Long-Term Follow-Up of Outcomes With F-18-Fluorodeoxyglucose Positron Emission Tomography Imaging–Assisted Management of Patients With Severe Left Ventricular Dysfunction Secondary to Coronary Disease

Background—

Whether viability imaging can impact long-term patient outcomes is uncertain. The PARR-2 study (Positron Emission Tomography and Recovery Following Revascularization) showed a nonsignificant trend toward improved outcomes at 1 year using an F-18-fluorodeoxyglucose positron emission tomography (PET)–assisted strategy in patients with suspected ischemic cardiomyopathy. When patients adhered to F-18-fluorodeoxyglucose PET recommendations, outcome benefit was observed. Long-term outcomes of viability imaging–assisted management have not previously been evaluated in a randomized controlled trial.

Methods and Results—

PARR-2 randomized patients with severe left ventricular dysfunction and suspected CAD being considered for revascularization or transplantation to standard care (n= 195) versus PET-assisted management (n=197) at sites participating in long-term follow-up. The predefined primary outcome was time to composite event (cardiac death, myocardial infarction, or cardiac hospitalization). After 5 years, 105 (53%) patients in the PET arm and 111 (57%) in the standard care arm experienced the composite event (hazard ratio for time to composite event =0.82 [95% confidence interval 0.62–1.07]; P =0.15). When only patients who adhered to PET recommendations were included, the hazard ratio for the time to primary outcome was 0.73 (95% confidence interval 0.54–0.99; P =0.042).

Conclusions—

After a 5-year follow-up in patients with left ventricular dysfunction and suspected CAD, overall, PET-assisted management did not significantly reduce cardiac events compared with standard care. However, significant benefits were observed when there was adherence to PET recommendations. PET viability imaging may be best applied when there is likely to be adherence to imaging-based recommendations.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00385242.

Abstract P4-13-12: Everolimus plus trastuzumab and vinorelbine for trastuzumab-resistant, taxane-pretreated, HER2+ advanced breast cancer: Overall survival results from BOLERO-3

Background

PI3K/AKT/mTOR pathway activation due to PTEN loss may lead to trastuzumab (TRAS) resistance. mTOR inhibition has been shown to restore TRAS sensitivity in PTEN-deficient tumors. This provided the rationale for the BOLERO-3 trial which evaluated the combination of everolimus (EVE), an mTOR inhibitor, plus TRAS and a taxane in HER2+ advanced breast cancer (ABC). The addition of EVE to TRAS plus vinorelbine (VNB) led to a statistically significant prolongation of 1.2 months in median progression free survival (PFS) vs TRAS plus VNB in patients with TRAS-resistant and taxane-pretreated, HER2+ ABC (7.0 months vs 5.78 months; hazard ratio, 0.78; p=0.0067). The final overall survival (OS) analysis from this study is presented here.

Materials and methods

BOLERO-3 is a randomized, double-blind, placebo-controlled, phase 3 trial. Women with HER2+ ABC progressing on prior TRAS and taxane therapy were randomized (1:1) to receive either daily EVE (5 mg) or PBO plus weekly TRAS (2 mg/kg) and VNB (25 mg/m2), in 3-week cycles, stratified by previous lapatinib use. The primary endpoint was PFS by local investigator assessment. Overall survival was a key secondary endpoint.

Results

Overall, 569 patients were enrolled; 284 patients received EVE and 285 patients received PBO. As of April 1, 2015, after a median follow-up of 44.7 months, 388 deaths had occurred, 191 (67.3%) in the EVE arm and 197 (69.1%) in the PBO arm. The median OS in the EVE arm vs PBO arm was 23.5 months vs 24.1 months (HR = 0.96; 95% CI, 0.79-1.17; p = 0.3392). In the HR+ subgroup, the median OS with EVE was 23.5 months (vs 25.5 months with PBO; HR = 1.03; 95% CI, 0.79-1.35); in the HR subgroup, the median OS with EVE was 22.9 months (vs 23.1 months with PBO; HR = 0.86; 95% CI, 0.64-1.17). AEs leading to treatment discontinuation were reported in 81 (28.9%) vs 46 (16.3%) patients in the EVE vs PBO arms. Serious adverse events (SAEs) were reported in 122 (43.6%) vs 58 (20.6%) patients in the EVE vs PBO arms. Overall, 14 on-treatment deaths were observed, 7 (2.5%) in the EVE arm and 7 (2.5%) in the PBO arm; on-treatment deaths due to AEs were balanced between treatment arms (0.7% in each treatment arm). Types of post-progression therapies were balanced across both treatment arms.

Conclusions

In BOLERO-3, EVE showed a statistically significant prolongation of PFS. OS was similar in both treatment arms. The safety profile of EVE was comparable to that observed previously with EVE in breast cancer. (Funded by Novartis; BOLERO-3 ClinicalTrials.gov number, NCT01007942.)

Citation Format: Isaacs C, O'Regan R, Xu B, Masuda N, Arena F, Yap Y-S, Papai Z, Lang I, Armstrong A, Lerzo G, White M, Shen K, Zhang Y, Jappe A, Pacaud LB, Taran T, Ozguroglu M. Everolimus plus trastuzumab and vinorelbine for trastuzumab-resistant, taxane-pretreated, HER2+ advanced breast cancer: Overall survival results from BOLERO-3. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-12.

Inflammasome-dependent IL-1β release depends upon membrane permeabilisation

Interleukin-1β (IL-1β) is a critical regulator of the inflammatory response. IL-1β is not secreted through the conventional ER–Golgi route of protein secretion, and to date its mechanism of release has been unknown. Crucially, its secretion depends upon the processing of a precursor form following the activation of the multimolecular inflammasome complex. Using a novel and reversible pharmacological inhibitor of the IL-1β release process, in combination with biochemical, biophysical, and real-time single-cell confocal microscopy with macrophage cells expressing Venus-labelled IL-1β, we have discovered that the secretion of IL-1β after inflammasome activation requires membrane permeabilisation, and occurs in parallel with the death of the secreting cell. Thus, in macrophages the release of IL-1β in response to inflammasome activation appears to be a secretory process independent of nonspecific leakage of proteins during cell death. The mechanism of membrane permeabilisation leading to IL-1β release is distinct from the unconventional secretory mechanism employed by its structural homologues fibroblast growth factor 2 (FGF2) or IL-1α, a process that involves the formation of membrane pores but does not result in cell death. These discoveries reveal key processes at the initiation of an inflammatory response and deliver new insights into the mechanisms of protein release.

Molecular Mechanism Linking BRCA1 Dysfunction to High Grade Serous Epithelial Ovarian Cancers with Peritoneal Permeability and Ascites

Ovarian cancer constitutes the second most common gynecological cancer with a five-year survival rate of 40%. Among the various histotypes associated with hereditary ovarian cancer, high-grade serous epithelial ovarian carcinoma (HGSEOC) is the most predominant and women with inherited mutations in BRCA1 have a lifetime risk of 40-60%. HGSEOC is a challenge for clinical oncologists, due to late presentation of patient, diagnosis and high rate of relapse. Ovarian tumors have a wide range of clinical presentations including development of ascites as a result of deregulated endothelial function thereby causing increased vascular permeability of peritoneal vessels. The molecular mechanisms remain elusive. Studies have shown that fallopian tube cancers develop in women with BRCA1 gene mutations more often than previously suspected. Recent studies suggest that many primary peritoneal cancers and some high-grade serous epithelial ovarian carcinomas actually start in the fallopian tubes. In this article we have addressed the molecular pathway of a recently identified potential biomarker Ubc9 whose deregulated expression due to BRCA1 dysfunction can result in HGSEOC with peritoneal permeability and formation of ascites. We also discuss the role of downstream targets Caveolin-1 and Vascular Endothelial Growth Factor (VEGF) in the pathogenesis of ascites in ovarian carcinomas. Finally we hypothesize a signaling axis between Ubc9 over expression, loss of Caveolin-1 and induction of VEGF in BRCA1 mutant HGSEOC cells. We suggest that Ubc9-mediated stimulation of VEGF as a novel mechanism underlying ovarian cancer aggressiveness and ascites formation. Agents that target Ubc9 and VEGF signaling may represent a novel therapeutic strategy to impede peritoneal growth and spread of HGSEOC.

Variation in the Williams syndrome GTF2I gene and anxiety proneness interactively affect prefrontal cortical response to aversive stimuli

Characterizing the molecular mechanisms underlying the heritability of complex behavioral traits such as human anxiety remains a challenging endeavor for behavioral neuroscience. Copy-number variation (CNV) in the general transcription factor gene, GTF2I, located in the 7q11.23 chromosomal region that is hemideleted in Williams syndrome and duplicated in the 7q11.23 duplication syndrome (Dup7), is associated with gene-dose-dependent anxiety in mouse models and in both Williams syndrome and Dup7. Because of this recent preclinical and clinical identification of a genetic influence on anxiety, we examined whether sequence variation in GTF2I, specifically the single-nucleotide polymorphism rs2527367, interacts with trait and state anxiety to collectively impact neural response to anxiety-laden social stimuli. Two hundred and sixty healthy adults completed the Tridimensional Personality Questionnaire Harm Avoidance (HA) subscale, a trait measure of anxiety proneness, and underwent functional magnetic resonance imaging (fMRI) while matching aversive (fearful or angry) facial identity. We found an interaction between GTF2I allelic variations and HA that affects brain response: in individuals homozygous for the major allele, there was no correlation between HA and whole-brain response to aversive cues, whereas in heterozygotes and individuals homozygous for the minor allele, there was a positive correlation between HA sub-scores and a selective dorsolateral prefrontal cortex (DLPFC) responsivity during the processing of aversive stimuli. These results demonstrate that sequence variation in the GTF2I gene influences the relationship between trait anxiety and brain response to aversive social cues in healthy individuals, supporting a role for this neurogenetic mechanism in anxiety.

Joint analysis of BICEP2/keck array and Planck Data

We report the results of a joint analysis of data from BICEP2/Keck Array and Planck. BICEP2 and Keck Array have observed the same approximately 400  deg^{2} patch of sky centered on RA 0 h, Dec. -57.5°. The combined maps reach a depth of 57 nK deg in Stokes Q and U in a band centered at 150 GHz. Planck has observed the full sky in polarization at seven frequencies from 30 to 353 GHz, but much less deeply in any given region (1.2  μK deg in Q and U at 143 GHz). We detect 150×353 cross-correlation in B modes at high significance. We fit the single- and cross-frequency power spectra at frequencies ≥150  GHz to a lensed-ΛCDM model that includes dust and a possible contribution from inflationary gravitational waves (as parametrized by the tensor-to-scalar ratio r), using a prior on the frequency spectral behavior of polarized dust emission from previous Planck analysis of other regions of the sky. We find strong evidence for dust and no statistically significant evidence for tensor modes. We probe various model variations and extensions, including adding a synchrotron component in combination with lower frequency data, and find that these make little difference to the r constraint. Finally, we present an alternative analysis which is similar to a map-based cleaning of the dust contribution, and show that this gives similar constraints. The final result is expressed as a likelihood curve for r, and yields an upper limit r_{0.05}<0.12 at 95% confidence. Marginalizing over dust and r, lensing B modes are detected at 7.0σ significance.

Safety of sublingual immunotherapy Timothy grass tablet in subjects with allergic rhinitis with or without conjunctivitis and history of asthma

BACKGROUND

Patients with asthma may be more susceptible to adverse events (AEs) with sublingual immunotherapy tablet (SLIT-tablet) treatment, such as severe systemic reactions and asthma-related events. Using data from eight trials of grass SLIT-tablet in subjects with allergic rhinitis with/without conjunctivitis (AR/C), AE frequencies were determined in adults and children with and without reported asthma.

METHODS

Data from randomized, double-blind, placebo-controlled trials of Timothy grass SLIT-tablet MK-7243 (2800 BAU/75 000 SQ-T, Merck/ALK-Abelló) were pooled for post hoc analyses. Subjects with uncontrolled and severe asthma were excluded from the trials. Frequencies for treatment-emergent AEs (TEAEs), local allergic swelling (mouth or throat), systemic allergic reactions, and asthma-related treatment-related AEs (TRAEs) were calculated.

RESULTS

Among adults (n = 3314) and children (n = 881), 24% and 31%, respectively, had reported asthma. No serious local allergic swellings or serious systemic allergic reactions occurred in subjects with asthma treated with SLIT-tablet. There was no evidence of increased TEAEs, systemic allergic reactions, or severe local allergic swellings in adults or children with asthma treated with grass SLIT-tablet versus subjects without asthma in or outside of pollen season. There were 6/120 asthma-related TRAEs assessed as severe with grass SLIT-tablet and 2/60 with placebo, without a consistent trend among subjects with and without asthma (5 and 3 events, respectively).

CONCLUSIONS

In the AR/C subjects with reported well-controlled mild asthma included in these studies, grass SLIT-tablet did not increase TEAE frequency, severe local allergic swelling, or systemic allergic reactions versus subjects without asthma. There was no indication that treatment led to acute asthma worsening.

Effects of agricultural conservation practices on N loads in the Mississippi-atchafalaya river basin

A modeling framework consisting of a farm-scale model, Agricultural Policy Environmental Extender (APEX); a watershed-scale model, Soil and Water Assessment Tool (SWAT); and databases was used in the Conservation Effects Assessment Project to quantify the environmental benefits of conservation practices on cropland. APEX is used to simulate conservation practices on cultivated cropland and Conservation Reserve Program land to assess the edge-of-field water-quality benefits. Flow and pollutant loadings from APEX are input to SWAT. SWAT simulates the remaining noncultivated land and routes flow and loads generated from noncultivated land, point sources, and cropland to the basin outlet. SWAT is used for assessing the effects of practices on local and in-stream water-quality benefits. Each river basin is calibrated and validated for streamflow and loads at multiple gauging stations. The objectives of the current study are to estimate the effects of currently existing and additional conservation practices on total N (TN) loads in the Mississippi-Atchafalaya River Basin (MARB) and draw insights on TN load reductions necessary for reducing the hypoxic zone in the Gulf of Mexico. The effects of conservation practice scenarios on local and in-stream (riverine) water quality are evaluated. Model results indicate that conservation practices currently on cropland have reduced the TN losses to local waters between 20 and 59% in the six river basins within MARB and the TN load discharged to the Gulf by 17%. Further water-quality improvement can be obtained in the MARB with additional conservation treatment.

A pilot randomized control trial to evaluate the feasibility of an Internet-based self-management and transitional care program for youth with haemophilia

Adolescents with haemophilia must assume responsibility for their health and management of their disease. An online self-management program was developed to support adolescents during this transition. To determine the feasibility of the program using a randomized control trial (RCT) design in terms of accrual/attrition rates, willingness to be randomized, compliance with the program/outcome measures and satisfaction. Adolescents, ages 13-18, were enrolled in a pilot RCT (NCT01477437) and randomized to either the intervention (8-week program with telephone coaching) or the control arm (no access to the website, weekly telephone call as attention-strategy). All participants completed pre/post-outcome measures. Twenty-nine teens participated (intervention n = 16, control n = 13). Participants in the intervention arm spent an average of 50 min on the website per week and completed the modules in an average of 14 weeks (SD = 4.9). Attrition was higher in the control group compared to the intervention group (54% vs. 25%). 17/18 (94%) who completed the program also completed the poststudy measures. Teens on the intervention arm showed significant improvement in disease-specific knowledge (P = 0.004), self-efficacy (P = 0.007) and transition preparedness (P = 0.046). There was a statistically significant improvement in knowledge in the intervention group when compared to the control group (P = 0.01). Overall, the teens found the website to be informative, comprehensive and easy to use and were satisfied with the program. This pilot RCT study suggests benefit to the program and indicates an RCT design to be feasible with minor adjustments to the protocol.