Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

The mechanism of RNA capping by SARS-CoV-2

The RNA genome of SARS-CoV-2 contains a 5′ cap that facilitates the translation of viral proteins, protection from exonucleases and evasion of the host immune response^1–4. How this cap is made in SARS-CoV-2 is not completely understood. Here we reconstitute the N7- and 2′-O-methylated SARS-CoV-2 RNA cap (^7MeGpppA_2′-O-Me) using virally encoded non-structural proteins (nsps). We show that the kinase-like nidovirus RdRp-associated nucleotidyltransferase (NiRAN) domain⁵ of nsp12 transfers the RNA to the amino terminus of nsp9, forming a covalent RNA–protein intermediate (a process termed RNAylation). Subsequently, the NiRAN domain transfers the RNA to GDP, forming the core cap structure GpppA-RNA. The nsp14⁶ and nsp16⁷ methyltransferases then add methyl groups to form functional cap structures. Structural analyses of the replication–transcription complex bound to nsp9 identified key interactions that mediate the capping reaction. Furthermore, we demonstrate in a reverse genetics system⁸ that the N terminus of nsp9 and the kinase-like active-site residues in the NiRAN domain are required for successful SARS-CoV-2 replication. Collectively, our results reveal an unconventional mechanism by which SARS-CoV-2 caps its RNA genome, thus exposing a new target in the development of antivirals to treat COVID-19.

Reconstitution of the SARS-CoV-2 RNA 5′ cap reveals the unconventional mechanism by which SARS-CoV-2 caps its RNA genome, providing a new target in the development of antiviral agents to treat COVID-19.

Fic-mediated AMPylation tempers the unfolded protein response during physiological stress

The proper balance of synthesis, folding, modification, and degradation of proteins, also known as protein homeostasis, is vital to cellular health and function. The unfolded protein response (UPR) is activated when the mechanisms maintaining protein homeostasis in the endoplasmic reticulum become overwhelmed. However, prolonged or strong UPR responses can result in elevated inflammation and cellular damage. Previously, we discovered that the enzyme filamentation induced by cyclic-AMP (Fic) can modulate the UPR response via posttranslational modification of binding immunoglobulin protein (BiP) by AMPylation during homeostasis and deAMPylation during stress. Loss of fic in Drosophila leads to vision defects and altered UPR activation in the fly eye. To investigate the importance of Fic-mediated AMPylation in a mammalian system, we generated a conditional null allele of Fic in mice and characterized the effect of Fic loss on the exocrine pancreas. Compared to controls, Fic-/- mice exhibit elevated serum markers for pancreatic dysfunction and display enhanced UPR signaling in the exocrine pancreas in response to physiological and pharmacological stress. In addition, both fic-/- flies and Fic-/- mice show reduced capacity to recover from damage by stress that triggers the UPR. These findings show that Fic-mediated AMPylation acts as a molecular rheostat that is required to temper the UPR response in the mammalian pancreas during physiological stress. Based on these findings, we propose that repeated physiological stress in differentiated tissues requires this rheostat for tissue resilience and continued function over the lifetime of an animal.

Cellular abundance of sodium phosphate cotransporter SLC20A1/PiT1 and phosphate uptake are controlled post-transcriptionally by ESCRT

Inorganic phosphate is essential for human life. The widely expressed mammalian sodium/phosphate cotransporter SLC20A1/PiT1 mediates phosphate uptake into most cell types; however, while SLC20A1 is required for development, and elevated SLC20A1 expression is associated with vascular calcification and aggressive tumor growth, the mechanisms regulating SLC20A1 protein abundance are unknown. Here, we found that SLC20A1 protein expression is low in phosphate-replete cultured cells but is strikingly induced following phosphate starvation, whereas mRNA expression is high in phosphate-replete cells and only mildly increased by phosphate starvation. To identify regulators of SLC20A1 protein levels, we performed a genome-wide CRISPR-based loss-of-function genetic screen in phosphate-replete cells using SLC20A1 protein induction as readout. Our screen revealed that endosomal sorting complexes required for transport (ESCRT) machinery was essential for proper SLC20A1 protein downregulation in phosphate-replete cells. We show that SLC20A1 colocalizes with ESCRT and that ESCRT deficiency increases SLC20A1 protein and phosphate uptake into cells. We also found numerous additional candidate regulators of mammalian phosphate homeostasis, including genes modifying protein ubiquitination and the Krebs cycle and oxidative phosphorylation pathways. Many of these targets have not been previously implicated in this process. We present here a model in which SLC20A1 protein abundance and phosphate uptake are tonically negatively regulated post-transcriptionally in phosphate-replete cells through direct ESCRT-mediated SLC20A1 degradation. Moreover, our screening results provide a comprehensive resource for future studies to elucidate the mechanisms governing cellular phosphate homeostasis. We conclude that genome-wide CRISPR-based genetic screening is a powerful tool to discover proteins and pathways relevant to physiological processes.

The mechanism of RNA capping by SARS-CoV-2

The SARS-CoV-2 RNA genome contains a 5'-cap that facilitates translation of viral proteins, protection from exonucleases and evasion of the host immune response1-4. How this cap is made is not completely understood. Here, we reconstitute the SARS-CoV-2 7MeGpppA2'-O-Me-RNA cap using virally encoded non-structural proteins (nsps). We show that the kinase-like NiRAN domain5 of nsp12 transfers RNA to the amino terminus of nsp9, forming a covalent RNA-protein intermediate (a process termed RNAylation). Subsequently, the NiRAN domain transfers RNA to GDP, forming the cap core structure GpppA-RNA. The nsp146 and nsp167 methyltransferases then add methyl groups to form functional cap structures. Structural analyses of the replication-transcription complex bound to nsp9 identified key interactions that mediate the capping reaction. Furthermore, we demonstrate in a reverse genetics system8 that the N-terminus of nsp9 and the kinase-like active site residues in the NiRAN domain are required for successful SARS-CoV-2 replication. Collectively, our results reveal an unconventional mechanism by which SARS-CoV-2 caps its RNA genome, thus exposing a new target in the development of antivirals to treat COVID-19.

Conjuring up a ghost: structural and functional characterization of FhuF, a ferric siderophore reductase from E. coli

Iron is a fundamental element for virtually all forms of life. Despite its abundance, its bioavailability is limited, and thus, microbes developed siderophores, small molecules, which are synthesized inside the cell and then released outside for iron scavenging. Once inside the cell, iron removal does not occur spontaneously, instead this process is mediated by siderophore-interacting proteins (SIP) and/or by ferric-siderophore reductases (FSR). In the past two decades, representatives of the SIP subfamily have been structurally and biochemically characterized; however, the same was not achieved for the FSR subfamily. Here, we initiate the structural and functional characterization of FhuF, the first and only FSR ever isolated. FhuF is a globular monomeric protein mainly composed by α-helices sheltering internal cavities in a fold resembling the "palm" domain found in siderophore biosynthetic enzymes. Paramagnetic NMR spectroscopy revealed that the core of the cluster has electronic properties in line with those of previously characterized 2Fe-2S ferredoxins and differences appear to be confined to the coordination of Fe(III) in the reduced protein. In particular, the two cysteines coordinating this iron appear to have substantially different bond strengths. In similarity with the proteins from the SIP subfamily, FhuF binds both the iron-loaded and the apo forms of ferrichrome in the micromolar range and cyclic voltammetry reveals the presence of redox-Bohr effect, which broadens the range of ferric-siderophore substrates that can be thermodynamically accessible for reduction. This study suggests that despite the structural differences between FSR and SIP proteins, mechanistic similarities exist between the two classes of proteins.

Smartphone App for monitoring Asthma in children and adolescents

PURPOSE

The asthma stepwise treatment approach recommended is based on monitoring patients' symptoms. The Asthma Research in Children and Adolescents (ARCA) cohort was created to provide evidence about the evolution of persistent asthma. This manuscript describes the development of an electronic health tool, comprising a mobile health application for patients with asthma and its associated online platform for pediatricians to monitor them.

METHODS

The development process followed 7 phases: the first 5 (Conceptualization, Preparation, Assessment scheduling, Image and user interface, and Technical development) defined and designed the tool, followed by a testing phase (functionality assessment and pilot test with ARCA patients), and a last phase which evaluated usability. Since the target population was aged 6-16 years, three versions were designed within the same smartphone application: parents/proxy, children, and adolescents. The online platform for pediatricians provides real-time information from the application: patients' responses over time with color-coded charts (red/amber/green, as in traffic lights).

RESULTS

The pilot test through semi-structured phone interviews of the first 50 participants included in the ARCA study (n = 53) detected their misunderstandings. Pediatricians were trained to emphasize that the application is free of charge and requires monthly answers. Median of the System Usability Scale scores (n = 85), ranging 0 (negative)-100 (positive), was > 93 in the three age versions of the application.

CONCLUSIONS

Technology has the capability of transforming the use of patient-reported outcomes. Describing all the development phases of a mobile health application for monitoring children and adolescents with asthma may increase the knowledge on how to design applications for young patients.

OP0296 SUPERIOR EFFICACY OF CALCIFEDIOL SOFT GELATIN CAPSULES VS CHOLECALCIFEROL FOR THE MANAGEMENT OF VITAMIN D DEFICIENCY IN POSTMENOPAUSAL WOMEN: A TREATMENT TO BE CONSIDERED IN THERAPEUTIC GUIDELINES

Background:

Vitamin D deficiency is a highly prevalent entity worldwide, with relevance in specific diseases and stages of life1. Few guidelines assess the indications and optimal dosing in the general population, and although there is no international consensus, 800IU/day is associated with benefits in bone metabolism. Calcifediol, a vitamin D analog, is presented as a therapeutic alternative.

Objectives:

To assess the efficacy of calcifediol in the treatment of vitamin D deficiency, compared with therapeutic guidelines recommendations for cholecalciferol in postmenopausal women.

Methods:

Phase III-IV, double blind, randomised, controlled, multicentre superiority clinical trial. Postmenopausal women with baseline levels of 25(OH)D < 20 ng/mL were randomised to three arms: 266 mcg of calcifediol/month for 4 or 12 months (standard and test regime), or to cholecalciferol 25000 IU/month for 12 months (as per therapeutic guidelines).

Results from an interim analysis - performed upon completion of month 4 visit by 100% of evaluable patients - are presented and reported without unblinding the study treatments. Both calcifediol groups are summarised for analysis.

The trial has been approved by the corresponding ethics committees and national competent authorities.

Results:

298 women were included in the ITT analysis. The average age was 63.4 ± 8.2 years, mean BMI was 29.3 ± 6 Kg/m2, 10.7% had osteoporosis and received treatment. All demographic characteristics and risk factors for osteoporosis were balanced amongst groups.

When analysing per treatment group,13.5% and 35% of women in the calcifediol group reached values of 25(OH)D > 30ng/mL at 1 and 4 months when compared to 0% and 8.2% respectively in the cholecalciferol group (p<0.01), achieving target levels in a rapid manner (Figure 1).

Figure 1.

Regarding baseline levels, 25% of the population had levels <10ng/mL; in this group there were no statistically significant differences between both treatments, possibly due to the limited sample size. In the group with baseline levels from 10 to<20 ng/mL, a statistically significant mean difference was observed at months 1 and 4, with a greater proportion of patients achieving both therapeutic levels in the calcifediol group (Table 1). No relevant safety issues were reported for the present analysis.

Table 1.Basal 25(OH)D levels< 10ng/mLNS10 to <20 ng/mL**Calcifediol (n= 54)Cholecalciferol(n= 20)Calcifediol(n= 146)Cholecalciferol(n= 78)Month 1>30 ng/mL2 (3.7%)0 (0%)25 (17.1%)0 (0%)>20 ng/mL12 (22.2%)2 (10%)106 (72.6%)31 (39.7%)Month 4>30 ng/mL8 (14.8%)1 (5%)62 (42.5%)7 (9%)>20 ng/mL27 (50%)8 (40%)135 (92.5%)63 (80.8%)

NSp>0.05; **p≤0.01

Conclusion:

Calcifediol shows a greater efficacy than cholecalciferol regime (as recommended in therapeutic guidelines), for the treatment of vitamin D deficiency in postmenopausal women and in a timely manner, which could impact osteoporosis treatment. Cholecalciferol fails to achieve recommended levels in a significant proportion of this population. Baseline vitamin D levels are to be considered for the supplementation of vitamin D.

References:

[1]Amrein, K., Scherkl, M., Hoffmann, M.et al.Vitamin D deficiency 2.0: an update on the current status worldwide.Eur J Clin Nutr(2020).

Acknowledgments:

Osteoferol Study Group principal investigators and their teams: F Cereto, ML Brandi, E Jodar, JM Quesada-Gómez, JM Olmos-Martínez, MA Colmenero-Camacho, R Alhambra, C Gómez-Alonso, B Galarraga

Disclosure of Interests:

Javier del Pino Grant/research support from: Roche, Bristol, Consultant of: Gedeon, José Luis Pérez-Castrillón Grant/research support from: Farmalider, Pfizer, Consultant of: Farmalider, Faes Farma, Gedeon-Richter, Speakers bureau: Amgen, Lilly, MSD, Faes Farma, Antonio Dueñas-Laita Grant/research support from: Faes Farma, Farmalider, Consultant of: Faes Farma, Speakers bureau: Farmalider, Gonzalo Hernandez Employee of: Faes Farma S.A., Paula Arranz-Gutiérrez Employee of: Faes Farma, Sandra Pamela Chinchilla Employee of: Faes Farma S.A.

Predictive models of minimum temperatures for the south of Buenos Aires province

Depending on the time of development of a crop temperature below 0 °C can cause damage to the plant, altering its development and subsequent yield. Since frosts are identified from the minimum air temperature, the objective of this research paper is to generate forecast -(predictive) models at 1, 3 and 5 days of the minimum daily temperature (T_min) for Bahía Blanca city. Non-linear numerical models are generated using artificial neural networks and geometric models of finite elements. Six independent variables are used: temperature and dew point temperature at meteorological shelter level, relative humidity, cloudiness observed above the station, wind speed and direction measured at 10 m altitude. Data have been obtained between May and September from 1956 to 2015. Once the available data had been analyzed, this period was reduced to 2007-2015. For the selection of the most suitable model, the correlation coefficient of Pearson (R), the determination coefficient (R²) and the Mean Absolute Error (MAE) are evaluated. The results of the study determine that the geometric model of finite elements with 4 variables, over 9 years (2007-2015) and separated by the season of the year is the one that presents better adjustment in the forecast of T_min with up to 5 days of anticipation.

Pancreatitis is an FGF21-deficient state that is corrected by replacement therapy

The exocrine pancreas expresses the highest concentrations of fibroblast growth factor 21 (FGF21) in the body, where it maintains acinar cell proteostasis. Here, we showed in both mice and humans that acute and chronic pancreatitis is associated with a loss of FGF21 expression due to activation of the integrated stress response (ISR) pathway. Mechanistically, we found that activation of the ISR in cultured acinar cells and mouse pancreata induced the expression of ATF3, a transcriptional repressor that directly bound to specific sites on the Fgf21 promoter and resulted in loss of FGF21 expression. These ATF3 binding sites are conserved in the human FGF21 promoter. Consistent with the mouse studies, we also observed the reciprocal expression of ATF3 and FGF21 in the pancreata of human patients with pancreatitis. Using three different mouse models of pancreatitis, we showed that pharmacologic replacement of FGF21 mitigated the ISR and resolved pancreatitis. Likewise, inhibition of the ISR with an inhibitor of the PKR-like endoplasmic reticulum kinase (PERK) also restored FGF21 expression and alleviated pancreatitis. These findings highlight the importance of FGF21 in preserving exocrine pancreas function and suggest its therapeutic use for prevention and treatment of pancreatitis.

Mitophagy protects against statin-mediated skeletal muscle toxicity

The deleterious effects of statins on skeletal muscle are well known, but the mechanism associated with these effects remains unresolved. Statins are associated with mitochondrial damage, which may contribute to muscle myopathy. Here we demonstrate that simvastatin induces mitophagy in skeletal muscle cells and hypothesized that attenuating this process by silencing the mitophagy adapter p62/sequestosome-1 (SQSTM1) might mitigate myotoxicity. Surprisingly, silencing p62/SQSTM1 in differentiated C2C12 muscle cells exacerbated rather than attenuated myotoxicity. This inhibition of mitophagy in the face of statin challenge correlated with increased release of cytochrome c to the cytosol, activation of caspase-3, and lactate dehydrogenase (LDH) release. Correspondingly, targeted knockdown of Parkin, a canonical E3 ubiquitin ligase important for mitophagy, mirrored the effects of p62/SQSTM1 silencing. To corroborate these findings in vivo, we treated Parkin knockout mice with simvastatin for 2 wk. In line with our findings in vitro, these mitophagy-compromised mice displayed reduced spontaneous activity, loss of grip strength, and increased circulating levels of muscle damage marker LDH. Our findings demonstrate that mitophagy is an important mechanism to resist statin-induced skeletal muscle damage.-Ramesh, M., Campos, J. C., Lee, P., Song, Y., Hernandez, G., Sin, J., Tucker, K. C., Saadaeijahromi, H., Gurney, M., Ferreira, J. C. B., Andres, A. M. Mitophagy protects against statin-mediated skeletal muscle toxicity.

Phase Ib study of atezolizumab combined with cobimetinib in patients with solid tumors

BACKGROUND

Preclinical evidence suggests that MEK inhibition promotes accumulation and survival of intratumoral tumor-specific T cells and can synergize with immune checkpoint inhibition. We investigated the safety and clinical activity of combining a MEK inhibitor, cobimetinib, and a programmed cell death 1 ligand 1 (PD-L1) inhibitor, atezolizumab, in patients with solid tumors.

PATIENTS AND METHODS

This phase I/Ib study treated PD-L1/PD-1-naive patients with solid tumors in a dose-escalation stage and then in multiple, indication-specific dose-expansion cohorts. In most patients, cobimetinib was dosed once daily orally for 21 days on, 7 days off. Atezolizumab was dosed at 800 mg intravenously every 2 weeks. The primary objectives were safety and tolerability. Secondary end points included objective response rate, progression-free survival, and overall survival.

RESULTS

Between 27 December 2013 and 9 May 2016, 152 patients were enrolled. As of 4 September 2017, 150 patients received ≥1 dose of atezolizumab, including 14 in the dose-escalation cohorts and 136 in the dose-expansion cohorts. Patients had metastatic colorectal cancer (mCRC; n = 84), melanoma (n = 22), non-small-cell lung cancer (NSCLC; n = 28), and other solid tumors (n = 16). The most common all-grade treatment-related adverse events (AEs) were diarrhea (67%), rash (48%), and fatigue (40%), similar to those with single-agent cobimetinib and atezolizumab. One (<1%) treatment-related grade 5 AE occurred (sepsis). Forty-five (30%) and 23 patients (15%) had AEs that led to discontinuation of cobimetinib and atezolizumab, respectively. Confirmed responses were observed in 7 of 84 patients (8%) with mCRC (6 responders were microsatellite low/stable, 1 was microsatellite instable), 9 of 22 patients (41%) with melanoma, and 5 of 28 patients (18%) with NSCLC. Clinical activity was independent of KRAS/BRAF status across diseases.

CONCLUSIONS

Atezolizumab plus cobimetinib had manageable safety and clinical activity irrespective of KRAS/BRAF status. Although potential synergistic activity was seen in mCRC, this was not confirmed in a subsequent phase III study.

CLINICALTRIALS.GOV IDENTIFIER

NCT01988896 (the investigators in the NCT01988896 study are listed in the supplementary Appendix, available at Annals of Oncology online).

Oral lesions in Sjogren's syndrome: A systematic review

BACKGROUND

Sjogren's syndrome (SS) is an autoimmune disease related to two common symptoms: dry mouth and eyes. Although, xerostomia and hyposialia have been frequently reported in these patients, not many studies have evaluated other oral manifestations. The aim of this systematic review was to investigate prevalence rates of oral lesions (OL) in SS patients and to compare it to a control group (CG), when available.

MATERIAL AND METHODS

An exhaustive search of the published literature of the Pubmed, Scopus, Web of Science and the Cochrane Library databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) for relevant studies that met our eligibility criteria (up to September 1st 2017).

RESULTS

Seventeen cross-sectional studies and one cohort study were finally included. The results showed that SS patients presented more OL compared to non-SS patients. The most frequent types of OL registered in primary and secondary SS were angular cheilitis, atrophic glossitis, recurrent oral ulcerations and grooves or fissurations of the tongue, also when compared to a CG.

CONCLUSIONS

OL are common and more frequent in SS patients when compared to a CG. This may be a consequence of low levels of saliva. More studies where these OL and all the possible cofounding factors are taken into account are needed.

FGF21 Is an Exocrine Pancreas Secretagogue

The metabolic stress hormone FGF21 is highly expressed in exocrine pancreas, where its levels are increased by refeeding and chemically induced pancreatitis. However, its function in the exocrine pancreas remains unknown. Here, we show that FGF21 stimulates digestive enzyme secretion from pancreatic acinar cells through an autocrine/paracrine mechanism that requires signaling through a tyrosine kinase receptor complex composed of an FGF receptor and β-Klotho. Mice lacking FGF21 accumulate zymogen granules and are susceptible to pancreatic ER stress, an effect that is reversed by administration of recombinant FGF21. Mice carrying an acinar cell-specific deletion of β-Klotho also accumulate zymogen granules but are refractory to FGF21-stimulated secretion. Like the classical post-prandial secretagogue, cholecystokinin (CCK), FGF21 triggers intracellular calcium release via PLC-IP₃R signaling. However, unlike CCK, FGF21 does not induce protein synthesis, thereby preventing protein accumulation. Thus, pancreatic FGF21 is a digestive enzyme secretagogue whose physiologic function is to maintain acinar cell proteostasis.

FGF21 Regulates Sweet and Alcohol Preference

Fibroblast growth factor 21 (FGF21) is a hormone induced by various metabolic stresses, including ketogenic and high-carbohydrate diets, that regulates energy homeostasis. In humans, SNPs in and around the FGF21 gene have been associated with macronutrient preference, including carbohydrate, fat, and protein intake. Here we show that FGF21 administration markedly reduces sweet and alcohol preference in mice and sweet preference in cynomolgus monkeys. In mice, these effects require the FGF21 co-receptor β-Klotho in the central nervous system and correlate with reductions in dopamine concentrations in the nucleus accumbens. Since analogs of FGF21 are currently undergoing clinical evaluation for the treatment of obesity and type 2 diabetes, our findings raise the possibility that FGF21 administration could affect nutrient preference and other reward behaviors in humans.

Asymptomatic peritoneal carcinomatosis originating from benign cystic peritoneal mesothelioma

Benign multicystic mesothelioma is a rare tumour that originates from the abdominal peritoneum with a predisposition to the pelvic peritoneum. It typically affects women of reproductive age. There have been less than 200 cases of this rare neoplasia reported to date.

We present the case of a 35-year-old woman who was referred to our centre because of the detection of a peritoneal carcinomatosis during a gynaecological exam. A diagnostic laparoscopy was performed. The findings included multiple cysts appearing as ‘a bunch of grapes’ occupying the omentum. Biopsies were taken during the surgery and the results showed benign multicystic peritoneal mesothelioma.

Benign multicystic mesothelioma can simulate other conditions, such as malignant ovarian tumours or cystic lymphangioma. It is often diagnosed accidentally during surgery performed for another reason. The diagnosis is interoperative, observing multicystic structures grouped as a ‘bunch of grapes’ containing clear fluid with thin walls made of connective tissue. Immunohistochemistry confirmed mesothelial origin. Surgery is considered the treatment of choice and is based on the removal of the cysts from the abdominal cavity.

Hyperthermic intraperitoneal chemotherapy can be considered as a primary treatment in patients with recurrences or even as a part of primary treatment associated with surgery. Survival at 5 years is 100% and invasive or malignant progression is extraordinary. The treatment approach should be multidisciplinary, and the patient should be referred to a referral centre.

A double-blind randomized controlled trial to assess the efficacy of daylight photodynamic therapy with methyl-aminolevulinate vs. Placebo and daylight in patients with facial photodamage

BACKGROUND

Daylight PDT (dPDT) is easy to use and does not require light equipment. Such therapy has been exhaustively proved to be successful in the treatment of actinic keratosis, but its use in skin photodamage remains unclear.

OBJECTIVE

To evaluate dPDT's efficacy in skin facial photodamage.

PATIENTS AND METHODS

This was a parallel-group double-blind, randomized placebo-controlled trial. Sixty participants with symmetric facial photodamage were allocated to topical methyl aminolevulinate (MAL) and daylight vs. matching placebo and daylight. Primary outcome was global photodamage improvement/failure 1 month after the third session. Secondary outcomes included: pain evaluation; specific photodamage severity scores; sun irradiance quantification and Skindex-29 scores. Adverse events were also investigated.

RESULTS

Primary analysis included all randomized patients. All patients sun-exposed for 120min in 3 sessions. The risk of failure was lower in the MAL-dPDT group than in the placebo plus daylight group (RR: 0.18; 95% CI: 0.08-0.41). Mean solar irradiance (W/m(2)) during the first, second and third sessions was 480.82, 430.07 and 435.84, respectively. Items 5 and 14 of Skindex-29 in the MAL-dPDT group showed statistical significant differences. Two patients in the MAL-dPDT group had serious and non-serious events not directly related to the product.

CONCLUSION

dPDT with MAL was un-painful, effective and safe for the treatment of facial photodamage. Herpes simplex prophylaxis should be considered before sessions.

Mitophagy is required for acute cardioprotection by simvastatin

AIMS

We have shown that autophagy and mitophagy are required for preconditioning. While statin's cardioprotective effects are well known, the role of autophagy/mitophagy in statin-mediated cardioprotection is not. In this study, we used HL-1 cardiomyocytes and mice subjected to ischemia/reperfusion to elucidate the mechanism of statin-mediated cardioprotection.

RESULTS

HL-1 cardiomyocytes exposed to simvastatin for 24 h exhibited diminished protein kinase B (Akt)/mammalian target of rapamycin (mTOR) signaling, increased activation of unc-51-like kinase 1, and upregulation of autophagy and mitophagy. Similar findings were obtained in hearts of mice given simvastatin. Mevalonate abolished simvastatin's effects on Akt/mTOR signaling and autophagy induction in HL-1 cells, indicating that the effects are mediated through inhibition of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase. Simvastatin-treated HL-1 cells exhibited mitochondrial translocation of Parkin and p62/SQSTM1, fission, and mitophagy. Because Parkin is required for mitophagy and is expressed in heart, we investigated the effect of simvastatin on infarct size in Parkin knockout mice. Simvastatin reduced infarct size in wild-type mice but showed no benefit in Parkin knockout mice. Inhibition of HMG-CoA reductase limits mevalonate availability for both cholesterol and coenzyme Q10 (CoQ) biosynthesis. CoQ supplementation had no effect on statin-induced Akt/mTOR dephosphorylation or macroautophagy in HL-1 cells, but it potently blocked mitophagy. Importantly, CoQ supplementation abolished statin-mediated cardioprotection in vivo.

INNOVATION AND CONCLUSION

Acute simvastatin treatment suppresses mTOR signaling and triggers Parkin-dependent mitophagy, the latter which is required for cardioprotection. Coadministration of CoQ with simvastatin impairs mitophagy and cardioprotection. These results raise the concern that CoQ may interfere with anti-ischemic benefits of statins mediated through stimulation of mitophagy.

Abstract 145: Mitophagy Protects Against Statin-Induced Cell Death in Muscle Cells

Statins are a family of cholesterol lowering drugs associated with undisputable cardiovascular benefits. However, their use is associated with the risk of developing skeletal muscle myopathy which remains a significant barrier to maximizing the efficacy of statin therapy. Many recognize that the instances of statin-associated myopathy reported grossly underestimate the actual frequency of these events. Statin myopathy is a major reason for why many patients are unable to comply with their prescribed statin treatments. Identifying and understanding the molecular events involved in the development of statin-induced myopathy will pave the way to mitigating the unwanted effect of statin-myopathy.

We have identified that statins induce mitochondrial loss in both C2C12 myotubes, and in gastrocnemius muscle of mice evidenced by loss of mitochondrial markers Tom70 and Cox4 by western blot analysis. C2C12 myotubes were treated with 2μM simvastatin for 24 hours, and wild-type C57BL/6 mice were given a daily i.p. dose of 20mg/kg simvastatin for 2 weeks. Pretreatment of C2C12 cells with 100nM bafilomycin for 2 hours before statin treatment attenuated autophagic flux, and prevents the observed loss of mitochondria through Tom70 and Cox4 mitochondrial markers. Thus, the loss of mitochondria is attributable to autophagy (mitophagy). Statin treatment increases the expression of Bnip3 and p62/SQSTM1 (sequestosome 1) which have been identified as important facilitators of mitophagy. We found increased Bnip3 dimerization via western blot under non-reducing conditions which implies increased activity. Furthermore, we observed increased mitochondrial translocation of p62/SQSTM1. Based on our findings, we hypothesized that statin-induced mitophagy may play a key role in the development of muscle myopathy.

To investigate the role of mitophagy in statin myopathy, we silenced p62/SQSTM1 via RNAi prior to statin treatment. Surprisingly, reducing mitophagic flux via p62/SQSTM1 silencing resulted in increased destruction of myotubes. This was associated with increased levels of cytosolic cytochrome c. Our data combined suggests that mitophagy protects against statin-mediated cell death by sequestering and eliminating decrepit mitochondria via autophagy.

A systematic review and individual patient data meta-analysis on intra-abdominal hypertension in critically ill patients: the wake-up project. World initiative on Abdominal Hypertension Epidemiology, a Unifying Project (WAKE-Up!)

Intra-abdominal hypertension (IAH), defined as a pathologically increase in intraabdominal pressure, is commonly found in critically ill patients. While IAH has been associated with several abdominal as well as extra-abdominal conditions, few studies have examined the occurrence of IAH in relation to mortality. The aim of this paper was to evaluate the prognostic role of IAH and its risk factors at admission in critically ill patients across a wide range of settings and countries. An individual patient meta-analysis of all available data and a systematic review of published (in full or as abstract) medical databases and studies between 1996 and June 2012 were performed. The search was limited to "clinical trials" and "randomized controlled trials", "adults", using the terms "intra-abdominal pressure", "intraabdominal hypertension" combined with any of the terms "outcome" and "mortality". All together data on 2707 patients, representing 21 centers from 11 countries was obtained. Data on 1038 patients were not analysed because of the following exclusion criteria: no IAP value on admission (N.=712), absence of information on ICU outcome (N.=195), age <18 or >95 years (N.=131). Data from 1669 individual patients (19 centers from 9 countries) were analyzed in the meta-analysis. Presence of IAH was defined as a sustained increase in IAP equal to or above 12 mmHg. At admission the mean overall IAP was 9.9±5.0 mmHg, with 463 patients (27.7%) presenting IAH with a mean IAP of 16.3±3.4 mmHg. The only independent predictors for IAH were SOFA score and fluid balance on the day of admission. Five hundred thirteen patients (30.8%) died in intensive care. The independent predictors for intensive care mortality were IAH, SAPS II score, SOFA score and admission category. This systematic review and individual patient data meta-analysis shows that IAH is frequently present in critically ill patients and it is an independent predictor for mortality.

A Systematic Review And Individual Patient Data Meta-Analysis On Intraabdominal Hypertension In Critically Ill Patients: The Wake-Up Project World Initiative on Abdominal Hypertension Epidemiology, a Unifying Project (WAKE-Up!)

Background: Intraabdominal hypertension (IAH), defined as a pathologically increase in intraabdominal pressure, is commonly found in critically ill patients. While IAH has been associated with several abdominal as well as extra-abdominal conditions, few studies have examined the occurrence of IAH in relation to mortality. Objective: To evaluate the prognostic role of IAH and its risk factors at admission in critically ill patients across a wide range of settings and countries. Data sources: An individual patient meta-analysis of all available data and a systematic review of published (in full or as abstract) medical databases and studies between 1996 and June 2012 were performed. The search was limited to "clinical trials" and "randomized controlled trials", "adults", using the terms "intraabdominal pressure", "intraabdominal hypertension" combined with any of the terms "outcome" and "mortality". All together data on 2707 patients, representing 21 centers from 11 countries was obtained. Data on 1038 patients were not analysed because of the following exclusion criteria: no IAP value on admission (n=712), absence of information on ICU outcome (n=195), age <18 or > 95 years (n=131). Results: Data from 1669 individual patients (19 centers from 9 countries) were analyzed in the meta-analysis. Presence of IAH was defined as a sustained increase in IAP equal to or above 12 mmHg. At admission the mean overall IAP was 9.9±5.0 mmHg, with 463 patients (27.7%) presenting IAH with a mean IAP of 16.3±3.4 mmHg. The only independent predictors for IAH were SOFA score and fluid balance on the day of admission. Five hundred thirteen patients (30.8%) died in intensive care. The independent predictors for intensive care mortality were IAH, SAPS II score, SOFA score and admission category. Conclusions: This systematic review and individual patient data meta-analysis shows that IAH is frequently present in critically ill patients and it is an independent predictor for mortality.

MitoTimer: a novel tool for monitoring mitochondrial turnover

Fluorescent Timer, or DsRed1-E5, is a mutant of the red fluorescent protein, dsRed, in which fluorescence shifts over time from green to red as the protein matures. This molecular clock gives temporal and spatial information on protein turnover. To visualize mitochondrial turnover, we targeted Timer to the mitochondrial matrix with a mitochondrial-targeting sequence (coined "MitoTimer") and cloned it into a tetracycline-inducible promoter construct to regulate its expression. Here we report characterization of this novel fluorescent reporter for mitochondrial dynamics. Tet-On HEK 293 cells were transfected with pTRE-tight-MitoTimer and production was induced with doxycycline (Dox). Mitochondrial distribution was demonstrated by fluorescence microscopy and verified by subcellular fractionation and western blot analysis. Dox addition for as little as 1 h was sufficient to induce MitoTimer expression within 4 h, with persistence in the mitochondrial fraction for up to 6 d. The color-specific conformation of MitoTimer was stable after fixation with 4% paraformaldehyde. Ratiometric analysis of MitoTimer revealed a time-dependent transition from green to red over 48 h and was amenable to analysis by fluorescence microscopy and flow cytometry of whole cells or isolated mitochondria. A second Dox administration 48 h after the initial induction resulted in a second round of expression of green MitoTimer. The extent of new protein incorporation during a second pulse was increased by administration of a mitochondrial uncoupler or simvastatin, both of which trigger mitophagy and biogenesis. MitoTimer is a novel fluorescent reporter protein that can reveal new insights into mitochondrial dynamics within cells. Coupled with organelle flow cytometry, it offers new opportunities to investigate mitochondrial subpopulations by biochemical or proteomic methods.

Geographical characterization of the triatomine infestations in north–central Guatemala

In an entomological study in 2002, the degree of domestic and peridomestic infestation with triatomine bugs and the geographical distribution of such infestations were investigated in north-central Guatemala. The survey team searched for triatomines in houses constructed with mud walls or thatched roofs, in villages suspected of being infested. The level of infestation observed was lower than that seen in the same area and in eastern Guatemala, in a preliminary survey, 3 years earlier. Most of the infestations detected were of Triatoma dimidiata but even this species was found in <7% of the houses investigated. Infestations with Rhodnius prolixus or other potential vectors of Trypanosoma cruzi were much rarer. The generally low levels of infestation make the elimination of R. prolixus and the reduction of the domestic population of Tri. dimidiata feasible in the study area. The southern part of the study area had higher levels of domestic infestation and colonization than the north, and peridomestic infestation was highest in the south-west. Given such geographical variation in the pattern of infestation, it would seem wise to stratify the study region into areas of high, moderate and low-risk of human-triatomine contact, so that appropriate vector-control strategies can be targeted at the worst-affected areas. Regular entomological surveillance, ideally with community participation, is recommended. Analysis of the relationship between the geographical patterns of infestation and factors such as vegetation, altitude and vector migration would be useful.

Fourier transform infrared absorption spectroscopy characterization of gaseous atmospheric pressure plasmas with 2 mm spatial resolution

This paper describes an optical setup built to record Fourier transform infrared (FTIR) absorption spectra in an atmospheric pressure plasma with a spatial resolution of 2 mm. The overall system consisted of three basic parts: (1) optical components located within the FTIR sample compartment, making it possible to define the size of the infrared beam (2 mm × 2 mm over a path length of 50 mm) imaged at the site of the plasma by (2) an optical interface positioned between the spectrometer and the plasma reactor. Once through the plasma region, (3) a retro-reflector module, located behind the plasma reactor, redirected the infrared beam coincident to the incident path up to a 45° beamsplitter to reflect the beam toward a narrow-band mercury-cadmium-telluride detector. The antireflective plasma-coating experiments performed with ammonia and silane demonstrated that it was possible to quantify 42 and 2 ppm of these species in argon, respectively. In the case of ammonia, this was approximately three times less than this gas concentration typically used in plasma coating experiments while the silane limit of quantification was 35 times lower. Moreover, 70% of the incoming infrared radiation was focused within a 2 mm width at the site of the plasma, in reasonable agreement with the expected spatial resolution. The possibility of reaching this spatial resolution thus enabled us to measure the gaseous precursor consumption as a function of their residence time in the plasma.