At-Home Administration of Gantenerumab by Care Partners to People with Early Alzheimer's Disease: Feasibility, Safety and Pharmacodynamic Impact

BACKGROUND

Monoclonal antibodies that target amyloid-beta and remove amyloid plaques can slow cognitive and functional decline in early Alzheimer's disease. Gantenerumab is a subcutaneously administered fully-human anti-amyloid-beta monoclonal antibody with highest affinity for aggregated amyloid-beta. Since the phase 3 GRADUATE trials did not meet the primary endpoint (change from baseline to Week 116 in Clinical Dementia Rating scale - Sum of Boxes), development of gantenerumab in sporadic Alzheimer's disease was stopped and all ongoing trials were terminated early due to sponsor decision. Subcutaneous administration at the clinic or at home by care partner would be an important option for other therapies in this class in order to increase flexibility and reduce overall burden. The insights obtained from the experience with gantenerumab home administration by care partner in the phase 2 GRADUATION trial will serve to guide the ongoing efforts with other anti-amyloid-beta antibodies.

OBJECTIVES

To evaluate the pharmacodynamic effects on brain amyloid load of once weekly subcutaneous administration of gantenerumab and the safety and feasibility of home administration by care partners.

DESIGN

Phase 2, open-label, single arm study.

SETTING

Multicenter trial conducted in 33 sites in 8 countries from November 2020 to March 2023.

PARTICIPANTS

Participants aged 50 to 90 with early symptomatic Alzheimer's disease (mild cognitive impairment/mild dementia due to Alzheimer's disease), and evidence of amyloid positron emission tomography positivity.

INTERVENTION

Participants could receive up to 255 mg gantenerumab once-weekly, administered subcutaneously at site or at home by healthcare professionals or non-healthcare-professional care partners.

MEASUREMENTS

The primary endpoint was the change from baseline to Week 52 and to Week 104 in brain amyloid load as measured by PET centiloid levels. The secondary endpoints were responses to the home administration questionnaire, plasma concentrations and safety.

RESULTS

The overall number of participants enrolled was 192, with a mean (standard deviation) amyloid PET load at baseline of 101.80 (29.80) centiloids. At the time of early study termination by sponsor, 149 participants had valid Week 52 amyloid PET data (primary endpoint), and 12 participants had an early termination PET within the pre-defined time range of Week 104. The mean change in amyloid PET from baseline to Week 52 and Week 104 was -26.19 centiloids (range: -75.6-15.8; n=149) and -35.48 centiloids (range: -63.2--7.0; n=12), respectively. Responses to the home administration questionnaire at Week 52 (n=148) indicated that the majority of care partners (88-97%) considered administration of study drug at home easy (30.4%) or very easy (57.4%), and convenient (25.7%) or very convenient (70.9%). Care partners felt confident (31.1%) or very confident (62.2%) and satisfied (29.7%) or very satisfied (64.9%) with giving the injection at home. Responses by care partners at Week 36 (n=72), Week 76 (n=126) and Week 104 (n=29) and participant (patient) assessment of convenience and satisfaction at these time points were similar. There were no new safety findings associated with gantenerumab administered subcutaneously once weekly at 255 mg or safety issues associated with at-home injections by non-healthcare professional care partners.

CONCLUSIONS

Once-weekly subcutaneous home administration of the anti-amyloid-beta antibody gantenerumab by non-healthcare-professional care partners to participants with early Alzheimer's disease was feasible, safe, well tolerated, and considered as a convenient option by both the care partners and participants with Alzheimer's disease. Although gantenerumab's development has been stopped due to lack of efficacy, this approach has the potential to reduce the frequency of hospital/outpatient clinic visits required for treatment with other anti-amyloid-β antibodies and can increase flexibility of drug administration for people living with Alzheimer's disease and their families.

Hypophosphatasia in adolescents and adults: overview of diagnosis and treatment

This article provides an overview of the current knowledge on hypophosphatasia-a rare genetic disease of very variable presentation and severity-with a special focus on adolescents and adults. It summarizes the available information on the many known mutations of tissue-nonspecific alkaline phosphatase (TNSALP), the epidemiology and clinical presentation of the disease in adolescents and adults, and the essential diagnostic clues. The last section reviews the therapeutic approaches, including recent reports on enzyme replacement therapy (EnzRT).

Thirty-Six-Month Amyloid Positron Emission Tomography Results Show Continued Reduction in Amyloid Burden with Subcutaneous Gantenerumab

Previous findings from the positron emission tomography (PET) substudy of the SCarlet RoAD and Marguerite RoAD open-label extension (OLE) showed gantenerumab doses up to 1200 mg every 4 weeks administered subcutaneously resulted in robust beta-amyloid (Aβ) plaque removal over 24 months in people with prodromal-to-moderate Alzheimer's disease (AD). In this 36-month update, we demonstrate continued reduction, with mean (standard error) centiloid values at 36 months of -4.3 (7.5), 0.8 (6.7), and 4.7 (8.0) in the SCarlet RoAD (double-blind pooled placebo and active groups), Marguerite RoAD double-blind placebo, and Marguerite RoAD double-blind active groups respectively, representing a change of -57.0 (10.3), -90.3 (9.0), and -74.9 (10.5) centiloids respectively. These results demonstrate that prolonged gantenerumab treatment, at doses up to 1200 mg, reduces amyloid plaque levels below the amyloid positivity threshold. The ongoing GRADUATE Phase III trials will evaluate potential clinical benefits associated with gantenerumab-induced amyloid-lowering in people with early (prodromal-to-mild) AD.

The Multiple Sclerosis Inventory of Cognition for Adolescents (MUSICADO): A brief screening instrument to assess cognitive dysfunction, fatigue and loss of health-related quality of life in pediatric-onset multiple sclerosis

OBJECTIVE

Screening for cognitive impairment (CI), fatigue and also Health-related quality of life (HRQoL) in patients with pediatric-onset multiple sclerosis (POMS) is of utmost importance in clinical practice. The aim of this study was to establish a new and validated pediatric screening tool "MUSICADO" that is easy to use and time economical.

METHODS

106 patients with POMS aged 12-18 years and 210 healthy controls (HCs) stratified for age and education underwent neuropsychological testing including a screening test "Multiple Sclerosis Inventory of Cognition" for adults and 8 standardized cognitive tests and established scales to assess fatigue and HRQoL.

RESULTS

The phonemic verbal fluency task (RWT "s-words"), the Trail Making Test A (TMT-A), and the Digit Span Forward discriminated significantly between patients and HCs (p = 0.000, respectively) and showed the highest proportion of test failure in patients (24.5%, 17.9%; 15.1%, respectively). Therefore, they were put together to form the cognitive part of the "MUSICADO". After applying a scoring algorithm with balanced weighting of the subtests and age and education correction and a cut-off score for impairment, 35.8% of patients were categorized to be cognitively impaired (specificity: 88.6%). Fatigue was detected in 37.1% of the patients (specificity: 94.0%) and loss of HRQoL in 41.8% (specificity 95.7%) with the screening version, respectively.

CONCLUSION

The MUSICADO is a newly designed brief and easy to use screening test to help to early identify CI, fatigue, and loss of HRQoL in patients with POMS as cut scores are provided for all three items. Further studies will have to show its usability in independent samples of patients with POMS.

Broadband multizone sound rendering by jointly optimizing the sound pressure and particle velocity

In this paper, a recently proposed approach to multizone sound field synthesis, referred to as joint pressure and velocity matching (JPVM), is investigated analytically using a spherical harmonics representation of the sound field. The approach is motivated by the Kirchhoff-Helmholtz integral equation and aims at controlling the sound field inside the local listening zones by evoking the sound pressure and particle velocity on surrounding contours. Based on the findings of the modal analysis, an improved version of JPVM is proposed, which provides both better performance and lower complexity. In particular, it is shown analytically that the optimization of the tangential component of the particle velocity vector, as is done in the original JPVM approach, is very susceptible to errors and thus not pursued anymore. Furthermore, the analysis provides fundamental insights as to how the spherical harmonics used to describe three-dimensional sound fields translate into two-dimensional basis functions as observed on the contours surrounding the zones. By means of simulations, it is verified that discarding the tangential component of the particle velocity vector ultimately leads to an improved performance. Finally, the impact of sensor noise on the reproduction performance is assessed.

The spatial coherence of noise fields evoked by continuous source distributions

In this work, analytic expressions for the spatial coherence of noise fields are derived in the modal domain with the aim of providing a sparse representation. For this purpose, the sound field in a region of interest is expressed in terms of a given pressure distribution on a virtual surrounding cylindrical or spherical surface. According to the Huygens-Fresnel principle, the sound pressure on this surface is represented by a continuous distribution of elementary line or point sources, where orthogonal basis functions characterize the spatial properties. To describe spatially windowed pressure distributions with arbitrary angular extensions, orthogonal basis functions of limited angular support are proposed. As special cases, circular and spherical pressure distributions with uncorrelated source modes of equal power are investigated. It is shown that these distributions result, respectively, in cylindrically isotropic and spherically isotropic, i.e., diffuse noise fields. The analytic expressions derived in this work allow for a prediction of the spatial coherence between arbitrary positions within the region of interest, such that no microphones need to be placed at the actual points of interest. Simulation results are presented to validate the derived relations.

Asfotase alfa: enzyme replacement for the treatment of bone disease in hypophosphatasia

Hypophosphatasia (HPP) is a rare disease caused by loss-of-function mutations in the tissue-nonspecific alkaline phosphatase (TNAP, TNSALP) gene. HPP causes a multisystemic syndrome with a predominant bone phenotype. The clinical spectrum ranges from high lethality in early onset (<6 months) HPP to mild late-onset syndromes. HPP management so far has been only supportive. Subcutaneous asfotase alfa, a first-in-class bone-targeted human TNAP enzyme replacement therapy, is the first compound to be approved for long-term treatment of bone manifestations in pediatric-onset HPP. In noncomparative clinical trials (treatment up to 7 years), this treatment was associated with skeletal, respiratory and functional improvement in perinatal, infantile and childhood-onset HPP. Compared with age-matched historical controls, patients with life-threatening perinatal and infantile HPP treated with asfotase alfa had substantially improved bone mineralization, survival and ventilation-free survival. In childhood HPP, asfotase alfa improved growth, gross motor function, strength and agility and decreased pain. The compound was well tolerated and most adverse events were of mild to moderate intensity. To date, data and experience concerning its efficacy and safety in long-term treatment are not yet available. Further studies to evaluate risks and benefits of enzyme replacement therapy with asfotase alfa in adults are in progress and are also strongly needed.

[Increased prevalence of congenital dacryostenosis following cesarean section]

BACKGROUND

Congenital nasolacrimal duct obstruction (dacryostenosis) with a persisting membrane at Hasner's valve is the most common cause of persistent tear and ocular discharge in infants.

PURPOSE

To evaluate whether there is an association between congenital dacryostenosis and delivery via cesarean section.

MATERIAL AND METHODS

In a prospective study we examined 107 children (mean age 9.2 ± 7.1 months) with congenital dacryostenosis. We evaluated data about the mode of delivery (vaginal delivery versus cesarean section) and gestational age at the time of birth. Within the first 8 months of life children were treated by probing using local anesthesia, whereas older children were treated using general anesthesia. After the age of 11 months treatment included nasolacrimal duct intubation with a bicanalicular stent. Statistical analyses were performed using binomial tests, Fisher's exact test and the t-test.

RESULTS

In this study 51 children delivered by cesarean section were compared with 56 children delivered by spontaneous vaginal delivery. A total of 44 age-matched pairs from both groups were evaluated in order to eliminate confounding factors due to gestational age at delivery. Based on the published rate of cesarean sections from the same region of the State of Hesse between 2002-2004 we observed a statistically significant association between congenital dacryostenosis and delivery by cesarean section among the 88 age-matched patients (P = 0.009). Moreover, subgroup analysis revealed a significant association between congenital dacryostenosis and delivery by primary cesarean section (P = 0.00004). The prevalence of surgical treatment was not statistically different between both groups based on the mode of delivery (P = 0.8).

CONCLUSION

Our results suggest that delivery via cesarean section is associated with a significantly higher prevalence of congenital dacryostenosis.

Impact of toll-like-receptor-9 (TLR9) deficiency on visceral adipose tissue adipokine expression during chronic DSS-induced colitis in mice

BACKGROUND

Studies postulate an involvement of adipokines in inflammatory gastrointestinal diseases. Leptin-deficient ob/ob mice as well as TLR9-deficient mice have a more moderate course of chronic DSS-induced colitis (DSS-CC) and adipocytes do express functional TLR9 molecules.

MATERIAL AND METHODS

Adipokine mRNA expression in visceral adipose tissue of mice before and after the induction of DSS-CC was investigated. Experiments were performed in both TLR9(wt/wt) and TLR9(-/-) mice. In vitro, the effect of TLR9 blocking peptide on leptin and visfatin protein secretion was studied in 3T3-L1 adipocytes.

RESULTS

Induction of DSS-CC led to an upregulation of leptin mRNA expression in TLR9(wt/wt) mice, while TLR9(-/-) animals showed a significant reduction of leptin expression even below baseline. While visfatin expression remained unchanged in TLR9(wt/wt) animals, TLR9(-/-) mice exhibited a significant induction during DSS-CC. CTRP-3 expression was reduced after colitis induction only in TLR9(-/-) animals. Of note, IL-6 expression levels remained unchanged, while CXCL1/KC and cyclophilin A expression was reduced in DSS-CC. Inhibition of TLR9 signaling by using TLR9 blocking peptide led to reduced leptin protein secretion into cell culture supernatants in 3T3-L1 adipocytes, while visfatin protein secretion was enhanced.

CONCLUSIONS

DSS-CC leads to differential adipokine expression profiles in the visceral fat pad in TLR9(wt/wt) vs. TLR9(-/-) mice. In vitro, inhibition of TLR9 signaling induces visfatin secretion while inhibiting leptin secretion in adipocytes. Thus, visceral adipokines are regulated by intact TLR9 signaling pathway and a specific interplay between the leptin- and the TLR9-pathways might be of pathophysiological importance in chronic intestinal inflammation.

Unified approach to probing Coulomb effects in tunnel ionization for any ellipticity of laser light

We present experimental data that show significant deviations from theoretical predictions for the location of the center of the electron momenta distribution at low values of ellipticity ε of laser light. We show that these deviations are caused by significant Coulomb focusing along the minor axis of polarization, something that is normally neglected in the analysis of electron dynamics, even in cases where the Coulomb correction is otherwise taken into account. By investigating ellipticity-resolved electron momenta distributions in the plane of polarization, we show that Coulomb focusing predominates at lower values of ellipticity of laser light, while Coulomb asymmetry becomes important at higher values, showing that these two complementary phenomena can be used to probe long-range Coulomb interaction at all polarizations of laser light. Our results suggest that both the breakdown of Coulomb focusing and the onset of Coulomb asymmetry are linked to the disappearance of Rydberg states with increasing ellipticity.

Compound heterozygosity of two functional null mutations in the ALPL gene associated with deleterious neurological outcome in an infant with hypophosphatasia

Hypophosphatasia (HPP) is a heterogeneous rare, inherited disorder of bone and mineral metabolism caused by different mutations in the ALPL gene encoding the isoenzyme, tissue-nonspecific alkaline phosphatase (TNAP). Prognosis is very poor in severe perinatal forms with most patients dying from pulmonary complications of their skeletal disease. TNAP deficiency, however, may also result in neurological symptoms such as neonatal seizures. The exact biological role of TNAP in the human brain is still not known and the pathophysiology of neurological symptoms due to TNAP deficiency in HPP is not understood in detail. In this report, we describe the clinical features and functional studies of a patient with severe perinatal HPP which presented with rapidly progressive encephalopathy caused by new compound heterozygous mutations in the ALPL gene which result in a functional ALPL "knock out", demonstrated in vitro. In contrast, an in vitro simulation of the genetic status of his currently asymptomatic parents who are both heterozygous for one mutation, showed a residual in vitro AP activity of above 50%. Interestingly, in our patient, the fatal outcome was due to progressive encephalopathy which was refractory to antiepileptic therapy including pyridoxine, rather than hypomineralization and respiratory insufficiency often seen in HPP patients. The patient's cranial MRI showed progressive cystic degradation of the cortex and peripheral white matter with nearly complete destruction of the cerebrum. To our knowledge, this is the first MRI-based report of a deleterious neurological clinical outcome due to a progressive encephalopathy in an infant harboring a functional human ALPL "knock out". This clinical course of disease suggests that TNAP is involved in development and may be responsible for multiple functions of the human brain. According to our data, a certain amount of residual TNAP activity might be mandatory for normal CNS function in newborns and early childhood.

Ultrashort echo time (UTE) MRI for the assessment of caries lesions

OBJECTIVE

Direct in vivo MRI of dental hard tissues by applying ultrashort echo time (UTE) MRI techniques has recently been reported. The objective of the presented study is to clinically evaluate the applicability of UTE MRI for the identification of caries lesions.

METHODS

40 randomly selected patients (mean age 41 ± 15 years) were enrolled in this study. 39 patients underwent a conventional clinical assessment, dental bitewing X-ray and a dental MRI investigation comprising a conventional turbo-spin echo (TSE) and a dedicated UTE scan. One patient had to be excluded owing to claustrophobia. In four patients, the clinical treatment of the lesions was documented by intraoral pictures, and the resulting volume of the cavity after excavation was documented by dental imprints and compared with the MRI findings.

RESULTS

In total, 161 lesions were identified. 157 (97%) were visible in the UTE images, 27 (17%) in the conventional TSE images and 137 (85%) in the X-ray images. In total, 14 teeth could not be analysed by MR owing to artefacts caused by dental fillings. All lesions appear significantly larger in the UTE images as compared with the X-ray and TSE images. In situ measurements confirm the accuracy of the lesion dimensions as observed in the UTE images.

CONCLUSION

The presented data provide evidence that UTE MR imaging can be applied for the identification of caries lesions. Although the current data suggest an even higher sensitivity of UTE MRI, some limitations must be expected from dental fillings.

First analytical evidences of precious colourants on Mediterranean illuminated manuscripts

Two Byzantine VI century manuscripts known as Vienna Dioskurides and Vienna Genesis, held in the Austrian National Library at Vienna, were analysed with in situ non-invasive techniques. Raman spectroscopy, UV-Vis diffuse reflectance spectrophotometry with optic fibres and X-ray fluorescence spectrometry were used to characterise the palette of these early Middle Ages manuscripts. The analytical study was performed to have a better knowledge on the colourants used by ancient miniature painters, a subject known more on the basis of traditional sources (i.e. medieval treatises) than of analytical evidences. Indeed these illuminated manuscripts are, to the authors' knowledge, among the oldest ever being analysed, so that the colourants found in them can be considered among the oldest evidences of their use. The main feature of Vienna Dioskurides and Vienna Genesis palettes is their richness, exemplified by the simultaneous presence of gold and ultramarine blue; in Vienna Dioskurides cinnabar is also present. Information regarding ultramarine blue is surprising, being the analytical evidence of the use of this precious pigment at least three centuries before its use in Western manuscripts, a feature justified by the fact that the Byzantine Empire was the dominant culture in early Middle Ages in the Mediterranean World. Other colourants include azurite and indigo, red lead, orpiment, red and yellow ochres, while a mixture of blue and yellow colourants, known as vergaut, was used to render green hues. Organic colourants were also used, such as madder and Tyrian purple, the latter employed to dye the parchment of Vienna Genesis.

Screening of multiparous women to avoid transfusion-related acute lung injury: a single centre experience

The aim of this study was to investigate which approach for serological testing of multiparous donors might be feasible and effective to reduce the risk of transfusion-related acute lung injury (TRALI). TRALI is a serious adverse event of blood transfusion. Antibodies to granulocytes and human leucocyte antigens (HLAs) are frequently detected in sera of implicated donors. These donors are often multiparous women. A general deferral of female plasma or screening strategies for leucocyte antibodies has been proposed to increase blood safety. A prospective study was initiated in 2003. Until 2006, serum samples from all female donors reporting three or more pregnancies (n = 229) were screened for the presence of antibodies against granulocytes and HLAs by immunofluorescence and agglutination tests as well as by a commercial HLA enzyme immunoassay. In total, 40% of all multiparous women were reactive in one of the assays. Twenty-nine percent of the reactive sera contained antibodies to granulocytes but not to HLAs. During the observation period, three TRALI reactions occurred in our hospital, two of which would have been prevented if the screening program had been extended to all previously pregnant donors. We conclude from these data that, not unexpectedly, the number of previous pregnancies is not a reliable indicator for the likelihood of inducing TRALI. More importantly, screening strategies for antibodies that might induce TRALI should probably not be reduced to HLA antibody screening. This finding awaits further research.

Myeloradiculitis: a rare event in schistosoma infection

Schistosomiasis a parasitic disease caused by trematodes is widely distributed in (sub-)tropical countries. Depending on the species the infection manifests clinically as gastrointestinal (preferentially Schistosoma mansoni and S. japonicum) or urinary (preferentially S. haematobium) disorders. Here we present an uncommon case of myeloradiculitis leading to bladder palsy and sensory loss at the lower limbs.