Post-intervention Status in Patients With Refractory Myasthenia Gravis Treated With Eculizumab During REGAIN and Its Open-Label Extension

OBJECTIVE: To evaluate whether eculizumab helps patients with anti-acetylcholine receptor-positive (AChR+) refractory generalized myasthenia gravis (gMG) achieve the Myasthenia Gravis Foundation of America (MGFA) post-intervention status of minimal manifestations (MM), we assessed patients' status throughout REGAIN (Safety and Efficacy of Eculizumab in AChR+ Refractory Generalized Myasthenia Gravis) and its open-label extension. METHODS: Patients who completed the REGAIN randomized controlled trial and continued into the open-label extension were included in this tertiary endpoint analysis. Patients were assessed for the MGFA post-intervention status of improved, unchanged, worse, MM, and pharmacologic remission at defined time points during REGAIN and through week 130 of the open-label study. RESULTS: A total of 117 patients completed REGAIN and continued into the open-label study (eculizumab/eculizumab: 56; placebo/eculizumab: 61). At week 26 of REGAIN, more eculizumab-treated patients than placebo-treated patients achieved a status of improved (60.7% vs 41.7%) or MM (25.0% vs 13.3%; common OR: 2.3; 95% CI: 1.1-4.5). After 130 weeks of eculizumab treatment, 88.0% of patients achieved improved status and 57.3% of patients achieved MM status. The safety profile of eculizumab was consistent with its known profile and no new safety signals were detected. CONCLUSION: Eculizumab led to rapid and sustained achievement of MM in patients with AChR+ refractory gMG. These findings support the use of eculizumab in this previously difficult-to-treat patient population. CLINICALTRIALSGOV IDENTIFIER: REGAIN, NCT01997229; REGAIN open-label extension, NCT02301624. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that, after 26 weeks of eculizumab treatment, 25.0% of adults with AChR+ refractory gMG achieved MM, compared with 13.3% who received placebo

Minimal Symptom Expression' in Patients With Acetylcholine Receptor Antibody-Positive Refractory Generalized Myasthenia Gravis Treated With Eculizumab

The efficacy and tolerability of eculizumab were assessed in REGAIN, a 26-week, phase 3, randomized, double-blind, placebo-controlled study in anti-acetylcholine receptor antibody-positive (AChR+) refractory generalized myasthenia gravis (gMG), and its open-label extension

Understanding the relation between Zika virus infection during pregnancy and adverse fetal, infant and child outcomes: a protocol for a systematic review and individual participant data meta-analysis of longitudinal studies of pregnant women and their infants and children

IntroductionZika virus (ZIKV) infection during pregnancy is a known cause of microcephaly and other congenital and developmental anomalies. In the absence of a ZIKV vaccine or prophylactics, principal investigators (PIs) and international leaders in ZIKV research have formed the ZIKV Individual Participant Data (IPD) Consortium to identify, collect and synthesise IPD from longitudinal studies of pregnant women that measure ZIKV infection during pregnancy and fetal, infant or child outcomes.Methods and analysisWe will identify eligible studies through the ZIKV IPD Consortium membership and a systematic review and invite study PIs to participate in the IPD meta-analysis (IPD-MA). We will use the combined dataset to estimate the relative and absolute risk of congenital Zika syndrome (CZS), including microcephaly and late symptomatic congenital infections; identify and explore sources of heterogeneity in those estimates and develop and validate a risk prediction model to identify the pregnancies at the highest risk of CZS or adverse developmental outcomes. The variable accuracy of diagnostic assays and differences in exposure and outcome definitions means that included studies will have a higher level of systematic variability, a component of measurement error, than an IPD-MA of studies of an established pathogen. We will use expert testimony, existing internal and external diagnostic accuracy validation studies and laboratory external quality assessments to inform the distribution of measurement error in our models. We will apply both Bayesian and frequentist methods to directly account for these and other sources of uncertainty.Ethics and disseminationThe IPD-MA was deemed exempt from ethical review. We will convene a group of patient advocates to evaluate the ethical implications and utility of the risk stratification tool. Findings from these analyses will be shared via national and international conferences and through publication in open access, peer-reviewed journals.Trial registration numberPROSPERO International prospective register of systematic reviews (CRD42017068915).</jats:sec

Interleukin-4 deficiency protects mice from acetaminophen-induced liver injury and inflammation by prevention of glutathione depletion

OBJECTIVE: Interleukin-4 (IL-4) is a multifunctional cytokine involved in many diseases such as autoimmune hepatitis and idiosyncratic drug reactions. However, its role in acetaminophen (APAP)-induced liver injury remains unclear. Our objective was to evaluate the contribution of IL-4 to the pathogenesis of APAP-induced liver injury. METHODS: Balb/C (WT) and IL-4 knockout (IL-4(-/-)) mice were orally overdosed with APAP. After 24 h, survival percentage, biochemical and morphological markers of liver injury, and tissue inflammation were assessed. RESULTS: IL-4(-/-) mice were protected from APAP toxicity. Intravital confocal microscopy, tissue histology and serum ALT levels showed significantly less liver injury and inflammation than in the WT group, which may explain the increased survival rate of IL-4(-/-) mice. In addition, IL-4(-/-) mice had decreased production of tumor necrosis factor α, CXCL1 and interleukin-1β in the liver, but not in a remote site such as the lungs. Hepatic macrophage activation was markedly reduced in IL-4-deficient mice. In addition, glutathione depletion-a primary cause of APAP-mediated injury-was significantly attenuated in IL-4(-/-) mice. CONCLUSIONS: Taken together, our data demonstrate that IL-4(-/-) mice are protected from APAP-induced liver injury due to reduced depletion of glutathione, which prevented liver damage and tissue inflammation.status: publishe

The Pivotal Role of 5-Lipoxygenase-Derived LTB₄ in Controlling Pulmonary Paracoccidioidomycosis

<div><p>Leukotrienes (LTs) produced from arachidonic acid by the action of 5-lipoxygenase (5-LO) are classical mediators of inflammatory responses. However, studies published in the literature regarding these mediators are contradictory and it remains uncertain whether these lipid mediators play a role in host defense against the fungal pathogen <i>Paracoccidioides brasiliensis</i>. To determine the involvement of LTs in the host response to pulmonary infection, wild-type and LT-deficient mice by targeted disruption of the 5-lipoxygenase gene (knockout mice) were studied following intratracheal challenge with <i>P. brasiliensis</i> yeasts. The results showed that infection is uniformly fatal in 5-LO-deficient mice and the mechanisms that account for this phenotype are an exacerbated lung injury and higher fungal pulmonary burden. Genetic ablation or pharmacological inhibition of LTs resulted in lower phagocytosis and fungicidal activity of macrophages <i>in vitro</i>, suggesting that deficiency in fungal clearance seems to be secondary to the absence of activation in 5-LO^−/− macrophages. Exogenous LTB₄ restored phagocytosis and fungicidal activity of 5-LO^−/− macrophages. Moreover, <i>P. brasiliensis</i> killing promoted by LTB₄ was dependent on nitric oxide (NO) production by macrophages. Taken together, these results reveal a fundamental role for 5-LO-derived LTB₄ in the protective response to <i>P. brasiliensis</i> infection and identify relevant mechanisms for the control of fungal infection during the early stages of the host immune response.</p></div

Effects of exogenous LTB₄ on phagocytosis and fungicidal activity <i>in vitro</i> during infection with <i>P. brasiliensis</i>.

<p>Peritoneal WT and 5-LO^−/− macrophages were treated with LTB₄ (100 mM) for 30 min before the addition of <i>P. brasiliensis</i> yeasts. Phagocytic index (A) and intracellular killing (B) were calculated 24 h after incubation. Killing assay was normalized according initial ingestion (PI) and presented as <i>P. brasiliensis</i> survival. The supernatants were harvested and nitrite concentrations (C) were measured. (D) ROS concentrations were determined by mean fluorescence intensity (DHR-123) in macrophage cultures after infection. Each value represents the mean ± SEM of triplicate cultures from two independent experiments. Symbol * represents significant difference (*p<0.05, **p<0.01, ***p<0.001) compared to WT infected group. Symbol ^† represents significant difference (^††p<0.01, ^†††p<0.001) between the same experimental group compared to different culture conditions.</p

Role of 5-LO in survival, myeloperoxidase activity, fungal load and histopathological alterations after <i>P. brasiliensis</i> infection.

<p>Groups of WT and 5-LO^−/− mice were infected with 10⁶ yeasts. (A) Survival rate was assessed daily until the 30^th day of infection. (B) Infiltration of neutrophils in the lungs of mice was determined by MPO activity and expressed in relative units. (C) Pulmonary fungal load in WT and 5-LO^−/− mice. Viable yeasts were evaluated by CFU counting in lung homogenates obtained 24 and 72 h after infection. (D) Inflammatory score of lung sections evaluated 24 and 72 h after infection in WT and 5-LO^−/− mice. (E) Representative photomicrographs of H&E-stained lung sections from WT (upper line) and 5-LO^−/− (bottom line) mice 24 and 72 h after <i>P. brasiliensis</i> infection (bars = 100 µm, original magnification, ×10). Control, uninfected mice (NI) received only sterile PBS. Results were expressed as the mean ± SEM and are representative of two independent experiments (n = 5). Symbol * represents significant difference (*p<0.05, **p<0.01, ***p<0.001) when compared to uninfected control or infected mice counterparts at 24 h after infection. Symbol ^† represents significant difference (^†p<0.05) to infected mice counterparts in evaluated periods. Symbol ^‡ represents significant difference (^‡p<0.05, ^‡‡‡p<0.001) between WT and 5-LO^−/− mice in the respective period evaluated.</p

Effect of LTB₄- or cysLT-receptor antagonists on macrophage phagocytosis and fungicidal activity against <i>P. brasiliensis</i>.

<p>Peritoneal WT macrophages were treated with vehicle, LTB₄ receptor antagonist CP-105,696 (CP) (1 mM) or cysteinyl-LT receptor antagonist montelukast (MK) (10 mM) for 30 min before the addition of <i>P. brasiliensis</i> yeasts. Phagocytic index (A) and intracellular killing (B) were calculated 24 h after incubation. Killing assay was normalized according initial ingestion (PI) and presented as <i>P. brasiliensis</i> survival. The supernatants were harvested and nitrite concentrations (C) were measured. (D) ROS concentrations were determined by mean fluorescence intensity (DHR-123) in macrophage cultures after infection. Each value represents the mean ± SEM of triplicate cultures from two independent experiments. Symbol * represents significant difference (*p<0.05, **p<0.01, ***p<0.001) compared to control group (macrophages that were treated with vehicle and infected with <i>P. brasiliens</i> yeasts). Symbol ^† represents significant difference (^†p<0.05, ^†††p<0.001) compared to IFN-γ control group (macrophages that were activated with IFN-γ, treated with vehicle and infected with <i>P. brasiliens</i> yeasts). Symbol ^‡ represents significant difference (^‡‡p<0.01) between the same experimental group compared to different culture conditions.</p