Randomised trial of genetic testing and targeted intervention to prevent the development and progression of Paget's disease of bone

INTRODUCTION

Paget's disease of bone (PDB) frequently presents at an advanced stage with irreversible skeletal damage. Clinical outcomes might be improved by earlier diagnosis and prophylactic treatment.

METHODS

We randomised 222 individuals at increased risk of PDB because of pathogenic SQSTM1 variants to receive 5 mg zoledronic acid (ZA) or placebo. The primary outcome was new bone lesions assessed by radionuclide bone scan. Secondary outcomes included change in existing lesions, biochemical markers of bone turnover and skeletal events related to PDB.

RESULTS

The median duration of follow-up was 84 months (range 0-127) and 180 participants (81%) completed the study. At baseline, 9 (8.1%) of the ZA group had PDB lesions vs 12 (10.8%) of the placebo group. Two of the placebo group developed new lesions versus none in the ZA group (OR 0.41, 95% CI 0.00 to 3.43, p=0.25). Eight of the placebo group had a poor outcome (lesions which were new, unchanged or progressing) compared with none of the ZA group (OR 0.08, 95% CI 0.00 to 0.42, p=0.003). At the study end, 1 participant in the ZA group had lesions compared with 11 in the placebo group. Biochemical markers of bone turnover were significantly reduced in the ZA group. One participant allocated to placebo required rescue therapy with ZA because of symptomatic disease. The number and severity of adverse events did not differ between groups.

CONCLUSIONS

Genetic testing for pathogenic SQSTM1 variants coupled with intervention with ZA is well tolerated and has favourable effects on the progression of early PDB.

TRIAL REGISTRATION NUMBER

ISRCTN11616770.

Molnupiravir versus placebo in unvaccinated and vaccinated patients with early SARS-CoV-2 infection in the UK (AGILE CST-2): a randomised, placebo-controlled, double-blind, phase 2 trial

BACKGROUND

The antiviral drug molnupiravir was licensed for treating at-risk patients with COVID-19 on the basis of data from unvaccinated adults. We aimed to evaluate the safety and virological efficacy of molnupiravir in vaccinated and unvaccinated individuals with COVID-19.

METHODS

This randomised, placebo-controlled, double-blind, phase 2 trial (AGILE CST-2) was done at five National Institute for Health and Care Research sites in the UK. Eligible participants were adult (aged ≥18 years) outpatients with PCR-confirmed, mild-to-moderate SARS-CoV-2 infection who were within 5 days of symptom onset. Using permuted blocks (block size 2 or 4) and stratifying by site, participants were randomly assigned (1:1) to receive either molnupiravir (orally; 800 mg twice daily for 5 days) plus standard of care or matching placebo plus standard of care. The primary outcome was the time from randomisation to SARS-CoV-2 PCR negativity on nasopharyngeal swabs and was analysed by use of a Bayesian Cox proportional hazards model for estimating the probability of a superior virological response (hazard ratio [HR]>1) for molnupiravir versus placebo. Our primary model used a two-point prior based on equal prior probabilities (50%) that the HR was 1·0 or 1·5. We defined a priori that if the probability of a HR of more than 1 was more than 80% molnupiravir would be recommended for further testing. The primary outcome was analysed in the intention-to-treat population and safety was analysed in the safety population, comprising participants who had received at least one dose of allocated treatment. This trial is registered in ClinicalTrials.gov, NCT04746183, and the ISRCTN registry, ISRCTN27106947, and is ongoing.

FINDINGS

Between Nov 18, 2020, and March 16, 2022, 1723 patients were assessed for eligibility, of whom 180 were randomly assigned to receive either molnupiravir (n=90) or placebo (n=90) and were included in the intention-to-treat analysis. 103 (57%) of 180 participants were female and 77 (43%) were male and 90 (50%) participants had received at least one dose of a COVID-19 vaccine. SARS-CoV-2 infections with the delta (B.1.617.2; 72 [40%] of 180), alpha (B.1.1.7; 37 [21%]), omicron (B.1.1.529; 38 [21%]), and EU1 (B.1.177; 28 [16%]) variants were represented. All 180 participants received at least one dose of treatment and four participants discontinued the study (one in the molnupiravir group and three in the placebo group). Participants in the molnupiravir group had a faster median time from randomisation to negative PCR (8 days [95% CI 8-9]) than participants in the placebo group (11 days [10-11]; HR 1·30, 95% credible interval 0·92-1·71; log-rank p=0·074). The probability of molnupiravir being superior to placebo (HR>1) was 75·4%, which was less than our threshold of 80%. 73 (81%) of 90 participants in the molnupiravir group and 68 (76%) of 90 participants in the placebo group had at least one adverse event by day 29. One participant in the molnupiravir group and three participants in the placebo group had an adverse event of a Common Terminology Criteria for Adverse Events grade 3 or higher severity. No participants died (due to any cause) during the trial.

INTERPRETATION

We found molnupiravir to be well tolerated and, although our predefined threshold was not reached, we observed some evidence that molnupiravir has antiviral activity in vaccinated and unvaccinated individuals infected with a broad range of SARS-CoV-2 variants, although this evidence is not conclusive.

FUNDING

Ridgeback Biotherapeutics, the UK National Institute for Health and Care Research, the Medical Research Council, and the Wellcome Trust.

1974. Title: A novel low-dose self-amplifying mRNA vaccine (GRT-R910) induces strong and broad boost in cellular and humoral immune response following primary series with a chimpanzee adenovirus SARS-CoV-2 vaccination

Disclosures

Ciaran Scallan, PhD, Gritstone Bio: Salaried employee of Gritstone|Gritstone Bio: Stocks/Bonds Andrew Ustianowski, MD, PhD, Gilead: Advisor/Consultant|Gilead: Board Member|Gilead: Honoraria|Gilead: Speaker fees|Pfizer: Honoraria|Pfizer: Speaker fees|Vir/GlaxoSmithKline: Advisor/Consultant|Vir/GlaxoSmithKline: Board Member.

Background

The SARS-CoV-2 pandemic continues, with new variants of concern fueling periodic increases in COVID-19 cases. Authorized vaccines have provided protection against severe disease but less so for incident cases. Boosts with these vaccines have demonstrated waning protection. New vaccines, including those which induce immunity against more conserved regions outside of Spike, may improve upon these and be key to long-term protection and may be a useful approach against novel coronaviruses.

Methods

GO-009 (CORAL-Boost, NCT05148962) is an open-label study, conducted in the UK, of a self-amplifying mRNA vaccine encoding for Wuhan Spike (S) and highly conserved non-S T cell epitopes (GRT-R910; R910). R910 is given as 1 or 2 doses after vaccination with an authorized adenovirus or mRNA SARS-CoV-2 vaccine. The first two cohorts assessed 10µg and 30µg doses of R910 in older (≥60y) adults who had previously received ChAdOx1. Subsequent cohorts assess two boost doses in older and younger adults who have received an adenovirus or mRNA vaccine. Primary objectives are safety and reactogenicity and secondary objectives include cellular and humoral immunogenicity.

Results

Ten and seven adults received 10 or 30µg (cohorts 1 and 2) of R910, respectively. Reactogenicity and unsolicited adverse events were mostly mild/moderate and transient. The majority of severe events (malaise, fatigue, myalgia, Inj. site pain/tenderness/swelling) after dose 1 were experienced by 1 subject in cohort 2. Analysis of both IgG binding and neutralizing antibodies demonstrated a boost of anti-S antibodies after one dose of R910; geomean ID50 titers from 92 to 2370 and 99 to 1553 for 10 and 30µg, respectively. ELISpot analyses demonstrated that R910 boosted and broadened T cell responses to S and non-S T cell epitopes.

Conclusion

R910 was well tolerated. One R910 boost vaccination increased existing humoral and cellular immunity against S while inducing a broad T cell response against non-S SARS-CoV-2 proteins. A 10µg R910 boost increased neutralizing antibody titers comparable to a 10-fold higher dose (100µg) with authorized mRNA vaccines in a similar population (Munro et al 2021). A 10µg dose was selected for further study. Data post mRNA primary series will also be presented.

Does left ventricular shape influence clinical outcome in heart failure?

BACKGROUND

Left ventricular (LV) shape tends to become spherical in patients with dilated cardiomyopathy of diverse etiology. Clinical and echocardiographic factors which affect the degree of LV spherical distortion and the impact of altered LV shape on prognosis have not been studied adequately.

HYPOTHESIS

This study was undertaken to investigate the prognostic implications of altered LV shape on clinical outcome in dilated cardiomyopathy.

METHODS

In 112 patients with depressed LV ejection fraction (19 +/- 9%) and symptomatic heart failure, and in 10 age- and gender-matched normal controls, we performed 2-dimensional echocardiography to assess LV shape using the eccentricity index. Eccentricity index was defined as the ratio of the LV long axis to the LV transverse diameter, measured at end systole and end diastole in the apical four-chamber view. We sought univariate and multivariate clinical and echocardiographic correlates of LV shape. Further, we sought correlations between eccentricity index and clinical outcomes (death and composite outcome of death or emergent heart transplant).

RESULTS

Compared with controls, patients with cardiomyopathy had significantly lower systolic (2.04 vs. 1.56; p = 0.001) and diastolic (1.75 vs. 1.53; p = 0.003) eccentricity index, implying a more spherical LV shape. Of all clinical and echocardiographic variables tested, mitral regurgitation, right ventricular dysfunction, and increased LV mass were independently associated with spherical LV shape. At a follow-up period of 17 +/- 12 months, no correlation was found between eccentricity index and the occurrence of death or the combined endpoint of death or emergent heart transplant, in univariate or multivariate analysis.

CONCLUSIONS

In patients with dilated cardiomyopathy, the degree of spherical distortion of the LV does not correlate with prognosis.

The independent effects of left ventricular ejection fraction on short-term outcomes and resource utilization following hospitalization for heart failure

BACKGROUND

While depressed left ventricular ejection fraction is clearly associated with poor long-term outcome in heart failure (HF), the effect of ejection fraction on short-term outcomes and resource utilization following hospitalization for HF remains unclear.

HYPOTHESIS

We evaluated the independent effect of depressed ejection fraction (< or = 40%) on short-term outcomes and resource utilization following hospitalization for HF.

METHODS

The study population included 443 consecutive patients hospitalized for DRG 127 (HF and shock) with known ejection fraction. For each patient, we assessed the hospitalization cost (1995 US$), length of stay, in-hospital mortality, 30-day mortality, and 30-day readmission rates.

RESULTS

Despite similar disease severity at admission, patients with ejection fraction < or = 40% (Group 1) had longer length of stay (4.0 vs. 3.7 days; p = 0.03), a tendency toward higher hospitalization cost ($3,054 vs. $2,770; p = 0.08), more readmissions for any cause (0.4 vs. 0.3; p = 0.05) and for HF (0.2 vs. 0.1; p = 0.01), but similar in-hospital (2.5 vs. 2.6%) and 30-day mortality (4.0 vs. 4.6%) compared with patients with ejection fraction > 40% (Group 2). In multivariate analyses, Group 1 patients were more likely to have higher than median hospitalization cost [odds ratio (OR) = 1.98; 95% confidence intervals (CI) = 1.02-3.91] and longer than median hospital stay (OR = 1.68; CI = 1.08-3.91); they were also more likely to be readmitted for any cause (OR = 2.07; CI = 1.15-3.78) or for HF (OR = 5.71; CI = 1.64-21.94), and they tended to have a higher 30-day incidence of death or readmission (OR = 1.65; CI = 0.96-2.84).

CONCLUSIONS

Depressed left ventricular ejection fraction is associated with higher resource utilization and readmission rates following hospitalization for HF. Greater focus on patients with depressed ejection fraction may increase cost savings from HF disease management programs.

Investigation of T cell receptors in the peripheral blood of patients with active pulmonary tuberculosis

T cells have the capability of recognizing target cells through their T cell receptors (TCRs). Thus, the percentages of CD3+/gamma-delta (gammadelta) TCR+ and CD3+/alpha-beta (alphabeta) TCR+ T lymphocytes were investigated in active and inactive pulmonary tuberculosis (PT) patients and in healthy individuals. CD3+ and CD3+/alphabeta TCR+ cell percentages were significantly lower in all PT patients than in healthy subjects. Percentages of CD3+/gammadelta and CD3+/alphabeta TCR+ were not statistically different between active and inactive PT patients. It was concluded that alphabeta TCR+ T cells might have a protective role in tuberculosis infection.

Diffusion magnetic resonance imaging may provide prognostic information in osmotic demyelination syndrome: report of a case

Hyponatremia and its rapid correction may cause osmotic demyelination syndrome (ODS) with damage to the pontine and extrapontine areas of the brain. The damage may become persistent or may regress and disappear during follow-up. We describe the case of a 35-year-old woman with chronic renal failure who was admitted to the emergency department with profound hyponatremia which was corrected rapidly after hemodialysis treatment. During follow-up, she developed quadriparesis and dysartria. Magnetic resonance imaging (MRI) demonstrated abnormalities characteristic of ODS in the pons as well as the basal ganglia with increased signal intensity on T2 and diffusion-weighted (DW) MRI and low apparent diffusion coefficient (ADC) values. After the sixth day, her clinical status improved progressively. Control MRI revealed rapid normalization of the ADC values during the first week and month parallel to the clinical improvement. However, the hyperintensities on T2-weighted images persisted. Four months later the MRI findings were completely normal. The close relationship between the ADC abnormality and the clinical status suggests that DW-MRI may be useful in predicting the prognosis of ODS.

Effect of osmotic stress on the derepression of invertase synthesis in nonconventional yeasts

AIMS

The aim of this study was to analyse the effect of osmotic stress on the biosynthesis of invertase enzyme in nonconventional yeasts.

METHODS AND RESULTS

Invertase activities of the nonconventional yeast species belonging to Kluyveromyces, Schwanniomyces and Pichia genus were measured either in the presence or in the absence of various amounts of NaCl. The effect of hyperosmotic stress on the glucose consumption of Saccharomyces cerevisiae and Pichia anomala were also compared. Like S. cerevisiae, derepression of invertase synthesis in Kluyveromyces lactis, Schwanniomyces occidentalis and Pichia jadinii is inhibited by hyperosmotic stress. However, derepression of invertase synthesis in P. anomala is not affected by hyperosmotic stress. In addition, low levels of osmotic stress activated invertase synthesis three- to fourfold in P. anomala and K. lactis.

CONCLUSIONS

This study shows that low levels of osmotic stress induces the invertase synthesis at very high levels in P. anomala and K. lactis. Glucose consumption was not influenced at significant levels by the hyperosmotic stress in P. anomala.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study shows the activation of invertase synthesis by low levels of osmotic stress in P. anomala and K. lactis.

[The current problems and cross-cultural perspectives of patient-doctor relation: an overview]

The success of the treatment in medicine, especially in psychiatry is based on the form and the strength of the patient-doctor relation. This complex and dynamic relation is changing in accordance with the social and technological development of the society. The context of the patient-doctor relation is determined by the present day culture as well as the traditional background. An overview of current patient-doctor relation and of problems that physicians and in particular psychiatrists meet is presented. Physicians have responsibilities in building patient-doctor relation. The ethical and legal aspects of these responsibilities are presented. The former paternalistic type of patient-doctor relation is evolving into a more equal and democratic relation. New problems are being encountered continuously in the changing process. Beside the of the process itself, the effects of progress in medical technology and communication systems on patient-doctor relation and the pressure, put from the insurance companies and/or authorities on physicians, which impair the trust between the physician and his patient, are making the process more difficult. The issues of compliance, sexual harassment and unique problems of patient-doctor relations in psychiatry are the other subtopics in the article. The cross-cultural aspects of patient-doctor relations and encountered clinical problems are discussed with case examples particularly about Turkish immigrants, who live in Germany. Suggestions for psychiatrists in Germany to work out the challenges facing them are presented in the conclusion.

Mutations in GCR1 affect SUC2 gene expression in Saccharomyces cerevisiae

Transcription of SUC2, the gene that encodes the cytoplasmic and secreted forms of the enzyme invertase, is controlled by glucose repression and derepression mechanisms in Saccharomyces cerevisiae. Several regulatory factors such as the Mig1p-Tup1p-Ssn6p repressor complex and the Snf1p kinase complex have been identified previously as regulators of SUC2 expression. We show that, in addition to these factors, expression of SUC2 is affected by mutations in the gene GCR1 that encodes the glycolysis regulatory protein Gcr1p. Expression of Suc2-LacZ was not repressed by glucose in gcr1 mutant yeast cells exposed to glucose. Furthermore, secreted invertase activity was constitutively expressed under glucose-repressed and derepressed conditions in gcr1 mutants. DNA gel mobility shift assays and in-vitro DNase I protection experiments mapped a DNA binding site for Gcr1p in the transcriptional control region of the SUC2 gene, next to a previously mapped Mig1p binding site. However, the mechanism by which gcr1 mutations relieve glucose repression remains obscure.

Effect of combined aspirin and angiotensin-converting enzyme inhibitor therapy versus angiotensin-converting enzyme inhibitor therapy alone on readmission rates in heart failure

An adverse interaction between aspirin and angiotensin-converting enzyme (ACE) inhibitors is suspected in patients with heart failure, but the effect of combined therapy with these agents on hospital readmission rates is unknown. Our study found that combining aspirin with ACE inhibitors is associated with higher early readmission rates than use of ACE inhibitors alone, particularly in patients with depressed ejection fraction and in those without coronary artery disease.

Simple clinical variables are markers of the propensity for readmission in patients hospitalized with heart failure

In a consecutive cohort of patients hospitalized for decompensated heart failure, we found that chronic obstructive pulmonary disease and history of hospitalization for any cause in the preceding 6 months were the strongest correlates of early readmission. Based on these findings, we propose a simple risk stratification system to classify patients who are hospitalized for heart failure as low, medium, or high risk for early readmission.

Does gender bias exist in the medical management of heart failure?

INTRODUCTION

The purpose of this study was to ascertain the presence of gender bias in the medical management of heart failure, and to assess its association with the specialty of the caregiver physician.

METHODS

In 309 patients with documented left ventricular systolic dysfunction (ejection fraction <45%) and at least one hospitalization for heart failure, we assessed the frequency of use of effective medical therapy for heart failure among male (n=187) and female (n=122) patients at the time of hospital discharge. We constructed multivariate models relating patient gender and caregiver specialty to utilization of each class of medications (angiotensin-converting enzyme inhibitors, effective vasodilator therapy (i.e., angiotensin-converting enzyme inhibitors or hydralazine-nitrate therapy), diuretics, digoxin), and combination therapy (i.e., vasodilator plus diuretic plus digoxin).

RESULTS

In crude analyses, we did not find any difference in utilization of medications between male and female patients. Multivariate analyses involving adjustment for age, race, coronary artery disease, ejection fraction, and other relevant variables, revealed higher utilization of combination therapy by cardiologists in male versus female patients (adjusted odds ratios=2.07; 95%CI=1.09-3.95), and higher utilization of digoxin therapy by non-cardiologists in female versus male patients (adjusted odds ratio=5.5; 95%CI=1.4-22.2). No gender or caregiver specialty differences were seen in models relating to the other classes of medications.

CONCLUSIONS

Our findings suggest the presence of gender bias in the medical management of heart failure, and identify an interesting interaction between caregiver specialty and gender bias.

Left ventricular apical puncture: a procedure surviving well into the new millennium

We report two patients with a history of prior mitral valve and aortic valve replacement with St. Jude prosthetic valves, who were referred for repeat valve replacement after noninvasive assessment was suggestive of prosthetic valve malfunction. Both patients were managed medically after evaluation with direct left ventricular apical puncture revealed normal hemodynamics in the first and mild aortic stenosis in the second patient. These two cases illustrate that, despite the advancements in the noninvasive evaluation of prosthetic heart valves, left ventricular direct puncture continues to have an important value in the evaluation of patients referred for repeat valve replacement, and it can prevent unnecessary surgeries associated with a high risk of morbidity and mortality. Cathet. Cardiovasc. Intervent. 49:68-73, 2000.

The prognostic implications of outpatient diuretic dose in heart failure

In 111 patients with left ventricular ejection fraction < or =30% who required hospitalization for heart failure, we examined the association between outpatient dose of diuretic agents and all-cause mortality. In comparison to patients who were not on treatment with diuretics prior to hospitalization, patients being treated with 'low' doses of diuretics (<80 mg/day of furosemide) and those being treated with 'high' doses of diuretics (> or =80 mg/day of furosemide) were more likely to die during follow-up after adjustment for other clinical parameters (adjusted relative risks, RR, 3.1 and 4.6).

Intra-arterial thrombolysis in a patient presenting with an ischemic stroke due to spontaneous internal carotid artery dissection

We describe a case of a 38-year-old male who presented with acute onset of right-sided hemiplegia and aphasia, who was transferred for emergent percutaneous intervention. Angiography revealed a dissection with total occlusion of the left internal carotid artery (ICA) with propagation of thrombus in the distribution of the middle cerebral artery (MCA). Therapy was directed at the MCA and not the ICA. Intra-arterial thrombolysis was performed on the M1 and M2 branches of the left middle cerebral artery, resulting in almost complete resolution of symptoms during the angiography procedure. Heparin was continued postprocedure, and the patient was discharged home on warfarin and aspirin with minimal residual symptoms.

Acute coronary occlusion and in-stent thrombosis in a patient with essential thrombocythemia

We describe a case of essential thrombocythemia in a 34-year-old male who presented with acute anterior wall myocardial infarction and a platelet count of 2,100,000/mm3. Primary percutaneous coronary angioplasty and stenting were performed. Postangioplasty course was complicated by stent thrombosis requiring repeat coronary angioplasty and persistent femoral arterial bleeding that was treated with surgical exploration and repair. The patient was subsequently treated with platelet pheresis, acetylsalicylic acid, ticlopidine, hydroxyurea, and anagrelide without further complications.

Effects of caregiver specialty on cost and clinical outcomes following hospitalization for heart failure

In 614 consecutive hospitalizations with the primary discharge diagnosis of diagnosis-related group (DRG) 127 (heart failure and shock), we sought to assess the effect of caregiver specialty (generalist, n = 217; cardiologist, n = 397) on hospital costs, length of stay, and in-hospital mortality. Patients treated by cardiologists were younger (68 vs 71 years) and less likely to have hypertension (52% vs 61%), but were more likely to be men (61% vs 44%), require an intensive care stay (13% vs 5%), have coronary artery disease (49% vs 23%), have a left ventricular ejection fraction <40% (74% vs 49%), and have lower systolic (132 vs 146 mm Hg) and diastolic (76 vs 81 mm Hg) blood pressures on admission. Predictors of acute disease severity were similarly distributed between the 2 groups. No difference was found between patients treated by cardiologists versus those treated by generalists with respect to crude or adjusted hospital cost, length of stay, and in-hospital mortality. However, in subsets of patients who required intensive care during hospitalization (n = 64), as well as those who did not (n = 550), care by cardiologists was associated with a lower adjusted hospital cost. Any potential cost savings that could have accrued from care by cardiologists was, however, negated by the higher proportion of patients treated by cardiologists who required intensive care during hospitalization. We conclude that when differences in clinical variables are adjusted, care by cardiologists versus generalists is associated with similar or lower hospital cost for patients with DRG 127. Our findings challenge the notion that in-patient care provided by specialists is more expensive than that provided by generalists.