A phase I/II study evaluating the pharmacokinetics, pharmacodynamics, and safety of drospirenone as an oral contraceptive in Japanese women

AIM

Drospirenone (DRSP) is a synthetic progestogen approved as a progestin-only pill for contraception in both the United States and Europe. Herein, we conducted a phase I/II study to evaluate the pharmacokinetics, pharmacodynamics, and safety of DRSP in Japanese women.

METHODS

Single and multiple doses of 4 mg of DRSP were orally administered to healthy premenopausal Japanese women. In the multiple-dose period, 4 mg of DRSP was administered once daily for 24 days. Pharmacokinetics, hormone levels, and adverse events (AEs) were investigated.

RESULTS

Twelve Japanese women participated in this study. The single- and multiple-dose pharmacokinetics of DRSP was similar to that reported in previous studies in Caucasians. In the multiple-dose period, no subject displayed a progesterone level of more than 5.03 ng/mL. AEs were observed in 11 (91.7%) subjects. The most common AE was genital hemorrhage, which was observed in six (50.0%) subjects, followed by diarrhea and acne in four (33.3%) subjects each. All AEs resolved or improved at the end of the study, and complete recovery was confirmed in all subjects at follow-up.

CONCLUSIONS

The pharmacokinetics of DRSP in Japanese women was similar to that of previous studies performed in Caucasian women. Repeated administration of DRSP maintained low plasma progesterone levels indicating effective inhibition of ovulation. No notable safety concerns were observed. In this phase I/II study, DRSP had no obvious pharmacokinetic, pharmacodynamic, or safety issues to consider in Japanese women.

COVID-19 vaccine effectiveness against severe COVID-19 requiring oxygen therapy, invasive mechanical ventilation, and death in Japan: A multicenter case-control study (MOTIVATE study)

INTRODUCTION

Since the SARS-CoV-2 Omicron variant became dominant, assessing COVID-19 vaccine effectiveness (VE) against severe disease using hospitalization as an outcome became more challenging due to incidental infections via admission screening and variable admission criteria, resulting in a wide range of estimates. To address this, the World Health Organization (WHO) guidance recommends the use of outcomes that are more specific to severe pneumonia such as oxygen use and mechanical ventilation.

METHODS

A case-control study was conducted in 24 hospitals in Japan for the Delta-dominant period (August-November 2021; "Delta") and early Omicron (BA.1/BA.2)-dominant period (January-June 2022; "Omicron"). Detailed chart review/interviews were conducted in January-May 2023. VE was measured using various outcomes including disease requiring oxygen therapy, disease requiring invasive mechanical ventilation (IMV), death, outcome restricting to "true" severe COVID-19 (where oxygen requirement is due to COVID-19 rather than another condition(s)), and progression from oxygen use to IMV or death among COVID-19 patients.

RESULTS

The analysis included 2125 individuals with respiratory failure (1608 cases [75.7%]; 99.2% of vaccinees received mRNA vaccines). During Delta, 2 doses provided high protection for up to 6 months (oxygen requirement: 95.2% [95% CI:88.7-98.0%] [restricted to "true" severe COVID-19: 95.5% {89.3-98.1%}]; IMV: 99.6% [97.3-99.9%]; fatal: 98.6% [92.3-99.7%]). During Omicron, 3 doses provided high protection for up to 6 months (oxygen requirement: 85.5% [68.8-93.3%] ["true" severe COVID-19: 88.1% {73.6-94.7%}]; IMV: 97.9% [85.9-99.7%]; fatal: 99.6% [95.2-99.97]). There was a trend towards higher VE for more severe and specific outcomes.

CONCLUSION

Multiple outcomes pointed towards high protection of 2 doses during Delta and 3 doses during Omicron. These results demonstrate the importance of using severe and specific outcomes to accurately measure VE against severe COVID-19, as recommended in WHO guidance in settings of intense transmission as seen during Omicron.

Modulation of the functional interfaces between retroviral intasomes and the human nucleosome

Infection by retroviruses as HIV-1 requires the stable integration of their genome into the host cells. This process needs the formation of integrase (IN)-viral DNA complexes, called intasomes, and their interaction with the target DNA wrapped around nucleosomes within cell chromatin. To provide new tools to analyze this association and select drugs, we applied the AlphaLISA technology to the complex formed between the prototype foamy virus (PFV) intasome and nucleosome reconstituted on 601 Widom sequence. This system allowed us to monitor the association between both partners and select small molecules that could modulate the intasome/nucleosome association. Using this approach, drugs acting either on the DNA topology within the nucleosome or on the IN/histone tail interactions have been selected. Within these compounds, doxorubicin and histone binders calixarenes were characterized using biochemical, in silico molecular simulations and cellular approaches. These drugs were shown to inhibit both PFV and HIV-1 integration in vitro. Treatment of HIV-1-infected PBMCs with the selected molecules induces a decrease in viral infectivity and blocks the integration process. Thus, in addition to providing new information about intasome-nucleosome interaction determinants, our work also paves the way for further unedited antiviral strategies that target the final step of intasome/chromatin anchoring. IMPORTANCE In this work, we report the first monitoring of retroviral intasome/nucleosome interaction by AlphaLISA. This is the first description of the AlphaLISA application for large nucleoprotein complexes (>200 kDa) proving that this technology is suitable for molecular characterization and bimolecular inhibitor screening assays using such large complexes. Using this system, we have identified new drugs disrupting or preventing the intasome/nucleosome complex and inhibiting HIV-1 integration both in vitro and in infected cells. This first monitoring of the retroviral/intasome complex should allow the development of multiple applications including the analyses of the influence of cellular partners, the study of additional retroviral intasomes, and the determination of specific interfaces. Our work also provides the technical bases for the screening of larger libraries of drugs targeting specifically these functional nucleoprotein complexes, or additional nucleosome-partner complexes, as well as for their characterization.

HERTHENA-Lung01: a phase II study of patritumab deruxtecan (HER3-DXd) in previously treated metastatic EGFR-mutated NSCLC

Limited treatment options exist for EGFR-mutated NSCLC that has progressed after EGFR TKI and platinum-based chemotherapy. HER3 is highly expressed in EGFR-mutated NSCLC, and its expression is associated with poor prognosis in some patients. Patritumab deruxtecan (HER3-DXd) is an investigational, potential first-in-class, HER3-directed antibody-drug conjugate consisting of a HER3 antibody attached to a topoisomerase I inhibitor payload via a tetrapeptide-based cleavable linker. In an ongoing phase I study, HER3-DXd demonstrated promising antitumor activity and a tolerable safety profile in patients with EGFR-mutated NSCLC, with or without identified EGFR TKI resistance mechanisms, providing proof of concept of HER3-DXd. HERTHENA-Lung01 is a global, registrational, phase II trial further evaluating HER3-DXd in previously treated advanced EGFR-mutated NSCLC. Clinical Trial Registration: NCT04619004 (ClinicalTrials.gov); 2020-000730-17 (EudraCT).

The whole blood transcriptional regulation landscape in 465 COVID-19 infected samples from Japan COVID-19 Task Force

Coronavirus disease 2019 (COVID-19) is a recently-emerged infectious disease that has caused millions of deaths, where comprehensive understanding of disease mechanisms is still unestablished. In particular, studies of gene expression dynamics and regulation landscape in COVID-19 infected individuals are limited. Here, we report on a thorough analysis of whole blood RNA-seq data from 465 genotyped samples from the Japan COVID-19 Task Force, including 359 severe and 106 non-severe COVID-19 cases. We discover 1169 putative causal expression quantitative trait loci (eQTLs) including 34 possible colocalizations with biobank fine-mapping results of hematopoietic traits in a Japanese population, 1549 putative causal splice QTLs (sQTLs; e.g. two independent sQTLs at TOR1AIP1), as well as biologically interpretable trans-eQTL examples (e.g., REST and STING1), all fine-mapped at single variant resolution. We perform differential gene expression analysis to elucidate 198 genes with increased expression in severe COVID-19 cases and enriched for innate immune-related functions. Finally, we evaluate the limited but non-zero effect of COVID-19 phenotype on eQTL discovery, and highlight the presence of COVID-19 severity-interaction eQTLs (ieQTLs; e.g., CLEC4C and MYBL2). Our study provides a comprehensive catalog of whole blood regulatory variants in Japanese, as well as a reference for transcriptional landscapes in response to COVID-19 infection.

Genetic mechanisms influencing COVID-19 susceptibility are not well understood. Here, the authors analyzed whole blood RNA-seq data of 465 Japanese individuals with COVID-19, highlighting thousands of fine-mapped variants affecting expression and splicing of genes, as well as the presence of COVID-19 severity-interaction eQTLs.

Association with sagittal alignment and osteoporosis-related fractures in outpatient women with osteoporosis

The baseline sagittal vertical axis (SVA) and pelvic tilt (PT) are independent risk factors of osteoporosis-related fractures in women with osteoporosis. We clarified the SVA and PT to predict the incidence of osteoporosis-related fractures.

PURPOSE

Sagittal alignment with osteoporosis women deteriorates with advancing age and sagittal alignment may indicate osteoporosis-related fractures in the future. However, whether the sagittal alignment predicts future osteoporosis-related fracture in patients with osteoporosis has not been clarified. We aimed to investigate the association between sagittal alignment and future osteoporosis-related fractures.

METHODS

This was a retrospective cohort study. Of the 313 participants (mean follow-up period, 2.9 years), 236 were included in the analysis. At baseline, we measured bone mineral density (BMD) of the lumbar spine and the femoral neck, sagittal vertical axis (SVA), thoracic kyphosis, pelvic incidence minus lumbar lordosis, sacral slope, pelvic tilt (PT), geriatric locomotive function scale (GLFS), two-step value, and stand-up test. The information on medications and the duration of treatment were reviewed from the medical records. Additionally, participants reported their history of falls at baseline. Multiple logistic regression analysis was used to determine the association of future osteoporosis-related fracture, and adjusted Odds ratios (OR) and 95% confidence interval (CI) were calculated with all predictors as covariates. All continuous variables were calculated using standardized OR (sOR).

RESULTS

Osteoporosis-related fractures occurred in 33 of 313 participants (10.5%). Multiple logistic regression analysis showed that a history of falls (OR =4.092, 95% CI: 1.029-16.265, p =0.045), SVA (sOR =4.228, 95% CI: 2.118-8.439, p <0.001), and PT (sOR =2.497, 95% CI: 1.087-5.733, p =0.031) were independent risk factors for future osteoporosis-related fractures.

CONCLUSIONS

This study revealed the SVA and PT to predict osteoporosis-related fractures.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

UMIN000036516 (April 1, 2019).

Cardio-renal protective effects of SGLT2 inhibitors in patients with type 2 diabetes mellitus and severely impaired renal function

Background

Prognostic impact of Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors on cardiovascular and renal outcome was unknown in patients with type-2 diabetes mellitus (DM) and severely impaired renal function.

Methods

From July 2015 to December 2020, patients with type-2 DM who were taken SGLT2 inhibitors for more than six months were retrospectively screened. Patients with estimated glomerular filtration rate (eGFR) over 60ml/min/1.73m2 were excluded. We divided those patients into two groups by eGFR; less than 45ml/min/1,73m2 were group A and 46–60ml/min/m2 were group B. Randomly selected patients with DM not taking SGLT2 inhibitors and having severe renal dysfunction: eGFR less than 45ml/min/m2 (Group C) were set as controls. The primary outcome was a composite of cardiovascular/renal death, initiation of dialysis, doubling of the serum creatine level, decline in the eGFR more than 30%, nonfatal myocardial infraction, nonfatal stroke, and hospitalization for heart failure.

Results

Totally 418 patients were enrolled. Median age was 71 years (group A, n=106), 64 years (group B, n=115), and 77 years (group C, n=201) (p&lt;0.001). After median 24 months follow-up, primary endpoints were observed 24.5% in group A, 4.3% in group B, 36.8% in group C (p&lt;0.001). In Kaplan-Meier analysis, significantly lower incidence of primary endpoints were observed in SGLT2 groups (group A and B) than controls (p&lt;0.001, Figure 1). In patients with severe renal dysfunction, taking SGLT2 inhibitors tended to decrease future renal event (Figure 2). The incidence of SGLT2 related adverse events was not different between 2 groups (A and B).

Conclusions

Even in patients with severe renal dysfunction, SGLT2 inhibitors would have cardio-renal protective effects without drug-related adverse effects.

Funding Acknowledgement

Type of funding sources: None.

Impact of polypharmacy on prognosis in patients with acute decompensated heart failure: from the CURE-HF registry

Background

Polypharmacy would be associated with poor prognosis in patients with heart failure (HF).

Methods

In 863 patients who discharged after treatment for HF were prospectively enrolled. Number of tablets prescribed at discharge was counted. Death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization for HF were tracked.

Results

In our study cohort (median age, 78), 447 patients experienced adverse events during median 503 days follow-up. In Kaplan-Meier analysis, a greater number of prescribed tablets was associated with future adverse cardiac events in the crude population. Although patients with the greater number of non-HF medications showed worse outcome, those of HF medications were not associate with the outcome (Figure). Furthermore, the number of tablets was an independent predictor of future cardiovascular events after adjustment for age, gender, B-type natriuretic peptide, hemoglobin, albumin, estimated glomerular filtration rate, and left ventricular ejection fraction (HR 95% CI: 1.295 (1.066–1.573), p=0.009).

Conclusions

Polypharmacy was associated with poor prognosis. Although the numbers of tablets and non-HF medications were significantly associated with worse out come in HF patients, the number of HF medications was not.

Funding Acknowledgement

Type of funding sources: None.

Large-Scale Prospective Genome-Wide Association Study of Oxaliplatin in Stage II/III Colon Cancer and Neuropathy

IMPORTANCE

The severity of oxaliplatin (L-OHP)-induced peripheral sensory neuropathy (PSN) exhibits substantial interpatient variability, and some patients suffer from long-term, persisting PSN.

OBJECTIVE

To identify single-nucleotide polymorphisms (SNPs) predicting L-OHP-induced PSN using a genome-wide association study (GWAS) approach.

DESIGN, SETTING, PARTICIPANTS

A large prospective GWAS including 1,379 patients with stage II/III colon cancer who received L-OHP-based adjuvant chemotherapy (mFOLFOX6/CAPOX) under the phase II (JOIN/JFMC41) or the phase III (ACHIVE/JFMC47) trial.

MAIN OUTCOMES AND MEASURES

First, GWAS comparison of worst grade PSN (grade 0/1 vs. 2/3) was performed. Next, to minimize the impact of ambiguity in PSN grading, extreme PSN phenotypes were selected and analyzed by GWAS. SNPs that could predict time to recovery from PSN were also evaluated. In addition, SNPs associated with L-OHP-induced allergic reactions (AR) and time to disease recurrence were explored.

RESULTS

No SNPs exceeded the genome-wide significance (p < 5.0 × 10^-8) in either GWAS comparison of worst grade PSN, extreme PSN phenotypes, or time to recovery from PSN. Association study focusing on AR or time to disease recurrence also failed to reveal any significant SNPs.

CONCLUSION AND RELEVANCE

Our results highlight the challenges of utilizing SNPs for predicting susceptibility to L-OHP-induced PSN in daily clinical practice.

An open-label, phase II study of patritumab deruxtecan (HER3-DXd, U3-1402) in patients (pts) with previously treated advanced/metastatic colorectal cancer (CRC)

TPS157

Background: Patritumab deruxtecan (HER3-DXd; U3-1402) is a novel, investigational antibody drug conjugate comprising an anti-HER3 monoclonal antibody, a tetrapeptide-based linker, and a topoisomerase I inhibitor payload. Ongoing clinical trials of HER3-DXd in pts with metastatic breast cancer or non-small cell lung cancer have shown promising clinical activity and acceptable safety. HER3 (human epidermal growth receptor 3), a member of the tyrosine kinase receptor family, is overexpressed in most CRC tumors and associated with an adverse prognosis. Significant tumor regression with HER3-DXd has been observed in CRC murine xenograft models, regardless of KRAS mutation status. Here we introduce the design of a phase 2 study (U31402-A-U202) that is evaluating HER3-DXd in previously treated pts with advanced/metastatic CRC. Methods: U31402-A-U202 (NCT04479436) is an open-label, multicenter phase 2 study that will enroll 80 pts in the USA, Europe and Asia. Pts are enrolled who are aged ≥ 18 years with advanced/metastatic colorectal adenocarcinoma that is resistant/refractory/intolerant to ≥ 2 prior lines of therapy including a fluoropyrimidine, irinotecan, a platinum agent, an anti-EGFR agent (if clinically indicated), an anti-VEGF agent (unless contraindicated [CI]), and an immune checkpoint inhibitor (unless CI) for microsatellite instability-high CRC. Pts with current/previous interstitial lung disease or clinically severe pulmonary compromise are excluded. Archival tumor biopsy and pre-treatment tumor biopsy are collected from all pts at screening, with HER3 protein expression measured by immunohistochemistry (IHC). In part 1, results of the HER3 IHC assay from the pre-treatment tumor biopsy are used to assign pts into 1 of 2 cohorts (C). C1: HER3 high (IHC 3+, 2+), n = 24; C2: HER3 low/negative (IHC 1+, 0), n = 12. Pts receive 5.6 mg/kg HER3-DXd IV every 3 weeks. An interim futility analysis will be conducted separately for C1 and C2 and will determine enrollment in part 2, with 2 potential scenarios: enrollment continues irrespective of HER3 IHC status, or enrollment continues in HER3 high pts only. The primary objective is the evaluation of the antitumor activity of HER3-DXd as measured by objective response rate (ORR) (assessed by BICR according to RECIST v1.1). ORR will be summarized with the 2-sided 95% confidence interval. Secondary objectives include the evaluation of efficacy as measured by ORR (assessed by investigator according to RECIST v1.1), duration of response, time to tumor response, disease control rate, progression-free survival (assessed by investigator and BICR according to RECIST v1.1), overall survival, safety and tolerability, HER3 protein expression in tumor tissue and relationship with efficacy, and pharmacokinetic properties. Clinical trial information: NCT04479436.

Time interval from left ventricular stimulation to QRS onset is a predictor of mortality in patients with cardiac resynchronization therapy

Introduction

In our previous report, the time interval from left ventricular (LV) pacing to the earliest onset of QRS (S-QRS interval) has been found to be an independent predictor of mechanical response to cardiac resynchronization therapy (CRT). The S-QRS interval may indicate the conduction disturbance relevant to the localized tissue property such as scar or fibrotic lesion. Therefore, S-QRS interval longer than 37ms was associated with poor response to CRT, and proposed as suboptimal LV lead position. Then, we hypothesized that the longer S-QRS interval at the LV pacing site could be related to long term mortality and heart failure events in patients with CRT.

Methods

This retrospective study included 82 consecutive heart failure patients with sinus rhythm, reduced LV ejection fraction (≤35%), and a wide QRS complex (≥120ms), who undergone CRT implantation between 2012 January and 2017 December. Patients were divided into Short S-QRS group (&lt;37ms, SS-QRS) and Long S-QRS group (≥37ms, LS-QRS) according to the previously reported optimal cut off value. A responder was defined as one with ≥15% reduction in LV end-systolic volume assessed by echocardiography at 6 months after CRT. The primary endpoint was total mortality, which included LV assist device implantation or heart transplantation. The secondary endpoints included the composite endpoint of total mortality or heart failure hospitalization.

Results

The study patients were divided into SS-QRS (N=43, age 65.9±13.2 years, 77% male) and LS-QRS (N=39, age 63.0±13.4, 85% male). In the electrocardiographic measurements, there were no significant differences in baseline QRS duration (162.4±30.3ms in SS-QRS vs. 154.5±31.6ms in LS-QRS, P=0.19) and LV local activation time assessed as Q-LV interval (118.3±34.3ms in SS-QRS vs. 115.3±32.0ms in LS-QRS, P=0.71). S-QRS interval was 25.9±5.3ms in SS-QRS and 51.5±13.7ms in LS-QRS (P&lt;0.01), and the responder rate was significantly higher in SS-QRS compared with LS-QRS (79% vs. 29%, P&lt;0.01). During mean follow up of 47.7±22.4 months, 24 patients (29%) reached to the primary endpoint, while the secondary endpoints were observed in 47 patients (57%). LS-QRS patients had significantly worse event-free survival for both primary and secondary endpoints (Figure). After the multivariate Cox regression analysis, LS-QRS (≥37ms) was an independent predictor of total mortality (HR=2.6, 95% CI: 1.11 to 6.12, P=0.03) and the secondary composite events (HR=2.4, 95% CI: 1.31 to 4.33, P&lt;0.01).

Conclusion

The S-QRS interval longer than 37ms, which may reflect the conduction disturbance relevant to the scar or fibrotic lesion at the LV pacing site, was a significant predictor of the total mortality and heart failure hospitalization. These findings have implications for the optimal LV lead placement in patients with CRT device.

Clinical outcomes according to S-QRS

Funding Acknowledgement

Type of funding source: None

Prognostic impact of free-fat mass index on elderly patients with acute decompensated heart failure: from CURE-HF registry

Background

Free-Fat Mass Index (FFMI) is an indicator of malnutrition and sarcopenia. We hypothesized that low FFMI would be associated with worse prognosis in elderly patients with heart failure.

Methods

In 800 patients who discharged after treatment for HF were prospectively enrolled from 13 medical centers. Free-Fat Mass Index was calculated dividing the square of the patients heights in meters into lean body mass. All-cause mortality (cardiovascular, non-cardiovascular) was followed-up by telephone interview and chart review.

Results

In our study cohort (median age, 78 [range 72–87]), FFMI was 16.7 [15.2, 18.0]. All-cause mortality was observed in 211 patients during 631 [266, 983] days follow-up. In Kaplan-Meier analysis, lower FFMI was associated with all-cause mortality. Furthermore, FFMI was an independent predictor of mortality after adjustment for age, gender, albumin, hemoglobin, creatinine, brain natriuretic peptide, and left ventricular ejection fraction (HR 95% CI: 0.841 (0.745–0.944), p=0.004). In subgroup analysis, low FFMI was associated with both cardiac and non-cardiac mortality in patients with HF with reduced ejection fraction (EF) (Log-rank p=0.002, p=0.013, respectively) (Figure). Furthermore, low FFMI was significantly associated non-cardiac death in patients with preserved EF (Log-rank p=0.033) (Figure).

Conclusions

Free-Fat Mass Index was significantly associated with mortality in elderly patients with HF.

Funding Acknowledgement

Type of funding source: None

Phenotypic difference of sarcopenia in the prediction of mortality for elderly patients with heart failure: from CURE-HF registry

Background

Sarcopenia and malnutrition are associated with mortality in elderly patients with heart failure (HF). However, impact of phenotypic difference of sarcopenia on mortality is not well investigated. We hypothesized that evaluation using both body mass index (BMI) and free-fat mass index (FFMI) enabled distinction of phenotypic difference of sarcopenia and risk stratification for mortality in elderly patients with heart failure.

Methods

In 800 patients who discharged after treatment for HF were prospectively enrolled from 13 medical centers. Body mass index and FFMI was evaluated. Free-fat mass index was calculated dividing the square of the patients' heights in meters into lean body mass. All-cause mortality was followed-up. Patients were divided into 3 subgroups according to BMI and FFMI values, and compared incidence of mortality among them.

Results

In our study cohort (median age, 78 [range 72–87]), BMI was 21.1 [18.9, 23.8] and FFMI was 16.7 [15.2, 18.0]. 211 patients were experienced all-cause mortality during 631 [266, 983] days follow-up. In Kaplan-Meier analysis, lower BMI and lower FFMI was associated with all-cause mortality (Log-rank p&lt;0.001, p&lt;0.001, respectively). Furthermore, FFMI was an independent predictor of adverse events after adjustment for age, gender, albumin, hemoglobin, creatinine, brain natriuretic peptide, and left ventricular ejection fraction (HR 95% CI: 0.841 (0.745–0.944), p=0.004). In subgroup analysis, comparing with low-BMI and low-FFMI subgroup, better prognosis was observed in the other 2 subgroups (Log-rank p&lt;0.001, p=0.022, Figure 1).

Conclusions

Phenotypic difference was evident in elderly patients with HF. A combination of BMI and FFMI would be useful for risk stratification of mortality in those patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

P450The difference in the prognosis among three categories of the post-procedural left ventricular ejection fraction in patients undergoing atrial fibrillation ablation

Funding Acknowledgements

None

Background

Atrial fibrillation (AF) ablation has been known to contribute to a good prognosis in heart failure patients and improve their systolic function. However, the impact of the post-procedural systolic function on the prognosis in them remains unclear. 

Purpose

To investigate the impact of the left ventricular ejection fraction (LVEF) following AF ablation in patients with systolic dysfunction. 

Methods

Out of 1078 consecutive patients who underwent AF ablation including extensive pulmonary vein and superior vena cava isolation, 170 with an impaired pre-procedural LVEF (&lt; 50%) were evaluated. They experienced at least one echocardiographic follow-up within one year after the index procedure. The primary outcome was the composite of all-cause death or heart failure hospitalisations (HFHs). In addition, we categorised the patients into three groups according to the post-procedural LVEF within one year to evaluate the outcome: reduced LVEF (rEF, LVEF &lt; 40%), mid-range EF (mrEF, 40% ≤ LVEF &lt; 50%) and preserved LVEF (pEF, LVEF &gt; 50%). 

Results

After the index procedure, the patients’ LVEF improved with an average increase of 8%, and the post-procedural LVEF consisted of an rEF in 27 (16%), mrEF in 41 (24%), and pEF in 102 (60%) patients. During a median follow-up of 31 months, a total of 22 (13%) patients experienced the composite outcome, including 18 (11%) HFHs and 10 (6%) all-cause deaths (5 with cardiac issues, 2 any malignancies, and 3 other issues). In the Kaplan-Meier analysis using a Bonferroni correction, there was a significant difference in achieving the outcome between the rEF and mrEF, and rEF and pEF, but not between the mrEF and pEF groups (Figure). In a univariate analysis, the hazard ratio of the outcome was shown as follows: an age ≥ 65 years (hazard ratio, HR: 3.4 [95% confidence interval, CI: 1.4–8.5], p = 0.006), history of HFHs for AF (HR: 1.7 [95%CI: 0.7–4.0], p = 0.25), known underlying heart disease (HR: 1.9 [95%CI: 0.8–1.2], p = 0.13), pre-procedural LVEF &lt; 40% (HR: 3.1 [95%CI: 1.3–7.5], p = 0.009), atrial tachyarrhythmia recurrence (HR: 3.0 [95%CI: 1.2–7.8], p = 0.01), and the post-procedural LVEF category (mrEF and rEF, compared with pEF) (HR: 2.0 [95%CI: 0.4–7.7], p = 0.34; and HR: 8.6 [95%CI: 2.7–37.5], p &lt; 0.0001). Furthermore, in a multivariate analysis, patients with a rEF was the sole independent predictor of the composite outcome after adjusting for confounders including an age≥65 years and pre-procedural LVEF &lt; 40% (HR: 12.0 [95%CI: 3.9–40.0], p &lt; 0.0001), whereas those with a mrEF was not (HR: 1.8 [95%CI: 0.4–7.3], p = 0.42), as compared to those with a pEF. 

Conclusions

Patients with a mrEF had a comparable prognosis to those with a pEF in a relatively long follow-up, while those with a rEF had the poorest outcome of the three categories, regardless of the pre-procedural LVEF severity.

Abstract Figure. The difference in the rate of outcome

Catalytic Chemoselective O-Phosphorylation of Alcohols

Phosphorylation of alcohols is a fundamentally important reaction in both life science and physical science. Product phosphate monoesters play key roles in living organisms, natural products, pharmaceuticals, and organic materials. Most of the chemical methods to date for synthesizing phosphate monoesters, however, require multistep sequences or are limited to specific types of substrates possibly due to harsh conditions. An alternative way to enable the simple production of phosphate monoesters from highly functionalized precursor alcohols is, thus, highly desired. We report herein a catalytic phosphorylation of alcohols with high functional group tolerance using tetrabutylammonium hydrogen sulfate (TBAHS) and phosphoenolpyruvic acid monopotassium salt (PEP-K) as the catalyst and phosphoryl donor, respectively. This method enables the direct introduction of a nonprotected phosphate group to the hydroxy group of a diverse menu of alcohol substrates, including functionalized small molecules, carbohydrates, and unprotected peptides. Nuclear magnetic resonance, mass spectrometric, and density functional theory analyses suggest that an unprecedented mixed anhydride species, generated from PEP-K and TBAHS, acts as an active phosphoryl donor in this reaction. This operationally simple and chemoselective catalytic phosphorylation allows for the efficient production of densely functionalized O-phosphorylated compounds, which are useful in diverse fields including biology and medicine.

P2696Clinical characteristics of late catch-up phenomenon after implantation of 2nd generation drug eluting stent

Introduction

Late catch-up phenomenon (LCU) of 1st generation drug eluting stent (DES) has been increasing yearly despite the rate of restenosis in 1 year has reduced compared with bare metal stent (BMS). 2nd generation DES was more improved than 1st generation DES and suggested more benefits about clinical outcome.

Purpose

To investigate the incidence and predictor of LCU after implantation of 2nd generation DES and to evaluate the association between LCU phenomenon and adverse events.

Methods

Between August 2012 and July 2013, a total of 1665 consecutive patients (1956 lesions with elective/urgent PCI) were enrolled in SHINANO 5 years Registry (a prospective observational multicenter cohort study) from 13 institutions in Nagano, Japan. 711 patients that were treated with 2nd generation DES and 576 patients with BMS were selected. Exclusion criterias were cases of 1st DES, only POBA, only aspiration and chronic total occulusion.

Results

There were significant difference about patients background between BMS and 2nd generation DES groups. Those groups were matched with propensity score. After matching, 822 patients (BMS group 411 patients, 2nd generation group 411 patients) were analyzed. The rates of 2nd DES and BMS restenosis 5 years after initial PCI were 9.2% and 8.5% (p=0.572), those of LCU were 2.6% and 5.6% (p=0.043) by 1 year landmark analysis. Cox proportional hazards analysis revealed that the DES in-stent restenosis (ISR) lesion and higher HbA1c were independent predictors for LCU from 1year to 5year (HR 5.304, p=0.009, HR 1.254, p=0.015), but 2nd generation DES was not. Kaplan Meier curve showed no association between LCU phenomenon and all cause death (p=0.446). Cox regression analysis showed LCU was not independent predictor for all cause death (p=0.414).

Conclusions

Implantation to DES-ISR lesion with 2nd generation DES was associated with higher LCU. Despite of more complex lesions with 2nd generation DES, there were no differences of LCU incidence between 2nd generation DES and BMS.

Acknowledgement/Funding

None

Association of NOD2 Mutations with Aggressive Periodontitis

Aggressive periodontitis (AgP) is characterized by rapid alveolar bone destruction and tooth loss early in life, and its etiology remains unclear. To explore the genetic risk factors of AgP, we performed genome-wide single-nucleotide polymorphism genotyping for identity-by-descent mapping and identified 32 distinct candidate loci, followed by whole exome sequencing with 2 pedigrees of AgP consisting of 3 cases and 1 control in 1 family and 2 sibling cases in the other. After variant filtering procedures and validation by targeted Sanger sequencing, we identified 2 missense mutations at 16q12 in NOD2 (p.Ala110Thr and p.Arg311Trp), which encodes nucleotide-binding oligomerization domain protein 2. We further examined 94 genetically unrelated AgP patients by targeted sequencing of NOD2 and found that 2 patients among them also carried the p.Arg311Trp variant. Furthermore, we found 3 additional missense mutations in this gene (p.His370Tyr, p.Arg459Cys, and p.Ala868Thr). These mutations either had not been previously observed or are extremely rare (frequency <0.001) in Asian populations. NOD2 plays a crucial role in innate immunity as an intracellular receptor initiating nuclear factor κB-dependent and mitogen-activated protein kinase-dependent gene transcription. These results demonstrated NOD2 as a novel gene involved in AgP.

Integrative biomarker analyses indicate etiological variations in hepatocellular carcinoma

BACKGROUND & AIMS

The purpose of this study was to determine whether biomarkers from baseline plasma and archival tissue specimens collected from patients enrolled in the EVOLVE-1 trial - a randomized phase 3 study of everolimus in hepatocellular carcinoma (HCC) - were associated with prognosis, etiology or ethnicity.

METHODS

Circulating plasma levels of bFGF, PLGF, VEGF, VEGF-D, c-Kit, collagen IV, sVEGFR1 and VEGFR2 were measured by ELISA (N=503). Protein levels of IGF-1R, c-Met, mTOR, Tsc2 were assayed by immunohistochemistry (N=125). Genomic DNA sequencing was conducted on a panel of 287 cancer-related genes (N=69).

RESULTS

Patients with baseline plasma concentrations of VEGF or sVEGFR1 above the cohort median had significantly shorter overall survival. These plasma biomarkers retained prognostic significance in a multivariate Cox regression model with geographic region, macroscopic vascular invasion and alpha fetoprotein AFP levels. Membranous c-Met protein levels were significantly lower for Asian patients, as well as for hepatitis B viral etiology. The prevalence of genetic changes were similar to previous reports, along with a trend towards higher PTEN and TSC2 mutations among Asians.

CONCLUSIONS

The angiogenesis biomarkers VEGF and sVEGFR1 were independent prognostic predictors of survival in patients with advanced HCC. Potential differences in c-Met and mTOR pathway activation between Asian and non-Asian patients should be considered in future clinical trials.

LAY SUMMARY

Our study demonstrates that circulating angiogenesis biomarkers can predict the survival outcome in patients with advanced hepatocellular carcinoma independent of the clinical variables. There is etiology and ethnicity variation in molecular pathway activation in hepatocellular carcinoma, which should be considered for future clinical trial design of targeted therapy.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01035229.

Investigation and treatment of pulmonary embolism as a potential etiology may be important to improve post-resuscitation prognosis in non-shockable out-of-hospital cardiopulmonary arrest: report on an analysis of the SOS-KANTO 2012 study

Background

The prognosis of non-shockable out-of-hospital cardiac arrest is worse than that of shockable out-of-hospital cardiac arrest. We investigated the associations between the etiology and prognosis of non-shockable out-of-hospital cardiac arrest patients who experienced the return of spontaneous circulation after arriving at hospital.

Methods and Results

All subjects were extracted from the SOS-KANTO 2012 study population. The subjects were 3,031 adults: (i) who had suffered out-of-hospital cardiac arrest, (ii) for whom there were no pre-hospital data on ventricular fibrillation/pulseless ventricular tachycardia until arrival at hospital, (iii) who experienced the return of spontaneous circulation after arriving at hospital. We compared the patients' prognosis after 1 and 3 months between various etiological and presumed cardiac factors. The proportion of the favorable brain function patients that developed pulmonary embolism or incidental hypothermia was significantly higher than that of the patients with presumed cardiac factors (1 month, P < 0.0001 and P < 0.0001, respectively; 3 months, P = 0.0018 and P < 0.0001, respectively). In multiple logistic regression analysis, pulmonary embolism and incidental hypothermia were found to be significant independent prognostic factors for 1- and 3-month survival and the favorable brain function rate.

Conclusions

In patients who suffer non-shockable out-of-hospital cardiac arrest, but who experience the return of spontaneous circulation after arriving at hospital, the investigation and treatment of pulmonary embolism as a potential etiology may be important for improving post-resuscitation prognosis.

Large-scale prospective pharmacogenomics study of oxaliplatin-induced neuropathy in colon cancer patients enrolled in the JFMC41-1001-C2 (JOIN Trial)

BACKGROUND

Peripheral sensory neuropathy (PSN) is a dose-limiting toxicity of oxaliplatin-based chemotherapy. Several genetic markers have been shown to predict oxaliplatin-induced PSN; however, results remain to be validated in a large-scale and prospective pharmacogenomics study.

PATIENTS AND METHODS

Among 882 patients enrolled in the JFMC41-1001-C2 (JOIN trial), which was designed to investigate the tolerability of adjuvant-modified FOLFOX6 (mFOLFOX6) in Japanese Patients with stage II or III colon cancers undergoing curative resection, 465 patients were eligible for this pharmacogenomics analysis. Twelve single-nucleotide polymorphisms (SNPs) were selected based on published data. The effect of each genotype on time to PSN onset was evaluated in all patients (n = 465) using the Cox proportional hazard model. For the association analysis between severity of PSN and 12 SNP markers, 84 patients who failed to complete 12 cycles of mFOLFOX6 from grade 0/1 PSN group were excluded because the termination of the protocol treatment had been caused by reasons other than PSN.

RESULTS

Comparison of grade 0/1 PSN with grade 2/3 PSN or grade 3 PSN showed no significant associations with any of the 12 SNP markers after adjustment for total dose of oxaliplatin. Time-to-onset analysis also failed to reveal any significant differences.

CONCLUSIONS

Our large-scale and prospective pharmacogenomics study of Japanese patients receiving protocol treatment of adjuvant mFOLFOX6 could not verify a role for any of the 12 SNP markers reported as being significantly associated with PSN. Considering the OR observed in this study (range: 0.76-1.89), further evaluation of these 12 SNP markers in the context of L-OHP-induced PSN is unlikely to be clinically informative.

An interconnected hierarchical model of cell death regulation by the BCL-2 family

Multidomain proapoptotic BAX and BAK, once activated, permeabilize mitochondria to trigger apoptosis, whereas antiapoptotic BCL-2 members preserve mitochondrial integrity. The BH3-only molecules (BH3s) promote apoptosis by either activating BAX-BAK or inactivating antiapoptotic members. Here, we present biochemical and genetic evidence that NOXA is a bona fide activator BH3. Using combinatorial gain-of-function and loss-of-function approaches in Bid^−/−Bim^−/−Puma^−/−Noxa^−/− and Bax^−/−Bak^−/− cells, we have constructed an interconnected hierarchical model that accommodates and explains how the intricate interplays between the BCL-2 members dictate cellular survival versus death. BID, BIM, PUMA and NOXA directly induce stepwise, bimodal activation of BAX-BAK. BCL-2, BCL-X_L and MCL-1 inhibit both modes of BAX-BAK activation by sequestering activator BH3s and “BH3-exposed” monomers of BAX-BAK, respectively. Furthermore, autoactivation of BAX and BAK can occur independently of activator BH3s through downregulation of BCL-2, BCL-X_L and MCL-1. Our studies lay a foundation on targeting the BCL-2 family for treating diseases with dysregulated apoptosis.

Aurora-A is a determinant of tamoxifen sensitivity through phosphorylation of ERα in breast cancer

Despite the clinical success of tamoxifen, its resistance remains a major challenge in breast cancer. Here we show that Aurora-A determines tamoxifen sensitivity by regulation of oestrogen receptor (ER)α. Ectopic expression of Aurora-A decreases and depletion of Aurora-A enhances tamoxifen sensitivity in ERα-positive breast cancer. Elevated Aurora-A was significantly associated with the recurrence of ERα-positive tumours. Notably, Aurora-A inhibitor MLN8237, which is currently in clinical trial, synergizes with tamoxifen and overcomes tamoxifen resistance. Furthermore, Aurora-A interacts with and phosphorylates ERα on serine-167 and -305, leading to increase in ERα DNA-binding and transcriptional activity. Elevated levels of Aurora-A are significantly associated with disease-free survival in ERα-positive but not ERα-negative breast cancers. These data suggest that Aurora-A has a pivotal role in tamoxifen resistance and ERα is a bona fide substrate of Aurora-A. Thus, Aurora-A represents a prognostic marker in ERα-positive tumour and a critical therapeutic target in tamoxifen-resistant breast cancer, and Aurora-A inhibitor could be used as either an independent or concurrent agent in tamoxifen-resistant tumour.

Abstract 4456: Aurora-A is a downstream target of RAS and forms a positive feedback regulation loop with NF-κB in non-small cell lung cancer

Previous studies have shown that inhibition of Aurora-A reduces mutant RAS oncogenic activity and that both Aurora-A and RAS activate NF-κB pathway through phosphorylation of IkBa and upregulation of GSKa, respectively. Here we show that Aurora-A expression and kinase activity are regulated by activating mutation of KRAS. Blockage of NF-κB by IκB-S32/36A abrogated KRAS-induced Aurora-A expression and kinase activity. Furthermore, we demonstrated that NF-κB directly bound to Aurora-A promoter and induces Aurora-A transcription. In addition, depletion of Aurora-A by siRNA and pharmacological inhibitor MLN8237 suppresses RAS-induced NF-κB activity and selectively induces cell death in KRAS mutant NSCLC cells. We also show that Aurora-A is induced by nicotine and is frequently overexpressed in NSCLCs. Overexpression of Aurora-A is associated with tobacco smoke and poor prognosis in lung adenocarcinoma but not squamous lung cancer. These data suggest that Aurora-A is regulated by RAS through NF-κB and that the feedback regulation loop between Aurora-A and NF-κB could play a pivotal role in NSCLC.

Citation Format: Donghwa Kim, Masayuki Kanai, Xiangqian Zheng, Dali Zheng, Domenico Coppola, Jin Q. Cheng. Aurora-A is a downstream target of RAS and forms a positive feedback regulation loop with NF-κB in non-small cell lung cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4456. doi:10.1158/1538-7445.AM2014-4456

Asparagine plays a critical role in regulating cellular adaptation to glutamine depletion

Many cancer cells consume large quantities of glutamine to maintain TCA cycle anaplerosis and support cell survival. It was therefore surprising when RNAi screening revealed that suppression of citrate synthase (CS), the first TCA cycle enzyme, prevented glutamine-withdrawal-induced apoptosis. CS suppression reduced TCA cycle activity and diverted oxaloacetate, the substrate of CS, into production of the nonessential amino acids aspartate and asparagine. We found that asparagine was necessary and sufficient to suppress glutamine-withdrawal-induced apoptosis without restoring the levels of other nonessential amino acids or TCA cycle intermediates. In complete medium, tumor cells exhibiting high rates of glutamine consumption underwent rapid apoptosis when glutamine-dependent asparagine synthesis was suppressed, and expression of asparagine synthetase was statistically correlated with poor prognosis in human tumors. Coupled with the success of L-asparaginase as a therapy for childhood leukemia, the data suggest that intracellular asparagine is a critical suppressor of apoptosis in many human tumors.