POS0236 SAFETY AND EFFICACY OF NEUROSTIMULATION WITH A MINIATURIZED VAGUS NERVE STIMULATION DEVICE IN PATIENTS WITH MULTIDRUG-REFRACTORY RHEUMATOID ARTHRITIS: 24-WEEK FOLLOW-UP OF A RANDOMIZED CONTROLLED FIRST-IN-HUMAN TRIAL

Background

Vagus nerve stimulation (VNS) activates innate neuroimmune reflexes that have been shown to reduce pro-inflammatory cytokines and clinical disease activity in subjects with rheumatoid arthritis (RA).1 We previously reported primary clinical outcomes from a first-in-human, double-blind study of a novel, implanted VNS device called a MicroRegulator (MR). That study showed 5/10 subjects with drug-refractory RA met or exceeded the minimal clinically important difference (MCID) in DAS28-CRP; 2 subjects achieved DAS28 remission (DAS28-CRP < 2.6); and pro-inflammatory cytokines were decreased by >30% following 12 weeks of VNS.2 We now report 24-week efficacy and safety findings from this study.

Objectives

Determine the long-term safety and exploratory efficacy of neurostimulation using a novel, miniaturized VNS device in patients with multiple drug refractory RA who were previously enrolled in a first in human study.

Methods

The primary study enrolled adult patients with active moderate-to-severe RA with incomplete response or intolerability to at least two biologic and/or targeted synthetic DMARDs having at least two different mechanisms of action. The study was enrolled in 2 Stages: Stage 1 (n=3) was open-label, and Stage 2 (n=11) was randomized and sham-controlled (Figure 1). Three weeks after MR implantation, the first 3 subjects in Stage 1 received active VNS for 1 minute, once per day (QD). Following safety review board approval, 11 patients in Stage 2 were implanted with the MR and randomized 1:1:1 into one of two active VNS groups (1 minute of VNS QD or 1 minute of active VNS four times per day [QID]) or a sham group. At Week 12, the blind was lifted, sham subjects were re-randomized and crossed over to either QD or QID active VNS dosing, and all actively treated subjects remained on their dosing through Week 24. Safety and tolerability were determined, and several secondary efficacy endpoints were evaluated measuring the change in disease activity from the start of active VNS to Week 24.

Figure 1.

Study Schematic

Results

There were no device-related adverse events from Week 12 through Week 24. Improvement in clinical disease activity was sustained through Week 24: 5/9 patients within the original, active VNS treatment groups met or exceeded EULAR response criteria for DAS28-CRP at Week 24 (Table 1) vs. 5/10 at Week 12 (one Week 12 responder was lost to follow-up). Similarly, 6/9 patients in the original, active VNS treatment groups met or exceeded the MCID in CDAI at Week 24 vs. 5/10 at Week 12. In the long-term extension, 1/4 sham crossover patients had both EULAR and CDAI response after 12 weeks of VNS (1/2 QD, 0/2 QID). Co-therapy with a b/tsDMARD was initiated in 2 subjects (Table 1). One crossover subject was treated with oral methylprednisolone at week 19 due to worsening RA disease activity. VECTRA composite scores and component analysis revealed an 18-point decrease in median multi-analyte disease activity index in the QD group over 24 weeks of VNS with a decrease in serum levels of several analytes in key component categories (IL-6, serum amyloid A, and VCAM-1). Erosion progression by hand MRI was stabilized or decreased in all but 1 of the stimulated patients at Week 24.

Table 1.

Change in DAS28-CRP at Week 24

SubjectTreatmentDAS28-CRP (MCID -1.2) *added b/tsDMARD co-therapy005-01QD-2.4005-03QD-2.21006-01QD-0.07002-01QD-4.95 *005-06QD-0.72 *006-03QID-0.69008-01QID0.49008-03QID-3.14008-04QID1.43005-05Sham to QD0.39006-04Sham to QD-0.78006-02Sham to QID-0.22008-02Sham to QID-0.09

Conclusion

Improvements in clinical disease activity and pro-inflammatory cytokine suppression were maintained through 24 weeks of VNS treatment. Safety outcomes continue to support the risk/benefit profile of VNS as a treatment option for patients with multiple-drug refractory RA.

References

[1]Koopman PNAS 2016

[2]Genovese et al. Lancet Rheum 2020.

Acknowledgements

Authors wish to thank the patients for participating in the study

Disclosure of Interests

Norman Gaylis Grant/research support from: Primary investigator at AARDS Research Inc, Mark C. Genovese Shareholder of: Gilead Sciences, Consultant of: SetPoint Medical Inc, Vorso, InMedix, Galvani, Employee of: Gilead Sciences, David Sikes: None declared, Alan Kivitz Shareholder of: Amgen, Gilead, GSK, Sanofi, Pfizer, Speakers bureau: Abbvie, Celegene, Pfizer, Horizon, Merck, Genzyme, Sanofi, Flexion, Paid instructor for: Abbvie, Celegene, Pfizer, Horizon, Merck, Genzyme, Sanofi, Flexion, Consultant of: Abbvie, Janssen, Pfizer, Genzyme, Sanofi, Regeneron, Sun Pharma, Boehringer Ingelheim, Gilead, Diane M Horowitz: None declared, Charles Peterfy Speakers bureau: Amgen, Bristol-Myers Squibb, Consultant of: Abbvie, Five Prime, Genentech, Modern Bioscience, Myriad, Novartis, Roche, SetPoint Medical, Vorso, Employee of: Spire Sciences Inc, Yaakov Levine Employee of: Setpoint Medical, Melissa Evangelista Employee of: SetPoint Medical, David Chernoff Employee of: SetPoint Medical

AB1318-HPR VAGUS NERVE STIMULATION IN PATIENTS WITH RHEUMATOID ARTHRITIS: 48 MONTH SAFETY AND EFFICACY

Background:

Rheumatoid arthritis (RA) is a disease with significant remaining unmet medical needs for better treatments. Vagus nerve stimulation (VNS) to activate the inflammatory reflex (cholinergic anti-inflammatory pathway) represents a novel experimental therapy for RA.1Previously, we reported that inflammatory reflex activation by VNS reduced pro-inflammatory cytokine production and improved disease activity in a 17-patient rheumatoid arthritis (RA) proof-of-concept study using a reprogrammed epilepsy stimulator2; clinical improvement was sustained for 24 months without untoward safety signals.3Here we report the 48 months results from this long-term observational study.

Objectives:

Determine the long-term safety and efficacy of VNS for the treatment of RA

Methods:

In the primary study, a VNS device was implanted into 17 RA patients, mostly with insufficient response to multiple conventional and biologic DMARDs, on stable background of methotrexate (≤25 mg weekly) therapy2. The device electrically stimulated the vagus nerve, 1-4 min/day, over a 12-week open label period. On completion, subjects were offered to enroll into a follow-up study, where the study physicians were given flexibility to alter VNS dosing parameters and/or to add a biologic disease-modifying antirheumatic drug (DMARD) to the treatment regimen to induce disease remission. Clinical disease activity measures and safety were accessed over 4 years.

Results:

All patients electively continued VNS treatment in the long-term follow-up study, 4 subjects withdrew prior to month 48. Reasons for discontinuation were withdrawal of consent (N=3) and adverse event due to device discomfort (N=1). At the start of the follow-up study, the mean DAS28-CRP, CDAI and HAQ-DI were significantly reduced compared to the pre-implant baseline (mean difference± SD: DAS28-CRP=-1.60± 1.13, p<0.001; CDAI=-21.19± 13.5, p<0.001; HAQ-DI=-0.44± 0.49, p<0.01), and this effect was retained through 48 months. Patients using VNS monotherapy and those using a combination of VNS with biologic DMARDs exhibited stable improvements in DAS28-CRP, CDAI and HAQ-DI at month 48 (Table 1). Improvements were observed for patients who both previously had an insufficient response to targeted biological therapies as well those who had an insufficient response to standard DMARDs. No association was seen between DAS28-CRP and stimulation frequency (Range= 1X-8X/day). There was no difference in the adverse events profile between the two groups.

Table 1.

Efficacy of VNS treatment.

Treatment ReinitiatedN=9VNS MonotherapyN=8TotalN=17Mo. 24Mo. 36Mo.48Mo. 24Mo. 36Mo. 48Mo. 24Mo. 36Mo. 48Mean change from baseline (SD)DAS28-CRP-2.58 (1.0)***-2.40 (1.0)**-2.28 (1.3)**-2.61 (1.3)*-1.77 (1.8)-2.0(1.7)-2.59 (1.1)***-2.19(1.2)**-2.17(1.4)**CDAI-24.06 (8.3)***-18.02 (13.3) *-16.2 (19.6)-33.5 (11.1)***-27.8 (16.0)*-27.9 (12.7)*-28.20 (10.5)***-21.93 (14.5)*-20.83(17.5)*HAQ-DI-.60 (0.64)*-.63(0.45)*-.31(0.60)-.89 (0.69)*-.88 (0.92)-.88(0.61)-0.73(0.66)***-0.73(0.64)**-0.54(0.64)*

*P<0.05, **P<0.01, ***P<0.001 versus primary study baseline (month -3.5)

Conclusion:

VNS was safe, well-tolerated, and resulted in significant and clinically important improvements in disease activity measures that were maintained over 48 months. These results support development of VNS devices as a new therapeutic option for RA treatment.

References:

[1]van Maanen MA, et al.Nat Rev Rheum2009

[2]Koopman FA, et al.PNAS2016

[3]Koopman FA, et al.Arthritis Rheum2018

Disclosure of Interests:

Frieda Koopman: None declared, Anne Musters: None declared, Marieke Backer: None declared, Danielle Gerlag Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline, Sanda Miljko: None declared, Simeon Grazio Speakers bureau: Abbvie., Roche, MSD, Eli Lilly, Pfizer, Mylan, Amgen, Fresenius Kabi, Stada, Berlin-Chemie, Sekib Sokolovic: None declared, Yaakov Levine Shareholder of: SetPoint Medical, Employee of: SetPoint Medical, Emmett Glass Employee of: SetPoint Medical, David Chernoff Shareholder of: SetPoint Medical, Adamas Pharmaceuticals, Olly Nutrition, NAIA Pharma, Aquinox Pharma, Consultant of: Adamas Pharmaceuticals, Olly Nutrition, NAIA Pharma, Aquinox Pharma, Crescendo Bioscience, Employee of: SetPoint Medical, Niek de Vries Grant/research support from: AbbVie, Janssen, Ergomed Clinical Research, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Roche, Consultant of: MSD, Pfizer, Paul P. Tak Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline

FRI0572 LEPTIN-ADJUSTMENT OF THE MULTI-BIOMARKER DISEASE ACTIVITY (MBDA) SCORE REDUCES THE INFLUENCE OF ADIPOSITY

Background:

Obesity and excess adiposity influence inflammatory markers and bias disease activity assessment, especially among women. A multi-biomarker disease activity (aMBDA) score has been developed to account for the effects of age, sex and adiposity (leptin) and improves prediction of radiographic damage progression.1

Objectives:

1) Determine if the adjusted measure demonstrates a reduced association with adiposity.

2) Assess the impact of the leptin-adjustment on the score over the range of adiposity.

3) Assess relationships between MBDA scores and clinical disease activity.

Methods:

Patients with rheumatoid arthritis (RA), ages 18-75 years, completed whole-body dual-energy x-ray absorptiometry to quantify fat mass indices (FMI, kg/m2). Age-, sex-, and race-specific Z-Scores were calculated based on the distributions in a healthy reference population. Disease activity was assessed with the CDAI and swollen joint count (SJC). Baseline van der Heijde-Sharpe (vdHS) scores were determined by a radiologist. MBDA assays were performed on stored serum samples. Descriptive statistics described relationships between the FMI Z-Score and the MBDA and the aMBDA. Clinical disease activity, SJC, and radiographic damage were also compared across MBDA score categories.

Results:

Of 104 participants (50% female), the mean (SD) age was 56.1 (12.5) and mean BMI was 28.8 (6.9) (Table 1). The unadjusted MBDA score was strongly associated with BMI among women (Women: Rho=0.46 [p< 0.001]; Men: Rho=-0.12), while the aMBDA was not associated with BMI in women and was inversely correlated in men (Women: Rho=0.17; Men: Rho=-0.32 [p=0.02]). The unadjusted MBDA score was also strongly associated with FMI Z-Score among women (Figure; Women: Rho=0.42 [p=0.002]; Men: Rho=-0.10; p=0.01). The aMBDA was not significantly associated with FMI Z-Score (Female: Rho= 0.17; Male: Rho=-0.26). Leptin-adjustment reduced the MBDA score in the highest quartile of FMI in women but not men, and increased the MBDA score in the lowest FMI quartiles in both women and men; these patients in the lowest FMI quartile had the highest median SJC (p=0.05 for men, p=0.78 for women; Figure). The aMBDA reclassified 4 women (8%) and 9 men (17%) into higher disease activity categories and 2 women (4%) and 2 men (4%) into lower categories. CDAI, SJC, and radiographic scores were similar across activity categories for the unadjusted MBDA score and aMBDA (Table 2).

Table 1.

Baseline Characteristics.

MenWomenN5252Age (yrs)59.1 (11.5)53.0 (12.8)Black, N (%)13 (25%)19 (36%)BMI27.3 (5.4)30.3 (8.0)FMI Z-Score-0.28 (1.3)0.05 (1.1)DAS28(CRP)3.09 (1.13)3.21 (1.24)Disease Duration11.4 (10.9)11.6 (11.9)CRP, mg/dL0.8 (0.5, 1.2)0.8 (0.5, 1.4)CCP Positive, N (%)45 (87%)40 (78%)vdHS (N=93)13 (4, 73)10.5 (2, 47)HAQ0.71 (0.59)0.83, (0.67)MBDA40.0 (13.8)42.1 (16.6)aMBDA43.6 (13.4)42.1 (15.3)Leptin, ng/mL15.1 (21.5)48.9 (41.5)Table 2.

Clinical assessments across MBDA score categories.

CDAISJCvdHSMBDAaMBDAMBDAaMBDAMBDAaMBDAMBDA CategoryLow14.6 (10.9)13.9 (9.9)2 (1, 5)2 (1, 5)9 (1, 33.5)9 (3, 32)Moderate13.2 (10.0)14.4 (11.4)2 (0, 5)3 (0, 6)10 (4, 49)10 (2, 53)High18.4 (12.3)17.7 (11.8)4 (1, 8)5 (2, 7)20.5 (5, 70.5)18 (4, 73)

Conclusion:

Leptin-adjustment of the MBDA score reduced bias related to excess adiposity in women with RA. Adjustment results in lower MBDA scores in women with greater adiposity, and higher MBDA scores in women and men with lesser adiposity. The aMBDA may reduce misclassification due to excess adiposity and improve identification of active disease among patients with lower adiposity. High aMBDA scores among men with low adiposity may reflect severe disease or excess comorbidity in this group.

References:

[1] Curtis et al.Rheumatology (Oxford) 2018. PMID: 30590790

Figure.

Impact of Adjustment on MBDA Score by FMI Z-Score Quartile.

Disclosure of Interests:

Joshua Baker Grant/research support from: Myriad RBM, Consultant of: Bristol-Myers Squib, Burns-White LLC, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, David Chernoff Employee of: Myriad, Michael George Grant/research support from: Bristol Myers Squibb, Consultant of: AbbVie

Investigation of a multi-biomarker disease activity score in rheumatoid arthritis by comparison with magnetic resonance imaging, computed tomography, ultrasonography, and radiography parameters of inflammation and damage

OBJECTIVES

To investigate the multi-biomarker disease activity (MBDA) score by comparison with imaging findings in an investigator-initiated rheumatoid arthritis (RA) trial (HURRAH trial, NCT00696059).

METHOD

Fifty-two patients with established RA initiated adalimumab treatment and had magnetic resonance imaging (MRI), ultrasonography (US), computed tomography (CT), and radiography performed at weeks 0, 26, and 52. Serum samples were analysed using MBDA score assays and associations between clinical measures, MBDA score, and imaging findings were investigated.

RESULTS

The MBDA score correlated significantly with MRI synovitis (rho = 0.65, p < 0.001), MRI bone marrow oedema (rho = 0.36, p = 0.044), and US power Doppler (PD) score at week 26 (rho = 0.35, p = 0.039) but not at week 0 or week 52. In the 15 patients who had achieved a Disease Activity Score based on C-reactive protein (DAS28-CRP) < 2.6 at week 26, MRI and/or US detected subclinical inflammation and 13 (87%) had a moderate/high MBDA score. For the cohort with available data, none of the four patients in MBDA remission (score ≤ 25) at week 26 had progression of imaging damage from baseline to week 52 whereas progression was observed in three out of nine (33%) and seven out of 21 (33%) patients with moderate (30-44) and high (> 44) MBDA scores, respectively.

CONCLUSIONS

In this cohort, the MBDA score correlated poorly with MRI/US inflammation. However, the MBDA score and MRI/US were generally concordant in showing signs of inflammation in most patients in clinical remission during anti-tumour necrosis factor (anti-TNF) therapy. MBDA scores were elevated in all patients with structural damage progression.

In vivo emergence of drug-resistant mutations at less than 50 HIV-1 RNA copies/mL that are maintained at viral rebound in longitudinal plasma samples from human immunodeficiency virus type-1-infected patients on highly active antiretroviral therapy

OBJECTIVE

Emergence of human immunodeficiency virus type-1 (HIV-1) genotypic drug resistance is generally attributed to noncompliance, poorly absorbed drugs, or drug-to-drug interaction. Attempts to determine emerging genotypic drug resistance from study subjects on highly active antiretroviral therapy (HAART) relied on insensitive polymerase chain reaction (PCR) techniques, revealing wild type HIV-1 or precursor resistant genotypes from few plasma samples successfully amplified with <50 copies/mL.

STUDY DESIGN/METHODS

In this analysis, using Applied Biosystems' ViroSeq HIV-1 Genotyping Systems, Version 2.0 (Applied Biosystems, Foster City, CA, USA) and the supplemental, for research use only, nested PCR primers, genotypic drug resistance was determined in longitudinal plasma samples from 11 study subjects on HAART.

RESULTS

In 4 of 11 study subjects, newly emerging genotypic primary resistant mutations were detected in plasma samples with <50 copies/mL. Most of these primary drug-resistant mutations were detected in subsequent longitudinal samples with detectable viral load (viral breakthrough).

CONCLUSIONS

This analysis suggests sufficient viral replication <50 copies/mL to generate genotypic drug resistance in study subjects on suppressive HAART.

Relation between HIV-1 and hepatitis C viral load in patients with hemophilia

Coinfection with hepatitis C virus (HCV) and HIV-1 is common in patients with hemophilia and in intravenous drug users. Little, however, is known about the relation between HIV-1 and HCV coinfection and the effects on HCV clearance and pathogenesis. We examined data from 207 HIV-1-infected and 126 HIV-1-uninfected patients with hemophilia enrolled in the multicenter Hemophilia Growth and Development Study. Participants were observed during prospective follow-up for approximately 7 years with annual measurements of alanine aminotransferase (ALT), CD4+ cells, and HCV and HIV-1 RNA levels. Clearance of HCV was more likely to occur in those uninfected with HIV-1 (14.3 versus 2.5%; odds ratio [OR] 4.79; 95% confidence interval [CI], 1.63-14.08, p =.005) and was more common with decreasing age (OR, 1.23; 95% CI, 1.04-1.47; p =.017). HCV RNA levels were higher throughout the 7 years of follow-up in those HIV-1-infected (p <.001). In the HIV-1-infected participants, baseline CD4+ cells were inversely related to HCV RNA with every 100-cell increase associated with a 0.19 log10 copy/ml decrease in HCV RNA (p =.002), and HIV-1 and HCV RNA levels were directly related (p =.008). Increasing HCV RNA levels were also associated with significantly higher ALT levels regardless of HIV-1 infection status. These results demonstrate that HIV-1/HCV co-infection is associated with a reduced likelihood of HCV clearance and that higher levels of HCV RNA are associated with increased hepatic inflammation.

The effect of plasma human immunodeficiency virus RNA and CD4(+) T lymphocytes on growth measurements of hemophilic boys and adolescents

OBJECTIVE

The investigation examined the associations of plasma human immunodeficiency virus (HIV) RNA and CD4(+) T lymphocytes with height, weight, skeletal maturation, testosterone levels, and height velocity for hemophilic children and adolescents with HIV infection in the Hemophilia Growth and Development Study.

STUDY DESIGN

Two hundred seven participants were evaluated over 7 years.

RESULTS

A threefold increment in baseline plasma HIV RNA was associated with a 0.98-cm decrease in height and a 1.67-kg decrease in weight; 100-cells/microL decrements in baseline CD4(+) were associated with a 2.51-cm decrease in height and a 3.83-kg decrease in weight. Participants with high plasma HIV RNA (>3125 copies/mL) experienced significant delay in achieving maximum height velocity and lower maximum velocity compared with those with low viral load. The high CD4(+) (>243)/low plasma HIV RNA group had earlier age at maximum height velocity compared with the other 3 groups and higher maximum height velocity compared with the low CD4(+)/high plasma HIV RNA and low CD4(+)/low plasma HIV RNA groups. Decrements in CD4(+) were associated with decreases in bone age and testosterone level.

CONCLUSIONS

CD4(+) and HIV RNA were important in predicting growth outcomes.

Hepatitis C virus load is associated with human immunodeficiency virus type 1 disease progression in hemophiliacs

Hepatitis C virus (HCV) and human immunodeficiency virus type 1 (HIV-1) coinfection is common in hemophiliacs and injection drug users. To assess the interaction between HCV load and HIV-1 disease progression, we examined 207 HIV-1/HCV-coinfected patients. Patients were followed prospectively for approximately 7 years, and annual measurements of CD4(+) cell counts and HCV and HIV-1 loads were obtained. Survival analysis was used to define the independent effects of HCV load on HIV-1 progression. After controlling for CD4(+) cell count and HIV-1 RNA level, every 10-fold increase in baseline HCV RNA was associated with a relative risk (RR) for clinical progression to acquired immunodeficiency syndrome (AIDS) of 1.66 (95% confidence interval [CI], 1.10-2.51; P=.016) and an RR for AIDS-related mortality of 1.54 (95% CI, 1.03-2.30; P=.036). These findings emphasize the need for further research regarding the use of HIV-1- and HCV-specific therapy in coinfected individuals.

Two double-blinded, randomized, comparative trials of 4 human immunodeficiency virus type 1 (HIV-1) envelope vaccines in HIV-1-infected individuals across a spectrum of disease severity: AIDS Clinical Trials Groups 209 and 214

The potential role of human immunodeficiency virus type 1 (HIV-1)-specific immune responses in controlling viral replication in vivo has stimulated interest in enhancing virus-specific immunity by vaccinating infected individuals with HIV-1 or its components. These studies were undertaken to define patient populations most likely to respond to vaccination, with the induction of novel HIV-1-specific cellular immune responses, and to compare the safety and immunogenicity of several candidate recombinant HIV-1 envelope vaccines and adjuvants. New lymphoproliferative responses (LPRs) developed in <30% of vaccine recipients. LPRs were elicited primarily in study participants with a CD4 cell count >350 cells/mm(3) and were usually strain restricted. Responders tended to be more likely than nonresponders to have an undetectable level of HIV-1 RNA at baseline (P=.067). Induction of new cellular immune responses by HIV-1 envelope vaccines is a function of the immunologic stage of disease and baseline plasma HIV-1 RNA level and exhibits considerable vaccine strain specificity.

Effects of plasma HIV RNA, CD4+ T lymphocytes, and the chemokine receptors CCR5 and CCR2b on HIV disease progression in hemophiliacs. Hemophilia Growth and Development Study

We have investigated the effects of plasma HIV RNA, CD4+ T lymphocytes and chemokine receptors CCR5 and CCR2b on HIV disease progression in hemophiliacs. We prospectively observed during follow-up 207 HIV-infected hemophiliacs in the Hemophilia Growth and Development Study. Plasma HIV RNA was measured on cryopreserved plasma from enrollment using the Chiron Corporation bDNA (version 2.0) assay. Genoytpe variants CCR2b-641 and CCR5-delta32 were detected using standard molecular techniques. Those with the mutant allele for CCR2b, and to a lesser extent CCR5, had lower plasma HIV RNA, and higher CD4+ T lymphocytes than did those without these genetic variants. After controlling for the effects of plasma HIV RNA and CD4+ T lymphocytes, those with the CCR2b mutant allele compared with those wild-type, had a trend toward a lower risk of progression to AIDS, adjusted relative hazard of 1.94 (95% confidence interval [CI], 0.9-4.18; p = .092), and AIDS-related death, relative hazard 1.97 (95% CI, 0.98-4.00; p = .059). We conclude that plasma HIV RNA, CD4+ T lymphocytes, and CCR genotypes are correlated, and the protective affect of CCR2b against HIV disease progression is not completely explained by plasma HIV RNA or CD4+ T-lymphocyte number.

Influenza vaccination of human immunodeficiency virus (HIV)-infected adults: impact on plasma levels of HIV type 1 RNA and determinants of antibody response

We assessed the effect of influenza vaccination on plasma levels of human immunodeficiency virus type 1 (HIV-1) RNA and the impact of age, plasma HIV-1 RNA level, CD4 cell count, and anti-HIV therapy on immune response. Forty-nine adults (mean age, 38.7 years; mean CD4 cell count +/- SD, 190 +/- 169/mL; mean plasma HIV-1 RNA level +/- SD, 154,616 +/- 317,192 copies/mL) were immunized. Elevations of > or = 0.48 log in plasma HIV-1 RNA levels occurred in two (4%) of 49 subjects within 4 weeks of vaccination. A fourfold or greater increase in antibody titer occurred in 13 (45%) of 29 subjects, correlating directly with CD4 cell count (P = .002) and inversely with plasma HIV-1 RNA level (P = .034). By multivariate analysis, CD4 cell count was a stronger predictor of antibody response than was plasma HIV-1 RNA level. We conclude that increases in plasma HIV-1 RNA levels following influenza vaccination are rare and transient and that antibody response is impaired with CD4 cell counts of < 100/mL and plasma HIV-1 RNA levels of > 100,000 copies/mL. Prospective trials are needed to evaluate the impact of highly active therapy on immune response after vaccination.

Increased transmission of vertical hepatitis C virus (HCV) infection to human immunodeficiency virus (HIV)-infected infants of HIV- and HCV-coinfected women

The transmission of perinatal hepatitis C virus (HCV) infection was studied retrospectively in 62 infants born to 54 HCV- and human immunodeficiency virus (HIV)-coinfected women enrolled in a prospective natural history study of HIV transmission. Infant HCV infection was assessed by nested RNA polymerase chain reaction. The overall rate of vertical HCV transmission was 16.4% (9/62). Most HCV-infected children did not develop antibodies to HCV. The rate of HCV infection was higher among HIV-infected infants (40%) than among HIV-uninfected infants (7.5%; odds ratio, 8.2; P = .009). This difference in transmission was not related to differences in maternal HCV load, as measured by branched DNA assay, or mode of delivery. Why HIV-infected infants of HCV- and HIV-coinfected women have significantly higher rates of perinatal HCV transmission remains to be elucidated. The rate of HCV transmission in HIV-uninfected infants of HCV- and HIV-coinfected women is similar to that reported for infants born to HIV-seronegative mothers.

Proinflammatory cytokine and human immunodeficiency virus RNA levels during early Mycobacterium avium complex bacteremia in advanced AIDS

The relationship between Mycobacterium avium complex (MAC) bacteremia and proinflammatory cytokine and human immunodeficiency virus type 1 (HIV-1) RNA levels in AIDS was investigated. During a prospective study, blood samples were drawn monthly for mycobacterial cultures. Sera were available at baseline and onset of MAC bacteremia from 20 cases and at corresponding times from 19 controls. Mean interleukin-6 (IL-6) levels were 154% greater at the time of MAC bacteremia in cases than in controls. The IL-6 levels correlated with body temperature, serum tumor necrosis factor (TNF-alpha) levels, and alkaline phosphatase levels (P < or = .004 for each). Although TNF-alpha levels tended to rise more in MAC patients than in controls, the difference was not significant. However, among both cases and controls, serum TNF-alpha levels rose significantly from baseline to the time of last sample, irrespective of MAC infection (P = .015). Bacteremia was not associated with increased serum HIV-1 RNA levels. Thus, early MAC bacteremia is associated with increases in serum IL-6 levels, while TNF-alpha levels rise over time during advanced AIDS.

Correlation of virus load in plasma and lymph node tissue in human immunodeficiency virus infection. INCAS Study Group. Italy, Netherlands, Canada, Australia, and (United) States

The impact of long-term changes in plasma viremia, produced by effective combination antiretroviral therapy, on human immunodeficiency virus (HIV) burden within tissue reservoirs is unknown. Fifteen patients who had received at least 1 year of therapy with two or three drug combinations of zidovudine, didanosine, and nevirapine had suitable samples of lymph node tissue obtained by ultrasound-guided core needle biopsy. HIV RNA was extracted from homogenized tissue samples and quantitated using a modified branched DNA assay. Results were correlated with antiretroviral treatment effect on the basis of plasma virus load measurements over the preceding 12-18 months. A statistically significant negative correlation was observed between magnitude of treatment effect on plasma viremia and lymph node virus load. These data suggest that combinations of antiretroviral drugs that produce sustained suppression of plasma HIV RNA may also be able to reduce the virus burden in lymphoid tissues.

Longitudinal analysis of quantitative virologic measures in human immunodeficiency virus-infected subjects with > or = 400 CD4 lymphocytes: implications for applying measurements to individual patients. National Institute of Allergy and Infectious Diseases AIDS Vaccine Evaluation Group

The natural variability of quantitative virologic measures among human immunodeficiency virus (HIV) type 1-infected persons was prospectively studied in 29 untreated persons with >600 CD4 cells/microL and in 15 persons receiving zidovudine monotherapy who had 400-550 CD4 cells/microL at study entry. Cell- and plasma-associated infectious HIV-1, provirus, and virion RNA were determined monthly as were numbers of CD4 and CD8 cells. HIV-1 replication varied widely among subjects with similar CD4 cell counts. The within-individual variability was significantly less than the variability between subjects for all virologic measures. Plasma virion HIV-1 RNA levels had the least variability. A mathematical model was devised to assess whether a potential therapeutic intervention significantly alters peripheral HIV-1 load. The model indicated that three measurements of plasma RNA would be outside the 95th percentile for the expected change in an individual due to natural variability. This approach can be used to accurately assess a therapeutic intervention among persons with low plasma HIV-1 titers.

Safety and immunogenicity of Env 2-3, a human immunodeficiency virus type 1 candidate vaccine, in combination with a novel adjuvant, MTP-PE/MF59. NIAID AIDS Vaccine Evaluation Group

We investigated the safety and immunogenicity of a candidate HIV-1 vaccine, Env 2-3 (Chiron Biocine Co.), in combination with an adjuvant emulsion, MF59, with or without an additional immune modulator, MTP-PE 78 healthy HIV-1-seronegative adults. Sixteen subjects participated in a dose escalation study of MTP-PE in MF59 without Env 2-3, given at 0 and 1 months; 48 subjects participated in a study of a fixed dose of 30 micrograms of Env 2-3 in MF59 with increasing doses of MTP-PE (0, 5, 10, 25, 50, and 100 micrograms), and 14 subjects participated in a study of 100 micrograms of Env 2-3 in MF59 without MTP-PE. Subjects were assigned to study groups under a randomized, double-blind allocation. Subjects received immunization at 0, 1, and 6 months, and had the option of receiving a fourth dose at 12-18 months. Env 2-3 in MTP-PE/MF59 was associated with significant reactogenicity, in that severe, although self-limited systemic and/or local reactions occurred in 15 of 30 vaccinees. In contrast, Env 2-3 in MF59 without MTP-PE was relatively well tolerated, and severe local and/or systemic reactions occurred in only 2 of 18 subjects. Env 2-3 stimulated serum antibodies to HIV-1 envelope protein (gp120) as detected by Western blot in 39 of 43 subjects and to HIV-1 virus lysate by EIA in 28 of 43 subjects after three injections. The majority of subjects also developed EIA antibodies to recombinant gp120 (SF-2), gp120 (LAI), and V3 peptide (SF-2). Neutralizing antibodies to the homologous SF-2 strain developed in 30 of 43 and 27 of 34 subjects, and fusion inhibition antibodies in 25 of 43 and 15 of 36 subjects after three and four injections, respectively. Lymphoproliferative responses to the immunogen, Env 2-3 were observed in over 80% of the vaccinees examined, and CD4+ cytotoxic T cell activity directed against HIV-1 was noted transiently in 2 of 20 vaccinees. Addition of MTP-PE to Env 2-3 or increasing the dose of Env 2-3 from 30 to 100 micrograms did not augment immunogenicity. Env 2-3 in MF59 was well tolerated and immunogenic in HIV-1-seronegative individuals. The addition of MTP-PE significantly increased reactogenicity, but had little, if any, effect on immunogenicity.

Clinical, immunologic, and virologic observations related to human immunodeficiency virus (HIV) type 1 infection in a volunteer in an HIV-1 vaccine clinical trial

A vaccine breakthrough occurred in a phase 1 clinical trial of a human immunodeficiency virus (HIV) type 1 candidate subunit vaccine. The vaccine antigen, gp120SF2, is a fully glycosylated protein produced in mammalian cells from the HIVSF2 isolate. After 4 immunizations, the subject developed neutralizing antibodies and lymphoproliferative responses to the gp120 protein. About 18 weeks after the last immunization, the subject became HIV infected. During the acute phase of infection, there was high virus burden, a decline in CD4+ T lymphocytes, increases in rgp120SF2-binding antibodies and HIVSF2- and HIVMN-neutralizing antibodies, and transient lymphoproliferative responses to HIV-1 envelope and core proteins. The nucleotide sequence of the V3 loop from 2 virus isolations displayed close similarity to the V3 sequence of the vaccine antigen. Thus, the immunologic responses induced by the vaccine in this subject did not protect him from HIV-1 infection.

MF59. Design and evaluation of a safe and potent adjuvant for human vaccines

MF59 is a safe, practical, and potent adjuvant for use with human vaccines. The formulation is easily manufactured, may be sterilized by filtration, and is both compatible and efficacious with all antigens tested to date. MF59 has been shown to be a potent stimulator of cellular and humoral responses to subunit antigens in both animal models and clinical studies. Toxicology studies in animal models and Phase I-III studies in humans have demonstrated the safety of MF59 with HSV, HIV, and influenza vaccines.

Clinical and immunologic responses to human immunodeficiency virus (HIV) type 1SF2 gp120 subunit vaccine combined with MF59 adjuvant with or without muramyl tripeptide dipalmitoyl phosphatidylethanolamine in non-HIV-infected human volunteers

A phase 1 study of 42 non-human immunodeficiency virus type 1 (HIV)-infected volunteers was initiated to determine the safety and immunogenicity of an HIV subunit vaccine consisting of recombinant envelope gp120 derived from HIVSF2 (rgp120SF2) combined with a novel adjuvant, MF59, with or without the immunomodulator muramyl tripeptide dipalmitoyl phosphatidylethanolamine (MTP-PE). All injections contained adjuvant MF59, and subjects were grouped according to MTP-PE dose. Injections were given on days 0, 30, 180, and 365. The vaccine was well tolerated with limited local and systemic reactions. These immunizations induced rgp120SF2-specific binding antibodies that persisted > or = 24 weeks. After three immunizations, all subjects receiving the antigen developed neutralizing antibodies to HIVSF2, and serum from 67% of these subjects also cross-neutralized HIVMN. ELISA-reactive antibodies to the HIVSF2 V3 region and strong lymphoproliferative responses to HIVSF2 envelope proteins were detected in all rgp120SF2-immunized subjects.

Natural history of HIV-associated salivary gland disease

To describe the natural history of HIV-associated salivary gland disease, which is characterized by enlarged major salivary glands and/or xerostomia in HIV-infected persons, we assessed 22 patients at an initial and follow-up examinations (median span of examinations, 15 months). Sixteen patients (73%) had bilateral parotid gland enlargement, 17 had symptoms of dry mouth, and 11 had both conditions. Parotid gland enlargement remained unchanged in 10 patients, it progressed in 2, and it regressed in 4 during treatment with zidovudine or steroids. Those patients with parotid gland enlargement had a significantly lower mean stimulated parotid flow rate (0.27 ml/min/per gland) than a control group of HIV+ persons without salivary gland disease (0.48 ml/min/per gland) (p less than 0.05), whereas the mean unstimulated whole salivary flow rates did not did not differ significantly between the two groups. The mean salivary flow rate of the study group did not change during the observation period. When HIV-associated salivary gland disease was diagnosed, 5 patients (23%) had AIDS, and at follow-up 10 (46%) had AIDS. Seven of these had Kaposi's sarcoma. The mean peripheral blood CD4 cell count was 280 and 225 per mm3 at the initial and follow-up examinations, respectively. The corresponding CD8 counts were 1138 and 900. The pathogenesis of HIV-associated salivary gland disease may include hyperplasia of intra-parotid lymphoid tissue. Because HIV-associated salivary gland disease can clinically resemble Sjögren's syndrome, the differential diagnosis of bilateral parotid enlargement should include HIV infection.

Intravenous or inhaled pentamidine for treating Pneumocystis carinii pneumonia in AIDS. A randomized trial

OBJECTIVE

To evaluate the efficacy and toxicity of aerosolized pentamidine and of reduced-dose intravenous pentamidine for the treatment of mild to moderate Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome (AIDS).

DESIGN

Randomized open study with serial pulmonary function testing and measurement of pentamidine concentrations in plasma and bronchoalveolar lavage fluid.

PATIENTS

Of 44 men and 1 woman with a mild to moderate first episode of P. carinii pneumonia (Pao2 greater than or equal to 7.3 kPa [55 mm Hg]), 23 received aerosolized pentamidine and 22, intravenous pentamidine.

INTERVENTIONS

Pentamidine isethionate, 600 mg by inhalation using a Respirgard II nebulizer (Marquest Medical Products, Inc., Englewood, Colorado) or 3 mg/kg body weight intravenously, administered once daily for 2 to 3 weeks.

MEASUREMENTS AND MAIN RESULTS

The planned 60-patient study was stopped after 45 patients had been enrolled. The rates (aerosolized compared with intravenous pentamidine) of initial failure, early recrudescence of symptoms, and relapse were 12% and 19% (difference, 7%; 99% confidence interval [CI], - 23% to 37%; P = 0.67), 35% and 0% (difference, 35%; CI, 13% to 58%; P = 0.02), and 24% and 0% (difference, 24%; CI, 4% to 49%; P = 0.03). The rates (aerosolized compared with intravenous pentamidine) of major toxicity were 0% (0 of 17 patients) and 10% (2 of 21 patients) (difference 10%; CI, -1% to 29%; P = 0.24). The mean (+/- SD) pentamidine concentration in bronchoalveolar lavage fluid for patients receiving aerosolized pentamidine was 96.6 +/- 65.1 ng/mL compared with 14.4 +/- 17.7 ng/mL for patients receiving intravenous treatment. Trough concentrations of pentamidine in plasma increased from 0 to 25.4 +/- 16.4, 56.5 +/- 26.1, and 61.1 +/- 56.0 ng/mL at the end of weeks 1, 2, and 3 of intravenous therapy, respectively.

CONCLUSIONS

The data suggest that reduced-dose intravenous pentamidine was more effective than aerosolized pentamidine for treating mild to moderate P. carinii pneumonia. Systemic absorption during aerosolized therapy was minimal; daily doses of intravenous pentamidine resulted in increased accumulation of pentamidine in plasma.

Does HIV cause salivary gland disease?

HIV-associated salivary gland disease (HIV-SGD) is characterized by enlargement of the major salivary glands and/or xerostomia. HIV does not appear to play a direct role in this disease since it was detected by immunohistochemistry in only occasional lymphocytes in labial salivary glands in two out of six patients; it was not found in the salivary gland epithelial cells. Moreover, HIV was not found in any of 21 saliva samples from seven patients. We conclude that HIV-SGD is not caused by direct infection of the salivary glands with HIV.

Prevention of Pneumocystis carinii pneumonia by inhaled pentamidine

The efficacy and toxicity of pentamidine inhaled once a month to prevent Pneumocystis carinii pneumonia (PCP) was investigated in 102 patients with the acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC). The cohort was compared with historical controls after a mean duration of prophylaxis of 6.38 months. 86% and 15% of the patients had AIDS or ARC, respectively. 50% of patients had had one previous episode of PCP, 9% had had two episodes, and 3% had had three. 11 patients acquired PCP. Among these 51 patients with one prior episode of PCP, the PCP-free survival after 3.03, 4.7, and 6.38 months of prophylaxis was 98%, 92%, and 82%, respectively. Compared with those for historical controls, the data suggest that inhaled pentamidine can delay relapse by 6 months and reduce the rate of relapse by 50%. PCP acquired while patients were inhaling pentamidine prophylactically was mild and had a case-fatality rate of only 9%. Further investigation of the prophylactic value of inhaled pentamidine is warranted.

Identification of the minor guanylated tRNA of rabbit reticulocytes

Two of the tRNA's found in rabbit reticulocytes are substrates for a post-transcriptional modification leading to the incorporation of guanine into the polynucleotide chain. The major guanylated tRNA was previously identified as tRNA (His). In the present report we show that the minor guanylated tRNA is tRNA (Asn), and that just as in the case of tRNA (His), the guanine is located in an internal position. There are only two tRNA (Asn) in reticulocytes. We further show that one of these, the one that is not labeled with guanine, contains the hypermodified base known as Q. tRNA (Asn) does not contain Q.