Circadian clock gene disruption in white blood cells of patients with celiac disease

Clock gene disruption has been reported in inflammatory and autoimmune diseases. Specifically, it has been shown that clock gene expression is down-regulated in intestinal tissue and peripheral blood mononuclear cells of patients with inflammatory bowel disease (IBD). We aimed to determine the systemic expression of the circadian clock genes in newly diagnosed untreated, young patients with celiac disease (CeD). We prospectively enrolled patients younger than 20 years old who underwent diagnostic endoscopic procedures either for CeD diagnosis or due to other gastrointestinal complaints, at the pediatric and adult gastroenterology units, the Tel Aviv Sourasky Medical Center from 8/2016-8/2022. Demographic data, anthropometric parameters, and endoscopic macroscopic and microscopic findings were obtained. Blood samples were obtained to determine tissue transglutaminase (tTG) and core clock gene (CLOCK, BMAL1, PER1, PER2, CRY1, CRY2) expression in white blood cells (WBC). Thirty individuals were analyzed (18 with newly diagnosed CeD and 12 controls). Expression of the clock genes CLOCK, BMAL1, CRY2, PER1 and PER2 was significantly reduced in CeD patients compared to controls, while CRY1 did not differ between the groups. In conclusion, newly diagnosed, untreated, young patients with CeD have reduced clock gene expression in WBC compared to controls. These results suggest that, in CeD, the inflammatory response is associated with systemic disruption of clock gene expression, as is manifested in other inflammatory and autoimmune diseases. CLINICALTRIALS.GOV IDENTIFIER: NCT03662646.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

The HOPE4MCI study: A randomized double-blind assessment of AGB101 for the treatment of MCI due to AD

INTRODUCTION

In addition to the accumulation of amyloid plaques and neurofibrillary tangles, the presence of excess neural activity is a pathological hallmark of Alzheimer's disease (AD) and a prognostic indicator for progression of AD pathology and clinical/cognitive worsening in mild cognitive impairment due to Alzheimer's disease (MCI due to AD). The HOPE4MCI clinical study tested the efficacy of a therapeutic with demonstrated ability to normalize heightened neural activity in the hippocampus in a randomized controlled trial of 78 weeks duration in patients with MCI due to AD.

METHODS

One hundred and sixty-four participants were randomized to placebo (n = 83) or AGB101 (n = 81), an extended-release formulation of low dose (220 mg) levetiracetam. The primary endpoint was the change in Clinical Dementia Rating Scale Sum of Boxes score (CDR-SB) comparing follow up at 18 months to baseline. The goal of the primary efficacy analysis was to estimate the difference between the AGB101 and placebo arms in the mean change of the primary endpoint.

RESULTS

The mean change in CDR-SB was estimated to be 1.12 (95% confidence interval [CI]: 0.66, 1.69) for the AGB101 arm and 1.22 (95% CI: 0.75, 1.78) for the placebo arm. The estimated difference between arms is -0.10 (95% CI: -0.85, 0.58), which was not statistically significant. In a prespecified analysis, the difference was -0.45 (95% CI: -1.43, 0.53) for ApoE-4 noncarriers and -0.10 (95% CI: -0.92, 0.72) for apolipoprotein E (ApoE)-4 carriers.

DISCUSSION

The possibility that ApoE-4 carriers and noncarriers will respond differently to therapeutic intervention is consistent with recently reported findings from biologics and the present results show further testing of AGB101 in patients with MCI due to AD who are noncarriers of the ApoeE-4 allele is warranted. Conclusions from the HOPE4MCI study are limited primarily due to the small sample size and results can only be regarded as a guide to future research.

The relationship between patients' kidney stone type and demographics in Israel: analysis of 10 K patients

PURPOSE

To analyze urinary stone composition in Israel and assess the effects of key demographic parameters (gender, age, socioeconomic status, ethnicity, medical history and geographic region) on stone composition.

METHODS

A retrospective review was conducted of stone analysis of 10,633 patients from an HMO Israeli database analyzed by a central laboratory from 2014 to 2019 and subjected to Fourier-transform infrared spectroscopy. Associations between stone composition and different demographic parameters were determined using the Chi-square test.

RESULTS

Calcium oxalate (CaOx) monohydrate accounted for 51.9% of the stones. Of the total sample, 5776 stones had one single component (54%), whereas 4857 (46%) had mixed components. Men had a higher frequency of CaOx stones (89.6% vs. 85.6%), whereas women had a higher frequency of calcium phosphate, infection, and cystine stones (27.2%, 17.7%, and 0.9% vs. 17.2%, 7.5%, and 0.5%, respectively). Cystine stones were more abundant in Arabs (1.2% vs. 0.5% in the Jewish population). Lower socioeconomic status was associated with a higher prevalence of calcium phosphate, uric acid, and infection stones and a lower prevalence of CaOx stones. Uric acid stones were associated with medical conditions such as diabetes, hypertension, ischemic heart disease, and obesity (28.3%, 24.9%, 25.7%, and 22.6% vs. 9.6%, 8.4%, 12.3%, and 10.3%, respectively).

CONCLUSIONS

Stone types were highly influenced by patients' demographics. COM was the most common stone component in either pure or complex form. UA stone prevalence was found to increase with age and was associated with medical conditions such as diabetes, hypertension, ischemic heart disease, and obesity.

Postal Delivery of Sleep Monitoring Devices: Research Implications

The purpose of this article is to describe the protocol development, feasibility, and lessons learned in the postal mail delivery of sleep monitoring devices to study participants. The original study protocol included four in-person visits with distribution of a sleep monitoring device (Actiwatch) and return of the Actiwatch via the postal service in a self-addressed, stamped envelope. The COVID-19 pandemic limited in-person research contact thus requiring a remote study protocol for application and return of the Actiwatches using postal delivery. While there were postal delivery and return challenges, the overall return rate of 94.4% confirmed remote protocol feasibility. Key lessons learned were: consistent and frequent communication via telephone calls and/or text; confirming required postage; and use of package tracking labels. All these strategies contributed to successful postal delivery/return and concomitantly decreased the potential loss of data and valuable research equipment.

Mixed method evaluation of a clinic waiting room-based health education program in the Dominican Republic

Waiting rooms provide an ideal location to disseminate health information. In this mixed-methods study, we evaluated waiting room-based health education talks at two clinics in the Dominican Republic and explored recommendations for implementing this intervention in similar settings. The talks addressed noncommunicable diseases, sexually transmitted infections, family planning and gender-based violence. We conducted pre- and posttests to assess attendees' change in knowledge and conducted semi-structured interviews with a subset of them. We conducted a semi-structured focus group with educators. Analyses included Wilcox Signed Rank Tests and McNemar tests for pre- and posttests, conventional content analysis for individual interviews and transcript coding for the focus group. Patient participants were 69.3% female aged 39.6 years (SD = 13.5) on average at one clinic (n = 127) and 100% female aged 17.4 (SD = 1.3) on average at the second clinic (n = 24). Focus group participants (n = 5) had 4.8 years (SD = 3.3) of health educator experience on average. Pre- and posttests showed significant improvement (P < 0.05) across all talks. Qualitative interviews emphasized engaging, clear and brief content delivery with visual aids. The focus group highlighted the importance of patient-centered design with culturally concordant delivery and identified implementation challenges. Findings demonstrate that waiting room-based education talks improve knowledge and provide suggestions for similar interventions.

Inverse Relationship Between Clock Gene Expression and Inflammatory Markers in Ulcerative Colitis Patients Undergoing Remission

BACKGROUND

Changes in the expression of clock genes have been reported in inflammatory bowel disease (IBD) patients.

AIMS

We aimed to investigate whether reduced inflammation restores clock gene expression to levels of healthy controls.

METHODS

This was a prospective study. Participants completed questionnaires providing data on demographics, sleeping habits, and disease activity. Anthropometric parameters, C-reactive protein (CRP), and fecal calprotectin (Fcal) levels were collected. Peripheral blood samples were analyzed for clock gene (CLOCK, BMAL1, CRY1, CRY2, PER1, PER2) expression. Patients with IBD were separated by diagnosis into ulcerative colitis (UC) and Crohn's disease (CD). Each diagnosis was further divided into active disease and disease under remission.

RESULTS

Forty-nine patients with IBD and 19 healthy controls completed the study. BMAL1 and PER2 were significantly reduced in active patients with UC compared to patients with UC in remission. BMAL1, PER1, and PER2 were significantly reduced in patients with UC with CRP > 5 mg/dl. PER2, CRY1, and CRY2 were significantly reduced in patients with UC with Fcal > 250 mg/kg. Clock gene expression of patients with UC in remission was comparable to healthy controls. When all patients with IBD were analyzed, an overshoot in CRY1 expression was observed in patients in remission, patients with CRP < 5 mg/dl, and patients with Fcal < 250 mg/kg.

CONCLUSION

CRP and Fcal are inversely related to clock gene levels in patients with UC. CRY1 may play a role in counteracting the anti-inflammatory processes when remission is induced in patients with IBD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03662646.

Suspected Non-ST-elevation acute coronary syndrome meeting rapid rule-out criteria: Resource utilization, diagnostic yield, and clinical outcomes of hospital admission

AIMS

Many patients with suspected non-ST-elevation (NSTE) acute coronary syndromes (ACS) are admitted, even those with initial high-sensitivity cardiac troponins (hs-cTn) values who meet rapid rule-out criteria for myocardial infarction (MI). We examined the clinical outcomes, resource utilization, and diagnostic yield of suspected NSTE-ACS patients, who presented with hs-cTnT values meeting these criteria but were nevertheless hospitalized.

METHODS AND RESULTS

Applying the 2020 ESC rapid rule-out MI criteria, we identified consecutive patients with an initial value of hs-cTnT <5 ng/L or an initial value of ≥5 ng/L but <14 ng/L (99th percentile) and a small increment in a subsequent test, who were nevertheless admitted. The majority (85.4%) of patients presented to the emergency department (ED) with suspected NSTE-ACS had an initial hs-cTnT < 99th percentile. We examined 3 775 admitted patients out of 11 477 patients who were triaged and met MI rule-out criteria. Only 0.32% (12 patients) of admitted patients experienced index MI or overall death within 30 days. Resource utilization in terms of ED stay, hospital stay, noninvasive and invasive tests was substantial, yet revascularization was uncommon (2.5%). Multivariate adjustment for age, gender and baseline cardiovascular risk factors demonstrates similar survival of admitted versus discharged patients (P = 0.88). Initial hs-cTnT even below the 99th percentile provided a prognostic stratification for long term mortality.

CONCLUSIONS

Our findings support a policy of ED discharge of suspected NSTE-ACS patients meeting rapid MI rule-out criteria and subsequent ambulatory evaluation, sparing resource-consuming admissions. In-hospital and ensuing prognosis were better with lower initial hs-cTnT values.

Lecanemab in Early Alzheimer's Disease

BACKGROUND

The accumulation of soluble and insoluble aggregated amyloid-beta (Aβ) may initiate or potentiate pathologic processes in Alzheimer's disease. Lecanemab, a humanized IgG1 monoclonal antibody that binds with high affinity to Aβ soluble protofibrils, is being tested in persons with early Alzheimer's disease.

METHODS

We conducted an 18-month, multicenter, double-blind, phase 3 trial involving persons 50 to 90 years of age with early Alzheimer's disease (mild cognitive impairment or mild dementia due to Alzheimer's disease) with evidence of amyloid on positron-emission tomography (PET) or by cerebrospinal fluid testing. Participants were randomly assigned in a 1:1 ratio to receive intravenous lecanemab (10 mg per kilogram of body weight every 2 weeks) or placebo. The primary end point was the change from baseline at 18 months in the score on the Clinical Dementia Rating-Sum of Boxes (CDR-SB; range, 0 to 18, with higher scores indicating greater impairment). Key secondary end points were the change in amyloid burden on PET, the score on the 14-item cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-cog14; range, 0 to 90; higher scores indicate greater impairment), the Alzheimer's Disease Composite Score (ADCOMS; range, 0 to 1.97; higher scores indicate greater impairment), and the score on the Alzheimer's Disease Cooperative Study-Activities of Daily Living Scale for Mild Cognitive Impairment (ADCS-MCI-ADL; range, 0 to 53; lower scores indicate greater impairment).

RESULTS

A total of 1795 participants were enrolled, with 898 assigned to receive lecanemab and 897 to receive placebo. The mean CDR-SB score at baseline was approximately 3.2 in both groups. The adjusted least-squares mean change from baseline at 18 months was 1.21 with lecanemab and 1.66 with placebo (difference, -0.45; 95% confidence interval [CI], -0.67 to -0.23; P<0.001). In a substudy involving 698 participants, there were greater reductions in brain amyloid burden with lecanemab than with placebo (difference, -59.1 centiloids; 95% CI, -62.6 to -55.6). Other mean differences between the two groups in the change from baseline favoring lecanemab were as follows: for the ADAS-cog14 score, -1.44 (95% CI, -2.27 to -0.61; P<0.001); for the ADCOMS, -0.050 (95% CI, -0.074 to -0.027; P<0.001); and for the ADCS-MCI-ADL score, 2.0 (95% CI, 1.2 to 2.8; P<0.001). Lecanemab resulted in infusion-related reactions in 26.4% of the participants and amyloid-related imaging abnormalities with edema or effusions in 12.6%.

CONCLUSIONS

Lecanemab reduced markers of amyloid in early Alzheimer's disease and resulted in moderately less decline on measures of cognition and function than placebo at 18 months but was associated with adverse events. Longer trials are warranted to determine the efficacy and safety of lecanemab in early Alzheimer's disease. (Funded by Eisai and Biogen; Clarity AD ClinicalTrials.gov number, NCT03887455.).

Investigating Partially Discordant Results in Phase 3 Studies of Aducanumab

OBJECTIVES

Efficacy and safety results from the EMERGE (NCT02484547) and ENGAGE (NCT02477800) phase 3 studies of aducanumab in early Alzheimer's disease (AD) have been published. In EMERGE, but not in ENGAGE, high-dose aducanumab demonstrated significant treatment effects across primary and secondary endpoints. Low-dose aducanumab results were consistent across studies with non-significant differences versus placebo that were intermediate to the high-dose arm in EMERGE. The present investigation examined data from EMERGE and ENGAGE through post-hoc analyses to determine factors that contributed to discordant results between the high-dose arms of the two studies.

DESIGN

EMERGE and ENGAGE were 2 phase 3, randomized, double-blind, placebo-controlled, parallel-group studies.

SETTING

EMERGE and ENGAGE were 2 global multicenter studies involving 348 sites in 20 countries.

PARTICIPANTS

Participants in EMERGE and ENGAGE were aged 50 to 85 years and had mild cognitive impairment or mild AD dementia with confirmed amyloid pathology. The randomized and dosed population (all randomized patients who received at least one dose of study treatment) included 1638 patients in EMERGE and 1647 in ENGAGE.

INTERVENTION

In EMERGE and ENGAGE, participants were randomized to receive low- or high-dose aducanumab or placebo (1:1:1) once every 4 weeks.

MEASUREMENTS

In this paper, 4 areas were investigated through post-hoc analyses to understand the discordance in the high-dose arms of the EMERGE and ENGAGE studies: baseline characteristics, amyloid-related imaging abnormalities, non-normality of the data, and dosing/exposure to aducanumab.

RESULTS

Post-hoc analyses showed that outcomes in the ENGAGE high-dose group were affected by an imbalance in a small number of patients with extremely rapid progression and by lower exposure to the target dose of 10 mg/kg. These factors were confounded and present in early enrolled patients but were not present in later-enrolled patients who were randomized to the target dosing regimen of 10 mg/kg after titration. Neither baseline characteristics nor amyloid-related imaging abnormalities contributed to the difference in results between the high-dose arms.

CONCLUSIONS

Results were consistent across studies in later enrolled patients in which the incidence of rapidly progressing patients was balanced across treatment arms.

Lecanemab Clarity AD: Quality-of-Life Results from a Randomized, Double-Blind Phase 3 Trial in Early Alzheimer's Disease

BACKGROUND

Lecanemab is a humanized IgG1 monoclonal antibody binding with high affinity to amyloid-beta protein protofibrils. In phase 3 development, lecanemab has been shown to reduce markers of amyloid in early Alzheimer's disease and reduce decline on clinical endpoints of cognition and function at 18 months.

OBJECTIVES

To describe the health-related quality-of-life (HRQoL) results from Clarity AD which were exploratory outcomes in this trial.

DESIGN

Clarity AD was an 18-month, multi-center, double-blind, phase 3 trial.

SETTING

Early Alzheimer's disease.

PARTICIPANTS

Individuals 50-90 years of age with a diagnosis of mild cognitive impairment or mild dementia due to Alzheimer's disease and positron emission tomography or cerebrospinal fluid evidence of cerebral amyloid accumulation.

INTERVENTION

Placebo or lecanemab 10-mg/kg IV biweekly.

MEASUREMENTS

HRQoL was measured at baseline and every 6 months using the European Quality of Life-5 Dimensions (EQ-5D-5L; by subject) and Quality of Life in AD (QOL-AD; by subject and proxy). Study partner burden was measured using the Zarit Burden Interview (ZBI).

RESULTS

A total of 1795 participants were enrolled (lecanemab:898; placebo:897). At month 18, adjusted mean change from baseline in EQ-5D-5L and QOL-AD by subject showed 49% and 56% less decline, respectively. QOL-AD rated by study partner as proxy resulted in 23% less decline. ZBI adjusted mean change from baseline at 18 months resulted in 38% less increase of care partner burden. Individual HRQoL test items and dimensions also showed lecanemab benefit.

CONCLUSIONS

Lecanemab was associated with a relative preservation of HRQoL and less increase in caregiver burden, with consistent benefits seen across different quality of life scales and within scale subdomains. These benefits provide valuable patient reported outcomes which, together with previously reported benefits of lecanemab across multiple measures of cognition, function, disease progression, and biomarkers, demonstrate that lecanemab treatment may offer meaningful benefits to patients, care partners, and society.

Portable diagnostic package for Thomson scattering and optical emission spectroscopy on Princeton field-reversed configuration 2 (PFRC 2)

An Advanced Research Projects Agency-Energy funded diagnostic system has been deployed to the Princeton field-reversed configuration 2 (PFRC-2) device, located at Princeton Plasma Physics Laboratory. The Portable Diagnostic Package (PDP), designed at Oak Ridge National Laboratory, allows for the measurement of Thomson Scattering (TS) for electron density and temperature and Optical Emission Spectroscopy (OES) for ion temperature, impurity density, and ion velocity. A tunable spectrometer on the PDP with three gratings provides the flexibility to measure low (1 eV) and high (1000 eV) electron temperature ranges from TS. Additionally, using a second spectrometer, the OES diagnostic can survey light emission from various ion excitation levels for wide wavelength ranges. The electron density (<2 × 10¹⁹ m^-3) of plasmas generated in PFRC-2 has been below the PDP TS discrimination threshold, which has made TS signal detection challenging against a high-background of laser stray light. The laser stray light was iteratively reduced by making modifications to the entrance and exit geometry on PFRC-2. Rayleigh scattering experiments on PFRC have yielded the TS discrimination sensitivity to be >1 × 10²⁰ m^-3 for the PDP. A recently implemented narrow-band notch spectral filter that masks the second harmonic 532 nm Nd:YAG laser wavelength has increased the system's TS light discrimination sensitivity 65 times compared to the instance when the notch filter was not implemented. The hardware implementation including design changes to the flight tubes and Brewster windows will be discussed, along with results from Rayleigh and rotational Raman scattering sensitivity analyses, which were used to establish a quantitative figure of merit on the system performance. The Raman scattering calibration with the notch filter has improved the PDP electron density threshold to 1 ± 0.5 × 10¹⁸ m^-3.

Atrial fibrillation diagnosis by a systematic 14-day continuous ECG-Holter in patients with high cardiovascular risk and clinical palpitation: the prospective AFTER study

Background

Atrial Fibrillation (AF) is asymptomatic in 20–30% of cases. New technologic tools for continuous ECG monitoring have been developed to detect and potentially treat AF in specific population with high cardiovascular risk.

Purpose

We aimed to evaluate the prevalence and the management of AF diagnosed in patients with no previous documented AF but with a high cardiovascular risk and clinical palpitation undergoing systematic 14-day continuous ECG-Holter monitoring and associated characteristics.

Methods

Patients were prospectively enrolled from December 2019 to December 2021 in this multicentered study, sponsored by the French National College of Cardiology. Patients needed to meet the following criteria: CHA2DS2VASc score ≥3 in women &gt;2 in men associated with clinical palpitation without previous documented arrhythmia, particularly AF. Exclusion criteria were: previous documented AF, participation to another study that could interfere with the current study, pregnancy, previous skin intolerance to ECG-Holter electrodes. Included patients underwent a 14-day monitoring Holter-ECG to detect cardiac arrhythmia, particularly AF. Patients' characteristics, type of arrythmias and management of detected AF were described.

Results

Among the 336 included patients, 39% were men, median age was 73 [64.5–78] years, 71.5% had hypertension and 46.5% had a previous history of stroke. AF was detected in 14% of patients, among which 23.4% in the first 24 hours monitoring. In univariate analyses, older age (p=0.045) was significantly associated with AF, and a trend was observed regarding male gender (p=0.067) and less antiplatelet therapy (p=0.058). Patients with diagnosed AF had a prescription of anticoagulation therapy in 90% of cases consisting in apixaban and rivaroxaban for 72% and 28% respectively. Antiarrhythmic drugs were administered in 90% of AF patients and 13% underwent AF ablation.

Conclusions

The systematic AF screening of selected patients based on CHA2DS2VASc score ≥3 in women &gt;2 in men associated with palpitations allows to diagnose AF in 14% of the population with a 14-day continuous ECG-Holter. This strategy seems efficient as it induced the prescription of anticoagulation and antiarrhythmic therapy in 90% of individuals.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): NATIONAL COLLEGE OF FRENCH CARDIOLOGISTS

Lower serum alpha 1 antitrypsin levels in patients with severe COVID-19 compared with patients hospitalized due to non-COVID-19 pneumonia

INTRODUCTION

Alpha 1 antitrypsin (A1AT) is the major human blood serine protease inhibitor. Transmembrane serine protease 2 (TMPRSS2), which is crucial for SARS-CoV-2 cell entry, is inhibited by A1AT. Therefore, we hypothesized that individuals with diminished levels of A1AT may be more prone to SARS-CoV-2 infection and severe COVID-19 disease. Our aim in this study was to evaluate the level of A1AT in hospitalized COVID-19 patients in comparison to hospitalized patients with non-COVID-19 pneumonia.

METHODS

We conducted an observational prospective study between October 2020 and April 2021 in Rabin Medical Centre in Israel. A1AT levels were measured from the routine serum samples of hospitalized patients with COVID-19 and non-COVID-19 pneumonia (control group). The primary outcome was A1AT level, secondary outcomes were clinical outcomes and predictors of morality.

RESULTS

Overall, 145 patients were included in the study, 98 in the COVID-19 group and 47 in the control group. The median A1AT level was 222 mg/dL (interquartile range (IQR) 188-269) and 258 mg/dL (IQR 210-281) in the COVID-19 and control groups, respectively (p = .045). Multivariate analysis for independent risk factors for mortality among COVID-19 patients showed that diabetes mellitus (p = .02), older age (p = .04), and high A1AT levels (p = .04) were all associated with increased mortality.

CONCLUSION

Patients admitted due to severe COVID-19 had lower A1AT levels in comparison to patients admitted due to non-COVID pneumonia. This observation may suggest an association between mildly diminished A1AT and higher risk of SARS-CoV-2 infection with severe COVID-19 disease.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

1049 IMPROVING TELEPHONE COMMUNICATION WITH FAMILIES ON A BUSY MEDICAL WARD DURING THE PANDEMIC

During the pandemic it became critical to reduce visiting to only very specific situations. This resulted in an increase of complaints where a lack of communication from the ward had been recognised as a theme, in spite of the fact that many doctors spent a great deal of time providing updates over the phone to patient’s families. It was noted there were a number of inefficiencies with respect to communicating with families; some families were being contacted repeatedly whereas others were struggling to get in touch. Chronic staffing shortages were also a barrier to effective and timely communication. Qualitative data collected via an online survey demonstrated that junior doctors valued the importance of communicating with families, particularly to provide clinical updates or obtain collateral histories, but found that the extra burden created by the pandemic resulted in far less time to do this efficiently and often resulted in time management difficulties.

We introduced a strategy, by way of a magnetic communication board, that provided a flexible, at-a-glance method of ensuring all families had received regular updates from the medical team and collateral histories had been obtained for all relevant patients. We collected weekly data regarding the number of interactions between the medical team and patient relatives’ as a percentage of the total number of bed spaces. An overall improvement was noted: 67% pre-intervention to 76% post, with a maximum of 88% during one particularly successful week. We also were able to demonstrate an increase in ReSPECT form completion (from 40% to 65%).

The introduction of an organisational tool such as our communication board resulted in improved patient and relatives’ satisfaction; and an improvement in team performance and overall time management. We are now aiming to build on this and roll it out during the next wave of the pandemic.

AB0432 EFAVALEUKIN ALFA, A NOVEL IL-2 MUTEIN, SELECTIVELY EXPANDS REGULATORY T CELLS IN PATIENTS WITH SLE: FINAL RESULTS OF A PHASE 1B MULTIPLE ASCENDING DOSE STUDY

Background

Defects in regulatory T cell (Treg) number and function are associated with autoimmune diseases including SLE. Interleukin (IL)-2 is essential for the development and suppressive function of Treg, and therapies that exploit the ability of IL-2 to expand Treg have shown disease-modifying potential in SLE1. However, low-dose IL-2 has a short half-life and narrow selectivity for Treg over conventional CD4+ T cells (Tcon) and natural killer (NK) cells. Efavaleukin alfa is an IL-2 mutein Fc fusion protein; an introduced mutation decreases binding to IL-2Rβ and increases dependence on IL-2Rα (CD25). This preferential binding to the high-affinity IL-2R, constitutively expressed at high levels on Treg, leads to increased cell surface retention and sustained Treg signaling compared with recombinant IL-2. In healthy subjects, a single dose of efavaleukin alfa was well tolerated and led to robust and selective Treg expansion2.

Objectives

This final analysis of a phase 1b, double-blind, placebo-controlled, multiple ascending dose study (NCT03451422) reports the safety, tolerability, pharmacokinetics (PK), and pharmacodynamic effects of efavaleukin alfa in patients with SLE.

Methods

The study included five ascending dose cohorts (cohort 1=lowest dose; cohort 5=highest dose). A total of 35 patients with SLE (age 24–71 years; 85.7% female; SLE diagnosed using SLICC or ACR criteria with ANA ≥1:80 and/or elevated anti-dsDNA antibodies) were randomized to receive efavaleukin alfa or placebo (5:2 ratio for cohorts 1–3; 3:1 ratio for cohorts 4–5) subcutaneously every 2 weeks (Q2W; cohorts 1, 2, 4, and 5) or every week (QW; cohort 3) in addition to standard of care therapy for a total of 12 weeks, with 6 weeks of follow-up. The primary endpoint was the incidence of treatment-emergent adverse events (TEAEs). Additional endpoints included serum PK of efavaleukin alfa and changes in numbers of Treg, CD4+ Tcon, CD8+ T cells, and NK cells in peripheral blood.

Results

The most commonly reported TEAEs (occurring in ≥25% of efavaleukin alfa-treated subjects) included non-serious, mild or moderate (grade 1–2) injection site reactions. No grade 4 TEAEs or deaths occurred. Two serious AEs were reported in efavaleukin alfa-treated subjects: one event of syncope (grade 3) was observed in cohort 2 and was not considered related to treatment, and one case of eosinophilia (grade 2) was observed in cohort 5 and was considered related to treatment. Efavaleukin alfa PK was generally linear and dose-proportional, with a terminal half-life ranging from 18–30 hours. Peak Foxp3+ Treg expansion was observed at 8 days post-dose, and the magnitude of the peak was generally sustained after multiple QW or Q2W doses. The mean peak increases in Foxp3+ Treg were 14.8-, 17.4-, 5.7-, 2.4-, and 1.1-fold above baseline for efavaleukin alfa Q2W dosing cohorts 5, 4, 2, and 1 and placebo, respectively. At the final study assessment (42 days after the last dose), the mean Treg count was 1.3-fold above baseline (95% CI, 0.9–1.9). Treatment with efavaleukin alfa also expanded CD25bright Treg (peak 53.8-fold change) and CD31+ recent thymic emigrant (RTE), naïve, and memory Treg subsets. At the highest dose (cohort 5), low-level increases in numbers of CD4+ Tcon (peak 2.3-fold), CD8+ T cells (peak 2.1-fold), and NK cells (peak 2.9-fold) were observed.

Conclusion

Multiple ascending doses of efavaleukin alfa were safe and well tolerated and led to selective and prolonged Treg expansion in SLE patients. Results at the highest dose suggest a plateau in Treg expansion with low-level increases in other IL-2–responsive cells, although interpretation is limited due to small subject numbers. The highest tested dose may be outside the therapeutic window and thus will not be assessed in phase 2 clinical studies. These findings confirm and extend previous results in healthy subjects and support the ongoing phase 2b adaptive randomized controlled trial in patients with SLE.

References

[1]Humrich J. Arthritis Rheumatol. 2016;68 (suppl 10);2Tchao N. Blood. 2017;130 (suppl 1).

Acknowledgements

Funding: Amgen Inc

Disclosure of Interests

Nadia Tchao Shareholder of: Amgen Inc., Employee of: Amgen Inc., Nandita Sarkar Shareholder of: Amgen Inc., Employee of: Amgen Inc., Xuguang Hu Shareholder of: Amgen Inc., Employee of: Amgen Inc., Rong Zhang Shareholder of: Amgen Inc., Employee of: Amgen Inc., Cassandra Milmont Shareholder of: Amgen Inc., Employee of: Amgen Inc., Yan Shi Jin Shareholder of: Amgen Inc., Employee of: Amgen Inc., Vincent Chow Shareholder of: Amgen Inc., Employee of: Amgen Inc., Mark Kroenke Shareholder of: Amgen Inc., Employee of: Amgen Inc., Kevin Gorski Shareholder of: Amgen Inc., Employee of: Amgen Inc., Richard Furie Consultant of: Amgen Inc, Grant/research support from: Amgen Inc, Alan Kivitz Shareholder of: Amgen Inc., Gilead, GlaxoSmithKline, Novartis, Pfizer, and Sanofi, Speakers bureau: AbbVie, Celgene, Flexion, Genzyme, GSK, Horizon, Lilly, Merck, Novartis, Pfizer, Sanofi, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Flexion, Gilead, Janssen, Pfizer, Sanofi, and Sun Pharma, Stanley Cohen Consultant of: Amgen Inc., AbbVie, Eli Lilly, Pfizer, Genentech, and Gilead, Grant/research support from: Amgen Inc., AbbVie, Eli Lilly, Pfizer, Genentech, and Gilead

Two Randomized Phase 3 Studies of Aducanumab in Early Alzheimer's Disease

BACKGROUND

Alzheimer's disease is a progressive, irreversible, and fatal disease for which accumulation of amyloid beta is thought to play a key role in pathogenesis. Aducanumab is a human monoclonal antibody directed against aggregated soluble and insoluble forms of amyloid beta.

OBJECTIVES

We evaluated the efficacy and safety of aducanumab in early Alzheimer's disease.

DESIGN

EMERGE and ENGAGE were two randomized, double-blind, placebo-controlled, global, phase 3 studies of aducanumab in patients with early Alzheimer's disease.

SETTING

These studies involved 348 sites in 20 countries.

PARTICIPANTS

Participants included 1638 (EMERGE) and 1647 (ENGAGE) patients (aged 50-85 years, confirmed amyloid pathology) who met clinical criteria for mild cognitive impairment due to Alzheimer's disease or mild Alzheimer's disease dementia, of which 1812 (55.2%) completed the study.

INTERVENTION

Participants were randomly assigned 1:1:1 to receive aducanumab low dose (3 or 6 mg/kg target dose), high dose (10 mg/kg target dose), or placebo via IV infusion once every 4 weeks over 76 weeks.

MEASUREMENTS

The primary outcome measure was change from baseline to week 78 on the Clinical Dementia Rating Sum of Boxes (CDR-SB), an integrated scale that assesses both function and cognition. Other measures included safety assessments; secondary and tertiary clinical outcomes that assessed cognition, function, and behavior; and biomarker endpoints.

RESULTS

EMERGE and ENGAGE were halted based on futility analysis of data pooled from the first approximately 50% of enrolled patients; subsequent efficacy analyses included data from a larger data set collected up to futility declaration and followed prespecified statistical analyses. The primary endpoint was met in EMERGE (difference of -0.39 for high-dose aducanumab vs placebo [95% CI, -0.69 to -0.09; P=.012; 22% decrease]) but not in ENGAGE (difference of 0.03, [95% CI, -0.26 to 0.33; P=.833; 2% increase]). Results of biomarker substudies confirmed target engagement and dose-dependent reduction in markers of Alzheimer's disease pathophysiology. The most common adverse event was amyloid-related imaging abnormalities-edema.

CONCLUSIONS

Data from EMERGE demonstrated a statistically significant change across all four primary and secondary clinical endpoints. ENGAGE did not meet its primary or secondary endpoints. A dose- and time-dependent reduction in pathophysiological markers of Alzheimer's disease was observed in both trials.

Remote photonic sensing of action potential in mammalian nerve cells via histogram-based analysis of temporal spatial acoustic vibrations

Label free and remote action potential detection in neurons can be of great importance in the neuroscience research field. This paper presents a novel label free imaging modality based on the detection of temporal vibrations of speckle patterns illuminating the sample. We demonstrated the feasibility of detecting action potentials originating from spontaneous and stimulated activity in cortical cell culture. The spatiotemporal vibrations of isolated cortical cells were extracted by illuminating the culture with a laser beam while the vibrations of the random back scattered secondary speckle patterns are captured by a camera. The postulated action potentials were estimated following correlation-based analysis on the captured vibrations, where the variance deviation of the signal from a Gaussian distribution is directly associated with the action potential events. The technique was validated in a series of experiments in which the optical signals were acquired concurrently with microelectrode array (MEA) recordings. Our results demonstrate the ability of detecting action potential events in mammalian cells remotely via extraction of acoustic vibrations.

Synthetic amyloid beta does not induce a robust transcriptional response in innate immune cell culture systems

BACKGROUND

Alzheimer's disease (AD) is a progressive neurodegenerative disease that impacts nearly 400 million people worldwide. The accumulation of amyloid beta (Aβ) in the brain has historically been associated with AD, and recent evidence suggests that neuroinflammation plays a central role in its origin and progression. These observations have given rise to the theory that Aβ is the primary trigger of AD, and induces proinflammatory activation of immune brain cells (i.e., microglia), which culminates in neuronal damage and cognitive decline. To test this hypothesis, many in vitro systems have been established to study Aβ-mediated activation of innate immune cells. Nevertheless, the transcriptional resemblance of these models to the microglia in the AD brain has never been comprehensively studied on a genome-wide scale.

METHODS

We used bulk RNA-seq to assess the transcriptional differences between in vitro cell types used to model neuroinflammation in AD, including several established, primary and iPSC-derived immune cell lines (macrophages, microglia and astrocytes) and their similarities to primary cells in the AD brain. We then analyzed the transcriptional response of these innate immune cells to synthetic Aβ or LPS and INFγ.

RESULTS

We found that human induced pluripotent stem cell (hIPSC)-derived microglia (IMGL) are the in vitro cell model that best resembles primary microglia. Surprisingly, synthetic Aβ does not trigger a robust transcriptional response in any of the cellular models analyzed, despite testing a wide variety of Aβ formulations, concentrations, and treatment conditions. Finally, we found that bacterial LPS and INFγ activate microglia and induce transcriptional changes that resemble many, but not all, aspects of the transcriptomic profiles of disease associated microglia (DAM) present in the AD brain.

CONCLUSIONS

These results suggest that synthetic Aβ treatment of innate immune cell cultures does not recapitulate transcriptional profiles observed in microglia from AD brains. In contrast, treating IMGL with LPS and INFγ induces transcriptional changes similar to those observed in microglia detected in AD brains.

Clinical Trial Endpoints and Their Clinical Meaningfulness in Early Stages of Alzheimer's Disease

As the focus of Alzheimer's disease (AD) therapeutic development shifts to the early stages of the disease, the clinical endpoints used in drug trials, and how these might translate into clinical practice, are of increasing importance. The clinical meaningfulness of trial outcome measures is often unclear, with a lack of conclusive evidence as to how these measures correlate to changes in disease progression and treatment response. Clarifying this would benefit all, including patients, care partners, primary care providers, regulators, and payers, and would enhance our understanding of the relationship between clinical trial endpoints and assessments used in everyday practice. At present, there is a wide range of assessment tools used in clinical trials for AD and substantial variability in measures selected as endpoints across these trials. The aim of this review is to summarize the most commonly used assessment tools for early stages of AD, describe their use in clinical trials and clinical practice, and discuss what might constitute clinically meaningful change in these measures in relation to disease progression and treatment response.

Implementation of a triage monitoring program for internal exposure to short-lived radionuclides in Israel-challenges and recommendations

Monitoring internal exposure to short-lived radionuclides is challenging, due to the frequent measurements required. ISO Standard 16 637 and the Swiss Personal Dosimetry Ordinance describe a screening measurement (triage monitoring) conducted in the workplace to identify workers suspected of internal exposure. Based on a previous study that examined the feasibility of using several commonly found radiation monitors in Israel in a triage monitoring program, we conducted a pilot study towards the implementation of triage monitoring in nuclear medicine facilities in Israel. The pilot study was conducted while considering the current Israeli regulations and local safety culture. We implemented the triage monitoring program in three nuclear medicine facilities in Israel, with a total of 55 monitored workers. The pilot study consisted of two stages: a short-term stage conducted in the largest manufacture of radiopharmaceuticals in Israel and a long-term stage in two nuclear medicine departments in Israel. During the first stage of the study, participants were asked to conduct a daily measurement at the end of the workday and send a urine sample to the national internal dosimetry laboratory. The second stage lasted 5 months in a major hospital and 18 months in a regional hospital. The workers were asked to perform the measurement at the end of the shift and send a urine sample if a defined threshold had been crossed. The mean participation rate in the long-term stage (>70%) indicates that implementation of the triage monitoring program could be successful in Israel. Based on the findings of the study, practical recommendations are listed: suitable monitoring devices, allocating a monitoring location, time of measurement, training of the workers, record keeping and coordination with a certified dosimetry laboratory. The pilot study recommendations were submitted to the Israel Institute for Occupational Safety and Hygiene at the Ministry of Labor, Social Affairs and Social Services.

Targeted delivery controlled release of hepatic growth factor and insulin-like growth factor-1 improves left ventricular repair in a porcine model of myocardial ischemia reperfusion injury

Introduction

Nanomedicine offers great potential for treatment of cardiovascular disease. We tested whether direct intramyocardial (IM) injection of pro-angiogenic hepatocyte growth factor (HGF) and pro-myogenic insulin-like growth factor (IGF-1) encapsulated in Alginate-Sulfate nanoparticles (AlgS-NP) enhances myocardial retention, controlled release and improves myocardial repair in a porcine ischemia-reperfusion model.

Methods

Bioactivity of HGF/IGF, released from AlgS-NP, was determined by cell proliferation assays in vitro. Myocardial infarction (MI) was induced by 75min balloon occlusion of the mid-LAD followed by reperfusion. After 1w, pigs (n=12) with marked LV dysfunction (EF&lt;45%) were randomized to fusion imaging-guided IM injections of 8 mg Cy5-labelled AlgS-NP loaded with 200μg HGF and 200μg IGF-1 (GF) or with phosphate-buffered saline (CON) using the MYOSTAR injection catheter. AlgS-NP retention after IM or intracoronary (IC) injection was determined by measuring Cy5 plasma levels. At 8w, treatment effect was evaluated using in vivo magnetic resonance imaging and coronary physiological measurements, and via post-mortem analysis of myocardial fibrosis and cardiomyocyte circumference.

Results

We confirmed the bioactivity of the AlgS-NP-released GF in C2C12 and HUVEC cell proliferation assays after 72h culture, being similar to the free GF (Fig. A). AlgS-NP retention was tested in a pig model, 1w after MI. Ejection fraction (EF) was 37±5% (range 27–45%) and infarct size (IS)/LVmass 24±6% (range 19–38%). AlgS-NP retention was better after IM delivery than after IC infusion with plasma Cy5 levels at 30 min after treatment indicating 5% systemic leakage for IM vs. 20% for IC. After 8w, IS/LVmass decreased 8% in GF-treated pigs vs. 3% in CON (P=0.03, Fig. B) and was associated with preserved myocardial blood flow during hyperemia in the infarct (P=0.036) and peri-infarct (PI) zones (P=0.008), increased coronary flow reserve (P=0.05) and decreased index of microcirculatory resistance (P=0.02). LVEF significantly increased in GF-treated pigs (+6±2% vs. −1±1% in CON, P=0.02, Fig. C), and was accompanied by significantly reduced fibrosis (P=0.01) and increased hypertrophy of cardiomyocyte (P=0.03) in the PI zone.

Conclusions

IM injection of AlgS-NP-encapsulated HGF and IGF-1 to the ischemic myocardium significantly improves LV repair, and offers the prospect of innovative treatment for patients with refractory ischemic heart disease.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EuroNanoMed II Figure AFigure B and C

Risk prediction of major adverse cardiac events by high sensitivity troponin is modified by comorbidities

Background

High-sensitivity cardiac troponin (hs-cTn) is a well-established biomarker for the evaluation of Emergency Department (ED) patients with possible acute coronary syndrome. These patients often have comorbid conditions that may impact hs-cTn values. However, prior studies and current guidelines addressing the relationship between comorbidities and hs-cTn are limited.

Purpose

To determine whether an interaction exists between comorbidities and baseline hsTnT values on the risk of 30-day major adverse cardiac events (MACE) in a multicenter United States (US) cohort.

Methods

Adult ED patients with suspected acute coronary syndrome were prospectively enrolled in a multicenter cohort study in the US. Baseline blood samples were collected and hs-cTnT concentrations were measured at a central laboratory. Comorbid conditions, such as obesity, hypertension, hyperlipidemia, diabetes, coronary artery disease, congestive heart failure, renal disease, peripheral vascular disease, prior stroke, and history of coronary interventions, were collected at time of enrollment. The primary outcome was adjudicated MACE, defined as occurrence of myocardial infarction, cardiovascular or uncertain death, or coronary revascularization within 30 days. Hs-cTnT values were dichotomized using manufacturer's limit of quantification (LOQ) at 6 ng/dL and the upper reference limit (URL) of 19 ng/dL. The utility the LOQ and URL cut-offs in predicting MACE was evaluated using logistic regression. Effect modification of comorbid conditions was independently evaluated by including an interaction term between comorbidity and hs-cTnT.

Results

Among 1460 participants with a baseline hs-cTn measurement, 46.3% (676/1460) were female and 37.1% (542/1460) were Black with a mean age of 57.6±12.9 years. The prevalence of MACE was 14.4% (210/1460). Participants with a baseline hs-cTnT below LOQ were 0.08 (95% CI: 0.04–0.16) times less likely to have MACE compared to those exceeding LOQ. Those with a baseline hs-cTnT exceeding URL were 9.5 (95% CI: 7.0–12.9) times more likely to have MACE. The presence of prior stroke significantly modified the association between baseline hs-cTnT below LOQ and risk of MACE (p=0.006). Among those with prior stroke (n=158), there was no significant association between baseline hs-cTnT below LOQ and risk of MACE (p=0.451). For the association between hs-cTnT above URL and MACE, significant negative interaction was detected by hypertension (p&lt;0.001), hyperlipidemia (p=0.002), coronary artery disease (p=0.002), percutaneous coronary intervention (p=0.001), and congestive heart failure (p=0.038) comorbidity.

Conclusion

In a diverse, multicenter, US cohort the association between baseline hs-cTnT and the risk of MACE was weakened by the presence of several comorbid conditions. This suggests that the safety of previously validated hs-cTnT diagnostic strategies may be diminished when applied to populations with a high prevalence of comorbid conditions.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Roche Diagnostics

468 IMPROVING ADVANCE CARE PLANNING SKILLS IN JUNIOR DOCTORS

Introduction

Junior doctors are increasingly encountering Advance Care Planning (ACP) when they look after frail, older or multi-morbid patients during their hospital rotations. However, there remains a lack of formal training and resources, particularly with DNACPR discussions and when engaging patients and their loved ones with Emergency Health Care Planning (EHCP). We aimed to assess the need for ACP, improve the infrastructure by which ACP is delivered, and better support junior doctors to have these difficult conversations.

Method

Discharges from the Geriatrics Department at Kettering General Hospital were reviewed initially in May 2019 and again in January 2020 following intervention. We introduced a focused communication skills training session delivered at departmental teaching, which included a combination of simulation training and lectures. We additionally designed and implemented an EHCP template to aid junior doctors’ discussions. This could also be copied to the discharge letter, to facilitate safe transfer of care to primary care.

Results

In May 2019 of 32 patients, 100% met at least one SPICTTM criterion, with median of 4 criteria, thus indicating a high need for ACP in this cohort. Despite this, only one discharge letter included an EHCP and two had a request for GP colleagues to complete one. Evaluation of discharges again in January of 2020 reconfirmed a similar need for ACP, but following our interventions, the number of EHCP’s performed had increased. Of 22 identified patients 4 had a completed EHCP and 3 were requested for completion by their GP. Qualitative questionnaires demonstrated an improvement in both knowledge and confidence amongst junior doctors following the training session.

Conclusion

We have shown that there is a necessity for ACP to be considered for Geriatrics inpatients, and that providing structure and training in this challenging area offers benefit to both patients and junior doctors.

AB0138 A MOLECULAR SIGNATURE RESPONSE CLASSIFIER STRATIFIES SEROPOSITIVE RHEUMATOID ARTHRITIS PATIENTS BASED ON THEIR LIKELIHOOD OF INADEQUATE RESPONSE TO TNF INHIBITOR THERAPIES

Background:

There is an urgent need for precision medicine in targeted therapy selection for the treatment of rheumatoid arthritis (RA). TNF inhibitor (TNFi) therapies are the most prescribed targeted therapy for RA patients, yet the majority of patients fail to achieve a clinically meaningful response using this medication class. A blood-based molecular signature test evaluates RNA and clinical metrics to stratify RA patients based on their likelihood of having an inadequate response to TNFi therapies.1 Patients unlikely to respond to TNFi therapies can be directed to a different treatment option such as a JAK inhibitor, thus reducing the time needed to identify an effective therapy, improving confidence in and adherence to treatment, and increasing the patients’ chance of reaching treat-to-target goals.

Objectives:

High-titers of anti-cyclic citrillunated protein (anti-CCP) have been independently associated with reduced response to TNFi therapy;2 thus, we evaluated the ability of a blood-based molecular signature response classifier (MSRC) test to stratify RA patients by their likelihood of inadequate response to TNFi therapies – regardless of their positive or negative anti-CCP status.

Methods:

A subset of patients enrolled in the Network-04 prospective observational trial evaluating the ability of a molecular signature response classifier to stratify patients were subdivided into two groups based upon whether they were positive (N = 72) or negative (N = 74) for anti-CCP. The odds of inadequate response to TNFi therapies were calculated based on whether or not a patient had a molecular signature of non-response to TNFi therapy at baseline before the start of treatment. Odds ratios and confidence intervals were calculated3,4 to represent the strength of association between detecting the molecular signature of non-response and the patient’s failure to achieve ACR50 at 6 months.

Results:

The odds that a patient with a molecular signature of non-response failed to meet ACR50 criteria at 6 months was approximately three times greater than among those patients who lacked the signal (Table 1). No significant difference in odds ratios was observed between patients who were positive or negative for anti-CCP.

Table 1.

The odds of patients with a molecular signature of non-response failing to achieve an ACR50 response 6 months after TNF inhibitor therapy initiation

Odds ratio (95% confidence interval)Anti-CCP positive3.5 (1.3-9.7)Anti-CCP negative3.1 (1.2-8.3)

Conclusion:

The MSRC test evaluates RA disease biology and accurately stratifies patients based on their likelihood of having an inadequate response to TNFi therapies, regardless of being negative or positive for anti-CCP autoantibodies. Rheumatologists can use the results of the MSRC test to inform targeted therapy selection for RA patients, instead of their anti-CCP serostatus, eliminating the variability inherent to the anti-CCP measurement and its inability to consistently predict TNFi therapy incompatibility. With the MSRC test, providers can rely on a more predictable and accurate assessment of TNFi therapy success or failure when coordinating patient management.

References:

[1]Mellors, T. et al. Clinical Validation of a Blood-Based Predictive Test for Stratification of Response to Tumor Necrosis Factor Inhibitor Therapies in Rheumatoid Arthritis Patients. Network and Systems Medicine3, 91-104, doi:10.1089/nsm.2020.0007 (2020).

[2]Braun-Moscovici, Y. et al. Anti-cyclic citrullinated protein antibodies as a predictor of response to anti-tumor necrosis factor-alpha therapy in patients with rheumatoid arthritis. J Rheumatol33, 497-500 (2006).

[3]Szumilas, M. Explaining odds ratios. J Can Acad Child Adolesc Psychiatry19, 227-229 (2010).

[4]Sperandei, S. Understanding logistic regression analysis. Biochem Med (Zagreb) 24, 12-18, doi:10.11613/BM.2014.003 (2014).

Disclosure of Interests:

Stanley Cohen: None declared, Vibeke Strand Consultant of: Abbvie, Amgen, Arena, BMS, Boehringer Ingelheim, Celltrion, Galapagos, Genentech/Roche, Gilead, GSK, Ichnos, Inmedix, Janssen,Kiniksa, Lilly,Merck, Novartis, Pfizer, Regeneron, Samsung, Sandoz, Sanofi, Setpoint, UCB, Erin Connolly-Strong Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Johanna Withers Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Lixia Zhang Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Ted Mellors Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Viatcheslav Akmaev Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation

AB0140 A HIGH-CONFIDENCE DEFINITION OF THERAPEUTIC RESPONSE IN RHEUMATOID ARTHRITIS USING A MONTE CARLO SIMULATION APPROACH

Background:

Therapy choice and therapy change depend on the ability to accurately assess patients’ disease activity. The clinical assessments used to evaluate treatment response in rheumatoid arthritis have inherent variability, normally considered as measurement error, intra-observer variability or within subject variability. Each contribute to variability in deriving response status as defined by composite measures such as the ACR or EULAR criteria, particularly when a one-time observed measurement lies near the boundary defining response or non-response. To select an optimal therapeutic strategy in the burgeoning age of precision medicine in rheumatology, achieve the lowest disease activity and maximize long-term health outcomes for each patient, improved treatment response definitions are needed.

Objectives:

Develop a high-confidence definition of treatment response and non-response in rheumatoid arthritis that exceeds the expected variability of subcomponents in the composite response criteria.

Methods:

A Monte Carlo simulation approach was used to assess ACR50 and EULAR response outcomes in 100 rheumatoid arthritis patients who had been treated for 6 months with a TNF inhibitor therapy. Monte Carlo simulations were run with 2000 iterations implemented with measurement variability derived for each clinical assessment: tender joint count, swollen joint count, Health Assessment Questionnaire disability index (HAQ-DI), patient pain assessment, patient global assessment, physician global assessment, serum C-reactive protein level (CRP) and disease activity score 28-joint count with CRP.1-3 Each iteration of the Monte Carlo simulation generated one outcome with a value of 0 or 1 indicating non-responder or responder, respectively.

Results:

A fidelity score, calculated separately for ACR50 and EULAR response, was defined as an aggregated score from 2000 iterations reported as a fraction that ranges from 0 to 1. The fidelity score depicted a spectrum of response covering strong non-responders, inconclusive statuses and strong responders. A fidelity score around 0.5 typified a response status with extreme variability and inconclusive clinical response to treatment. High-fidelity scores were defined as >0.7 or <0.3 for responders and non-responders, respectively, meaning that the simulated clinical response status label among all simulations agreed at least 70% of the time. High-confidence true responders were considered as those patients with high-fidelity outcomes in both ACR50 and EULAR outcomes.

Conclusion:

A definition of response to treatment should exceed the expected variability of the clinical assessments used in the composite measure of therapeutic response. By defining high-confidence responders and non-responders, the true impact of therapeutic efficacy can be determined, thus forging a path to development of better treatment options and advanced precision medicine tools in rheumatoid arthritis.

References:

[1]Cheung, P. P., Gossec, L., Mak, A. & March, L. Reliability of joint count assessment in rheumatoid arthritis: a systematic literature review. Semin Arthritis Rheum43, 721-729, doi:10.1016/j.semarthrit.2013.11.003 (2014).

[2]Uhlig, T., Kvien, T. K. & Pincus, T. Test-retest reliability of disease activity core set measures and indices in rheumatoid arthritis. Ann Rheum Dis68, 972-975, doi:10.1136/ard.2008.097345 (2009).

[3]Maska, L., Anderson, J. & Michaud, K. Measures of functional status and quality of life in rheumatoid arthritis: Health Assessment Questionnaire Disability Index (HAQ), Modified Health Assessment Questionnaire (MHAQ), Multidimensional Health Assessment Questionnaire (MDHAQ), Health Assessment Questionnaire II (HAQ-II), Improved Health Assessment Questionnaire (Improved HAQ), and Rheumatoid Arthritis Quality of Life (RAQoL). Arthritis Care Res (Hoboken) 63 Suppl 11, S4-13, doi:10.1002/acr.20620 (2011).

Disclosure of Interests:

Vibeke Strand Consultant of: Abbvie, Amgen, Arena, BMS, Boehringer Ingelheim, Celltrion, Galapagos, Genentech/Roche, Gilead, GSK, Ichnos, Inmedix, Janssen, Kiniksa, Lilly, Merck, Novartis, Pfizer, Regeneron, Samsung, Sandoz, Sanofi, Setpoint, UCB, Stanley Cohen: None declared, Lixia Zhang Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Ted Mellors Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Alex Jones Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Johanna Withers Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation, Viatcheslav Akmaev Shareholder of: Scipher Medicine Corporation, Employee of: Scipher Medicine Corporation

Mosquito oviposition and larvae development in response to kairomones originated by different fish

Predator-released kairomones indicating the presence of predatory fish are known to alter the behaviour and life-history traits of several aquatic herbivores. Culex mosquitoes (Diptera: Culicidae) respond to such cues by altering oviposition habitat selection and larval development time. These responses differ among fish species indicating composition differences among fish-released cues, but the recognition pattern is not clear. This study tested the dependence of fish recognition to co-evolution and the level of threat to larvae. We compared Culex responses to three fish, the invasive larvivorous Gambusia affinis (Cyprinodontiformes: Poeciliidae), the native larvivorous Aphanius mento (Cyprinodontiformes: Cyprinodontidae) and the native algivorous Garra rufa (Cypriniformes: Cyprinidae). The effects of cues released by the three fish on Culex oviposition and life-history shifts were compared in field mesocosms and lab tests. Our results showed that ovipositing females were significantly repelled only by cues originated from G. affinis, while developing larvae response was a more general one. Our results support the idea that fish-released kairomones differ in composition or quantities among different species.

The clinical importance of early acute hepatic porphyria diagnosis: a national cohort

Acute hepatic porphyria (AHP) attacks begin with abdominal pain and can progress to severe life-threatening conditions. Early diagnosis and treatment may prevent these complications. We investigated the difference between the severity of porphyria attacks before and after porphyria diagnosis. A retrospective study including AHP patients hospitalized for an acute attack in Israel during a 15-year period. Diagnosis of an attack was based on typical clinical symptoms accompanied by at least one documented elevated urinary porphobilinogen above fourfold of normal values. The primary outcome was intensive care unit (ICU) admissions. Secondary outcomes included the length of hospital stay, severe hyponatremia, seizures, and psychiatric symptoms. 42 attacks in 9 patients were included. Most attacks occurred in women (78.6%) and in acute intermittent porphyria patients (76.2%). The mean age of attack was 26.5 (± 6.3) years. Attacks following porphyria diagnosis had a lower prevalence of ICU admission (3.3% versus 75.0%, p < 0.001), seizures (0% versus 50.0%, p < 0.001), psychiatric symptoms (23.3% versus 66.7%, p = 0.01), severe hyponatremia (16.7% versus 83.3%, p < 0.001), and median length of hospital stay (5 versus 11.0 days, p < 0.001). These results remained significant after simple univariate logistic regression for ICU admission [odds ratio (OR) 0.01, 95% confidence interval (CI) 0.00-0.12], prolonged hospital stay (OR 0.08, 95% CI 0.01-0.41), seizures or neurological symptoms (OR 0.06, 95% CI 0.01-0.30), and severe hyponatremia (OR 0.02, 95% CI 0.00-0.20). Previously diagnosed AHP patients have a significantly milder attack course as compared to previously undiagnosed patients. Family screening following sentinel cases might prevent severe AHP attacks.

Efficacy and Safety of Lanabecestat for Treatment of Early and Mild Alzheimer Disease: The AMARANTH and DAYBREAK-ALZ Randomized Clinical Trials

Importance

Alzheimer disease (AD) is a neurodegenerative disorder characterized by cognitive deterioration and impaired activities of daily living. Current treatments provide only minor symptomatic improvements with limited benefit duration. Lanabecestat, a brain-permeable inhibitor of human beta-site amyloid precursor protein-cleaving enzyme 1 (BACE1/β-secretase), was developed to modify the clinical course of AD by slowing disease progression.

Objective

To assess whether lanabecestat slows the progression of AD compared with placebo in patients with early AD (mild cognitive impairment) and mild AD dementia.

Design, Setting, and Participants

AMARANTH (first patient visit on September 30, 2014; last patient visit on October 4, 2018) and DAYBREAK-ALZ (first patient visit on July 1, 2016; last patient visit on September 28, 2018) were randomized, placebo-controlled, phase 2/3 and phase 3 clinical trials lasting 104 weeks and 78 weeks, respectively. AMARANTH and DAYBREAK-ALZ were multicenter, global, double-blind studies conducted at 257 and 251 centers, respectively, located in 15 and 18 countries or territories, respectively. A population-based sample of men and women aged 55 to 85 years who met National Institute on Aging-Alzheimer's Association criteria for early AD or mild AD dementia was screened using cognitive assessments, and the presence of amyloid was confirmed. Patients were excluded for unstable medical conditions or medication use, significant cerebrovascular pathologic findings, or a history of vitiligo and/or current evidence of postinflammatory hypopigmentation. AMARANTH screened 6871 patients; 2218 (32.3%) were randomized, and 539 patients completed the study. DAYBREAK-ALZ screened 5706 patients; 1722 (30.2%) were randomized, and 76 patients completed the study.

Interventions

Patients were randomized (1:1:1) to once-daily oral doses of lanabecestat (20 mg), lanabecestat (50 mg), or placebo.

Main Outcomes and Measures

The primary outcome measure was change from baseline on the 13-item Alzheimer Disease Assessment Scale-cognitive subscale. Secondary outcomes included Alzheimer's Disease Cooperative Study-Instrumental Activities of Daily Living Inventory, Clinical Dementia Rating, Functional Activities Questionnaire, Mini-Mental State Examination, and Neuropsychiatric Inventory. Efficacy analyses were conducted on the intent-to-treat population.

Results

Among 2218 AMARANTH patients, the mean (SD) age was 71.3 (7.1) years, and 1177 of 2218 (53.1%) were women. Among 1722 DAYBREAK-ALZ patients, the mean (SD) age was 72.3 (7.0) years, and 1023 of 1722 (59.4%) were women. Both studies were terminated early after futility analysis. There were no consistent, reproducible dose-related findings on primary or secondary efficacy measures. Psychiatric adverse events, weight loss, and hair color changes were reported in a higher percentage of patients receiving lanabecestat than placebo.

Conclusions and Relevance

Treatment with lanabecestat was well tolerated and did not slow cognitive or functional decline.

Trial Registration

ClinicalTrials.gov identifiers: NCT02245737 and NCT02783573.

Serial and syntactic processing in the visual analysis of multi-digit numbers

The visual analysis of letter strings and digit strings is done by two separate cognitive processes. Recent studies have hypothesized that these processes are not only separate but also qualitatively different, in that they may encode information specific to numbers or to words. To examine this hypothesis and to shed further light on the visual analysis of numbers, we asked adults to read aloud multi-digit strings presented to them for brief durations. Their performance was better in digits on the number's left side than in digits farther to the right, with better performance in the two outer digits than their neighbors. This indicates the digits were processed serially, from left to right. Visual similarity of digits increased the likelihood of errors, and when a digit migrated to an incorrect position, it was most often to an adjacent location. Interestingly, the positions of 0 and 1 were encoded better than the positions of 2-9, and 2-9 were identified better when they were next to 0 or 1. To accommodate these findings, we propose a detailed model for the visual analysis of digit strings. The model assumes imperfect digit detectors in which a digit's visual information leaks to adjacent locations, and a compensation mechanism that inhibits this leakage. Crucially, the compensating inhibition is stronger for 0 and 1 than for the digits 2-9, presumably because of the importance of 0 and 1 in the number system. This sensitivity to 0 and 1 makes the visual analyzer specifically adapted to numbers, not words, and may be one of the brain's reasons to implement the visual analysis of numbers and words in two separate cognitive processes.