Widespread Pain Phenotypes Impact Treatment Efficacy Results in Randomized Clinical Trials for Interstitial Cystitis/Bladder Pain Syndrome: A MAPP Network Study

Clinical trials of pain are notoriously difficult and inefficient in demonstrating efficacy even for known efficacious treatments. Determining the appropriate pain phenotype to study can be problematic. Recent work has identified the extend of widespread pain as an important factor in the likelihood of response to therapy, but has not been tested in clinical trials. Using data from three previously published negative studies of the treatment of interstitial cystitis/ bladder pain with data on the extent of widespread pain, we examined the response of patients to different therapies base on the amount of pain beyond the pelvis. Participants with predominately local but not widespread pain responded to therapy targeting local symptoms. Participants with widespread and local pain responded to therapy targeting widespread pain. Differentiating patients with and without widespread pain phenotypes may be a key feature of designing future pain clinical trials to demonstrate treatments that are effective versus not.

Mavacamten induces a clinical, hemodynamic, and biomarker response beyond the primary endpoint in EXPLORER-HCM: results from a post hoc machine learning analysis

Introduction

Mavacamten, a first-in-class selective inhibitor of cardiac myosin, was demonstrated in EXPLORER-HCM (NCT03470545) to be superior to placebo in achieving a primary endpoint of either (1) a ≥1.5 mL/kg/min increase in peak oxygen consumption (pVO2) and at least one New York Heart Association (NYHA) class reduction, or (2) a ≥3.0 mL/kg/min pVO2 increase without NYHA class worsening, in adults with obstructive hypertrophic cardiomyopathy (oHCM). However, the observed benefits of mavacamten were broader than the primary endpoint, suggesting a complex effect of the drug beyond improvements in these two parameters.

Purpose

A post hoc investigation of mavacamten clinical effects beyond the primary endpoint of EXPLORER-HCM.

Methods

EXPLORER data at week 30 were analyzed to evaluate improvements from baseline in primary (specified above), secondary (e.g. postexercise left ventricular outflow tract gradient and Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score) and exploratory endpoints (e.g. circulating NT-ProBNP and cardiac Troponin I). Responses were classified as improved or not improved based on published thresholds, clinical standards and analyses of the EXPLORER data. Patients were grouped according to their improvement status using unsupervised hierarchical clustering.

Results

The cluster analysis resulted in four main groups with the following trends (Table); Group 1 = patients who met the primary endpoint and showed improvement in secondary/exploratory endpoints; Group 2 = patients with improvement in secondary/exploratory endpoints who did not meet the primary endpoint; Group 3 = patients who met the primary endpoint without substantial secondary/exploratory endpoint responses; Group 4 = patients without appreciable improvement in any endpoint. A substantially larger proportion of patients in Group 1 received mavacamten compared with placebo (88% vs. 12%, respectively). A similar trend was observed in Group 2 patients who exhibited improvements in secondary/exploratory endpoints (85% mavacamten vs. 15% placebo). Group 3 consisted predominantly of placebo-treated patients who met the primary endpoint but had negligible responses to secondary/exploratory endpoints (5% mavacamten vs. 95% placebo). Group 4 consisted predominantly of placebo-treated patients without appreciable clinically relevant responses from this analysis (10% mavacamten vs. 90% placebo).

Conclusions

Mavacamten was associated with clinical improvements beyond the primary endpoint of EXPLORER-HCM and was predominantly accompanied by amelioration of other measures associated with oHCM pathophysiology. In contrast, most placebo-treated patients who met the primary endpoint did not exhibit improvement in the underlying pathophysiology. These findings suggest a potential underestimation of mavacamten clinical impact based on the primary endpoint and prompt a deeper examination of mavacamten efficacy in patients with oHCM based on other clinically relevant endpoints.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb

POS1040 IMPLEMENTATION OF THE OMERACT PSAMRIS IN A PHASE IIB, RANDOMISED PLACEBO-CONTROLLED STUDY OF ABATACEPT IN PSORIATIC ARTHRITIS

Background:

The semi-quantitative Outcome Measures in Rheumatology (OMERACT) Psoriatic Arthritis Magnetic Resonance Imaging Score (PsAMRIS) was developed for the evaluation of inflammatory and destructive changes in PsA,1 but has limited trial usage.

Objectives:

To retrospectively utilise the PsAMRIS in a multi-dose, randomised Phase IIb study of abatacept in patients with PsA who have inadequate response to DMARDs (NCT00534313).2

Methods:

Patients were randomised to abatacept (3, 10 or 30/10 mg/kg [the 30-mg/kg group switched to 10 mg/kg after the first two doses]) or placebo and treated for 169 days, after which all patients received abatacept 10 mg/kg through to Day 365. MRI scans of one hand or foot from 123 patients with PsA collected at baseline and on Days 85, 169 and 365 were centrally evaluated by two readers blinded to chronological order and treatment arm. Synovitis, bone oedema, tenosynovitis, periarticular inflammation, bone erosion, bone proliferation and joint space narrowing were assessed as per OMERACT PsAMRIS; a novel total inflammation score was calculated from the sum of synovitis, bone oedema, tenosynovitis and periarticular inflammation. Variables were analysed using all cases (hand or foot) and by hand and foot cases separately.

Results:

At Day 169, the abatacept 30/10 mg/kg or 10 mg/kg group showed the most decrease (improvement) in each inflammatory assessment (Figure 1). The Day 169 change from baseline severity in synovitis and tenosynovitis in the abatacept 30/10 mg/kg and 10 mg/kg groups, respectively, were significantly reduced (improved) compared with placebo (estimated differences of –0.966 [p=0.039] and –1.652 [p=0.014], respectively) (Table 1). Patients originally randomised to placebo and then switched to abatacept 10 mg/kg at Day 169 showed significant improvements in synovitis, tenosynovitis and total inflammation from Day 169 to Day 365 (Table 1, Figure 1). The structural outcomes joint space narrowing and bone erosion remained stable within each treatment group, showing little change from baseline to Days 85, 169 and 365. After separating hand and foot analyses (72 hand and 51 foot cases), only hand tenosynovitis in the 10-mg/kg group and foot synovitis in the 3-mg/kg group were significantly reduced (improved) at Day 169 compared with placebo (differences of –2.331 [p=0.017] and –1.689 [p=0.010], respectively). In general, more comparisons in the hand analysis were statistically significant versus in the foot analysis.

Conclusion:

This analysis confirmed the efficacy of abatacept 10 and 30/10 mg/kg when assessed with the OMERACT PsAMRIS. The inflammatory pathologies, synovitis and tenosynovitis, appeared to be the most responsive MRI outcomes. Analysing hand and foot cases together yielded results consistent with the primary clinical efficacy endpoint (ACR20 response rate), as the abatacept 10- and 30/10-mg/kg groups showed significant differences versus placebo at Day 169;2 reduced sample size in separate hand and foot assessments may have prevented finding significant results corresponding to the combined analysis. These results also demonstrate the responsiveness of the PsAMRIS in PsA randomised clinical trials.

References:

[1]Glinatsi D, et al. J Rheumatol 2015;42:2473–2479.

[2]Mease P, et al. Arthritis Rheum 2011;63:939–948.

Table 1.

MRI variables showing significant treatment effectsa

Between groups at Day 169MRI scoreComparatorComparatorDifferenceSEp valueSynovitisPlaceboAbatacept 30/10 mg/kg–0.9660.4610.039TenosynovitisPlaceboAbatacept 10 mg/kg–1.6520.6620.014Placebo group before/after switchbMRI scoreTreatment, Day 169Treatment, Day 365DifferenceSEp valueSynovitisPlaceboAbatacept 10 mg/kg–1.0180.4580.029TenosynovitisPlaceboAbatacept 10 mg/kg–0.9400.3900.018Total inflammationPlaceboAbatacept 10 mg/kg–2.2751.0670.036

aBased on change from baseline at the stated time points (unadjusted p values).

bPatients were switched to abatacept 10 mg/kg after Day 169.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Rob Coover, MPH, at Caudex and was funded by Bristol Myers Squibb.

Disclosure of Interests:

Mikkel Østergaard Speakers bureau: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Merck, Novartis, Paul Bird Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Novartis, Pfizer, UCB, Grant/research support from: Gilead, Chahin Pachai Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Shuyan Du Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Chun Wu Employee of: Bristol Myers Squibb, Jessica Landis Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Thomas Fuerst Employee of: Bioclinica, Inc., a contract research service providing radiology central reading services to pharmaceutical, biotech and medical device companies, Harris A Ahmad Employee of: Bristol Myers Squibb, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Philip G Conaghan Speakers bureau: AbbVie, Novartis, Consultant of: AstraZeneca, Bristol Myers Squibb, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer.

Adolescent Health Risk and Behavior Survey: A School Based Survey in Central Nepal

Background A comprehensive study of adolescent health risk specific to the Dhulikhel catchment area has not been performed. Objective This survey assesses trends in demographics, nutrition, hygiene and related infrastructure, causes of injury, violence, mental health, substance abuse, and menstrual hygiene. Method A 40 question survey was adapted from the Center for Disease Control (CDC) Youth Risk Behavior Surveillance System, translated into the Nepali language, and administered to 1200 students in eight different schools in central Nepal. Descriptive statistics were used to summarize the data. Result The data has identified nutrition, infrastructure, mental health, and menstrual hygiene as areas for improvement. The number of adolescents who reported going hungry some, most, or all of the time (30.5%, 25.8%, 13.9%) reveals a need for better food access. Approximately 44.5 % of students had no access to soap and water at school. Students who endorse dissatisfaction with themselves was 6.5% and those with suicidal ideation or attempt was 11.8% of the surveyed population. A significantly greater percentage of students who reported suicidal ideation also reported engaging in behaviors related to physical violence, substance abuse, being dissatisfaction with themselves, insomnia due to anxiety, and loneliness. Of the female students, 40.1% reported missing school at least once in the last three months due to their period. Conclusion This data shows a need for better food access, improved infrastructure in schools in central Nepal, and the need to address the prevalence of mental health issues through program interventions.

Transit Joint Development in the USA: An Inventory and Policy Assessment

The joint development of urban mass transit facilities and private real estate projects has become a popular practice throughout the United States. As of October 1990, 114 transit joint-development projects had been constructed in more than two dozen US cities, although the vast majority of projects have been concentrated in just five cities: New York City, Washington, DC, Philadelphia, Atlanta, and Boston. Of completed joint-development projects 58% have occurred at or near heavy-rail transit stations; another 18% of projects have been developed around commuter rail facilities. Transit joint-development activity can be classified into two basic forms: (1) revenue-sharing arrangements, and (2) cost-sharing arrangements. Of the joint-development projects completed to date, 40% have involved cost-sharing, and 25% have involved revenue-sharing. The remaining projects have involved both types. Joint-development projects have yet to generate very much income to local transit operators, either through capital contributions or through yearly lease payments. Except in New York City, capital contributions from joint development have generally amounted to less than 1% of yearly capital expenditures. This study reveals that there are four conditions necessary for successful joint-development projects. First, the local real estate market must be active and healthy. Second, the agency with the lead responsibility for pursuing joint development must have an entrepreneurial bent. Third, coordination is essential when joint-development projects involve more than one public agency. Fourth, sponsoring agencies need to understand that there are benefits to joint development that go beyond generating revenues. To date, in fact, the direct revenue benefits of joint development have been quite small. The best joint-development projects are those that encourage greater transit usage, create more interesting station environments, and reinforce other planning and development goals.

The Second Generation of the California Urban Futures Model. Part 2: Specification and Calibration Results of the Land-Use Change Submodel

In this paper, part 2 of a three-part series, we present the formal specification and calibration results of the land-use change component of the second-generation California urban futures model. The land-use change component consists of a series of nonordinal multinomial logit models of site-specific land-use changes. These models incorporate spatial measures (for example, mix of adjacent land uses, and proximity to similar activities) as well as local policy and accessibility measures. Various model forms are developed and explained, as are multiple approaches to evaluating the equation for goodness-of-fit.

Endometrial microbiome at the time of embryo transfer: next-generation sequencing of the 16S ribosomal subunit

PURPOSE

Characterization of the human microbiome has become more precise with the application of powerful molecular tools utilizing the unique 16S ribosomal subunit's hypervariable regions to greatly increase sensitivity. The microbiome of the lower genital tract can prognosticate obstetrical outcome while the upper reproductive tract remains poorly characterized. Here, the endometrial microbiome at the time of single embryo transfer (SET) is characterized by reproductive outcome.

METHODS

Consecutive patients undergoing euploid, SET was included in the analysis. After embryo transfer, performed as per routine, the most distal 5-mm portion of the transfer catheter was sterilely placed in a DNA free PCR tube. Next-generation sequencing of the bacteria specific 16S ribosome gene was performed, allowing genus and species calls for microorganisms.

RESULTS

Taxonomy assignments were made on 35 samples from 33 patients and 2 Escherichia coli controls. Of the 33 patients, 18 had ongoing pregnancies and 15 did not. There were a total of 278 different genus calls present across patient samples. The microbiome at time of transfer for those patients with ongoing pregnancy vs. those without ongoing pregnancy was characterized by top genera by sum fraction. Lactobacillus was the top species call for both outcomes.

CONCLUSIONS

The data presented here show the microbiome at the time of embryo transfer can successfully be characterized without altering standard clinical practice. This novel approach, both in specimen collection and analysis, is the first step toward the goal of determining physiologic from pathophysiologic microbiota. Further studies will help delineate if differences in the microbiome at the time of embryo transfer have a reliable impact on pregnancy outcome.

Bilateral seventh nerve palsy: a report of two cases and a review

The onset of bilateral face weakness is uncommon. Two cases are presented, followed by a discussion of a differential diagnosis.

Alternative/complementary therapies

The national trends and our regional experience of the utilization of complementary therapies suggest that a significant number of our patients will continue to employ remedies that are outside the mainstream of what has been defined as conventional Western medicine. The data obtained from our survey is very consistent with the national survey published in 1993. Indeed the national interest in alternative/complementary therapies seems to be growing. A recent newspaper article from Minneapolis noted that Allina, one of Minnesota's largest hospital and HMO systems, found, in a 1995 survey, that two-thirds of surveyed households had a least one member who had used some type of alternative or holistic care over the prior two year period. Certainly continued study of the safety and efficacy of alternative/complementary therapies is warranted. This work is being done on many fronts, including the Office of Alternative Medicine at the National Institutes of Health. A most important aspect of such investigations is to improve the understanding of why patients choose these unconventional remedies. For many patients, the answer is simple. They believe these alternative treatments work. For such patients, alternative therapies may constitute a practical way to move from the sterile "high tech" realm of traditional medicine to a more intimate, "high touch" intervention offered by non-physicians. In the end, physicians' most pressing mandate is "to be of use" to patients in their struggles with illness, disability, and impending death. None of us have all the answers, and the studies alluded to in this essay suggest that a significant segment of the population yearns for interventions that have been traditionally outside the practice of most physicians and nurses. The data from our survey corroborates the high utilization rate of alternative/complementary therapies, regionally and is consistent with national data. Our challenge, as caregivers, is to appropriately respond to the notable prevalence of alternative health practices and to the complex societal factors which nurture this usage.

Three synchronous multiorgan primary cancers. All stage I

A patient who has three separate, synchronous, early (stage I) primary cancers of the right lung, right breast, and stomach and whose disease is simultaneously diagnosed and successfully treated sequentially within a single hospital admission is unique. While multiple primary malignant neoplasms are not uncommon, to our knowledge, there has been no report of triple stage I synchronous carcinomas in separate major organ systems. Age, immunodeficiency, somatotype, hereditary tendencies, hormonal and environmental factors, and previous therapy have been incriminated as etiologic factors. Accurate tissue diagnosis and tumor staging are mandatory. In patients with diagnosed cancer, pulmonary lesions should never be presumed metastatic. Individual tumors should be treated independently of other concomitant lesions, and each treatment approach should be curative in nature. Patients with proven multiple malignant neoplasms carry a higher risk of developing other primary neoplasms.