Single-inhaler fluticasone furoate/umeclidinium/vilanterol versus fluticasone furoate/vilanterol plus umeclidinium using two inhalers for chronic obstructive pulmonary disease: A randomized non-inferiority study

Background: Single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) 100/62.5/25 μg has been shown to improve lung function and health status, and reduce exacerbations, versus budesonide/formoterol in patients with chronic obstructive pulmonary disease (COPD). We evaluated the non-inferiority of single-inhaler FF/UMEC/VI versus FF/VI + UMEC using two inhalers. Methods: Eligible patients with COPD (aged ≥40 years; ≥1 moderate/severe exacerbation in the 12 months before screening) were randomized (1:1; stratified by the number of long-acting bronchodilators [0, 1 or 2] per day during run-in) to receive 24-week FF/UMEC/VI 100/62.5/25 μg and placebo or FF/VI 100/25 μg + UMEC 62.5 μg; all treatments/placebo were delivered using the ELLIPTA inhaler once-daily in the morning. Primary endpoint: change from baseline in trough forced expiratory volume in 1 s (FEV1) at Week 24. The non-inferiority margin for the lower 95% confidence limit was set at − 50 mL. Results: A total of 1055 patients (844 [80%] of whom were enrolled on combination maintenance therapy) were randomized to receive FF/UMEC/VI (n = 527) or FF/VI + UMEC (n = 528). Mean change from baseline in trough FEV1 at Week 24 was 113 mL (95% CI 91, 135) for FF/UMEC/VI and 95 mL (95% CI 72, 117) for FF/VI + UMEC; the between-treatment difference of 18 mL (95% CI -13, 50) confirmed FF/UMEC/VI’s was considered non-inferior to FF/ VI + UMEC. At Week 24, the proportion of responders based on St George’s Respiratory Questionnaire Total score was 50% (FF/UMEC/VI) and 51% (FF/VI + UMEC); the proportion of responders based on the Transitional Dyspnea Index focal score was similar (56% both groups). A similar proportion of patients experienced a moderate/severe exacerbation in the FF/UMEC/VI (24%) and FF/VI + UMEC (27%) groups; the hazard ratio for time to first moderate/ severe exacerbation with FF/UMEC/VI versus FF/VI + UMEC was 0.87 (95% CI 0.68, 1.12). The incidence of adverse events was comparable in both groups (48%); the incidence of serious adverse events was 10% (FF/UMEC/VI) and 11% (FF/VI + UMEC). Conclusions: Single-inhaler triple therapy (FF/UMEC/VI) is non-inferior to two inhalers (FF/VI + UMEC) on trough FEV1 change from baseline at 24 weeks. Results were similar on all other measures of efficacy, health-related quality of life, and safety. Trial registration: GSK study CTT200812; ClinicalTrials.gov NCT02729051 (submitted 31 March 2016)

Increased CO₂ loss from vegetated drained lake tundra ecosystems due to flooding

Tundra ecosystems are especially sensitive to climate change, which is particularly rapid in high northern latitudes resulting in significant alterations in temperature and soil moisture. Numerous studies have demonstrated that soil drying increases the respiration loss from wet Arctic tundra. And, warming and drying of tundra soils are assumed to increase CO2 emissions from the Arctic. However, in this water table manipulation experiment (i.e., flooding experiment), we show that flooding of wet tundra can also lead to increased CO2 loss. Standing water increased heat conduction into the soil, leading to higher soil temperature, deeper thaw and, surprisingly, to higher CO2 loss in the most anaerobic of the experimental areas. The study site is located in a drained lake basin, and the soils are characterized by wetter conditions than upland tundra. In experimentally flooded areas, high wind speeds (greater than ~4 m s−1) increased CO2 emission rates, sometimes overwhelming the photosynthetic uptake, even during daytime. This suggests that CO2 efflux from C rich soils and surface waters can be limited by surface exchange processes. The comparison of the CO2 and CH4 emission in an anaerobic soil incubation experiment showed that in this ecosystem, CO2 production is an order of magnitude higher than CH4 production. Future increases in surface water ponding, linked to surface subsidence and thermokarst erosion, and concomitant increases in soil warming, can increase net C efflux from these arctic ecosystems

Temperature Response of Respiration Across the Heterogeneous Landscape of the Alaskan Arctic Tundra

AbstractPredictions of the response of ecosystem respiration to warming in the Arctic are not well constrained, partly due to the considerable spatial heterogeneity of these permafrost‐dominated areas. Accurate calculations of in situ temperature sensitivities of respiration (Q10) are vital for the prediction of future Arctic emissions. To understand the impact of spatial heterogeneity on respiration rates and Q10, we compared respiration measured from automated chambers across the main local polygonized landscape forms (high and low centers, polygon rims, polygon troughs) to estimates from the flux‐partitioned net ecosystem exchange collected in an adjacent eddy covariance tower. Microtopographic type appears to be the most important variable explaining the variability in respiration rates, and low‐center polygons and polygon troughs show the greatest cumulative respiration rates, possibly linked to their deeper thaw depth and higher plant biomass. Regardless of the differences in absolute respiration rates, Q10 is surprisingly similar across all microtopographic features, possibly indicating a similar temperature limitation to decomposition across the landscape. Q10 was higher during the colder early summer and lower during the warmer peak growing season, consistent with an elevated temperature sensitivity under colder conditions. The respiration measured by the chambers and the estimates from the daytime flux‐partitioned eddy covariance data were within uncertainties during early and peak seasons but overestimated respiration later in the growing season. Overall, this study suggests that it is possible to simplify estimates of the temperature sensitivity of respiration across heterogeneous landscapes but that seasonal changes in Q10 should be incorporated into model simulations

Deformable Model for 3D Intramodal Nonrigid Breast Image Registration with Fiducial Skin Markers

We implemented a new approach to intramodal non-rigid 3D breast image registration. Our method uses fiducial skin markers (FSM) placed on the breast surface. After determining the displacements of FSM, finite element method (FEM) is used to distribute the markers’ displacements linearly over the entire breast volume using the analogy between the orthogonal components of the displacement field and a steady state heat transfer (SSHT). It is valid because the displacement field in x, y and z direction and a SSHT problem can both be modeled using LaPlace’s equation and the displacements are analogous to temperature differences in SSHT. It can be solved via standard heat conduction FEM software with arbitrary conductivity of surface elements significantly higher than that of volume elements. After determining the displacements of the mesh nodes over the entire breast volume, moving breast volume is registered to target breast volume using an image warping algorithm. Very good quality of the registration was obtained. Following similarity measurements were estimated: Normalized Mutual Information (NMI), Normalized Correlation Coefficient (NCC) and Sum of Absolute Valued Differences (SAVD). We also compared our method with rigid registration technique

Single-inhaler triple therapy fluticasone furoate/umeclidinium/vilanterol versus fluticasone furoate/vilanterol and umeclidinium/vilanterol in patients with COPD:results on cardiovascular safety from the IMPACT trial

BACKGROUND: This analysis of the IMPACT study assessed the cardiovascular (CV) safety of single-inhaler triple therapy with fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) versus FF/VI and UMEC/VI dual therapy. METHODS: IMPACT was a 52-week, randomized, double-blind, multicenter Phase III study comparing the efficacy and safety of FF/UMEC/VI 100/62.5/25 mcg with FF/VI 100/25 mcg or UMEC/VI 62.5/25 mcg in patients ≥40 years of age with symptomatic chronic obstructive pulmonary disease (COPD) and ≥1 moderate/severe exacerbation in the previous year. The inclusion criteria for the study were intentionally designed to permit the enrollment of patients with significant concurrent CV disease/risk. CV safety assessments included proportion of patients with and exposure-adjusted rates of on-treatment CV adverse events of special interest (CVAESI) and major adverse cardiac events (MACE), as well as time-to-first (TTF) CVAESI, and TTF CVAESI resulting in hospitalization/prolonged hospitalization or death. RESULTS: Baseline CV risk factors were similar across treatment groups. Overall, 68% of patients (n = 7012) had ≥1 CV risk factor and 40% (n = 4127) had ≥2. At baseline, 29% of patients reported a current/past cardiac disorder and 58% reported a current/past vascular disorder. The proportion of patients with on-treatment CVAESI was 11% for both FF/UMEC/VI and UMEC/VI, and 10% for FF/VI. There was no statistical difference for FF/UMEC/VI versus FF/VI or UMEC/VI in TTF CVAESI (hazard ratio [HR]: 0.98, 95% confidence interval [CI]: 0.85, 1.11; p = 0.711 and HR: 0.92, 95% CI: 0.78, 1.08; p = 0.317, respectively) nor TTF CVAESI leading to hospitalization/prolonged hospitalization or death (HR: 1.19, 95% CI: 0.93, 1.51; p = 0.167 and HR: 0.96, 95% CI: 0.72, 1.27; p = 0.760, respectively). On-treatment MACE occurred in ≤3% of patients across treatment groups, with similar prevalence and rates between treatments. CONCLUSIONS: In a symptomatic COPD population with a history of exacerbations and a high rate of CV disease/risk, the proportion of patients with CVAESI and MACE was 10-11% and 1-3%, respectively, across treatment arms, and the risk of CVAESI was low and similar across treatment arms. There was no statistically significant increased CV risk associated with the use of FF/UMEC/VI versus FF/VI or UMEC/VI, and UMEC/VI versus FF/VI. TRIAL REGISTRATION: NCT02164513 (GSK study number CTT116855)

InforMing the PAthway of COPD Treatment (IMPACT) Trial: Fibrinogen Levels Predict Risk of Moderate or Severe Exacerbations

Background: Fibrinogen is the frst qualifed prognostic/predictive biomarker for exacerbations in patients with chronic obstructive pulmonary disease (COPD). The IMPACT trial investigated futicasone furoate/umeclidinium/ vilanterol (FF/UMEC/VI) triple therapy versus FF/VI and UMEC/VI in patients with symptomatic COPD at risk of exacer‑ bations. This analysis used IMPACT trial data to examine the relationship between fbrinogen levels and exacerbation outcomes in patients with COPD. Methods: 8094 patients with a fbrinogen assessment at Week 16 were included, baseline fbrinogen data were not measured. Post hoc analyses were performed by fbrinogen quartiles and by 3.5 g/L threshold. Endpoints included on-treatment exacerbations and adverse events of special interest (AESIs). Results: Rates of moderate, moderate/severe, and severe exacerbations were higher in the highest versus lowest fibrinogen quartile (0.75, 0.92 and 0.15 vs 0.67, 0.79 and 0.10, respectively). The rate ratios (95% confidence interval [CI]) for exacerbations in patients with fibrinogen levels ≥ 3.5 g/L versus those with fibrinogen levels \u3c 3.5 g/L were 1.03 (0.95, 1.11) for moderate exacerbations, 1.08 (1.00, 1.15) for moderate/severe exacerbations, and 1.30 (1.10, 1.54) for severe exacerbations. There was an increased risk of moderate/severe exacerbation (hazard ratio [95% CI]: highest vs lowest quartile 1.16 [1.04, 1.228]; ≥ 3.5 g/L vs \u3c 3.5 g/L: 1.09 [1.00, 1.16]) and severe exacerbation (1.35 [1.09, 1.69]; 1.27 [1.08, 1.47], respectively) with increasing fibrinogen level. Cardiovascular AESIs were highest in patients in the highest fibrinogen quartile. Conclusions: Rate and risk of exacerbations was higher in patients with higher fbrinogen levels. This supports the validity of fbrinogen as a predictive biomarker for COPD exacerbations, and highlights the potential use of fbrinogen as an enrichment strategy in trials examining exacerbation outcomes

Ipilimumab administration for advanced melanoma in patients with pre-existing Hepatitis B or C infection: a multicenter, retrospective case series

Ipilimumab is a fully human, monoclonal antibody directed against Cytotoxic T Lymphocyte Antigen-4 (CTLA-4) that has demonstrated a survival benefit and durable disease control in patients with advanced melanoma. Ipilimumab is associated with potentially serious immune-related adverse events, including autoimmune hepatitis. Because clinical trials of ipilimumab excluded patients with pre-existing hepatitis B or C infection, there is a paucity of data on the safety of ipilimumab administration to that patient population. Here, we report the largest case series to date of patients with hepatitis B or C who received ipilimumab for advanced melanoma. Two of the nine patients described in this case series experienced fluctuations in their liver function tests (LFTs) and were subsequently treated with corticosteroids. Although this is a small series, the rate of hepatotoxicity appears similar to what has been seen in the general population treated with ipilimumab, and the ability to administer ipilimumab did not appear to be affected by concomitant hepatitis B or C infection. The use of ipilimumab in patients with metastatic melanoma who have pre-existing hepatitis can be considered among other therapeutic options

The proteasome cap RPT5/Rpt5p subunit prevents aggregation of unfolded ricin A chain

The plant cytotoxin ricin enters mammalian cells by receptor-mediated endocytosis, undergoing retrograde transport to the endoplasmic reticulum (ER) where its catalytic A chain (RTA) is reductively separated from the holotoxin to enter the cytosol and inactivate ribosomes. The currently accepted model is that the bulk of ER-dislocated RTA is degraded by proteasomes. We show here that the proteasome has a more complex role in ricin intoxication than previously recognised, that the previously reported increase in sensitivity of mammalian cells to ricin in the presence of proteasome inhibitors simply reflects toxicity of the inhibitors themselves, and that RTA is a very poor substrate for proteasomal degradation. Denatured RTA and casein compete for a binding site on the regulatory particle of the 26S proteasome, but their fates differ. Casein is degraded, but the mammalian 26S proteasome AAA-ATPase subunit RPT5 acts as a chaperone that prevents aggregation of denatured RTA and stimulates recovery of catalytic RTA activity in vitro. Furthermore, in vivo, the ATPase activity of Rpt5p is required for maximal toxicity of RTA dislocated from the Saccharomyces cerevisiae ER. Our results implicate RPT5/Rpt5p in the triage of substrates in which either activation (folding) or inactivation (degradation) pathways may be initiated