Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Effect of VTE1 AND VTE4 gene inactivation on salt stress response in Arabidopsis thaliana

The effect of inactivation of VTE1 and VTE4 genes, encoding enzymes involved in tocopherol biosynthesis, on concentrations of chlorophylls, carotenoids, anthocyanins and activity of catalase and guaiacol peroxidase in Arabidopsis thaliana under salt stress conditions were studied. It was shown, that the inactivation of the VTE4 gene in A. thaliana caused the decrease in concentrations of chlorophylls and carotenoids, and at the same time, inactivation of VTE1 gene resulted in 3.6-fold increase of catalase activity in comparison with the wild type. Under salt stress, the activities of guaiacol peroxidase increased in all investigated plant groups, while the concentrations of carotenoids increased only in the wild type and vte4 mutant line of A. thaliana. Salt stress did not change the concentrations of protein carbonyl groups and activities of catalase.

Feet rolled over by cars: radiological and histological considerations from experiments

This study investigates the question of whether bone structures are injured when a vehicle rolls over a foot. A total of 15 detached feet from deceased persons who had donated their bodies to research were rolled over using a VW Passat station wagon. The feet were enclosed in various types of shoes. The front left tire of the vehicle, inflated to 1.8 bar and driven at walking speed, ran over the feet at a right angle to the long axis. The feet were dissected, and histological and radiological examinations were carried out. The only macroscopically well-defined abrasions of the epidermis were on the back of the foot in the area of contact with the tire and only where the foot had not been covered by a shoe. These abrasions were also well presented histologically. No injuries to the bone structures of the feet, in the form of incomplete fractures, corticalis interruptions or spongiosa compressions were ascertained, either radiologically or microradiologically.

[Traumatic partial amputation of a penis--a reconstruction of the circumstances of the accident]

A 61-year-old man was admitted to hospital with a partially severed penis. The head of the penis (glans) had been completely severed, and the skin of the shaft and the corpora cavernosa had been ripped open. In the hospital the patient reported that his penis got caught in the hose attachment of an old Kobold vacuum cleaner that he was using to inflate an air mattress. He later made contradictory statements in his report to the insurance company, so we were asked to reconstruct the circumstances of the accident. The literature available to us only makes clinical observations about similar accidents, always with the assumption that the vacuum cleaner was used during masturbation or in order to achieve an erection. According to our reconstruction of the accident and an investigation of the vacuum cleaner attachment, however, we could not rule out the possibility of a household accident as described by the patient.

Acute coronary syndrome: pharmacotherapy

Acute coronary syndrome (ACS) refers to the spectrum of cardiac disease, from unstable angina to ST-segment-elevation myocardial infarction. In the emergency medical services (EMS) setting, ACS may be more broadly thought to include patients with chest pain or other symptoms believed to have a cardiac origin who have evidence of ischemia or acute myocardial infarction on a 12-lead electrocardiogram, or symptomatic patients with a previous cardiac event or known cardiac disease. Pharmacologic management of these patients is based on the use of three primary classes of drugs: those that affect clotting, those that establish and maintain hemodynamic control, and those that relieve pain. Many of these agents have been evaluated in large clinical trials for in-hospital use, and a number of ongoing studies are assessing their efficacy in the prehospital setting. The appropriateness of prehospital use of specific agents within each class depends on proper patient selection, the necessity of immediate intervention, ease of use in the field, expertise of EMS personnel, and cost-effectiveness of therapy. This consensus group reviewed agents from all three classes (including aspirin, GPIIb/IIIa inhibitors, unfractionated and low-molecular-weight heparins, fibrinolytics, beta-adrenergic blockers, calcium antagonists, nitrates, and morphine) for their overall indication, applicability to the prehospital setting, and current prehospital use.

The eye irritation and odor potencies of four terpenes which are major constituents of the emissions of VOCs from Nordic soft woods

Eye goggles were used to estimate human thresholds for sensory eye irritation from four monoterpenes: (+)3-carene, (-)limonene and (+)alpha-pinene and (rac)alpha-terpineol all known as air pollutants emitted from wood. Only a ranking of the irritation thresholds relative to that of n-butanol is given. The measurements showed that the thresholds for eye irritation of the terpenes ranged from subthreshold to below 1,250 mg/m3. It appears that the irritation of 3-carene and limonene in contrast to the expectations was of the same size as or less than that of n-butanol. Too few subjects reported eye-irritation for alpha-pinene and alpha-terpineol to allow estimates of thresholds of these compounds which therefore have much less irritative potency than n-butanol, 3-carene, and limonene. The measurements of one terpene alcohol do not support the hypothesis that monoterpene alcohols, would have lower eye irritation threshold than monoterpene hydrocarbons. The sequence from strongest odorant to weakest was alpha-terpineol, 3-carene, n-butanol, limonene and alpha-pinene. In conclusion, the tested terpenes can probably be ruled out as cause of acute eye irritation indoors. The measured odor thresholds did not deviate from the few values reported in the literature.

[Smoking habits and attitude toward tobacco use among health professionals in Denmark in 1996]

The purpose of the study was to investigate smoking habits in different groups of health professionals. A total of 7844 were interviewed using postally distributed questionnaires. The response rate was 85%. The study showed a much lower smoking prevalence among groups of health professionals compared to the normal population apart from social assistants and hospital porters, where the smoking rate was even higher than in the Danish population. Among medical doctors, dentists, nurses and midwives the smoking rate had decreased faster from earlier investigations than among the Danish population. Future strategy in Danish policy concerning campaigns in the population and among health professionals as role-models is discussed. Fifty-two percent of the interviewed agreed that health professionals should not smoke, while on duty, but with quite big differences between the groups (min. 31% among hospital porters, max. 73% among dentists).

Isolation of endothelial cells and their progenitor cells from human peripheral blood

PURPOSE

We have developed techniques to isolate endothelial cell (EC) progenitors from human peripheral and umbilical cord blood.

METHODS

Human adult peripheral and umbilical cord blood monocytes were isolated by centrifugation, and progenitor cells were separated with the use of magnetic polystyrene beads that were coated with a monoclonal antibody specific for the CD34 cell-membrane antigen. Cells were propagated in selective media, and developing cultures were immunostained for CD31, CD34, factor VIII, and vascular endothelial growth factor cell receptors. ECs that developed were transfected with a gene for prourokinase and used to line ePTFE grafts, which were evaluated in vitro in a pulsatile flow system.

RESULTS

Umbilical cord monocyte cultures demonstrated colonies that resembled ECs at approximately 2 weeks, with growth being best supported by EC growth media plus 20% calf serum with iron. Immunostaining of colonies was positive for CD31 and factor VIII. After 18 days in culture, CD34(+) cells from adult peripheral blood were noted, which had the typical cobblestone appearance of ECs and immunostained positively for CD31 and factor VIII-related antigens. Cultures of umbilical cord-derived cells and adult peripheral blood-derived cells developed complex line formations within 1 week in culture that stained positively for vascular endothelial growth factor receptor-2. Urokinase-transfected ECs were shown to overexpress urokinase. Prosthetic grafts lined with transfected cells showed 87.33% +/- 4.97% cell adherence after 2 hours in a pulsatile flow system at clinically relevant shear stress.

CONCLUSION

We conclude that endothelial progenitor cells can be isolated from human adult peripheral and umbilical cord blood and developed into EC cultures as a source of cells for vascular graft seeding and gene therapy.

NrCAM, cerebellar granule cell receptor for the neuronal adhesion molecule F3, displays an actin-dependent mobility in growth cones

The neuronal adhesion glycoprotein F3 is a multifunctional molecule of the immunoglobulin superfamily that displays heterophilic binding activities. In the present study, NrCAM was identified as the functional receptor mediating the inhibitory effect of F3 on axonal elongation from cerebellar granule cells. F3Fc-conjugated microspheres binding to neuronal growth cones resulted from heterophilic interaction with NrCAM but not with L1. Time-lapse video-microscopy indicated that F3Fc beads bind at the leading edge and move retrogradely to reach the base of the growth cone within a lapse of 30–60 seconds. Such velocity (5.7 microm/minute) is consistent with a coupling between F3 receptors and the retrograde flow of actin filaments. When actin filaments were disrupted by cytochalasin B, the F3Fc beads remained immobile at the leading edge. The retrograde mobility appeared to be dependent on NrCAM clustering since it was induced upon binding with cross-linked but not dimeric F3Fc chimera. These data indicate that F3 may control growth cone motility by modulating the linkage of its receptor, NrCAM, to the cytoskeleton. They provide further insights into the mechanisms by which GPI-anchored adhesion molecules may exert an inhibitory effect on axonal elongation.

The Dysphagia Outcome and Severity Scale

The Dysphagia Outcome and Severity Scale (DOSS) is a simple, easy-to-use, 7-point scale developed to systematically rate the functional severity of dysphagia based on objective assessment and make recommendations for diet level, independence level, and type of nutrition. Intra- and interjudge reliabilities of the DOSS was established by four clinicians on 135 consecutive patients who underwent a modified barium swallow procedure at a large teaching hospital. Patients were assigned a severity level, independence level, and nutritional level based on three areas most associated with final recommendations: oral stage bolus transfer, pharyngeal stage retention, and airway protection. Results indicate high interrater (90%) and intrarater (93%) agreement with this scale. Implications are suggested for use of the DOSS in documenting functional outcomes of swallowing and diet status based on objective assessment.

Adenocarcinoma of the pancreatic head: a community teaching hospital's experience from 1982 to 1992

The treatment of adenocarcinoma of the pancreatic head remains variable, with multiple therapeutic options including surgery, biliary stenting, chemotherapy, and radiation therapy. We retrospectively reviewed our experience from 1982 through 1992, which included 160 patients with this diagnosis, evaluating their treatments and outcomes. There were 66 males and 94 females, with a mean age of 70+/-11 years. Forty patients (25%) had no surgery; of these, 27 had no further treatment, whereas 13 received chemotherapy and/or radiation therapy (CT/RT). Of 120 patients who had surgical exploration, only 19 (16%) were resectable for a potential cure. Eleven of these resected patients had no additional therapy, whereas 8 patients received adjuvant CT/RT. Of the 101 unresectable patients, 62 had no further therapy and 39 received CT/RT. Twenty-two patients (14%) had biliary stents placed, 11 in lieu of surgery, 7 preoperatively, and 4 postoperatively. Perioperative mortality was no different for resectable patients (16%) versus unresectable patients (14%). Overall, 90 patients (56%) had one or more complications related to their disease or treatment, with no differences between groups. Median survivals were as follows: no treatment, 1 month; no surgery with CT/RT, 3.5 months; unresectable with no further treatment, 4 months; unresectable with CT/RT, 8 months; resection with no additional treatment, 17 months; and resection with CT/RT, 13 months. Patients with resectable disease had a significantly longer survival than patients who had no surgery (P < 0.001) or who were unresectable at exploration (P < 0.001); the addition of CT/RT after resection had no effect on survival (P = 0.8). The addition of CT/RT significantly increased survival for patients who had no surgery (p = .001) and for patients who were explored but were unresectable (p = .002). In conclusion, despite dismal results, surgery remains the mainstay of treatment for adenocarcinoma of the pancreatic head. Although CT/RT did not increase the median survival after resection, it doubled the median survival after noncurative surgery.

Improved adherence of genetically modified endothelial cells to small-diameter expanded polytetrafluoroethylene grafts in a canine model

PURPOSE

A significant limitation to using genetically modified endothelial cells (ECs) to seed prosthetic grafts before implantation has been poor cell adherence to the graft lumen. Methodologic changes to improve cell adherence were evaluated in a canine carotid interposition graft model using 4 mm interior diameter expanded polytetrafluoroethylene.

METHODS

ECs harvested from external jugular veins were grown in culture, with 80% of the cells from each culture transduced by incubation with an LXSN-type retroviral vector carrying a gene for human prourokinase and a neomycin resistance gene for selection in antibiotic G418. Control grafts had passive luminal coating with fibronectin and were seeded with transduced ECs immediately after G418 selection; these grafts were incubated for 2 days before implantation. Experimental grafts had fibronectin forcefully squeezed through the interstices and were seeded with ECs that had recovered in culture for 5 days after G418 selection; these grafts were incubated for 4 days before implantation. For each control (n = 9) and experimental (n = 12) graft, a graft prepared in the same fashion but seeded with the remaining autologous nontransduced cells was placed in the contralateral carotid artery. Grafts were explanted after 30 days and were evaluated for patency, thrombus-free surface area, and cell-free surface area.

RESULTS

No significant differences in patency rates were seen between any groups. The thrombus-free surface area was improved for experimental grafts (90%) compared with control grafts (76%), but this improvement did not achieve statistical significance. The cell-free surface area for transduced cells on experimental grafts was 65% compared with 96% for control grafts (p = 0.021) and was comparable with that for nontransduced cells on both control grafts (62%) and experimental grafts (51%; p = 0.201).

CONCLUSIONS

Adherence of genetically modified endothelial cells to small-diameter expanded polytetrafluoroethylene grafts in an in vivo physiologic flow model is significantly improved when cells have a more prolonged recovery from G418 selection, when the graft lumen is more uniformly coated with fibronectin before EC seeding, and when seeded grafts are left longer in culture before implantation to develop cell lining stability. The short-term patency rate of these seeded grafts is not affected by increased cell retention; long-term graft patency data and luminal healing require further evaluation.

Transcriptionally active chromosomes (TACs) of barley chloroplasts contain the alpha-subunit of plastome-encoded RNA polymerase

Transcriptionally active chromosomes (TACs) were isolated from mature chloroplasts of barley, from proplastids enriched in basal segments of barley primary foliage leaves, and from ribosome-deficient plastids of heat-bleached barley leaves. Immunological analysis with a specific antibody raised against the plastid rpoA gene product revealed that chloroplasts contain an immunoreactive protein of 38 kDa in the TAC fraction which appears to be identical to the alpha-subunit contained in the soluble RNA polymerase (sRNAP) fraction of the same chloroplasts. However, only traces of immunoreactive protein were detected in a TAC preparation derived from "proplastids". A positive correlation could be demonstrated between transcriptional activity and the amount of immunoreactive 38-kDa protein by analyzing different TAC fractions eluting at different times during gel filtration of a standard TAC preparation as well as in TAC preparations obtained under various detergent conditions.

Polarization-dependent phase locking in stimulated Brillouin scattering systems

Measurements of the mutual coherence of the output beams from a seeded, two-pump-beam, stimulated Brillouin scattering system are reported. Mutual coherence depends on the relative polarizations of the pump beams and the seed beam. A seed beam can phase-lock the Stokes outputs even if the pump beams are orthogonally polarized. Four-wave mixing is responsible for this phase locking.

Immunoepidemiology of post-Salmonella reactive arthritis in a cohort of women

Following a foodborne outbreak of Salmonella dysentery in a group of 79 women and 4 men, 6 individuals were found to have reactive arthritis (ReA). None of the affected individuals had the classical genetic marker HLA B27 although 2 of the 6 had CREG antigens. IgA antibodies to the lipopolysaccharide of the causative organism, Salmonella heidelberg, were found to be elevated in those patients with active ReA compared to those with inactive ReA or those who had dysentery but did not develop ReA. The lymphocyte proliferative response to both PHA and the whole S. heidelberg organism was impaired in the patients with ReA (active or inactive) compared with the non-ReA patient controls. In this predominantly female outbreak of Salmonellosis, the development of ReA lacked an association with HLA class I antigens commonly recognized.

Interplay of microbe and major histocompatibility complex: a family study

We describe a 24-year-old man who developed reactive arthritis (ReA) after a dysenteric illness caused by Salmonella hadar. Serologic tests suggested recent exposure of family members to Salmonella. All members of the family were HLA-B27 positive, but no other family member developed acute ReA, although 2 of them had clinical evidence of previously existing B27 associated arthritis.

Beam coupling, stimulated Brillouin scattering, and four-wave mixing

Measurements of the probability density function of the mutual coherence of two stimulated-Brillouin-scattered Stokes outputs are reported. The variation of the probability density function with the polarization, relative intensities, and overlap of the pumping laser beams demonstrates that the coupling between the Stokes outputs is due to four-wave mixing.

Conditioned taste aversion but not adrenal activity develops to ICV administration of interleukin-1 in rats

In a previous investigation with mice, the paired presentation of either odor or taste cues with the peripheral (IP) administration of the immunoactive peptide interleukin-1 (IL-1) led to the conditioned enhancement of glucocorticoid production. The present study found that an initial central infusion of IL-1 in the presence of saccharin cues produced a robust taste aversion but not a conditioned elevation of either ACTH or corticosterone production. These results indicate that the glucocorticoid response induced by centrally administered IL-1 in rats is independent of the behaviorally aversive properties of this cytokine which are conditionable. The differential effects of IP versus ICV administration of IL-1 on glucocorticoid conditioning requires a clearer specification of the respective signaling mechanisms and pathways activated by these two routes of administration.

Suppression of splenic macrophage interleukin-1 secretion following intracerebroventricular injection of interleukin-1 beta: evidence for pituitary-adrenal and sympathetic control

Intracerebroventricular (ICV) injections of interleukin-1 beta (IL-1 beta) produced a dose-dependent increase in plasma corticosterone and adrenocorticotropic hormone (ACTH) within 2 hr of injection and then declined over the next 24 hr. Using a potent steroidogenic dose of IL-1 beta (5 ng), ICV injection resulted in suppression of splenic macrophage IL-1 secretion following stimulation by LPS in vitro. Macrophage TGF-beta secretion was not affected, indicating a differential action of ICV IL-1 beta on macrophage cytokine production. Following adrenalectomy (ADX), the suppressive effect of ICV IL-1 beta was reversed and resulted in stimulation of macrophage IL-1 secretion, indicating that the suppression was mediated by adrenocorticol activation. However, surgical interruption of the splenic nerve to eliminate autonomic innervation of the spleen also prevented the macrophage suppressive signal in rats given ICV IL-1 beta. Furthermore, the combination of ADX and splenic nerve section resulted in a potent stimulatory effect of ICV IL-1 beta on splenic macrophage IL-1 secretion which was greater than either ADX or splenic nerve section alone. These results support the concept of a negative feedback on macrophage IL-1 secretion by the central action of IL-1 beta and indicate that both the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system mediate this effect.

The Pavlovian conditioning of IL-1-induced glucocorticoid secretion

Recombinant IL-1-beta, which is capable of stimulating the pituitary-adrenal axis to secrete corticosterone, was paired with environmental cues in either a taste aversion or odor conditioning procedure. Among mice receiving paired delivery of cues and IL-1, subsequent re-exposure to cues elicited corticosterone production. This response was significantly greater than in animals that were conditioned but not re-exposed to the cues or were exposed to the cues alone. These results indicate that the IL-1 activation of adrenal cortical secretion can be conditioned to environmental stimuli.

The significance of the anti-class I antibody response. I. Clinical and pathologic features of anti-class I-mediated rejection

In renal transplantation, preformed cytotoxic antibody against donor HLA class I antigens causes hyperacute rejection of renal allografts, but its pathogenic significance when it develops in the posttransplant period is unknown. In the present studies we describe the clinical and pathologic features of patients with rejection associated with anti-class I. In the course of 400 consecutive cadaveric renal transplants, 7 patients were identified who had antibody against donor class I HLA antigens in association with atypical but distinctive patterns of rejection. All 7 were presensitized. In 3 patients, the transplant had been inadvertently performed with a positive donor-specific T cell crossmatch. In the remaining 4, the T cell crossmatch on current sera was negative but became positive posttransplant. The clinical picture was deterioration of graft function with rapid onset of oliguria, apparently due to acute tubular necrosis, but with persistence of blood flow demonstrable by radioisotope scan studies. Renal histology showed that the typical lesions observed in cell-mediated rejection, such as tubulitis and interstitial infiltration, were absent. Granular complement deposition (6), polymorphonuclear infiltration (6), and endothelial injury in the microvasculature (6) were common, and mononuclear infiltrates were absent (2) or not prominent (4). In 3 patients the glomerular changes resembled a picture of hemolytic uremic syndrome, with capillary fibrin thrombi and widening of the subendothelial space. IgG staining was negative. The pathologic features suggest that anti-class I antibody appearing or persisting in the early posttransplant period injures the endothelium of the microvasculature, with the clinical presentation different from that of hyperacute rejection. Particularly in sensitized patients, rapid deterioration in function, leading to a picture of acute tubular necrosis, with pathologic features of endothelial injury in the microcirculation, should suggest the diagnosis of anti-class I-mediated rejection.