Building global development strategies for cf therapeutics during a transitional cftr modulator era

As CFTR modulator therapy transforms the landscape of cystic fibrosis (CF) care, its lack of uniform access across the globe combined with the shift towards a new standard of care creates unique challenges for the development of future CF therapies. The advancement of a full and promising CF therapeutics pipeline remains a necessary priority to ensure maximal clinical benefits for all people with CF. It is through collaboration across the global CF community that we can optimize the evaluation and approval process of new therapies. To this end, we must identify areas for which harmonization is lacking and for which efficiencies can be gained to promote ethical, feasible, and credible study designs amidst the changing CF care landscape. This article summarizes the counsel from core advisors across multiple international regions and clinical trial networks, developed during a one-day workshop in October 2019. The goal of the workshop was to identify, in consideration of the highly transitional era of CFTR modulator availability, the drug development areas for which global alignment is currently uncertain, and paths forward that will enable advancement of CF therapeutic development.

Cardiorespiratory fitness and accelerometer-determined physical activity following one year of free-living high-intensity interval training and moderate-intensity continuous training: a randomized trial

Background

Free-living adherence to high-intensity interval training (HIIT) has not been adequately tested. This randomized trial examined changes in cardiorespiratory fitness (CRF) and accelerometer-measured purposeful physical activity over 12 months of free-living HIIT versus moderate-intensity continuous training (MICT).

Methods

Ninety-nine previously low-active participants with overweight/obesity were randomly assigned to HIIT (n = 47) or MICT (n = 52). Both interventions were combined with evidence-based behaviour change counselling consisting of 7 sessions over 2 weeks. Individuals in HIIT were prescribed 10 X 1-min interval-based exercise 3 times per week (totalling 75 min) whereas individuals in MICT were prescribed 150 min of steady-state exercise per week (50 mins 3 times per week). Using a maximal cycling test to exhaustion with expired gas analyses, CRF was assessed at baseline and after 6 and 12 months of free-living exercise. Moderate-to-vigorous physical activity of 10+ minutes (MVPA10+) was assessed by 7-day accelerometry at baseline, 3, 6, 9, and 12 months. Intention to treat analyses were conducted using linear mixed models.

Results

CRF was improved over the 12 months relative to baseline in both HIIT (+ 0.15 l/min, 95% CI 0.08 to 0.23) and MICT (+ 0.11 l/min, 95% CI 0.05 to 0.18). Both groups improved 12-month MVPA10+ above baseline (HIIT: + 36 min/week, 95% CI 17 to 54; MICT: + 69 min/week, 95% CI 49 to 89) with the increase being greater (by 33 min, 95% CI 6 to 60) in MICT (between group difference, P = 0.018).

Conclusion

Despite being prescribed twice as many minutes of exercise and accumulating significantly more purposeful exercise, CRF improvements were similar across 12 months of free-living HIIT and MICT in previously low-active individuals with overweight/obesity.

Instrumental Color Classification of Honey: Collaborative Study

A collaborative study was carried out to test the use of the Lovibond 2000 honey color comparator. Fourteen collaborators classified 6 honeys in the test. Results were generally favorable and the method has been adopted official first action.

Reproducible Crystallization of Sodium Dodecyl Sulfate·1/8 Hydrate by Evaporation, Antisolvent Addition, and Cooling

Sodium dodecyl sulfate (SDS)·1/8 hydrate (NaC₁₂H₂₅SO₄·1/8H₂O) crystals were successfully produced by evaporation, antisolvent addition, cooling crystallization, and isothermal aging in a common stirred tank. A clear 33.3 wt % SDS aqueous solution was concentrated by evaporation to a 60 wt % coagel consisting of numerous SDS hydrates and water. The coagel was transformed to a clear solution when two times the volume of acetone relative to the water remaining were added. By this fluid property, a controlled crystallization was made possible in a homogeneous solution. Moreover, acetone with a water-to-acetone volume ratio of 1:15 was then added as an antisolvent to induce crystallization of SDS·1/8 hydrate by cubic addition. Finally, cooling crystallization and isothermal aging were carried out to further increase the yields and gave monodispersed particle size. The stability test showed that the produced SDS·1/8 hydrate could be stored at various relative humidity environments for at least 5 days.

Simultaneous Detection of Seven Drugs of Abuse by the TriageTM Panel for Drugs of Abuse

This novel, competitive immunoassay simultaneously detects seven drugs of abuse in urine. A urine sample is placed in contact with lyophilized reagents, the reaction mixture is allowed to come to equilibrium (10 min), and then the whole mixture is applied to a solid phase that contains various immobilized antibodies in discrete drug-class-specific zones. After a washing step, the operator visually examines each zone for the presence of a red bar. The method incorporates present threshold concentrations that are independent for each drug. In the absence of drug or in the presence of drug in quantities less than the threshold concentration, no colored bar is visible. Samples containing drug(s) at or above the threshold concentration cause a red bar to appear for the appropriate drug(s). Positive and negative procedural control zones are incorporated into each determination. The performance of the assay methodology matches that of instrumented immunoassay systems.

Determination of Total Dietary Fiber (CODEX Definition) by Enzymatic-Gravimetric Method and Liquid Chromatography: Collaborative Study

A method for the determination of total dietary fiber (TDF), as defined by the CODEX Alimentarius, was validated in foods. Based upon the principles of AOAC Official MethodsSM 985.29, 991.43, 2001.03, and 2002.02, the method quantitates high- and low-molecular-weight dietary fiber (HMWDF and LMWDF, respectively). In 2007, McCleary described a method of extended enzymatic digestion at 37C to simulate human intestinal digestion followed by gravimetric isolation and quantitation of HMWDF and the use of LC to quantitate low-molecular-weight soluble dietary fiber (LMWSDF). The method thus quantitates the complete range of dietary fiber components from resistant starch (by utilizing the digestion conditions of AOAC Method 2002.02) to digestion resistant oligosaccharides (by incorporating the deionization and LC procedures of AOAC Method 2001.03). The method was evaluated through an AOAC collaborative study. Eighteen laboratories participated with 16 laboratories returning valid assay data for 16 test portions (eight blind duplicates) consisting of samples with a range of traditional dietary fiber, resistant starch, and nondigestible oligosaccharides. The dietary fiber content of the eight test pairs ranged from 11.57 to 47.83. Digestion of samples under the conditions of AOAC Method 2002.02 followed by the isolation and gravimetric procedures of AOAC Methods 985.29 and 991.43 results in quantitation of HMWDF. The filtrate from the quantitation of HMWDF is concentrated, deionized, concentrated again, and analyzed by LC to determine the LMWSDF, i.e., all nondigestible oligosaccharides of degree of polymerization 3. TDF is calculated as the sum of HMWDF and LMWSDF. Repeatability standard deviations (sr) ranged from 0.41 to 1.43, and reproducibility standard deviations (sR) ranged from 1.18 to 5.44. These results are comparable to other official dietary fiber methods, and the method is recommended for adoption as Official First Action.

Rapid Determination of Total trans Fat Content—An Attenuated Total Reflection Infrared Spectroscopy International Collaborative Study

Interest in trans fat labeling has prompted efforts to develop new, more efficient methods for rapidly and accurately determining trans fat content of foods. A novel and rapid (5 min) attenuated total reflection–Fourier transform infrared (ATR–FTIR) spectroscopic procedure was recently developed and applied to food products. This procedure was voted official method AOCS Cd 14d-99 by the American Oil Chemists' Society in 1999 after testing in a 12 laboratory international collaborative study. The results of the study are described in this paper. Analytical ATR–FTIR results exhibited high accuracy in the range 5–40% trans; results tended to have <2% high bias relative to the gravimetrically determined values. The precision of this internal reflection method was found to be superior to the precision of transmission infrared official methods. It is recommended that the applicability of the ATR–FTIR method be limited to trans levels of >5% (as percent of total fat).

Extracorporeal shock wave lithotripsy versus ureteroscopy for management of pediatric nephrolithiasis in upper urinary tract stones: multi-institutional outcomes of efficacy and morbidity

INTRODUCTION

As the incidence of pediatric nephrolithiasis rises, understanding the efficacy and morbidity of surgical treatment options is critical. Currently, there are limited comparative data assessing shock wave lithotripsy (SWL) and ureteroscopy (URS) outcomes in children.

OBJECTIVE

The objective of this study was to compare stone clearance, 30-day emergency department visits, and the number of general anesthetics required per stone treatment for both modalities.

STUDY DESIGN

A multi-institutional retrospective review of children presenting for either URS or SWL between 2000 and 2017 was performed. Stone clearance, need for retreatment, the number of anesthetics, as well as the number and reason for emergency room visit were captured and compared between groups. Multivariate statistical analysis accounting for age, stone location, stone diameter, pre-intervention stent, and provider volume was performed for adjusted analysis.

RESULTS

A total of 84 SWL and 175 URS procedures were included. Complete stone clearance and rates of residual stone fragments <4 mm after final procedure for SWL were 77.0% and 90.8% and for URS were 78.5% and 91.7%, respectively. Retreatment rates for both procedures were not significantly different (17.9% SWL vs. 18.9% URS, P = 0.85). Children who underwent SWL had lower rates of emergency room visits for infections (0% vs. 5.1%, P = 0.03) and flank pain (3.6% vs. 10.9%, P = 0.05) and required fewer general anesthetics per treatment (1.2 vs. 2.0, P < 0.01) than those who underwent URS (Figure).

DISCUSSION

Stone clearance after both the initial and final treatments and need for repeat interventions were similar between surgical modalities. However, SWL carries less morbidity than URS. Specifically, patients who underwent SWL experienced lower rates of ED visits for urinary tract infection and for flank pain, parallel to conclusions in current comparative literature. In addition, SWL requires less general anesthetics (2.0 vs. 1.2), secondary to lower rates of ureteral stent placement and removal. Data on the potential risk of general anesthetics to neurodevelopment support thoughtful utilization of these medications. Limitations of this study include its retrospective nature and the prolonged 20-year time period over which data were collected.

CONCLUSIONS

When adjusting for confounders, SWL and URS achieve similar stone clearance. In the setting of equivalent efficacy, considerations regarding necessity of repeat interventions, morbidity of anesthesia, and complications should be integrated into clinical practice.

P5618Coronary flow capacity to identify stenosis associated with coronary flow improvement after coronary revascularization

Background

Coronary flow capacity (CFC) has recently been introduced as a comprehensive assessment of the coronary circulation by combining coronary flow reserve (CFR) and maximal coronary flow velocity to overcome the limitations of using CFR alone, and was reported to provide enhanced risk stratification compared with CFR. However, its potential to identify stenosis that would be associated with clinically relevant flow coronary flow improvement after revascularization has not been investigated.

Aims

The aim of this study is to quantify coronary flow changes after revascularization in relation to CFC and CFR.

Methods and results

Using a combined dataset of DEFINE FLOW and the Amsterdam UMC prospective ComboWire database, a total of 133 patients (135 vessels) with intermediate coronary artery lesions who underwent intracoronary physiologic assessment including intracoronary Doppler flow measurement before and after PCI were analyzed. The median values of fractional flow reserve (FFR) and CFR before PCI were 0.70 (Q1–3: 0.56–0.80) and 1.64 (Q1–3: 1.30–2.06). The number of lesions classified by CFC before PCI were 14 for normal CFC, 40 for mildly reduced CFC, 33 for moderately reduced CFC and 48 for severely reduced CFC. The lesions with larger impairment of CFC showed greater increase in coronary flow, and vice versa (median percent increase in coronary flow by revascularization: 4.2% for normal CFC; 25.9% for mildly reduced; 50.1% for moderately reduced; 145.5% for severely reduced, P<0.0001). Using the same CFR distribution based on CFC criteria showed that only lesions with severely reduced CFR showed a significantly higher coronary flow increase after PCI (−2.6% for CFR in the normal zone; 26.6% for CFR in the mildly reduced zone; 33.3% for CFR in the moderately reduced zone; 81.7% for CFR in the severely reduced zone, P=0.0007). Compared with the established CFR cut-off value of 2.0, moderate to severely reduced CFC showed higher specificity and positive predictive value (PPV) to predict at least 20% increase in coronary flow after PCI (specificity and PPV: 86.4% and 72.5% for ischemic CFC vs. 75.8% and 40% for CFR cut-off value 2.0). Multivariate logistic regression analysis revealed that the lesions with moderately or severely reduced CFC (odd ratio [OR] = 7.606 95%interconfidence interval [CI]: 2.834–20.412, P<0.001) and pre-PCI FFR (OR=0.0002, 95% CI: 0.0002–0.0204, P<0.001) were the independent predictors of coronary flow increase after PCI.

Conclusion

CFC showed a higher diagnostic efficiency for identification of lesions which benefit from revascularization compared to CFR with respect to coronary flow improvement. This study provides the physiological rational of revascularization for the lesions with moderately to severely reduced CFC from the perspective of coronary flow increase.

Acknowledgement/Funding

Philips Volcano

P6439Clinical outcomes of acute coronary syndrome with intact-fibrous cap plaque at the culprit lesions in diabetic and non-diabetic patients

Background

Previous studies revealed that the morphological substrates of the culprit lesion assessed by optical coherence tomography (OCT) in acute coronary syndrome (ACS), which includes ruptured plaque (RP) and intact fibrous cap (IFC) plaque, are associated with subsequent clinical outcomes. Nevertheless, the impact of culprit morphology on clinical outcomes has not been evaluated in patients with diabetes mellitus (DM), which is one of the major determinants of clinical prognosis.

Purpose

We sought to investigate the association of the culprit lesion morphology with clinical outcomes in patients with DM and those without DM.

Methods

We retrospectively investigated a total of 508 patients with acute myocardial infarction (AMI) experiencing their first episode of ACS in whom OCT-guided, primary percutaneous coronary intervention (PCI) was performed and a culprit lesion was observed by OCT with sufficient image quality. Patients were divided into two groups according to the culprit lesion morphology into patients with RP (RP group) and those without RP (IFC group). The rate of major adverse cardiac events (MACE) including death, myocardial infarction, target or non-target lesion revascularizations were compared between RP and IFC groups in patients with DM (DM) and those without DM (non-DM), separately.

Results

MACE was captured in 80 patients during the median follow-up of 505 (IQR 274–1300) days. In non-DM, RP group showed significantly worse MACE-free rate than in IFC group (Figure), In DM, there was no significant difference between RP and IFC groups (Figure).

Figure 1

Conclusion

Culprit lesion morphology assessed by OCT was not associated with clinical outcomes in DM patients unlike non-DM patients. Distinct strategy for secondary prevention may be required for DM patients.

P5589Patterns of extended apixaban treatment for unprovoked venous thromboembolism in routine clinical practice

Background

Current CHEST guidelines recommend extended anticoagulation therapy without a scheduled stop in patients with unprovoked VTE and low bleeding risk following initial anticoagulation treatment of 3 months. AMPLIFY-EXT suggests that extended treatment with apixaban beyond 6 months reduces the risk of recurrent VTE without increasing major bleeding rates. This study evaluated patterns of extended apixaban treatment among unprovoked VTE patients.

Methods

Utilizing 4 US commercial claims databases, this retrospective study assessed unprovoked VTE patients (VTE events that were not preceded by a provoked factor or event) who initiated apixaban within 30 days from the VTE event (01SEPT2014–31MAR2018). Patients were required to have ≥6 months continuous apixaban treatment (without a gap of >30 days). Characteristics of patients treated beyond 6 months and those who discontinued at 6 months were evaluated respectively. An additional analysis was conducted to assess proportion with apixaban treatment for ≥3 months.

Results

Among unprovoked VTE patients, 60.8% and 34.6% had apixaban treatment for ≥3 and ≥6 months, respectively. Of those treated for ≥6 months (3,015 after applying additional selection criteria), 75.6% continued treatment beyond 6 months and 24.4% discontinued at 6 months. Younger age and having thrombophilia were associated with a higher likelihood of treatment beyond 6 months (Table). Among patients with treatment beyond 6 months, 7.5% of patients switched from apixaban 5mg to 2.5mg, 36.5% discontinued therapy, and 1.1% switched to another oral anticoagulant (Figure).

Baseline characteristics Variables Discontinued at 6 months Continued treatment beyond 6 months P-value N=735 N=2,280 Age, Mean (SD) 63.0 (15.2) 61.7 (14.3) 0.037 Gender – Female, n (%) 307 (41.8%) 892 (39.1%) 0.203 Setting of Unprovoked VTE Event – Ambulatory, n (%) 592 (80.5%) 1,834 (80.4%) 0.950 VTE Diagnosis – DVT Only, n (%) 494 (67.2%) 1,498 (65.7%) 0.452 Deyo-Charlson Comorbidity Index, Mean (SD) 1.3 (1.9) 1.3 (1.8) 0.305 Thrombophilia, n (%) 54 (7.3%) 296 (13.0%) <0.001 Coagulation Defects, n (%) 38 (5.2%) 153 (6.7%) 0.136 Baseline Bleed, n (%) 77 (10.5%) 210 (9.2%) 0.309

KM curve after 6 months of apixaban use

Conclusion

Among unprovoked VTE patients treated with apixaban, a large proportion did not receive ≥3 months of treatment. Although AMPLIFY-EXT showed beneficial effects of extended treatment, the percentage of patients with ≥6 months of treatment was low. Thrombophilia was the only meaningful predictor of treatment beyond 6 months.

Acknowledgement/Funding

This study was funded by Bristol-Myers Squibb and Pfizer Inc

6111Optical coherence tomography derived predictors of restenosis after non-stenting coronary intervention with drug-coated balloon

Background

One of the limitations of metallic stents including contemporary drug eluting stents lies in the permanent existence of metallic materials within the coronary arteries, which may lead to neoatherosclerosis and a long-term use of dual antiplatelet therapy. Some reports have recently suggested the efficacy and safety of non-stent strategy with drug-coated balloon (DCB) angioplasty in combination with debulking devices for de novo lesions. However, little is known about the potential risk of restenosis after percutaneous coronary intervention (PCI) with DCB.

Purpose

We sought to assess the predictive factors of restenosis by optical coherence tomography (OCT) after PCI with DCB instead of metallic stents.

Methods

We retrospectively investigated 49 de novo lesions in 38 patients treated by DCB without stent implantation in whom OCT was performed immediately after PCI and follow-up angiography was performed at median of 5.6 (3.7–6.9) months. OCT findings after PCI and the incidence of restenosis at follow-up angiography were evaluated. By means of OCT images, medial coronary dissection was defined as a dissection which reached the medial layer of the vessel, and major dissection was defined as a dissection with more than 60 degrees of the circumference of the vessel or more than 3mm in length. Restenosis was defined as more than 50% diameter stenosis evaluated by Quantitative Coronary Angiography.

Results

Restenosis was observed in 13 of 49 lesions (27%). In univariate logistic regression analysis, major dissection and medial dissection at the final OCT were associated with restenosis (Odds ratio [OR] 10.0; 95% confidence interval [CI] 2.5–52.6; p<0.01 and OR 5.8; 95% CI 1.5–25.1; p=0.01, respectively). Lesion preparation prior to DCB were performed with rotational atherectomy (n=9), orbital atherectomy (n=2), directional atherectomy (n=4), excimer laser angioplasty (n=17), scoring balloon angioplasty (n=13), or balloon angioplasty (n=4). OCT-defined major dissection remained a significant predictor for restenosis independent of debulking devices used for the preparation (OR 8.1; 95% CI 1.2–70.2; p=0.03).

Conclusions

Major dissection was associated with restenosis after non-stenting PCI with DCB. Stent implantation should be considered in cases of OCT-defined major dissection.

Acknowledgement/Funding

None