Lower-intensity CPX-351 + venetoclax for patients with newly diagnosed AML who are unfit for intensive chemotherapy

7031

Background: CPX-351 (US: Vyxeos; Europe: Vyxeos liposomal) is a dual-drug liposomal encapsulation of daunorubicin and cytarabine in a synergistic 1:5 molar ratio. CPX-351 is approved for newly diagnosed, therapy-related AML or AML with myelodysplasia-related changes in patients (pts) who are candidates for intensive chemotherapy (IC) and aged ≥1 year in the US and adults in Europe. However, the appropriate dosage of CPX-351 in pts unfit for IC may be different from the label dosage. Venetoclax (VEN; BCL-2 inhibitor) + low-dose cytarabine has demonstrated efficacy in unfit pts with AML, and drug synergism/additivity in preclinical studies provided a rationale for combining CPX-351 + VEN clinically. Our study evaluates the safety and efficacy of lower-intensity CPX-351 + VEN in adults with newly diagnosed AML who are unfit for IC. Methods: This is an ongoing, open-label, phase 1b study (NCT04038437). Pts who achieve at least partial remission after 1 or 2 cycles may receive up to 4 similar cycles in the dose-exploration phase (DEP) or up to 8 similar cycles in the expansion phase (EP). Pts are assessed for response (morphology, measurable residual disease [MRD]) and monitored for safety and survival. Results: The data include 31 pts enrolled by 9/15/2021, with a data cutoff of 12/2/2021: 4 pts in DEP at dose level 1 (CPX-351 20 units/m2 on Days 1 and 3 + VEN 400 mg on Days 2 to 21 of each cycle), 7 pts in DEP at dose level 2 (CPX-351 40 units/m2 + VEN 400 mg), and a total of 20 pts in DEP and EP at dose level 1b (CPX-351 30 units/m2 + VEN 400 mg; established as the recommended phase 2 dose). Pts were unfit for IC based on age ≥75 y (n = 15) or health (ECOG PS of 2 to 3 and/or comorbidities [n = 16]). Median age was 74 y (range: 60, 90); 65% were male; 77% had de novo AML; 58% had poor-risk disease; and 23% had a TP53 mutation. Nonhematologic treatment-emergent adverse events (TEAEs) in ≥20% of pts were diarrhea (26%), cough (23%), dyspnea (23%), and nausea (23%). Hematologic grade ≥3 TEAEs were reported in 17 (55%) pts; no nonhematologic grade ≥3 TEAE was reported in > 10% of pts. There were no deaths by Day 30; mortality at Day 60 was 13%, with deaths due to myocardial infarction unrelated to therapy (n = 1), worsening lung infection (n = 1), and disease progression (n = 2). Median (IQR) recovery times were 30 d (22, 34.5) to neutrophils ≥500/μL and 21 d (21, 27) to platelets ≥50,000/μL. Complete remission (CR) or CR with incomplete neutrophil or platelet recovery (CRi) was achieved by 16/28 (57%) evaluable pts. All 16 of these pts achieved remission (CR or CRi) after the first cycle. MRD negativity was achieved by 12/16 (75%) pts with CR or CRi, primarily after Cycle 1 (Cycle 1: n = 8; Cycle 2: n = 2; Cycle 3: n = 1; Cycle 4: n = 1). Survival data are not yet mature. Conclusions: Lower-intensity CPX-351 + VEN was generally well tolerated in adults with newly diagnosed AML who are unfit for IC and showed promising initial efficacy, with CR or CRi in the majority of pts. Clinical trial information: NCT04038437.

POS0032 FUNCTIONAL ROLE OF SURVIVIN IN ORGANIZATION OF BIVALENT CHROMATIN REGIONS AND CONSEQUENCE FOR ARTHRITIS-RELEVANT GENE EXPRESSION

Background

Bivalent chromatin (BvCR) is characterized by the presence of simultaneous active and repressive modifications on histone H3 proteins. Influencing expression of the genes, BvCR determine cell fate and direct differentiation and lineage commitment in primary T cells and contribute to autoimmunity. Survivin is highly expressed during cell division and in effector Th1 cells contributing to aggravation of autoimmune inflammation. Survivin can physically bind to DNA, specifically to Threonine-3 of histone H3 (1). Thus, functional, and mechanistic data point to a potential chromatin regulatory role for survivin, potentially acting in combination with histone epigenetic modifications (EMs).

Objectives

The goal of our study is to establish the colocalization of survivin with BvCRs and to deduce functional effects of this collaboration on chromatin organization and gene expression.

Methods

Chromatin from CD4+ T cells of 14 female subjects was immunoprecipitated with survivin antibodies and histone H3K27ac, H3K27me3, H3K4me3 antibodies, and coupled with DNA sequencing (ChIPseq, Hiseq2000, Illumina). BvCR were identified as exact overlaps of the three histone EM peaks and the overlapping regions were searched for co-localization with survivin using the ‘ChIPPeakAnno’ Bioconductor package. Tag counts K27me3>K27ac were defined as inactive/poised BvCR, while tag count K27me3<K27ac were identified asactive BvCR. Motif search was done through the MEME tool, and high/moderate complexity motifs with E-value >10e-5 were selected and scanned through the HOCOMOCO database to identify consensus transcription factor (TF) motifs. TFs co-localized with the BvCD were identified through ReMap database. To identify survivin sensitive genes, CD4+ T cells were treated with survivin inhibitor YM155 and a list of reproducible DEG (log2FC>[0.4], >1 experiment) was mapped and analysed for clustering with BvCR.

Results

Co-localization of survivin ChIP peaks with individual H3-peaks was significantly less frequent compared to overlap with all three (a3)-H3 BvCR (7.1 vs 29.8%, p=8.9e-13). Overlap of a3-H3 peaks not containing survivin was less frequent (34%) compared to those which contained survivin (66%). Notably, survivin peak size was 5.5-fold higher when colocalized with a3-H3 peaks, compared to no, or any single H3 (p<2.2e-16). In contrast, no size difference for any of the H3 EM peaks was found.

Further analysis of two non-redundant groups of BvCR that contain (survivin-a3H3, n=4085), and not containing survivin (a3H3noSurv, n = 2131) demonstrated that survivin was mostly associated with inactive BvCR (OR1.29, p=6.6e-6), while no such specificity was found for BvCR with no survivin. Additionally, survivin containing BvCR contained abundant binding sites matching known consensus TF motifs. No sequence-specific motifs were identified in BvCR with no survivin. Comparison of results obtained through HOCOMOCO and ReMap databases resulted in a list of 68 unique TFs. Many of those are key regulators of adaptive immune responses, cellular metabolism, and pluripotency. Differentially expressed genes mapped to BvCR demonstrated enrichment for cellular hormone metabolic processes, regeneration and DNA biosynthesis.

Conclusion

This study provides experimental evidence that survivin defines binding specificity in bivalent chromatin regions being associated with regulation of cellular metabolism and renewal of CD4+ T cells that are functionally important to resist autoimmunity.

References

[1]Kelly AE, Ghenoiu C, Xue JZ, Zierhut C, Kimura H, Funabiki H. Survivin reads phosphorylated histone H3 threonine 3 to activate the mitotic kinase Aurora B Science. 2010 Oct 8; 330(6001): 235–239.

Disclosure of Interests

None declared

V-FAST master trial: Preliminary results of treatment with CPX-351 plus midostaurin in adults with newly diagnosed FLT3-mutated acute myeloid leukemia

7043

Background: CPX-351 (US: Vyxeos; Europe: Vyxeos liposomal), a dual-drug liposomal encapsulation of daunorubicin and cytarabine in a synergistic 1:5 molar ratio, is approved for newly diagnosed, therapy-related AML or AML with myelodysplasia-related changes in patients aged ≥1 year in the US and in adults in Europe. In a phase 3 study in older adults with newly diagnosed, high-risk/secondary AML, CPX-351 significantly improved overall survival and remission rates versus conventional 7+3, with a comparable safety profile. Preclinical data suggest CPX-351 may have synergistic activity with targeted agents, including the FLT3 inhibitor midostaurin (MID). Herein, we report preliminary results for the cohort of adults treated with CPX-351 + MID in the V-FAST (Vyxeos – First Phase Assessment with Targeted Agents) trial. Methods: V-FAST is an open-label, multicenter, multiarm, nonrandomized, phase 1b master trial (NCT04075747) to evaluate the safety and preliminary efficacy of CPX-351 combined with targeted agents (midostaurin, venetoclax, enasidenib). Eligible adults in the CPX-351 + MID cohort were aged 18 to 75 years, had newly diagnosed AML with a FLT3 internal tandem duplication (ITD) or tyrosine kinase domain (TKD) mutation, were fit for intensive chemotherapy, and had an ECOG performance status of 0 to 2. The dose-exploration phase (3+3 design) determined a recommended phase 2 dose of CPX-351 100 units/m2 (daunorubicin 44 mg/m2 + cytarabine 100 mg/m2) on Days 1, 3, and 5 + MID 50 mg BID on Days 8 to 21. There were no dose-limiting toxicities, and additional patients were enrolled in the expansion phase at this dose. Results: A total of 23 patients received CPX-351 + MID and had sufficient data to be included in the analysis (cutoff date: 1/20/2022). Patient baseline characteristics are shown in the Table. Treatment-emergent adverse events (TEAEs) in ≥40% of patients included febrile neutropenia (78%), nausea (65%), increased alanine aminotransferase (57%), leukopenia (57%), thrombocytopenia (57%), headache (43%), and hyponatremia (43%). All patients experienced a grade 3/4 TEAE, primarily hematologic events. Nonhematologic grade 3/4 TEAEs in ≥2 patients included pneumonia (17%), lung infection (13%), and hyperglycemia (9%). There were no grade 5 TEAEs and no deaths on or before Day 60. Complete remission was achieved by 18/22 (82%) evaluable patients after the first induction cycle. Conclusions: Preliminary results from the V-FAST trial suggest CPX-351 + MID is feasible, with a manageable safety profile and promising remission rates in adults with newly diagnosed AML who have a FLT3 mutation. Clinical trial information: NCT04075747. [Table: see text]

AB0024 PLURIPOTENCY MARKER PBX1 PREDICTS TREATMENT EFFECT IN RHEUMATOID ARTHRITIS

Background

Accelerated immunosenescence with contraction of T cell repertoire, demise of thymic function and expansion of CD28null T cells with poor T cell reconstitution is the hallmark of rheumatoid arthritis (RA)1.

Objectives

In this study we assessed if PBX1 transcription factor that maintains the pluripotency of hematopoietic stem cells could be used to predict treatment response in RA patients.

Methods

CD4+ T cells of 87 RA female patients (age, median 61y (23-76); disease duration, median 9y (0-45)) were isolated from the perpheral blood, activated with aCD3 and subjected to transcriptional analysis by RNAseq (Illumina). External RNAseq of CD4+ T cells of 80 RA patients (f 56, m 24) was used for validation. The genes differentially expressed (DEG, nominal p<0.05) between PBX1hi and PBX1lo groups were identified by R-studio using Benjamini-Hochberg correction (Bioconductor, DESeq2 package). DEGs were clustered by covariance to identify PBX1 associated genes and biological processes. Clinical variates and treatment regimens in PBX1hi and PBX1lo groups were compared.

Results

The patients of PBX1hi and PBX1lo groups were of similar age and disease duration but differed in anti-rheumatic treatment. PBX1hi group was often treated with conventional DMARDs and monotherapy, while PBX1lo group was mostly treated with biologics and/or JAK-inhibitors in combination with cDMARDs (χ2, p=0.0099). This treatment led to sufficient disease control in both PBX1 groups (median DAS28; 2.6 and 2.7, respectively). In the external RA cohort of the patients resistant to conventional DMARDs, PBX1hi patients had significantly fewer frequency of non-responders to anti-TNF treatment compared to PBX1lo (χ2, p=0.026).

Pathway analysis of the DEGs identified strong enrichment for regulation of transcription (cor.p=10-23), RNA metabolic processes (cor.p=10-18) and differentiation (cor.p=10-7) in PBX1hi CD4+ cells, which corresponds to the known biological properties of PBX12. PBX1hiCD4+ cells in both datasets had imprinted features of pluripotency3 and expressed higher levels of KIT and CAT, low proliferation markers Ki67 and BIRC5, and had virtually no cytokine production. In the main cohort, PBX1hiCD4+ cells were recognized by naïve T cell marks CD62L (SELL) and CD45 (PTPRC), and also PECAM1, CR2, and CD28, indicating recent thymic egress. In the validation cohort, PBX1hiCD4+ cells were enriched with stem cell markers CD34, MEG3, and DNMT3B. Lineage specific TFs (TBET, GATA3, FOXP3, RORC) and cytokines (IFNG, TNF, IL10, IL17F, etc.) were accumulated in PBX1loCD4+ cells indicating terminally differentiated effector CD4+ T cells.

Conclusion

This study shows that enrichment with PBX1hi CD4+ cells is associated with naïve pluripotent phenotype of CD4 lymphocytes. Patients with high PBX1 expression are less heavily treated and respond better to treatment. This suggests boosting of PBX1-expression to be a way of treating RA.

References

[1]Keotz K et al, PNAS 2000:97(16) 9203-9208. T cell homeostasis in patients with rheumatoid arthritis.

[2]Veiga RN et al, J Mol Med (Berl) 2021:99(12) 1667-1680. PBX1: a key character of the hallmarks of cancer.

[3]Bock C et al, Cell 2011:144(3) 439-452. Reference Maps of human ES and iPS cell variation enable high-throughput characterization of pluripotent cell lines

Disclosure of Interests

None declared

POS0397 AGGREGATED SURVIVIN BINDING AROUND HISTONE H3 EPIGENETIC MODIFICATIONS IN RISK LOCI ASSOCIATED WITH RHEUMATOID ARTHRITIS

Background:

Survivin is an integral part of the Chromosomal Passenger Complex (CPC) which plays a vital role in mitosis. Experiments have demonstrated that survivin can physically bind to DNA. Crystallographic studies show that survivin binds to Threonine-3 of histone H3. In patients with autoimmune diseases, increased survivin expression contributes to an aggravated disease phenotype. Thus, functional, and mechanistic data point to a potential chromatin regulatory role for survivin, possibly in combination with the established gene regulatory function carried out by histone epigenetic modifications (EM).

Objectives:

The objective of the study was to analyse the co-localization of chromatin bound survivin with three histone H3 epigenetic modifications – acetylated lysine 27 (K27ac) and trimethylated lysine 4 (K4me3) and lysine-27 (K27me3). The second objective was to analyse if survivin-bound DNA sequences overlapped with sequences in the vicinity of 106 GWAS SNPs that are associated with a risk of developing rheumatoid arthritis (RA).

Methods:

Chromatin from CD4 T cells of 14 female subjects was immunoprecipitated with survivin antibodies and each of the histone H3 antibodies, and coupled with sequencing (ChIPseq, Hiseq2000, Illumina). After mapping the annotations of sequenced regions to the human reference genome hg38, enriched peaks were identified through Homer software. The identified survivin ChIP peaks were analysed for colocalization with peaks of the three histone H3 EMs and with RA risk loci, using the Bioconductor package ‘ChIPPeakAnno’ through RStudio.

Results:

Among the total of ~13,000 individual survivin ChIP-peaks, 33% colocalized with histone H3 EM peaks. The overlapping peaks show a linear increase in average peak size compared with the peaks showing no colocalization with any H3 EM peak. A maximum of 5.5-fold increase in average peak size was observed when survivin bound peaks overlap with peaks of all three H3 EMs. A major proportion (86%) of top RA risk SNPs was associated with either binding of survivin or H3 EMs. In this subset, 63% of RA risk SNPs were found within an area of 100 kilobases from survivin ChIP-peaks, with preferential enrichment of high-scoring peaks when survivin colocalizes with all 3 H3 EMs. Survivin was bound to risk SNPs annotated to, among others, the major immunological genes CD83, IRF4, CD28, ICOS and IL2RA

Conclusion:

This study presents experimental evidence that survivin binding to DNA preferentially occurred in regions with high density of histone EMs. The increased aggregation of survivin around histone H3 EMs point to its potential regulatory function in gene transcription. Since regions around RA risk SNPs overlap with survivin peaks, survivin’s nuclear function could have immunologically important effects in mechanisms of autoimmune diseases.

Disclosure of Interests:

None declared

POS0360 COMPLEX LANDSCAPE OF BIRC5/SURVIVIN GENOME BINDING IN HUMAN CD4+ T CELLS

Background:

Survivin, coded by BIRC5 gene, is a multitasking protein essential for cell renewal and homeostasis. In autoimmune conditions as rheumatoid and psoriasis arthritis, survivin was associated with inflammation severity and joint damage. Importantly, inhibition of survivin alleviated experimental arthritis in mice. We have recently shown survivin to be essential for T cell differentiation and micro-RNA processing. The known anti-apoptotic and proliferation facilitating functions of survivin does not explain the nuclear localization of survivin in interphase.

Objectives:

We aimed to uncover nuclear functions of BIRC5/survivin in CD4 cell of RA patients and healthy.

Methods:

CD4 T cells were isolated from the peripheral blood using positive selection on magnetic beads (EasySep) and activated for 48h with ConA+LPS. Chromatin immunoprecipitation (ChIP) with polyclonal anti-survivin antibodies was done in four independent samples of healthy donors (n=5), healthy smokers (n=3), rheumatoid arthritis (n=3) and breast cancer (n=2). Pooled libraries were constructed for each group and ChIPseq was carried out (Illumina). For comparative RNAseq analysis, activated CD4 T cells were incubated with or without survivin inhibitor (YM155) for 24h. State-of-the-art bioinformatics pipelines were applied for NGS data and the survivin-binding peaks were used for comparison with genes, chromatin state annotation and functional gene- and regulatory regions-based functional analysis. Co-localization of peaks in the whole genome and in vicinity of the differentially expressed genes (DEG) was done using ReMap integrated ChIPseq datasets for all human cells and tissues.

Results:

We identified 13 thousands non-overlapping survivin ChIP-peaks (>3000 peaks were present in at least 3 samples). Survivin-bound regions were enriched near the genes and promoters (p=e-30 and p=e-8), which implied that survivin role in transcription could be mediated by known transcription factors. Thus, we analyzed survivin peaks vs binding regions of 1135 transcription regulators (TR) available in ReMap.

Potential partner proteins of survivin were selected based on the enrichment of the overlapping peaks in the whole genome and in CD4-active regulatory areas. Both, strict overlaps and location within 10 and 100kb survivin peak vicinity were analyzed. This approach allowed us to select >150 TRs enriched in all tests. The enriched TRs were involved in immunity and RA-relevant pathways including cytokine response and production, JAK-STAT signaling, etc. Among the TRs co-localized with survivin were CHD8, MAX, EP300, BRD2, CTCF and RAD21, all responsible for chromatin architecture. Several TRs were massively enriched in the vicinity of DEGs after survivin depletion including MAX, AR, CTCF, MYC and IRF1. Search for TR binding motifs in survivin peaks supported over-representation of binding sites for IRFs (p=e-5) and several proteins of the bZIP-family (p=e-5).

Conclusion:

Analysis of the survivin bound DNA in CD4 cells demonstrated the nonrandom distribution with specific enrichment within the regulatory elements of the genes and co-localizeation with protein partners to regulate their transcription.

Disclosure of Interests:

None declared

Preliminary results of V-FAST, a phase 1b master trial to investigate CPX-351 combined with targeted agents in newly diagnosed AML

7026

Background: CPX-351 (US: Vyxeos; EU: Vyxeos Liposomal), a dual-drug liposomal encapsulation of daunorubicin and cytarabine in a synergistic 1:5 molar drug ratio, is approved by the US FDA and EMA for adults with newly diagnosed t-AML or AML with myelodysplasia-related changes. Preclinical data suggest CPX-351 may exert synergistic activity when combined with agents such as the BCL-2 inhibitor venetoclax (VEN) or FLT3 inhibitor midostaurin (MIDO). Methods: V-FAST (Vyxeos – First Phase Assessment With Targeted Agents) is an open-label, multicenter, phase 1b master trial (NCT04075747) to evaluate safety and establish the recommended phase 2 dose (RP2D) of CPX-351 combined with targeted agents in patients (pts) aged 18-75 y with untreated AML who are fit for intensive chemotherapy. The study includes a dose-exploration phase (3+3 design) and subsequent expansion phase. Pts received CPX-351 (dose level 1 for first induction [DL1]: 100 units/m2 on Days 1, 3, and 5) plus VEN (Arm A; DL1: 400 mg on Days 1-14), MIDO (Arm B; DL1: 50 mg BID on Days 8-21), or the IDH2 inhibitor enasidenib ([ENA] Arm C; DL1: 100 mg on Days 8-28) based on mutation testing. Results: Among 21 pts with available data enrolled by 11/06/20 (24 pts enrolled total; data cut-off: 01/19/21), the median age was 54 y (range: 35, 69). In Arm A (n = 17), 11 (65%) pts had de novo AML, 5 (29%) had an antecedent hematologic disorder (2 [12%] had myelofibrosis), and 2 (12%) had t-AML; 12 (71%) had adverse-risk AML; and 6 (35%) had mutated TP53. In Arms B (n = 3) and C (n = 1), all pts had intermediate-risk de novo AML. DL1 was the RP2D in Arms A and B; the RP2D in Arm C is still under investigation. In Arm A, 1/6 pts in the dose-exploration phase had 2 dose-limiting toxicities (DLTs) of grade 4 neutropenia and thrombocytopenia that extended beyond 49 days; no DLTs have occurred for Arms B and C. The combinations exhibited manageable safety profiles (Table). Of pts with available response data, complete remission (CR) or CR with incomplete platelet or neutrophil recovery was achieved by 6/14 (43%) pts in Arm A, including 4 (29%) with CR. All pts in Arms B and C achieved CR. Conclusions: These preliminary results suggest CPX-351 can be combined with VEN and MIDO with manageable toxicities in newly diagnosed AML pts, with DL1 determined to be the RP2D. The study is ongoing and actively enrolling pts; updated results will be presented at the meeting. Clinical trial information: NCT04075747. [Table: see text]

16-month outcomes following hybrid ablation for long-standing persistent atrial fibrillation in patients with dilated atria

Introduction

Although catheter ablation therapy is a well-established treatment for cardiac dysrhythmias, the success rates for longstanding, persistent AF with dilated atria remain unsatisfactory. The minimally invasive hybrid technology is a novel form of therapy.

Methods

A prospective, single-center UK study to evaluate the hybrid ablation technique for patients with longstanding (&gt;1 year) persistent AF and dilated atria. Stage 1 was a minimally invasive epicardial approach for ablation of the posterior wall of left atrium (LA) and pulmonary veins (PVs). Stage 2 was a transcatheter approach via the femoral veins to isolate the endocardial aspect of the PVs +/− posterior wall. Occasionally, the sequence of the stages was reversed.

Results

Forty-one patients were enrolled for the study with a mean follow-up for 16±9 months. Mean age was 65±9 years and the mean BMI was 32±7. Males constituted 75% of the study cohort. Mean LA size was 48±7 mm and mean left ventricular ejection fraction (LVEF) was 51.9%, although 51.6% of patients had impaired LVSF (LVEF below 55%). 87.8% CI (0.7–0.9) of patients remained in sinus rhythm (SR) without repeat ablation, whereas only 12.2% CI (0.04–0.02) had redeveloped persistent AF. Although numerically different, there was no statistically significant difference in maintaining SR between patients with severely dilated LA (&gt;50 mm) and those without (70% vs. 90%, respectively; z=−1.39, p=0.165). Major perioperative complications during stage 1 ablation were low, with IVC injury in 1 patient and a mild stroke in 1 patient. Median LOS was 1 day (1–4 days) and there was no 30-day mortality after stage 1.

Conclusions

The hybrid ablation therapy has a conversion rate from longstanding persistent AF to SR of 87.8% at a mean follow-up of 16±9 months, without repeat ablation. LOS was short, with very few complications and no peri-operative mortality. The hybrid approach appears to be very encouraging for a condition with otherwise low success rates by conventional endocardial techniques alone.

Funding Acknowledgement

Type of funding source: None

Effect of raxibacumab on immunogenicity of Anthrax Vaccine Adsorbed: a phase 4, open-label, parallel-group, randomised non-inferiority study

BACKGROUND

Raxibacumab is a monoclonal antibody against protective antigen, which is the cell-binding part of Bacillus anthracis toxin, and is approved for treatment and postexposure prophylaxis of inhalational anthrax. Anthrax Vaccine Adsorbed (AVA), for anthrax prophylaxis, consists primarily of adsorbed protective antigen. We did a postapproval study to assess the effect of raxibacumab on immunogenicity of AVA.

METHODS

We did an open-label, parallel-group, randomised non-inferiority study at three centres in the USA. We enrolled healthy volunteers (aged 18-65 years) with no evidence of exposure to protective antigen. Participants were randomly allocated (1:1) according to a pregenerated balanced independent randomisation schedule to either subcutaneous 0·5 mL AVA on days 1, 15, and 29 or raxibacumab intravenous infusion (40 mg/kg) immediately before AVA on day 1, followed by AVA only on days 15 and 29. It was an open-label study to investigators and participants; however, the sponsor remained blinded during the study. The primary outcome was the ratio of geometric mean concentrations (GMCs) of anti-protective antigen antibodies (attributable to the immune response to AVA) between AVA and AVA plus raxibacumab 4 weeks after the first AVA dose in the per-protocol population. The per-protocol population comprised all individuals who received the allocated treatment within the protocol-specified visit window and completed the primary study outcome assessment, without a protocol deviation requiring exclusion. The non-inferiority margin for the ratio of GMCs was predefined (upper limit of 90% CI <1·5). This trial is registered with ClinicalTrials.gov, NCT02339155.

FINDINGS

Between Feb 24, 2015, and June 6, 2017, 873 participants were screened for eligibility, of whom 300 were excluded. 573 were randomly allocated either AVA (n=287) or AVA plus raxibacumab (n=286). The per-protocol population comprised 276 individuals assigned AVA and 269 allocated AVA plus raxibacumab. At week 4, the GMC of anti-protective antigen antibodies in participants allocated AVA was 26·5 μg/mL (95% CI 23·6-29·8) compared with 22·5 μg/mL (20·1-25·1) among individuals allocated AVA plus raxibacumab. The ratio between groups was 1·18 (90% CI 1·03-1·35; p=0·0019), which met the predefined non-inferiority margin. Adverse events in the safety population were similar across groups (87 [30%] of 286 in the AVA group vs 80 [29%] of 280 in the AVA plus raxibacumab group) and no treatment-related serious adverse events were reported.

INTERPRETATION

Co-administration of raxibacumab with AVA does not negatively affect AVA immunogenicity. This finding suggests that combining raxibacumab with AVA might provide added benefit in postexposure prophylaxis against inhalational anthrax.

FUNDING

US Biomedical Advanced Research and Development Authority, and GlaxoSmithKline.

Residue from vacuum ultraviolet irradiation of benzene ices: Insights into the physical structure of astrophysical dust

We have irradiated benzene ices deposited at 4 K on a cold, interstellar dust analog with vacuum ultraviolet (9 eV) irradiation for periods lasting from several hours to nearly a day, after which the irradiated ice was warmed to room temperature. Vacuum ultraviolet photoabsorption spectra of the aromatic residue left at room temperature were recorded and showed the synthesis of benzene derivatives. The residue was also imaged using an electron microscope and revealed crystals of various sizes and shapes. The result of our experiments suggests such geometrically shaped dust particles may be a key component of interstellar dust.

Fungal infection in a post-renal transplant patient with Diaporthe

Post-renal transplant fungal infections continue to be a major cause of mortality and morbidity. Universally reported fungi are Candida, especially Candida albicans, Cryptococcus, Aspergillus, Trichophyton rubrum and Pityriasis versicolor. Here, we report a case of infection caused by a rare fungus Diaporthe. It is an endophyte reported as plant pathogens and infrequently in humans and mammals. The patient was a renal transplant recipient on immunosuppressant. He had hypothyroidism and diagnosed with permanent pacemaker due to a complete heart block. The patient was treated with itraconazole (200 mg) successfully.

Anamnestic Immune Response and Safety of an Inactivated Quadrivalent Influenza Vaccine in Primed Versus Vaccine-Naïve Children

BACKGROUND

It has not yet been demonstrated whether 2 doses of inactivated quadrivalent influenza vaccine (IIV4) prime a booster response in infants. We evaluated the anamnestic immune response to an IIV4 in children 17-48 months of age.

METHODS

Children were randomized to 2 doses of IIV4 or control in the primary phase III study (NCT01439360). One year later, in an open-label revaccination extension study (NCT01702454), a subset of children who received IIV4 in the primary study (primed group) received 1 IIV4 dose and children who received control in the primary study (unprimed) received 2 IIV4 doses 28 days apart. The primary objective was to evaluate hemagglutination inhibition (HI) antibody titers 7 days after first IIV4 vaccination in the per-protocol cohort (N = 224 primed; N = 209 unprimed). Neutralizing and antineuraminidase antibodies were also measured. Safety was analyzed in the total vaccinated cohort (N = 241 primed; N = 229 unprimed).

RESULTS

An anamnestic response was observed in primed children relative to unprimed controls, measured by age-adjusted geometric mean HI titer ratios against strains homologous (A/H1N1: 9.0; B/Victoria: 3.9) and heterologous (A/H3N2: 2.7; B/Yamagata: 6.7) to those in the primary vaccination series. The anamnestic response in primed children included increases in neutralizing antibodies (mean geometric increase: 5.0-10.6) and antineuraminidase antibodies (4.9-8.8). No serious adverse events related to vaccination were reported.

CONCLUSIONS

In this study, 2-dose priming with IIV4 induced immune memory that was recalled with 1-dose IIV4 the following year to boost HI, antineuraminidase and neutralizing antibodies, even though the IIV4 strain composition partially changed.

Intrapatient variability in plasma rifampicin & isoniazid in tuberculosis patients

Background & objectives:

Large variability in anti-tuberculosis (TB) drug concentrations between patients is known to exist. However, limited information is available on intrapatient drug levels during the course of anti-TB treatment (ATT). This study was conducted to evaluate intrapatient variability in plasma rifampicin (RMP) and isoniazid (INH) concentrations during ATT at start of the treatment, at the end of intensive phase (IP) of ATT and at the end of ATT in adult TB patients being treated in the Revised National TB Control Programme (RNTCP).

Methods:

Adult TB patients (n=485), receiving thrice-weekly ATT in the RNTCP, were studied. Two-hour post-dosing concentrations of RMP and INH were determined at month 1, end of IP and end of ATT, after directly observed drug administration. Drug concentrations were estimated by high-performance liquid chromatography.

Results:

The median (inter-quartile range) RMP concentrations during the first month, at end of IP and end of ATT were 2.1 (0.4-5.0), 2.4 (0.6-5.5) and 2.2 (0.5-5.3) μg/ml, respectively. The corresponding INH concentrations were 7.1 (4.2-9.9), 7.2 (3.9-10.9) and 6.7 (3.9-9.5) μg/ml. None of the differences in drug concentrations obtained at different time points during ATT were significant. RMP and INH concentrations at different time points were significantly correlated. Age and body mass index caused significant variability in drug concentrations.

Interpretation & conclusions:

Plasma RMP and INH estimations in adult TB patients at two hours after drug administration remained unaltered during ATT. Clinicians can consider testing drug concentrations at any time point during ATT. These findings may assume significance in the context of therapeutic drug monitoring of anti-TB drug concentrations.

Ultraslow isomerization in photoexcited gas-phase carbon cluster [Formula: see text]

Isomerization and carbon chemistry in the gas phase are key processes in many scientific studies. Here we report on the isomerization process from linear [Formula: see text] to its monocyclic isomer. [Formula: see text] ions were trapped in an electrostatic ion beam trap and then excited with a laser pulse of precise energy. The neutral products formed upon photoexcitation were measured as a function of time after the laser pulse. It was found using a statistical model that, although the system is excited above its isomerization barrier energy, the actual isomerization from linear to monocyclic conformation takes place on a very long time scale of up to hundreds of microseconds. This finding may indicate a general phenomenon that can affect the interstellar medium chemistry of large molecule formation as well as other gas phase processes.

Pharmacokinetics of thrice-weekly rifampicin, isoniazid and pyrazinamide in adult tuberculosis patients in India

OBJECTIVE

To study the pharmacokinetics of rifampicin (RMP), isoniazid (INH) and pyrazinamide (PZA) in adult tuberculosis (TB) patients and examine factors that influence drug pharmacokinetics.

METHODS

Adult TB patients (n = 101) receiving thrice-weekly anti-tuberculosis treatment in the Revised National TB Control Programme (RNTCP) were studied. The study was conducted at steady state after directly observed drug administration. RMP, INH and PZA concentrations were estimated using high-performance liquid chromatography and NAT2 genotyping by real-time polymerase chain reaction.

RESULTS

RMP peak concentration (Cmax) was sub-therapeutic (<8 μg/ml) in 88% of the patients. The Cmax of RMP, INH and PZA at 2 h was observed in respectively 83.2%, 97.0% and 92.1% of the patients. The Cmax and area under the curve from 0 to 8 h (AUC0-8) of PZA was lower in TB patients with diabetes mellitus than in non-diabetics. Significant associations were observed between the Cmax and the AUC0-8 of RMP, INH and PZA with drug doses; RMP with category of treatment; INH with smoking, body mass index and N-acetyl transferase 2 genotype; and PZA with sex and smoking.

CONCLUSIONS

Several risk factors for drug concentration variations were identified. Two-hour post-dosing drug concentrations mimicked Cmax. A high proportion of TB patients had RMP Cmax below the expected range, which is a matter of concern.

Genetic diversity of Mycobacterium tuberculosis isolates from central India

Background & objectives:

There is a paucity of data available on genetic biodiversity of Mycobacterium tuberculosis isolates from central India. The present study was carried out on isolates of M. tuberculosis cultured from diagnostic clinical samples of patients from Bhopal, central India, using spoligotyping as a method of molecular typing.

Methods:

DNA was extracted from 340 isolates of M. tuberculosis from culture, confirmed as M. tuberculosis by molecular and biochemical methods and subjected to spoligotyping. The results were compared with the international SITVIT2 database.

Results:

Sixty five different spoligo international type (SIT) patterns were observed. A total of 239 (70.3%) isolates could be clustered into 25 SITs. The Central Asian (CAS) and East African Indian (EAI) families were found to be the two major circulating families in this region. SIT26/CAS1_DEL was identified as the most predominant type, followed by SIT11/EAI3_IND and SIT288/CAS2. Forty (11.8%) unique (non-clustered) and 61 (17.9%) orphan isolates were identified in the study. There was no significant association of clustering with clinical and demographic characteristics of patients.

Interpretation & conclusions:

Well established SITs were found to be predominant in our study. SIT26/CAS1_DEL was the most predominant type. However, the occurrence of a substantial number of orphan isolates may indicate the presence of active spatial and temporal evolutionary dynamics within the isolates of M. tuberculosis.

An experimental setup to study delayed electron emission upon photoexcitation of trapped polyatomic anions

A Velocity Map Imaging (VMI) spectrometer has been designed and integrated with an electrostatic ion beam trap to study delayed electron emission from trapped polyatomic anions upon photodetachment. The VMI spectrometer is small in size and can record a wide range of photoelectron energies, with variable magnification. Delayed electron emission can be recorded in our experimental setup for any time duration after the photoexcitation of the polyatomic anions. Experiments were carried out with trapped O^- and C₅^- ions to demonstrate the capability of the spectrometer. Delayed electron emissions from C₅^- as well as prompt photoelectrons from O^- were detected by the VMI spectrometer upon photoexcitation. The design and performance of the spectrometer are presented in detail.

Time to Change Dosing of Inactivated Quadrivalent Influenza Vaccine in Young Children: Evidence From a Phase III, Randomized, Controlled Trial

BACKGROUND.

Children under 3 years of age may benefit from a double-dose of inactivated quadrivalent influenza vaccine (IIV4) instead of the standard-dose.

METHODS.

We compared the only United States-licensed standard-dose IIV4 (0.25 mL, 7.5 µg hemagglutinin per influenza strain) versus double-dose IIV4 manufactured by a different process (0.5 mL, 15 µg per strain) in a phase III, randomized, observer-blind trial in children 6-35 months of age (NCT02242643). The primary objective was to demonstrate immunogenic noninferiority of the double-dose for all vaccine strains 28 days after last vaccination. Immunogenic superiority of the double-dose was evaluated post hoc. Immunogenicity was assessed in the per-protocol cohort (N = 2041), and safety was assessed in the intent-to-treat cohort (N = 2424).

RESULTS.

Immunogenic noninferiority of double-dose versus standard-dose IIV4 was demonstrated in terms of geometric mean titer (GMT) ratio and seroconversion rate difference. Superior immunogenicity against both vaccine B strains was observed with double-dose IIV4 in children 6-17 months of age (GMT ratio = 1.89, 95% confidence interval [CI] = 1.64-2.17, B/Yamagata; GMT ratio = 2.13, 95% CI = 1.82-2.50, B/Victoria) and in unprimed children of any age (GMT ratio = 1.85, 95% CI = 1.59-2.13, B/Yamagata; GMT ratio = 2.04, 95% CI = 1.79-2.33, B/Victoria). Safety and reactogenicity, including fever, were similar despite the higher antigen content and volume of the double-dose IIV4. There were no attributable serious adverse events.

CONCLUSIONS.

Double-dose IIV4 may improve protection against influenza B in some young children and simplifies annual influenza vaccination by allowing the same vaccine dose to be used for all eligible children and adults.

Immunogenicity and Safety of an Inactivated Quadrivalent Influenza Vaccine in US Children 6-35 Months of Age During 2013-2014: Results From A Phase II Randomized Trial

BACKGROUND

Viruses from 2 influenza B lineages co-circulate, leading to suboptimal protection with trivalent influenza vaccines (TIV). Quadrivalent influenza vaccines (QIV) containing both lineages offer broader protection.

METHODS

We compared inactivated seasonal QIV versus TIV (15 and 7.5 μg hemagglutinin [HA] for each influenza strain, respectively) in a phase II randomized (1 : 1), observer-blind trial in US children 6-35 months of age (identifier NCT01974895). The primary objective was to evaluate immune responses induced by QIV for the 4 vaccine strains 28 days after completion of vaccination. A secondary objective was to demonstrate superiority of QIV versus TIV for the B/Victoria strain contained in QIV but not TIV. Immunogenicity was evaluated in the per-protocol cohort (N = 280), and safety was evaluated in the intent-to-treat cohort (N = 314).

RESULTS

Seroconversion rates (SCRs) for QIV were 80.4% (95% confidence interval [CI], 73.0%-86.6%), 72.0% (95% CI, 63.9%-79.2%), 86.0% (95% CI, 79.2%-91.2%), and 66.4% (95% CI, 58.1%-74.1%) for A/H1N1, A/H3N2, B/Yamagata, and B/Victoria, respectively. Quadrivalent influenza vaccines demonstrated immunogenic superiority over TIV for B/Victoria with a geometric mean titer ratio of 4.73 (95% CI, 3.73%-5.99%) and SCR difference of 54.02% (95% CI, 43.88%-62.87%). Safety was similar between the vaccine groups despite the QIV's higher antigen content. No serious adverse events were reported related to vaccination.

CONCLUSIONS

Quadrivalent influenza vaccine (15 µg HA/strain) was immunogenic with an acceptable safety profile. The next phase of its development in children 6-35 months of age is a phase III trial in countries where it is not yet licensed. In countries where it is already licensed, a switch from TIV to QIV would provide broader protection in this vulnerable group.

Evidence update: GlaxoSmithKline's inactivated quadrivalent influenza vaccines

Inactivated trivalent influenza vaccines (IIV3s) are designed to protect against illness caused by two influenza A virus subtypes and one influenza B virus lineage. They may provide inadequate protection due to the co-circulation of viruses from two antigenically distinct influenza B lineages. Incorporating strains from both B lineages as in inactivated quadrivalent influenza vaccines (IIV4s) reduces this risk. We summarize the evidence supporting two IIV4s manufactured by GSK Vaccines. Compared to IIV3s, these two IIV4s demonstrated noninferior immunogenicity against the shared influenza strains and superior immunogenicity for the strain of the additional B lineage, particularly in subjects who were seronegative for that B strain. One IIV4's efficacy in children aged 3-8 years was 55.4% against influenza of any severity and 73.1% against moderate-to-severe influenza. Both IIV4s were well-tolerated with a similar safety profile to IIV3s. These IIV4s are more likely than IIV3s to protect against the added influenza B strain.

Immunogenicity and Reactogenicity of an Inactivated Quadrivalent Influenza Vaccine Administered Intramuscularly to Children 6 to 35 Months of Age in 2012-2013: A Randomized, Double-Blind, Controlled, Multicenter, Multicountry, Clinical Trial

BACKGROUND

Influenza attack rates are high in 6- to 35-month-old children; vaccines containing both lineages of influenza B (Yamagata and Victoria), in addition to the H3N2 and H1N1 antigens, may improve protection rates.

METHODS

In a randomized double-blind controlled trial, the immunogenicity and reactogenicity of an inactivated quadrivalent influenza vaccine (QIV) and a trivalent control vaccine (TIV) were assessed.

RESULTS

Six hundred one children (QIV, n = 299; TIV, n = 302) were enrolled at 8 sites in 3 countries. The primary immunogenicity objective was met: the lower limit (LL) of the 2-sided 95% confidence interval (CI) for the seroconversion rate in QIV recipients ranged from 66.6% to 81.3%, which was ≥40% against all 4 strains. The immunogenic superiority of the additional B/Victoria strain in the QIV compared to that in the TIV was confirmed: the LL of the 2-sided 95% CI of the geometric mean titer ratio (QIV/TIV) (6.28 [95% CI, 5.32-7.41]) was greater than 1.5, and the LL of the 2-sided 95% CI for the difference in the seroconversion rate (QIV - TIV) (64.19% [95% CI, 57.65%-69.95%]) was greater than 10%. Injection-site pain and irritability/fussiness were the most commonly reported solicited injection-site and general adverse events, respectively, from days 0 to 6 and were similar in frequency between the groups.

CONCLUSIONS

In children aged 6 to 35 months, a QIV has superior immunogenicity for the added B strain and acceptable immunogenicity for shared strains, with no notable difference in reactogenicity and safety when compared to a TIV.

Could repeated prevalence surveys lead to decreasing tuberculosis prevalence in a community?

SETTING

Tiruvallur District, South India, where one baseline tuberculosis (TB) disease prevalence survey followed by three repeat prevalence surveys were conducted every 2.5 years between 1999 and 2008, and where the DOTS strategy was implemented in 1999.

OBJECTIVE

To rule out the possibility that the observed decline in TB prevalence was influenced by conducting repeat prevalence surveys, we compared the findings from two surveys: the third repeat survey conducted in 2006-2008 and an independent single survey in a neighbouring area conducted in 2008-2009.

DESIGN

An independent survey was conducted to estimate the prevalence of TB in the same district in 2008-2009 using a different set of villages and employing repeat survey methodology. The independent survey findings were compared with those of the third repeat survey.

RESULTS

The estimated prevalence rate of culture- and smear-positive TB was respectively 401 per 100,000 and 186 per 100,000 population in the third repeat survey area. The corresponding rates were 340 and 184/100,000 in the independent survey area. The difference in prevalence was not significant (culture P = 0.09; smear P = 0.93).

CONCLUSION

The estimated prevalence rates in the two different sample survey areas were comparable, indicating that the repeated prevalence surveys in the study area did not influence the observed decline in TB disease prevalence.

High rates of ofloxacin resistance in Mycobacterium tuberculosis among both new and previously treated patients in Tamil Nadu, South India

Periodic drug resistance surveillance provides useful information on trends of drug resistance and effectiveness of tuberculosis (TB) control measures. The present study determines the prevalence of drug resistance among new sputum smear positive (NSP) and previously treated (PT) pulmonary TB patients, diagnosed at public sector designated microscopy centers (DMCs) in the state of Tamil Nadu, India. In this single-stage cluster-sampling prevalence survey, 70 of 700 DMCs were randomly selected using a probability-proportional to size method. A cluster size of 24 for NSP and a varying size of 0 to 99 for PT cases were fixed for each selected DMC. Culture and drug susceptibility testing was done on Lowenstein-Jensen medium using the economic variant of proportion sensitivity test for isoniazid (INH), rifampicin (RMP), ofloxacin (OFX) and kanamycin (KAN). Human Immunodeficiency Virus (HIV) status was collected from patient records. From June 2011 to August 2012, 1524 NSP and 901 PT patients were enrolled. Any RMP resistance and any INH resistance were observed in 2.6% and 15.1%, and in 10.4% and 30% respectively in NSP and PT cases. Among PT patients, multi drug resistant TB (MDR-TB) was highest in the treatment failure (35%) group, followed by relapse (13%) and treatment after default (10%) groups. Extensively drug resistant TB (XDRTB) was seen in 4.3% of MDR-TB cases. Any OFX resistance was seen in 10.4% of NSP, 13.9% of PT and 29% of PT MDR-TB patients. The HIV status of the patient had no impact on drug resistance levels. RMP resistance was present in 2.6% of new and 15.1% of previously treated patients in Tamil Nadu. Rates of OFX resistance were high among NSP and PT patients, especially among those with MDR-TB, a matter of concern for development of new treatment regimens for TB.

Prevalence of chest symptoms amongst brick kiln migrant workers and care seeking behaviour: a study from South India

BACKGROUND

Early detection and treatment of tuberculosis (TB) have been key principles of TB control. However, this can be a challenge with 'hard to reach' populations such as migrants. Brick kiln workers are one such group of migrants who are exposed to smoke, heat and dust from brick kilns which are one of the major causes of respiratory illnesses.

METHODOLOGY

A cross-sectional community based study was carried out in Thiruvallur, Tamil Nadu, South India, from August 2011 to June 2012. A total of 4002 individuals from 55 brick kiln chambers were interviewed to determine the prevalence of chest symptoms and care seeking behaviour patterns.

RESULTS

Three hundred and seventy-seven (9.4%) chest symptomatics were identified. The most significant variables associated with chest symptoms were illiteracy, alcohol abuse and heavy smoking. Of the chest symptomatics identified, 50.4% took action to get relief from their symptoms. The duration of over 6-month stay in the chamber was significantly associated with taking action (OR, 5.5, 95% CI: 2.3, 13.3).

CONCLUSIONS

The TB control programme needs to further explore how to extend its services to such 'hard to reach' groups. Active case finding to ensure early diagnosis and treatment initiation amongst such groups needs consideration.

A historically-controlled Phase III study in adults to characterize the acceptability of a process change for manufacturing inactivated quadrivalent influenza vaccine

BACKGROUND

An inactivated quadrivalent influenza vaccine (QIV) was recently licenced in the US as a thimerosal-free formulation presented in a pre-filled syringe. A multidose presentation is preferred in some settings due to reduced acquisition and cold storage costs. We assessed the immunogenicity and safety of a thimerosal-containing QIV formulated using a new manufacturing process for presentation in multidose vials.

METHODS

Two Phase III non-randomized studies separately evaluated inactivated trivalent influenza vaccine (TIV; 2010-2011; historical control) and a QIV (2011-2012). The QIV contained the same strains as the TIV plus an additional B strain. Both vaccines contained thimerosal to allow multidose presentation: this preservative was added to the QIV during the final formulation step using a new process, whereas it was added to the TIV early in the manufacturing process using an established method. The TIV study included 50 and 70 subjects aged 18-60 and >60 years, respectively; the QIV study included 56 subjects in each age stratum. Immunogenicity was assessed using hemagglutination-inhibition (HI) assays. Reactogenicity was assessed during the 4-day post-vaccination periods and unsolicited adverse events (AEs) were assessed during the 21-day post-vaccination periods.

RESULTS

The TIV and QIV were immunogenic in both age strata. With the QIV and TIV respectively, the seroconversion rates were 48.2-62.7% and 71.4-83.7% for influenza A, and 33.9-62.5% and 67.3-72.9% for influenza B. With the QIV and TIV respectively, the seroprotection rates were 92.9-98.2% and 98.2-100% for influenza A, and 88.6-100% and 95.9-98.6% for influenza B. Pre-vaccination titers were higher in the QIV versus TIV study which confounds a direct comparison and likely explains the lower seroconversion rates observed in the QIV study. There were no safety concerns raised with TIV or QIV.

CONCLUSIONS

The thimerosal-containing QIV formulated using a new process was immunogenic, conforming to regulatory acceptance criteria, with a reactogenicity and safety profile in line with the TIV manufactured using a licensed process. These results support acceptability of a manufacturing process change in which the thimerosal preservative is added at the point at which batches are filled into multidose vials.

TRIAL REGISTRATION

These trials were registered at ClinicalTrials.gov: NCT01440387; NCT01153685.

Common mental disorders: a challenge among people living with human immunodeficiency virus infection/acquired immunodeficiency syndrome in udupi, India

BACKGROUND

Globally, the prevalence of common mental disorders (CMD) is greater among people living with human immunodeficiency virus/acquired immunodeficiency syndrome (PLHA) as opposed to the general population. There is relatively limited research on mental health in PLHA in India and this study seeks to gain insight in this area.

AIM

The aim of this study is to find the prevalence of CMD among PLHA in Udupi district.

SUBJECTS AND METHODS

In this cross-sectional study, 227 PLHA were selected using a convenience sampling method and interviewed at a district antiretroviral treatment center. The Kessler Psychological Distress Scale (K10 scale) and the General Health Questionnaire (GHQ-12) were used to measure distress and stress, respectively to assess CMD. Statistical analysis was performed with categorical variables expressed as frequencies and percentages. Continuous variables were measured using mean and standard deviation. Univariate and multivariate analyses using binomial logistic regression was carried out. SPSS version 15 (SPSS Inc., Chicago, IL, USA) was used to analyze the data.

RESULTS

The K10 Psychological Distress Scale indicated that 78.9% (n = 179/227) of participants suffered from mild to severe mental disorder and it was higher among divorced, separated or widowed PLHA followed by the married participants versus unmarried individuals. The GHQ-12 scale showed 68.3% (n = 155/227) suffering from mild to severe mental stress with the female gender developing stress 2.3 times more often.

CONCLUSION

High levels of distress were seen among PLHA. They should be periodically screened for CMD and provided early psychological intervention at the point of contact with health professionals. Psychological care needs to be integrated along with the clinical care.

Vaccine for prevention of mild and moderate-to-severe influenza in children

BACKGROUND

Commonly used trivalent vaccines contain one influenza B virus lineage and may be ineffective against viruses of the other B lineage. We evaluated the efficacy of a candidate inactivated quadrivalent influenza vaccine (QIV) containing both B lineages.

METHODS

In this multinational, phase 3, observer-blinded study, we randomly assigned children 3 to 8 years of age, in a 1:1 ratio, to receive the QIV or a hepatitis A vaccine (control). The primary end point was influenza A or B confirmed by real-time polymerase chain reaction (rt-PCR). Secondary end points were rt-PCR-confirmed, moderate-to-severe influenza and rt-PCR-positive, culture-confirmed influenza. The vaccine efficacy and the effect of vaccination on daily activities and utilization of health care resources were assessed in the total vaccinated cohort (2584 children in each group) and the per-protocol cohort (2379 children in the QIV group and 2398 in the control group).

RESULTS

In the total vaccinated cohort, 62 children in the QIV group (2.40%) and 148 in the control group (5.73%) had rt-PCR-confirmed influenza, representing a QIV efficacy of 59.3% (95% confidence interval [CI], 45.2 to 69.7), with efficacy against culture-confirmed influenza of 59.1% (97.5% CI, 41.2 to 71.5). For moderate-to-severe rt-PCR-confirmed influenza, the attack rate was 0.62% (16 cases) in the QIV group and 2.36% (61 cases) in the control group, representing a QIV efficacy of 74.2% (97.5% CI, 51.5 to 86.2). In the per-protocol cohort, the QIV efficacy was 55.4% (95% CI, 39.1 to 67.3), and the efficacy against culture-confirmed influenza 55.9% (97.5% CI, 35.4 to 69.9); the efficacy among children with moderate-to-severe influenza was 73.1% (97.5% CI, 47.1 to 86.3). The QIV was associated with reduced risks of a body temperature above 39°C and lower respiratory tract illness, as compared with the control vaccine, in the per-protocol cohort (relative risk, 0.29 [95% CI, 0.16 to 0.56] and 0.20 [95% CI, 0.04 to 0.92], respectively). The QIV was immunogenic against all four strains. Serious adverse events occurred in 36 children in the QIV group (1.4%) and in 24 children in the control group (0.9%).

CONCLUSIONS

The QIV was efficacious in preventing influenza in children. (Funded by GlaxoSmithKline Biologicals; ClinicalTrials.gov number, NCT01218308.).

Immunogenicity and safety of an inactivated quadrivalent influenza vaccine candidate: a phase III randomized controlled trial in children

BACKGROUND

Mismatch between circulating influenza B viruses (Yamagata and Victoria lineages) and vaccine strains occurs frequently.

METHODS

In a randomized controlled trial, immunogenicity and safety of an inactivated quadrivalent influenza vaccine candidate (QIV) versus trivalent inactivated influenza vaccine (TIV)-Victoria(Vic) and TIV-Yamagata(Yam) in children 3-17 years of age was evaluated. In an open-label study arm, QIV only was assessed in children 6-35 months of age.

RESULTS

A total of 3094 children (932 QIV, 929 TIV-Vic, 932 TIV-Yam, and 301 QIV only) were vaccinated. QIV was noninferior to the TIVs for shared strains (A/H3N2 and A/H1N1) based on hemagglutination-inhibition (HI) antibodies 28 days after last vaccination, and superior for the unique B strains Victoria and Yamagata (geometric mean titer ratios 2.61, 3.78; seroconversion rate differences 33.96%, 44.63%). Among children in the randomized trial, adverse event rates were similar except for injection site pain (dose 1: 65.4% QIV, 54.6% TIV-Vic, 55.7% TIV-Yam).

CONCLUSION

QIV elicited superior HI responses to the added B strains compared to TIV controls, potentially improving its effectiveness against influenza B. HI responses were similar between QIV and TIV controls for the shared strains. QIV had an acceptable safety profile relative to TIVs.

CLINICAL TRIALS REGISTRATION

NCT01198756.

Improving screening and chemoprophylaxis among child contacts in India's RNTCP: a pilot study

BACKGROUND

While contact screening and chemoprophylaxis is recommended by India's Revised National Tuberculosis Control Programme for asymptomatic children aged <6 years who are household contacts of smear-positive pulmonary tuberculosis (PTB) patients, implementation is suboptimal.

OBJECTIVE

To evaluate the effectiveness of an isoniazid preventive therapy (IPT) register and card in improving the adherence of health care workers (HCWs) to programmatic guidelines.

METHODOLOGY

This prospective study was conducted in two Tuberculosis Units in South India. Child contacts of smear-positive PTB patients initiated on treatment between November 2009 and January 2010 were screened, and IPT was initiated in asymptomatic children. HCWs were trained in the use of the IPT register and card. The process was evaluated using patient and HCW interviews.

RESULTS

Of 87 children identified aged <6 years, 71 (82%) were traced by HCWs; 53 were screened for TB and initiated on IPT, and 39 completed treatment. HCWs expressed satisfaction with the use of the IPT card and register, saying that it helped them to remember to complete required tasks.

CONCLUSION

In a programme setting, with HCW training and introduction of specific documentation (IPT card and register), implementation of contact tracing and chemoprophylaxis for child contacts improved from 19% to 61%.

Absolute photo-destruction and photo-fragmentation cross section measurements using an electrostatic ion beam trap

We describe a technique to measure absolute photo-induced cross sections for cluster anions stored in an electrostatic ion beam trap (EIBT) with a central deflector. The setup allows determination of total photo-destruction cross sections as well as partial cross sections for fragmentation and electron detachment. The unique properties of this special EIBT setup are investigated and illustrated using small Al(n)(-) clusters.

Trend in tuberculosis infection prevalence in a rural area in South India after implementation of the DOTS strategy

SETTING

Three tuberculin surveys were conducted at intervals of 5 years following the implementation of a DOTS-based programme in 1999 in Tiruvallur District, South India.

OBJECTIVE

To estimate the trend in the prevalence of tuberculosis (TB) infection among children and to evaluate the impact of the DOTS strategy.

METHODS

Children aged 1-9 years in the sample for each survey were registered and administered 1 tuberculin unit of purified protein derivative RT 23 with Tween 80 by intradermal injection on the volar aspect of the left forearm. The induration diameter of the reaction was measured in mm after 72 h (3 days) and the prevalence of TB infection estimated.

RESULTS

The induration data of bacille Calmette-Guérin (BCG) vaccinated and non-vaccinated children were analysed using the mixture model. The estimated prevalence of TB infection among non-BCG-vaccinated children in the three tuberculin surveys were respectively 19.4%, 13.8% and 11.4%, with an average annual decline of 5.2% (95%CI 3.6-6.8). The prevalence of TB infection among BCG-vaccinated children decreased, with an average annual decline of 5.4% (95%CI 10.0-18.6).

CONCLUSION

A significant declining trend in the prevalence of TB infection among children was observed following the implementation of the DOTS strategy in the area.

Immunogenicity and Safety of 2 Dose Levels of a Thimerosal-Free Trivalent Seasonal Influenza Vaccine in Children Aged 6-35 Months: A Randomized, Controlled Trial

BACKGROUND

Improved influenza vaccine strategies for infants and preschool children are a high priority.

METHODS

The immunological response and safety of a thimerosal-free trivalent inactivated influenza vaccine at 2 different doses (0.50 mL vs 0.25 mL) was evaluated in children aged 6-35 months. The study was randomized, observer blind, multicenter, and stratified by age (6-23 months and 24-35 months), and it accounted for prior influenza immunization status.

RESULTS

Three hundred seventy-four children were in the total vaccinated cohort (study vaccine 0.25-mL dose, n = 164; 0.50-mL dose, n = 167; comparator 0.25 mL, n = 43). Regulatory criteria for immunogenicity of influenza vaccines in adults were met for all virus strains and doses for both age strata. A modest but not statistically significant improvement in immune responses was observed with the higher dose and reactogenicity, and safety of the 2 doses was not significantly different.

CONCLUSIONS

The 0.5-mL dose of the study vaccine, when administered to children aged 6-35 months, resulted in a modest but not statistically significant improvement in immunogenicity with clinically similar safety and reactogenicity compared with the 0.25-mL dose. Further studies comparing full- and half-dose influenza vaccine in young children are needed.

CLINICAL TRIALS REGISTRATION

NCT00778895.

Alcohol use disorders (AUD) among tuberculosis patients: a study from Chennai, South India

BACKGROUND

Alcohol Use Disorders (AUDs) among tuberculosis (TB) patients are associated with nonadherence and poor treatment outcomes. Studies from Tuberculosis Research Centre (TRC), Chennai have reported that alcoholism has been one of the major reasons for default and mortality in under the DOTS programme in South India. Hence, it is planned to conduct a study to estimate prevalence of alcohol use and AUDs among TB patients attending the corporation health centres in Chennai, India.

METHODOLOGY

This is a cross-sectional cohort study covering 10 corporation zones at Chennai and it included situational assessment followed by screening of TB patients by a WHO developed Alcohol Use Disorders Identification Test AUDIT scale. Four zones were randomly selected and all TB patients treated during July to September 2009 were screened with AUDIT scale for alcohol consumption.

RESULTS

Out of 490 patients, 66% were males, 66% were 35 years and above, 57% were married, 58% were from the low monthly income group of 8. Age (>35 years), education (less educated), income (

CONCLUSIONS

AUD among TB patients needs to be addressed urgently and the findings suggest the importance of integrating alcohol treatment into TB care.

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Key Words Collapse

MESH Headings

• Adult
• Alcohol Drinking/epidemiology
• Alcohol-Related Disorders/complications
• Alcohol-Related Disorders/epidemiology
• Alcohol-Related Disorders/therapy
• Demography
• Female
• Humans
• India/epidemiology
• Male
• Mass Screening
• Treatment Outcome
• Tuberculosis/complications
• Tuberculosis/diagnosis
• Tuberculosis/epidemiology
• Tuberculosis/therapy

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Grants Collapse

Affiliation(s)

Mohanarani Suhadev Tuberculosis Research Centre, Chetput, Chennai, Tamilnadu, India.
Beena E Thomas
M Raja Sakthivel
P Murugesan
V Chandrasekaran
Niruparani Charles
R Durga
M Auxilia
Trini A Mathew
Fraser Wares

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Hierarchical assembly of Sm2Co7/Co magnetic nanoparticles into highly stable and uniform nanospheres

Hierarchical assembly of colloidal Sm2Co7/Co clusters in the form of nanospheres has been processed through a polyol process. The SmCo nanospheres are found to be robust, uniform ( 100 nm) and tend to self-assemble in the form of ordered superstructures. Each nanosphere consists of large number of discrete fine particles ( 6.0 nm), having two-phase structure of both Sm2Co7 and Co-phases. Upon annealing, these phases transform into Sm2Co17 phase with very high magnetization (169 emu/g). A possible mechanism on the formation of nanospheres from the individual Sm2Co2o7 and Co nanoparticles is also discussed.

Revised National Tuberculosis Control Programme (RNTCP)

The global annual inicidence is estimated to be 1.98 million cases in India. This situation is further threatened by emergence of multidrug-resistant tuberculosis. The Revised National Tuberculosis Control Programme is based on Directly Observed Treatment Short-course (DOTS) strategy. DOTS facilitates relapse-free cure for TB. Diagnostic algorithms for pulmonary tuberculosis have been narrated in this article. Treatment of tuberculosis stands on patients' categorisation in 3 groups and schedule is described. The side-effects and their remedies are also narrated. The IMA has a role to join hands with the government to work closely to bring down the disease burden.

Depressive symptoms and human immunodeficiency virus risk behavior among men who have sex with men in Chennai, India

Men who have sex with men (MSM) in India are a hidden population, facing unique environmental stressors and cultural pressures that place them at risk for depression. Depression may affect HIV risk behavior in MSM, and may affect the degree to which MSM may benefit from HIV prevention interventions. Depression in MSM in India, however, has largely been understudied. Two hundred ten MSM in Chennai completed an interviewer-administered behavioral assessment battery, which included the 20-item Center for Epidemiologic Studies Depression Scale (CES-D), demographics, sexual risk and identity, and other psychosocial variables. Over half (55%) of the sample exceeded the cutoff (CES-D >or= 16) to screen in for clinically significant depressive symptoms; this was associated with having had unprotected anal sex (OR = 1.97; 95% CI: 1.01-3.87) and higher number of male partners (OR = 1.04; 95% CI: 1.01-1.07). Statistically significant bivariate predictors of meeting the screen in for depressive symptoms included sexual identity (Kothi > Panthi; OR = 4.90; 95% CI: 2.30-10.54), not being married (OR = 3.40; 95% CI: 1.72-6.81), not having a child (OR = 4.40; 95% CI: 2.07-9.39), family not knowing about one's MSM identity (OR = 2.30; 95% CI: 1.18-4.90), having been paid for sex (OR = 5.10; p 95% CI: 2.87-9.47), and perceiving that one is at risk for acquiring HIV (OR = 1.10; 95% CI: 1.02-1.17; continuous). In a multivariable logistic-regression model, unique predictors of screening in for depressive symptoms included not being married (AOR = 3.10; 95% CI: 1.23-7.65), having been paid for sex (AOR = 3.80; 95% CI: 1.87-7.99) and the perception of increased risk for HIV (AOR = 1.10; 95% CI: 1.03-1.21; continuous); unprotected anal sex in the 3 months prior to study enrollment approached statistical significance (AOR = 2.00; 95% CI: 0.91-4.48). Depression among MSM in Chennai is of concern and should be considered while developing HIV prevention interventions with this population. MSM who are not married, sex workers, and those who perceive they are at risk for acquiring HIV may be of higher risk for symptoms of depression.

Topology constraint free fuzzy gated neural networks for pattern recognition

In this paper, a novel topology constraint free neural network architecture using a generalized fuzzy gated neuron model is presented for pattern recognition task. The main feature is that the network does not require weight adaptation at its input and the weights are initialized directly from the training pattern set. The elimination of the need for iterative weight adaptation schemes facilitates quick network set up times which make the fuzzy gated neural networks very attractive. The performance of the proposed network is found to be functionally equivalent to spatio-temporal feature maps under a mild technical condition. The classification performance of fuzzy gated neural network is demonstrated on a 12-class synthetic three-dimensional (3-D) object data set, real-world eight-class texture data set, and real-world 12-class 3-D object data set. The performance results are compared with the classification accuracies obtained from spatiotemporal feature map, adaptive subspace self-organizing map, multilayer feedforward neural networks, radial basis function neural networks, and linear discriminant analysis. Despite the network's ability to accurately classify seen data and adequately generalize validation data, its performance is found to be sensitive to noise perturbations due to fine fragmentation of the feature space. This paper also provides partial solutions to the above robustness issue by proposing certain improvements to various modules of the proposed fuzzy gated neural network.

Contact screening and chemoprophylaxis in India's Revised Tuberculosis Control Programme: a situational analysis

BACKGROUND

India's Revised National Tuberculosis Control Programme (RNTCP) recommends screening of all household contacts of smear-positive pulmonary tuberculosis (PTB) cases for tuberculosis (TB) disease, and 6-month isoniazid preventive therapy (IPT) for asymptomatic children aged <6 years.

OBJECTIVE

To assess the implementation of child contact screening and IPT administration under the RNTCP.

METHODS

A cross-sectional study conducted in four randomly selected TB units (TUs), two in an urban (Chennai City) and two in a rural (Vellore District) area of Tamil Nadu, South India, from July to September 2008. The study involved the perusal of TB treatment cards of source cases (new or retreatment smear-positive PTB patients started on treatment), interview of source cases and focus group discussions (FGDs) among health care workers.

RESULTS

Interviews of 253 PTB patients revealed that of 220 contacts aged <14 years, only 31 (14%) had been screened for TB, and that of 84 household children aged <6 years, only 16 (19%) had been initiated on IPT. The treatment cards of source cases lacked documentation of contact details. FGDs revealed greater TB awareness among urban health care workers, but a lack of detailed knowledge about procedures.

CONCLUSION

Provision for documentation using a separate IPT card and focused training may help improve the implementation of contact screening and IPT.

HIV prevention interventions in Chennai, India: are men who have sex with men being reached?

India has the greatest number of HIV infections in Asia and the third highest total number of infected persons globally. Men who have sex with men (MSM) are considered by the Government of India's National AIDS Control Organization (NACO) a "core risk group" for HIV in need of HIV prevention efforts. However there is a dearth of information on the frequency of participation in HIV prevention interventions and subsequent HIV risk and other correlates among MSM in India. Recruited through peer outreach workers, word of mouth and snowball sampling techniques, 210 MSM in Chennai completed an interviewer-administered assessment, including questions about participating in any HIV prevention interventions in the past year, sexual risk taking, demographics, MSM identities, and other psychosocial variables. Bivariate and multivariable logistic regression procedures were used to examine behavioral and demographic correlates with HIV prevention intervention participation. More than a quarter (26%) of the sample reported participating in an HIV prevention intervention in the year prior to study participation. Participants who reported engaging in unprotected anal sex (UAS; odds ratio [OR] = 0.28; p = 0.01) in the 3 months prior to study enrollment were less likely to have participated in an HIV prevention program in the past year. MSM who were older (OR = 1.04; p = 0.05), kothis (feminine acting/appearing and predominantly receptive partners in anal sex) compared to panthis (masculine appearing, predominantly insertive partners; OR = 5.52, p = 0.0004), those with higher educational attainment (OR = 1.48, p = 0.01), being "out" about having sex with other men (OR = 4.03, p = 0.0001), and MSM who reported ever having been paid in exchange for sex (OR = 2.92, p = 0.001) were more likely to have reported participation in an HIV prevention intervention in the preceding year. In a multivariable model, MSM reporting UAS in the prior 3 months were less likely to have participated in an HIV prevention intervention (AOR = 0.34, p = 0.04). MSM who were older (AOR = 1.05, p = 0.05), those with higher educational attainment (AOR = 1.92, p = 0.0009), and MSM who were "out" about having sex with other men (AOR = 2.71, p = 0.04) were more likely to have reported participating in an HIV prevention program. Findings suggest that exposure to HIV prevention interventions may be protective against engaging in UAS for some MSM in India. Understanding predictors of participation in an HIV prevention intervention is helpful for identifying Indian MSM who might have had no exposure to HIV prevention information and skills building, hence allowing researchers and prevention workers to focus efforts on individuals at greatest need.

Perceptions of tuberculosis patients about private providers before and after implementation of Revised National Tuberculosis Control Programme

BACKGROUND

Most of the persons with chest symptoms in India approach private providers (PPs) for health care. It has been observed that patients who start treatment with PPs for tuberculosis (TB) frequently switch over subsequently to the public sector. The reasons for this discontinuation and their perceptions of the TB care provided by the PPs are unknown.

OBJECTIVE

To document the perceptions about PPs India's Revised National TB Control Programme (RNTCP) and the reasons for discontinuation of treatment with PPs and subsequent attendance at a public provider.

METHODS

This was a cross sectional study on patients registered under TB programme during 1997 and 2005 in rural and urban areas. During this period patients who were initially diagnosed and treated for TB in a private clinic and subsequently shifted to public health facility were considered for the study. A semi-structured interview schedule was used to collect the factors related to patient's perceptions on PPs, the factors responsible for initiating treatment with PPs, reasons for discontinuing treatment with PPs, and their willingness to continue treatment from government health facilities were collected. This data was compared with data collected in 1997 before implementation of the RNTCP.

RESULTS

A total of 1000 and 1311 TB patients were registered during 1997 and 2005 respectively. Among them, 203 (20%) and 104 (8%) patients were identified as having been initially diagnosed and started on TB treatment by PPs and subsequently shifted to government health facilities. There were significant changes in reasons for selecting PPs between the two periods: being convenient (47% vs 10%; p < 0.001), quality care (41% vs 19%; p < 0.001), motivated by others (49% vs 19%; p < 0.001), confidentiality (19% vs 9%; p < 0.05) and known doctor (6% vs 28%; p < 0.001) respectively. Financial problems were the most common reason for discontinuation of treatment in both periods. The use of sputum test for diagnosing TB by PPs was significantly increased after RNTCP implementation.

CONCLUSION

This study suggests that slowly perceptions of patients have changed towards PPs, and RNTCP has begun to gain acceptance amongst patients in terms of convenience, confidentiality and personal care.

DOTS reaches socially marginalized population in the community: a study from a rural area of South India

We report here that the Directly Observed Treatment, Short course (DOTS) is reaching all tuberculosis patients in the community irrespective of social classification based on the analysis from the tuberculosis prevalence survey and programme performance during 1999-2003 from a rural area in Tamilnadu, South India. New smear- positive cases treated under a DOTS programme were classified in two groups namely; scheduled caste living in colony and other population. The prevalence of smear- positive cases among the scheduled caste population was 1.9 times higher than the other population and this was reflected in the notification also. The successful treatment outcome was also similar in these two groups (75% and 78% respectively; overall 77%). From these findings it is concluded that people living in colony have equal access to DOTS as those in the village.