Clinical Proof Research Articles

Clinical development and proof of principle testing of new regenerative vascular endothelial growth factor-D therapy for refractory angina: rationale and design of the phase 2 ReGenHeart trial

BackgroundDespite tremendous therapeutic advancements, a significant proportion of coronary artery disease patients suffer from refractory angina pectoris, that is, quality-of-life-compromising angina that is non-manageable with established pharmacological and interventional treatment...

Accuracy and precision of Volumetric Matching Micromotion Analysis (V3MA) is similar to RSA for tibial component migration in TKA.

Radiostereometric analysis (RSA) is the current gold standard to determine implant migration, but it requires bone markers and special equipment. Therefore, we developed VoluMetric Matching Micromotion Analysis (V3MA), a software program for Computed Tomography-based radiostereometric analysis (CT-RSA). This study aimed to determine the accuracy and precision of V3MA in vitro compared to RSA and provide a clinical proof of concept. The accuracy (RMSE (Root Mean Squared Error)) and precision (SD (standard deviation)) of V3MA were compared to RSA. A tibial component was placed in 21 different positions within a cadaveric bone to assess accuracy. For precision,a total of 20 repeated zero-migration examinations from 4 cadaveric bones with cemented tibial components were performed. In 6 total knee arthroplasty (TKA) patients 1 to 5 year migration was measured with V3MA and RSA. V3MA accuracy ranged between 0.02 and 0.09 mm for translations and was 0.01° for internal-external rotations. For RSA, the accuracy ranged between 0.03 and 0.09 mm for translations and was 0.09° for internal-external rotations. V3MA precision ranged between 0.01 and 0.06 mm for translations and 0.02 to 0.07° for rotations. RSA precision ranged between 0.00 and 0.06 mm for translations and 0.04 to 0.25° for rotations. V3MA was successful in 6 clinical cases and no systematic bias was present. In conclusion, the accuracy and precision of V3MA were similar to RSA. Therefore, V3MA is a promising alternative to RSA in migration measurements of tibial components in TKA.

Abstract C073: FOLFIRINOX with Glycogen Synthase Kinase-3 Beta (GSK-3β) Inhibitor Elraglusib and Transforming Growth Factor- β (TGFβ) Inhibitor Losartan in Untreated Metastatic Pancreatic Ductal Adenocarcinoma(PDAC): Interim analysis of safety cohort

Abstract Introduction: Epithelial-mesenchymal transition (EMT) is one of the key drivers of aggressive biology and development of chemoresistance in PDAC. Inhibition of glycogen synthase kinase 3β (GSK3β) may offer a promising novel approach for modulating dynamic EMT plasticity to overcome resistance to FOLFIRINOX (5-Fluororuacil, Irinotecan, Oxaliplatin, FFX). Methods: Cell line panels comprising both epithelial (E) and quasi-mesenchymal (QM) subtypes were used and treated with IC50 (0.3125 mM) and IC100 (1.25 mM) doses of elraglusib (ELR). Gene expression patters in response to treatment were analyzed using bulk RNA sequencing. 6 patients in the safety run-in cohort of NCT05077800 treated with standard doses of FFX, ELR and losartan were included in this interim analysis. Biopsy specimens were processed for RNA-in situ hybridization (RNA-ISH), a clinically validated assay, and Nanostring (GeoMx) spatial transcriptomics. Results: In preclinical models, exposure to the higher IC100 (1.25 mM) doses of ELR in the QM cell lines caused a shift in transcriptional expression patterns similar to the E cell line, with strong downregulation of EMT. FFX exposure alone in QM cell lines was associated with significant resistance, but addition of ELR (even at IC50 dose) caused a synergistic effect with decreased cell viability. However, in the E cell lines, there was no benefit from addition of ELR. In the safety cohort, clinical results are encouraging with a long-term (>6 month) response in 3/6 patients. 2/6 achieved partial response, 1/6 had stable disease. Nanostring (GeoMx) spatial transcriptomic profiling on available biopsy samples showed significant global gene expression changes before and after treatment. There were concordant changes in 97 differentially expressed genes (DEGs) within the epithelial compartment with treatment, similar to ELR induced changes in PDAC cell lines, with a shift in transcriptional expression patterns from QM to E subtype. Gene set enrichment analysis demonstrated downregulation of the EMT pathway, as well as decreased TGF-β signaling. RNA-ISH analysis on baseline biopsy samples showed that the two partial (best) responders had higher degrees of QM marker expression (82.58% and 63.76%). The regimen was well tolerated with no dose limiting toxicity noted in the safety cohort. Conclusion: Our experiments demonstrate that the E subtype PDAC cell lines are inherently sensitive to FFX chemotherapy with no added advantage with GSK3β inhibition. Meanwhile, GSK3β inhibition in QM cell lines induces mesenchymal to epithelial transition, thereby rendering it sensitive to FFX. The data from our safety cohort provide a clinical proof of concept that GSK-3β inhibition with ELR, in combination with FFX, may be an effective therapeutic strategy in metastatic PDAC. NCT05077800 is currently enrolling. Citation Format: Priyadarshini Pathak, Eric Lin, Ildiko Phillips, David Ting, Colin Weekes. FOLFIRINOX with Glycogen Synthase Kinase-3 Beta (GSK-3β) Inhibitor Elraglusib and Transforming Growth Factor- β (TGFβ) Inhibitor Losartan in Untreated Metastatic Pancreatic Ductal Adenocarcinoma(PDAC): Interim analysis of safety cohort [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Advances in Pancreatic Cancer Research; 2024 Sep 15-18; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2024;84(17 Suppl_2):Abstract nr C073.

Inhibition of lysine acetyltransferase KAT6 in ER+HER2− metastatic breast cancer: a phase 1 trial

Inhibition of histone lysine acetyltransferases (KATs) KAT6A and KAT6B has shown antitumor activity in estrogen receptor-positive (ER+) breast cancer preclinical models. PF-07248144 is a selective catalytic inhibitor of KAT6A and KAT6B. In the present study, we report the safety, pharmacokinetics (PK), pharmacodynamics, efficacy and biomarker results from the first-in-human, phase 1 dose escalation and dose expansion study (n = 107) of PF-07248144 monotherapy and fulvestrant combination in heavily pretreated ER+ human epidermal growth factor receptor-negative (HER2−) metastatic breast cancer (mBC). The primary objectives of assessing the safety and tolerability and determining the recommended dose for expansion of PF-07248144, as monotherapy and in combination with fulvestrant, were met. Secondary endpoints included characterization of PK and evaluation of antitumor activity, including objective response rate (ORR) and progression-free survival (PFS). Common treatment-related adverse events (any grade; grades 3–4) included dysgeusia (83.2%, 0%), neutropenia (59.8%, 35.5%) and anemia (48.6%, 13.1%). Exposure was approximately dose proportional. Antitumor activity was observed as monotherapy. For the PF-07248144–fulvestrant combination (n = 43), the ORR (95% confidence interval (CI)) was 30.2% (95% CI = 17.2–46.1%) and the median PFS was 10.7 (5.3–not evaluable) months. PF-07248144 demonstrated a tolerable safety profile and durable antitumor activity in heavily pretreated ER+HER2− mBC. These findings establish KAT6A and KAT6B as druggable cancer targets, provide clinical proof of concept and reveal a potential avenue to treat mBC. clinicaltrial.gov registration: NCT04606446.

An open-label study to assess the safety and efficacy of naporafenib (ERAS-254) administered with trametinib in previously treated patients with locally advanced unresectable or metastatic solid tumor malignancies with RAS Q61X mutations (SEACRAFT-1).

TPS3178 Background: The rat sarcoma viral oncogene (RAS)/mitogen-activated protein kinase (MAPK) pathway is a key signaling cascade that drives cell proliferation, differentiation, and survival. Inappropriate activation of this pathway drives tumorigenesis in a subset of solid tumors. There are 3 isoforms of RAS (KRAS, NRAS, and HRAS) with the most commonly mutated codons being 12, 13, and 61. While these codon mutations map to the active site of RAS, they appear to have differential impacts on pathway activation. Mutations at codon 61 (RAS Q61X) are generally thought to be the most MAPK pathway-activating relative to mutations at codons 12 and 13 and are therefore thought to be the most oncogenic. Naporafenib is a pan-RAF inhibitor that is being evaluated in combination with trametinib, which inhibits MEK, a downstream node of the RAS/MAPK pathway. Clinical proof of concept (PoC) in patients with NRASm melanoma (of which 80 to 90% have Q61X mutations) and preliminary PoC for patients with RAS Q61X NSCLC have been established for the combination. Preclinical data across tumor types suggest that RAS Q61X is a potential predictive biomarker for the combination of naporafenib with trametinib, a hypothesis being tested in this trial. Methods: SEACRAFT-1 (NCT05907304) is a Phase 1b, open-label study evaluating the clinical activity and safety of the combination of naporafenib and trametinib in pts with locally advanced, unresectable, or metastatic solid tumor malignancies that are not responsive to standard therapies or for which there are no standard therapies. Eligible pts must be ≥18 years (or ≥12 and <18 years in an adolescent substudy) with documented RAS Q61X mutation by an analytically validated assay. Pts must also have ≥1 measurable lesion per RECIST (Response Evaluation Criteria in Solid Tumors, v1.1) and Eastern Cooperative Oncology Group (ECOG) Performance Status ≤2 (or Karnofsky/Lansky Performance Status ≥70 for adolescent pts). Exclusion criteria include prior therapy with an ERK, MEK, RAF, or RAS inhibitor, QTcF >450 ms at baseline, and left ventricular ejection fraction (LVEF) <50% at baseline. A total of up to 115 pts will be enrolled to receive naporafenib 200 mg BID and trametinib 1 mg QD continuous in 28-day cycles until disease progression, unacceptable toxicity, or withdrawal of consent. The primary endpoint is ORR; secondary endpoints include assessment of PFS, DOR, safety, and tolerability. Clinical trial information: NCT05907304 .

Targeted protein degradation: from mechanisms to clinic.

Targeted protein degradation refers to the use of small molecules to induce the selective degradation of proteins. In its most common form, this degradation is achieved through ligand-mediated neo-interactions between ubiquitin E3 ligases - the principal waste disposal machines of a cell - and the protein targets of interest, resulting in ubiquitylation and subsequent proteasomal degradation. Notable advances have been made in biological and mechanistic understanding of serendipitously discovered degraders. This improved understanding and novel chemistry has not only provided clinical proof of concept for targeted protein degradation but has also led to rapid growth of the field, with dozens of investigational drugs in active clinical trials. Two distinct classes of protein degradation therapeutics are being widely explored: bifunctional PROTACs and molecular glue degraders, both of which have their unique advantages and challenges. Here, we review the current landscape of targeted protein degradation approaches and how they have parallels in biological processes. We also outline the ongoing clinical exploration of novel degraders and provide some perspectives on the directions the field might take.

A measles-vectored vaccine candidate expressing prefusion-stabilized SARS-CoV-2 spike protein brought to phase I/II clinical trials: candidate selection in a preclinical murine model.

In the early COVID-19 pandemic with urgent need for countermeasures, we aimed at developing a replicating viral vaccine using the highly efficacious measles vaccine as vector, a promising technology with prior clinical proof of concept. Building on our successful pre-clinical development of a measles virus (MV)-based vaccine candidate against the related SARS-CoV, we evaluated several recombinant MV expressing codon-optimized SARS-CoV-2 spike glycoprotein. Candidate V591 expressing a prefusion-stabilized spike through introduction of two proline residues in HR1 hinge loop, together with deleted S1/S2 furin cleavage site and additional inactivation of the endoplasmic reticulum retrieval signal, was the most potent in eliciting neutralizing antibodies in mice. After single immunization, V591 induced similar neutralization titers as observed in sera of convalescent patients. The cellular immune response was confirmed to be Th1 skewed. V591 conferred long-lasting protection against SARS-CoV-2 challenge in a murine model with marked decrease in viral RNA load, absence of detectable infectious virus loads, and reduced lesions in the lungs. V591 was furthermore efficacious in an established non-human primate model of disease (see companion article [S. Nambulli, N. Escriou, L. J. Rennick, M. J. Demers, N. L. Tilston-Lunel et al., J Virol 98:e01762-23, 2024, https://doi.org/10.1128/jvi.01762-23]). Thus, V591 was taken forward into phase I/II clinical trials in August 2020. Unexpected low immunogenicity in humans (O. Launay, C. Artaud, M. Lachâtre, M. Ait-Ahmed, J. Klein et al., eBioMedicine 75:103810, 2022, https://doi.org/10.1016/j.ebiom.2021.103810) revealed that the underlying mechanisms for resistance or sensitivity to pre-existing anti-measles immunity are not yet understood. Different hypotheses are discussed here, which will be important to investigate for further development of the measles-vectored vaccine platform.IMPORTANCESARS-CoV-2 emerged at the end of 2019 and rapidly spread worldwide causing the COVID-19 pandemic that urgently called for vaccines. We developed a vaccine candidate using the highly efficacious measles vaccine as vector, a technology which has proved highly promising in clinical trials for other pathogens. We report here and in the companion article by Nambulli et al. (J Virol 98:e01762-23, 2024, https://doi.org/10.1128/jvi.01762-23) the design, selection, and preclinical efficacy of the V591 vaccine candidate that was moved into clinical development in August 2020, 7 months after the identification of SARS-CoV-2 in Wuhan. These unique in-human trials of a measles vector-based COVID-19 vaccine revealed insufficient immunogenicity, which may be the consequence of previous exposure to the pediatric measles vaccine. The three studies together in mice, primates, and humans provide a unique insight into the measles-vectored vaccine platform, raising potential limitations of surrogate preclinical models and calling for further refinement of the platform.

Abstract 4075: Targeting attenuated IL-18 to PD-1: A next generation checkpoint inhibitor with enhanced anti-tumor activity

Abstract PD-1 antagonists have shown strong clinical proof of concept, but the development of next-generation versions that can target tumors that weakly respond and/or acquire drug resistance is a critical medical need. Lymphocytes, including T cells and NK cells, upregulate PD-1 and other immunoregulatory receptors in response to neoantigens. Such immunoregulation is important for maintaining the persistence of immune responses in a controllable manner so that immune pathology does not overwhelm the host. In addition to microbial proteins, neoantigens are often expressed by tumor cells. These 'tumor antigens' are derived from mutated genes or proteins not presented during T cell education. As such, many established tumors contain areas of chronic inflammation, including a subset of PD-1+ T cells that can be 'de-immuno-regulated' by anti-PD-1 antagonist antibodies, thus enhancing anti-tumor activity. IL-18 is a cytokine that delivers a 'danger' signal to NK cells and T cell subsets that express the IL-18 receptor complex (RC) and increases their capacity to kill, induces proliferation, diminishes terminal exhaustion, and sustains survival. Importantly, IL-18RC is expressed on progenitor exhausted T cells, the population of T cells in solid tumors that is most active and responds to anti-PD-1, but not terminal exhausted T cells. The latter have been shown to be non-responsive to PD-1 antagonism. Thus, we engineered an anti-PD-1-IL-18 antibody to enhance anti-tumor immune responses. Such a therapeutic requires two key characteristics: resistance to inhibition by IL-18BP, IL-18's natural antagonist, and PD-1-dependent cis-restricted binding to the IL18RC on PD-1+ cells to reduce trans-based systemic toxicity. We have engineered an IL-18BP-resistant mutant of IL-18 and generated variants with different degrees of attenuation for PD-1-dependent cis targeting. Attenuation was achieved by sterically hindering the capacity of IL-18 to bind the IL-18RC while maintaining cis activity without a requirement for proteolytic activation. We identified a variant of IL-18 that is 10,000-fold attenuated and, when fused to an anti-PD-1 antibody, mediated (1) PD-1-dependent cis activity in vitro equivalent to ~5x that of anti-PD-1 alone and (2) tumor shrinkage in mouse tumor models, including an ~80% frequency of complete responses. Due to the high degree of IL-18 attenuation, we were able to dose mice without toxicity to levels at which full PD-1 antagonism is maintained. To our knowledge, this anti-PD-1-IL-18 variant is the first PD-1 targeted cytokine capable of activating PD-1+ T cells via the cytokine’s receptor and fully antagonizing PD-1 as a single agent. Thus, targeting a highly attenuated variant of IL-18 that retains strong cis activity to PD-1 holds promise as a clinical candidate for the treatment of cancer indications that respond weakly to anti-PD-1 and/or are associated with acquired resistance. Citation Format: Xueyuan Zhou, Jeffrey Takimoto, Sunny Yoon, Nikhita Khanna, Brian Rabinovich. Targeting attenuated IL-18 to PD-1: A next generation checkpoint inhibitor with enhanced anti-tumor activity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4075.

근원적 인지 메커니즘을 통한 난독증 탐구

Objectives The purpose of this paper is to identify dyslexia among various types of learning disabilities, explain its manifestation mechanism, and demonstrate it clinically.
 Methods This paper shows that through the fundamental cognitive mechanism, not only can the characteristics of dyslexia be understood in the most fundamental, essential, and holistic way, but also a better understanding of how dyslexia is fundamentally manifested. For clinical proof, non-verbal intelligence test (K-CTONI-2), Korean version of Children's Visual Perception Development Test (K-DTVP-3), the Korean Reading Test (KOLRA), and speech hearing test were administered to 7 elementary school students who continued to experience difficulties despite receiving reading education.
 Results Dyslexia begins with an excessively imbalanced structure of the brain's large visual and small auditory cognitive spaces. Due to the imbalance between the two cognitive spaces, visual acuity and visual memory appear strong, while auditory acuity and auditory memory appear weak, resulting in auditory internal attention deficit, which is the most important cognitive condition for language development. Auditory internal attention deficit in turn interferes with auditory information processing, resulting in serious difficulties in written language development and various symptoms observed in dyslexic children. The test results showed a low auditory function score compared to a high visual function score.
 Conclusions Dyslexia occurs due to functional defects in hierarchical cognitive processes such as auditory sensation, memory, and thought processing caused by an imbalance between the brain's small auditory cognitive space and large visual cognitive space. This paper presents directions for effective dyslexia treatment based on research results.

Extraperitoneal robot assisted laparoscopic prostatectomy with Versius system: single centre experience.

Versius Surgical System (CMR Surgical, Cambridge, UK) is a novel tele-operated robotic surgical system designed to assist surgeons for minimally invasive surgery which is gaining momentum in the world of robotic surgery. We describe our single centre experience with Versius and report the advantages and challenges posed by this new robotic system in a series of 53 extraperitoneal robotic assisted laparoscopic prostatectomies (eRALP) for prostate cancer (PCa). Data of 53 eRALP performed with Versius in our centre were collected and analysed, Descriptive statistics were used to report our results. In 16 months we performed 53 eRALP: 18 (34%) with PLND, 33 (62%) nerve sparingcases. Mean setup time was 15 min, mean console time was 100 min and mean operative time was 130 min. We observed a substantial reduction of console time and set-up time after only 5 procedures. In the first 4 procedures, the dissection of the neurovascular bundle was performed laparoscopically, to switch back to robotic assisted approach afterwards. No major system failures were observed. No major intra-operative and post-operative complications occurred. Mean follow-up time was 9 months (range 3-15 months); no patients experienced biochemical recurrence or metastatic progression over this period, 8 (15%) patients had adjuvant radiotherapy based on unfavourable pathology report (positive surgical margins or positive limphnodes). This represents to our knowledge the largest extraperitoneal RALP case series with Versius, and it aims to provide solid clinical proof of the safety, effectiveness and versatility of this innovative system. In our experience, this platform represents a good option for every urologic surgeon who wants to start a robotic programme and it appears particularly suitable for urologists with a large laparoscopic expertise.

The association between new inflammation markers and frequent peritoneal dialysis-associated peritonitis

ObjectiveTo validate an association between new inflammation and frequent peritoneal dialysis-associated peritonitis (PDAP).Materials and methodsIn China, retrospective clinical data were collected on 208 patients who received continuous ambulatory peritoneal dialysis (CAPD) between 2010 and 2021. The patients were divided into two groups: non-frequent PDAP (the interval between two peritonitis episodes of more than one year) and frequent PDAP (the interval between two peritonitis episodes of less than one year). Patients with their first episode of peritonitis had their age, gender, history of hypertension, diabetic disease, underlying renal disease, bacterial infection, and laboratory data collected. The outcomes of bacterial dispersion, systemic immune-inflammation index (SII), high-density lipoprotein cholesterol (HDL-C), C-reactive protein (CRP), and risk variables associated with frequent PDAP were analyzed.ResultsThere are differences between the two groups in dialysis time (p = 0.006), hypertensive nephropathy (p = 0.038), staphylococcus (p = 0.035), white blood cells (p = 0.001), neutrophil (p < 0.01), lymphocyte (p < 0.01), platelet(p = 0.01), SII(p < 0.01), CRP/HDL-C (p = 0.002), CRP (p < 0.001), serum creatinine (p = 0.007), blood urea nitrogen (p = 0.05), serum magnesium (0.03), serum potassium (p = 0.007), and dialysate polymorphonuclear cells (p = 0.004). Multifactorial logistic regression analysis found that SII (p < 0.001), CRP/HDL-C (p = 0.041), and Diabetes mellitus (p = 0.027) were independent risk factors for frequent PDAP. The ROC curve analysis revealed that combining SII with CRP/HDL-C resulted in the largest AUC area (AUC = 0.814).ConclusionsOur findings offer clinical proof of the combination of SII and CRP/HDL-C in patients with frequent PDAP.

Using protein geometry to optimize cytotoxicity and the cytokine window of a ROR1 specific T cell engager.

T cell engaging bispecific antibodies have shown clinical proof of concept for hematologic malignancies. Still, cytokine release syndrome, neurotoxicity, and on-target-off-tumor toxicity, especially in the solid tumor setting, represent major obstacles. Second generation TCEs have been described that decouple cytotoxicity from cytokine release by reducing the apparent binding affinity for CD3 and/or the TAA but the results of such engineering have generally led only to reduced maximum induction of cytokine release and often at the expense of maximum cytotoxicity. Using ROR1 as our model TAA and highly modular camelid nanobodies, we describe the engineering of a next generation decoupled TCE that incorporates a "cytokine window" defined as a dose range in which maximal killing is reached but cytokine release may be modulated from very low for safety to nearly that induced by first generation TCEs. This latter attribute supports pro-inflammatory anti-tumor activity including bystander killing and can potentially be used by clinicians to safely titrate patient dose to that which mediates maximum efficacy that is postulated as greater than that possible using standard second generation approaches. We used a combined method of optimizing TCE mediated synaptic distance and apparent affinity tuning of the TAA binding arms to generate a relatively long but persistent synapse that supports a wide cytokine window, potent killing and a reduced propensity towards immune exhaustion. Importantly, this next generation TCE induced significant tumor growth inhibition in vivo but unlike a first-generation non-decoupled benchmark TCE that induced lethal CRS, no signs of adverse events were observed.

The Science Underlying the Probiotic Strain Bifidobacterium in Beneficial Effects on Immunological and Gastrointestinal Health

Probiotics have demonstrated a lot of promise in improving gut health in humans. Despite the encouraging data, nothing is known about the therapeutic effectiveness of many of the probiotics on the market, and it&amp;apos;s sometimes unclear how they work. Humans have long used Bifidobacterium, a well-known, multifunctional probiotic, to treat gastrointestinal, immunological, and infectious disorders. It is also therapeutically useful. This review provides a theoretical framework for comprehending the mechanisms of action of Bifidobacterium and highlights the functional advantages from the most pertinent animal and clinical trials. The genus Bifidobacterium belongs to the Actinobacteria phylum. = Firmicutes, Bacteroidetes, and Actinobacteria constitute the most abundant phyla in the human intestinal microbiota, Firmicutes and Bacteroidetes being predominant in adults, and Actinobacteria in breast-fed infants, where bifidobacteria can reach levels higher than 90% of the total bacterial population. They are among the first microbial colonizers of the intestines of newborns, and play key roles in the development of their physiology, including maturation of the immune system and use of dietary components. Indeed, some nutrients, such as human milk oligosaccharides, are important drivers of bifidobacterial development. Some Bifidobacterium strains are considered probiotic microorganisms because of their beneficial effects, and they have been included as bioactive ingredients in functional foods, mainly dairy products, as well as in food supplements and pharma products, alone, or together with, other microbes or microbial substrates. Well-documented scientific evidence of their activities is currently available for bifidobacteria containing preparations in some intestinal and extraintestinal pathologies. In particular, it regulates luminal metabolism, maintains gut microbiota stability, and eventually promotes a precisely calibrated homeostatic equilibrium in the host-microbiome relationship. An ideal probiotic selection would benefit from clinical proof of the multifunctional activities&amp;apos; efficacy and mechanism of action.

Middle Molecular Uremic Toxin and Blood Purification Therapy

The purpose of blood purification therapy is to remove uremic toxins, and middle molecules (MMs) are a specific target. An MM is defined as a solute that passes through the glomerulus with a molecular weight in the range of 0.5–58 kDa, and new classifications of “small-middle 0.5–15 kDa,” “medium-middle 15–25 kDa,” and “large-middle 25–58 kDa” were proposed. In Japan, the removal of α1-microglobulin (αMG) in the large-middle range has been the focus, but a new theory of removal has been developed, emphasizing the antioxidant effect of αMG as a physiological function. Clinical proof of this mechanism will lead to further development of blood purification therapies.

Opportunities in Cancer Therapies: Deciphering the Role of Cancer Stem Cells in Tumour Repopulation.

Tumour repopulation during treatment is a well acknowledged yet still challenging aspect of cancer management. The latest research results show clear evidence towards the existence of cancer stem cells (CSCs) that are responsible for tumour repopulation, dissemination, and distant metastases in most solid cancers. Cancer stem cell quiescence and the loss of asymmetrical division are two powerful mechanisms behind repopulation. Another important aspect in the context of cancer stem cells is cell plasticity, which was shown to be triggered during fractionated radiotherapy, leading to cell dedifferentiation and thus reactivation of stem-like properties. Repopulation during treatment is not limited to radiotherapy, as there is clinical proof for repopulation mechanisms to be activated through other conventional treatment techniques, such as chemotherapy. The dynamic nature of stem-like cancer cells often elicits resistance to treatment by escaping drug-induced cell death. The aims of this scoping review are (1) to describe the main mechanisms used by cancer stem cells to initiate tumour repopulation during therapy; (2) to present clinical evidence for tumour repopulation during radio- and chemotherapy; (3) to illustrate current trends in the identification of CSCs using specific imaging techniques; and (4) to highlight novel technologies that show potential in the eradication of CSCs.

Clinical proof of concept for anti-FGF2 therapy in exudative age-related macular degeneration (nAMD): phase 2 trials in treatment-naïve and anti-VEGF pretreated patients

Background/ObjectiveIntravitreal injections of anti-vascular endothelial growth factor (VEGF) agents are the first-line treatment for exudative age-related macular degeneration (nAMD). Due to the limitations of these standard therapies, targeting alternative mechanisms of action may be helpful for treatment of this very common disease. Here, we investigated an anti-fibroblast growth factor-2 (FGF2) aptamer, umedaptanib pegol, a next generation therapeutic for the treatment of nAMD.MethodsThree phase 2 studies were designed. First, a multicentre, randomized, double-masked TOFU study assessed the efficacy of intravitreal injections of umedaptanib pegol monotherapy or in combination with aflibercept, compared to aflibercept monotherapy in 86 subjects with anti-VEGF pretreated nAMD. Second, 22 subjects who had exited the TOFU study received 4 monthly intravitreal injections of umedaptanib pegol (extension, RAMEN study). Third, as an investigator-sponsored trial (TEMPURA study), a single-center, open-label, 4-month study was designed to evaluate the safety and treatment efficacy of umedaptanib pegol in five naïve nAMD patients who had not received any prior anti-VEGF treatment.ResultsThe TOFU study demonstrated that umedaptanib pegol alone or in combination with aflibercept did not improve best-corrected visual acuity (BCVA) and central subfield thickness (CST) over aflibercept alone. However, the change in BCVA and CST at primary endpoint was marginal in all the three treatment groups, suggesting that umedaptanib pegol is effective to prevent the disease progression. The RAMEN study confirmed the cessation of disease progression. In the TEMPURA study, naïve nAMD patients showed improvement and no further macular degeneration, with striking improvement of visual acuity and central subfield thickness in some of the patients.ConclusionsThese results demonstrate, for the first time, clinical proof of concept for aptamer based anti-FGF2 therapy of nAMD.

A fully 3D-printed versatile tumor-on-a-chip allows multi-drug screening and correlation with clinical outcomes for personalized medicine.

Optimal clinical outcomes in cancer treatments could be achieved through the development of reliable, precise ex vivo tumor models that function as drug screening platforms for patient-targeted therapies. Microfluidic tumor-on-chip technology is emerging as a preferred tool since it enables the complex set-ups and recapitulation of the physiologically relevant physical microenvironment of tumors. In order to overcome the common hindrances encountered while using this technology, a fully 3D-printed device was developed that sustains patient-derived multicellular spheroids long enough to conduct multiple drug screening tests. This tool is both cost effective and possesses four necessary characteristics of effective microfluidic devices: transparency, biocompatibility, versatility, and sample accessibility. Compelling correlations which demonstrate a clinical proof of concept were found after testing and comparing different chemotherapies on tumor spheroids, derived from ten patients, to their clinical outcomes. This platform offers a potential solution for personalized medicine by functioning as a predictive drug-performance tool.

Vitamin D Dependent Rickets Type 1a as a Rare Cause of Rickets: Case Report and Literature Review

Aim: The purpose of this paper is to describe one example of type Ia, vitamin D-dependent rickets. Methods: A diagnosis has been made based on physical examination, laboratory results, and radiographic examination. A positive gentic mutation has also been used to corroborate the diagnosis. Results: Here, we present a case of a 2-year-old Saudi girl who exhibits delayed motor development and valgus deformity of the feet together with biochemical and radiographic signs of vitamin D abnormalities. She was initially treated at a peripheral hospital for rickets as Vitamin D deficiency and given cholecalciferol for six months; however, there was little improvement. Later, she was referred to us, and we performed a genetic study that revealed a positive gentic mutation at CYP27B1, confirming the diagnosis of Vitamin D dependent Rickets 1a, and Calcitriol treatment followed. Within 4 weeks, the patient exhibits significant recovery, and both PTH and alkaline phosphatase levels return to normal. After three months of calcitriol treatment, clinical and radiological proof of the improvement was observed. Conclusions: In this research, we raise the knowledge that rickets is not always caused by vitamin deficiency and that early presentations should increase awareness of inherited causes of rickets such VDDR1a that do not react to cholecalciferol and gentic investigation is helpful in such cases.

Time Limited Exposure to a ROR1 Targeting Bispecific T Cell Engager (NVG-111) Leads to Durable Responses in Subjects with Relapsed Refractory Chronic Lymphocytic Leukemia (CLL) and Mantle Cell Lymphoma (MCL)

Background: Receptor tyrosine kinase-like orphan receptor 1 (ROR1) is an oncofetal protein that is absent or expressed at low levels in normal adult tissues but overexpressed in a range of malignancies including CLL and MCL. NVG-111 is a humanized first in class, tandem scFv, ROR1xCD3 bispecific T cell engager. NVG-111 mediates potent killing of ROR1 + tumors by engaging a unique epitope on the Frizzled domain of ROR1 and redirecting T cell activity via the CD3 binder engineered for attenuated cytokine release. Methods: In this phase 1, first-in-human, dose-escalation study (ClinicalTrials.gov identifier: NCT04763083), NVG-111 was evaluated in relapsed/refractory CLL and MCL subjects with an ECOG PS of 0-2 who received ≥2 prior lines of treatment including a Bruton tyrosine kinase inhibitor (BTKi). Bayesian continual reassessment method with overdose control was implemented to guide escalation over a dose range of 0.3-45ug/day. Each subject received at least one dose of NVG-111, administered as a continuous intravenous infusion (cIV) over 21 days followed by 7 days off drug (=1 cycle). NVG-111 was administered in combination (N=8) with ibrutinib to subjects who had achieved a partial response to &amp;gt;1 year of ibrutinib therapy, or as monotherapy in subjects that progressed after covalent BTKi/B-cell lymphoma 2 inhibitor (BCL2i) (N=4). Primary objective was safety, with the secondary objectives being efficacy (overall response rates [ORR], minimal residual disease (MRD) measured by ERIC-compliant flow cytometry and duration of response [DoR]). Serum cytokine levels were determined using a human high sensitivity cytokine premixed magnetic Luminex assay and T cell function was longitudinally evaluated using cytometry by time of flight (CyTOF) analysis. Results: Between May 2021 and July 2023 12 subjects (10 males and 2 females, median age 60 years) completed a maximum of 6 cycles of treatment with NVG-111 (median=3 cycles [range 1-6 cycles]). Pharmacokinetic and pharmacodynamic data demonstrated systemic NVG-111 exposure and exposure-dependent NVG-111 targeting of ROR1 on circulating tumor cells. Adverse events (AEs) related to NVG-111 occurred in 10 subjects (83%), with the most common being nausea (58%), headaches (67%), and fatigue (33%), majority of which were grade 1 or 2. Grade 1(71%) or 2(29%) cytokine release syndrome (CRS) occurred in 58% of subjects during week 1 of cycle 1 except in one subject who had a second grade 1 CRS in cycle 2. Grade 3 dose limiting toxicities (DLTs) occurred in three subjects (25%) consisting of transient elevation of liver enzymes (ALT and AST) in one subject dosed at 3ug/day, immune effector cell-associated neurotoxicity syndrome-like symptoms (ICANS) in one subject dosed at 30ug/day and headache in one subject dosed at 45ug/day. All AEs were fully reversible with no late emergent grade 3 or greater toxicities. Evidence of T cell activation was observed in all 12 subjects with peak cytokine levels at the 30µg/day dose levels (mean±SEM): TNFα, 43±17pg/ml; IL6, 566±541pg/ml; IFNɣ, 18±12pg/ml; and IL10, 103±56pg/ml. Furthermore, T cell profiling showed an increase in cytotoxic CD8 + T cell activation marker expression during each NVG-111 treatment cycle without evidence of T cell exhaustion. Efficacy was evaluable in 11 subjects with objective clinical responses observed in 55% (6/11), including two subjects with clear evidence of single agent activity. Amongst these, three CLL subjects were rendered MRD negative in peripheral blood and one MCL subject achieved complete metabolic response by the Lugano criteria. Two subjects had stable disease but in one of these subjects there was a &amp;gt;50% reduction in peripheral blood lymphocytosis and a 40% reduction in lymphadenopathy. Despite time limited exposure to NVG-111, the restricted mean survival time for DoR is currently 13.6 months (SEM 3.07), the median is not yet calculable with response ongoing in four subjects. The median progression-free survival currently is 18.7 months (95% CI 2.6 - not calculable). Conclusion: These data provide clinical proof of concept for selective targeting of ROR1 with a TCE leading to objective evidence of antitumor activity with encouraging response durability even in CLL patients known to have defective T cell function. The safety profile was consistent with the mechanism of action. Further evaluation of this promising molecule is ongoing.

Klinische Forschung im Dienst der Heilkunde: Kontexte, Praxis, Methodik und Theorie des „klinischen Beweises“ von Paul Martini. Beitrag 3: Kausalanalytisch relevante Elemente des klinischen Beweises und epistemologische Kommentare

In the third part of our quadripartite series on Paul Martini and his concept of clinical proof we shortly present the mostly procedural elements of his test of treatment. We discuss their causal conduciveness: what do they contribute to infer causality from effect? Finally we comment on some of Martini’s epistemological assumptions and methodological decisions that underpin his method of proof.