Linzagolix therapy versus a placebo in patients with endometriosis-associated pain: a prospective, randomized, double-blind, Phase 3 study (EDELWEISS 3)

STUDY QUESTION

Does linzagolix administered orally once daily for up to 3 months at a dose of 75 mg alone or 200 mg in combination with add-back therapy (ABT) (1.0 mg estradiol; 0.5 mg norethindrone acetate, also known as norethisterone acetate [NETA]) demonstrate better efficacy than placebo in the management of endometriosis-related dysmenorrhea and non-menstrual pelvic pain?

SUMMARY ANSWER

Combining 200 mg linzagolix with ABT was found to significantly reduce dysmenorrhea and non-menstrual pelvic pain at 3 months of therapy, while a daily dose of 75 mg linzagolix yielded a significant decrease only in dysmenorrhea at 3 months.

WHAT IS KNOWN ALREADY?

A previously published Phase 2, dose-finding study reported that at a dose of 200 mg daily, linzagolix promotes full suppression of estradiol secretion to serum levels below 20 pg/ml and noted that the addition of ABT may be needed to manage hypoestrogenic side effects. At lower doses (75 mg and 100 mg/day), linzagolix maintains estradiol values within the target range of 20-60 pg/ml, which could be ideal to alleviate symptoms linked to endometriosis.

STUDY DESIGN, SIZE, DURATION

EDELWEISS 3 was a multicenter, prospective, randomized, placebo-controlled, double-blind, double-dummy Phase 3 study to evaluate the safety and efficacy of linzagolix for the treatment of moderate-to-severe endometriosis-associated pain. Treatment was administered orally once daily for up to 6 months.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In the EDELWEISS 3 trial, 486 subjects with moderate-to-severe endometriosis-associated pain were randomized at a 1:1:1 ratio to one of the three study groups: placebo, 75 mg linzagolix alone or 200 mg linzagolix in association with ABT. Pain was measured daily on a verbal rating scale and recorded in an electronic diary.

MAIN RESULTS AND THE ROLE OF CHANCE

At 3 months, the daily 200 mg linzagolix dose with ABT met the primary efficacy objective, showing clinically meaningful and statistically significant reductions in dysmenorrhea and non-menstrual pelvic pain, with stable or decreased use of analgesics. The proportion of responders for dysmenorrhea in the 200 mg linzagolix with ABT group was 72.9% compared with 23.5% in the placebo group (P < 0.001), while the rates of responders for non-menstrual pelvic pain were 47.3% and 30.9% (P = 0.007), respectively. The 75 mg linzagolix daily dose demonstrated a clinically meaningful and statistically significant reduction in dysmenorrhea versus placebo at 3 months. The proportion of responders for dysmenorrhea in the 75 mg linzagolix group was 44.0% compared with 23.5% in the placebo group (P < 0.001). Although the 75 mg dose showed a trend toward reduction in non-menstrual pelvic pain at 3 months relative to the placebo, it was not statistically significant (P = 0.279). Significant improvements in dyschezia and overall pelvic pain were observed in both linzagolix groups when compared to placebo. Small improvements in dyspareunia scores were observed in both linzagolix groups but they were not significant. In both groups, hypoestrogenic effects were mild, with low rates of hot flushes and bone density loss of <1%. A daily dose of 200 mg linzagolix with ABT or 75 mg linzagolix alone was found to significantly reduce dysmenorrhea and non-menstrual pelvic pain also at 6 months of therapy.

LIMITATIONS, REASONS FOR CAUTION

Efficacy was compared between linzagolix groups and placebo; however, it would be useful to have results from comparative studies with estro-progestogens or progestogens. It will be important to ascertain whether gonadotropin-releasing hormone antagonists have significant benefits over traditional first-line medications.

WIDER IMPLICATIONS OF THE FINDINGS

Linzagolix administered orally once daily at a dose of 200 mg in combination with add-back therapy (ABT) demonstrated better efficacy and safety than placebo in the management of moderate-to-severe endometriosis-associated pain. The quality of life was improved and the risks of bone loss and vasomotor symptoms were minimized due to the ABT. The 75 mg dose alone could be suitable for chronic treatment of endometriosis-associated pain without the need for concomitant hormonal ABT, but further research is needed to confirm this. If confirmed, it would offer a viable option for women who do not want to wish to have ABT or for whom it is contraindicated.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for the EDELWEISS 3 study was provided by ObsEva (Geneva, Switzerland). Analysis of data and manuscript writing were partially supported by ObsEva (Geneva, Switzerland), Theramex (London, UK) and Kissei (Japan) and grant 5/4/150/5 was awarded to M.-M.D. by FNRS. J.D. was a member of the scientific advisory board of ObsEva until August 2022, a member of the scientific advisory board of PregLem, and received personal fees from Gedeon Richter, ObsEva and Theramex. J.D. received consulting fees, speakers' fees, and travel support from Gedeon Richter, Obseva and Theramex, which was paid to their institution. C.B. has received fees from Theramex, Gedeon Richter, and Myovant, and travel support from Gedeon Richter-all funds went to the University of Oxford. He was a member of the data monitoring board supervising the current study, and served at an advisory board for endometriosis studies of Myovant. H.T. has received grants from Abbvie and was past president of ASRM. F.C.H. has received fees from Gedeon Richter and Theramex. O.D. received fees for lectures from Gedeon Richter and ObsEva and research grants for clinical studies from Preglem and ObsEva independent from the current study. A.H. has received grants from NIHR, UKRI, CSO, Wellbeing of Women, and Roche Diagnostics; he has received fees from Theramex. A.H.'s institution has received honoraria for consultancy from Roche Diagnostics, Gesynta, and Joii. M.P. has nothing to declare. F.P. has received fees from Theramex. S.P.R. has been a member of the scientific advisory board of Gedeon Richter and received fees from Gedeon Richter. A.P. and M.B. are employees of Theramex. E.B. was an employee of ObsEva, sponsor chair of the data monitoring board supervising the current study, and has been working as a consultant for Theramex since December 2022; she owns stock options in ObsEva. M.-M.D. has received fees and travel support from Gedeon Richter and Theramex.

TRIAL REGISTRATION NUMBER

NCT03992846.

TRIAL REGISTRATION DATE

20 June 2019.

DATE OF FIRST PATIENT’S ENROLLMENT

13 June 2019.

Biallelic loss-of-function variants of ZFTRAF1 cause neurodevelopmental disorder with microcephaly and hypotonia

PURPOSE

Neurodevelopmental disorders exhibit clinical and genetic heterogeneity, ergo manifest dysfunction in components of diverse cellular pathways; the precise pathomechanism for the majority remains elusive.

METHODS

We studied five affected individuals from three unrelated families manifesting global developmental delay, postnatal microcephaly, and hypotonia. We employed exome sequencing and prioritized variants that were subsequently characterized using immunofluorescence, immunoblotting, pulldown assays, and RNA sequencing.

RESULTS

We identified biallelic variants in ZFTRAF1, encoding a protein of yet unknown function. Four affected individuals from two unrelated families segregated two homozygous frameshift variants in ZFTRAF1, whereas, in the third family, an intronic splice site variant was detected. We investigated ZFTRAF1 at the cellular level and signified it as a nucleocytoplasmic protein in different human cell lines. ZFTRAF1 was completely absent in the fibroblasts of two affected individuals. We also identified 110 interacting proteins enriched in mRNA processing and autophagy-related pathways. Based on profiling of autophagy markers, patient-derived fibroblasts show irregularities in the protein degradation process.

CONCLUSION

Thus, our findings suggest that biallelic variants of ZFTRAF1 cause a severe neurodevelopmental disorder.

Noninvasive minimal residual disease assessment in relapsed/refractory large B-cell lymphoma using digital droplet PCR

Although several promising approaches for the treatment of relapsed/refractory diffuse large B-cell lymphoma (rrDLBCL) have been approved recently, it remains unclear which patients will ultimately achieve long-term responses. Circulating tumor (ct)DNA sequencing has emerged as a valuable tool to assess minimal residual disease (MRD). Correlations between MRD and outcomes have been shown in previously untreated DLBCL, but data on the repeated assessment of MRD in the dynamic course of rrDLBCL is limited. Here, we present an approach leveraging cost- and time-sensitivity of digital droplet (dd)PCR to repeatedly assess MRD in rrDLBCL and present proof-of-principle for its ability to predict outcomes.

Evaluation of mobility recovery after hip fracture: a scoping review of randomized controlled studies

Few older adults regain their pre-fracture mobility after a hip fracture. Intervention studies evaluating effects on gait typically use short clinical tests or in-lab parameters that are often limited to gait speed only. Measurements of mobility in daily life settings exist and should be considered to a greater extent than today. Less than half of hip fracture patients regain their pre-fracture mobility. Mobility recovery is closely linked to health status and quality of life, but there is no comprehensive overview of how gait has been evaluated in intervention studies on hip fracture patients. The purpose was to identify what gait parameters have been used in randomized controlled trials to assess intervention effects on older people's mobility recovery after hip fracture. This scoping review is a secondary paper that identified relevant peer-reviewed and grey literature from 11 databases. After abstract and full-text screening, 24 papers from the original review and 8 from an updated search and manual screening were included. Records were eligible if they included gait parameters in RCTs on hip fracture patients. We included 32 papers from 29 trials (2754 unique participants). Gait parameters were primary endpoint in six studies only. Gait was predominantly evaluated as short walking, with gait speed being most frequently studied. Only five studies reported gait parameters from wearable sensors. Evidence on mobility improvement after interventions in hip fracture patients is largely limited to gait speed as assessed in a controlled setting. The transition from traditional clinical and in-lab to out-of-lab gait assessment is needed to assess effects of interventions on mobility recovery after hip fracture at higher granularity in all aspects of patients' lives, so that optimal care pathways can be defined.

Long-read sequencing identifies a common transposition haplotype predisposing for CLCNKB deletions

BACKGROUND

Long-read sequencing is increasingly used to uncover structural variants in the human genome, both functionally neutral and deleterious. Structural variants occur more frequently in regions with a high homology or repetitive segments, and one rearrangement may predispose to additional events. Bartter syndrome type 3 (BS 3) is a monogenic tubulopathy caused by deleterious variants in the chloride channel gene CLCNKB, a high proportion of these being large gene deletions. Multiplex ligation-dependent probe amplification, the current diagnostic gold standard for this type of mutation, will indicate a simple homozygous gene deletion in biallelic deletion carriers. However, since the phenotypic spectrum of BS 3 is broad even among biallelic deletion carriers, we undertook a more detailed analysis of precise breakpoint regions and genomic structure.

METHODS

Structural variants in 32 BS 3 patients from 29 families and one BS4b patient with CLCNKB deletions were investigated using long-read and synthetic long-read sequencing, as well as targeted long-read sequencing approaches.

RESULTS

We report a ~3 kb duplication of 3'-UTR CLCNKB material transposed to the corresponding locus of the neighbouring CLCNKA gene, also found on ~50 % of alleles in healthy control individuals. This previously unknown common haplotype is significantly enriched in our cohort of patients with CLCNKB deletions (45 of 51 alleles with haplotype information, 2.2 kb and 3.0 kb transposition taken together, p=9.16×10-9). Breakpoint coordinates for the CLCNKB deletion were identifiable in 28 patients, with three being compound heterozygous. In total, eight different alleles were found, one of them a complex rearrangement with three breakpoint regions. Two patients had different CLCNKA/CLCNKB hybrid genes encoding a predicted CLCNKA/CLCNKB hybrid protein with likely residual function.

CONCLUSIONS

The presence of multiple different deletion alleles in our cohort suggests that large CLCNKB gene deletions originated from many independently recurring genomic events clustered in a few hot spots. The uncovered associated sequence transposition haplotype apparently predisposes to these additional events. The spectrum of CLCNKB deletion alleles is broader than expected and likely still incomplete, but represents an obvious candidate for future genotype/phenotype association studies. We suggest a sensitive and cost-efficient approach, consisting of indirect sequence capture and long-read sequencing, to analyse disease-relevant structural variant hotspots in general.

Cross-presenting Langerhans cells are required for the early reactivation of resident CD8+ memory T cells in the epidermis

Tissue-resident memory CD8+ T cells (TRM) reside at sites of previous infection, providing protection against reinfection with the same pathogen. In the skin, TRM patrol the epidermis, where keratinocytes are the entry site for many viral infections. Epidermal TRM react rapidly to cognate antigen encounter with the secretion of cytokines and differentiation into cytotoxic effector cells, constituting a first line of defense against skin reinfection. Despite the important protective role of skin TRM, it has remained unclear, whether their reactivation requires a professional antigen-presenting cell (APC). We show here, using a model system that allows antigen targeting selectively to keratinocytes in a defined area of the skin, that limited antigen expression by keratinocytes results in rapid, antigen-specific reactivation of skin TRM. Our data identify epidermal Langerhans cells that cross-present keratinocyte-derived antigens, as the professional APC indispensable for the early reactivation of TRM in the epidermal layer of the skin.

Global endometrial DNA methylation analysis reveals insights into mQTL regulation and associated endometriosis disease risk and endometrial function

Endometriosis is a leading cause of pain and infertility affecting millions of women globally. Herein, we characterize variation in DNA methylation (DNAm) and its association with menstrual cycle phase, endometriosis, and genetic variants through analysis of genotype data and methylation in endometrial samples from 984 deeply-phenotyped participants. We estimate that 15.4% of the variation in endometriosis is captured by DNAm and identify significant differences in DNAm profiles associated with stage III/IV endometriosis, endometriosis sub-phenotypes and menstrual cycle phase, including opening of the window for embryo implantation. Menstrual cycle phase was a major source of DNAm variation suggesting cellular and hormonally-driven changes across the cycle can regulate genes and pathways responsible for endometrial physiology and function. DNAm quantitative trait locus (mQTL) analysis identified 118,185 independent cis-mQTLs including 51 associated with risk of endometriosis, highlighting candidate genes contributing to disease risk. Our work provides functional evidence for epigenetic targets contributing to endometriosis risk and pathogenesis. Data generated serve as a valuable resource for understanding tissue-specific effects of methylation on endometrial biology in health and disease.

Deformed wing virus of honey bees is inactivated by cold plasma ionized hydrogen peroxide

Deformed wing virus (DWV) is a widespread pathogen of Apis mellifera honey bees, and is considered a major causative factor for the collapse of infected honey bee colonies. DWV can be horizontally transmitted among bees through various oral routes, including via food sharing and by interactions of bees with viral-contaminated solid hive substrates. Cold plasma ionized hydrogen peroxide (iHP) is used extensively by the food production, processing and medical industries to clean surfaces of microbial contaminants. In this study, we investigated the use of iHP to inactivate DWV particles in situ on a solid substrate. iHP-treated DWV sources were ~105-fold less infectious when injected into naïve honey bee pupae compared to DWV receiving no iHP treatment, matching injected controls containing no DWV. iHP treatment also greatly reduced the incidence of overt DWV infections (i.e., pupae having >109 copies of DWV). The level of DWV inactivation achieved with iHP treatment was higher than other means of viral inactivation such as gamma irradiation, and iHP treatment is likely simpler and safer. Treatment of DWV contaminated hive substrates with iHP, even with honey bees present, may be an effective way to decrease the impacts of DWV infection on honey bees.

First Conclusions on Damage Behaviour of Recycled Carbon Staple Fibre Yarn Using X-ray and Acoustic Emission Techniques

This paper presents the first results on the characterisation of the damage behaviour of recycled carbon fibre (rCF) rovings manufactured into unidirectionally (UD) reinforced plates. In the first step, the mechanical properties of several material combinations were determined by mechanical tests (tensile, flexural, compression). This proves the usability of the material for load-bearing structures. For example, a tensile modulus of up to 80 GPa and a tensile strength of 800 MPa were measured. Subsequently, the fracture surface was analysed by scanning electron microscopy (SEM) to characterise the fibre-matrix adhesion and to obtain first indications of possible failure mechanisms. Despite the high mechanical properties, poor fibre-matrix adhesion was found for all matrix systems. In situ X-ray microscopy tests were then performed on smaller specimens under predefined load levels as transverse tensile and bending tests. The results provide further predictions of the failure behaviour and can be compared to the previous test results. The three-dimensional scan reconstruction results were used to visualise the failure behaviour of the staple fibres in order to detect fibre pull-out and fibre or inter-fibre failure and to draw initial conclusions about the damage behaviour in comparison to conventional fibre composites. In particular, a benign failure behaviour in the transverse tensile test was demonstrated with this procedure. In addition, first concepts and tests for the integration of AE analysis into the in situ setup of the X-ray microscope are presented.

Deletion of endothelial leptin receptors in mice promotes diet-induced obesity

Obesity promotes endothelial dysfunction. Endothelial cells not only respond, but possibly actively promote the development of obesity and metabolic dysfunction. Our aim was to characterize the role of endothelial leptin receptors (LepR) for endothelial and whole body metabolism and diet-induced obesity. Mice with tamoxifen-inducible, Tie2.Cre-ER^T2-mediated deletion of LepR in endothelial cells (End.LepR knockout, KO) were fed high-fat diet (HFD) for 16 weeks. Body weight gain, serum leptin levels, visceral adiposity and adipose tissue inflammation were more pronounced in obese End.LepR-KO mice, whereas fasting serum glucose and insulin levels or the extent of hepatic steatosis did not differ. Reduced brain endothelial transcytosis of exogenous leptin, increased food intake and total energy balance were observed in End.LepR-KO mice and accompanied by brain perivascular macrophage accumulation, whereas physical activity, energy expenditure and respiratory exchange rates did not differ. Metabolic flux analysis revealed no changes in the bioenergetic profile of endothelial cells from brain or visceral adipose tissue, but higher glycolysis and mitochondrial respiration rates in those isolated from lungs. Our findings support a role for endothelial LepRs in the transport of leptin into the brain and neuronal control of food intake, and also suggest organ-specific changes in endothelial cell, but not whole-body metabolism.

Temporal disturbance of a model stream ecosystem by high microbial diversity from treated wastewater

Microbial communities in freshwater streams play an essential role in ecosystem functioning via biogeochemical cycling. Yet, the impacts of treated wastewater influx into stream ecosystems on microbial strain diversity remain mostly unexplored. Here, we coupled full‐length 16S ribosomal RNA gene Nanopore sequencing and strain‐resolved metagenomics to investigate the impact of treated wastewater on a mesocosm system (AquaFlow) run with restored river water. Over 10 days, community Bray–Curtis dissimilarities between treated and control mesocosm decreased (0.57 ± 0.058 to 0.26 ± 0.046) based on ribosomal protein S3 gene clustering, finally converging to nearly identical communities. Similarly, strain‐resolved metagenomics revealed a high diversity of bacteria and viruses after the introduction of treated wastewater; these microbes also decreased over time resulting in the same strain clusters in control and treatment at the end of the experiment. Specifically, 39.2% of viral strains detected in all samples were present after the introduction of treated wastewater only. Although bacteria present at low abundance in the treated wastewater introduced additional antibiotic resistance genes, signals of naturally occurring ARG‐encoding organisms resembled the resistome at the endpoint. Our results suggest that the previously stressed freshwater stream and its microbial community are resilient to a substantial introduction of treated wastewater.

Improving ICU Risk Predictive Models Through Automation Designed for Resiliency Against Documentation Bias

OBJECTIVES

Electronic health records enable automated data capture for risk models but may introduce bias. We present the Philips Critical Care Outcome Prediction Model (CCOPM) focused on addressing model features sensitive to data drift to improve benchmarking ICUs on mortality performance.

DESIGN

Retrospective, multicenter study of ICU patients randomized in 3:2 fashion into development and validation cohorts. Generalized additive models (GAM) with features designed to mitigate biases introduced from documentation of admission diagnosis, Glasgow Coma Scale (GCS), and extreme vital signs were developed using clinical features representing the first 24 hours of ICU admission.

SETTING

eICU Research Institute database derived from ICUs participating in the Philips eICU telecritical care program.

PATIENTS

A total of 572,985 adult ICU stays discharged from the hospital between January 1, 2017, and December 31, 2018, were included, yielding 509,586 stays in the final cohort; 305,590 and 203,996 in development and validation cohorts, respectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Model discrimination was compared against Acute Physiology and Chronic Health Evaluation (APACHE) IVa/IVb models on the validation cohort using the area under the receiver operating characteristic (AUROC) curve. Calibration assessed by actual/predicted ratios, calibration-in-the-large statistics, and visual analysis. Performance metrics were further stratified by subgroups of admission diagnosis and ICU characteristics. Historic data from two health systems with abrupt changes in Glasgow Coma Scale (GCS) documentation were assessed in the year prior to and after data shift. CCOPM outperformed APACHE IVa/IVb for ICU mortality (AUROC, 0.925 vs 0.88) and hospital mortality (AUROC, 0.90 vs 0.86). Better calibration performance was also attained among subgroups of different admission diagnoses, ICU types, and over unique ICU-years. The CCOPM provided more stable predictions compared with APACHE IVa within an external cohort of greater than 120,000 patients from two health systems with known changes in GCS documentation.

CONCLUSIONS

These mortality risk models demonstrated excellent performance compared with APACHE while appearing to mitigate bias introduced through major shifts in GCS documentation at two large health systems. This provides evidence to support using automated capture rather than trained personnel for capture of GCS data used in benchmarking ICUs on mortality performance.

Performance and Usability Evaluation of Brainwave Authentication Techniques with Consumer Devices

Brainwaves have demonstrated to be unique enough across individuals to be useful as biometrics. They also provide promising advantages over traditional means of authentication, such as resistance to external observability, revocability, and intrinsic liveness detection. However, most of the research so far has been conducted with expensive, bulky, medical-grade helmets, which offer limited applicability for everyday usage. With the aim to bring brainwave authentication and its benefits closer to real world deployment, we investigate brain biometrics with consumer devices. We conduct a comprehensive measurement experiment and user study that compare five authentication tasks on a user sample up to 10 times larger than those from previous studies, introducing three novel techniques based on cognitive semantic processing. Furthermore, we apply our analysis on high-quality open brainwave data obtained with a medical-grade headset, to assess the differences. We investigate both the performance, security, and usability of the different options and use this evidence to elicit design and research recommendations. Our results show that it is possible to achieve Equal Error Rates as low as 7.2% (a reduction between 68-72% with respect to existing approaches) based on brain responses to images with current inexpensive technology. We show that the common practice of testing authentication systems only with known attacker data is unrealistic and may lead to overly optimistic evaluations. With regard to adoption, users call for simpler devices, faster authentication, and better privacy.

Estimating Prevalence and Characteristics of Statin Intolerance among High and Very High Cardiovascular Risk Patients in Germany (2017 to 2020)

Statin intolerance (SI) (partial and absolute) could lead to suboptimal lipid management. The lack of a widely accepted definition of SI results into poor understanding of patient profiles and characteristics. This study aims to estimate SI and better understand patient characteristics, as reflected in clinical practice in Germany using supervised machine learning (ML) techniques. This retrospective cohort study utilized patient records from an outpatient setting in Germany in the IQVIA™ Disease Analyzer. Patients with a high cardiovascular risk, atherosclerotic cardiovascular disease, or hypercholesterolemia, and those on lipid-lowering therapies between 2017 and 2020 were included, and categorized as having “absolute” or “partial” SI. ML techniques were applied to calibrate prevalence estimates, derived from different rules and levels of confidence (high and low). The study included 292,603 patients, 6.4% and 2.8% had with high confidence absolute and partial SI, respectively. After deploying ML, SI prevalence increased approximately by 27% and 57% (p < 0.00001) in absolute and partial SI, respectively, eliciting a maximum estimate of 12.5% SI with high confidence. The use of advanced analytics to provide a complementary perspective to current prevalence estimates may inform the identification, optimal treatment, and pragmatic, patient-centered management of SI in Germany.

Protease- and cell type-specific activation of protease-activated receptor 2 in cutaneous inflammation

BACKGROUND

Protease-activated receptor 2 (PAR2) signaling controls skin barrier function and inflammation, but the roles of immune cells and PAR2-activating proteases in cutaneous diseases are poorly understood.

OBJECTIVE

To dissect PAR2 signaling contributions to skin inflammation with new genetic and pharmacological tools.

METHODS/RESULTS

We found markedly increased numbers of PAR2+ infiltrating myeloid cells in skin lesions of allergic contact dermatitis (ACD) patients and in the skin of contact hypersensitivity (CHS) in mice, a murine ACD model for T cell-mediated allergic skin inflammation. Cell type-specific deletion of PAR2 in myeloid immune cells as well as mutation-induced complete PAR2 cleavage insensitivity significantly reduced skin inflammation and hapten-specific Tc1/Th1 cell response. Pharmacological approaches identified individual proteases involved in PAR2 cleavage and demonstrated a pivotal role of tissue factor (TF) and coagulation factor Xa (FXa) as upstream activators of PAR2 in both the induction and effector phase of CHS. PAR2 mutant mouse strains with differential cleavage sensitivity for FXa versus skin epithelial cell-expressed proteases furthermore uncovered a time-dependent regulation of CHS development with an important function of FXa-induced PAR2 activation during the late phase of skin inflammation.

CONCLUSIONS

Myeloid cells and the TF-FXa-PAR2 axis are key mediators and potential therapeutic targets in inflammatory skin diseases.

Simulation study on LDL cholesterol target attainment, treatment costs, and ASCVD events with bempedoic acid in patients at high and very-high cardiovascular risk

BACKGROUND AND AIMS

The LDL cholesterol (LDL-C) treatment goals recommended by the 2019 ESC/EAS guidelines are only achieved in a minority of patients. The study objective was to estimate the impact of bempedoic acid treatment on LDL-C target attainment, drug costs, and atherosclerotic cardiovascular disease (ASCVD) events. The simulation used a Monte Carlo approach in a representative cohort of German outpatients at high or very-high cardiovascular risk. Additionally to statins, consecutive treatment with ezetimibe, bempedoic acid, and a PCSK9 inhibitor was simulated in patients not achieving their LDL-C goal. Considered were scenarios without and with bempedoic acid (where bempedoic acid was replaced by a PCSK9 inhibitor when LDL-C was not controlled).

RESULTS

The simulation cohort consisted of 105,577 patients, of whom 76,900 had very-high and 28,677 high cardiovascular risk. At baseline, 11.2% of patients achieved their risk-based LDL-C target. Sequential addition of ezetimibe and bempedoic acid resulted in target LDL-C in 33.1% and 61.9%, respectively. Treatment with bempedoic acid reduced the need for a PCSK9 inhibitor from 66.6% to 37.8% and reduced drug costs by 35.9% per year on stable lipid-lowering medication. Compared to using only statins and ezetimibe, this approach is projected to prevent additional 6,148 ASCVD events annually per 1 million patients, whereas PCSK9 inhibition alone would prevent 7,939 additional ASCVD events annually.

CONCLUSIONS

A considerably larger proportion of cardiovascular high- and very-high-risk patients can achieve guideline-recommended LDL-C goals with escalated lipid-lowering medication. Bempedoic acid is projected to substantially decrease the need for PCSK9 inhibitor treatment to achieve LDL-C targets, associated with reduced drug costs albeit with fewer prevented events.

Estimating prevalence and characteristics of statin intolerance among high and very high cardiovascular risk patients in Germany between 2017–2020

Background

Statins remain the backbone of lipid management. Nevertheless, the degree to which statins can be used and dosed in clinical practice remains a great challenge, also due to statin intolerance (SI). The lack of widely accepted SI definition leads to poor understanding of the condition and SI patient profile

Purpose

To estimate the current SI prevalence and understand better the patient characteristics, using machine learning techniques

Methods

Retrospective cohort study, based on representative sample of electronic patient records from outpatient setting in Germany. Patients were included if they had high CV risk, atherosclerotic cardiovascular disease (ASCVD) or hypercholesterolemia (HC), between 2017 and 2020. Patients were categorized as having “absolute” (history of SI events and permanent statin discontinuation) or “partial” (history of SI events while treated with statins) SI. Machine learning techniques were utilized to calibrate the prevalence estimates and to identify patient clusters. Estimates of SI prevalence were derived based on different rules and confidence levels (high, moderate and low). The low confidence estimates contain the most uncertainty in identifying SI

Results

The study population consisted of 292,603 patients (57.3% aged &gt;70 years; 55.6% male). Of these, ∼24% had high CV risk, ∼56% had ASCVD, and ∼20% had HC. After deploying machine learning, the SI identification improved by ∼27% in absolute SI and by ∼57% in partial SI patients, resulting in a maximum estimate of 12.5% SI with high/moderate confidence and further 11.8% with low confidence (absolute SI 15.8%, partial SI 8.5%). The low confidence group may contain patients with insufficient statin treatment due to reasons other than SI (e.g. clinical inertia). Statistically significant risk factors for SI were hypothyroidism, vitamin D deficiency, liver and chronic kidney disease. Cramps, muscle spasms, myalgia and myopathy were the most common statin associated muscle symptoms (SAMS) observed in the SI population. Atorvastatin 40mg was the most frequently down-titrated statin, while simvastatin to atorvastatin was the most predominant class switch in SI patients. Machine learning techniques applied on high confidence SI patients characteristics and the most commonly observed cluster for patients over 60 years showed predominant musculoskeletal disorders, concomitant high SAMS incidence and high use of multiple statins. In males under 60 years, depression and somatoform disorders along with musculoskeletal disorders, pain, and gastric events were common, while females under 60 years had predominant depressive episodes, along with musculoskeletal, mental, and metabolic disorders

Conclusion

Addressing the complexity in defining SI using advanced analytics, this study provides prevalence estimates and describes distinct patients clusters that may inform diagnosis and optimal treatment pathways for SI patients in Germany

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH

Simulation study on LDL cholesterol target attainment, ASCVD events, and treatment cost of bempedoic acid in a representative German cohort of high- and very-high-CV risk patients

Background

The LDL cholesterol (LDL-C) treatment goals recommended by the 2019 ESC/EAS guidelines are only achieved in a minority of patients. For patients above goal despite statins and ezetimibe, additional LDL-C lowering can be achieved by treatment with bempedoic acid (BA) or PCSK9 inhibitors (PCSK9i).

Purpose

Simulation of LDL-C target attainment with BA as additional lipid-lowering medication in a representative cohort of German outpatients at high or very-high cardiovascular (CV) risk, calculation of the number of prevented atherosclerotic cardiovascular disease (ASCVD) events and budget impact.

Methods

Data were obtained from IQVIA™ Disease Analyzer database containing a representative sample of German outpatients. We selected patients with high or very-high CV risk (based on ESC/EAS guidelines), diagnosed hypercholesterolaemia and treatment with lipid-lowering medication. In patients with uncontrolled LDL-C, sequentially adding ezetimibe and BA was simulated using a Monte Carlo approach. Drug costs to control LDL-C by adding BA vs. PCSK9i were calculated based on current pricing in Germany. Considered were a scenario without BA and one with BA, in which BA was replaced by PCSK9i if LDL-C was still not controlled. The number of prevented events was calculated based on simulated LDL-C reduction.

Results

105,577 patients met the inclusion criteria and entered the simulation model. 76,900 patients had very-high and 28,677 high CV risk. The baseline characteristics are depicted in Table 1. Only a minority of total patients (11.2%) achieved their risk-based LDL-C goal. Simulation of the sequential addition of ezetimibe to statins resulted in controlled LDL-C in 33.1% of total patients. Simulated addition of BA in patients with uncontrolled LDL-C despite statin and ezetimibe increased the percentage of controlled patients to 61.9% of total. The proportion of patients achieving LDL-C goals was higher in high- compared to very-high risk patients (Figure 1). Treatment with BA reduced the need for PCSK9i in patients on statin and ezetimibe from 66.6% to 37.8%. The considered scenario resulted in an anticipated reduction of drug costs by 35.9% per year on stable lipid-lowering medication. This effect was more pronounced in high-risk compared to very-high-risk patients (cost reductions of 40.6% and 34.4%, respectively). In this simulation model, the BA/PCSK9i strategy is projected to prevent 6,148 ASCVD events annually per 1 million patients on top of statin+ezetimibe, whereas LDL-C target achievement with PCSK9i alone would prevent 7,939 events.

Conclusions

A considerable larger proportion of high- and very-high-risk patients can achieve guideline-recommended LDL-C targets with escalated lipid-lowering medication. BA is projected to substantially decrease the need for PCSK9i treatment to achieve LDL-C targets which reduces drug costs compared to PCSK9i. LDL-C target attainment is projected to markedly reduce ASCVD events.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Deutschland GmbH

Microbial community profiling by next-generation DNA sequencing of adenocarcinoma of the prostate with evidence of ochratoxin A producing fungi

BACKGROUND

Prostatic carcinomas are a leading cancer and leading cause of mortality in the developed world. The etiology is diverse with underlying patient genetics, environmental factors, and microbial associations. Sequencing DNA for microbes allows the detection of potential disease relationships.

OBJECTIVE

Targeted 16S (prokaryotic) and 18S (eukaryotic) rDNA sequencing was performed to map the tumor microbial flora.

DESIGN

Twelve patients undergoing elective laparoscopic prostatectomy for biopsy proven adenocarcinoma of the prostate were enrolled. PCR and amplicon based sequencing was conducted; a portion of the sequencing results were confirmed by special stains.

SETTING

Patients were recruited by the urologist were prospectively scheduled for radical prostatectomy by 'Da Vinci' robotically assisted procedure in an outpatient setting. Samples were portioned in the hospital surgical suite at the time of prostatectomy.

PARTICIPANTS

Male patients were requested to enter the study on a first come basis.

OUTCOME MEASUREMENT AND STATISTICAL ANALYSIS

Average age of the 12 participants was 64.3 years.

RESULTS AND LIMITATIONS

DNA reads were detected and by 'best match' were identified belonging to Perkinsus, Hydrurus, Diversispora and Funneliformis genera, few samples displayed bacteria. Out of the 12 total patients, 11 patients had detectable DNA sequences matching arbuscular mycorrhizal fungi in the Glomeromycetes Class; Funneliformis mosseae and Diversasporum versiformis. Specific PCR for arbuscular mycorrhizal fungi failed to confirm Glomeromycetes Class; in-depth taxonomic analysis suggests a newer fungal grouping, not falling within an accepted Phylum of fungi. Calcoflour white staining of histological sections confirmed potential fungal markers in all 12 cases. Ochratoxin A antigen was identified by immunofluorescence in all 12 patient samples. The study was limited by the low sample volume and disease free normal controls.

CONCLUSIONS

Fungi may play a significant role in adenocarcinoma of the prostate.

CortexVR: Immersive analysis and training of cognitive executive functions of soccer players using virtual reality and machine learning

Goal

This paper presents an immersive Virtual Reality (VR) system to analyze and train Executive Functions (EFs) of soccer players. EFs are important cognitive functions for athletes. They are a relevant quality that distinguishes amateurs from professionals.

Method

The system is based on immersive technology, hence, the user interacts naturally and experiences a training session in a virtual world. The proposed system has a modular design supporting the extension of various so-called game modes. Game modes combine selected game mechanics with specific simulation content to target particular training aspects. The system architecture decouples selection/parameterization and analysis of training sessions via a coaching app from an Unity3D-based VR simulation core. Monitoring of user performance and progress is recorded by a database that sends the necessary feedback to the coaching app for analysis.

Results

The system is tested for VR-critical performance criteria to reveal the usefulness of a new interaction paradigm in the cognitive training and analysis of EFs. Subjective ratings for overall usability show that the design as VR application enhances the user experience compared to a traditional desktop app; whereas the new, unfamiliar interaction paradigm does not negatively impact the effort for using the application.

Conclusion

The system can provide immersive training of EF in a fully virtual environment, eliminating potential distraction. It further provides an easy-to-use analyzes tool to compare user but also an automatic, adaptive training mode.

Full-Length Spatial Transcriptomics Reveals the Unexplored Isoform Diversity of the Myocardium Post-MI

We introduce Single-cell Nanopore Spatial Transcriptomics (scNaST), a software suite to facilitate the analysis of spatial gene expression from second- and third-generation sequencing, allowing to generate a full-length near-single-cell transcriptional landscape of the tissue microenvironment. Taking advantage of the Visium Spatial platform, we adapted a strategy recently developed to assign barcodes to long-read single-cell sequencing data for spatial capture technology. Here, we demonstrate our workflow using four short axis sections of the mouse heart following myocardial infarction. We constructed a de novo transcriptome using long-read data, and successfully assigned 19,794 transcript isoforms in total, including clinically-relevant, but yet uncharacterized modes of transcription, such as intron retention or antisense overlapping transcription. We showed a higher transcriptome complexity in the healthy regions, and identified intron retention as a mode of transcription associated with the infarct area. Our data revealed a clear regional isoform switching among differentially used transcripts for genes involved in cardiac muscle contraction and tissue morphogenesis. Molecular signatures involved in cardiac remodeling integrated with morphological context may support the development of new therapeutics towards the treatment of heart failure and the reduction of cardiac complications.

O-305 SPIRIT long-term extension study: two-year efficacy and safety of relugolix combination therapy in women with endometriosis-associated pain

Study question

To assess the long-term efficacy and safety of once-daily Relugolix combination therapy (Relugolix-CT) in the treatment of endometriosis-associated pain over two years.

Summary answer

Relugolix-CT previously demonstrated sustained improvement of endometriosis-associated pain and was generally well tolerated over 52 weeks. Research is ongoing: two-year results will be reported.

What is known already

SPIRIT 1&2 were international, Phase 3, replicate, randomized, double-blind, placebo-controlled studies of Relugolix-CT (relugolix 40mg, estradiol 1mg, norethisterone acetate 0.5mg) in premenopausal women with moderate-to-severe endometriosis-associated pain, which were followed by the open-label, 80-week, long-term extension. 52-week results showed sustained improvement in dysmenorrhea and non-menstrual pelvic pain (NMPP) with 84.8% and 73.3% of responders, respectively. Efficacy was evidenced by reductions in dysmenorrhea (82.8%,) NMPP (62.9%,) proportion of women using opioids, and improvements in function. Relugolix-CT was generally well tolerated. Bone mineral density (BMD) assessment showed minimal initial decline (&lt;1%) from baseline followed by stabilization from Week 24 to 52.

Study design, size, duration

Women who completed the 24-week pivotal studies (SPIRIT 1&2) were eligible to enroll in an 80-week open-label, single-arm, long-term extension study of safety and efficacy, representing up to 104 weeks of treatment in total. All women enrolled in the long-term extension study received once-daily oral Relugolix-CT. Analyses were performed based on the initial randomized treatment groups in pivotal studies: Relugolix-CT, delayed Relugolix-CT (relugolix 40mg alone for 12 weeks, then Relugolix-CT for 12 weeks), or placebo.

Participants/materials, setting, methods

Primary endpoints are proportion of dysmenorrhea and NMPP responders at Weeks 52 and 104 based on daily Numerical Rating Scale (NRS) scores (0=no pain, 10=worst pain imaginable) and analgesic use. Responders are women who achieved a predefined, clinically meaningful reduction from baseline in NRS score and no increase in analgesic use. Secondary efficacy endpoints include change in Endometriosis Health Profile-30 pain domain scores, use of opioids/analgesics. Safety endpoints include adverse events and BMD (percent change).

Main results and the role of chance

Of 1251 randomized patients in SPIRIT 1&2, 1044 (83.4%) completed the pivotal studies; 802 (76.8%) enrolled in the long-term extension, and 681 (84.9%) completed 52 weeks of treatment. Baseline demographics and clinical characteristics of the long-term extension population were consistent with those of the pivotal study population. The study remains ongoing at the time of writing. Efficacy and safety data with Relugolix-CT for up to Week 104, will be presented at the scientific session of the 2022 congress.

Limitations, reasons for caution

The study was conducted as an open-label study without a control group over the 80 weeks of the extension period.

Wider implications of the findings

Through 52 weeks of treatment, Relugolix-CT demonstrated sustained improvement of dysmenorrhea, NMPP, function, and reduced need for opiates in women with endometriosis-associated pain. No new safety concerns were identified, and treatment was associated with BMD loss &lt;1%. Data from 104 weeks of treatment will be presented at the 2022 congress.

Trial registration number

NCT03654274

O-027 Small extracellular vesicle (sEV) protein cargo as potential biomarker for endometriosis

Study question

Can an endometriosis-specific protein signature in small extracellular vesicles (sEV) from peritoneal fluid (PF) be utilised as a non-invasive biomarker of the condition?

Summary answer

Yes, potentially. We found differences in the concentrations and protein cargo of PF-derived sEV between controls and endometriosis samples, most notably in CD44 expression.

What is known already

Endometriosis, defined as endometrial-like tissue outside the uterus, causes pain and/or subfertility in 10% of reproductive age women. The cause is unknown, resulting in inadequate diagnostic methods and treatment options. There is no clinically relevant biomarker for endometriosis yet. Small extracellular vesicles (sEV), produced by virtually every cell, have been described in diseases such as cancer, diabetes, and pre-eclampsia, and could similarly be important in endometriosis. We previously identified sEV in PF of women with endometriosis, and here investigated the protein cargo of PF sEV as biomarker of the disease.

Study design, size, duration

PF samples were obtained from participants in the ENDOX study, Endometriosis CaRe Centre, Nuffield Department of Women’s and Reproductive Health, University of Oxford (REC ref. 09/H0604/58) according to WERF EPHect standards. Women between 18-49 years of age (n = 63) who had undergone diagnostic laparoscopy were classified according to cycle phase (proliferative/secretory/menstrual) and severity of endometriosis (ASRM stages I+II or stages III+IV). Exclusion criteria were hormonal treatment, malignancy, pregnancy, breastfeeding, and inability to understand the consent form.

Participants/materials, setting, methods

The participant groups were control proliferative, n = 7; control secretory, n = 9; control menstrual, n = 3; StI+II proliferative, n = 8; StI+II secretory, n = 10; St1+II menstrual, n = 7; StIII+IV proliferative, n = 5; StIII+IV secretory, n = 11; StIII+IV menstrual, n = 3. 1 mL PF was centrifuged to remove cells, debris, and microvesicles. sEV were isolated using size exclusion chromatography (SEC) and analysed by nanoparticle tracking analysis (NTA), immunoblotting, and mass spectrometry (LC-MS/MS).

Main results and the role of chance

We confirmed the presence of exosomes in PF from women at different stages of endometriosis and from disease-free patients at different menstrual cycle phases by NTA, immunoblotting and mass spectrometry. Enriched sEV were positive for ALIX, CD9, and syntenin. The mode size of PF particles from women with endometriosis was 115 ± 15.5 nm, whereas in non-endometriotic women it was 95 ± 17.3 nm (n.s.). sEV concentrations were higher in endometriosis compared to controls, and highest in stage III-IV endometriosis, followed by stage I-II endometriosis and controls, irrespective of menstrual cycle phase (P = 0.0210). sEV concentration in stage III-IV endometriosis decreased consistent with a transition from proliferative to secretory phase. Likewise, PF-derived sEV numbers within stage I-II endometriosis samples increased, as these samples transitioned from proliferative to secretory cycle phases. Proteomic analysis showed distinct distribution patterns of proteins within endometriosis PF-derived sEVs compared to controls. Consistent with earlier studies, we found CD44 as an sEV protein uniquely within the endometriosis population and contributing significantly to the separation of endometriosis and control samples by the highest variable importance projection (VIP) score in our data set.

Limitations, reasons for caution

The main limitation of this study is the small number of samples across the different groups, and the limited amount of PF per sample.

Wider implications of the findings

PF-derived sEV differ between endometriosis and control patients. Concentrations vary regardless of cycle phase and disease stage, and this difference appears to be reflected in the proteomics analysis. The presence of CD44 within sEV could help diagnose endometriosis.

Trial registration number

not applicable

O-178 Timed intercourse for couples trying to conceive: an updated Cochrane systematic review and meta-analysis

Study question

Does timing intercourse around the ‘fertile window’ using ovulation detection methods increase the chance of pregnancy in couples trying to conceive?

Summary answer

This update suggests that timed intercourse using urinary ovulation detection may increase the chances of pregnancy in couples trying to conceive. 

What is known already

Development of health apps has surged, with many tracking menstrual cycles, generating ‘fertile window’ predictions for couples hoping to conceive as well as avoid pregnancy. Adjuncts have been marketed to improve the accuracy of ovulation detection, using LH/oestrogen urinary tests and fertility-based awareness method (FAMB) biosensors. These may all influence sexual behaviours, making timed intercourse more widely practiced. Thus, there is an increased need for clinicians and couples to understand the effectiveness of these methods and potential adverse effects such as stress.

Study design, size, duration

A Cochrane systematic review and meta-analysis was performed. The Cochrane Gynaecology and Fertility (CGF) Group trials register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO were searched in January 2022 to identify relevant randomised controlled trials (RCTs). In addition, relevant references lists were checked, and study authors were contacted to obtain unpublished data. 

Participants/materials, setting, methods

Participants: Couples (fertile and subfertile) trying to conceive.

Intervention: Timed intercourse using ovulation detection methods such as digital apps, LH/oestrogen urine ovulation tests, and FABM.

Comparison: Intercourse not timed around the ‘fertile window’.

Two independent authors screened studies and extracted data. Risk ratios (RR) were calculated for dichotomous data and mean differences (MD) for continuous data, with 95% confidence intervals (CI). Heterogeneity was examined via the I² statistic. 

Main results and the role of chance

In this update, 881 references were screened. Six studies were included, involving 2,374 women. 

We are uncertain whether timed intercourse using FAMB resulted in a difference in live birth (RR 0.92, 95%CI 0.73 to 1.16, I²= 0%, 2 studies, 160 women: low-certainty evidence). No other studies reported live birth. We are uncertain whether timed intercourse using FAMB resulted in a difference in clinical or self-reported pregnancy (RR 0.96, 95% CI 0.8 to 1.15, I²=0, 2 studies, 160 women; low-certainty evidence). However, timed intercourse using urinary ovulation detection was associated with higher clinical or self-reported pregnancy (RR 1.28, 95% CI 1.10 to 1.50, I²=0, four studies, 2214 women; moderate-certainty evidence). This suggested that if the chance of a clinical or self-reported pregnancy following intercourse without ovulation prediction is assumed 18%, the chance following timed intercourse with urinary ovulation detection would be 20% to 28%. Subgroup analysis of all ovulation detection methods showed no difference between couples trying to conceive for under 12 months versus couples trying for over 12 months (subfertile). Finally, we are uncertain whether timed intercourse using urinary ovulation detection resulted in a difference in stress (MD 1.98, 95 CI% -0.87 to 4.83, 1 study, 77 women, low-certainty evidence). 

Limitations, reasons for caution

Insufficient studies reported our specified outcomes including live birth (primary outcome), time to pregnancy, stress, and quality of life. Moreover, there were insufficient studies with large sample sizes assessing FABM, a key method used in timed intercourse and fertility apps.

Wider implications of the findings

This update provides evidence for the practice of timed intercourse using urinary ovulation detection. However, the majority of menstrual cycle apps use FABM for which there is currently insufficient evidence to support the use of when trying to conceive. This review highlights key areas where future research should be conducted. 

Trial registration number

not applicable

P-313 The Cyprus women’s health research (COHERE) initiative: estimating the prevalence, symptomatology, associated risk factors and economic burden of endometriosis in an Eastern Mediterranean population

Study question

In this previous undescribed population of women, what is the prevalence of endometriosis and associated symptomatology, and how are women affected?

Summary answer

Prevalence of endometriosis was 5.4% (95%CI; 4.9%-5.9%). Cases suffered from worse physical health, higher use of pain medication and decreased productivity at work.

What is known already

There is a lack of population level data on prevalence and distribution of women’s health conditions, such as endometriosis, from the Eastern Mediterranean region, despite their known negative effects on quality of life. In addition, there is a complete absence of any health statistics from Northern Cyprus, an emerging region in Europe. Most current endometriosis research comes from Western populations and is not generalisable to non-Western populations due to differences in culture, lifestyle, and care seeking patterns. Therefore, it is important to investigate endometriosis in a variety of settings.

Study design, size, duration

The COHERE Initiative is a cross-sectional, population-based study that recruited 7,646 women between the ages 18-55 residing in Northern Cyprus between January 31st 2018, and January 31st 2020. Recruitment took place face-to-face (90%) and online (10%). Participants completed an expanded version of the WERF Endometriosis Phenome and Biobanking Harmonisation Project (EPHect) questionnaire, consisting of previously validated measurement instruments, such as the Short-Form-36-version-2 questionnaire (SF-36v2) and the Work Productivity and Impairment Questionnaire: General Health (WPAI:GH).

Participants/materials, setting, methods

Endometriosis cases were defined using a combination of self-reported and pelvic ultrasound data. Controls were women without endometriosis. Chi-square, Fisher’s exact test, Student’s t-test, linear regression, and multivariable logistic regression were used for data analysis. The significance level was set at p &lt; 0.05.

Main results and the role of chance

Endometriosis prevalence was 5.4% (95%CI; 4.9%-5.9%;n=410). The mean age women with endometriosis reported to first experience related-symptoms was 25.9-years, despite average age of first menstrual-pain occurring at 16.2-years. Average age of first gynaecologist visit was 21.0-years and endometriosis diagnostic-delay was 1.5-years. Physical health-related-quality-of-life was lower in women with endometriosis compared to those without (48.4 vs 50.2, p = 0.001). Cases had a higher mean percentage of activity impairment (25.8% vs 22.5%, p = 0.03) and reduced effectiveness whilst working (23.4% vs 19.5%, p = 0.006) than controls. Hormone-use was higher in women with endometriosis compared to controls for heavy-bleeding (5.9% vs 1.4%, p &lt; 0.001), irregular periods (14.4% vs 7.2%, p &lt; 0.001) and pelvic-pain (9.3% vs 1.7%, p &lt; 0.001), though overall hormone use was low at 24.1%. Iron and vitamin-D deficiency were the most reported co-morbidities, and these proportions were significantly different from women without endometriosis (38.8% vs 28.3%, 23.9% vs 17.0% respectively, p &lt; 0.001). Migraine headaches were more frequent in women with endometriosis than in those without (19.8% vs 13.2%, p &lt; 0.001). Women with endometriosis were more likely to have ever used drugs for pain relief (77.1% vs 60.5%, p &lt; 0.001). Further analysis will include estimation of economic burden of endometriosis and investigation into Mediterranean-specific factors including sun-exposure and dietary-habits.

Limitations, reasons for caution

Given the cross-sectional nature of this study, causality cannot be inferred. The majority of endometriosis cases are self-reported which is not as reliable as hospital diagnosis/surgeries and laparoscopy is not available in Northern Cyprus. However, research has shown that women self-report endometriosis diagnoses with reasonable accuracy (&gt;70%).

Wider implications of the findings

This is the first study that has estimated prevalence of endometriosis in the region and provided insight into the current-status of healthcare. It has highlighted gaps in the public’s general knowledge of common gynaecological conditions. The results form the basis for targeted follow-up-studies and promotes evidence-based reproductive-medicine in the Eastern-Mediterranean-region.

Trial registration number

Not applicable

O-283 Evidence based management of endometriosis – what has changed since 2013?

In 2005, under the auspices of ESHRE, a group of international experts evaluated the existing best evidence and published the first European guideline on the management of endometriosis. This highly successful project was the first guideline by ESHRE and was adopted by many counties as their national standard. A second, fully-updated edition was presented in 2013.

For the new ESHRE Endometriosis Guideline, published in February 2022, all available evidence for twelve chosen topics was gathered by a senior research specialist. Subgroups comprised of patient representatives and experts in healthcare, reproductive science and epidemiology evaluated the data according to GRADE criteria. Each subgroup wrote a chapter and formulated their recommendations which were then presented by a representative to the core group. There, a provisional document was generated and made available for stakeholder review. The resulting comments were taken into account and where relevant incorporated into the final guideline document for which approval was sought and gained from the ESHRE Executive Committee.

35 PICO (Patients, Interventions, Comparison, Outcome) and seven narrative questions were addressed resulting in 78 Research Recommendations were formulated. Where sufficient scientific evidence was lacking and the Guideline Development Group (GDG) was of the opinion that an important topic needed to be highlighted Good Clinical Practice Points where created based on experts’ experience.

During the process of reviewing the literature it became apparent that large knowledge gaps of the best clinical approach to endometriosis exist. As a result, 30 research recommendations were also produced.

One of the main differences to the 2013 version of the ESHRE guidelines is that laparoscopy is no longer the gold standard for endometriosis per se as there exist sufficient data to support the use of transvaginal ultrasound performed by an experienced operator or MRI can equally identify or rule out ovarian and most of deep endometriosis. However, it is recognised by the GDG that the required imaging standards are not ubiquitously available and for peritoneal disease both sensitivity and specificity using either imaging modalities are still poor. As opposed to the 2013 recommendation, the GDG does not anymore recommend an ultralong protocol for the women with rASRM stage III/IV endometriosis to improve IVF success rates. Furthermore, gonadotropin releasing hormone antagonists seem to be effective in the treatment of endometriosis-associate pain and, where available, could be considered as second-line treatment.

Other changes were specific chapters on endometriosis in adolescents and in menopausal women as the GDG strongly felt that these groups are concerningly underrepresented in clinical care and research. Finally, a chapter focussing on the association of endometriosis with certain forms of cancer namely subgroups of ovarian cancer, breast and thyroid cancer was added to give both patients and clinicians a better insight into the current evidence of this complex topic.

The GDG hope that the new ESHRE Endometriosis Guideline will improve the clinical management of a highly prevalent and heterogenous disease and that the freely-available patient-friendly version of the guideline empowers symptomatic and asymptomatic women to seek the best available advice, support and treatment.

The Dendritic Cell Dilemma in the Skin: Between Tolerance and Immunity

Dendritic cells (DC) are uniquely capable of initiating and directing immune responses. The range of their activities grounds in the heterogeneity of DC subsets and their functional plasticity. Numerical and functional DC changes influence the development and progression of disease, and correction of such dysregulations has the potential to treat disease causally. In this review, we discuss the major advances in our understanding of the regulation of DC lineage formation, differentiation, and function in the skin. We describe the alteration of DC in disease as well as possibilities for therapeutic reprogramming with a focus on tolerogenic DC. Because regulatory T cells (Treg) are indispensable partners of DC in the induction and control of tolerance, we pay special attention to the interactions with these cells. Above all, we would like to arouse fascination for this cell type and its therapeutic potential in skin diseases.

Low serum albumin as a risk factor for delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage: eICU collaborative research database analysis

BACKGROUND

Delayed cerebral ischemia (DCI) represents a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH) and is a significant predictor of morbidity and mortality. Recent studies have implicated inflammatory processes in the pathogenesis of DCI.

METHODS

aSAH patient data were retrospectively obtained from the eICU Collaborative Research Database (eICU CRD). Multivariable logistic regression models and receiver operating characteristic (ROC) curve analyses were employed to assess the association between low serum albumin (< 3.4 g/dL) and clinical endpoints: DCI and in-hospital mortality.

RESULTS

Among 276 aSAH patients included in the analysis, 35.5% (n=98) presented with low serum albumin levels and demonstrated a higher incidence of DCI (18.4% vs. 8.4%, OR=2.45, 95% CI 1.17, 5.10; p=0.017) and in-hospital mortality (27.6% vs. 16.3%, OR=1.95, 95% CI 1.08, 3.54; p=0.027) compared to patients with normal admission albumin values. In a multivariable model controlling for age and World Federation of Neurosurgical Societies grade, low serum albumin remained significantly associated with DCI (OR=2.52, 95% CI 1.18, 5.36; p=0.017), but not with in-hospital mortality. A combined model for prediction of DCI, encompassing known risk factors in addition to low serum albumin, achieved an area under the curve of 0.65 (sensitivity=0.55, specificity=0.75).

CONCLUSIONS

Serum albumin, a routine and inexpensive laboratory measurement, can may potentially aid in the identification of patients with aSAH at risk for the development of DCI.

Monoallelic and biallelic variants in LEF1 are associated with a new syndrome combining ectodermal dysplasia and limb malformations caused by altered WNT signaling

PURPOSE

LEF1 encodes a transcription factor acting downstream of the WNT-β-catenin signaling pathway. It was recently suspected as a candidate for ectodermal dysplasia in 2 individuals carrying 4q35 microdeletions. We report on 12 individuals harboring LEF1 variants.

METHODS

High-throughput sequencing was employed to delineate the genetic underpinnings of the disease. Cellular consequences were characterized by immunofluorescence, immunoblotting, pulldown assays, and/or RNA sequencing.

RESULTS

Monoallelic variants in LEF1 were detected in 11 affected individuals from 4 unrelated families, and a biallelic variant was detected in an affected individual from a consanguineous family. The phenotypic spectrum includes various limb malformations, such as radial ray defects, polydactyly or split hand/foot, and ectodermal dysplasia. Depending on the type and location of LEF1 variants, the inheritance of this novel Mendelian condition can be either autosomal dominant or recessive. Our functional data indicate that 2 molecular mechanisms are at play: haploinsufficiency or loss of DNA binding are responsible for a mild to moderate phenotype, whereas loss of β-catenin binding caused by biallelic variants is associated with a severe phenotype. Transcriptomic studies reveal an alteration of WNT signaling.

CONCLUSION

Our findings establish mono- and biallelic variants in LEF1 as a cause for a novel syndrome comprising limb malformations and ectodermal dysplasia.

Frustrated Lewis pair chemistry of hydride sponges

An improved synthesis for 1,8-bis(dimethylboranyl)naphthalene (1, hydride sponge) was developed avoiding the use of tin(IV) reagents. The related 1,2-bis(dimethylboranyl)benzene (2) was prepared. 1 combined with 1,8-bis(dimethylamino)naphthalene (3, proton sponge) is a Frustrated Lewis pair (FLP) that forms adducts [1-EH_n-1][3-H] with the protic compounds EH_n = H₂O, NH₃, H₂S, PH₃, H₂Se, HCN. Their structures show the chelation of the deprotonated substrates, except for CN^- (binds to one B atom of 1). The mechanisms of formation of [1-EH_n-1][3-H] were explored by NMR spectroscopy. Similar reactions took places for the FLP system 2 + 3, but the adducts [2-EH_n-1][3-H] are less stable; only the PH₃ adduct was isolated and AsH₃ forms a chelated adduct [2-NC(CD₃)AsH₂][3-H]. FLP 1 + 3 does not react with molecular hydrogen, but the formal adduct [1-H][3-H] was isolated via salt metathesis from K[1-H] and [3-H]Cl; it is stable towards water, atmospheric oxygen and up to 100 °C; its thermal decomposition proceeds without formation of H₂. The stabilities of both, the mixture 1 + 3 + H₂ and the formal adduct [1-H][3-H], allow concluding that hydrogen activation of FLP 1 + 3 is kinetically prevented.

para-Chlorotetrafluorophenyl-boranes - syntheses and structures of a series of mono- and bidentate Lewis acids

Mono- and bidentate tri-coordinated boron compounds bearing the yet unexplored para-chlorotetrafluorophenyl substituent have been synthesized and structurally investigated. The acidity of tris(para-chlorotetraphenyl)borane (7) was shown to exceed that of the widely used tris(pentafluorophenyl)borane (BCF) according to the Gutmann-Beckett method. Acid-base adducts of 7 with diethyl ether and triethylphosphine oxide were crystallized. Dihydrogen splitting at room temperature was observed with a Frustrated Lewis Pair consisting of 7 and 2,2,6,6-tetramethylpiperidine (TMP). The hydrogen adduct was isolated and characterized by NMR, SC-XRD and elemental analysis. Its solid-state structure contains a H⋯H distance on the verge of dihydrogen bonding (2.28(6) Å). Bis(para-chlorotetrafluorophenyl)hydridoborane was prepared in situ and shown to be applicable in hydroboration reactions similarly to Piers' borane.

A new dimension for magnetosensitive e-skins: active matrix integrated micro-origami sensor arrays

Magnetic sensors are widely used in our daily life for assessing the position and orientation of objects. Recently, the magnetic sensing modality has been introduced to electronic skins (e-skins), enabling remote perception of moving objects. However, the integration density of magnetic sensors is limited and the vector properties of the magnetic field cannot be fully explored since the sensors can only perceive field components in one or two dimensions. Here, we report an approach to fabricate high-density integrated active matrix magnetic sensor with three-dimensional (3D) magnetic vector field sensing capability. The 3D magnetic sensor is composed of an array of self-assembled micro-origami cubic architectures with biased anisotropic magnetoresistance (AMR) sensors manufactured in a wafer-scale process. Integrating the 3D magnetic sensors into an e-skin with embedded magnetic hairs enables real-time multidirectional tactile perception. We demonstrate a versatile approach for the fabrication of active matrix integrated 3D sensor arrays using micro-origami and pave the way for new electronic devices relying on the autonomous rearrangement of functional elements in space.

Inflammatory Monocyte Counts Determine Venous Blood Clot Formation and Resolution

BACKGROUND

Monocytes are thought to be involved in venous thrombosis but the role of individual monocyte subpopulations on thrombus formation, clot inflammation, and degradation is an important unresolved issue. We investigate the role of inflammatory Ly6Chi monocytes in deep vein thrombosis and their potential therapeutic impact.

METHODS

Frequencies and compositions of blood monocytes were analyzed by flow cytometry in CCR2-/- (C-C chemokine receptor type 2) and wild-type mice of different ages and after treatment with the NR4A1 (nuclear receptor group 4 family A member 1, Nur77) agonist CnsB (cytosporone B). TF (tissue factor) sufficient and deficient Ly6Chi monocytes were adoptively transferred into aged CCR2-/- mice. Thrombus formation and size were followed by ultrasound over a 3-week period after surgical reduction of blood flow (stenosis) in the inferior vena cava.

RESULTS

Reduced numbers of peripheral monocytes in aged (>30 w) CCR2-/- mice are accompanied by reduced thrombus formation after inferior vena cava ligation. Reducing the number of inflammatory Ly6Chi monocytes in wild-type mice by CsnB treatment before ligation, similarly suspends clotting, while later treatment (d1 or d4) reduces thrombus growth and accelerates resolution. We describe how changes in inflammatory monocyte numbers affect the gradual differentiation of monocytes in thrombi and show that only tissue factor-competent Ly6Chi monocytes restore thrombosis in aged CCR2-/- mice.

CONCLUSIONS

We conclude that the number of inflammatory Ly6Chi monocytes controls deep vein thrombosis formation, growth, and resolution and can be therapeutically manipulated with a NR4A1 agonist at all disease stages.

Roadmap for edge AI

Based on the collective input of Dagstuhl Seminar (21342), this paper presents a comprehensive discussion on AI methods and capabilities in the context of edge computing, referred as Edge AI. In a nutshell, we envision Edge AI to provide adaptation for data-driven applications, enhance network and radio access, and allow the creation, optimisation, and deployment of distributed AI/ML pipelines with given quality of experience, trust, security and privacy targets. The Edge AI community investigates novel ML methods for the edge computing environment, spanning multiple sub-fields of computer science, engineering and ICT. The goal is to share an envisioned roadmap that can bring together key actors and enablers to further advance the domain of Edge AI.

Post-acute COVID-19 geriatric rehabilitation : A European perspective

Coronavirus disease 2019 (COVID-19) poses a threat to the health and independence of older people in particular. In this article we elaborate on the content and importance of post-acute COVID-19 geriatric rehabilitation from a European perspective. We explain the geriatric rehabilitation paradox and how this can and should be solved. We also present what post-acute COVID-19 geriatric rehabilitation should entail. This might not only help us to develop better geriatric rehabilitation services, but it should also inform pandemic preparedness in the future.

Electronically integrated microcatheters based on self-assembling polymer films

Existing electronically integrated catheters rely on the manual assembly of separate components to integrate sensing and actuation capabilities. This strongly impedes their miniaturization and further integration. Here, we report an electronically integrated self-assembled microcatheter. Electronic components for sensing and actuation are embedded into the catheter wall through the self-assembly of photolithographically processed polymer thin films. With a diameter of only about 0.1 mm, the catheter integrates actuated digits for manipulation and a magnetic sensor for navigation and is capable of targeted delivery of liquids. Fundamental functionalities are demonstrated and evaluated with artificial model environments and ex vivo tissue. Using the integrated magnetic sensor, we develop a strategy for the magnetic tracking of medical tools that facilitates basic navigation with a high resolution below 0.1 mm. These highly flexible and microsized integrated catheters might expand the boundary of minimally invasive surgery and lead to new biomedical applications.

NT-proBNP as a marker for atrial fibrillation and heart failure in four observational outpatient trials

Aims

Heart failure (HF) and atrial fibrillation (AF) frequently coexist and are both associated with increased levels of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP). It is known that AF impairs the diagnostic accuracy of NT‐proBNP for HF. The aim of the present study was to compare the diagnostic and predictive accuracy of NT‐proBNP for HF and AF in stable outpatients with cardiovascular risk factors.

Methods and results

Data were obtained from the DIAST‐CHF trial, a prospective cohort study that recruited individuals with cardiovascular risk factors and followed them up for 12 years. Data were validated in three independent population‐based cohorts using the same inclusion/exclusion criteria: LIFE‐Adult (n = 2869), SHIP (n = 2013), and SHIP‐TREND (n = 2408). Serum levels of NT‐proBNP were taken once at baseline. The DIAST‐CHF study enrolled 1727 study participants (47.7% female, mean age 66.9 ± 8.1 years). At baseline, patients without AF or HF (n = 1375) had a median NT‐proBNP of 94 pg/mL (interquartile range 51;181). In patients with AF (n = 93), NT‐proBNP amounted to 667 (215;1130) pg/mL. It was significantly higher than in the first group (P < 0.001) and compared with those with only HF [n = 201; 158 (66;363) pg/mL; P < 0.001]. The highest levels of NT‐proBNP [868 (213;1397) pg/mL] were measured in patients with concomitant HF and AF (n = 58; P < 0.001 vs. control and vs. HF, P = 1.0 vs. AF). In patients with AF, NT‐proBNP levels did not differ between those with HF and preserved ejection fraction (EF) > 50% [n = 38; 603 (175;1070) pg/mL] and those without HF (P = 1.0). Receiver‐operating characteristic curves of NT‐proBNP showed a similar area under the curve (AUC) for the detection of AF at baseline (0.84, 95% CI [0.79–0.88]) and for HF with EF < 50% (0.78 [0.72–0.85]; P = 0.18). The AUC for HF with EF > 50% was significantly lower (0.61 [0.56–0.65]) than for AF (P = 0.001). During follow‐up, AF was newly diagnosed in 157 (9.1%) and HF in 141 (9.6%) study participants. NT‐proBNP was a better predictor of incident AF during the first 2 years (AUC: 0.79 [0.75–0.83]) than of newly diagnosed HF (0.59 [0.55–0.63]; P < 0.001). Data were validated in three independent population‐based cohorts (LIFE‐Adult, n = 2869; SHIP, n = 2013; and SHIP‐TREND, n = 2408).

Conclusions

In stable outpatients, NT‐proBNP is a better marker for prevalent and incident AF than for HF. In AF patients, the diagnostic value of NT‐proBNP for HF with EF > 50% is very limited.

Self-sufficient self-oscillating microsystem driven by low power at low Reynolds numbers

Oscillations at several hertz are a key feature of dynamic behavior of various biological entities, such as the pulsating heart, firing neurons, or the sperm-beating flagellum. Inspired by nature’s fundamental self-oscillations, we use electroactive polymer microactuators and three-dimensional microswitches to create a synthetic electromechanical parametric relaxation oscillator (EMPRO) that relies on the shape change of micropatterned polypyrrole and generates a rhythmic motion at biologically relevant stroke frequencies of up to ~95 Hz. We incorporate an Ag-Mg electrochemical battery into the EMPRO for autonomous operation in a nontoxic environment. Such a self-sufficient self-oscillating microsystem offers new opportunities for artificial life at low Reynolds numbers by, for instance, mimicking and replacing nature’s propulsion and pumping units.

RNA polymerase II is required for spatial chromatin reorganization following exit from mitosis

Mammalian chromosomes are three-dimensional entities shaped by converging and opposing forces. Mitotic cell division induces marked chromosome condensation, but following reentry into the G₁ phase of the cell cycle, chromosomes reestablish their interphase organization. Here, we tested the role of RNA polymerase II (RNAPII) in this transition using a cell line that allows its auxin-mediated degradation. In situ Hi-C showed that RNAPII is required for both compartment and loop establishment following mitosis. RNAPs often counteract loop extrusion, and in their absence, longer and more prominent loops arose. Evidence from chromatin binding, super-resolution imaging, and in silico modeling allude to these effects being a result of RNAPII-mediated cohesin loading upon G₁ reentry. Our findings reconcile the role of RNAPII in gene expression with that in chromatin architecture.

Therapeutic melanoma inhibition by local micelle-mediated cyclic nucleotide repression

The acidic tumor microenvironment in melanoma drives immune evasion by up-regulating cyclic adenosine monophosphate (cAMP) in tumor-infiltrating monocytes. Here we show that the release of non-toxic concentrations of an adenylate cyclase (AC) inhibitor from poly(sarcosine)-block-poly(L-glutamic acid γ-benzyl ester) (polypept(o)id) copolymer micelles restores antitumor immunity. In combination with selective, non-therapeutic regulatory T cell depletion, AC inhibitor micelles achieve a complete remission of established B16-F10-OVA tumors. Single-cell sequencing of melanoma-infiltrating immune cells shows that AC inhibitor micelles reduce the number of anti-inflammatory myeloid cells and checkpoint receptor expression on T cells. AC inhibitor micelles thus represent an immunotherapeutic measure to counteract melanoma immune escape.

The acidic tumour microenvironment in melanoma drives immune evasion by cAMP in tumor-infiltrating monocytes. Here, the authors show that the release of an adenylate cyclase inhibitor from micelles restores antitumor immunity and, when combined with regulatory T cell depletion, leads to remission of established B16-F10-OVA tumors.

A concentration-QTc analysis of vericiguat

Introduction

Vericiguat is a soluble guanylate cyclase stimulator developed for the treatment of symptomatic chronic heart failure (HF) in patients with ejection fraction less than 45% who had a previous decompensation event. A dedicated, randomised, Phase Ib, QT study of vericiguat (NCT03504982) in 74 adult patients with stable coronary artery disease demonstrated no clinically significant prolongation of the time-matched, placebo-adjusted change from baseline in the Fridericia-corrected QT interval (QTcF) after vericiguat 10 mg once daily at steady state.

Purpose

We conducted a concentration–QTc (C-QTc) modelling analysis, on data from the QT study, to investigate the potential effect of vericiguat on QTcF and define the vericiguat plasma concentration window within which a relevant prolongation in QTcF can be excluded.

Methods

In the QT study, the effect of vericiguat once daily (2.5 mg titrated to 5 mg and then to 10 mg [treatments A, B, C] over 42±9 days) on the QT interval was investigated. The positive control was a single dose of moxifloxacin 400 mg (treatment D) on Day 8 or Day 50 (7 days before the first vericiguat dose or 7 days after the last vericiguat dose), depending on the treatment sequence (Figure 1).

Baseline electrocardiogram assessments were performed 24 h before the start of treatment (“baseline”) and at follow-up (“back-up baseline”; Figure 1). Time-matched, baseline- and placebo-adjusted QTcF (ΔΔQTc) mean values and 90% confidence intervals (CIs) were calculated. Two analytical approaches were used to calculate ΔΔQTc. The first one (“single baseline ΔΔQTc” approach) was data-driven, where ΔΔQTc was adjusted with placebo- and either “baseline” or “back-up baseline”. The second one (“modelled baseline ΔΔQTc”) accounted for individual baseline and placebo effects, such as diurnal time course, used linear mixed effects and integrated all individual baseline and placebo data. Calculated ΔΔQTc values were then related to observed vericiguat concentrations in the C-QTc modelling step, performed with linear mixed effects implemented in R (R, the R Foundation for Statistical Computing, version 3.2.5).

Results

The C-QTc modelling of ΔΔQTc calculated with the “single baseline ΔΔQTc” approach indicated a positive, but non-significant, slope (Figure 2A). The “modelled baseline ΔΔQTc” approach indicated a positive and statistically significant slope (Figure 2B). In both cases, the upper limits of the 90% CI were below the threshold of clinical relevance of 10 ms within the investigated exposure range (up to 745 μg/l).

Conclusion

Based on the presented analysis, a clinically meaningful QT prolongation was robustly excluded within the plasma concentration range associated with the recommended target dose of vericiguat 10 mg. The C-QTc analysis supports the conclusion of the primary study statistical analysis that administration of vericiguat between 2.5 and 10 mg is not associated with a clinically meaningful QTc prolongation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Funding was provided by Bayer AG, Berlin, Germany and Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA Figure 1Figure 2

Leveraging translational approaches for accelerated clinical development of vericiguat

Background/Introduction

Vericiguat is a soluble guanylate cyclase (sGC) stimulator, like riociguat and nelociguat, and entered clinical development in 2012. Before entering Phase 2, pharmacokinetics (PK) and pharmacodynamics (PD) of vericiguat had been studied in healthy volunteers only, whereas riociguat and nelociguat had also been studied in patients with pulmonary hypertension (PH) and left ventricular dysfunction (LVD) or biventricular chronic heart failure (HF). We hypothesised that integrating all PK/PD data from these compounds into population PK/PD (popPK/PD) and physiology-based PK (PBPK) models could be used to predict optimal and safe dose ranges of vericiguat for Phase 2b studies in patients with worsening chronic HF. This novel bridging approach was applied in one of several translational stages to accelerate the development of vericiguat (Figure 1).

Purpose

We used prior knowledge from other sGC stimulators in a combined PK/PD and PBPK modelling approach to directly initiate Phase 2b studies of vericiguat in patients after Phase 1 studies in healthy volunteers.

Methods

PK, heart rate (HR) and systemic vascular resistance (SVR) data for vericiguat, nelociguat and riociguat were used to calculate PK/PD slopes of linear models, corrected with fraction unbound percentages (2.2%, 3.6% and 3.9%, respectively), to compare potency relative to riociguat based on unbound concentrations. PK estimates for nelociguat and riociguat were derived using population PK modelling (NONMEM) from patient studies with sparse PK sampling. PBPK models informed by preclinical physicochemical and PK data as well as clinical data for vericiguat were used to predict vericiguat PK in patients with HF (PK-Sim). Exposure–response data for riociguat in patients indicated the optimal range of PD responses for vericiguat (blood pressure for safety and cardiac index for efficacy).

Results

Vericiguat and nelociguat had lower potency than riociguat when comparing PK/PD slopes for HR and SVR (slope ratios of 0.23–0.32 for vericiguat and 0.33–0.47 for nelociguat). Plasma concentrations of vericiguat would need to be ∼3.6 times that of riociguat for equivalent responses. In patients with PH and LVD the optimal plasma concentration range for riociguat was ∼10–100 μg/l in exposure–response and safety studies, which translates to a target exposure range of ∼90–900 μg/l for vericiguat in patients with HF. PBPK modelling showed that vericiguat 2.5 mg and 10 mg would cover the target exposure range and that 1.25 mg would be a “non-effective” dose level with respect to haemodynamics.

Conclusions

Our novel translational approach combining popPK/PD analyses of other sGC stimulators with PBPK modelling enabled vericiguat to move directly from Phase 1 to Phase 2b, reducing development time by ∼2 years. PK and safety results from Phase 2b (SOCRATES-REDUCED) and Phase 3 (VICTORIA) trials confirmed that use of this translational approach to predict dose ranges of vericiguat was successful.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Funding for this research was provided by Bayer AG, Berlin, Germany Figure 1

Vericiguat: a QTc interval study in patients with coronary artery disease

Background

Vericiguat is a soluble guanylate cyclase stimulator developed for the treatment of symptomatic chronic heart failure (HF) in adult patients with ejection fraction less than 45% who had a previous decompensation event. Guidelines on QT studies recommend evaluation of investigational drugs at supratherapeutic exposures in healthy volunteers. We anticipated that supratherapeutic doses of vericiguat would decrease blood pressure. We conducted an adjusted QT study using the therapeutic range of vericiguat in patients with coronary artery disease (CAD), who were expected to be more haemodynamically stable with fewer confounders (e.g., on the electrocardiogram) than a HF population.

Purpose

To assess the effect of vericiguat 10 mg once-daily on placebo-adjusted change from baseline of the Fridericia-corrected QT interval (QTcF) in patients with stable CAD.

Methods

This was a randomised, Phase Ib, placebo-controlled, double blind, double-dummy, multicentre study (NCT03504982). Test drug was vericiguat once-daily (up-titrated from 2.5 mg to 5 mg and then to 10 mg [treatments A, B, C] at 14-day intervals). The positive control was moxifloxacin 400 mg (single dose on Day 8 or Day 50 with placebo on other days [treatment D]; Figure). Patients were randomised to one of two sequences.

We evaluated QTcF interval prolongation potential of vericiguat at increasing doses up to 10 mg, steady state. We investigated the pharmacokinetics, safety and tolerability of vericiguat. A clinically meaningful effect was defined as a QTcF change from baseline &gt;10 ms relative to placebo. Assay sensitivity for moxifloxacin was confirmed by the lower limit of the 90% confidence interval (CI) of the time-matched, baseline-adjusted mean difference to placebo exceeding 5 ms at &gt;1 time point.

Results

A total of 74 patients (66 males and 8 females) with CAD, mean (standard deviation) age 63.4 (8.0) years, were included. Mean difference between vericiguat and placebo in QTcF change from baseline (≤7 h post-dose) was &lt;6 ms; no upper limit of the 90% CIs crossed the threshold of 10 ms. Lower limits of the two-sided 90% CI of the differences between moxifloxacin and placebo in QTcF change from baseline were &gt;5 ms at 3 of 4 time points (Table).

Peak plasma concentration (Cmax) of vericiguat following administration of vericiguat 10 mg was 322 μg/l and median time of maximum concentration (Tmax) was 4.5 h post-dose, in line with concentrations observed following administration of vericiguat 10 mg to patients with HF [1]. For moxifloxacin 400 mg, Cmax was 1960 μg/l and median Tmax was 3 h post-dose, in line with previously reported values [2]. Vericiguat up to 10 mg was generally safe and well tolerated.

Conclusion

This study supports the assessment that administration of vericiguat 10 mg is not associated with clinically meaningful QTc prolongation. These data contribute to the overall safety profile of vericiguat for the treatment of patients with HF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Funding was provided by Bayer AG, Berlin, Germany, and Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA QTc study design

Chemical Synthesis and Semisynthesis of Lipidated Proteins

Lipidation is a ubiquitous modification of peptides and proteins that can occur either co‐ or post‐translationally. An array of different lipid classes can adorn proteins and has been shown to influence a number of crucial biological activities, including the regulation of signaling, cell–cell adhesion events, and the anchoring of proteins to lipid rafts and phospholipid membranes. Whereas nature employs a range of enzymes to install lipid modifications onto proteins, the use of these for the chemoenzymatic generation of lipidated proteins is often inefficient or impractical. An alternative is to harness the power of modern synthetic and semisynthetic technologies to access lipid‐modified proteins in a pure and homogeneously modified form. This Review aims to highlight significant advances in the development of lipidation and ligation chemistry and their implementation in the synthesis and semisynthesis of homogeneous lipidated proteins that have enabled the influence of these modifications on protein structure and function to be uncovered.