Efficacy and safety of onasemnogene abeparvovec in children with spinal muscular atrophy type 1: real-world evidence from 6 infusion centres in the United Kingdom

Background

Real-world data on the efficacy and safety of onasemnogene abeparvovec (OA) in spinal muscular atrophy (SMA) are needed, especially to overcome uncertainties around its use in older and heavier children. This study evaluated the efficacy and safety of OA in patients with SMA type 1 in the UK, including patients ≥2 years old and weighing ≥13.5 kg.

Methods

This observational cohort study used data from patients with genetically confirmed SMA type 1 treated with OA between May 2021 and January 2023, at 6 infusion centres in the United Kingdom. Functional outcomes were assessed using age-appropriate functional scales. Safety analyses included review of liver function, platelet count, cardiac assessments, and steroid requirements.

Findings

Ninety-nine patients (45 SMA therapy-naïve) were treated with OA (median age at infusion: 10 [range, 0.6-89] months; median weight: 7.86 [range, 3.2-20.2] kg; duration of follow-up: 3-22 months). After OA infusion, mean ± SD change in CHOP-INTEND score was 11.0 ± 10.3 with increased score in 66/78 patients (84.6%); patients aged <6 months had a 13.9 points higher gain in CHOP-INTEND score than patients ≥2 years (95% CI, 6.8-21.0; P < 0.001). Asymptomatic thrombocytopenia (71/99 patients; 71.7%), asymptomatic troponin-I elevation (30/89 patients; 33.7%) and transaminitis (87/99 patients; 87.9%) were reported. No thrombotic microangiopathy was observed. Median steroid treatment duration was 97 (range, 28-548) days with dose doubled in 35/99 patients (35.4%). There were 22.5-fold increased odds of having a transaminase peak >100 U/L (95% CI, 2.3-223.7; P = 0.008) and 21.2-fold increased odds of steroid doubling, as per treatment protocol (95% CI, 2.2-209.2; P = 0.009) in patients weighing ≥13.5 kg versus <8.5 kg. Weight at infusion was positively correlated with steroid treatment duration (r = 0.43; P < 0.001). Worsening transaminitis, despite doubling of oral prednisolone, led to treatment with intravenous methylprednisolone in 5 children. Steroid-sparing immunosuppressants were used in 5 children to enable steroid weaning. Two deaths apparently unrelated to OA were reported.

Interpretation

OA led to functional improvements and was well tolerated with no persistent clinical complications, including in older and heavier patients.

Funding

Novartis Innovative Therapies AG provided a grant for independent medical writing services.

Antineurofascin IgG2-associated paediatric autoimmune nodopathy

In this case series of four paediatric patients, we present the first described cases of immunotherapy-responsive autoimmune nodopathy with IgG2 antineurofascin antibodies. In three cases, the antineurofascin antibodies were predominantly of the IgG2 subclass, a novel finding in comparison to previously described adult cases where IgG4 and/or IgG1/3 have typically been described. One patient had low signal for IgG2 with predominant IgG1 and IgG4 antibodies, a pattern commonly seen in adult patients. Two patients had antibodies targeting all three neurofascin isoforms (155, 186, and 140), whereas antibodies in the sera from the third targeted only the nodal isoforms 186 and 140, and the fourth patient only neurofascin 155. The three patients with IgG2 predominant antibodies appear to be responsive to intravenous immunoglobulin (IVIG) to varying degrees thus far, whereas the patient with IgG1/4 antibodies had poor response to IVIG but good response to steroids. Although the full clinical significance of IgG2 predominant antineurofascin antibodies in the context of childhood polyneuropathy remains unclear, emerging evidence of serological-phenotypic correlation may inform prognostication and therapeutic decision-making, warranting further study into this area. WHAT THIS PAPER ADDS: Paediatric immunotherapy-responsive nodopathies were associated with antineurofascin antibodies predominantly of the IgG2 subclass in 3 out of 4 patients. Identification of antibodies and understanding their phenotypic relevance could predict response to treatment and guide therapeutic decision-making in children.

Dental drill noise reduction using a commercially-available earplug device

AIM

The dental handpiece noise in a dental surgery is concerning to both patients and staff as a major cause of dental phobia in patients and potential hearing loss in clinical staff. High-frequency noise generated by dental handpieces is considered to be the worst of the many noises in a dental clinic. Methods to reduce this noise have been proposed and either passive or active noise reduction headphones are often suggested. However, in a dental surgery environment, the need for good verbal communication with the patient needs to be maintained. As a result, this paper aims to evaluate one proprietary anti-noise device considered suitable for this specific purpose.

METHODS

Lab-based experiments were set up and carried out to evaluate QuietOn, using GRAS 43AG-1 Ear and Cheek Simulator to mimic a section of the human head and ear to represent the acoustic characteristics of an actual ear. Two types of dental drill noise recordings, one for electric motor-driven and another one for air turbine-driven, were played back through high-definition speakers. Sound data captured by the simulator are then visualised and plotted using MATLAB for analysis.

MAIN FINDINGS

QuietOn is effective at low frequencies (< 1kHz). However, when dealing with high-frequency noise such as dental handpieces it is ineffective yet subdues verbal communication.

CONCLUSIONS

Further development of passive or active noise cancellation earplugs is still needed to target dental handpiece noise while maintaining verbal communication.

Real-world experience of gene therapy with onasemnogene-abeparvovec (Zolgensma®) for patients with SMA-type1 in UK

Conclusion

All patients tolerated the Zolgensma®-therapy well and have recovered well from any transient issues. No persistent complications from gene-therapy or steroid-cover were reported.

How paediatricians investigate early developmental impairment in the UK: a qualitative descriptive study

Background

Early developmental impairment (EDI) is common and has many aetiologies and, therefore, potential investigations. There are several published guidelines recommending aetiological investigations, and paediatricians’ views of them varies. Little is known on the thought processes underlying clinical decisions in investigating EDI. This study aimed to describe the thought processes affecting clinical decisions on the investigation of EDI within a nationalised health care system.

Methods

A qualitative descriptive study using semi-structured qualitative interviews performed in person or via video link with paediatricians who see children with EDI in England. As part of the interview, a case study of a fictional disease, Cavorite deficiency, modelled on biotinidase deficiency, was given to participants with the cost of testing, incidence and likelihood it would respond to treatment. This allowed exploration of cost without encumbrance from predisposing views and training on the condition. Thematic analysis was performed by iterative approach. Where participants stated they wanted to redirect money from investigations to treatment, were that even possible, we asked which services they would like to be better funded in their area.

Results

Interviews were conducted with 14 consultant paediatricians: 9 Community / Neurodisability, 2 General paediatricians, and 3 Paediatric Neurologists. Two themes were identified: the value of an aetiological diagnosis to families and managing risk and probability when investigating EDI. The latter contained 4 subthemes: ‘circumspection’ involved blanket investigations chosen irrespective of phenotype and high regard for guidelines; ‘accepting appropriate risk’ involved participants choosing investigations based on clinical phenotype, recognising some aetiologies would be missed; consultants found they ‘transitioned between practices’ during their career; and ‘improved practice’ was thought possible with better evidence on how to stratify investigations based on phenotype. Services that were most frequently reported to need additional funding were therapy services, early community developmental services, management of behaviour, sleep and mental health, and educational support.

Conclusions

There are many factors that influence paediatricians’ choice of aetiological investigation in EDI, but clinical factors are the most important. Paediatricians want better evidence to allow them to select the right investigations for each child without a significant risk of missing an important diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03233-1.

The association of peak systolic velocity in the carotid artery with coronary heart disease: A study based on portable ultrasound

Cardiovascular disease (CVD) is the highest cause of death globally with more people dying annually from it than from any other cause. CVD is associated with modifiable risk factors (dyslipidaemia, hypertension and diabetes) and treating each of these factors lowers the risk of CVD. It is impossible to estimate the benefit of risk factor modification in the individual patient and extrapolating data from multiple trials is difficult. It would be useful to have a marker of risk that accurately estimates real time risk by measuring blood flow factors associated with the pathogenesis of atheroma. The aim of this preliminary study was to validate a low-cost measurement technique for obtaining blood flow velocity profiles and assess whether any of the measured and calculated factors, based on computational fluid dynamics (CFD) simulation, known to be associated with atheroma was associated with coronary heart disease (CHD), thus establishing its feasibility and acceptability as a clinical tool and suggesting areas for future research. Our study identified (i) that mean peak systolic (PS) velocity being associated with CHD; individuals without CHD: mean (SD) = 62.8 (16.1) cm/s, with CHD: mean (SD)  = 53.6 (17.3) cm/s, p = 0.042; and (ii) that low-cost, portable ultrasound, which is routinely available in general practice, is a suitable assessment tool.

Aetiological investigations in early developmental impairment: are they worth it?

OBJECTIVE

To study the frequency a diagnosis is made in children with early developmental impairment (EDI), and the contribution made to diagnosis by specific investigations.

DESIGN

Retrospective case note review.

SETTING

Community, neurodisability and neurology department at a UK tertiary centre.

PARTICIPANTS

Children referred to determine the aetiology of EDI where a cause was not evident on history and examination. Participants were divided into two groups: EDI and no additional features (EDI-) and EDI with additional features (EDI+).

MAIN OUTCOME MEASURES

The frequency a cause was found for the child's EDI and which tests contributed to a diagnosis.

RESULTS

699 participants, 68.8% boys, median age at investigation 2 years 8 months (range 3 months to 11 years 5 months). 61 (8.7%) of participants had no investigations, and children with EDI- were less likely to be investigated (χ²=12.5, p<0.05). A diagnosis was made in 166 children (23.7%) and was more frequent in EDI+ (EDI- 9.9%, EDI+ 27.3%, χ²=19.0; p<0.05). Full blood count, zinc protoporphyrin, renal or liver function, bone profile, biotinidase, creatine kinase or lead level revealed no diagnoses. The following investigations found causes for EDI: MRI (23.1%), microarray (11.5%), Fragile X (0.9%), plasma amino acids (1.2%), urine organic acids (0.9%) and thyroid function tests (0.5%).

CONCLUSIONS

The majority of 'screening' investigations for EDI do not contribute to a diagnosis, highlighting an area of cost saving for the NHS and reduced burden for patients and families. We propose a streamlined guideline for the investigation of EDI based on our data.

Design for invention: annotation of functional geometry interaction for representing novel working principles

In some mechanical engineering devices the novelty or inventive step of a patented design relies heavily upon how geometric features contribute to device functions. Communicating the functional interactions between geometric features in existing patented designs may increase a designer's awareness of the prior art and thereby avoid conflict with their emerging design. This paper shows how functional representations of geometry interactions can be developed from patent claims to produce novel semantic graphical and text annotations of patent drawings. The approach provides a quick and accurate means for the designer to understand the patent that is well suited to the designer's natural way of understanding the device. Through several example application cases we show the application of a detailed representation of functional geometry interactions that captures the working principle of familiar mechanical engineering devices described in patents. A computer tool that is being developed to assist the designer to understand prior art is also described.

Loss of MIR15A and MIR16-1 at 13q14 is associated with increased TP53 mRNA, de-repression of BCL2 and adverse outcome in chronic lymphocytic leukaemia

This study was conducted to investigate the possibility that TP53 mRNA is variably expressed in chronic lymphocytic leukaemia (CLL) and that under-expression is associated with TP53 dysfunction and adverse outcome. Although TP53 mRNA levels did indeed vary among the 104 CLL samples examined, this variability resulted primarily from over-expression of TP53 mRNA in 18 samples, all of which lacked TP53 deletion/mutation. These patients had higher lymphocyte counts and shorter overall and treatment-free survival times compared to cases with low TP53 mRNA expression and no TP53 deletion/mutation. Furthermore, TP53 mRNA levels did not correlate with levels of TP53 protein or its transcriptional target CDKN1A. We speculated that the adverse outcome associated with TP53 mRNA over-expression might reflect variation in levels of MIR15A and MIR16-1, which are encoded on chromosome 13q14 and target TP53 and some oncogenes including BCL2. In keeping with our hypothesis, 13q14 copy number and levels of MIR15A/MIR16-1 correlated positively with one another but negatively with levels of TP53 mRNA and BCL2 mRNA. Our findings support a model in which loss of MIR15A/MIR16-1 at chromosome 13q14 results in adverse outcome due to de-repression of oncogenes such as BCL2, and up-regulation of TP53 mRNA as a bystander effect.

Can uroflowmetry patterns in women be reliably interpreted?

Our aim was to investigate the proposition that uroflowmetry patterns can be reliably interpreted and correspond with specific urodynamic diagnoses. Uroflowmetry traces from 129 women with diagnoses of either genuine stress incontinence or detrusor instability were interpreted by four physicians with a minimum of 6 months experience in urogynecology. To test intraobserver variability, the traces were classified a second time 8 weeks later. Inter- and intraobserver variability was calculated by kappa analysis. There was marked intra- and interobserver variability in classification of traces, but no evidence of a correlation between urodynamic diagnosis and uroflowmetry pattern. Neither peak flow, total voided volume nor rate of acceleration of flow correlated with diagnosis. Although flow rates are important in predicting possible problems following surgery for stress incontinence, there is no evidence that flow patterns can be used as a screening test for specific urodynamic diagnoses.

Feminine and masculine personnas in performance

Abstract Sade Huron is a self-confessed Lesbian drag artist. In this article she discusses how her performance character, the highly glamorized Tutu L'Amour, came into existence. She considers the role of Cabaret within her work, its importance historically for gay performers as a vehicle for raising issues concerned with sexuality. Sade goes on to explain that her performance looks at the complexities that surround the notion of gender, in particular femininity, and how she paradoxically presents Tutu L'Amour as a ludicrous parody of her own sex and an affirmation of 'glamorous femininity.' She introduces Elvis as a butch dyke icon to challenge the idea of binary opposites within gender, i.e., the masculine and the feminine. Lastly she looks at how these issues are received by different audiences.

Generation of lipid peroxidation products in culinary oils and fats during episodes of thermal stressing: a high field 1H NMR study

The oxidative deterioration of glycerol-bound polyunsaturated fatty acids (PUFAs) in culinary oils and fats during episodes of heating associated with normal usage (30-90 min at 180 degrees C) has been monitored by high field 1H NMR spectroscopy. Thermal stressing of PUFA-rich culinary oils generated high levels of n-alkanals, trans-2-alkenals, alka-2,4-dienals and 4-hydroxy-trans-2-alkenals via decomposition of their conjugated hydroperoxydiene precursors, whereas only low concentrations of selected aldehydes were produced in oils with a low PUFA content, lard and dripping when subjected to the above heating episodes. Samples of repeatedly used, PUFA-rich culinary oils obtained from restaurants also contained high levels of each class of aldehyde. The dietary, physiological and toxicological ramifications of the results obtained are discussed.

The effect of halothane on neonatal ciliary beat frequency

The effect of a commonly used anaesthetic agent, halothane, on neonatal cilial function was determined. A nasal cilial sample was taken from 13 healthy, term, newborn infants. For 1 h, half of each sample was exposed to halothane and half to air. Cilial function was assessed by measuring beat frequency with a modified light transmission method. Cilial beat frequency was significantly slower in the cilia exposed to halothane, 9(s.d. 2.5)Hz, than to air, 12.9(s.d. 1.5)Hz. Decreased mucociliary clearance following halothane anaesthesia is due, at least in part, to a directly depressant effect of halothane on ciliated cells.

An approach to studies of cancer subsequent to clusters of chronic fatigue syndrome: use of data from the Nevada State Cancer Registry

Chronic fatigue syndrome (CFS) has been increasingly associated with immune dysregulation, including depressed natural killer cell activity; this phenomenon is associated with increased susceptibility to cancer. Although anecdotal reports have suggested an association between CFS and cancer, particularly non-Hodgkin's lymphoma and brain cancer, there has been no a priori justification for evaluating such an association and no consideration of relevant parameters, such as length of latent period vs. tumor type. We reviewed data from the Nevada State Cancer Registry subsequent to a reported outbreak of a CFS-like illness in Nevada that occurred during 1984-1986. We concentrated on non-Hodgkin's lymphoma and brain/CNS tumors, with particular emphasis on persons 15-34 and 35-54 years of age. An upward trend in the incidence of brain/CNS tumors, which could be related to a national upward trend for this disease, was noted. No consistent trends were noted for non-Hodgkin's lymphoma. Because of the difficulties inherent in studies of cancer subsequent to various exposures, we evaluated the methodology for determining an association between outbreaks of CFS-like disease and cancer. We propose several approaches that should be considered in future studies for investigation of possible associations between CFS and cancer, including expected latent periods for specific tumors.

Does chronic fatigue syndrome predispose to non-Hodgkin's lymphoma?

Chronic fatigue syndrome, an illness that frequently is associated with abnormalities of cellular immunity, has been reported anecdotally to be associated with an increased incidence of lymphoid hyperplasia and malignancy. This report describes an initial analysis of population-based cancer incidence data in Nevada, focusing on the patterns of non-Hodgkin's lymphoma prior to and subsequent to well described, documented outbreaks of chronic fatigue syndrome during 1984-1986. In a study of time trends in four age groups, the observed time trends were consistent with the national trends reported in the Surveillance, Epidemiology, and End Results Program. No statistically significant increase attributable to the chronic fatigue syndrome outbreak was identified at the state level. Additional studies are in progress analyzing the data at the country level, reviewing patterns in other malignancies, and continuing to monitor the cancer patterns over subsequent years.