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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Boehringer Ingelheim and Eli Lilly.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Prior employment status and obesity do not predict post-stroke fatigue

Aim: To investigate whether prior employment status or obesity pose as risk factors for post stroke fatigue in patients following an ischemic stroke. Materials & methods: A total of 121 patients with a confirmed diagnosis of ischemic stroke in the past 3 years were enrolled into the study. Post-stroke fatigue (PSF) was assessed using the fatigue assessment scale (no PSF ≤21, PSF 22–50). Patients were then identified based on their employment status (previously worked) or obesity (BMI) and compared with the presence of PSF. Results: A Fisher’s exact test was applied to determine the association between PSF and obesity (p = 1.000). A Fisher’s exact test was applied to show the association between PSF and employment status (p = 0.384). In logistic regression, employment status did not independently predict dichotomized fatigue assessment scale (adjusted odds ratio 1.34, 95% CI: 0.51–3.50, p = 0.557). Conclusion: Previous employment status and obesity did not independently predict PSF in an urban, minority community.

Health professionals' attitudes on integrated care and social work practice

Research regarding the intersection of social work and integrated care has recently increased. Although research specific to the role and engagement of social workers in integrated care is promising, research regarding attitudes toward social workers on integrated behavioral health (IBH) teams remains scant. This study provides perspective regarding healthcare professionals' attitudes toward the role of social workers on IBH teams. A survey was constructed and distributed to health professionals (n = 104) from medicine, nursing, pharmacy, and social work. Mixed methods were used to evaluate survey findings. Results suggest attitudes toward social workers on IBH teams are generally favorable.

Abstract 3197: Blockade of regulatory signaling pathways reduces immunosuppression in the PDAC tumor microenvironment

Pancreatic cancer (PDAC) has the highest mortality rate of all major cancers, with few treatment options that provide long-term benefit to patients. Cancer associated fibroblasts (CAFs), the primary cellular component of the pancreatic tumor stroma, play a key role in the formation of an immunosuppressive tumor microenvironment (TME). A better understanding of the disease biology and cellular pathways that could be targeted for treatment of PDAC are needed.

To investigate mechanisms driving immune suppression and pathways that might be targetable for treatment in PDAC, we used models where cross-talk between stromal and tumor cells could be evaluated. Three PDAC tumor cell lines were co-cultured (CC) with primary CAFs from multiple donors for 3 days, and secretion of numerous immunosuppressive cytokines, including IL6, IL8, IL10, CXCL12, was found to be upregulated in CC vs single culture (SC). IL6 and IL8 were shown to increase 2-38-fold in CC vs SC CAFs, and 1.5-20,000-fold vs SC PANCs, dependent upon cell line. By whole genome array, an upregulation of genes involved in NFkB, IL6, IL8, and AKT signaling was also observed (-log(p-value)&gt;4) in CAF cells following CC.

Multiple pathways have been implicated in regulating the immunosuppressive PDAC TME, including: CD73, a critical mediator of adenosine formation which is known to alter immune activity; and IL1, which is secreted by PDAC tumor cells, known to increase inflammation in the TME, and promote PDAC progression. The effects of CD73 inhibition and IL1R inhibition were evaluated to better characterize the downstream effects of these pathways on regulating tumor immunosuppression. Inhibition of CD73 in the CC reduced production of the immunosuppressive cytokines IL6, IL8, MCP1 CXCL12, IL1a, IL1b, IL10 (16-59%). Preliminary genomic studies indicated that inhibition of CD73 decreased genes involved in invasion, migration, metastasis, EMT and angiogenesis, as well as increasing genes involved in type 1 IFN activation, including OAS1, DDX60, IFIT1 and IRF7 (FC 1.5-2). Similarly, blockade of IL1R (which is highly expressed on PDAC CAFs and is the receptor for both IL1a and IL1b) reduced immune suppressive cytokine production from PDAC tumor conditioned media-stimulated CAFs, e.g. lowering secretion of IL6 and IL8 (4-20-fold) in a dose-dependent manner. Blocking IL1R in a PDAC dissociated tumor cell (DTC) model resulted in decreased secretion of CXCL1 and IL6 (60-75% over 3-6 days in culture), and an upregulation of IFNg (2-10-fold) in this culture by d3.

These results suggest that a blockade of regulatory signaling pathways may be useful to reduce immune suppression and return the PDAC TME to a phenotype more amenable to immune checkpoint inhibition. Further characterization of these pathways may lead to new therapeutic combination approaches for pancreatic cancer.

Citation Format: Lydia Greenlees, Li Cheng, Bilal Omar, Yelena Lazdun, Jixin Wang, Fernanda Pilataxi, Michael Kuziora, Zachary Cooper, Luis Vence, Katie Streicher. Blockade of regulatory signaling pathways reduces immunosuppression in the PDAC tumor microenvironment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3197.

Safety and efficacy of the anti-CD73 monoclonal antibody (mAb) oleclumab ± durvalumab in patients (pts) with advanced colorectal cancer (CRC), pancreatic ductal adenocarcinoma (PDAC), or EGFR-mutant non-small cell lung cancer (EGFRm NSCLC)

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Background: Upregulation of CD73 in multiple cancers increases adenosine production, leading to local immunosuppression. Oleclumab, a human IgG1λ mAb, inhibits CD73 function and may increase antitumor immunity. Initial data from a Phase I, first-in-human, dose-escalation and expansion study showed that oleclumab ± durvalumab had manageable safety and encouraging clinical activity in pts with advanced CRC or PDAC. We report updated safety and activity in these cohorts and the first results in an expansion cohort of pts with advanced EGFRm NSCLC. Methods: Previously treated pts with histologically or cytologically confirmed microsatellite stable CRC, PDAC, or EGFRm NSCLC received oleclumab 5–40 mg/kg (escalation) and 40 mg/kg (expansion) IV Q2W, alone (escalation only) or with durvalumab 10 mg/kg IV Q2W. The primary objective was safety; secondary efficacy objectives included objective response (OR) per RECIST v1.1 and duration of response (DoR). Results: 66 pts were enrolled in the escalation phase (35 CRC, 31 PDAC) and 126 in the expansion phase (42 CRC, 42 PDAC, 42 EGFRm NSCLC). At data cutoff (DCO; June 9, 2020), the median number of oleclumab doses was 4 in pts on monotherapy (range 1–26) and 4 in pts on combination therapy across both phases (range 1–76). In the escalation phase, there were no DLTs in pts on monotherapy or combination therapy; treatment-related adverse events (TRAEs) occurred in 54.8% of pts on monotherapy (Grade 3–4 in 7.1%) and 54.2% of pts on combination therapy (Grade 3–4 in 20.8%); fatigue was the most common TRAE with both regimens. No TRAEs resulted in death. In previous interim analyses before this DCO, no ORs were reported in the escalation phase. In the expansion phase, 5 pts were treated for ≥12 mos; 6 pts were ongoing at DCO. TRAEs occurred in 54.0% (Grade 3–5 in 15.1%); the most common TRAEs were fatigue (15.1%), diarrhea (9.5%), and rash (7.1%). One pt had a TRAE resulting in death (systemic inflammatory response syndrome). ORs were seen in 1 CRC pt (DoR 35.9+ mos [+ = ongoing response]), 2 PDAC pts (DoR 22.1+ and 28.6+ mos), and 4 EGFRm NSCLC pts (DoR range 5.6 to 15.7+ mos, median not reached; only 1 of the 4 pts had ≥25% programmed cell death ligand-1 [PD-L1]+ tumor cells). Nine CRC pts, 8 PDAC pts, and 9 EGFRm NSCLC pts had SD. Of 6 pts with matched biopsies who received combination therapy, 5 had increases in CD8+ T cells, PD-L1, and granzyme B. Baseline tumor CD73 expression and association with clinical response will be presented. Conclusions: Oleclumab ± durvalumab had a tolerable safety profile and combination therapy showed promising antitumor activity in EGFRm NSCLC. ORs and SD were durable, even in tumor types that are generally immunotherapy-resistant. Clinical trial information: NCT02503774.

How COVID-19 has impacted integrated care practice: lessons from the frontlines

Primary care systems are a mainstay for how many Americans seek health and behavioral health care. It is estimated that almost a quarter of behavioral health conditions are diagnosed and/or treated in primary care. Many clinics treat the whole person through integrated models of care such as the Primary Care Behavioral Health (PCBH) model. COVID-19 has disrupted integrated care delivery and traditional PCBH workflows requiring swift adaptations. This paper synthesizes how COVID-19 has impacted clinical services at one federally qualified health center and describes how care has continued despite the challenges experienced by frontline behavioral health providers.

Conversion of ATP to adenosine by CD39 and CD73 in multiple myeloma can be successfully targeted together with adenosine receptor A2A blockade

Background

PD1/PDL1-directed therapies have been unsuccessful for multiple myeloma (MM), an incurable cancer of plasma cells in the bone marrow (BM). Therefore, other immune checkpoints such as extracellular adenosine and its immunosuppressive receptor should be considered. CD39 and CD73 convert extracellular ATP to adenosine, which inhibits T-cell effector functions via the adenosine receptor A2A (A2AR). We set out to investigate whether blocking the adenosine pathway could be a therapy for MM.

Methods

Expression of CD39 and CD73 on BM cells from patients and T-cell proliferation were determined by flow cytometry and adenosine production by Liquid chromatograpy-mass spectrometry (HPCL/MS). ENTPD1 (CD39) mRNA expression was determined on myeloma cells from patients enrolled in the publicly available CoMMpass study. Transplantable 5T33MM myeloma cells were used to determine the effect of inhibiting CD39, CD73 and A2AR in mice in vivo.

Results

Elevated level of adenosine was found in BM plasma of MM patients. Myeloma cells from patients expressed CD39, and high gene expression indicated reduced survival. CD73 was found on leukocytes and stromal cells in the BM. A CD39 inhibitor, POM-1, and an anti-CD73 antibody inhibited adenosine production and reduced T-cell suppression in vitro in coculture of myeloma and stromal cells. Blocking the adenosine pathway in vivo with a combination of Sodium polyoxotungstate (POM-1), anti-CD73, and the A2AR antagonist AZD4635 activated immune cells, increased interferon gamma production, and reduced the tumor load in a murine model of MM.

Conclusions

Our data suggest that the adenosine pathway can be successfully targeted in MM and blocking this pathway could be an alternative to PD1/PDL1 inhibition for MM and other hematological cancers. Inhibitors of the adenosine pathway are available. Some are in clinical trials and they could thus reach MM patients fairly rapidly.

Functional properties of dairy phospholipid gels

In this study dairy phospholipid (PL) gels were made using 3 different concentrations of PL (15%, 30%, and 45%) and soybean oil to determine the gel-forming ability and functional traits that dairy PL have. After 24 h of storage the visual stability, crystal morphology, solid fat content, melting behavior, viscosity, and oil binding capacity of the gels were evaluated. All samples showed visual stability, whereas polarized light microscopy showed that high concentrations of PL reduced PL mobility, preventing tubular micelles from forming at high concentrations of PL (45%). Solid fat content increased with an increase in PL concentration. The melting enthalpy increased as the concentration of PL increased. The viscosity was assessed at 0.01, 0.1, and 1.0 1/s shear rates. A significant difference was observed between the 45% PL samples and the other samples at low and intermediate shear, but at high shear levels, a significant difference was only seen between the 15% PL sample and the other samples. The oil binding capacity showed a significant difference between the 45% PL sample and the other 2 samples. This study shows that dairy PL can be added to a vegetable oil to produce semi-solid material with appropriate functional properties.

Abstract PR02: Melanoma evolves complete immunotherapy resistance through acquisition of a hypermetabolic phenotype

Advances in our understanding of tumor immune biology and development of cancer immunotherapies have led to improved outcomes for patients who suffer from aggressive cancers such as melanoma. Despite the clinical success of immune checkpoint blockade, a majority of patients still fail to respond, and the underlying mechanisms that drive resistance remain unclear. To understand why a subset of tumors fail to respond to immunotherapy, we established a novel murine model of melanoma that is fully resistant to immune checkpoint blockade. By in vivo passaging nonresponding B16 melanoma tumor cells, we selected for a resistant variant that fails to respond to the combination of CTLA-4, PD-1, and PD-L1 blockade. In comparing gene expression of parental versus resistant tumor cells and analyzing the corresponding immune infiltrate, we determined the adaptations associated with resistance to therapy. We found that evasion of immunotherapy was associated with a “hypermetabolic” phenotype, characterized by an upregulation of glycolytic, oxidoreductase, and mitochondrial oxidative phosphorylation pathways to establish a hypoxic, metabolically hostile microenvironment. Enforced expression of two key genes associated with these pathways in parental tumor cells was sufficient to mediate resistance to triple checkpoint blockade. Flow cytometry assays determined that T cells infiltrating resistant tumors had diminished glycolytic capacity and effector function, indicating a metabolic disadvantage. Consistent with our findings, melanoma patients who failed dual checkpoint blockade exhibited similar metabolic alterations as seen in our resistant variant. Using a novel MRI-based imaging approach, we observed distinct metabolic changes that stratified responding versus nonresponding tumors in live mice. Applying this method to patients could provide insight into predicting response rates to checkpoint modulation. Overall, our data indicate that resistant melanoma tumor cells acquire a “hypermetabolic” phenotype to establish a hostile microenvironment that is capable of inhibiting the antitumor immune response.

This abstract is also being presented as Poster A24.

Citation Format: Ashvin R. Jaiswal, Arthur J. Liu, Shivanand Pudakalakatti, Prasanta Dutta, Priyamvada Jayaprakash, Todd Bartkowiak, Casey Ager, Zhiqiang Wang, Alex Reuben, Zachary Cooper, Cristina Ivan, Zhenlin Ju, Felix Nwajei, Jing Wang, Michael A. Davies, R. Eric Davis, Jennifer A. Wargo, Pratip K. Bhattacharya, David S. Hong, Michael A. Curran. Melanoma evolves complete immunotherapy resistance through acquisition of a hypermetabolic phenotype [abstract]. In: Proceedings of the AACR Special Conference on Melanoma: From Biology to Target; 2019 Jan 15-18; Houston, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(19 Suppl):Abstract nr PR02.

Abstract 911: Anti-PD-L1 and anti-CD73 combination therapy promotes T cell response to EGFR mutant NSCLC

It has been reported that NSCLC patients with EGFR mutation do not respond to anti-PD-1(L1) therapies as well as patients without the mutation. We have previously shown that EGFR mutant tumors express more CD73 compared to EGFR wildtype tumors and we hypothesized that this may contribute to the resistance to anti-tumor immunity and anti-PD-1(L1) therapies. To understand how CD73 expression in EGFR mutant tumors may confer immunosuppression, we compared EGFR mutant cell lines (PC9, HCC2935) and wildtype cell lines (H1666, H1355) in in vitro T cell killing assays. Furthermore, we investigated the effect of anti-CD73 antibody, either as a monotherapy or in combination with anti-PD-L1 antibody, in promoting tumor growth inhibition (TGI) using a xenograft mouse model. In this model, NSG mice were implanted with MART1-expressing PC9 cells and treated with MART1-specific CD8+ T cells together with anti-PD-L1, anti-CD73 or combination.

We showed that CD73 expression is regulated by EGFR signaling in NSCLC, possibly through activation of Protein Kinase C (PKC). EGFR mutant cell lines were significantly more resistant to T cells killing compared to wildtype cell lines in vitro, by suppressing T cell proliferation and function as indicated by Ki-67 and granzyme B expression. In the xenograft mouse model using MART1-expressing PC9 cells, anti-PD-L1 did not promote TGI compared to isotype control, which closely mimicked the limited therapeutic effect of anti-PD-1(L1) antibodies on EGFR mutant NSCLC. Although anti-CD73 alone did not reduce tumor size, mice treated with anti-CD73 and anti-PD-L1 combination therapy had significantly smaller tumors compared to mice treated with isotype control (~38%, p&lt;0.0001), anti-PD-L1 alone (~32%, p&lt;0.0001) or anti-CD73 alone (~32%, p&lt;0.01). The combination therapy increased the number of MART1-specific CD8+ T cells in the tumor compared to isotype control (~280%, p&lt;0.01), anti-PD-L1 alone (~556%, p&lt;0.001) and anti-CD73 alone (~270%, p&lt;0.01). The combination therapy also increased the frequency of CD62L+CD45RO+CCR7+ phenotype in CD8+ T cells in the spleen compared to isotype control (~120%, p&lt;0.001), but not in the tumor, as well as enhancing IFNγ production by tumor antigen-specific CD8+ T cells compared to isotype control (~224%, p&lt;0.001). Together, these results further support the ongoing clinical trials evaluating combination of anti-CD73 and anti-PD-L1 in treating EGFR mutant NSCLC while suggesting the increased central memory T cells may play a role in response to therapy.

Citation Format: Eric Tu, Kelly McGlinchey, Yelena Lazdun, James Kurasawa, Susan Wilson, Leslie Wetzel, Karen Coffman, Zachary Cooper, Katie Streicher. Anti-PD-L1 and anti-CD73 combination therapy promotes T cell response to EGFR mutant NSCLC [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 911.

Intratumoral immunotherapy with TLR7/8 agonist MEDI9197 modulates the tumor microenvironment leading to enhanced activity when combined with other immunotherapies

Background

Immune checkpoint blockade (ICB) promotes adaptive immunity and tumor regression in some cancer patients. However, in patients with immunologically “cold” tumors, tumor-resident innate immune cell activation may be required to prime an adaptive immune response and so exploit the full potential of ICB. Whilst Toll-like receptor (TLR) agonists have been used topically to successfully treat some superficial skin tumors, systemic TLR agonists have not been well-tolerated.

Methods

The response of human immune cells to TLR7 and 8 agonism was measured in primary human immune cell assays. MEDI9197 (3M-052) was designed as a novel lipophilic TLR7/8 agonist that is retained at the injection site, limiting systemic exposure. Retention of the TLR7/8 agonist at the site of injection was demonstrated using quantitative whole-body autoradiography, HPLC-UV, and MALDI mass spectrometry imaging. Pharmacodynamic changes on T cells from TLR7/8 agonist treated B16-OVA tumors was assessed by histology, quantitative real time PCR, and flow cytometry. Combination activity of TLR7/8 agonism with immunotherapies was assessed in vitro by human DC-T cell MLR assay, and in vivo using multiple syngeneic mouse tumor models.

Results

Targeting both TLR7 and 8 triggers an innate and adaptive immune response in primary human immune cells, exemplified by secretion of IFNα, IL-12 and IFNγ. In contrast, a STING or a TLR9 agonist primarily induces release of IFNα. We demonstrate that the TLR7/8 agonist, MEDI9197, is retained at the sight of injection with limited systemic exposure. This localized TLR7/8 agonism leads to Th1 polarization, enrichment and activation of natural killer (NK) and CD8⁺ T cells, and inhibition of tumor growth in multiple syngeneic models. The anti-tumor activity of this TLR7/8 agonist is enhanced when combined with T cell-targeted immunotherapies in pre-clinical models.

Conclusion

Localized TLR7/8 agonism can enhance recruitment and activation of immune cells in tumors and polarize anti-tumor immunity towards a Th1 response. Moreover, we demonstrate that the anti-tumor effects of this TLR7/8 agonist can be enhanced through combination with checkpoint inhibitors and co-stimulatory agonists.

Electronic supplementary material

The online version of this article (10.1186/s40425-019-0724-8) contains supplementary material, which is available to authorized users.

Abstract 4697: Intratumoral immunotherapy with TLR7/8 agonist MEDI9197 modulates the tumor microenvironment and holds potential for combination with immune checkpoint inhibitors

Recent successes in immuno-oncology have focussed primarily on the T-cell synapse, targeting co-activatory /inhibitory pathways to modulate T cell function. However, strategies that target tumor-resident myeloid cells may be required to fully exploit the therapeutic potential of the anti-cancer immune response. TOLL-like receptors (TLRs) are expressed on a broad range of myeloid cells and function to recognise highly evolutionarily conserved pathogen-associated molecular patterns. Signalling through TLRs leads to the activation of antigen-presenting cells (APCs) and to expression of inflammatory cytokines. However, whilst topical application of TLR agonists have proved successful in the treatment of dermatological tumors, systemic administration have proved to be poorly tolerated. MEDI9197 (formerly 3M-052), is a novel lipophilic TLR7/8 agonist designed with a lipid tail to facilitate retention at the site of injection, limiting systemic exposure. These properties make MEDI9197 ideal for intratumoral (IT) administration. We have demonstrated that MEDI9197 is a potent TLR7 and TLR8 agonist and induces pro-inflammatory cytokines through activation of a diverse range of myeloid and lymphoid cells. In mice bearing established tumors, IT injection of MEDI9197 induces a local inflammatory response, characterized by upregulation of genes associated with the activation of innate and adaptive immunity in the injected tumor and tumor draining lymph nodes. Moreover, treatment leads to an increase in the frequency of tumor infiltrating lymphocytes (TILs), such as CD8+ cytotoxic T cells and increased expression of activation markers, such as CD69. Cellular depletion studies reveal that CD8+ T cells are required for therapeutic activity. Furthermore, using in vitro co-cultures we demonstrate that MEDI9197 is able to enhance cytotoxic activity of NK cell and T cells. Importantly, in models that respond poorly to mAbs targeting either PD-L1 or CTLA-4, combination with MEDI9197 significantly improved anti-tumor activity when compared to either monotherapy alone. These preclinical data demonstrate that MEDI9197 can modulate both the myeloid and lymphoid immune compartments to mediate anti-tumor activity and combines productively with immune checkpoint blockade. MEDI9197 is currently being evaluated as a monotherapy for safety and efficacy in human clinical trials (NCT02556463).

Citation Format: Stefanie R. Mullins, Katharina Vogel, John Vasilakos, Iwen Grigsby, Simon Dovedi, Ryan Patricia, Zachary Cooper, Ronald Herbst, Rakesh Kumar, Mark Tomai, Robert W. Wilkinson. Intratumoral immunotherapy with TLR7/8 agonist MEDI9197 modulates the tumor microenvironment and holds potential for combination with immune checkpoint inhibitors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4697. doi:10.1158/1538-7445.AM2017-4697

Increased CD73 and reduced IFNG signature expression in relation to response rates to anti-PD-1(L1) therapies in EGFR-mutant NSCLC

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Background: Anti-PD-1(L1) therapies appear to be less efficacious in NSCLC patients whose tumors have EGFR activating mutations, but the underlying mechanism is poorly understood. We investigated the relationship between Methods: Flow cytometry and/or quantitative PCR were used to evaluate genes and proteins in five NSCLC EGFR mt cell lines and 6 wt lines. Anti-EGFR TKIs gefitinib and osimertinib were used at concentrations ranging from 0.001-100uM; EGF was used at 50 ng/mL. CP1108/NCT01693562 was a nonrandomized phase 1/2 trial evaluating durvalumab (10 mg/kg Q2W) in advanced NSCLC. As of 24OCT16, 304 previously treated patients in CP1108 were enrolled. RNA sequencing was conducted on available tumor specimens from 97 patients in CP1108. CP1108 and TCGA were separated by EGFR status for genomic comparisons. Results: Median CD73 expression was increased 10-fold in EGFR mt NSCLC cell lines (n = 5) compared to wt cell lines (n = 6). EGF induced CD73 protein levels 5-40-fold in 3/6 EGFR wt lines. There was dose-dependent inhibition of CD73 expression (45-70 fold maximum) following treatment with gefitinib or osimertinib in 3/5 mt cell lines and 4/6 wt lines, suggesting a causal relationship between the EGFR pathway and CD73 expression. Consistent with these observations, EGFR mutant tumors had ≥2 fold increased expression of CD73 compared to wt (p < 0.05) in TCGA and CP1108 NSCLC adenocarcinoma patients. These EGFR mutants had significantly lower levels of IFNg signature, previously reported to be associated with enhanced benefit from durvalumab. Conclusions: Our findings identify a novel relationship in NSCLC between EGFR pathway activation, expression of the immunosuppressive molecule CD73 and reduced expression of IFNg mRNA signature. These results prompt the hypothesis that over-expression of CD73 in EGFR-mt NSCLC may explain, at least in part, the reduced benefit from anti-PD-1(L1) in this subset of NSCLC, and suggest evaluating anti-CD73 in combination with EGFR TKIs or anti-PD-L1 in EGFR-mt NSCLC.

Mutually exclusive expression of CD73 and PDL1 in tumors from patients (pt) with NSCLC, gastroesophageal (GE) and urothelial bladder carcinoma (UBC)

3079

Background: Tumors use multiple means of immune evasion, notably the programmed death-1 (PD1)/PDL1 pathway. Anti-PD1/PDL1 therapy induces anti-tumor activity and has improved pt outcomes. Activation of the immunosuppressive CD39/CD73/adenosine pathway might play a role in pts who do not benefit from anti-PD1/PDL1 therapies. We evaluated expression of CD73 and PDL1 and explored the association between CD73 and intraepithelial (IE) CD8+ cells (TILs) to begin to understand their potential interplay in cancer. Methods: Immunohistochemistry for PDL1, CD73 and CD8 was conducted on tumors of non-squamous NSCLC (NSq) (n=42), GE (n=50), and UBC (n=50). PDL1 and CD73 were scored by image analysis with Definiens software. IE CD8+ TILs were scored semi-quantitatively by a pathologist (0-2 = low; 3-4 = high). Using the top tertile of PDL1 and CD73 for high expression levels, a Fisher’s meta-analysis was calculated across the three indications. Results: Across all tumors, 25% (35/142) were PDL1 high (+), but CD73 low (-) and another 25% (35/142) were CD73+ but PDL1- (p=0.06, see table). This trend for mutually exclusive high expression of PDL1/CD73 was strongest in GE (p<0.01). In the PDL1+ group 76% (35/46) had high IE CD8+ TILs whereas in the CD73+ group only 35% (16/46) had high TILs (p<0.0001 using a proportions test). In the PDL1+/CD73- pt subset 77% (27/35) were CD8+ high vs only 23% (8/35) in the PDL1-/CD73+ subset. Conclusions: The identification of distinct pt subsets based on high PDL1 and/or CD73 expression suggests that tumors have multiple mechanisms of immune evasion. Increased IE CD8+ TILs were associated with PDL1 expression. The finding that PDL1-/ CD73+ tumors have lower IE CD8+ TILs compared to PDL1+/CD73- tumors suggests a role for CD73 in excluding IE TILs. Larger sample sets are needed to confirm these findings and to further explore any relationship with the tumor microenvironment. Our data suggests potential approaches to identify subsets of pts likely to benefit from immunotherapy targeting PDL1 and CD73. [Table: see text]

Controversies in anaesthesia for noncardiac surgery in older adults

As the population of the world is rapidly ageing, the amount of surgery being performed in older patients is also increasing. Special attention is required for the anaesthetic and perioperative management of these patients. The clinical and non-clinical issues specific to older surgical patients are reviewed, with a special emphasis on areas of debate related to anaesthesia care in this group. These issues include the role of frailty and disability in preoperative assessment, choice of anaesthesia technique for hip fracture, postoperative delirium, and approaches to shared decision-making before surgical procedures.

Outcomes after emergency abdominal surgery in patients with advanced cancer: Opportunities to reduce complications and improve palliative care

BACKGROUND

There is increasing emphasis on the appropriateness and quality of acute surgical care for patients with serious illness and at the end of life. However, there is a lack of evidence regarding outcomes after emergent major abdominal surgery among patients with advanced cancer to guide treatment decisions. This analysis sought to characterize adverse outcomes (mortality, complications, institutional discharge) and to identify factors independently associated with 30-day mortality among patients with disseminated cancer who undergo emergent abdominal surgery for intestinal obstruction or perforation.

METHODS

This is a retrospective cohort study of 875 disseminated cancer patients undergoing emergency surgery for perforation (n = 499) or obstruction (n = 376) at hospitals participating in the American College of Surgeons' National Surgical Quality Improvement Program from 2005 to 2012. Predictors of 30-day mortality were identified using multivariate logistic regression.

RESULTS

Among patients who underwent surgery for perforation, 30-day mortality was 34%, 67% had complications, and 52% were discharged to an institution. Renal failure, septic shock, ascites, dyspnea at rest, and dependent functional status were independent preoperative predictors of death at 30 days. When complications were considered, postoperative respiratory complications and age (75-84 years) were also predictors of mortality.Patients who had surgery for obstruction had a 30-day mortality rate of 18% (n = 68), 41% had complications, and 60% were discharged to an institution. Dependent functional status and ascites were independent predictors of death at 30 days. In addition to these predictors, postoperative predictors of mortality included respiratory and cardiac complications. Few patients (4%) had do-not-resuscitate orders before surgery.

CONCLUSION

Emergency abdominal operations in patients with disseminated cancer are highly morbid, and many patients die soon after surgery. High rates of complications and low rates of preexisting do-not-resuscitate orders highlight the need for targeted interventions to reduce complications and integrate palliative approaches into the care of these patients.

LEVEL OF EVIDENCE

Prognostic study, level III; therapeutic study, level IV.

Abstract PR04: A melanoma transcriptional state distinction influences sensitivity to MAPK pathway inhibitors

The deployment of cancer therapeutics that exploit oncogenic dependencies has yielded remarkable advances in patient treatment. However, the therapeutic benefit of these approaches is transient and the majority of patients develop resistance within several months. BRAFV600E-mutant malignant melanoma provides an illustrative example of this phenomenon: treatment with RAF and MEK inhibitors yields clinical responses in 50-80% of patients. However, 10-20% fail to respond to treatment (intrinsic resistance) and patients that do respond become drug resistant within ∼9 months (acquired resistance), presenting a formidable and unsolved clinical challenge.

It remains incompletely understood why a subset of BRAFV600-mutant melanoma patients (10-20%) fail to respond to MAPK-pathway inhibition. Here, we show that RAF inhibitor sensitive and resistant BRAFV600-mutant melanomas display distinct transcriptional profiles. RAF-inhibitor sensitive cell lines are distinguishable by expression and activity of the melanocytic lineage transcription factor MITF, whereas intrinsically drug-resistant cell lines are defined by expression of the receptor tyrosine kinase AXL and elevated levels of NF-κB signaling. In vitro, these signatures were sufficient to predict MAPK-pathway inhibitor responsiveness in independent panels of melanoma cell lines. MITF-low, AXL/NF-κB high melanomas were resistant to single-agent RAF, MEK and ERK and combined RAF/MEK inhibition. In treatment-naïve patient biopsies, markers of the drug sensitive transcriptional states were associated with improved therapeutic responses to combined RAF/MEK inhibitors in BRAFV600-mutant melanoma. Moreover, in cell lines, NF-κB activation antagonized MITF expression and induced both resistance marker genes and drug resistance.

Thus, distinct cell states characterized by MITF and AXL/NF-κB activity can influence intrinsic resistance to MAPK pathway inhibitors in BRAFV600-mutant melanoma. More broadly, these data suggest that the transcriptional context in which an oncogenic event arises can have a profound impact on the establishment of oncogene-dependencies and associated drug susceptibilities.

Citation Format: Cory Johannessen, David Konieczkowski, Omar Abudayyeh, Jong Wook Kim, Zachary Cooper, Adriano Piris, Dennie Frederick, Michal Barzily-Rokni, Ravid Straussman, Rizwan Haq, David Fisher, Jill Mesirov, William Hahn, Keith Flaherty, Jennifer Wargo, Pablo Tamayo, Levi Garraway. A melanoma transcriptional state distinction influences sensitivity to MAPK pathway inhibitors. [abstract]. In: Proceedings of the AACR Precision Medicine Series: Drug Sensitivity and Resistance: Improving Cancer Therapy; Jun 18-21, 2014; Orlando, FL. Philadelphia (PA): AACR; Clin Cancer Res 2015;21(4 Suppl): Abstract nr PR04.

Abstract 5201: Elucidating distinct roles for NF1 in melanomagenesis

BRAF mutations play a well-established role in melanomagenesis; however, without additional genetic alterations tumor development is restricted by oncogene-induced senescence (OIS). Here we show that mutations in the NF1 tumor suppressor gene cooperate with BRAF mutations in melanomagenesis by preventing OIS. In a genetically engineered mouse model, Nf1 mutations suppress Braf-induced senescence, promote melanocyte hyperproliferation, and enhance melanoma development. Nf1 mutations function by deregulating both PI3K and ERK pathways. As such, Nf1/Braf mutant tumors are resistant to BRAF inhibitors but are sensitive to combined MEK/mTOR inhibition. Importantly, NF1 is mutated or suppressed in human melanomas that harbor concurrent BRAF mutations, NF1 ablation decreases the sensitivity of melanoma cell lines to BRAF inhibitors, and NF1 is lost in tumors from patients following treatment with these agents. Collectively, these studies provide mechanistic insight into how NF1 cooperates with BRAF mutations in melanoma and demonstrate that NF1-inactivation may impact responses to targeted therapies.

Citation Format: Ophélia Maertens, Bryan Johnson, Pablo Hollstein, Dennie Frederick, Zachary Cooper, Ludwine Messiaen, Roderick Bronson, Martin McMahon, Scott Granter, Keith Flaherty, Jennifer Wargo, Richard Marais, Karen Cichowski. Elucidating distinct roles for NF1 in melanomagenesis. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 5201. doi:10.1158/1538-7445.AM2013-5201

A computational analysis of localized Ca2+-dynamics generated by heterogeneous release sites

We investigate the role of heterogeneous expression of IP3R and RyR in generating diverse elementary Ca2+ signals. It has been shown empirically (Wojcikiewicz and Luo in Mol. Pharmacol. 53(4):656-662, 1998; Newton et al. in J. Biol. Chem. 269(46):28613-28619, 1994; Smedt et al. in Biochem. J. 322(Pt. 2):575-583, 1997) that tissues express various proportions of IP3 and RyR isoforms and this expression is dynamically regulated (Parrington et al. in Dev. Biol. 203(2):451-461, 1998; Fissore et al. in Biol. Reprod. 60(1):49-57, 1999; Tovey et al. in J. Cell Sci. 114(Pt. 22):3979-3989, 2001). Although many previous theoretical studies have investigated the dynamics of localized calcium release sites (Swillens et al. in Proc. Natl. Acad. Sci. U.S.A. 96(24):13750-13755, 1999; Shuai and Jung in Proc. Natl. Acad. Sci. U.S.A. 100(2):506-510, 2003a; Shuai and Jung in Phys. Rev. E, Stat. Nonlinear Soft Matter Phys. 67(3 Pt. 1):031905, 2003b; Thul and Falcke in Biophys. J. 86(5):2660-2673, 2004; DeRemigio and Smith in Cell Calcium 38(2):73-86, 2005; Nguyen et al. in Bull. Math. Biol. 67(3):393-432, 2005), so far all such studies focused on release sites consisting of identical channel types. We have extended an existing mathematical model (Nguyen et al. in Bull. Math. Biol. 67(3):393-432, 2005) to release sites with two (or more) receptor types, each with its distinct channel kinetics. Mathematically, the release site is represented by a transition probability matrix for a collection of nonidentical stochastically gating channels coupled through a shared Ca2+ domain. We demonstrate that under certain conditions a previously defined mean-field approximation of the coupling strength does not accurately reproduce the release site dynamics. We develop a novel approximation and establish that its performance in these instances is superior. We use this mathematical framework to study the effect of heterogeneity in the Ca2+-regulation of two colocalized channel types on the release site dynamics. We consider release sites consisting of channels with both Ca2+-activation and inactivation ("four-state channels") and channels with Ca2+-activation only ("two-state channels") and show that for the appropriate parameter values, synchronous channel openings within a release site with any proportion of two-state to four-state channels are possible, however, the larger the proportion of two-state channels, the more sensitive the dynamics are to the exact spatial positioning of the channels and the distance between channels. Specifically, the clustering of even a small number of two-state channels interferes with puff/spark termination and increases puff durations or leads to a tonic response.

Heat shock co-activates interleukin-8 transcription

The heat shock (HS) response is a phylogenetically ancient cellular response to stress, including heat, that shifts gene expression to a set of conserved HS protein (HSP) genes. In our earlier studies, febrile-range hyperthermia (FRH) not only activated HSP gene expression, but also increased expression of CXC chemokines in mice, leading us to hypothesize that the CXC chemokine family of genes might be HS-responsive. To address this hypothesis we analyzed the effect of HS on the expression of IL-8/CXCL-8, a member of the human CXC family of ELR(+) chemokines. HS markedly enhanced TNF-alpha-induced IL-8 secretion in human A549 respiratory epithelial-like cells and in primary human small airway epithelial cells. IL-8 mRNA was also up-regulated by HS, but the stability of IL-8 mRNA was not affected. TNF-alpha-induced reporter activity of an IL-8 promoter construct IL8(-1471/+44)-luc stably transfected in A549 cells was also enhanced by HS. Electrophoretic mobility and chromatin immunoprecipitation assays showed that the stress-activated transcription factor heat shock factor-1 (HSF-1) binds to at least two putative heat shock response elements (HSE) present in the IL-8 promoter. Deletional reporter constructs lacking either one or both of these sites showed reduced HS responsiveness. Furthermore, depletion of HSF-1 using siRNA also reduced the effects HS on TNF-alpha-induced IL-8 expression, demonstrating that HSF-1 could also act to regulate IL-8 gene transcription. We speculate that during evolution the CXC chemokine genes may have co-opted elements of the HS response to amplify their expression and enhance neutrophil delivery during febrile illnesses.

Weight maintenance and relapse in obesity: a qualitative study

OBJECTIVE

To investigate, among women with obesity who have lost weight, the psychological factors associated with successfully maintaining the new lower weight, as opposed to weight regain.

DESIGN

Qualitative research methods (in-depth individual interviews and group interviews) were used to assess the characteristics of successful weight maintainers, as compared with weight regainers and healthy-weight women.

SUBJECTS

In all, 76 females were recruited from the community, comprising 28 formerly obese women who had lost weight and maintained their new lower weight for at least 1 y; 28 obese women who had lost weight but regained the weight that they had lost; and 20 women with a stable weight in the healthy range.

RESULTS

Certain psychological factors were identified which characterised the regainers but not the maintainers. These factors were: failure to achieve weight goals and dissatisfaction with the weight achieved; the tendency to evaluate self-worth in terms of weight and shape; a lack of vigilance with regard to weight control; a dichotomous (black-and-white) thinking style; and the tendency to use eating to regulate mood.

CONCLUSION

The results suggest that psychological factors may provide some explanation as to why many people with obesity regain weight following successful weight loss. The factors identified in this study need to be examined further using prospective designs.

Hybrid laparoscopic flexure takedown and open procedure for rectal resection is associated with significantly shorter length of stay than equivalent open resection

PURPOSE

Laparoscopic-assisted, sphincter-saving resection (largest incision < 7 cm) of the middle and distal rectum is technically very difficult and, with regard to cancers, has not been demonstrated to be oncologically safe. The hypothesis of this retrospective study is that a hybrid operation that combines laparoscopic and open methods would be associated with short-term outcome benefits compared with open surgery results for patients undergoing sphincter-saving proctectomy.

METHODS

A total of 31 hybrid and 25 fully open rectal resection patients were compared in this retrospective review. All patients had splenic flexure takedown and rectal anastomosis. The hybrid approach consisted of laparoscopic splenic flexure takedown (with or without partial rectal mobilization and devascularization) followed by completion of the procedure via infraumbilical midline laparotomy. The indication was neoplasm in 87 percent of hybrid patients and in 68 percent of open patients. The majority of tumors were located between 4 and 10 cm from the dentate line.

RESULTS

Fifty-eight percent of hybrid and 68 percent of open patients had low anterior or coloanal resections, and 48 percent of hybrid and 64 percent of open patients underwent temporary diversion via ileostomy. The mean hybrid midline incision length was 11 cm compared with 24 cm for open patients (P < 0.0001). The neoplastic specimens were similar with regard to margins and lymph node harvest. Similar complication rates were noted in both groups. Nonsignificant benefits for hybrid patients (0.9-1.2 days) were seen with regard to length of time until toleration of liquid or solid diet and first flatus. Hybrid patients experienced their first bowel movements 4.1 days vs. 5.7 days for the open group (P = 0.03). Mean length of stay was significantly shorter for hybrid patients (6.1. days) than for open patients (11.1 days; P = 0.0006).

CONCLUSION

This preliminary retrospective study suggests that a combined hybrid laparoscopic and open approach to sphincter-saving proctectomy permits a similar resection as open methods and may be associated with a length-of-stay benefit and more rapid return of bowel function. Prospective studies will be needed before any firm conclusions can be drawn.

A new cognitive behavioural approach to the treatment of obesity

While behavioural approaches to the management of obesity are often successful in achieving clinically significant weight loss, the weight lost is generally regained. The great majority of patients return to their pre-treatment weight within 3 years. There have been attempts to improve the long-term effectiveness of behavioural treatment but the results have been disappointing. In this paper we suggest that, among other factors, this is because of the neglect of the contribution of cognitive factors to weight regain, and because there is often ambiguity over the goals of treatment. We present a cognitive behavioural analysis of the processes involved in weight regain, and we describe a new cognitive behavioural treatment derived from it. This treatment is designed to minimise the problem of weight regain by addressing psychological obstacles to the acquisition of, and long-term adherence to, effective weight-control behaviour.

The natural course of bulimia nervosa and binge eating disorder in young women

BACKGROUND

Little is known about the relative course and outcome of bulimia nervosa and binge eating disorder.

METHODS

Two community-based cohorts were studied prospectively over a 5-year year period. One comprised 102 participants with bulimia nervosa and the other 48 participants with binge eating disorder (21% [9/42] of whom had comorbid obesity). All participants were female and aged between 16 and 35 years at recruitment. The assessments were at 15-month intervals and addressed eating disorder features, general psychiatric symptoms, and social functioning.

RESULTS

Both cohorts showed marked initial improvement followed by gradual improvement thereafter. Between half and two thirds of the bulimia nervosa cohort had some form of eating disorder of clinical severity at each assessment point, although only a minority continued to meet diagnostic criteria for bulimia nervosa. Each year about a third remitted and a third relapsed. The outcome of the binge eating disorder cohort was better, with the proportion with any form of clinical eating disorder declining to 18% (7 of 40) by the 5-year follow-up. The relapse rate was low among this cohort. There was little movement of participants across the 2 diagnostic categories and few sought treatment. Both groups gained weight, with 39% of the binge eating disorder cohort (14 of 36) meeting criteria for obesity at 5-year follow-up.

CONCLUSIONS

These findings suggest that, among young women in the community, bulimia nervosa and binge eating disorder have a different course and outcome. Whereas the prognosis of those with bulimia nervosa was relatively poor, the great majority of those with binge eating disorder recovered.

Risk factors for anorexia nervosa: three integrated case-control comparisons

BACKGROUND

Many risk factors have been implicated in the development of anorexia nervosa. Little is known about their relative contributions, nor in most cases is it clear whether they are specific to anorexia nervosa or risk factors for all eating disorders or for psychiatric disorder in general.

METHODS

We used a case-control design involving the comparison of 67 female subjects with a history of anorexia nervosa with 204 healthy control subjects, 102 subjects with other psychiatric disorders, and 102 subjects with bulimia nervosa. A broad range of risk factors was assessed by interview.

RESULTS

The subjects with anorexia nervosa and the healthy controls differed in their exposure to most of the putative risk factors. There was no greater exposure to factors that increased the likelihood of dieting, once the influence of other classes of risk factors had been taken into account. Premorbid perfectionism and negative self-evaluation were especially common and more so than among the general psychiatric controls. Parental obesity and an early menarche, together with parental psychiatric disorder, distinguished those with bulimia nervosa from those with anorexia nervosa.

CONCLUSIONS

There appears to be a broad range of risk factors for anorexia nervosa and bulimia nervosa, some of which are shared with other psychiatric disorders. Factors that increase the likelihood of dieting seem to have more important influence as risk factors for bulimia nervosa than anorexia nervosa. Perfectionism and negative self-evaluation appear to be particularly common and characteristic antecedents of both eating disorders.

A cognitive behavioural theory of anorexia nervosa

A cognitive behavioural theory of the maintenance of anorexia nervosa is proposed. It is argued that an extreme need to control eating is the central feature of the disorder, and that in Western societies a tendency to judge self-worth in terms of shape and weight is superimposed on this need for self-control. The theory represents a synthesis and extension of existing accounts. It is 'new', not so much because of its content, but because of its exclusive focus on maintenance, its organisational structure and its level of specification. It is suggested that the theory has important implications for treatment.

Expressed emotion and depression. A longitudinal study

BACKGROUND

Previous studies show that criticism by relatives during acute depressive illness predicts relapse over nine months, but the course of criticism over time and its relation to the course of illness, have not been examined in depressed patients.

METHOD

Thirty-nine depressed patients and their partners, were interviewed separately at three-monthly intervals over about one year. Illness was assessed by Research Diagnostic Criteria and Hamilton Depression Rating Scale. Criticism was measured by the Camberwell Family Interview.

RESULTS

Criticism when patients were most depressed predicted neither remission nor subsequent relapse. Patients who fully recovered, with or without later relapse, had partners who were consistently uncritical, or critical only at presentation. Patients with residual symptoms during remission had more persistently critical partners.

CONCLUSIONS

The nature of the association between criticism and depression could not be unequivocally established, although it appeared likely that continuing criticism was a result of continuing depression. Relatives' understanding of the illness may mediate between levels of criticism and the course of depression.

Life events, social support and marital relationships in the outcome of severe depression

The effects of life events, social support and marital relationships on outcome were examined in a predominantly recurrent in-patient sample of depressives studied longitudinally every 3 months to remission and up to 15 months thereafter. Outcomes examined were length of time to remission, presence of residual symptoms at remission, and subsequent relapse. There were few associations between these outcomes and the social variables. These findings add to other recent evidence that psychosocial factors are relatively unimportant in the subsequent course of severe and recurrent depressions, in contrast to their contribution to onset of such depressions and subsequent outcome of milder depressions.

Remission and relapse in major depression: a two-year prospective follow-up study

This paper reports the course with respect to remission and relapse of a cohort of predominantly in-patient RDC major depressive subjects, who were followed at 3-monthly intervals to remission and for up to 15 months thereafter. Remission was comparatively rapid with 70% of subjects remitting within 6 months. Only 6% failed to do so by 15 months. However, 40% relapsed over the subsequent 15 months, with all the relapses occurring in the first 10 months. Greater severity of the depression and longer duration of the illness predicted a longer time to remission. Greater initial severity of depression also predicted relapse. Subjects with a worse outcome had not received less adequate treatment than the remainder. Our results confirm the comparatively poor outcome subsequent to remission that has been reported in recent literature, in spite of the availability of modern methods of treatment. The clustering of relapses in the first 10 months gives some support to the distinction between relapse and later recurrence.

Residual symptoms after partial remission: an important outcome in depression

This paper draws attention to an important adverse outcome in depression, the occurrence of residual symptoms after partial remission. Among patients with definite major depression followed every 3 months to remission and thereafter, residual symptoms reaching 8 or more on the Hamilton Depression Scale 17-item total were present in 32% (19) of the 60 who remitted below major depression by 15 months. The pattern was of mild but typical depressive symptoms. Residual symptoms were more common in subjects with more severe initial illness, but were not related to any other predictors, including longer prior illness, dysthymia, or lower dose of drug treatment during the illness episode. There were weak associations with personality that might have been consequences of symptom presence. Residual symptoms were very strong predictors of subsequent early relapse, which occurred in 76% (13/17) of those with residual symptoms and 25% (10/40) of those without.

Depressive thinking: shifts in construct accessibility or in schematic mental models?

Alternative explanations for depression-related changes in thinking were examined. Forty-one depressed patients and 40 controls completed sentence stems involving social approval or personal achievement such as "If I could always be right then others would __ me." The view that depressive thinking primarily reflects a generalized increase in accessibility of negative constructs predicts patients will give more negative completions (e.g., "dislike"). Alternatively, depression could affect the interrelationships between constructs: Use in depression of schematic mental models implying closer dependence of personal worth--acceptance on success--approval predicts patients may give more positive completions (e.g., "like"). Results supported the latter prediction and suggest that depressive thinking reflects changes in high-level mental models used to interpret experience.

Depressive thinking: shifts in construct accessibility or in schematic mental models?

Alternative explanations for depression-related changes in thinking were examined. Forty-one depressed patients and 40 controls completed sentence stems involving social approval or personal achievement such as "If I could always be right then others would __ me." The view that depressive thinking primarily reflects a generalized increase in accessibility of negative constructs predicts patients will give more negative completions (e.g., "dislike"). Alternatively, depression could affect the interrelationships between constructs: Use in depression of schematic mental models implying closer dependence of personal worth--acceptance on success--approval predicts patients may give more positive completions (e.g., "like"). Results supported the latter prediction and suggest that depressive thinking reflects changes in high-level mental models used to interpret experience.

The validity of the eating disorder examination and its subscales

The EDE is a semistructured interview which has been developed as a measure of the specific psychopathology of anorexia nervosa and bulimia nervosa. To establish its discriminant validity it was administered to 100 patients with anorexia nervosa or bulimia nervosa and to 42 controls. The two groups differed significantly on all items. Five subscales were derived on rational grounds and evaluated on the two populations. The alpha coefficients for each subscale indicated a satisfactory degree of internal consistency. The EDE provides clinicians and research workers with a detailed and comprehensive profile of the psychopathological features of patients with eating disorders.

The effects of depression on structural aspects of the recall of prose

Investigated depressed patients' memory for stories. This indicated that although normal Ss showed particularly good recall for units central to the structure of the story, this did not hold for depressed Ss. In contrast, effects of centrality were comparable in high- and low-IQ Ss and effects of imageability of story units were comparable in both depressed and normal Ss. These results are consistent with the hypothesis that depressed patients do not use structure to organize stories when encoding them. A failure to identify central aspects of material and selectively recall them is likely to be a handicap to everyday functioning.

The effects of depression on structural aspects of the recall of prose

Investigated depressed patients' memory for stories. This indicated that although normal Ss showed particularly good recall for units central to the structure of the story, this did not hold for depressed Ss. In contrast, effects of centrality were comparable in high- and low-IQ Ss and effects of imageability of story units were comparable in both depressed and normal Ss. These results are consistent with the hypothesis that depressed patients do not use structure to organize stories when encoding them. A failure to identify central aspects of material and selectively recall them is likely to be a handicap to everyday functioning.