Okan Elci

Safety and durability of effect of contralateral-eye administration of AAV2 gene therapy in patients with childhood-onset blindness caused by RPE65 mutations: a follow-on phase 1 trial

BACKGROUND Safety and efficacy have been shown in a phase 1 dose-escalation study involving a unilateral subretinal injection of a recombinant adeno-associated virus (AAV) vector containing the RPE65 gene (AAV2-hRPE65v2) in individuals with inherited retinal dystrophy caused by RPE65 mutations. This finding, along with the bilateral nature of the disease and intended use in treatment, prompted us to determine the safety of administration of AAV2-hRPE65v2 to the contralateral eye in patients enrolled in the phase 1 study. METHODS In this follow-on phase 1 trial, one dose of AAV2-hRPE65v2 (1.5 × 10(11) vector genomes) in a total volume of 300 μL was subretinally injected into the contralateral, previously uninjected, eyes of 11 children and adults (aged 11-46 years at second administration) with inherited retinal dystrophy caused by RPE65 mutations, 1.71-4.58 years after the initial subretinal injection. We assessed safety, immune response, retinal and visual function, functional vision, and activation of the visual cortex from baseline until 3 year follow-up, with observations ongoing. This study is registered with ClinicalTrials.gov, number NCT01208389. FINDINGS No adverse events related to the AAV were reported, and those related to the procedure were mostly mild (dellen formation in three patients and cataracts in two). One patient developed bacterial endophthalmitis and was excluded from analyses. We noted improvements in efficacy outcomes in most patients without significant immunogenicity. Compared with baseline, pooled analysis of ten participants showed improvements in mean mobility and full-field light sensitivity in the injected eye by day 30 that persisted to year 3 (mobility p=0.0003, white light full-field sensitivity p<0.0001), but no significant change was seen in the previously injected eyes over the same time period (mobility p=0.7398, white light full-field sensitivity p=0.6709). Changes in visual acuity from baseline to year 3 were not significant in pooled analysis in the second eyes or the previously injected eyes (p>0.49 for all time-points compared with baseline). INTERPRETATION To our knowledge, AAV2-hRPE65v2 is the first successful gene therapy administered to the contralateral eye. The results highlight the use of several outcome measures and help to delineate the variables that contribute to maximal benefit from gene augmentation therapy in this disease. FUNDING Center for Cellular and Molecular Therapeutics at The Childrens Hospital of Philadelphia, Spark Therapeutics, US National Institutes of Health, Foundation Fighting Blindness, Institute for Translational Medicine and Therapeutics, Research to Prevent Blindness, Center for Advanced Retinal and Ocular Therapeutics, Mackall Foundation Trust, F M Kirby Foundation, and The Research Foundation-Flanders.

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

BACKGROUND Phase 1 studies have shown potential benefit of gene replacement in RPE65-mediated inherited retinal dystrophy. This phase 3 study assessed the efficacy and safety of voretigene neparvovec in participants whose inherited retinal dystrophy would otherwise progress to complete blindness. METHODS In this open-label, randomised, controlled phase 3 trial done at two sites in the USA, individuals aged 3 years or older with, in each eye, best corrected visual acuity of 20/60 or worse, or visual field less than 20 degrees in any meridian, or both, with confirmed genetic diagnosis of biallelic RPE65 mutations, sufficient viable retina, and ability to perform standardised multi-luminance mobility testing (MLMT) within the luminance range evaluated, were eligible. Participants were randomly assigned (2:1) to intervention or control using a permuted block design, stratified by age (<10 years and ≥10 years) and baseline mobility testing passing level (pass at ≥125 lux vs <125 lux). Graders assessing primary outcome were masked to treatment group. Intervention was bilateral, subretinal injection of 1·5 × 1011 vector genomes of voretigene neparvovec in 0·3 mL total volume. The primary efficacy endpoint was 1-year change in MLMT performance, measuring functional vision at specified light levels. The intention-to-treat (ITT) and modified ITT populations were included in primary and safety analyses. This trial is registered with ClinicalTrials.gov, number NCT00999609, and enrolment is complete. FINDINGS Between Nov 15, 2012, and Nov 21, 2013, 31 individuals were enrolled and randomly assigned to intervention (n=21) or control (n=10). One participant from each group withdrew after consent, before intervention, leaving an mITT population of 20 intervention and nine control participants. At 1 year, mean bilateral MLMT change score was 1·8 (SD 1·1) light levels in the intervention group versus 0·2 (1·0) in the control group (difference of 1·6, 95% CI 0·72-2·41, p=0·0013). 13 (65%) of 20 intervention participants, but no control participants, passed MLMT at the lowest luminance level tested (1 lux), demonstrating maximum possible improvement. No product-related serious adverse events or deleterious immune responses occurred. Two intervention participants, one with a pre-existing complex seizure disorder and another who experienced oral surgery complications, had serious adverse events unrelated to study participation. Most ocular events were mild in severity. INTERPRETATION Voretigene neparvovec gene replacement improved functional vision in RPE65-mediated inherited retinal dystrophy previously medically untreatable. FUNDING Spark Therapeutics.

Using a Personal Digital Assistant for Self-Monitoring Influences Diet Quality in Comparison to a Standard Paper Record among Overweight/Obese Adults

Self-monitoring has traditionally been done using a paper record, which can be tedious and burdensome. A personal digital assistant (PDA) with dietary software can provide an alternative to a paper record. The study aimed to describe the differences in dietary changes at 6 months between participants randomly assigned to use a paper record or PDA for self-monitoring in a clinical trial of weight-loss treatment. Self-monitoring adherence and changes in weight and diet were assessed between 2006 and 2009. The sample (n=192) was 84% female and 78% white, with a mean age of 49 years and body mass index (calculated as kg/m(2)) of 34.1. At baseline, the groups did not differ in energy intake, percent calories from fat, and number of servings of the examined food groups. At 6 months, both groups had significant reductions in weight, energy intake, and percent calories from total fat and saturated fatty acids (P<0.001); no between-group differences were found. Compared to the paper record group, the PDA group significantly increased consumption of fruit (P=0.02) and vegetables (P=0.04) and decreased consumption of refined grains (P=0.02). Interactions among self-monitoring and the two groups were found in relation to changes in percent calories from total fat (P=0.02), monounsaturated fatty acids (P=0.002), and trans-fatty acids (P=0.04). Frequent self-monitoring was significantly associated with total sugar (P=0.02) and added sugar (P=0.01) intake in both groups. Our findings suggest that use of a PDA for self-monitoring might improve self-awareness of behavior and dietary changes.

Genetics of Bone Mass in Childhood and Adolescence: Effects of Sex and Maturation Interactions

We aimed to determine if adult bone mineral density (BMD) susceptibility loci were associated with pediatric bone mass and density, and if sex and pubertal stage influenced any association. We analyzed prospective areal BMD (aBMD) and bone mineral content (BMC) data from the Bone Mineral Density in Childhood Study (n = 603, European ancestry, 54% female). Linear mixed models were used to assess if 77 single‐nucleotide polymorphisms (SNPs) near known adult BMD susceptibility loci interacted with sex and pubertal stage to influence the aBMD/BMC; adjusting for age, BMI, physical activity, and dietary calcium. The strongest main association was observed between an SNP near C7orf58 and distal radius aBMD. However, this association had a significant sex•SNP interaction, revealing a significant association only in females (b = –0.32, p = 1.8 × 10–6). Furthermore, the C12orf23 locus had significant interactions with both sex and pubertal stage, revealing associations in females during Tanner stage I for total hip aBMD (b = 0.24, p = 0.001) and femoral neck aBMD (b = 0.27, p = 3.0 × 10–5). In contrast, the sex•SNP interactions for loci near LRP5 and WNT16 uncovered associations that were only in males for total body less head BMC (b = 0.22, p = 4.4 × 10–4) and distal radius aBMD (b = 0.27, p = 0.001), respectively. Furthermore, the LRP5 locus interacted with both sex and pubertal stage, demonstrating associations that were exclusively in males during Tanner V for total hip aBMD (b = 0.29, p = 0.003). In total, significant sex•SNP interactions were found at 15 loci; pubertal stage•SNP interactions at 23 loci and 19 loci interacted with both sex and pubertal stage. In conclusion, variants originally associated with adult BMD influence bone mass in children of European ancestry, highlighting the fact that many of these loci operate early in life. However, the direction and magnitude of associations for a large number of SNPs only became evident when accounting for sex and maturation.

Reduction of soluble CD163, substance P, programmed death 1 and inflammatory markers: phase 1B trial of aprepitant in HIV-1-infected adults.

Objective:We evaluated safety, antiviral, immunomodulatory and anti-inflammatory properties of aprepitant – a neurokinin 1 receptor antagonist. Design:Phase IB randomized, placebo-controlled, double-blinded study. Methods:Eighteen patients were randomized (nine to aprepitant and nine to placebo). The patients received once-daily treatment (375 mg aprepitant or placebo by oral administration) for 2 weeks and were followed off drug for 4 weeks. Results:There were no significant changes in the plasma viremia or CD4+ T cells during the dosing period. Aprepitant treatment was associated with significant decreases of median within patient change in percentages of CD4+ T cells expressing programmed death 1 (−4.8%; P = 0.04), plasma substance P (−34.0 pg/ml; P = 0.05) and soluble CD163 (−563 ng/ml; P = 0.02), with no significant changes in the placebo arm. Mean peak aprepitant plasma concentration on day 14 was 7.6 ± 3.1 &mgr;g/ml. The use of aprepitant was associated with moderate increases in total cholesterol, low-density lipoprotein and high-density lipoprotein (median change = +31 mg/dl, P = 0.01; +26 mg/dl, P = 0.02; +3 mg/dl, P = 0.02, respectively). Conclusion:Aprepitant was safe and well tolerated. At the dose used in this proof-of-concept phase IB study, aprepitant did not show a significant antiviral activity. Aprepitant-treated patients had decreased numbers of CD4+ programmed death 1-positive cells and decreased plasma levels of substance P and soluble CD163, suggesting that blockade of the neurokinin 1 receptor pathway has a role in modulating monocyte activation in HIV infection. Prospective studies in virologically-suppressed individuals are warranted to evaluate the immunomodulatory properties of aprepitant. Exposures exceeding those attained in this trial are more likely to elicit clinical benefit.

Genetic Risk Scores Implicated in Adult Bone Fragility Associate with Pediatric Bone Density

Using adult identified bone mineral density (BMD) loci, we calculated genetic risk scores (GRS) to determine if they were associated with changes in BMD during childhood. Longitudinal data from the Bone Mineral Density in Childhood Study were analyzed (N = 798, 54% female, all European ancestry). Participants had up to 6 annual dual energy X‐ray scans, from which areal BMD (aBMD) Z‐scores for the spine, total hip, and femoral neck were estimated, as well as total body less head bone mineral content (TBLH‐BMC) Z‐scores. Sixty‐three single‐nucleotide polymorphisms (SNPs) were genotyped, and the percentage of BMD‐lowering alleles carried was calculated (overall adult GRS). Subtype GRS that include SNPs associated with fracture risk, pediatric BMD, WNT signaling, RANK‐RANKL‐OPG, and mesenchymal stem cell differentiation were also calculated. Linear mixed effects models were used to test associations between each GRS and bone Z‐scores, and if any association differed by sex and/or chronological age. The overall adult, fracture, and WNT signaling GRS were associated with lower Z‐scores (eg, spine aBMD Z‐score: βadult = –0.04, p = 3.4 × 10−7; βfracture = –0.02, p = 8.9 × 10−6; βWNT = –0.01, p = 3.9 × 10−4). The overall adult GRS was more strongly associated with lower Z‐scores in females (p‐interaction ≤ 0.05 for all sites). The fracture GRS was more strongly associated with lower Z‐scores with increasing age (p‐interaction ≤ 0.05 for all sites). The WNT GRS associations remained consistent for both sexes and all ages (p‐interaction > 0.05 for all sites). The RANK‐RANKL‐OPG GRS was more strongly associated in females with increasing age (p‐interaction < 0.05 for all sites). The mesenchymal stem cell GRS was associated with lower total hip and femoral neck Z‐scores, in both boys and girls, across all ages. No associations were observed between the pediatric GRS and bone Z‐scores. In conclusion, adult identified BMD loci associated with BMD and BMC in the pediatric setting, especially in females and in loci involved in fracture risk and WNT signaling.

Physical Activity Benefits the Skeleton of Children Genetically Predisposed to Lower Bone Density in Adulthood

Both genetics and physical activity (PA) contribute to bone mineral density (BMD), but it is unknown if the benefits of physical activity on childhood bone accretion depend on genetic risk. We, therefore, aimed to determine if PA influenced the effect of bone fragility genetic variants on BMD in childhood. Our sample comprised US children of European ancestry enrolled in the Bone Mineral Density in Childhood Study (N = 918, aged 5 to 19 years, and 52.4% female). We used a questionnaire to estimate hours per day spent in total, high‐, and low‐impact PA. We calculated a BMD genetic score (% BMD lowering alleles) using adult genome‐wide association study (GWAS)‐implicated BMD variants. We used dual‐energy X‐ray absorptiometry to estimate femoral neck, total hip, and spine areal‐BMD and total body less head (TBLH) bone mineral content (BMC) Z‐scores. The BMD genetic score was negatively associated with each bone Z‐score (eg, TBLH‐BMC: estimate = –0.03, p = 1.3 × 10−6). Total PA was positively associated with bone Z‐scores; these associations were driven by time spent in high‐impact PA (eg, TBLH‐BMC: estimate = 0.05, p = 4.0 × 10−10) and were observed even for children with lower than average bone Z‐scores. We found no evidence of PA‐adult genetic score interactions (p interaction > 0.05) at any skeletal site, and there was no evidence of PA‐genetic score–Tanner stage interactions at any skeletal site (p interaction > 0.05). However, exploratory analyses at the individual variant level revealed that PA statistically interacted with rs2887571 (ERC1/WNT5B) to influence TBLH‐BMC in males (p interaction = 7.1 × 10−5), where PA was associated with higher TBLH‐BMC Z‐score among the BMD‐lowering allele carriers (rs2887571 AA homozygotes: estimate = 0.08 [95% CI 0.06, 0.11], p = 2.7 × 10−9). In conclusion, the beneficial effect of PA on bone, especially high‐impact PA, applies to the average child and those genetically predisposed to lower adult BMD (based on GWAS‐implicated BMD variants). Independent replication of our exploratory individual variant findings is warranted.

Impact of contextualized pediatric resuscitation training on pediatric healthcare providers in Botswana

BACKGROUND Worldwide, 6.6 million children die each year, partly due to a failure to recognize and treat acutely ill children. Programs that improve provider recognition and treatment initiation may improve child survival. OBJECTIVES Describe provider characteristics and hospital resources during a contextualized pediatric resuscitation training program in Botswana and determine if training impacts provider knowledge retention. DESIGN/METHODS The American Heart Associations Pediatric Emergency Assessment Recognition and Stabilization (PEARS) course was contextualized to Botswana resources and practice guidelines in this observational study. A cohort of facility-based nurses (FBN) was assessed prior to and 1-month following training. Survey tools assessed provider characteristics, cognitive knowledge and confidence and hospital pediatric resources. Data analysis utilized Fishers exact, Chi-square, Wilcoxon rank-sum and linear regression where appropriate. RESULTS 61 healthcare providers (89% FBNs, 11% physicians) successfully completed PEARS training. Referral facilities had more pediatric specific equipment and high-flow oxygen. Median frequency of pediatric resuscitation was higher in referral compared to district level FBNs (5 [3,10] vs. 2 [1,3] p=0.007). While 50% of FBNs had previous resuscitation training, none was pediatric specific. Median provider confidence improved significantly after training (3.8/5 vs. 4.7/5, p<0.001), as did knowledge of correct management of acute pneumonia and diarrhea (44% vs. 100%, p<0.001, 6% vs. 67%, p<0.001, respectively). CONCLUSION FBNs in Botswana report frequent resuscitation of ill children but low baseline training. Provider knowledge for recognition and initial treatment of respiratory distress and shock is low. Contextualized training significantly increased FBN provider confidence and knowledge retention 1-month after training.

Improved Retention of Chest Compression Psychomotor Skills With Brief “Rolling Refresher” Training

Introduction High-quality cardiopulmonary resuscitation (CPR) is critical to improve survival from cardiac arrest. However, cardiopulmonary resuscitation knowledge and psychomotor skill proficiency are transient. We hypothesized that brief, in situ refresher training will improve chest compression (CC) psychomotor skill retention for bedside providers. Methods Nurses completed a baseline skill evaluation of CC quality 6 months after traditional basic life support recertification. Data collected using ResusciAnne with SkillReporter included the following: CC depth, rate, complete release, and correct hand position. Total compliance was defined as 100% CC with depth of 50 mm or greater, rate of 100/min or greater, and more than 90% complete release. After the baseline evaluation, the subjects completed “Rolling Refresher” (RR) CC psychomotor training using audiovisual feedback every 2 to 3 months for 12 months until 30 seconds of CCs fulfilling total compliance criteria was achieved. Chest compression quality evaluations were repeated twice (“RR 6 month” and “RR 12 month” evaluation) after implementation of RR program. Results Thirty-seven providers enrolled and completed the baseline evaluation. Mean depth was 36.3 (9.7) mm, and 8% met criteria for depth, 35% for rate, and 5% for total compliance. After RRs were implemented, CC quality improved significantly at RR 6-month evaluation: odds ratio for meeting criteria were the following: depth of 35.1 (95% confidence interval = 2.5496, P = 0.009) and total compliance of 22.3 (95% confidence interval = 2.1239, P = 0.010). There was no difference in CC quality at RR 12-month versus RR 6-month evaluation. Conclusions Retention of CC psychomotor skill quality is limited to 6 months after traditional basic life support recertification. Rolling Refresher CC training can significantly improve retention of CC psychomotor skills. Whether CC skills are improved, maintained, or deteriorate after 12 months of Refresher training and optimal frequency of Refreshers is unknown.

Intraoperative dexmedetomidine reduces postoperative mechanical ventilation in infants after open heart surgery.

Objective: The inclusion of dexmedetomidine in the operative and postoperative management of infants with congenital heart defects has lessened the need for opioids that may cause respiratory depression. Our objective was to show that a dexmedetomidine bolus at or about the time of sternal closure is associated with a decrease in the use of mechanical ventilation in the immediate postoperative period. Design: Retrospective cohort study. Setting: Single pediatric tertiary cardiac center. Patients: Infants undergoing surgical intervention for congenital heart defects requiring cardiopulmonary bypass, age 30–365 days in a 5-year time period from June 1, 2008, to December 31, 2012. Interventions: None. Measurements and Main Results: Of 1,057 total encounters, 441 met inclusion criteria and were evenly distributed over the 5-year time period. Dexmedetomidine had been given at or about the time of sternal closure in 57% of patients. When the exposed and unexposed groups were compared in terms of mechanical ventilation immediately postoperative, there was a statistically significant effect of using dexmedetomidine on the odds of receiving mechanical ventilation (p = 0.0019). This difference remained significant after adjusting for covariates affecting the decision for mechanical ventilation, including year of the procedure, age and weight of subject, cardiopulmonary bypass time, the use of deep hypothermic circulatory arrest, intraoperative fentanyl dose, and the Risk Adjustment for Congenital Heart Surgery Score 1 (p = 0.0317). The odds of receiving mechanical ventilation are estimated to be two times higher for patients who did not receive dexmedetomidine than for patients who received dexmedetomidine after adjusting for variables. Conclusion: The use of dexmedetomidine bolus in the operating room at the time of sternal closure in infants undergoing open heart surgery is associated with reduced need for mechanical ventilation in the immediate postoperative period.