Efficacy and safety of voretigene neparvovec (AAV2-hRPE65v2) in patients with RPE65-mediated inherited retinal dystrophy: a randomised, controlled, open-label, phase 3 trial

BACKGROUND

Phase 1 studies have shown potential benefit of gene replacement in RPE65-mediated inherited retinal dystrophy. This phase 3 study assessed the efficacy and safety of voretigene neparvovec in participants whose inherited retinal dystrophy would otherwise progress to complete blindness.

METHODS

In this open-label, randomised, controlled phase 3 trial done at two sites in the USA, individuals aged 3 years or older with, in each eye, best corrected visual acuity of 20/60 or worse, or visual field less than 20 degrees in any meridian, or both, with confirmed genetic diagnosis of biallelic RPE65 mutations, sufficient viable retina, and ability to perform standardised multi-luminance mobility testing (MLMT) within the luminance range evaluated, were eligible. Participants were randomly assigned (2:1) to intervention or control using a permuted block design, stratified by age (<10 years and ≥10 years) and baseline mobility testing passing level (pass at ≥125 lux vs <125 lux). Graders assessing primary outcome were masked to treatment group. Intervention was bilateral, subretinal injection of 1·5 × 10¹¹ vector genomes of voretigene neparvovec in 0·3 mL total volume. The primary efficacy endpoint was 1-year change in MLMT performance, measuring functional vision at specified light levels. The intention-to-treat (ITT) and modified ITT populations were included in primary and safety analyses. This trial is registered with ClinicalTrials.gov, number NCT00999609, and enrolment is complete.

FINDINGS

Between Nov 15, 2012, and Nov 21, 2013, 31 individuals were enrolled and randomly assigned to intervention (n=21) or control (n=10). One participant from each group withdrew after consent, before intervention, leaving an mITT population of 20 intervention and nine control participants. At 1 year, mean bilateral MLMT change score was 1·8 (SD 1·1) light levels in the intervention group versus 0·2 (1·0) in the control group (difference of 1·6, 95% CI 0·72-2·41, p=0·0013). 13 (65%) of 20 intervention participants, but no control participants, passed MLMT at the lowest luminance level tested (1 lux), demonstrating maximum possible improvement. No product-related serious adverse events or deleterious immune responses occurred. Two intervention participants, one with a pre-existing complex seizure disorder and another who experienced oral surgery complications, had serious adverse events unrelated to study participation. Most ocular events were mild in severity.

INTERPRETATION

Voretigene neparvovec gene replacement improved functional vision in RPE65-mediated inherited retinal dystrophy previously medically untreatable.

FUNDING

Spark Therapeutics.

Acquired CD40-ligand deficiency in chronic lymphocytic leukemia

Patients with B-cell chronic lymphocytic leukemia (CLL) acquire an immunodeficiency with many characteristics similar to those of persons with inherited defects in the gene encoding the CD40-ligand (CD154). We found that the blood and splenic CD4+ T cells of patients with CLL failed to express surface CD154 after CD3 ligation. However, using an enzyme-linked immunosorbent assay (ELISA)-based quantitative competitive polymerase chain reaction (PCR), we noted that CD3 ligation could induce such T cells to express CD154 messenger RNA at levels similar to that of CD3-activated T cells from normal donors. Moreover, addition of increasing numbers of CLL B cells to activated normal donor T cells rapidly resulted in progressively greater down-modulation of CD154. Such down-modulation of CD154 could be blocked by addition of CD40 monoclonal antibody to cultures in vitro. We propose that leukemia cell-mediated down-modulation of CD154 on activated T cells accounts for some of the acquired immune defects of patients with CLL.

Differential expression of Met/hepatocyte growth factor receptor in subtypes of non-small cell lung cancers

Hepatocyte growth factor (HGF)/scatter factor (SF) is a multifunctional factor that stimulates epithelial cell motility, invasion and morphogenesis. Its receptor is a transmembrane tyrosine kinase encoded by the Met proto-oncogene. Several studies have suggested a possible role for HGF/Met in tumor development and progression. To investigate the potential roles of Met in human lung cancer biology, we have studied the mRNA and protein expression of Met in normal lung tissue, primary non-small cell lung carcinoma (NSCLC), and NSCLC cell lines. The results indicated a differential pattern of Met expression among various subtypes of NSCLC. The majority of squamous cell carcinoma (SQCC), either in vivo or in vitro, expressed Met mRNA and its protein product at levels much lower than or similar to normal lung tissue or bronchial epithelium. Moreover, SQCC characteristically over-expressed a variant Met mRNA which corresponds to a 5' partially deleted transcript produced by alternative splicing. In contrast, the expression of Met mRNA and its protein product in adenocarcinoma (ADC) and large cell undifferentiated carcinoma were more heterogeneous. Overexpression was demonstrated in approximately 35% and 20% of these subtypes of NSCLC, respectively. Among ADC, intermediate to high levels of Met immunoreactivity correlated with greater degree of tumor differentiation. Furthermore, an accentuation of Met immunoreactivity was often noted in cancer cells at the advancing edge of tumors. These findings support a role for Met in lung cancer cell invasion and differentiation in vivo, but its expression and functions may be modified by the differentiation phenotype of the tumor cells.

The salvage of open grade IIIB ankle and talus fractures

Between 1983 and 1989, 11 open grade IIIB ankle or talus fractures were treated according to protocol including debridement, temporary placement of antibiotic beads, soft tissue coverage (including seven free vascular tissue transfers), intravenous antibiotics and fusion using an anterior plate, and bone graft. All patients had a minimum of three separate hospitalizations. Each had at least five operative procedures performed with an average of 8.2/patient (range: 5-12). The total in-patient hospital stay averaged 61.6 days (20-107 days) and in patient costs averaged $62,174.43/patient (range: $33,535.06-$143,847.45). Overall hospital cost averaged $1,009.32/day. Follow-up averaged 47.8 months (range 32-85 months), with an average time to union of 4.4 months. Fusion rate and muscle flap success was 100%. Although fusion and eradication of infection in this specific group of patients was possible, significant functional and psychosocial disability remained. Eight of eleven patients had significant pain, difficulty with stairs, and limited ambulation. All changed jobs or were unemployed. Patients with open grade IIIB tibiotalar injuries with significant bone loss may therefore benefit from early amputation. A multicenter randomized clinical outcome study is needed.

Variants of alpha 1-antitrypsin in Puerto Rican children with asthma

A survey of 393 Puerto Rican and 354 non-Hispanic pediatric patients at Beth Israel Hospital, New York, revealed a significantly larger percentage of asthmatic subjects among Puerto Ricans, confirming findings of a study of Puerto Rican adults in New York. Assays of alpha 1-antitrypsin (AAT) concentration and phenotypes in 61 Puerto Rican asthmatic children revealed a significantly larger number with an S or Z variant in AAT phenotype. The AAT concentration was not a significant variable in this relationship, since four of five subjects with intermediate deficient AAT concentrations and a PiM phenotype were among control nonasthmatic Puerto Rican subjects. A family history of asthma was more common among asthmatic than control subjects and was most common for variant AAT phenotypes in either asthmatic or control subjects. We speculate that the S or Z variant of AAT affects the inflammatory response in such a way as to predispose to asthma.

Infarction of the corpus callosum: computed tomography and magnetic resonance imaging

OBJECTIVE

To describe the computed tomography (CT) and magnetic resonance (MR) features of corpus callosum (CC) infarctions.

METHODS

We reviewed retrospectively 352 consecutive cranial CT and MR scans showing cerebral infarcts. Involvement of the CC was identified in 28 patients.

RESULTS

Infarctions of the CC were diffuse (n = 3) or focal (n = 25). The former were seen in the setting of diffuse cerebral ischemia secondary to cardiopulmonary arrest or status epilepticus. The latter were divided into those affecting predominantly the genu, body or splenium. The most common location of the insult was the splenium (n = 13), followed by the body (n = 6) and genu (n = 3). In the remaining three patients combined genu/body infarctions were seen.

CONCLUSION

Infarction of the CC may be more common than previously thought and is most often the result of cerebral embolism. MR is better suited than CT for the detection of vascular lesions of the CC.

An outbreak of shigellosis associated with the consumption of raw oysters

We describe an outbreak of Shigella sonnei infection among 24 persons who had eaten raw oysters in restaurants in southeastern Texas within five days before the onset of symptoms. The oysters in all eight restaurants were supplied by the same dealer, but examination of a routine water sample collected six days before the probable time of contamination showed the waters where the oysters were harvested to be free of fecal contamination, making widespread sewage contamination unlikely. The suspect oysters were traced to a single boat. Stool swabs from that boat's oyster harvesters allowed the identification of one asymptomatic carrier who had a strain of S. sonnei (determined by colicin typing, plasmid analysis, and testing for susceptibility to antibiotics) that was similar to or the same as that infecting the patients. Although the source of this man's infection was unknown, he reported having eaten no oysters. Investigation revealed that 5-gallon (19-liter) pails were used as toilets aboard the oyster boats. Sewage collected in these pails was often dumped overboard into the harvesting area. We conclude that this outbreak of S. sonnei resulted from poor sanitary procedures that probably allowed stool from a carrier to contaminate oysters either just before or after they were taken aboard the boat.

Tumor necrosis factor-alpha, interleukin-6, and nitric oxide in sterile ascitic fluid and serum from patients with cirrhosis who subsequently develop ascitic fluid infection

Ascitic fluid infection probably results from repeated episodes of bacteremia and seeding of ascitic fluid. The outcome of these episodes of colonization is probably a function of serum and ascitic fluid defense mechanisms and the virulence of the organism. Patients who develop spontaneous bacterial peritonitis may have serum and ascitic fluid characteristics that are different from those who do not develop infection. We prospectively collected serum and ascitic fluid specimens at the time of admission from patients with sterile cirrhotic ascites, and tested these specimens for interleukin-6, tumor necrosis factor-alpha, and nitric oxide and compared these results as well as other characteristics of patients who did not develop infection to those who did. An elevated baseline serum tumor necrosis factor-alpha as well as an increased proportion of polymorphonuclear leukocytes in sterile ascitic fluid from patients who subsequently developed infection probably represent a subclinical activation of defense mechanisms from prior silent colonizations with bacteria.

Nasopharyngeal cancer in patients under the age of thirty years

There is evidence that patients under 30 years of age with nasopharyngeal cancer present a somewhat different form of disease than patients of the older age group. Serum immunologic reactivity in the former was quantitatively different. Histologically, tumors in the younger age group are always of the undifferentiated type, and clinically, the disease is aggressive, characterized by frequent bone and lung metastases. The lymphatic spread into the mediastinum is accompanied by a paraneoplastic syndrome consisting of finger clubbing and hypertrophic osteoarthropathy, which is reversible after successful therapy. High rates of recovery have been obtained, even in the presence of advanced disease or metastases. This warrants a radical and persistent radiotherapeutic and or chemotherapeutic approach.

Molecular characterization of strains of enteroinvasive Escherichia coli O143, including isolates from a large outbreak in Houston, Texas

A large diarrhea outbreak due to enteroinvasive Escherichia coli (EIEC) serogroup O143 occurring in Houston, Tex., provided the opportunity to investigate aspects of the molecular epidemiology of this and related organisms. This was done by comparing the plasmid patterns and the chromosomal restriction endonuclease digestion patterns by pulsed-field gel electrophoresis (PFGE) of EIEC from the outbreak, other E. coli from the same serogoup (O143), and EIEC isolated from other patients with diarrhea. Among the isolates studied, there was marked restriction fragment length polymorphism. All 3 non-O143 EIEC isolates had very different restriction endonuclease digestion patterns, as did 5 of 5 O143 non-EIEC isolates and 6 of 15 O143 EIEC isolates. Four Houston outbreak O143 EIEC isolates had the same restriction pattern as an O143 EIEC strain isolated 2 months before in Mexico and was nearly identical to another two O143 EIEC Mexican isolates. These related strains also had the same plasmid pattern; however, the presence of only a few plasmid bands, versus the 21 to 30 chromosomal bands seen with PFGE, suggests that plasmid patterns could be a less specific way to distinguish different strains. These results demonstrate that PFGE can distinguish between different E. coli strains of the same serogroup and phenotype. This technique can also identify relatedness within O143 EIEC, and our data suggest the spread of a strain of EIEC from Mexico to Houston, where it caused a large outbreak. PFGE may be useful to study the epidemiology of EIEC.

Thecoperitoneal shunt for syringomyelia: report of three cases

During 8 months, three consecutive cases of syringomyelia were treated by the placement of thecoperitoneal shunts. In the first two patients, the cord cavitation was idiopathic in one and thought to be related to spinal trauma in the other. In the third case, there was associated anomaly of the craniocervical junction of the Chiari I type. Surgery was followed by clinical improvement in all patients. Postoperative magnetic resonance images showed definite diminution of the syringomyelic cavity. The results of treatment seem to support the use of the technique as a primary treatment of syringomyelia associated with progressive myelopathy.

The third component of Xenopus complement: cDNA cloning, structural and functional analysis, and evidence for an alternate C3 transcript

Although the third component of complement has been purified from two amphibian species, Xenopus laevis and the axolotl, only limited information is available about its primary structure in these species. We now present (a) 95% of the cDNA sequence encoding C3 from a Xenopus laevis/Xenopus gilli (Xenopus LG) hybrid (b) an analysis of the C3 convertase and factor I cleavage sites in Xenopus C3, and (c) evidence for an alternative form of C3. The Xenopus LG sequence has a 57% nucleotide and 52% amino acid sequence identity to human C3 and contains one potential N-glycosylation site in the beta-chain. The deduced amino acid sequence showed that the C3 convertase and factor I cleavage sites (Arg-Ser) are conserved in Xenopus C3 and protein sequencing of Xenopus C3 fragments fixed on zymosan during complement activation demonstrated that Xenopus C3 is indeed cleaved by C3 convertase and factor I at these sites. Our screening of a liver cDNA library identified an unusual C3 clone with a deletion of 2502 bp, suggesting the presence of a novel C3 transcript in Xenopus LG liver. The presence of this C3 transcript was confirmed by reverse transcription polymerase chain reaction using Xenopus LG liver mRNA and specific oligonucleotide probes. This transcript encoded a putative 102-kDa protein comprising the beta-chain of C3, together with the first 59 residues and the last 103 residues of the alpha-chain; it would therefore lack many of the ligand binding sites found in the intact alpha-chain. However, the molecule may be an analog of a truncated C3 molecule that is found in the serum of allergic dermatitis patients and acts as an inhibitor of eosinophil cytotoxicity and neutrophil adherence.

Biexponential T2 relaxation time analysis of the brain: correlation with magnetization transfer ratio

RATIONALE AND OBJECTIVES

To measure T2 relaxation times of normal white and gray matter using a novel CPMG sequence and investigate if any correlation exists between magnetization transfer ratio (MTR) and T2 relaxation-related parameters.

MATERIALS AND METHODS

Seventeen normal volunteers participated on this study. A single-slice 32-echo sequence was used to calculate the T2 relaxation time of frontal and occipital white matter and cortical gray matter. T2 relaxation analysis included monoexponential and biexponential fitting whereas an F test was used to determine if biexponential fitting was statistically more accurate than monoexponential fitting. Short and long T2 constants were calculated as well as the signal fractions of each pool. MTR calculations were based on a three-dimensional gradient echo (3D FFE) proton density weighted sequence with and without an on-resonance composite prepulse. MTR and T2 relaxation times were calculated and linear regression analysis was applied.

RESULTS

Biexponential fitting was more accurate comparing with monoexponential fitting in all WM and GM regions (F > 2.47, P < 0.01). Mean values of short T2 constant for frontal white matter (fWM), occipital white matter (oWM) and gray matter (GM) were 8.10, 9.36, and 22.23 milliseconds, respectively, whereas the mean values of long T2 constant were 85.1, 93.02, and 118.72 milliseconds, respectively. Mean restricted water percentages (RWP)-corresponding to the signal fraction of the protons with short T2-for the fWM, oWM, and GM were 22.01%, 23.36%, and 18.7%. Mean free water percentages (FWP)-corresponding to the signal fraction of the protons with long T2-for the fWM, oWM and GM were 77.99%, 76.64%, and 81.3%. Mean MTR values for fWM, oWM and GM were 68.4%, 68.2%, and 61.3%, respectively. No significant correlation was found in fWM and oWM between MTR and RWP, short and long T2 components while a moderate correlation existed in GM between MTR and RWP (r = 0.57; P = 0.02), MTR and short T2 component (r = -0.69; P = 0.004) and MTR and long T2 component (r = -0.62; P = 0.012).

CONCLUSIONS

Two proton pools with different T2 decay characteristics can be separated in normal gray and white matter when using a multiecho sequence with short echo spacing. MTR and T2 relaxation times were significantly correlated in gray matter and the combination of both types of measurements may be helpful in studying myelin related disorders.

Acute subarachnoid haemorrhage: detection with magnetic resonance imaging

The purpose of this study was the evaluation of fluid attenuated turbo inversion recovery (FLAT TIRE) MR pulse sequence for detecting acute subarachnoid hemorrhage (SAH). Seven patients with SAH were studied within 6 days of ictus. Six of them underwent both CT and MRI and one MRI only. Pulse sequences included T1 spin echo (SE), PD and T2 turbo spin echo (TSE) and FLAT TIRE (TR/TI/TE = 6500/1800/140-180). All studies were performed on a 0.5 T system (Gyroscan T5, Philips Medical Systems). Simulated acute SAH was also studied with MRI. The FLAT TIRE sequence was better than the SE and TSE in all seven cases and better than CT in two cases. In two cases MRI was equivalent to CT, and in another two MRI underestimated the extent of SAH. The simulated acute SAH could be detected easily with the FLAT TIRE sequence, with difficulty on the T1 weighted images and not at all on the PD/T2 weighted images. The specific FLAT TIRE sequence used seems promising for the detection of acute SAH.

In vitro antimicrobial activity of six pulp-capping agents

The antimicrobial activity of six commonly used pulp-capping agents was compared to reagent Ca(OH)2 by means of an in vitro microbiologic assay. Microbial samples were collected from deep carious lesions in each of twelve teeth and plated onto T-soy blood agar. Uniform disks of each pulp-capping agent were pressed slightly below the surface of each agar dish, and zones of bacterial inhibition were measured at 24 hours to the nearest 0.1 mm. All agents, including IRM, demonstrated significantly more antimicrobial activity than reagent Ca(OH)2 with the exception of Pulpdent. This tends to indicate that the antibacterial properties associated with these capping compounds are not entirely due to the high pH associated with Ca(OH)2.

Treatment of bladder carcinoma with irradiation combined with misonidazole

One hundred patients suffering from cancer of the bladder were treated by external beam irradiation, 400 cGy twice a week to a total dose of 4800 cGy. One half of the patients were randomized to receive the electron affinic sensitizer agent, misonidazole, at a dose of 1 gr/m2 and a total dose of 12 gr/m2. There was no statistically significant difference in tumor responses and in recurrence--free survival time between the patients who received irradiation and misonidazole as compared to those who received irradiation and placebos.

Implementation and evaluation of Nursing Interventions Classification and Nursing Outcomes Classification in a patient education plan

Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) are recognized examples of standardized nursing languages used to describe the contribution nursing makes to patient care. Columbus Regional Hospital nursing leadership recognized the need to use standardized nursing interventions and nursing-sensitive patient outcomes to describe the unique contribution nursing makes to patient education. In collaboration with the University of Iowa, NIC/NOC languages were implemented in the development of a patient education plan for a clinical pathway population.

Growth factor expression and effects of amrinone in monocrotaline-induced pulmonary hypertension in rats

Platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF) have been implicated in myointimal proliferative arteriopathy, a lesion seen in monocrotaline-induced pulmonary hypertension (MIPH). The purpose of this study was to examine the expression of PDGF and bFGF in the lungs of rats given monocrotaline and to examine the effects of amrinone on the hearts and lungs of these rats. Twenty-four 26-day-old rats were randomized to receive either monocrotaline (approximately 3.6 mg/kg/d) or no monocrotaline and concomitantly to receive either amrinone (100 mg/kg/d) or no amrinone for 21 days. Lungs were examined for immunohistochemical evidence of PDGF and bFGF, and hearts were examined for effects of pulmonary hypertension and amrinone. Immunohistochemical staining of lungs showed no evidence of PDGF except in bronchioles. bFGF staining was similar between groups (no monocrotaline 25%, monocrotaline 27%, monocrotaline and amrinone 22%), and the staining was confined to the arterial walls. Rats given monocrotaline showed significantly greater right ventricular (RV) weight (0.13 +/- 0.02 g versus 0.23 +/- 0.04 g [mean +/- SD], P < 0.001), right ventricular/left ventricular (RV/LV) weight ratio (0.29 +/- 0.06 versus 0.59 +/- 0.1, P < 0.001), and lung/body weight ratio (0.006 +/- 0.001 versus 0.01 +/- 0.003, P < 0.05) than controls. Rats given monocrotaline and amrinone were not significantly different from rats given only monocrotaline with regard to RV weight, RV/LV weight ratio, or lung/body weight ratio. We conclude that the vasculopathy seen in MIPH is not associated with the presence of PDGF or bFGF, suggesting that other growth factors may mediate this process. The course of MIPH is not altered by amrinone.

Peritoneal metastases from transitional cell carcinoma of the urinary tract: CT and MR imaging

We present three patients with peritoneal metastases from transitional cell carcinoma of the urinary tract. CT scan in one patient showed massive ascites with subtle peritoneal thickening and infiltration of omental fat. We had the opportunity to study the other patients with both CT and MR. Both examinations showed numerous large and small peritoneal implants in the abdomen and pelvis, mostly in the greater omentum.