Albiglutide and cardiovascular outcomes in patients with type 2 diabetes and cardiovascular disease (Harmony Outcomes): a double-blind, randomised placebo-controlled trial

Background: Glucagon-like peptide 1 receptor agonists differ in chemical structure, duration of action, and in their effects on clinical outcomes. The cardiovascular effects of once-weekly albiglutide in type 2 diabetes are unknown. We aimed to determine the safety and efficacy of albiglutide in preventing cardiovascular death, myocardial infarction, or stroke. Methods: We did a double-blind, randomised, placebo-controlled trial in 610 sites across 28 countries. We randomly assigned patients aged 40 years and older with type 2 diabetes and cardiovascular disease (at a 1:1 ratio) to groups that either received a subcutaneous injection of albiglutide (30–50 mg, based on glycaemic response and tolerability) or of a matched volume of placebo once a week, in addition to their standard care. Investigators used an interactive voice or web response system to obtain treatment assignment, and patients and all study investigators were masked to their treatment allocation. We hypothesised that albiglutide would be non-inferior to placebo for the primary outcome of the first occurrence of cardiovascular death, myocardial infarction, or stroke, which was assessed in the intention-to-treat population. If non-inferiority was confirmed by an upper limit of the 95% CI for a hazard ratio of less than 1·30, closed testing for superiority was prespecified. This study is registered with ClinicalTrials.gov, number NCT02465515. Findings: Patients were screened between July 1, 2015, and Nov 24, 2016. 10 793 patients were screened and 9463 participants were enrolled and randomly assigned to groups: 4731 patients were assigned to receive albiglutide and 4732 patients to receive placebo. On Nov 8, 2017, it was determined that 611 primary endpoints and a median follow-up of at least 1·5 years had accrued, and participants returned for a final visit and discontinuation from study treatment; the last patient visit was on March 12, 2018. These 9463 patients, the intention-to-treat population, were evaluated for a median duration of 1·6 years and were assessed for the primary outcome. The primary composite outcome occurred in 338 (7%) of 4731 patients at an incidence rate of 4·6 events per 100 person-years in the albiglutide group and in 428 (9%) of 4732 patients at an incidence rate of 5·9 events per 100 person-years in the placebo group (hazard ratio 0·78, 95% CI 0·68–0·90), which indicated that albiglutide was superior to placebo (p<0·0001 for non-inferiority; p=0·0006 for superiority). The incidence of acute pancreatitis (ten patients in the albiglutide group and seven patients in the placebo group), pancreatic cancer (six patients in the albiglutide group and five patients in the placebo group), medullary thyroid carcinoma (zero patients in both groups), and other serious adverse events did not differ between the two groups. There were three (<1%) deaths in the placebo group that were assessed by investigators, who were masked to study drug assignment, to be treatment-related and two (<1%) deaths in the albiglutide group. Interpretation: In patients with type 2 diabetes and cardiovascular disease, albiglutide was superior to placebo with respect to major adverse cardiovascular events. Evidence-based glucagon-like peptide 1 receptor agonists should therefore be considered as part of a comprehensive strategy to reduce the risk of cardiovascular events in patients with type 2 diabetes. Funding: GlaxoSmithKline

Evaluation of Alloreactivity in Kidney Transplant Recipients Treated with Antithymocyte Globulin Versus IL-2 Receptor Blocker

Induction therapy is used in kidney transplantation to inhibit the activation of donor reactive T cells which are detrimental to transplant outcomes. Choice of induction therapy is decided based on perceived immunological risk rather than by direct measurement of donor T cell reactivity. We hypothesized that immune cellular alloreactivity pre-transplantation can be quantified and that blocking versus deleting therapies have differential effects on the level of donor and third party cellular alloreactivity. We studied 31 kidney transplant recipients treated with either anti-thymocyte globulin (ATG) or an IL-2 receptor blocker. We tested pre- and post-transplant peripheral blood cells by flow cytometry to characterize T cell populations and by IFN-γ ELISPOT assays to assess the level of cellular alloreactivity. CD8(+) T cells were more resistant to depletion by ATG than CD4(+) T cells. Post-transplantation, frequencies of donor reactive T cells were markedly decreased in the ATG-treated group but not in the IL-2 receptor blocker group, whereas the frequencies of third party alloreactivity remained nearly equivalent. In conclusion, when ATG is used, marked and prolonged donor hyporesponsiveness with minimal effects on non-donor responses is observed. In contrast, induction with the IL-2 receptor blocker is less effective at diminishing donor T cell reactivity

Molecular Diagnosis of Ewing Family Tumors: Too Many Fusions… ?

In the field of sarcoma molecular diagnosis, the “test” most frequently requested is for the gene fusions generated by the chromosomal translocations in Ewing family tumors (EFTs). Of note, this test is perhaps the most complicated of all of the molecular assays in the sarcoma diagnostic toolbox. Starting with the frequent 11;22 translocation involving the EWS gene on chromosome 22 and the FLI1 gene on chromosome 11, the chromosome breakpoints are spread among four introns in the EWS gene and six introns in the FLI1 gene to give a large number of possible EWS-FLI1 fusion products.1 The size of the fusion transcripts can vary over a 700-bp range, thereby necessitating cautious investigation of a large range of product sizes in diagnostic reverse transcription-polymerase chain reaction (RT-PCR) assays. To increase the complexity further, a relatively frequent variant 21;22 chromosomal translocation generates a fusion of EWS to ERG, which encodes an ETS domain-containing transcription factor highly related to FLI1 with a comparable distribution of chromosomal breakpoints.1 Next, as described in the article by Wang and associates in this issue of The Journal of Molecular Diagnostics,2 the complexity continues to rise as there are three additional translocations [t(2;22), t(7;22), and t(17;22)] that juxtapose EWS to genes, encoding three additional members of the ETS transcription factor family (FEV, ETV1, and E1AF, respectively) in small numbers of EFT cases. In addition to these rare variant fusions, there is also a second set of rare variants involving the FUS gene, which encodes an RNA-binding protein highly related to EWS. This second set includes a 16;21 translocation in which FUS is juxtaposed to ERG,3 which was found in a small group of cases and, as described by Ng and colleagues4 also in this issue of the JMD, a FUS-FEV fusion resulting from a novel 2;16 translocation found in a single case. Based on these collective findings, a definitive investigation of the gene fusions associated with EFT is, to put it simply, a daunting task