Maternal microbe-specific modulation of the offspring microbiome and development during pregnancy and lactation

The maternal microbiome is essential for the healthy growth and development of offspring and has long-term effects later in life. Recent advances indicate that the maternal microbiome begins to regulate fetal health and development during pregnancy. Furthermore, the maternal microbiome continues to affect early microbial colonization via birth and breastfeeding. Compelling evidence indicates that the maternal microbiome is involved in the regulation of immune and brain development and affects the risk of related diseases. Modulating offspring development by maternal diet and probiotic intervention during pregnancy and breastfeeding could be a promising therapy in the future. In this review, we summarize and discuss the current understanding of maternal microbiota development, perinatal microbial metabolite transfer, mother-to-infant microbial transmission during/after birth and its association with immune and brain development as well as corresponding diseases.

A critical role of AMP-activated protein kinase in regulating intestinal nutrient absorption, barrier function, and intestinal diseases

As one of the most important organs in animals, the intestine is responsible for nutrient absorption and acts as a barrier between the body and the environment. Intestinal physiology and function require the participation of energy. 5'-adenosine monophosphate-activated protein kinase (AMPK), a classical and highly expressed energy regulator in intestinal cells, regulates the process of nutrient absorption and barrier function and is also involved in the therapy of intestinal diseases. Studies have yielded findings that AMPK regulates the absorption of glucose, amino acids, and fatty acids in the intestine primarily by regulating transportation systems, as we detailed here. Moreover, AMPK is involved in the regulation of the intestinal mechanical barrier and immune barrier through manipulating the expression of tight junctions, antimicrobial peptides, and secretory immunoglobulins. In addition, AMPK also participates in the regulation of intestinal diseases, which indicates that AMPK is a promising therapeutic target for intestinal diseases and cancer. In this review, we summarized the current understanding regarding how AMPK regulates intestinal nutrient absorption, barrier function, and intestinal diseases.

[Preconception reproductive health and birth outcome cohort in Chongqing: the cohort profile]

Birth cohort is an important platform to study the effect of early-life exposure on health outcome, but large cohorts to investigate the effect of preconception exposure, especially paternal exposure, on reproductive health and birth outcome are limited. The Preconception Reproductive Health and Birth Outcome Cohort (PREBIC) is a prospective birth cohort study which pays equal attention to the contribution of environmental, psychological, behavioral as well as other factors to reproductive health and adverse birth outcomes in both men and women in Chongqing, China. PREBIC started in 2019 and plans to recruit 20 800 reproductive-age couples with child-bearing willingness. Followed up was conducted to understand the conception status of the women within two years. Women in pregnancy would be visited at first, second, third trimesters and after delivery. The offspring would be monitored until 2 years old to understand the incidences of preterm birth, low birth weight, birth defects, neurodevelopmental disorders and other outcomes. Related information and biospecimen collections (including semen, peripheral blood, urine, placenta, umbilical cord, cord blood and oral swab) were scheduled in each period. By January 2022, PREBIC had recruited 8 698 participants from all 38 districts in Chongqing. The goal of PREBIC is to establish one of the largest prospective preconception birth cohorts covering both men and women, which might provide a unique insight to understand the effects of the full reproductive cycle on reproductive health and adverse outcomes, with especial emphasis on preconception exposures.

Nutritional strategies to alleviate oxidative stress in sows

The performance of high-yielding sows is directly related to the productivity of pig farming. Fetal development mainly occurs during the last month of pregnancy, and the aggressive metabolic burden of sows during this stage eventually leads to systemic oxidative stress. When affected by oxidative stress, sows exhibit adverse symptoms such as reduced feed intake, hindered fetal development, and even abortion. In addition, milk synthesis during the lactation period causes a severe metabolic burden. The biological response to oxidative stress during this period is associated with a decrease in milk production, which further affects the growth of piglets. Understanding the nutritional strategies to alleviate oxidative stress in sows is crucial to maintain their reproduction and lactation performance. Recently, advances have been made in the field of nutrition to relieve oxidative stress in sows during late pregnancy and lactation. This review highlights the nutritional strategies to relieve oxidative stress in sows reported within the last 20 years.

Review of the Impact of Whale Fall on Biodiversity in Deep-Sea Ecosystems

“Whale Fall” is a collective term for the whale carcass, the process of dead whale fall, and the formed deep-sea ecosystem. The whale fall process produces a lot of unstable organic matter that has a significant impact on deep-sea ecosystems. Scientists speculate that organic matter input is the source of energy and material for organisms in deep-sea ecosystems. In the seafloor of the North Pacific, whale fall supports the survival of at least 12,490 organisms of 43 species, contributing to the prosperity of deep-sea life. Due to the specificity of the time and space of the formation of whale fall, there are few studies on whale fall and its impact on the deep-sea ecosystem. This article summarizes and analyses the current research status on the distribution of whale fall and its impact on the deep-sea ecosystem at home and abroad. The results show that the current distribution of whale fall is mainly concentrated in the Pacific and Atlantic regions, and the research on the impact of whale fall on deep-sea ecosystems focuses on the formation process, degradation rate and impact on deep-sea biological systems. This article has some significance to the understanding of biodiversity and ecosystem succession in the deep-sea “desert area.”

Effects of Nutrient Levels on Microbial Diversity in Sediments of a Eutrophic Shallow Lake

Microorganisms can both indicate the water quality characteristics and the health of the aquatic environment, which have an important influence on the cycling of organic carbon, nitrogen (N), and phosphorus (P) in nature. In this study, we took Taihu Lake, a typical eutrophic lake in China, as the research object, and monitored the northern (Changzhou City) and southern (Changxing County) regions of Taihu Lake for three consecutive years (2019–2021), respectively. We also analyzed the microbial diversity in sediments, and then summarized the effects of different nutrient environments on microorganisms in the aquatic environment. The results showed that the pollution level in the northern part of Taihu Lake was higher than that in the southern region of Taihu Lake, where the pollution was mainly in summer (June–July). The pollution in the southern region of Taihu Lake is relatively stable between 2019 and 2021; the changes in the northern part of Taihu Lake are relatively significant. Microbial diversity in the study area was negatively correlated with the degree of eutrophication of water bodies; microbial abundance was positively correlated with nutrient levels. The functional difference analysis indicated that the microorganisms in the sediments of Taihu Lake in the study area were involved in the nutrient transport and transformation, and played an important role in the purification of the lake water body. This study reveals the relationship between water eutrophication and microbial diversity, and then provides a theoretical basis for the management of eutrophic lakes.

Energy deprivation-induced AMPK activation inhibits milk synthesis by targeting PrlR and PGC-1α

Background

The mammary gland is responsible for milk production and secretion, which is critical for neonatal health during lactation. Lactation efficiency is largely affected by energy status with unclear mechanism.

Results

In the current study, we found that synthesis of milk fat and protein was significantly inhibited under energy-deficient conditions, which is accompanied with AMP-activated protein kinase (AMPK) activation. Modulating the AMPK signaling pathway directly or indirectly affects the synthesis of milk fat and protein. Besides mammalian target of rapamycin complex 1 (mTORC1) signaling in the regulation of milk synthesis, we discovered that AMPK mainly regulates the synthesis of milk protein through prolactin signaling. Mechanistically, AMPK triggers the ubiquitination of prolactin receptor (PrlR) through regulating the activity of β-transducin repeat-containing protein (β-TrCP, an E3 ligase). Subsequently, PrlR is degraded by the endocytosis process of lysosomes, which further attenuates prolactin signaling. In addition, our results revealed that AMPK activation inhibits milk fat synthesis through decreasing and accelerating de novo synthesis and β-oxidation of fatty acids, respectively. To be precise, AMPK activation inhibits rate limiting enzymes and transcriptional regulatory factors involved in de novo fatty acid synthesis and decreases the acetylation process of peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGC-1α) to strengthen the oxidation of fatty acids.

Conclusions

Taken together, AMPK regulates the synthesis of milk not only depends on canonical mTORC1 signaling and key rate-limiting enzymes, but also through manipulating the degradation of PrlR and the acetylation of PGC-1α.

Maternal Nutrition During Late Gestation and Lactation: Association With Immunity and the Inflammatory Response in the Offspring

The immature immune system at birth and environmental stress increase the risk of infection in nursing pigs. Severe infection subsequently induces intestinal and respiratory diseases and even cause death of pigs. The nutritional and physiological conditions of sows directly affect the growth, development and disease resistance of the fetus and newborn. Many studies have shown that providing sows with nutrients such as functional oligosaccharides, oils, antioxidants, and trace elements could regulate immunity and the inflammatory response of piglets. Here, we reviewed the positive effects of certain nutrients on milk quality, immunoglobulin inflammatory response, oxidative stress, and intestinal microflora of sows, and further discuss the effects of these nutrients on immunity and the inflammatory response in the offspring.

Sequential P-GEMOX and radiotherapy for early-stage extranodal natural killer/T-cell lymphoma: A multicenter study

Extranodal natural killer/T-cell lymphoma, nasal-type (ENKTL) is a distinct subtype of non-Hodgkin lymphoma and most of the patients presented localized disease. Combined modality therapy (CMT), namely chemotherapy combined with radiotherapy, has been recommended for patients with early-stage ENKTL. However, the optimal CMT has not been fully clarified. This study reports the efficacy and toxicity of sequential P-GEMOX (pegaspargase, gemcitabine and oxaliplatin) and radiotherapy in a large Chinese cohort comprising of 202 patients diagnosed with early-stage ENKTL from six medical centers. The observed best overall response rate was 96.0% and 168 (83.2%) patients achieved complete remission. With a median follow-up of 44.1 months, the 3-year progression-free survival (PFS) and overall survival (OS) were 74.6% and 85.2%, respectively. Multivariate analysis suggested that extensive primary tumor (PFS, hazard ratio [HR] 3.660, 95% CI 1.820-7.359, p <  0.001; OS, HR 3.825, 95% CI 1.442-10.148, p = 0.007) and Eastern Cooperative Oncology Group performance status ≥ 2 (PFS, 3.042, 95% CI 1.468-6.306, p = 0.003; OS, HR 3.983, 95% CI 1.678-9.457, p = 0.02) were independent prognostic factors for survival outcomes. Among the established prognostic models for ENKTL, the nomogram-revised risk index model had optimal prognostic risk stratification ability (PFS, p < 0.001; OS, p < 0.001) and relatively balanced population distribution. The adverse events of this CMT were well-tolerated and manageable. In conclusion, sequential P-GEMOX and radiotherapy showed favorable efficacy with acceptable toxicity, and could be an effective treatment option for early-stage ENKTL patients.

Down-regulated LINC00115 inhibits prostate cancer cell proliferation and invasion via targeting miR-212-5p/FZD5/Wnt/β-catenin axis

Prostate cancer is the second most frequent malignancy in men worldwide, and its incidence is increasing. Therefore, it is urgently required to clarify the underlying mechanisms of prostate cancer. Although the long non‐coding RNA LINC00115 was identified as an oncogene in several cancers, the expression and function of LINC00115 in prostate cancer have not been explored. Our results showed that LINC00115 was significantly up‐regulated in prostate cancer tissues, which was significantly associated with a poor prognosis for prostate cancer patients. Functional studies showed that knockdown LINC00115 inhibited cell proliferation and invasion. In addition, LINC00115 served as a competing endogenous RNA (ceRNA) through sponging miR‐212‐5p to release Frizzled Family Receptor 5 (FZD5) expression. The expression of miR‐212‐5p was noticeably low in tumour tissues, and FZD5 expression level was down‐regulated with the knockdown of LINC00115. Knockdown LINC00115 inhibited the Wnt/β‑catenin signalling pathway by inhibiting the expression of FZD5. Rescue experiments further showed that LINC00115 inhibits prostate cancer cell proliferation and invasion via targeting miR‐212‐5p/ FZD5/ Wnt/β‐catenin axis. The present study provided clues that LINC00115 may be a promising novel therapeutic target for prostate cancer patients.

Interleukin-1 receptor-associated kinase gene polymorphisms contribute to rheumatoid arthritis risk: A meta-analysis

AIM

Rheumatoid arthritis (RA) is a systemic autoimmune disease affecting about 1% of world population. Three polymorphisms of Interleukin-1 receptor-associated kinase (IRAK1) gene, rs3027898, rs1059702 and rs1059703, are studied to associate with RA risk. However, the findings are inconclusive. Therefore, we performed a meta-analysis to derive a more precise estimation of the impact of the 3 polymorphisms on RA risk.

METHOD

The strength of association between 3 polymorphisms and RA risk was assessed by calculating odds ratios (ORs) with the corresponding 95% confidence intervals (CIs).

RESULTS

Overall, for rs3027898 polymorphism, no association was observed in pooled analysis, but the stratified analysis suggested that rs3027898 CA genotype was associated with a reduced risk of RA in an Asian population (heterozygous model: OR = 0.79, 95% CI = 0.66-0.96, P = .018). Rs1059702 polymorphism was related with an increased RA risk (homozygous model: OR = 1.59, 95% CI = 1.19-2.13, P = .002, heterozygous model: OR = 1.49, 95% CI = 1.17-1.88, P = .001, and allele comparison model: OR = 1.35, 95% CI = 1.20-1.53, P < .001). Moreover, rs1059703 was also associated with an increased RA risk (dominant model: OR = 1.26, 95% CI = 1.07-1.49, P = .006), especially in Caucasian populations.

CONCLUSION

These results indicated that all 3 Interleukin-1 receptor-associated kinase (IRAK1) gene polymorphisms, rs3027898, rs1059702 and rs1059703 were related to RA risk.

[Rituximab combined with short-course and intensive regimen for Burkitt leukemia: efficacy and safety analysis]

目的

探讨利妥昔单抗联合短疗程、高强度方案治疗成人Burkitt白血病患者的疗效和安全性。

方法

收集2006年1月30日至2018年9月12日中国医学科学院血液病医院收治的11例Burkitt白血病患者病例资料，分析统计患者的临床特征、完全缓解（CR）率、总生存率、无复发生存率及不良事件。

结果

11例患者中位年龄34（15~54）岁，其中男6例，女5例。发病时中位WBC 12.28（2.21~48.46）×10⁹/L，HGB 113（74~147）g/L，PLT 35（13~172）×10⁹/L，乳酸脱氢酶2 721（803~17 370）U/L，外周血中位原始细胞比例0.40（0.03~0.76），骨髓中位原始细胞比例0.840（0.295~0.945）。10例患者接受利妥昔单抗联合短疗程、高强度化疗，其中2例患者巩固化疗后行自体造血干细胞移植。所有治疗患者1个疗程CR率为100%，4年总生存率为90%，4年无复发生存率为90%。所有治疗患者中，只有1例患者在诱导化疗中出现肿瘤溶解综合征，经血液透析等治疗后肾功能恢复。无治疗相关性死亡病例。

结论

利妥昔单抗联合短疗程、高强度方案治疗成人Burkitt白血病疗效及安全性均较为理想。

[Clinical and laboratory characteristics in patients with myeloid neoplasms complicated with clonal T large granular lymphocyte proliferation]

Objective: To analyze the clinical manifestations and laboratory features in patients with myeloid neoplasms complicated with clonal T large granular lymphocyte (T-LGL) proliferation. Methods: The clinical data of 5 patients with myeloid neoplasms complicated with clonal T-LGL proliferation from November 2017 to November 2018 in Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College were analyzed retrospectively. Results: The median age was 60 years old. All patients had a history of abnormal peripheral blood cell counts for over 6 months. The absolute lymphocyte count in peripheral blood was less than 1.0×10(9)/L. In addition to the typical T-LGL phenotype, the immunophenotype was heterogenous including CD4(+)CD8(-) in 2 patients, the other 3 CD4(-)CD8(+). Four patients were αβ type T cells, the other one was γδ type. STAT3 mutation was detected in 1 patient by next-generation sequencing, the other 4 cases were negative. Conclusions: Clonal T-LGL proliferation with myeloid neoplasm develops in an indolent manner, mainly in elderly patients. Hemocytopenia is the most common manifestation. The diagnosis of T-LGL proliferation does not have specific criteria, that it should be differentiated from other T cell proliferative disorders, such as T-cell clones of undetermined significance. STAT3 or STAT5b mutation may help distinguish.

Effect of heat stress on mitogen-activated protein kinases in the hypothalamic-pituitary-gonadal axis of developing Wenchang chicks

The regulatory roles of mitogen-activated protein kinase (MAPK) signaling pathways on the hypothalamic-pituitary-gonadal axis (HPG axis) of Wenchang chicks under heat stress (HS) were investigated. Additionally, the crosstalk between these signaling pathways was explored. Immunohistochemical experiments and Western blotting were employed to quantify extracellular regulated protein kinases (ERK), c-Jun N-terminal kinases (JNK), and p38MAPK (P38). In female chicks, hypothalamic ERKs were upregulated in Weeks 1 and 2 in the HS group compared with the control group (CK), while JNK and p38 were downregulated (P < 0.05). Pituitary MAPKs were all downregulated in the HS group compared with the CK group in Week 3, but p38 was upregulated in Week 4 (P < 0.01). In the HS group, ovarian MAPKs were all upregulated compared with the CK group during Week 5, whereas ERK was downregulated in Week 6 (P < 0.01). In contrast to the patterns of MAPK expression in female chicks in the HS and CK groups, ERK in male chicks showed a completely opposite pattern in Weeks 1, 2, and 5, while p38 and JNK were downregulated in both female and male chicks under HS during Weeks 2 and 3. In the HS group, pituitary and testis MAPKs showed a pattern opposite to that observed in female chicks under HS in Week 5; MAPKs were all downregulated (P < 0.05). Thus, there are gender differences in the MAPK signaling pathways in the HPG axis in chicks, and these pathways showed plasticity. Early HS can enhance chick growth and development as well as promote developing in the MAPK signaling pathways in the HPG axis. However, after heated brooding was discontinued in chicks, long-term HS obstructed chick development and caused tissue and function injury to the HPG axis.

[Myeloid/lymphoid neoplasms with eosinophilia and FGFR1 rearrangement: 5 cases report and literatures review]

目的

分析罕见疾病伴嗜酸性粒细胞增多和FGFR1重排的髓系/淋系肿瘤（即8p11骨髓增殖综合征，EMS）的临床特征、诊断及治疗。

方法

总结中国医学科学院血液病医院2014年1月至2018年5月收治的5例确诊EMS患者的临床表现、实验室特征、诊治经过及转归。

结果

5例EMS患者外周血白细胞计数均明显升高，伴有嗜酸性粒细胞绝对值增高（均值18.89×10⁹/L）；骨髓髓系极度增生，原始细胞均<5%，嗜酸性粒细胞比例增高（均值17.24%）。5例患者染色体核型各不相同，但FISH检查均存在FGFR1基因重排。发病至确诊平均时间为4.8个月，中位生存期仅14个月。

结论

EMS是一种罕见病，恶性程度高，对常规化疗反应差，生存期短，且易发生误诊漏诊，细胞遗传学及分子生物学检查有助于早期诊断。

[Potential mechanism of transcription factor peroxisome proliferator-activated receptor-gamma coactivator-1 beta on promoting osteoclastogenesis]

Objective: To investigate the role of transcription factor peroxisome proliferator-activated receptor-gamma coactivator-1 beta (PGC-1β) on osteoclastogenesis and related regulatory mechanism in the mouse monocyte-macrophage cell line (RAW264.7). Methods: PGC-1β expression and location in RAW264.7 cells was detected by immunofluorescence, flow cytometry and western blot analysis with nuclear protein extraction. RAW264.7 cells were transfected with lentivirus for gene silencing or over-expression of PGC-1β and cultured with macrophage colony-stimulating factor and receptor activator for nuclear factor-κB ligand. Cell viability was detected by cell counting kit-8. Cell apoptosis and cell cycle were detected by flow cytometry. Mature osteoclasts and their bone resorption activity were determined by tartrate-resistant acid phosphatase (TRAP) expression and toluidine blue staining. Western blot analysis was performed for detecting dendritic cell-specific transmembrane protein (DC-STAMP), cathepsin K, TRAP and matrix metalloproteinase (MMP)-9 expression, as well as cytoplasmic NF-κB-inducing kinase (NIK) and nuclear RelB. Results: PGC-1β expression was observed in the nuclei of RAW264.7 cells. Down-regulation or overexpression of PGC-1β in RAW264.7 cells did not affect cell viability, apoptosis or cell cycle. Down-regulation of PGC-1β decreased the count of mature osteoclasts (49±21 cells vs. 147±42 cells, P=0.004) and the pit area of bone resorption lacunae (42.11μm(2)±11.30 μm(2) vs. 204.80μm(2)±31.09 μm(2), P<0.001), as well as the expression of cathepsin K, TRAP and MMP-9, but not DC-STAMP. Overexpression of PGC-1β promoted osteoclast differentiation and bone resorption activity, as well as the expression of cathepsin K, TRAP and MMP-9. Down-regulation of PGC-1β suppressed the protein expression of cytoplasmic NIK and nuclear RelB in RAW264.7 cells. Conclusion: PGC-1β can promote the differentiation of RAW264.7 into osteoclasts and improve the bone resorption ability of the cells via activation of NIK/RelB pathway, which might be a promising therapeutic target for osteoporosis.

[An interlaboratory comparison study on the detection of RUNX1-RUNX1T1 fusion transcript levels and WT1 transcript levels]

Objective: To investigate the current status and real performance of the detection of RUNX1-RUNX1T1 fusion transcript levels and WT1 transcript levels in China through interlaboratory comparison. Methods: Peking University People's Hospital (PKUPH) prepared the samples for comparison. That is, the fresh RUNX1-RUNX1T1 positive (+) bone morrow nucleated cells were serially diluted with RUNX1-RUNX1T1 negative (-) nucleated cells from different patients. Totally 23 sets with 14 different samples per set were prepared. TRIzol reagent was added in each tube and thoroughly mixed with cells for homogenization. Each laboratory simultaneously tested RUNX1-RUNX1T1 and WT1 transcript levels of one set of samples by real-time quantitative PCR method. All transcript levels were reported as the percentage of RUNX1-RUNX1T1 or WT1 transcript copies/ABL copies. Spearman correlation coefficient between the reported transcript levels of each participated laboratory and those of PKUPH was calculated. Results: ①RUNX1-RUNX1T1 comparison: 9 samples were (+) and 5 were (-) , the false negative and positive rates of the 20 participated laboratories were 0 (0/180) and 5% (5/100) , respectively. The reported transcript levels of all 9 positive samples were different among laboratories. The median reported transcript levels of 9 positive samples were from 0.060% to 176.7%, which covered 3.5-log. The ratios of each sample's highest to the lowest reported transcript levels were from 5.5 to 12.3 (one result which obviously deviated from other laboratories' results was not included) , 85% (17/20) of the laboratories had correlation coefficient ≥0.98. ②WT1 comparison: The median reported transcript levels of all 14 samples were from 0.17% to 67.6%, which covered 2.6-log. The ratios of each sample's highest to the lowest reported transcript levels were from 5.3-13.7, 62% (13/21) of the laboratories had correlation coefficient ≥0.98. ③ The relative relationship of the reported RUNX1-RUNX1T1 transcript levels between the participants and PKUPH was not always consistent with that of WT1 transcript levels. Both RUNX1-RUNX1T1 and WT1 transcript levels from 2 and 7 laboratories were individually lower than and higher than those of PKUPH, whereas for the rest 11 laboratories, one transcript level was higher than and the other was lower than that of PKUPH. Conclusion: The reported RUNX1-RUNX1T1 and WT1 transcript levels were different among laboratories for the same sample. Most of the participated laboratories reported highly consistent result with that of PKUPH. The relationship between laboratories of the different transcript levels may not be the same.

P1226Very low achieved low-density lipoprotein cholesterol level with alirocumab treatment after acute coronary syndrome: ODYSSEY OUTCOMES

Background

Recent guidelines for cholesterol management recognize uncertainty regarding long-term efficacy and safety of prolonged very low levels of LDL-C on treatment with a PCSK9 inhibitor, including risk of new-onset diabetes. ODYSSEY OUTCOMES used a treat-to-target approach to demonstrate reduction of coronary heart disease death, non-fatal myocardial infarction, ischaemic stroke, or unstable angina (MACE) with the PCSK9 inhibitor alirocumab (ALI) vs placebo (PBO) in 18,924 patients with recent acute coronary syndrome and elevated LDL-C despite intensive statin therapy. ALI was blindly adjusted (75 or 150 mg dose) to target LDL-C 0.6–1.3 mmol/L (25–50 mg/dL). To avoid sustained very low LDL-C, blind substitution of PBO for ALI was intended if 2 consecutive LDL-C levels were <0.39 mmol/L (15 mg/dL). Patients were followed for median of 2.8 years (maximum of 5 years).

Purpose

We report the efficacy and safety of ALI in patients who reached very low LDL-C (consecutively <0.39 mmol/L), compared with matched patients from the PBO group.

Methods

Of 9462 patients randomized to receive ALI, 730 (7.7%) reached very low LDL-C and had substitution of PBO a median 8.3 months after randomization. Using propensity score matching, they were compared (3:1) with 2152 patients initially assigned to PBO. Propensity score matching was also used to compare the incidence of new-onset diabetes in 525 patients without diabetes at baseline who had very low LDL-C levels on ALI with 1675 matched patients in the PBO group. Neurocognitive events and haemorrhagic stroke were also evaluated in relation to very low LDL-C.

Results

Overall, ALI reduced the incidence of MACE (9.5% vs 11.1%; HR 0.85, 95% CI 0.78–0.93; P<0.001). Characteristics used in propensity score matching (and associated with very low LDL-C on ALI) included sex (male), diabetes (present), baseline LDL-C and lipoprotein(a) (lower), region (Asia), statin treatment, smoking, hypertension, and body mass index. Despite being switched to PBO, patients with very low LDL-C on ALI had fewer MACE than matched patients from the PBO group (6.4% vs 8.5%; HR 0.71, 95% CI 0.52–0.98; P=0.039; Figure). Very low LDL-C on ALI was not associated with risk of new-onset diabetes, compared with matched patients from the PBO group (15.1% vs 13.0%; HR 1.10, 95% CI 0.85–1.43; P=0.46). There was no association of very low LDL-C on ALI with neurocognitive events or haemorrhagic stroke.

Conclusions

The overall efficacy of ALI on cardiovascular outcomes was not diminished by the patients who had blinded substitution of PBO for sustained very low LDL-C. Despite a short duration of active treatment, these patients had fewer MACE than matched controls from the PBO group. No adverse consequence of very low LDL-C was identified. However, because patients with sustained very low LDL-C were switched to PBO, the long-term safety of more prolonged very low LDL-C, including risk of new-onset diabetes, deserves further study.

Acknowledgement/Funding

Funded by Sanofi and Regeneron Pharmaceuticals

4115Effect of alirocumab on recurrent cardiovascular events after acute coronary syndrome, according to the intensity of background statin treatment

Background

Statins are a cornerstone of therapy for coronary heart disease. We describe the effects of alirocumab (ALI) in patients (pts) with recent acute coronary syndrome (ACS) and dyslipidaemia per category of statin use.

Methods

ODYSSEY OUTCOMES compared ALI with placebo (PBO) in 18,924 pts with recent ACS and dyslipidaemia despite high-intensity/maximum tolerated statin (atorvastatin 40–80 mg/d or rosuvastatin 20–40 mg/d). Lower doses could be used if there were symptoms, laboratory abnormalities, or contraindications with higher doses. In cases of documented intolerance to ≥2 statins, pts could qualify on no statin treatment. Pts were randomized to ALI (75 mg SC Q2W, with possible uptitration to 150 mg Q2W) or PBO. Median follow-up was 2.8 years. Primary endpoint was major adverse cardiovascular events (MACE: CHD death, non-fatal MI, ischaemic stroke, or unstable angina requiring hospitalization). Pts were categorized by statin therapy at baseline: high intensity (88.8%), low or moderate intensity (8.7%), or no statin use (2.4%). In each category we determined the relative (hazard ratio [HR]) and absolute risk reductions (ARR) for MACE with ALI.

Results

Overall, ALI reduced MACE (HR 0.85, 95% CI 0.78–0.93; P<0.001). HRs were consistent across statin categories (Table). Baseline LDL-C increased across high-intensity, low/moderate-intensity, and no statin categories. Correspondingly, there was a gradient of the risk of MACE in the PBO group across these categories (10.8%, 10.7%, and 26%). With ALI treatment, the mean reduction in LDL-C from baseline to Month 4 increased across the 3 statin categories and correspondingly the ARRs for MACE were 1.3%, 3.2%, and 8.0% (P interaction <.001).

LDL-C values and MACE events All patients High-intensity statin Low-/moderate-intensity statin No statin Interaction P-value N=18,924 (100%) N=16,811 (88.8%) N=1653 (8.7%) N=460 (2.4%) (treatment x statin category) PBO (N=9462) ALI (N=9462) PBO (N=8431) ALI (N=8380) PBO (N=804) ALI (N=849) PBO (N=227) ALI (N=233) LDL-C at baseline, mmol/L, mean (SE)* 2.39 (0.01) 2.39 (0.01) 2.35 (0.01) 2.35 (0.01) 2.41 (0.03) 2.43 (0.03) 3.76 (0.08) 3.82 (0.08) Change in LDL-C from baseline to Month 4, mmol/L, mean (SE) 0.03 (0.01) −1.4 (0.01) 0.03 (0.01) −1.37 (0.01) 0.01 (0.02) −1.47 (0.02) −0.004 (0.06) −2.27 (0.06) <0.001 MACE, n (%)* 1052 (11.1) 903 (9.5) 907 (10.8) 797 (9.5) 86 (10.7) 64 (7.5) 59 (26.0) 42 (18.0) HR (95% CI) 0.85 (0.78−0.93) 0.88 (0.80−0.96) 0.69 (0.50−0.95) 0.65 (0.43−0.96) 0.14 ARR (%) (95% CI) 1.6 (0.7−2.4) 1.3 (0.3−2.2) 3.2 (0.4−5.9) 8.0 (0.4−15.5) <0.001 *P<0.001 for difference among statin categories.

Conclusions

In ODYSSEY OUTCOMES, patients unable to receive high-intensity statin treatment showed greater ARRs with ALI, consistent with higher baseline LDL-C concentration and greater absolute LDL-C reduction. Patients unable to receive high-intensity statin treatment are an important group to consider for treatment with ALI after ACS.

Acknowledgement/Funding

Funded by Sanofi and Regeneron Pharmaceuticals

4114Efficacy of alirocumab treatment after acute coronary syndrome according to new ACC/AHA guidelines for lipid-lowering therapy

Background

The 2018 ACC/AHA cholesterol management guidelines recommend additional lipid-lowering therapies for secondary prevention in patients with LDL-C ≥1.8 mmol/L despite maximally tolerated statin therapy who are considered “very high-risk” on the basis of history of multiple ischaemic events or an ischaemic event and multiple high-risk conditions.

Purpose

We examined the frequency of major adverse cardiovascular events (MACE) and efficacy of PCSK9 inhibition with alirocumab to reduce MACE in patients with recent acute coronary syndrome (ACS) categorized as very high-risk or not very high-risk by guideline criteria.

Methods

Patients in ODYSSEY OUTCOMES (n=18,924) with recent ACS and residual dyslipidaemia despite optimal statin therapy were randomized to alirocumab or placebo and followed for median 2.8 years. The primary MACE outcome was a composite of coronary heart disease death, non-fatal myocardial infarction (MI), ischaemic stroke, or hospitalization for unstable angina.

Results

Of 18,924 randomized patients, 11,935 (63.1%) were categorized as very high-risk and 6989 (36.9%) as not very high risk (per ACC/AHA guidelines criteria). In the very high-risk category, 4450 (37.3%) had a prior ischaemic event plus the trial-qualifying index ACS (MI, 3633; stroke, 524; peripheral artery disease, 759); 7485 (62.7%) had no ischaemic event before the index ACS but had ≥2 high-risk conditions (diabetes, 3319; age ≥65 years, 3087; current smoking, 2371; chronic kidney disease, 1583). In the placebo group, the incidence of MACE was higher among those in the very high-risk category (14.4%) vs those not at very high-risk (5.6%). Overall, alirocumab reduced the risk of MACE vs placebo (9.5% vs 11.1%, hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.78–0.93; P=0.003), with consistent relative reductions in both risk categories (very high risk HR 0.84, 95% CI 0.76–0.92; not very high risk HR 0.86, 95% CI 0.70–1.06). However, the absolute reduction in MACE with alirocumab was greater among patients classified as very high-risk (2.1%) vs not very high risk (0.8%), and greater in particular among those classified as very high risk based on multiple ischaemic events (2.4%, Figure).

Conclusions

Application of 2018 ACC/AHA cholesterol guidelines criteria accurately identifies patients with ACS and dyslipidaemia who are at very high risk for recurrent MACE, and who derive a large absolute benefit from alirocumab treatment. Patients categorized as very high-risk based upon multiple ischaemic events derive a particularly large absolute benefit from treatment with alirocumab.

Acknowledgement/Funding

Supported by Sanofi and Regeneron Pharmaceuticals

[Characteristics and clinical significance of body composition in gout patients]

Objective: To investigate the characteristics of body composition (BC) in gout patients and its clinical significance. Methods: Consecutive gout patients were recruited between August 2017 and December 2018. Demographic information, clinical characteristics and comorbidities were collected. BC was assessed by bioelectric impedance analysis including body fat percentage (BF%), trunk and limb BF%, appendicular skeletal muscle index. Overfat was defined by BF% ≥25% for male and ≥35% for female. The association between BC and serum uric acid (sUA) was evaluated by multiple linear regression. Results: A total of 362 gout patients were recruited with median age 38 (30, 52) years, 96.1% (348/362) were male. Mean sUA was (551±133) μmol/L. The mean BF% was (25.8±6.4)% with 53.6%(194/362) patients overfat. Male gout patients with overfat showed more affected joints [4(2, 6) vs. 2(2, 5)], higher sUA [(576±126)μmol/L vs. (523±134) μmol/L], higher prevalence of dyslipidemia [70.1%(131/187) vs. 54.0%(87/161)], metabolic syndrome [60.8%(118/187) vs. 28.0%(47/161)], fatty liver [58.2%(113/187) vs. 35.1%(59/161)] and hypertension [44.4%(83/187) vs. 25.5%(41/161)] than male patients with normal fat (all P<0.05). Their BF%, trunk BF% and limb BF% were positively correlated with the numbers of affected joints, sUA, metabolic syndrome, fatty liver, and hypertension, respectively (r=0.154-0.435, all P<0.05). Multivariable linear regression suggested that BF% (β=4.29, P=0.020) and trunk BF% (β=9.11, P=0.007), but not limb BF%, were positively correlated with sUA. Conclusion: Overfat is very common in gout patients. The proportion of trunk fat in male patients is positively correlated with sUA. When assessing obesity in gout patients clinically, body composition analysis should be performed simultaneously.