Fast versus slow onset of depressive episodes: A clinical criterion for subtyping patients with major depression

Purpose:

The speed of onset of depressive episodes is a clinical aspect of affective disorders that has not been sufficiently investigated. Thus, we aimed to explore whether patients with fast onset of the full-blown depressive symptomatology (≤ 7 days) differ from those with slow onset (> 7 days) with regard to demographic and clinical aspects.

Subjects and methods:

Data were obtained within an observational study conducted in outpatients with major depression who were treated with duloxetine (30–120 mg/day). Onset of depression (without any preceding critical life event) was fast in 416 (less than one week) and slower in 2220 patients.

Results:

Compared to patients with slow onset, those with fast onset of depression had more suicide attempts in the previous 12 months (2.7% versus 1.3%, P = 0.046) and less somatic comorbidity (61.7% versus 74.1%, P < 0.0001). In addition, they were slightly younger at onset of depression (mean ± SD 40.2 ± 14.6 versus 42.8 ± 14.2 years, P < 0.001) and used analgesics at baseline significantly less frequently (22.8% versus 33.4%, P < 0.0001).

Discussion and conclusion:

The speed of onset of depression has to be regarded as a relevant clinical characteristic in patients with unipolar depression.

Underlying Immune Disorder May Predispose Some Transthyretin Amyloidosis Subjects to Inotersen-Mediated Thrombocytopenia

Inotersen, a 2'-O-methoxyethyl (2'-MOE) phosphorothioate antisense oligonucleotide, reduced disease progression and improved quality of life in patients with hereditary transthyretin amyloidosis with polyneuropathy (hATTR-PN) in the NEURO-TTR and NEURO-TTR open-label extension (OLE) trials. However, 300 mg/week inotersen treatment was associated with platelet count reductions in several patients. Mean platelet counts in patients in the NEURO-TTR-inotersen group remained ≥140 × 10⁹/L in 50% and ≥100 × 10⁹/L in 80% of the subjects. However, grade 4 thrombocytopenia (<25 × 10⁹/L) occurred in three subjects in NEURO-TTR trial, and one of these suffered a fatal intracranial hemorrhage. The two others were treated successfully with corticosteroids and discontinuation of inotersen. Investigations in a subset of subjects in NEURO-TTR (n = 17 placebo; n = 31 inotersen) and OLE (n = 33) trials ruled out direct myelotoxicity, consumptive coagulopathy, and heparin-induced thrombocytopenia. Antiplatelet immunoglobulin G (IgG) antibodies were detected at baseline in 5 of 31 (16%) inotersen-treated subjects in NEURO-TTR, 4 of whom eventually developed grade 1 or 2 thrombocytopenia while on the drug. In addition, 24 subjects in the same group developed treatment-emergent antiplatelet IgG antibodies, of which 2 developed grade 2, and 3 developed grade 4 thrombocytopenia. Antiplatelet IgG antibodies in two of the three grade 4 thrombocytopenia subjects targeted GPIIb/IIIa. Plasma cytokines previously implicated in immune dysregulation, such as interleukin (IL)-23 and a proliferation-inducing ligand (APRIL) were often above the normal range at baseline. Collectively, these findings suggest an underlying immunologic dysregulation predisposing some individuals to immune-mediated thrombocytopenia during inotersen treatment.

A 24-week multicentre, randomized, open-label, parallel-group study comparing the efficacy and safety of ixekizumab vs. fumaric acid esters and methotrexate in patients with moderate-to-severe plaque psoriasis naive to systemic treatment

Background

Interleukin‐17 antagonists have received a first‐line label for moderate‐to‐severe plaque psoriasis.

Objectives

We conducted the first head‐to‐head trial between the two most commonly used first‐line therapies in Germany, fumaric acid esters (FAEs) and methotrexate, and the interleukin‐17A antagonist, ixekizumab.

Methods

Systemic‐naive patients were randomized in this parallel‐group, active‐comparator, open‐label, rater‐blinded trial (each group n = 54). The primary outcome was the proportion of patients achieving ≥ 75% improvement in Psoriasis Area and Severity Index (PASI 75) at 24 weeks. Key secondary outcomes included 24‐week PASI 90 and 100, static Physician's Global Assessment (sPGA) score of 0 or 1, and Dermatology Life Quality Index (DLQI) score of 0 or 1. Safety events at week 24 were analysed using Fisher's exact test. Missing data were imputed using nonresponder imputation. The trial was registered at ClinicalTrials.gov (NCT02634801) and EudraCT (2015‐002649‐69).

Results

At week 24, more ixekizumab‐treated patients achieved PASI 75 [91% vs. 22% FAEs (P < 0·001) and 70% methotrexate (P = 0·014)], PASI 90 [80% vs. 9% FAEs (P < 0·001) and 39% methotrexate (P < 0·001)] and PASI 100 [41% vs. 4% FAEs (P < 0·001) and 13% methotrexate (P = 0·0041)], as well as sPGA (0,1) and DLQI (0,1).

Conclusions

Ixekizumab was superior in inducing PASI 75/90/100, sPGA (0,1) and DLQI (0,1) responses at week 24 compared with methotrexate and FAEs. Safety profiles for all treatments were consistent with prior studies.

What's already known about this topic?

Fumaric acid esters (FAEs) and methotrexate are two frequently used conventional systemic therapies for chronic plaque psoriasis.

A recent meta‐analysis of methotrexate showed a ≥ 75% reduction in Psoriasis Area and Severity Index (PASI 75) rate of 45·2% from primary end points at either 12 or 16 weeks.

Until recently, FAEs were licensed for psoriasis only in Germany, but were used in many other European countries as off‐label treatment of psoriasis. In 2017, the European Medicines Agency approved dimethyl fumarate, presumed to be the main active ingredient of FAEs, for the treatment of adult patients with moderate‐to‐severe chronic plaque psoriasis.

What does this study add?

This study is the first randomized, head‐to‐head trial comparing a biologic treatment with these therapies in a systemic‐treatment‐naive patient population.

This study shows the low tolerability of FAEs leading to a significant discontinuation rate, the better tolerability and moderate efficacy of methotrexate, and the good tolerability, fast onset of action and high efficacy of ixekizumab in an unbiased comparison.

Our findings reinforce the favourable risk–benefit profile of ixekizumab shown previously and provide further evidence of its efficacy at 24 weeks.

https://doi.org/10.1111/bjd.18905 available online

Nusinersen improves walking distance and reduces fatigue in later-onset spinal muscular atrophy

Introduction

Ambulatory individuals with spinal muscular atrophy (SMA) experience muscle weakness, gait impairments, and fatigue that affect their walking ability. Improvements have been observed in motor function in children treated with nusinersen, but its impact on fatigue has not been studied.

Methods

Post hoc analyses were used to examine changes in 6‐minute walk test (6MWT) distance and fatigue in children and adolescents with SMA type II and III who received their first dose of nusinersen in the phase Ib/IIa, open‐label CS2 study and were ambulatory during CS2 or the extension study, CS12.

Results

Fourteen children performed the 6MWT. Median (25th, 75th percentile) distance walked increased over time by 98.0 (62.0, 135.0) meters at day 1050, whereas median fatigue changed by −3.8% (−19.7%, 1.4%).

Discussion

These results support previous studies demonstrating clinically meaningful effects of nusinersen on motor function in children and adolescents with later‐onset SMA.

Nusinersen in later-onset spinal muscular atrophy: Long-term results from the phase 1/2 studies

Objective

To report results of intrathecal nusinersen in children with later-onset spinal muscular atrophy (SMA).

Methods

Analyses included children from a phase 1b/2a study (ISIS-396443-CS2; NCT01703988) who first received nusinersen during that study and were eligible to continue treatment in the extension study (ISIS-396443-CS12; NCT02052791). The phase 1b/2a study was a 253-day, ascending dose (3, 6, 9, 12 mg), multiple-dose, open-label, multicenter study that enrolled children with SMA aged 2–15 years. The extension study was a 715-day, single-dose level (12 mg) study. Time between studies varied by participant (196–413 days). Assessments included the Hammersmith Functional Motor Scale–Expanded (HFMSE), Upper Limb Module (ULM), 6-Minute Walk Test (6MWT), compound muscle action potential (CMAP), and quantitative multipoint incremental motor unit number estimation. Safety also was assessed.

Results

Twenty-eight children were included (SMA type II, n = 11; SMA type III, n = 17). Mean HFMSE scores, ULM scores, and 6MWT distances improved by the day 1,150 visit (HFMSE: SMA type II, +10.8 points; SMA type III, +1.8 points; ULM: SMA type II, +4.0 points; 6MWT: SMA type III, +92.0 meters). Mean CMAP values remained relatively stable. No children discontinued treatment due to adverse events.

Conclusions

Nusinersen treatment over ∼3 years resulted in motor function improvements and disease activity stabilization not observed in natural history cohorts. These results document the long-term benefit of nusinersen in later-onset SMA, including SMA type III.

Clinicaltrials.gov identifier

NCT01703988 (ISIS-396443-CS2); NCT02052791 (ISIS-396443-CS12).

Classification of evidence

This study provides Class IV evidence that nusinersen improves motor function in children with later-onset SMA.

IONIS-PKKRx a Novel Antisense Inhibitor of Prekallikrein and Bradykinin Production

Kallikrein is the key contact system mediator responsible for the conversion of high-molecular-weight kininogen into the inflammatory vasodilator peptide bradykinin, a process regulated by C1-esterase inhibitor (C1-INH). In hereditary angioedema (HAE), genetic mutations result in deficient or dysfunctional C1-INH and dysregulation of the contact system leading to recurrent, sometimes fatal, angioedema attacks. IONIS-PKK_Rx is a second-generation 2'-O-(2-methoxyethyl)-modified chimeric antisense oligonucleotide, designed to bind and selectively reduce prekallikrein (PKK) mRNA in the liver. IONIS-PKK_Rx demonstrated dose-dependent reduction of human prekallikrein hepatic mRNA and plasma protein in transgenic mice and dose- and time-dependent reductions of plasma PKK in Cynomolgus monkeys. Similar dose-dependent reductions of plasma PKK levels were observed in healthy human volunteers accompanied by decreases in bradykinin generation capacity with an acceptable safety and tolerability profile. These results highlight a novel and specific approach to target PKK for the treatment of HAE and other diseases involving contact system activation and overproduction of bradykinin.

IL-3-producing basophils are required to exacerbate airway hyperresponsiveness in a murine inflammatory model

BACKGROUND

Basophils are commonly associated with allergic responses because of their ability to produce large amounts of pro-Th2 cytokines and histamine. However, the mechanisms through which bone marrow-resident basophils (BMRB) become fully competent cytokine and histamine producers in response to IgE crosslinking are poorly understood. Here, we sought to determine the role of IL-3 in promoting pro-Th2 basophils.

METHODS

BMRB and basophils exposed to IL-3 in vitro and in vivo were evaluated for their production of Th2 cytokines and histamine in response to FcεRI crosslinking on both protein and gene expression levels. In vivo relevance of our findings was assessed in a model of ovalbumin-induced allergic asthma using IL-3-deficient and wild-type mice in a protocol of adoptive basophil transfer.

RESULTS

We show that BMRB and basophils previously exposed to IL-3 differ in their ability to generate cytokines (IL-4, IL-6, IL-13, and GM-CSF) and histamine in response to FcεRI crosslinking, reflecting two stages of maturation. Exposure to IL-3 initiated an autocrine loop of endogenous IL-3 production that enhanced histamine and cytokine production upon FcεRI crosslinking. This increased responsiveness required calcium flux and was dependent on calcineurin and store-operated calcium channels. Our findings are of pathophysiological relevance, as assessed by the failure of IL-3-deficient mice to develop airway hyperreactivity, which could be restored by adoptive transfer of IL-3-derived basophils recovered from wild-type mice.

CONCLUSION

IL-3-dependent basophils promote Th2 allergic AHR, which designates the IL-3/basophil axis as a promising therapeutic target for the treatment of basophil-dependent asthma.

Performance of a composite flow moulded carbon fibre reinforced osteosynthesis plate

Non-metallic implants have the advantage over metallic implants of reduction in artefact with CT and MR diagnostic imaging. In-vivo performance of a carbon fibre reinforced polyetheretherketone radiolucent plate (Snake Plate [SP]) with high stiffness, and fixed angle converging screws was compared with a seven-hole titanium Locking Compression Plate (LCP), using a sheep tibial osteotomy model (gap 0.6 mm). The sheep were divided into two groups, and the osteotomies were stabilized with a SP (n=6) or a LCP (n=6). The callus dimensions were measured radiographically at zero, two, four, six and eight weeks. The animals were euthanatized after eight weeks. Osteotomised and contralateral tibiae were tested in pairs torsion, to determine strength and stiffness. In the radii of six separate sheep, initial vascular disturbance after plate implantation was evaluated. All of the sheep of the SP and LCP groups showed maximal callus areas at six weeks. The differences between the groups, in callus dimension, were not significant at any time point. The median values for relative reduction (100 x [operated – contralateral] / contralateral) in strength of osteotomized tibiae was ™13.93% for the SP group and ™7.49% for the LCP group (p = 0.5228), and for stiffness it was ™24.44 % for the SP group and ™27.08% for the LCP group (p = 0.6481). Neither the SP nor LCP caused any notable disturbance in periosteal circulation. The SP appears to represent a valuable alternative to metallic implants for shaft fracture repair. The main advantages of the SP are radiolucency, high deformation resistance, internal fixator concept and converging screw configuration for optimal loading conditions in the bone-implant construct.

Quantification of histomorphometric and structural bone changes in a sheep model for fracture treatment in osteoporotic bone

The histomorphometrical cancellous bone parameters of osteoporotic ewes were examined to establish a large animal model for the investigation of fracture treatment and healing in osteoporotic bone. Eighteen animals were divided into 2 groups. Group 1 (n = 8, age 3 to 5 years) served as an untreated control. In Group 2 (n = 10, age 7 to 9 years) osteoporosis was induced by means of ovariectomy, methylprednisolone application (average dose 160 mg/week) and Ca./Vit.D restricted diet during 7 months. Biopsies from iliac crest, femoral head and lumbar spine were harvested. Structural parameters from the biopsies were determined using μCT. In order to investigate static and dynamic parameters of bone remodelling, undecalcified sections were digitized and evaluated by means of image analysing software. Morphologically, bone area and trabecular thickness were reduced in osteoporotic sheep. Bone perimeter (−20%), trabecular number (−16%) and separation (+39%) showed a significant change in the iliac crest. The structure model index indicated a shift from the plate-to the rodmodel. At different skeletal sites of osteoporotic sheep bone resorption was significantly increased (250-675%), and bone formation significantly decreased (77-89%). Osteoid thickness (O.Th) was reduced (28-62%). In osteoporotic sheep the mean length of single labels was significantly shortened (64-73%) and the mineralising surface showed a significant decrease (80-92%). The mineralisation of the osteoid was comparable to the control group. The histomorphometrical changes in this sheep model of osteoporosis are comparable to the human situation of a combined post-menopausal and steroid-induced osteoporosis.

Nusinersen versus Sham Control in Later-Onset Spinal Muscular Atrophy

BACKGROUND

Nusinersen is an antisense oligonucleotide drug that modulates pre-messenger RNA splicing of the survival motor neuron 2 ( SMN2) gene. It has been developed for the treatment of spinal muscular atrophy (SMA).

METHODS

We conducted a multicenter, double-blind, sham-controlled, phase 3 trial of nusinersen in 126 children with SMA who had symptom onset after 6 months of age. The children were randomly assigned, in a 2:1 ratio, to undergo intrathecal administration of nusinersen at a dose of 12 mg (nusinersen group) or a sham procedure (control group) on days 1, 29, 85, and 274. The primary end point was the least-squares mean change from baseline in the Hammersmith Functional Motor Scale-Expanded (HFMSE) score at 15 months of treatment; HFMSE scores range from 0 to 66, with higher scores indicating better motor function. Secondary end points included the percentage of children with a clinically meaningful increase from baseline in the HFMSE score (≥3 points), an outcome that indicates improvement in at least two motor skills.

RESULTS

In the prespecified interim analysis, there was a least-squares mean increase from baseline to month 15 in the HFMSE score in the nusinersen group (by 4.0 points) and a least-squares mean decrease in the control group (by -1.9 points), with a significant between-group difference favoring nusinersen (least-squares mean difference in change, 5.9 points; 95% confidence interval, 3.7 to 8.1; P<0.001). This result prompted early termination of the trial. Results of the final analysis were consistent with results of the interim analysis. In the final analysis, 57% of the children in the nusinersen group as compared with 26% in the control group had an increase from baseline to month 15 in the HFMSE score of at least 3 points (P<0.001), and the overall incidence of adverse events was similar in the nusinersen group and the control group (93% and 100%, respectively).

CONCLUSIONS

Among children with later-onset SMA, those who received nusinersen had significant and clinically meaningful improvement in motor function as compared with those in the control group. (Funded by Biogen and Ionis Pharmaceuticals; CHERISH ClinicalTrials.gov number, NCT02292537 .).

Measurement of bone surface strains on the sheep metacarpus in vivo and ex vivo

Bone surface strains were measured on the dorsal ovine metacarpus during normal locomotion on a treadmill at different walking speeds to determine physiological strain levels. These measured strains were related to the strains measured in an ex vivo model of the sheep forelimb with two types of load application: loading by two Schanz-screws and loading via the radius. In vivo, the average surface strains were found to be dependent upon body weight as well as the walking speed. The orientation of the peak principal strain corresponded to the longitudinal axis of the bone. Ex vivo, loads applied via Schanz screws in the screw-loading model lead to strains on the dorsal metacarpus that corresponds to strains experienced in vivo during intermittent peak loads. Screw loading imparted primarily a bending load to the metacarpus, with the dorsal aspect in compression and the palmar aspect in tension. Loads, applied via the radius and the hoof in the radius-loading model, resulted in bone surface strains comparable to those measured during slow walking in vivo. In both ex vivo loading situations, peak strain orientation was parallel to the longitudinal axis of the sheep metacarpus. In conclusion, the results show that although the ex vivo loading models do not exactly replicate the load experienced in vivo, the magnitude and orientation of the principal strains on the dorsal metacarpus are within the range of strains occurring during normal physiological loading. These data validate the physiological significance of the ex vivo model and aid in understanding effects of mechanical loading on interstitial fluid flow and mass transport through bone.

The effect of gestagens on bone turnover in sheep

The effects of two gestagens on bone turnover were investigated in three groups of female sheep comparable in age and weight. Group A (n = 10) was given a single intramuscular injection of 50 mg chlormadinon acetate (CMA), group B (n = 9) received 140 mg medroxyprogesterone acetate (MPA), and control group C (n = 9) received 5 ml physiological NaCI-solution. Plasma progesterone was measured weekly over 3 months. Bone mineral density (BMD) in the right distal tibia and calcaneus were determined every four weeks during the four months of the study duration, using peripheral quantitative computed tomography (pQCT). At the same times total alkaline phosphatase (AP) was determined. No significant changes of BMD were found in the three groups during the four months. Total alkaline phosphatase showed a significant decrease of 36-45% in all groups during the first six weeks. Sheep seem to have a comparable bone metabolism to humans with respect to the short term effect of gestagens, i. e. MPA and CMA.

Vestibulo-ocular reflex dynamics with head-impulses discriminates spinocerebellar ataxias types 1, 2 and 3 and Friedreich ataxia

OBJECTIVE

Although the diagnosis of inherited ataxias is ultimately genetic, this usually means an extensive and expensive process. This justifies the search for distinct clinical signs that may potentially help orient molecular diagnosis.

METHODS

We explored the vestibulo-ocular reflex (VOR) with the video Head Impulse Test in patients diagnosed with spinocerebellar ataxia (SCA) type 3 (n = 15), type 1 (n = 4) and type 2 (n = 4), Friedreich's ataxia (FA) (n = 9) and healthy controls (n = 40). We estimated the latency, regression (VORr) and instantaneous VOR gain at 40, 60 and 80 ms (VOR40, VOR60 and VOR80), and determined the latency, peak-velocity and occurrence rate of catch-up saccades triggered with head-impulses.

RESULTS

VOR latency was higher in FA (p < 0.001) and SCA3 (p = 0.02) as compared to controls, discriminating FA from other ataxic patients with an overall diagnostic accuracy of 88%. VORr, VOR40 and VOR60 were significantly lower in FA and SCA3 (p < 0.01). VOR80 was only significantly lower than controls in SCA3 (p < 0.01), discriminating these from other ataxic patients with an overall diagnostic accuracy of 78%. Covert saccades were only triggered in SCA3 but with low occurrence rate and peak velocity (11.1 ± 28.5% and 77.50 ± 15.30°/s) whereas overt saccades were present in all groups. VORr gain showed a negative correlation with disease severity evaluated with SARA (Spearman r = -0.46, p = 0.01).

CONCLUSIONS

vHIT provides phenotypic information that differentiates these autosomal ataxias and can serve as a strategy to orient genetic diagnosis. A correlation between VOR and SARA raises the possibility of using VOR gain as a neurophysiologic biomarker for disease severity.

Dosimetrische Grundlagen für die endo vaskuläre Therapie mit Re-188 zur Prävention der Restenose nach Angioplastie

Ziel: Für die endovaskuläre Brachytherapie stehen unterschiedliche Radionuklide zur Verfügung. Ein interessantes Konzept ist die Nutzung eines flüssigen Betastrahlers in einem Ballonkatheter. Re-188 kann aus einem Generatorsystem gewonnen werden und steht somit täglich zur Verfügung. Es sollten dosimetrische Daten erhoben werden. Methode: Es wurde die radiale Abnahme der Dosis von Re-188 bei einem typischen Dilatationskatheter (Durchmesser 3 mm, Länge 20 mm) berechnet und mit TLD-Messungen verglichen. Ergebnisse: Bei einer spezifischen Aktivität von 370 MBq/ml konnten 0,3 Gy pro 1 min in 0,5 mm Abstand von der Ballonwand gemessen werden. Doppelmessungen wiesen eine Abweichung von 3% auf. Ein schneller Dosisabfall von 50% innerhalb von 0,5 mm bzw. von 90% innerhalb von 2,5 mm wurde beobachtet. Meßwerte und Berechnungen stimmten gut überein. Die Daten von Re-188 und Y-90 entsprechen sich weitgehend. Schlußfolgerung: Berechnungen über die Dosisverteilung von Re-188 stimmen mit TLD-Messungen gut überein. Bei einer spezifischen Aktivität von 1,85 GBq/ml können in 2-3 Minuten 10-15 Gy an der Gefäßwand einer Koronararterie appliziert werden. Gegenüber radioaktiven Stents oder radioaktiven Drähten bietet sich hiermit eine einfache Alternative für die Prävention der Restenose an.