Long-term safety and efficacy of tezepelumab in people with severe, uncontrolled asthma (DESTINATION): a randomised, placebo-controlled extension study

BACKGROUND

Tezepelumab is a human monoclonal antibody that blocks thymic stromal lymphopoietin. The drug has been tested previously in the phase 3 NAVIGATOR (NCT03347279) and SOURCE (NCT03406078) studies, and was subsequently approved as a treatment for severe asthma. This extension study recruited from NAVIGATOR and SOURCE and aimed to evaluate the long-term safety and efficacy of tezepelumab in individuals with severe, uncontrolled asthma.

METHODS

DESTINATION was a phase 3, multicentre, randomised, double-blind, placebo-controlled, long-term extension study. The study was done across 182 sites (including hospitals, clinics, medical centres, clinical trial centres, and private practices) in 18 countries. Participants (aged 12-80 years) were required to have good treatment compliance in the parent study. Randomisation was stratified by the parent study and all participants were re-randomised. Those who were previously randomised to receive tezepelumab in either parent study continued treatment of subcutaneous tezepelumab (210 mg every 4 weeks); those who were previously randomised to receive placebo in either parent study were re-randomised 1:1 to receive either subcutaneous tezepelumab (210 mg every 4 weeks) or placebo (every 4 weeks) using a randomisation list prepared by a computerised system. Total treatment duration (including the parent studies) was 104 weeks for all groups. Participants, investigators, and site staff were masked to treatment assignment. The primary endpoints were exposure-adjusted incidence of adverse events and serious adverse events and the secondary endpoint was the annualised asthma exacerbation rate; these were assessed from week 0 of the parent studies to week 104 of DESTINATION in all participants who were randomised and who received at least one dose of tezepelumab or placebo in either of the parent studies. The trial is registered with ClinicalTrials.gov, NCT03706079, and is closed to new participants.

FINDINGS

Participants were recruited between Jan 7, 2019, and Oct 15, 2020. For individuals who initially received tezepelumab (n=528) in NAVIGATOR, incidence of adverse events over 104 weeks was 49·62 (95% CI 45·16 to 54·39) per 100 patient-years, compared with 62·66 (56·93 to 68·81) for those receiving placebo (n=531; difference -13·04, 95% CI -17·83 to -8·18). For serious adverse events, incidence was 7·85 (6·14 to 9·89) per 100 patient-years for individuals who initially received tezepelumab and 12·45 (9·97 to 15·35) for those who received placebo (difference -4·59, -7·69 to -1·65). In SOURCE, incidence of adverse events was 47·15 (36·06 to 60·56) per 100 patient-years for those who initially received tezepelumab (n=74) and 69·97 (54·54 to 88·40) for those who received placebo (n=76; difference -22·82, -34·77 to -10·01). For serious adverse events, incidence was 13·14 (7·65 to 21·04) per 100 patient-years for those who initially received tezepelumab and 17·99 (10·66 to 28·44) for those who received placebo (difference -4·85, -14·88 to 4·53). Tezepelumab reduced the annualised asthma exacerbation rate over 104 weeks compared with placebo. In participants initially from NAVIGATOR, the annualised asthma exacerbation rate ratio over 104 weeks was 0·42 (95% CI 0·35 to 0·51); in those initially from SOURCE, the ratio over 104 weeks was 0·61 (0·38 to 0·96).

INTERPRETATION

Tezepelumab treatment was well tolerated for up to 2 years and resulted in sustained, clinically meaningful reductions in asthma exacerbations in individuals with severe, uncontrolled asthma. These findings are consistent with previous randomised, placebo-controlled studies and show the long-term safety and sustained efficacy of tezepelumab in individuals with severe, uncontrolled asthma.

FUNDING

AstraZeneca and Amgen.

Bronx Community Collaborative Opportunities for Research and Education: Implementation and Evaluation of a Community-Academic Partnership

BACKGROUND

Collaborations between community health and academic partners hold promise for improving community health through research.

OBJECTIVES

To develop, implement, and evaluate a partnership to build capacity for community-based research.

METHODS

Development of the partnership was based on a participatory model that aimed to nurture strong infrastructure, clear communication, and trust between partners. Research training was individualized to assessed needs. Methods of evaluation included online surveys of partnership members comparing years 1 and 2 and appreciative inquiry (AI) interviews in year 3.Results and Lessons Learned: Course corrections from year 1 responses were implemented, and reflected in improvements on the second survey. Interviews highlighted mutual benefits of infrastructure developed in partnership; threats to sustainability were identified. Lessons learned included the importance of early course correction based on feedback, opportunities for communication, and building trust and a shared language.

CONCLUSIONS

Partnerships develop through commitment and trust. Routine assessments and course correction may enable productive research partnerships.

Perinatal myocardial infarction in a newborn with a structurally normal heart

Myocardial infarction in a newborn infant in the absence of congenital heart disease and anomalous coronary artery anatomy is extremely rare. We report a case of a newborn with a structurally normal heart who presented shortly after birth with congestive heart failure and cardiovascular collapse suggestive of a hypoplastic left ventricle or critical aortic stenosis. This newborn had a massive myocardial infarction caused by thromboembolic occlusion of the left main coronary artery. Clinical, laboratory, and autopsy data suggest the event occurred in utero.

The structural organization of the human skeletal muscle ryanodine receptor (RYR1) gene

The RYR1 gene encoding the Ca2+ release channel of human skeletal muscle sarcoplasmic reticulum has been cloned and exon/intron boundaries have been determined, together with a minimum of 30 bp of intron sequence flanking each splice junction. The gene contains 106 exons, of which two are alternatively spliced. The length of the gene, determined by the alignment of 16 genomic phage clones, a cosmid clone, and several long polymerase chain reaction products, is approximately 160 kb. Exons range from 15 to 813 bp, while introns range from 85 to about 16,000 bp. Analysis of the gene has confirmed published errors in the human RYR1 cDNA and confirmed the structure of two alternatively spliced exons. The numbering of the nucleotides comprising the RYR1 cDNA and the numbering of amino acids encoded by them were corrected to account for these earlier errors and omissions. Analysis of 2.4 kb of the 5' upstream sequence indicated the presence of a CCAAT box and several Sp1 binding sites between nucleotides -200 and -60 bp, flanking the proposed transcription start site at -130 bp. Several other potential transcription factor binding sites were identified throughout the 5' sequence. Knowledge of the structure of the RYR1 gene will provide an invaluable resource for the discovery of mutations in the gene that are causal of human malignant hyperthermia and central core disease.

A DNA-activated protein kinase from HeLa cell nuclei

A DNA-activated protein kinase (DNA-PK) was purified from nuclei of HeLa cells. Activity was associated with a single high-molecular-mass (approximately-300,000 Da) polypeptide when analyzed by gel filtration, denaturing polyacrylamide gel electrophoresis, and Western immunoblotting using a monoclonal antibody that also inhibits enzyme activity. Nuclear localization was indicated by subcellular fractionation and confirmed by immunofluorescence on whole cells. Double-stranded DNA stimulated phosphorylation of the 300-kDa polypeptide in purified preparations as well as phosphorylation of the exogenous substrates alpha-casein, simian virus 40 large T antigen, and the human heat shock protein hsp90. Autophosphorylation led to inactivation of the enzyme. The phosphorylation of casein was stimulated over 30-fold by DNA and was specific for serine and threonine residues. Bovine serum albumin and histone H1 were poor substrates for DNA-PK, and no phosphorylation of immunoglobulin G or histones other than H1 was observed. Supercoiled or heat-denatured DNA and synthetic double-stranded RNA or RNA-DNA copolymers did not stimulate casein phosphorylation by DNA-PK. Interaction of the enzyme with DNA in the absence of exogenous substrates was demonstrated by thermal inactivation and gel mobility shifts. These characteristics identify DNA-PK as distinct from other protein kinases described in the literature and suggest that activation by DNA is an important feature of the enzyme's in vivo function.

Choreoathetosis after deep hypothermia without circulatory arrest

In 8 of 758 patients undergoing an intracardiac operation under cardiopulmonary bypass and hypothermia, choreoathetosis developed 3 to 7 days postoperatively. Before the onset of choreoathetosis, varying degrees of neurological dysfunction were noted. Electroencephalography and neuroimaging failed to detect any responsible functional or structural changes. Six patients are alive 1 to 3 years postoperatively, and their condition is improving. Two patients died of aspiration or sepsis. All patients were grouped based on factors identified as being possibly causative: depth of hypothermia, cooling time, flow rate, and repeated hypothermia. The incidence of choreoathetosis was significantly different in group A (rectal temperature greater than 25 degrees C) compared with group B (rectal temperature less than or equal to 25 degrees C) (0/295 versus 8/463; p = 0.02). Based on cooling time, the incidence of choreoathetosis was significantly different in group B1 (cooling time less than 1 hour) compared with group B2 (cooling time greater than or equal to 1 hour) (1/220 versus 7/243; p = 0.05). Based on flow rate during cooling, group B2 was further divided into the low-flow group (less than 1,500 mL.min-1.m-2) and the high-flow group (greater than or equal to 1,500 mL.min-1.m-2). Although not significant, the incidence of choreoathetosis was higher in the high-flow group (6/153 versus 1/90; p = 0.22). In group B patients having reoperation, the incidence of choreoathetosis was higher than in patients operated on for the first time (5/54 versus 3/409; p less than or equal to 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Repair of complete atrioventricular septal defect with tetralogy of Fallot

Repair of complete atrioventricular canal with tetralogy of Fallot was performed in 9 patients. Ventricular septal defect was closed through the right atrium using a single polytetrafluoroethylene patch with ample anterior extension to avoid subaortic obstruction. The atrial septal defect was closed with a separate patch. Undivided atrioventricular valve leaflets were sandwiched between the two patches. Right ventricular outflow tract stenosis was relieved by pulmonary valvotomy and an infundibular patch in 7, a supravalvar patch (none transannular) in 6, and right ventricle-to-pulmonary artery conduit in 2. There was one hospital death (1/9, 11%) in a patient with persistent clinically significant postoperative pulmonary stenosis and low cardiac output requiring reoperation and right ventricle-to-pulmonary artery conduit insertion. There was no late mortality. All patients are asymptomatic 0.3 to 5.6 years after operation. Follow-up right ventricular outflow tract gradient ranged from 11 to 43 mm Hg and was 70 mm Hg in 1 patient who later had successful relief of obstruction. Three patients had mitral valve insufficiency; 1 needed reoperation. Aggressive relief of right ventricular outflow tract stenosis with maintenance of pulmonary valve competence and use of two separate patches for closure of the septal defects contribute to optimum immediate and long-term results after repair of this lesion.

Intracardiac Wilms' tumor: diagnosis and management

Complete excision of Wilms' tumor may require resection of adjacent organs and removal of intracaval tumor propagation. Extension of tumor to the right atrium can be determined preoperatively guiding a direct and safe approach to intracardiac tumor at the time of nephrectomy. Preoperative ultrasonography of two children with Wilms' tumor demonstrated caval and right atrial tumor. Laparotomy for nephrectomy and abdominal caval exposure was combined with cardiopulmonary bypass and atriotomy. In both patients, tumor contiguous with the renal pelvis extended from the iliac bifurcation into the right atrium with a large atrial mass. In one patient nephrectomy was performed first, and she was then placed on cardiopulmonary bypass. Caval tumor was easily removed through the atriotomy and open renal vein. In the second patient, bypass was instituted first because of cardiac instability. The large right atrial mass extended through an atrial septal defect into the left atrium. The cardiac tumor and a large amount of caval tumor were removed. Bypass was discontinued after repair of the ASD. Tumor remained in the IVC below the renal veins necessitating a separate venotomy. Combined abdominal and cardiac exploration allows safe and complete excision of all gross tumor. Ultrasonography is a sensitive and noninvasive method of diagnosing retrohepatic and atrial tumor extension and can be obtained easily even on very sick patients.

Echocardiographic diagnosis of tricuspid valve endocarditis in a child with a normal heart. Special emphasis on surgical considerations

A previously healthy 8-year-old girl with a normal heart had development of tricuspid valve staphylococcal endocarditis. Serial two-dimensional echocardiograms first demonstrated an enlarging vegetation and later showed reduction in its size coincident with a pulmonary embolus. The occurrence of the pulmonary embolus along with persistent fevers, despite adequate antibiotic treatment, prompted surgical intervention. Surgical excision of a large residual vegetation, valve debridement, and pulmonary embolectomy led to prompt subsidence of fever and improvement in the patient's condition. Three months after surgery, the child remained asymptomatic with minimal tricuspid insufficiency. However, by eight months after surgery, the hemodynamic consequences of the tricuspid insufficiency had progressed, and the patient is mildly symptomatic. Additional tricuspid valve repair or replacement is expected.

Two dimensional echocardiography in evaluation of right atrial masses: five cases in pediatric patients

Five unusual cases of a right atrial mass in children are described to illustrate the very valuable contribution that two dimensional echocardiographic examinations can bring to both the initial diagnosis and the subsequent management of patients with these findings. One patient had a large benign hemangioendothelioma of the right atrium. Two infants had extension of a Wilms' tumor from the kidney by way of the inferior vena cava to the right atrium. A fourth patient, an 8 year old girl, had no cardiac disease, and manifested Staphylococcus aureus endocarditis of the tricuspid valve with a large pedunculated mass and subsequent pulmonary embolus. A fifth patient, a premature infant with a central hyperalimentation catheter in the right atrium, had a large thrombus on the catheter that was successfully eradicated with urokinase-induced thrombolysis. Two dimensional echocardiography provides real time imaging of the entire right atrium, interatrial septum, inferior and superior venae cavae and tricuspid orifice and hence is valuable in the diagnosis and management of these clinical problems.