Lack of Racial and Ethnic Diversity in Surgical Education, as Reflected by Skin Tone in General Surgery Textbooks

INTRODUCTION

Disparity in healthcare is an important and timely topic. One example of such disparity appears to be the disproportionate use of lighter skin tone illustrations in medical and surgical educational material.1 Visual representation of pathology in instructional material is one key element that informs decision making in surgical disease and could contribute to disparity in outcomes in underrepresented tonal groups. Our hypothesis is that visual examples (illustrations) of clinical pathology in major surgical texts are biased in that they are heavily weighted to Caucasian skin tones and therefore fail to accurately represent the racial distribution of patients in the United States population.

METHODS

Images from 4 commonly used general surgery textbooks were screened independently by 2 reviewers from Maimonides Medical Center and SUNY (State University of New York) Downstate College of Medicine. Human photographic and cartoon images (where skin tone could be determined), with adequate skin shown, were included. These images were assigned a Fitzpatrick skin photo type (FP) score (1-6). The distribution of images among the 6 FP categories were compared to the expected distribution of images in the United States population, as described from a previous National Health and Nutrition Examination Survey (NHANES). Differences in distribution were compared using a chi-squared test, with p-value <0.05 considered as statistically significant.

RESULTS

There were 556 total images deemed adequate for assessment from the 4 textbooks chosen. 169 from Sabiston, 61 from Mulholland and Greenfield, 177 from Schwartz, and 149 from ACS. About 539 of these images (96.9%) were depictions of patients with light skin tone (FP scores 1-3.) while less than 4% of images were of dark-skinned individuals (FP score between 4 and 6.) An FP score 1 accounted for most images, comprising 477 images (86.1%). There was a 1.8% analytical discrepancy noted between the textbook reviewers. The distribution on the general US population (NHANES) is: FP score 1: 1.6%, FP score 2: 33.1%, FP score 3: 47.8%, FP score 4: 4.9%, FP score 5: 3.6%, FP score 6: 9.0%.

CONCLUSIONS

Screening of commonly used general surgery textbooks showed a significant lack of diversity in image-based skin tone representation when compared to the United States population at large. The overwhelming majority of images were of light skin tones. Improving diversity of imagery in educational material, such as basic textbooks, might help reduce observed disparities in outcomes among surgical patients in the future.

Nivolumab in sorafenib-naive and sorafenib-experienced patients with advanced hepatocellular carcinoma: 5-year follow-up from CheckMate 040

BACKGROUND

Patients with advanced hepatocellular carcinoma (aHCC) have a poor prognosis and high mortality. Nivolumab monotherapy demonstrated clinical benefit with an acceptable safety profile in patients with aHCC in the CheckMate 040 study. Five-year follow-up of the sorafenib-naive and sorafenib-experienced groups of CheckMate 040 is presented here.

PATIENTS AND METHODS

Patients received nivolumab monotherapy at dose levels of 0.1-10.0 mg/kg (dose-escalation phase) or 3 mg/kg (dose-expansion phase) every 2 weeks until disease progression or unacceptable toxicity. Primary endpoints were safety and tolerability (dose escalation), and objective response rate (ORR) by blinded independent central review (BICR) and by investigator as per RECIST version 1.1 (dose expansion).

RESULTS

Eighty sorafenib-naive and 154 sorafenib-experienced patients were treated. Minimum follow-up in both groups was 60 months. ORR as per BICR was 20% [95% confidence interval (CI) 12% to 30%] and 14% (95% CI 9% to 21%) in the sorafenib-naive and sorafenib-experienced groups, respectively. Responses occurred regardless of HCC etiology or baseline tumor cell programmed death-ligand 1 (PD-L1) expression levels. Median overall survival (OS) was 26.6 months (95% CI 16.6-30.6 months) and 15.1 months (95% CI 13.0-18.2 months) in sorafenib-naive and sorafenib-experienced patients, respectively. The 3-year OS rates were 28% in the sorafenib-naive and 20% in the sorafenib-experienced groups; 5-year OS rates were 14% and 12%, respectively. No new safety signals were identified; grade 3/4 treatment-related adverse events were observed in 33% and 21% of patients in the sorafenib-naive and sorafenib-experienced groups, respectively. Biomarker analyses showed that baseline PD-L1 expression ≥1% was associated with higher ORR and longer OS compared with PD-L1 <1%. In the sorafenib-naive group, patients with OS ≥3 years exhibited higher baseline CD8 T-cell density compared with those with OS <1 year.

CONCLUSION

With 5 years of follow-up, nivolumab monotherapy continued to provide durable clinical benefit with manageable safety in sorafenib-naive and sorafenib-experienced patients with aHCC.

Reconstruction of Angstrom resolution exit-waves by the application of drift-corrected phase-shifting off-axis electron holography

Phase-shifting electron holography is an excellent method to reveal electron wave phase information with very high phase sensitivity over a large range of spatial frequencies. It circumvents the limiting trade-off between fringe spacing and visibility of standard off-axis holography. Previous implementations have been limited by the independent drift of biprism and sample. We demonstrate here an advanced drift correction scheme for the hologram series that exploits the presence of an interface of the TEM specimen to the vacuum area in the hologram. It allows to obtain reliable phase information up to 2π/452 at the 1 Å information limit of the Titan 80-300 kV environmental transmission electron microscope used, by applying a moderate voltage of 250 V to a single biprism for a fringe spacing of 1 Å. The obtained phase and amplitude information is validated at a thin Pt sample by use of multislice image simulation with the frozen lattice approximation and shows excellent agreement. The presented method is applicable in any TEM equipped with at least one electron biprism and thus enables achieving high resolution off-axis holography in various instruments including those for in-situ applications. A software implementation for the acquisition, calibration and reconstruction is provided.

Impact of Immune, Inflammatory, and Nutritional Indices on Outcome in Patients with Cervical Cancer Treated with Definitive (Chemo)radiotherapy

PURPOSE/OBJECTIVE(S)

Systemic immune, inflammatory, and nutritional indices have been shown to be prognostic for outcome across a range of tumor sites. However, a comprehensive analysis of these markers in patients with cervical cancer treated with definitive (chemo)radiotherapy [(C)RT] has not been performed. We hypothesized that systemic immune, inflammatory, and nutritional indices may be associated with progression free survival (PFS) and overall survival (OS) in patients undergoing definitive (C)RT for cervical cancer.

MATERIALS/METHODS

Patients with cervical cancer treated with definitive (C)RT from 1999 - 2015 were identified from a single cancer institution's retrospective clinicopathological database. Pre-treatment immune, inflammatory, and nutritional parameters were collected, and indices derived. Systemic immune-inflammation index (SII) = neutrophil count x platelet count / lymphocyte count(10^9/L); PLR = platelet count / lymphocyte count(10^9/L), NLR = neutrophil count / lymphocyte count (10^9/L); MLR = monocyte count / lymphocyte count (10^9/L); albumin to alkaline phosphatase ratio (AAPR) = serum albumin level (g/L)/alkaline phosphatase level (U/L) and prognostic nutritional index (PNI) = serum albumin (g/L) + 5 x lymphocyte count (10^9/L). Univariate analysis was first performed on each parameter as continuous variables for PFS and OS. For variables with statistically significant associations, ROC curves were analyzed to determine if an optimal cut point could be established for each outcome. Common cut points were then defined for each variable. PFS and OS were analyzed by the Kaplan-Meier method and the Log-Rank test. Multivariate analysis was performed using Cox regression with covariates of tumor stage, histology, and age. P-values of <0.05 were considered statistically significant.

RESULTS

A total of 196 patients were identified; median follow-up 7 years. 131 (67%) had stage I-II and 65 (33%) stage III-IV disease. 187 (95%) received CRT and 9 (5%) RT alone. Higher SII (≤700 vs >700; p = 0.01), higher PLR (≤ 250 vs >250; p<0.001) and higher NLR (≤ 5 vs >5; p = 0.003) were associated with worse PFS. Higher SII [≤700 vs >700: 5y OS 74.9 vs 55.8; p = 0.02], higher PLR [≤ 250 vs >250: 5y OS 69.9% vs 42.0%; p<0.001] and higher NLR [≤ 5 vs >5: 5y OS 65.3% vs 51.0%; p = 0.01] were associated with worse OS. MLR, AAPR and PNI were not associated with outcome on univariate analysis. On multivariate analysis, SII and PLR were independently associated with both PFS [SII: HR 1.647 (CI 1.029-2.639), p = 0.038; PLR: HR 2.301 (95% CI 1.507 - 3.512), p = <0.001], and OS [SII: HR 1.649 (95% CI 1.009-2.696), p = 0.046; PLR: HR 2.212 (95% CI 1.416-3.455), p<0.001]; NLR did not remain statistically significant.

CONCLUSION

SII and PLR, but not nutritional indices, were independently associated with PFS and OS in patients with cervical cancer treated with definitive (C)RT. Further evaluation of these systemic immune and inflammatory indices in a validation set will be required to better define their clinical utility.

Hypomagnesemia and Survival in Patients with Cervical Cancer Treated with Definitive Chemoradiotherapy

PURPOSE/OBJECTIVE(S)

Hypomagnesemia is a common side effect of platinum-based chemotherapy regimens. Although there are data reporting that hypomagnesemia is associated with worse survival in patients receiving platinum-based chemotherapy or chemoradiotherapy (CRT), this has not been documented in patients with cervical cancer treated with definitive CRT. We hypothesized that in patients with cervical cancer undergoing definitive CRT, on-treatment hypomagnesemia would be associated with longer treatment duration and worse cancer-specific survival (CSS).

MATERIALS/METHODS

Patients with cervical cancer treated with definitive CRT from 1999 to 2015 were identified from a single cancer center's clinicopathologic database. Lowest on-treatment magnesium value was recorded and categorized as per Common Terminology Criteria for Adverse Events (CTCAE) v5.0 grading (grade 1: <0.7 - 0.5 mmol/L, grade 2: <0.5 - 0.4 mmol/L, grade 3: <0.4-0.3 mmol/L, and grade 4 <0.3 mmol/L). Grade 0 was defined as ≥ 0.7 mmol/L. Treatment duration was defined as the number of days between the first day of radiotherapy until the last day of pelvic treatment (either brachytherapy or pelvic external beam radiotherapy boost). Prolonged treatment was considered as any treatment duration greater than 63 days. CSS for patients with either grade 0-1 or grade ≥ 2 CTCAE v5.0 magnesium toxicity was estimated using the Kaplan-Meier method, and the Peto & Peto modification to the generalized Gehan-Wilcoxon was used to determine statistical significance between groups. Associations with prolonged treatment duration was explored using logistic regression. P-values of <0.05 were considered statistically significant.

RESULTS

A total of 186 patients were identified; median follow-up was 7 (IQR 2-11) years. 125 (67%) had stage I-II disease and 61 (33%) stage III-IV. Median treatment duration was 51 (IQR 48-57) days. All patients received concurrent weekly cisplatin-based chemotherapy with RT: the majority (n = 133; 72%) received 5 or 6 cycles. 147 (79%) patients received routine IV magnesium infusion with their chemotherapy and 173 (93%) received routine IV mannitol. During treatment the highest CTCAE v5.0 magnesium toxicity score was grade 0-1 in 158 (85%) and grade ≥ 2 in 28 (15%). Magnesium grade ≥ 2 was associated with worse 5-year CSS [grade 0-1: 5yr CSS 67.2%, (95% CI 60.1-75.1); grade ≥ 2: 5yr CSS 50%, (95% CI 34.5-72.4); p = 0.039]. Magnesium status was not associated with an increase in treatment duration [OR 1.465 (95% CI 0.3177 - 6.753); p = 0.625].

CONCLUSION

On-treatment hypomagnesemia ≥ grade 2 (CTCAE v5.0) was associated with worse CSS but did not predict longer treatment duration. This is the first study that shows a detrimental survival impact of on-treatment hypomagnesemia in this patient population. These findings highlight the need to ensure adequate monitoring, support and correction of magnesium during definitive CRT.

Protein expression of prognostic genes in primary melanoma and benign nevi

PURPOSE

To evaluate the protein expression characteristics of genes employed in a recently introduced prognostic gene expression assay for patients with cutaneous melanoma (CM).

METHODS

We studied 37 patients with CM and 10 with benign (melanocytic) nevi (BN). Immunohistochemistry of primary tumor tissue was performed for eight proteins: COL6A6, DCD, GBP4, KLHL41, KRT9, PIP, SCGB1D2, SCGB2A2.

RESULTS

The protein expression of most markers investigated was relatively low (e.g., DCD, KRT9, SCGB1D2) and predominantly cytoplasmatic in melanocytes and keratinocytes. COL6A6, GBP4, and KLHL41 expression was significantly enhanced in CM when compared to BN. DCD protein expression was significantly correlated with COL6A6, GBP4, and KLHL41. GBP4 was positively correlated with KLHL41 and inversely correlated with SCGB2B2. The latter was also inversely correlated with serum S100B levels at time of initial diagnosis. The presence of SCGB1D2 expression was significantly associated with ulceration of the primary tumor. KRT9 protein expression was significantly more likely found in acral lentiginous melanoma. The presence of DCD expression was less likely associated with superficial spreading melanoma subtype but significantly associated with non-progressive disease. The absence of SCGB2A2 expression was significantly more often observed in patients who did not progress to stage III or IV.

CONCLUSIONS

The expression levels observed were relatively low but differed in part with those found in BN. Even though we detected some significant correlations between the protein expression levels and clinical parameters (e.g., CM subtype, course of disease), there was no major concordance with the protective or risk-associated functions of the corresponding genes included in a recently introduced prognostic gene expression assay.

P12.15.B Astrocyte immunometabolic regulation of the glioblastoma microenvironment drives tumor pathogenicity

Background

Malignant brain tumors are the cause of a disproportionate level of morbidity and mortality among cancer patients, an unfortunate statistic that has remained constant for decades. Despite considerable advances in the molecular characterization of these tumors, targeting the cancer cells has yet to produce significant advances in treatment. An alternative strategy is to target cells in the glioblastoma microenvironment, such as tumor associated astrocytes. Astrocytes control multiple processes in health and disease, ranging from maintaining the brain's metabolic homeostasis, to modulating neuroinflammation. However, their role in glioblastoma pathogenicity is not well understood.

Material and Methods

Immunocompetent mice were implanted with murine glioma cell lines and the role of astrocyte in the tumor pathogenicity was analyzed, and further investigated using in-vitro co-cultures.

Results

Here we report that depletion of reactive astrocytes regresses glioblastoma and prolongs mouse survival. Analysis of the tumor-associated astrocyte translatome, revealed that astrocytes initiate transcriptional programs that shape the immune and metabolic compartments in the glioma microenvironment. Specifically, their expression of CCL2 and CSF1 governs the recruitment of tumor-associated macrophages and promotes a pro-tumorigenic macrophage phenotype. Concomitantly, we demonstrate that astrocyte-derived cholesterol is key to glioma cell survival, and that targeting astrocytic cholesterol efflux, via ABCA1, halts tumor progression. In summary, astrocytes control glioblastoma pathogenicity by reprogramming the immunological properties of the tumor microenvironment and supporting the non-oncogenic metabolic dependency of glioblastoma on cholesterol.

Conclusion

These findings suggest that targeting astrocyte immunometabolic signaling may help treat this uniformly lethal brain tumor.

Off-ball behavior in association football: A data-driven model to measure changes in individual defensive pressure

This study describes an approach to evaluate the off-ball behaviour of attacking players in association football. The aim was to implement a defensive pressure model to examine an offensive player's ability to create separation from a defender using 1411 high-intensity off-ball actions including 988 Deep Runs (DRs) DRs and 423 Change of Directions (CODs). Twenty-two official matches (14 competitive matches and 8 friendlies) of the German National Team were included in the research. To validate the effectiveness of the pressure model, each pass (n = 25,418) was evaluated for defensive pressure on the receiver at the moment of the pass and for the pass completion rate (R = -.34, p < .001). Next, after assessing the inter-rater reliability (Fleiss Kappa of 80 for DRs and 78 for CODs), three expert raters annotated all DRs and CODs that met the pre-set criteria. A time-series analysis of each DR and COD was calculated to the nearest 0.1 second, finding a slight increase in pressure from the start to the end of the off-ball actions as defenders re-established proximity to the attacker after separation was created. A linear mixed model using run type (DR or COD) as a fixed effect with the local maximum as a fixed effect on a continuous scale resulted in p < 0.001, d = 4.81, CI = 0.63 to 0.67 for the greatest decrease in pressure, p < 0.001, d = 0.143, CI = 9.18 to 10.61 for length of the longest decrease in pressure, and p < 0.001, d = 1.13, CI = 0.90 to 1.11 for the fastest rate of decrease in pressure. As these values pertain to the local maximum, situations with greater starting pressure on the attacker often led to greater subsequent decreases. Furthermore, there was a significant (p < .0001) difference between offensive and defensive positions and the number of off-ball actions. Results suggest the model can be applied to quantify and visualise the pressure exerted on non-ball-possessing players. This approach can be combined with other methods of match analysis, providing practitioners with new opportunities to measure tactical performance in football.

IDAC-ALPHA: AN ALPHA DOSIMETRY SOFTWARE FOR NORMAL ORGANS AND TISSUES

Radiopharmaceuticals have been used for the treatment of various forms of cancer since the 1940s. In recent years, the advantages of alpha emitting radionuclides have emerged as a favourable treatment option. However, most alpha emitting radionuclides have long decay chains with long-lived daughter radionuclides. This leads to uncertainties in the dosimetry for normal organs and tissues, when established dosimetry models are employed. The aim of this project is to assign each progeny its own biokinetic behaviour. The novel dosimetry model was applied to 223Ra-dichloride, frequently used for the treatment of patients with metastatic bone disease from castration-resistant prostate cancer. In this dosimetry model, individual biokinetics for each daughter radionuclide was included. This resulted in a decrease in absorbed dose to bone surfaces and red marrow and increased absorbed dose to liver and kidney, when compared with dosimetry models assuming that the daughter nuclides follow the biokinetics of the parent radionuclide.

Humoral and cellular immune response to tick-borne-encephalitis (TBE) vaccination depends on booster doses in patients with Juvenile Idiopathic Arthritis (JIA)

Juvenile Idiopathic Arthritis (JIA) patients living in areas with high prevalence of tick-borne-encephalitis-virus-(TBEV)-infection are recommended for administration of inactivated TBE-vaccination. However, there are serious concerns regarding protective vaccine-induced immune responses against TBEV in immunocompromised patients. The present study aimed to analyze the humoral and cellular immune response to TBE-vaccination in previously TBE-vaccinated JIA patients compared to healthy controls (HC) including investigation of IgG-anti-TBEV avidity, neutralization capacity, cellular reactivity by IFNgamma-ELISPOT and cytokine secretion assays. Similar IgG-anti-TBEV antibody concentrations, neutralization titers and cellular reactivity were found between JIA and HC. The number and the early timing of booster vaccinations after primary vaccination had the most prominent effect on neutralizing antibodies in JIA and on IgG-anti-TBEV concentrations in both JIA and HC. Administration of booster vaccinations made it more likely for JIA patients to have IgG-anti-TBEV concentrations ≥165 VIEU/ml and avidities >60%. TNF-alpha inhibitors had a positive and MTX administration a negative effect on humoral immune responses. In conclusion, irrespective of having JIA or not, vaccinated children showed similar humoral and cellular immunity against TBEV several years after primary TBE-vaccination. However, in JIA, booster vaccinations mounted a significantly higher humoral immune response than in JIA without boosters. Our results highlight the need for timely administration of boosters particularly in JIA. Although immunosuppressive treatment at vaccinations in diagnosed JIA had a negative effect mainly on TBEV-specific cellular immunity, most JIA patients mounted a favorable humoral immune response which was maintained over time. Thus, successful TBE-vaccination seems highly feasible in JIA patients with immunosuppressive regimens.

[Coincidence of hydatid of Morgagni and undescended testis: more common than expected !]

As part of a retrospective data analysis over a period of 6 years, the coincidence of undescended testis and hydatid of Morgagni (appendix testis) was examined on the basis of 814 operated testes. The overall prevalence of hydatids after opening of the testicular envelope of undescended testes was 62.66%. In addition, we were able to establish a correlation between patient age and the hydatid size. According to the results of the study, the size of the hydatid-with growth most likely to be influenced by hormones-can be assumed to be associated with the patient's age.

Nanotechnology for catalysis and solar energy conversion

This roadmap on Nanotechnology for Catalysis and Solar Energy Conversion focuses on the application of nanotechnology in addressing the current challenges of energy conversion: 'high efficiency, stability, safety, and the potential for low-cost/scalable manufacturing' to quote from the contributed article by Nathan Lewis. This roadmap focuses on solar-to-fuel conversion, solar water splitting, solar photovoltaics and bio-catalysis. It includes dye-sensitized solar cells (DSSCs), perovskite solar cells, and organic photovoltaics. Smart engineering of colloidal quantum materials and nanostructured electrodes will improve solar-to-fuel conversion efficiency, as described in the articles by Waiskopf and Banin and Meyer. Semiconductor nanoparticles will also improve solar energy conversion efficiency, as discussed by Boschloo et al in their article on DSSCs. Perovskite solar cells have advanced rapidly in recent years, including new ideas on 2D and 3D hybrid halide perovskites, as described by Spanopoulos et al 'Next generation' solar cells using multiple exciton generation (MEG) from hot carriers, described in the article by Nozik and Beard, could lead to remarkable improvement in photovoltaic efficiency by using quantization effects in semiconductor nanostructures (quantum dots, wires or wells). These challenges will not be met without simultaneous improvement in nanoscale characterization methods. Terahertz spectroscopy, discussed in the article by Milot et al is one example of a method that is overcoming the difficulties associated with nanoscale materials characterization by avoiding electrical contacts to nanoparticles, allowing characterization during device operation, and enabling characterization of a single nanoparticle. Besides experimental advances, computational science is also meeting the challenges of nanomaterials synthesis. The article by Kohlstedt and Schatz discusses the computational frameworks being used to predict structure-property relationships in materials and devices, including machine learning methods, with an emphasis on organic photovoltaics. The contribution by Megarity and Armstrong presents the 'electrochemical leaf' for improvements in electrochemistry and beyond. In addition, biohybrid approaches can take advantage of efficient and specific enzyme catalysts. These articles present the nanoscience and technology at the forefront of renewable energy development that will have significant benefits to society.

A master protocol to investigate a novel therapy acetyl-L-leucine for three ultra-rare neurodegenerative diseases: Niemann-Pick type C, the GM2 gangliosidoses, and ataxia telangiectasia

BACKGROUND

The lack of approved treatments for the majority of rare diseases is reflective of the unique challenges of orphan drug development. Novel methodologies, including new functionally relevant endpoints, are needed to render the development process more feasible and appropriate for these rare populations and thereby expedite the approval of promising treatments to address patients' high unmet medical need. Here, we describe the development of an innovative master protocol and primary outcome assessment to investigate the modified amino acid N-acetyl-L-leucine (Sponsor Code: IB1001) in three separate, multinational, phase II trials for three ultra-rare, autosomal-recessive, neurodegenerative disorders: Niemann-Pick disease type C (NPC), GM2 gangliosidoses (Tay-Sachs and Sandhoff disease; "GM2"), and ataxia telangiectasia (A-T).

METHODS/DESIGN

The innovative IB1001 master protocol and novel CI-CS primary endpoints were developed through a close collaboration between the Industry Sponsor, Key Opinion Leaders, representatives of the Patient Communities, and National Regulatory Authorities. As a result, the open-label, rater-blinded study design is considerate of the practical limitations of recruitment and retention of subjects in these ultra-orphan populations. The novel primary endpoint, the Clinical Impression of Change in Severity© (CI-CS), accommodates the heterogenous clinical presentation of NPC, GM2, and A-T: at screening, the principal investigator appoints for each patient a primary anchor test (either the 8-m walk test (8MWT) or 9-hole peg test of the dominant hand (9HPT-D)) based on his/her unique clinical symptoms. The anchor tests are videoed in a standardized manner at each visit to capture all aspects related to the patient's functional performance. The CI-CS assessment is ultimately performed by independent, blinded raters who compare videos of the primary anchor test from three periods: baseline, the end of treatment, and the end of a post-treatment washout. Blinded to the time point of each video, the raters make an objective comparison scored on a 7-point Likert scale of the change in the severity of the patient's neurological signs and symptoms from video A to video B. To investigate both the symptomatic and disease-modifying effects of treatment, N-acetyl-L-leucine is assessed during two treatment sequences: a 6-week parent study and 1-year extension phase.

DISCUSSION

The novel CI-CS assessment, developed through a collaboration of all stakeholders, is advantageous in that it better ensures the primary endpoint is functionally relevant for each patient, is able to capture small but meaningful clinical changes critical to the patients' quality of life (fine-motor skills; gait), and blinds the primary outcome assessment. The results of these three trials will inform whether N-acetyl-L-leucine is an effective treatment for NPC, GM2, and A-T and can also serve as a new therapeutic paradigm for the development of future treatments for other orphan diseases.

TRIAL REGISTRATION

The three trials (IB1001-201 for Niemann-Pick disease type C (NPC), IB1001-202 for GM2 gangliosidoses (Tay-Sachs and Sandhoff), IB1001-203 for ataxia telangiectasia (A-T)) have been registered at www.clinicaltrials.gov (NCT03759639; NCT03759665; NCT03759678), www.clinicaltrialsregister.eu (EudraCT: 2018-004331-71; 2018-004406-25; 2018-004407-39), and https://www.germanctr.de (DR KS-ID: DRKS00016567; DRKS00017539; DRKS00020511).