severe mental illness: a meta-analytic review

OBJECTIVE

Several studies have observed that dissociative experiences are frequently reported by individuals with severe mental illness (SMI), especially amongst patients that report a history of adverse/traumatic life experiences. This review examined the magnitude and consistency of the relationship between childhood adversity (sexual abuse, physical abuse, emotional abuse, neglect, bullying, natural disasters and mass violence) and dissociation across three SMI diagnostic groups: schizophrenia, bipolar disorder and personality disorders.

METHOD

A database search (EMBASE, PubMed and PsycINFO) identified 30 eligible empirical studies, comprising of 2199 clinical participants. Effect sizes representing the relationship between exposure to childhood adversity and dissociation were examined and integrated using a random-effects meta-analysis.

RESULTS

The results indicated that exposure to childhood trauma was associated with heightened dissociation across SMIs. Positive significant associations were also found between specific childhood adversities and dissociation, with aggregated effect sizes in the small-to-moderate range.

CONCLUSION

These findings support calls for the routine assessment of traumatic experiences in clients with SMIs presenting with dissociative symptoms and the provision of adequate therapeutic support (e.g. trauma-focused therapies) to manage and resolve these difficulties.

Multiplex real-time RT-PCR assay for transfusion transmitted viruses in sero-negative allogeneic blood donors: an experience from Southern Pakistan

BACKGROUND

Blood transfusion safety commences with healthy donor recruitment. The threat of transfusion transmitted infections is greatly minimized by serological tools but not entirely eliminated. Recently, nucleic-acid testing for blood donor screening has virtually eliminated this jeopardy.

METHODS

This prospective study was conducted from February 2015 to February 2016. Samples from seronegative donors were run on multiplex assay (Cobas, S-201 system platform, Roche) in a batch of six [MP-NAT]. In case of reactive pool, tests were run on every individual sample [IDNAT].

RESULTS

Of 16957 donors, 16836 (99.2%) were replacement donors and the remaining 121 (0.7%) were voluntary donors, with a mean age of 29.09 ± 7.04 years. After serologic screening of all 16957 donors, 955 (5.6%) were found to be reactive; 291(1.71%) were reactive for hepatitis-B surface antigen, 361 (2.12%) for antibody to hepatitis C virus (anti-HCV), 14 (0.08%) for antibody to human immunodeficiency virus, 287 (1.69%) for syphilis and 2 (0.01%) for malaria. 14 (0.08%) NAT reactive donors were identified after testing the 16002 seronegative donors, with an overall NAT yield of one reactivity out of 1143 blood donations; 10 donors for HBV-DNA (HBV NAT yield-1:1600) and remaining 4 for HCV-RNA (HCV-NAT yield-1:4000). None were HIV positive.

CONCLUSION

NAT has improved the safety attributes in blood products. Although the positivity rate for NAT testing is low but in view of the high prevalence of transfusion transmitted infections in our country, we recommend the parallel use of both serology and NAT screening of all donated blood.

Pediatric tuberculosis drug market: an insider perspective on challenges and solutions

Representative stakeholders were consulted on how they felt access to pediatric tuberculosis (TB) drugs could be improved. A key recommendation is the development of new child-friendly, adequately dosed formulations with a good shelf life in all climate zones. There is also an urgent need to improve the diagnosis and reporting of children with TB. Manufacturers of pediatric TB medications are to be incentivized through improved coordination among all stakeholders, with streamlined regulatory approvals and increased consumer education on drug and regimen guidelines. Finally, pooled procurement is advised to ensure sustained market supply against affordable prices.

Association analysis of 31 common polymorphisms with type 2 diabetes and its related traits in Indian sib pairs

AIMS/HYPOTHESIS

Evaluation of the association of 31 common single nucleotide polymorphisms (SNPs) with fasting glucose, fasting insulin, HOMA-beta cell function (HOMA-β), HOMA-insulin resistance (HOMA-IR) and type 2 diabetes in the Indian population.

METHODS

We genotyped 3,089 sib pairs recruited in the Indian Migration Study from four cities in India (Lucknow, Nagpur, Hyderabad and Bangalore) for 31 SNPs in 24 genes previously associated with type 2 diabetes in European populations. We conducted within-sib-pair analysis for type 2 diabetes and its related quantitative traits.

RESULTS

The risk-allele frequencies of all the SNPs were comparable with those reported in western populations. We demonstrated significant associations of CXCR4 (rs932206), CDKAL1 (rs7756992) and TCF7L2 (rs7903146, rs12255372) with fasting glucose, with β values of 0.007 (p = 0.05), 0.01 (p = 0.01), 0.007 (p = 0.05), 0.01 (p = 0.003) and 0.08 (p = 0.01), respectively. Variants in NOTCH2 (rs10923931), TCF-2 (also known as HNF1B) (rs757210), ADAM30 (rs2641348) and CDKN2A/B (rs10811661) significantly predicted fasting insulin, with β values of -0.06 (p = 0.04), 0.05 (p = 0.05), -0.08 (p = 0.01) and -0.08 (p = 0.02), respectively. For HOMA-IR, we detected associations with TCF-2, ADAM30 and CDKN2A/B, with β values of 0.05 (p = 0.04), -0.07 (p = 0.03) and -0.08 (p = 0.02), respectively. We also found significant associations of ADAM30 (β = -0.05; p = 0.01) and CDKN2A/B (β = -0.05; p = 0.03) with HOMA-β. THADA variant (rs7578597) was associated with type 2 diabetes (OR 1.5; 95% CI 1.04, 2.22; p = 0.03).

CONCLUSIONS/INTERPRETATION

We validated the association of seven established loci with intermediate traits related to type 2 diabetes in an Indian population using a design resistant to population stratification.

Emergency thoracotomies in the largest trauma center in Denmark: 10 years' experience

AIM

The aim of our study was to investigate the outcome in terms of 30-day survival and to determine whether preoperative factors could predict the outcome.

METHODS

All patients who underwent an emergency thoracotomy (ET) during the period 2000 to 2009 were included. The patients were divided into two groups: emergency department thoracotomy and operating room thoracotomy. Data on demographics, mechanism of injury, intraoperative data, Injury Severity Scores (ISS), probability of survival, signs of life, transportation time, indications, and outcome were collected.

RESULTS

Forty-four ETs were performed. The mechanisms of injury were penetrating in 28 (64%) and blunt in 16 (36%) cases. In the emergency department thoracotomy group, the survival was 45 versus 20% for penetrating and blunt trauma, respectively. The total survival was 33%. In the operating room thoracotomy group, the survival was 83%. The survivors had a significantly lower ISS and a higher calculated probability of survival. The calculated mean probability of survival was 44 and 84% in the emergency department thoracotomy and operating room thoracotomy groups, respectively. The actual survival was similar, with 33% in the emergency department thoracotomy group and 83% in the operating room thoracotomy group.

CONCLUSIONS

The probability of survival and ISS are good predictors of survival in these patients and should be included in the future in order to make upcoming studies easier to compare. Patients with very high ISS or low probability of survival survived, justifying the procedure in our center.

Assessing association of common variation in the C1Q gene cluster with systemic lupus erythematosus

Recent studies have tested genetic variation at the C1QA, C1QB and C1QC (complement component 1, q subcomponent, A chain, complement component 1, q subcomponent, B chain and complement component 1, q subcomponent, c chain) loci in relation to systemic lupus erythematosus (SLE) risk. Evidence for a significant effect of C1Q locus gene polymorphisms on SLE predisposition remains unclear. We aimed to identify associations between common C1Q polymorphisms and SLE risk and serum C1q, C3 and C4 levels. We performed family-based association tests in 295 nuclear families with one affected proband. Tag-single nucleotide polymorphisms (SNPs) ranging from 35.4 kb upstream of the C1QA gene to 28 kb downstream of the C1QB gene were selected to represent the entire C1Q gene locus. We performed transmission disequilibrium tests for affectation status and continuous traits, including C1q, C3 and C4 levels using family-based association tests (FBAT). There was no evidence for a significant role of C1Q locus gene polymorphisms in SLE risk predisposition. The strongest association was observed with a variant in the 3'UTR region of the C1QB gene (rs294223, P = 0.06). We found nominally significant associations with a second variant (rs7549888) in the 3'UTR region of the C1QB gene and C1q (P = 0.01), C3 (P = 0.004) and C4 levels (P = 0.01). In a large family-based association study of C1Q gene cluster polymorphisms no evidence for a genetic role of C1Q locus SNP in SLE risk predisposition was obtained in patients of European ancestry. This is in contrast to other cohorts, in which single variants associated with C1Q, C3 and C4 levels and nephritis have been studied and shown associations.

Evaluation of the effect of TRU-016, an anti-CD37 directed SMIP in combination with other therapeutic drugs in models of non-Hodgkin's lymphoma

8571

Background: TRU-016, a single chain anti-CD37 Fc fusion molecule has been shown to display pro-apoptotic and Fc-dependent cellular cytotoxicity activities against primary CLL cells and NHL cell lines. The pro-apoptotic signal generated by TRU-016 binding to CD37 on CLL cells has been shown to be caspase-independent and distinct from the signal generated by many other therapeutics including rituximab. We have tested drug combinations using the mantle cell lymphoma line Rec-1 and diffuse large B-cell lymphoma line SU-DHL-6 in vitro and extended these results to in vivo settings using the follicular lymphoma cell line DOHH2 treated with the combination of TRU-016 and bendamustine. Methods: To determine TRU-016 interactions with the established therapeutics rituximab, doxorubicin, rapamycin, and bendamustine, drugs were tested alone or in combination with TRU-016 and the anti-proliferative effects on cell lines measured after 96 hours. Combination index analysis was performed for drug combinations over the 20–90% effect levels using the Calcusyn software package. To determine if in vitro synergy could be recapitulated in vivo, SCID mice were implanted with DOHH2 cells and therapeutic treatment was initiated when tumor volumes reached 200 mm3. Treatments consisted of TRU-016, bendamustine, or the combination of TRU-016 and bendamustine. Results: Combination index analyses determined that TRU-016 is synergistic with rituximab, bendamustine, or rapamycin and additive with doxorubicin in NHL models. In vivo results show that treatment with the combination of TRU-016 and bendamustine resulted in increased efficacy compared to the efficacy attained with the individual drugs. This demonstrates that the in vitro synergy results were extendable to a more complex in vivo disease model. Conclusions: TRU-016 in combination with rituximab, rapamycin, or bendamustine increases cell killing of NHL cells. Furthermore, the combination of TRU-016 and bendamustine displayed greater in vivo anti-tumor activity than either agent alone against a follicular lymphoma tumor model.

[Table: see text]

Gene variants influencing measures of inflammation or predisposing to autoimmune and inflammatory diseases are not associated with the risk of type 2 diabetes

AIMS/HYPOTHESIS

There are strong associations between measures of inflammation and type 2 diabetes, but the causal directions of these associations are not known. We tested the hypothesis that common gene variants known to alter circulating levels of inflammatory proteins, or known to alter autoimmune-related disease risk, influence type 2 diabetes risk.

METHODS

We selected 46 variants: (1) eight variants known to alter circulating levels of inflammatory proteins, including those in the IL18, IL1RN, IL6R, MIF, PAI1 (also known as SERPINE1) and CRP genes; and (2) 38 variants known to predispose to autoimmune diseases, including type 1 diabetes. We tested the associations of these variants with type 2 diabetes using a meta-analysis of 4,107 cases and 5,187 controls from the Wellcome Trust Case Control Consortium, the Diabetes Genetics Initiative, and the Finland-United States Investigation of NIDDM studies. We followed up associated variants (p < 0.01) in a further set of 3,125 cases and 3,596 controls from the UK.

RESULTS

We found no evidence that inflammatory or autoimmune disease variants are associated with type 2 diabetes (at p <or= 0.01). The OR observed between the variant altering IL-18 levels, rs2250417, and type 2 diabetes (OR 1.00 [95% CI 0.99-1.03]), is much lower than that expected given (1) the effect of the variant on IL-18 levels (0.28 SDs per allele); and (2) estimates, based on other studies, of the correlation between IL-18 levels and type 2 diabetes risk (approximate OR 1.15 [95% CI 1.09-1.21] per 0.28 SD increase in IL-18 levels).

CONCLUSIONS/INTERPRETATION

Our study provided no evidence that variants known to alter measures of inflammation, autoimmune or inflammatory disease risk, including type 1 diabetes, alter type 2 diabetes risk.

A common variant of the interleukin 6 receptor (IL-6r) gene increases IL-6r and IL-6 levels, without other inflammatory effects

Interleukin-6 (IL-6) is a key inflammatory cytokine, signalling to most tissues by binding to a soluble IL-6 receptor (sIL-6r), making a complex with gp130. We used 1273 subjects (mean age 68 years) from the InCHIANTI Italian cohort to study common variation in the IL-6r locus and associations with interleukin 6 receptor (IL-6r), IL-6, gp130 and a battery of inflammatory markers. The rs4537545 single nucleotide polymorphism (SNP) tags the functional non-synonymous Asp358Ala variant (rs8192284) in IL-6r (r(2)=0.89, n=343). Individuals homozygous for the rs4537545 SNP minor allele (frequency 40%) had a doubling of IL-6r levels (132.48 pg/ml, 95% CI 125.13-140.27) compared to the common allele homozygous group (68.31 pg/ml, 95% CI 65.35-71.41): in per allele regression models, the rs4537545 SNP accounted for 20% of the variance in sIL-6r, with P=5.1 x 10(-62). The minor allele of rs4537545 was also associated with higher circulating IL-6 levels (P=1.9 x 10(-4)). There was no association of this variant with serum levels of gp130 or with any of the studied pro- and anti-inflammatory markers. A common variant of the IL-6r gene results in major changes in IL-6r and IL-6 serum levels, but with no apparent effect on gp130 levels or on inflammatory status in the general population.

Common genetic variation in the gene encoding interleukin-1-receptor antagonist (IL-1RA) is associated with altered circulating IL-1RA levels

Interleukin-1-receptor antagonist (IL-1RA) modulates the biological activity of the proinflammatory cytokine interleukin-1 (IL-1) and could play an important role in the pathophysiology of inflammatory and metabolic traits. We genotyped seven single nucleotide polymorphisms (SNPs) that capture a large proportion of common genetic variation in the IL-1RN gene in 1256 participants from the Invecchiare in Chianti study. We identified five SNPs associated with circulating IL-1RA levels with varying degrees of significance (P-value range=0.016-4.9 x 10(-5)). We showed that this association is likely to be driven by one haplotype, most strongly tagged by rs4251961. This variant is only in weak linkage disequilibrium (r(2)=0.25) with a previously reported variable number of tandem repeats polymorphism (VNTR) in intron-2 although a second variant, rs579543, that tags the VNTR (r(2)=0.91), may also be independently associated with IL-1RA levels (P=0.03). We found suggestive evidence that the C allele at rs4251961 that lowers IL-1RA levels is associated with an increased IL-1beta (P=0.03) level and may also be associated with interferon -gamma (P=0.03), alpha-2 macroglobulin (P=0.008) and adiponectin (P=0.007) serum levels. In conclusion, common variation across the IL-1RN gene is strongly associated with IL-1RA levels.

Current procedures for bladder substitution and urinary diversion at King Faisal Specialist Hospital and Research Centre

Following radical cystectomy for bladder cancer, 14 male patientts had a detubularized colic or ileocolic bladder substitute anastomosed to the membranous urethra and two female patients had urinary diversion to the valved and augmented rectum. There were no early deaths and the complication rate was low. The patients were followed for a mean of 12 months (2-28 months). During this short-term follow-up, no patients suffered deterioration of renal function or symptomatic urinary tract infection. Of the male patients, nine were perfectly continent, four had some incontinence during sleep, and one patient was incontinent day and night. Four had normal erections and three weak erections. Three have received penile implants, but it is too early to assess the need for this in the others. The two female patients were continent. Continent urinary diversion without a stoma appears to be a safe and reliable procedure, and patients should be offered one of these newer alternatives for replacement of the urinary bladder after cystectomy for cancer.