EuReCa ONE—27 Nations, ONE Europe, ONE Registry A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe

AbstractIntroductionThe aim of the EuReCa ONE study was to determine the incidence, process, and outcome for out of hospital cardiac arrest (OHCA) throughout Europe.MethodsThis was an international, prospective, multi-centre one-month study. Patients who suffered an OHCA during October 2014 who were attended and/or treated by an Emergency Medical Service (EMS) were eligible for inclusion in the study. Data were extracted from national, regional or local registries.ResultsData on 10,682 confirmed OHCAs from 248 regions in 27 countries, covering an estimated population of 174 million. In 7146 (66%) cases, CPR was started by a bystander or by the EMS. The incidence of CPR attempts ranged from 19.0 to 104.0 per 100,000 population per year. 1735 had ROSC on arrival at hospital (25.2%), Overall, 662/6414 (10.3%) in all cases with CPR attempted survived for at least 30 days or to hospital discharge.ConclusionThe results of EuReCa ONE highlight that OHCA is still a major public health problem accounting for a substantial number of deaths in Europe.EuReCa ONE very clearly demonstrates marked differences in the processes for data collection and reported outcomes following OHCA all over Europe. Using these data and analyses, different countries, regions, systems, and concepts can benchmark themselves and may learn from each other to further improve survival following one of our major health care events

Effect of aliskiren on post-discharge outcomes among diabetic and non-diabetic patients hospitalized for heart failure: insights from the ASTRONAUT trial

Aims The objective of the Aliskiren Trial on Acute Heart Failure Outcomes (ASTRONAUT) was to determine whether aliskiren, a direct renin inhibitor, would improve post-discharge outcomes in patients with hospitalization for heart failure (HHF) with reduced ejection fraction. Pre-specified subgroup analyses suggested potential heterogeneity in post-discharge outcomes with aliskiren in patients with and without baseline diabetes mellitus (DM). Methods and results ASTRONAUT included 953 patients without DM (aliskiren 489; placebo 464) and 662 patients with DM (aliskiren 319; placebo 343) (as reported by study investigators). Study endpoints included the first occurrence of cardiovascular death or HHF within 6 and 12 months, all-cause death within 6 and 12 months, and change from baseline in N-terminal pro-B-type natriuretic peptide (NT-proBNP) at 1, 6, and 12 months. Data regarding risk of hyperkalaemia, renal impairment, and hypotension, and changes in additional serum biomarkers were collected. The effect of aliskiren on cardiovascular death or HHF within 6 months (primary endpoint) did not significantly differ by baseline DM status (P = 0.08 for interaction), but reached statistical significance at 12 months (non-DM: HR: 0.80, 95% CI: 0.64-0.99; DM: HR: 1.16, 95% CI: 0.91-1.47; P = 0.03 for interaction). Risk of 12-month all-cause death with aliskiren significantly differed by the presence of baseline DM (non-DM: HR: 0.69, 95% CI: 0.50-0.94; DM: HR: 1.64, 95% CI: 1.15-2.33; P < 0.01 for interaction). Among non-diabetics, aliskiren significantly reduced NT-proBNP through 6 months and plasma troponin I and aldosterone through 12 months, as compared to placebo. Among diabetic patients, aliskiren reduced plasma troponin I and aldosterone relative to placebo through 1 month only. There was a trend towards differing risk of post-baseline potassium ≥6 mmol/L with aliskiren by underlying DM status (non-DM: HR: 1.17, 95% CI: 0.71-1.93; DM: HR: 2.39, 95% CI: 1.30-4.42; P = 0.07 for interaction). Conclusion This pre-specified subgroup analysis from the ASTRONAUT trial generates the hypothesis that the addition of aliskiren to standard HHF therapy in non-diabetic patients is generally well-tolerated and improves post-discharge outcomes and biomarker profiles. In contrast, diabetic patients receiving aliskiren appear to have worse post-discharge outcomes. Future prospective investigations are needed to confirm potential benefits of renin inhibition in a large cohort of HHF patients without D

Large expert-curated database for benchmarking document similarity detection in biomedical literature search

Document recommendation systems for locating relevant literature have mostly relied on methods developed a decade ago. This is largely due to the lack of a large offline gold-standard benchmark of relevant documents that cover a variety of research fields such that newly developed literature search techniques can be compared, improved and translated into practice. To overcome this bottleneck, we have established the RElevant LIterature SearcH consortium consisting of more than 1500 scientists from 84 countries, who have collectively annotated the relevance of over 180 000 PubMed-listed articles with regard to their respective seed (input) article/s. The majority of annotations were contributed by highly experienced, original authors of the seed articles. The collected data cover 76% of all unique PubMed Medical Subject Headings descriptors. No systematic biases were observed across different experience levels, research fields or time spent on annotations. More importantly, annotations of the same document pairs contributed by different scientists were highly concordant. We further show that the three representative baseline methods used to generate recommended articles for evaluation (Okapi Best Matching 25, Term Frequency-Inverse Document Frequency and PubMed Related Articles) had similar overall performances. Additionally, we found that these methods each tend to produce distinct collections of recommended articles, suggesting that a hybrid method may be required to completely capture all relevant articles. The established database server located at https://relishdb.ict.griffith.edu.au is freely available for the downloading of annotation data and the blind testing of new methods. We expect that this benchmark will be useful for stimulating the development of new powerful techniques for title and title/abstract-based search engines for relevant articles in biomedical research.Peer reviewe

Synthesis and characterisation of allosteric modulators of the muscarinic M2-receptor - structural variations of the bis(ammonio)alkane-compound W84

Die vorliegende Arbeit befasst sich mit der Synthese und Charakterisierung allosterer Modulatoren muscarinischer Rezeptoren. Allostere Modulatoren binden an einer topographisch anderen Stelle am Rezeptor als klassische orthostere Liganden und sind so in der Lage, die Dissoziation und die Assoziation orthosterer Agonisten und Antagonisten zu beeinflussen. Die fünf Subtypen des Muscarinrezeptors M1-M5 unterscheiden sich vor allem in der Aminosäuresequenz der in den äußeren Bereichen des Rezeptorproteins vorhandenen Loops, während sie im Bereich des Rezeptorkanals, wo die orthostere Bindungsstelle lokalisiert ist, eine hohe Sequenzhomologie aufweisen. Die gemeinsame Bindungsstelle allosterer Modulatoren des M2-Rezeptors befindet sich im weniger konservierten extrazellulären Bereich. Somit sind allostere Modulatoren in der Lage, spezifisch an einen der Rezeptorsubtypen zu binden. Als Leitstruktur zum Entwurf der im Rahmen dieser Arbeit synthetisierten Verbindungen diente die Bis(ammonium)alkanverbindung W84. Über Weg A wurden Phthalsäure- bzw. Naphthalsäureanhydridderivate in einer Kondensationsreaktion mit dem entsprechenden N,N-Dimethylpropan-1,3-diaminderivat zum jeweiligen Phthalimidopropylaminderivat umgesetzt. Durch die Reaktion von zwei Äquivalenten des Amins mit einem Äquivalent 1,6-Dibromhexan wurden dann die symmetrischen W84-Derivate erhalten. Um die unsymmetrischen W84-Derivate zu erhalten, musste zunächst das jeweilige Phthalimidopropylamin einseitig durch 1,6-Dibromhexan alkyliert werden. Im letzten Schritt wurden äquimolare Mengen der alkylierten Verbindung und eines Phthalimidopropylamins umgesetzt. Da sich im Laufe der Arbeit die Methylierung an Position 2 der Propylketten als kritische Position zur Beeinflussung der Gleichgewichtsbindung herausstellte, wurden Verbindungen hergestellt, die an den Propylketten Alkylgruppen verschiedener Länge tragen. Aus diesem Grund wurde Syntheseweg B entwickelt. Zunächst wurden in mehreren Stufen, ausgehend von Malonsäurediethylester, einfach und zweifach mit Alkylgruppen substituierte 1,3-Dibrompropanderivate hergestellt. Diese wurden dann mit Kaliumphthalimid zu den jeweiligen 3-Brompropylphthalimidderivaten umgesetzt. Zwei Äquivalente dieser 3-Brompropylphthalimide reagierten mit einem Äquivalent N,N,N’,N’-Tetramethyl-1,6-hexandiamin zu den entsprechenden symmetrischen W84-Derivaten. Ein weiteres Ziel der Arbeit bestand darin, stark fluoreszierende W84-Derivate herzustellen. Die fluoreszierenden Eigenschaften N-substituierter Naphthalimide könnten zur direkten Charakterisierung allosterer Interaktionen oder zur Verfolgung des „Rezeptor-Traffickings“ mittels Fluoreszenzkorrelationsspektroskopie genutzt werden. Deshalb wurden in Position 3 und 4 des Naphthalimidringes des potentesten allosteren Modulators Aminogruppen eingeführt. Hexamethonio-Derivate beeinflussen in nennenswertem Maße bisher nur die Bindung von Antagonisten am M2-Rezeptor. Da die allostere und die orthostere Bindungsstelle räumlich nahe zusammenliegen, wurde der Versuch unternommen, einen orthosteren Agonisten und einen allosteren Modulator in einem Molekül miteinander zu verknüpfen. Es wurden zwölf Hybridmoleküle aus einem Teil des hochaffinen allosteren Modulators 3a und Derivaten des Muscarinagonisten Oxotremorin-M, verbunden durch aliphatische Spacer verschiedener Länge, hergestellt. In pharmakologischen Testungen soll aufgeklärt werden, ob es möglich ist, mit einem Agonist/Alloster-Hybridmolekül gleichzeitig die orthostere und die allostere Bindungsstelle zu besetzen. Die pharmakologische Testung der synthetisierten Verbindungen erfolgte durch Radioligandbindungsstudien. Der allostere Effekt der Testsubstanzen wurde indirekt über die Verzögerung der Dissoziation des radioaktiv markierten orthosteren Antagonisten [3H]N-Methylscopolamin bestimmt. Alle bisquartären Testverbindungen weisen deutlich höhere Affinitätswerte als die Leitstruktur W84 auf. Die 1,8-Naphthalimid-substituierten Verbindungen mit gleichzeitiger zweifacher Methylierung erwiesen sich als hochaffin und zugleich positiv kooperativ. Die wirksamste Verbindung dieser Serie ist Verbindung 3a (Naphmethonium), deren Affinität zum NMS-besetzten Rezeptor im einstelligen nanomolaren Bereich liegt (pEC50 = 8.36). Somit stellt Naphmethonium den potentesten in der Literatur bekannten allosteren Modulator des M2 Rezeptors dar. Mittels QSAR-Analysen wurden die ermittelten Affinitäten zum freien und zum NMS-besetzten Rezeptor in Zusammenhang mit verschiedenen physikochemischen Parametern gebracht. Die Affinität zum NMS-besetzten Rezeptor der Verbindungen der Serie 2 lässt sich mit hoher Güte durch das Volumen eines lateralen N-Methylimids in Kombination mit der benachbarten Dimethylierung der Propylkette beschreiben. Somit wird deutlich, dass zur Erzielung von positiver Kooperativität die Kombination aus einem hochaffinen aromatischen Imid in direkter Nachbarschaft zu einer 2,2-Alkylpropylkette essentiell ist.The present work deals with the synthesis and characterization of allosteric modulators of muscarinic receptors. Allosteric modulators bind to a topographically different site than classical orthosteric ligands and, thus, are capable of influencing both the dissociation and the association of orthosteric agonists and antagonists. Allosteric modulators are capable of binding selectively to specific subtypes. The bis(ammonio)alkane-type compound W84 served as a lead for the compounds synthesized in this work. Via pathway A, phthalic- and naphthalic anhydride derivatives were converted with N,N-dimethylpropane-1,3-diamines to the phthalimidopropylamine derivatives. The symmetrical W84-derivatives were obtained by the conversion of two equivalents of the amine with one equivalent 1,6 dibromohexane. To obtain the non-symmetrical W84-derivatives the phthalimidopropylamines were unilaterally alkylated by 1,6-dibromohexane. In the last step equimolar amounts of the monoalkylated compound and a phthalimidopropylamine were connected. During our studies the methylation of position 2 of the propylene chains was identified as critical position for the influence on equilibrium binding. Therefore, compounds with varying alkyl substituents were synthesized. First, starting from malonic diethyl ester, 1,3-dibromo-propane derivatives carrying one or two ethyl-, propyl- or iso-butyl groups, respectively, were synthesized first. The latter were converted to the corresponding 3-bromopropylphthalimid derivatives with potassium phthalimide. In the last step two equivalents of the bromopropyl-phthalimides reacted with one equivalent tetramethyl-1,6-hexane-diamine to the symmetrical hexamethonio-derivatives. A further aim of the work was to synthesize highly fluorescent W84-derivatives. The fluorescent properties of N-substituted naphthalimides could be utilized for the direct characterization of allosteric interactions. Therefore, amino groups were introduced in positions 3 and 4 of the naphthalimide moiety. Until now, only the binding of antagonists of the M2 receptor was influenced by hexamethonio derivatives. Because of the spatial proximity of the orthosteric to the allosteric binding site it was tried to combine an agonist and an allosteric modulator in one molecule. Twelve hybride molecules consisting of a part of a highly affin allosteric modulator and of derivatives of the muscarinic agonist oxotremorine-M were synthesized. In the pharmacological evaluation it will be elucidated if it is possible for an agonist/alloster-hybride molecule to bind simultaneously to the orthosteric and the allosteric site. The pharmacological testing of the compounds was accomplished by radioligand binding studies . The allosteric effect of the compounds was determined by measurement of the inhibition of the dissociation of the radioactive marked orthosteric antagonist [3H]N-methylscopolamine. All compounds revealed higher affinitiy values than the lead structure W84. The most potent compound of that series is compound 3a (naphmethonium) that reveals an affinity to the NMS-occupied receptor in the low nanomolar range (pEC50 = 8.36). Taking all results together, the highest affinity values in combination with positive cooperativity were obtained for W84-derivatives carrying at least one naphthalimide moiety directly connected to a 2,2-dimethylpropyl chain. By the introduction of different alkyl groups in the propylene chains it was possible to verify the critical position with respect to the cooperative behaviour of W84-derivatives. QSAR-studies were performed in order to check whether the pharmacologically determined affinities to the free and to the NMS-occupied receptor can be explained by physicochemical properties of the compounds. The affinity to the NMS-occupied receptor of the compounds of series 2 can be described using the volume of one lateral N-methylimide in combination with the dimethylation of the neighbored propylene chain. Summarizing these results it can be concluded that the compounds feature a dominant side with regard to allosteric potency. To achieve positive cooperativity the combination of an affinity generating lateral aromatic imide moiety connected to a 2,2-alkylated propylene chain is essential

Final Safety and Efficacy Analysis of a Phase I/II Trial with Imatinib and Vinorelbine for Patients with Metastatic Breast Cancer

BACKGROUND: Imatinib is a tyrosine kinase inhibitor of BCR-ABL, ABL, PDGFR-α and -β, KIT, and DDR. In solid tumors, it inhibits proliferation and invasiveness and facilitates higher intratumoral cytotoxic drug concentrations. Vinorelbine has good tolerability and efficacy in metastatic breast cancer (MBC). This study evaluates the safety and efficacy of imatinib and vinorelbine in combination. METHODS: In a prospective, open-label, phase I/II trial, 400 mg imatinib p.o. daily (corrected from 600 mg) was combined with an escalating dose of vinorelbine i.v. weekly in four dose levels of 10, 15, 20, and 25 mg/m(2) (each n ≥ 5) to treat patients with MBC (expressing PDGFR-α and/or -β, and/or KIT). The last patient of each level was treated for >28 days, before enrolment for the next dose level started. Study endpoints were feasibility and tolerability, incidence of hematological and nonhematological toxicity, and clinical efficacy (data cutoff: November 18, 2011). A total of 33 patients have been enrolled, and all dose levels have been fully recruited. One patient is still on study medication. A translational subprotocol is ongoing. RESULTS: All 33 included patients are evaluable for safety (32 within the ITT population). Eleven patients were excluded early from the study (progressive disease, toxicity, and withdrawal of consent). Twenty-two patients participated in the study for >28 days ('ITT >28'). Within the ITT population, the response rate [complete response (CR) and partial response (PR)] was 9.4% (n = 3), the clinical benefit rate (CBR; CR+PR+stable disease) 50% (n = 16), and the median time to progression (TTP) 155 days. A total of 21.3% of the patients were on study medication for >6 months, and 15.2% for >12 months (mean 140 days, range 15-643). Within 'ITT >28', the response rate was 13.6%, CBR 72.7%, and median TTP 176 days. The response was independent of the receptor status (PDGFR-α, -β, and KIT). Toxicities were as follows (safety population): 21.6% severe leukopenia, 9.1% severe neutropenia (with 1 febrile neutropenia), 1 case of bowel perforation, 36% diarrhea (3% severe), 84.8% nausea (severe 15.2%), 48.5% vomiting (severe 9.1%), 27.3% infections (severe 6.1%), 12.1% peripheral neuropathy (severe 9.1%), and 36.4% dyspnea (3% severe). Four patients on trial died (nondrug-related). CONCLUSION: The combination of imatinib and vinorelbine in MBC appeared to be feasible and tolerable. A CBR of 50% (ITT) in pretreated patients suggests that this combination may be active. Although toxicities were frequent, they appeared to be manageable

The impact of mammalian target of rapamycin inhibition on bone health in postmenopausal women with hormone receptor-positive advanced breast cancer receiving everolimus plus exemestane in the phase IIIb 4EVER trial

Background: Breast cancer and its treatments are associated with a detrimental effect on bone health. Here we report the results of an exploratory analysis assessing changes in levels of biomarkers of bone metabolism in patients enrolled in the phase IIIb 4EVER study. Methods: The 4EVER trial investigated everolimus in combination with exemestane in postmenopausal women with hormone receptor-positive, human epidermal growth factor receptor 2-negative locally advanced or metastatic breast cancer. In this prespecified exploratory analysis, changes in biomarkers of bone turnover were assessed in patients from baseline to weeks 4, 12, and 24. The serum bone markers assessed were procollagen type 1 N-terminal propeptide (P1NP), C-terminal cross-linking telopeptide of type 1 collagen (CTX), osteocalcin, parathyroid hormone (PTH), and 25-hydroxyvitamin D (25-OH-vitamin D). On-treatment changes in bone markers over time were described per subgroup of interest and efficacy outcomes. Results: Bone marker data were available for 241 of 299 enrolled patients. At the final assessment, P1NP, osteocalcin, PTH, 25-OH-vitamin D (all P < 0.001), and CTX (P = 0.036) were significantly decreased from baseline values per the Wilcoxon signed-rank test. At the last assessment (24 weeks or earlier), levels of serum CTX and PTH were significantly lower (P = 0.009 and P = 0.034, respectively) among patients with vs. without prior antiresorptive treatment (ART). Serum CTX levels were significantly lower (P < 0.001), and 25-OH-vitamin D concentrations significantly higher (P = 0.029), at the last postbaseline assessment in patients receiving concomitant ART vs. those without ART. Changes from baseline in PTH and 25-OH-vitamin D concentrations to the final assessment were significantly smaller in patients with prior ART. Lower baseline serum concentrations of osteocalcin and PTH were associated with clinical response (partial vs. non-response) at 24 weeks. High serum levels of CTX and P1NP at baseline were risk factors for progression at 12 weeks. Conclusions: These exploratory analyses support use of everolimus plus exemestane for the treatment of postmenopausal women with hormone receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer, and add to the body of evidence suggesting a potentially favorable impact of everolimus on bone turnover. Trial registration: NCT01626222. Registered 22 June 2012, https://clinicaltrials.gov/ct2/show/NCT01626222. Keywords: Bone health, Bone marker, Breast cancer, Everolimus, Hormone receptor-positive, Mammalian target of rapamyci

FemZone trial: a randomized phase II trial comparing neoadjuvant letrozole and zoledronic acid with letrozole in primary breast cancer patients

Background: The objective of this prospectively randomized phase II trial (Trial registration: EUCTR2004-004007-37-DE) was to compare the clinical response of primary breast cancer patients to neoadjuvant therapy with letrozole alone (LET) or letrozole and zoledronic acid (LET + ZOL). Methods: Patients were randomly assigned to receive either LET 2.5 mg/day (n = 79) or the combination of LET 2.5 mg/day and a total of seven infusions of ZOL 4 mg every 4 weeks (n = 89) for 6 months. Primary endpoint was clinical response rate as assessed by mammogram readings. The study was terminated prematurely due to insufficient recruitment. We report here on an exploratory analysis of this data. Results: Central assessment of tumor sizes during the treatment period was available for 131 patients (66 LET, 65 LET + ZOL). Clinical responses (complete or partial) were seen in 54.5% (95% CI: 41.8-66.9) of the patients in the LET arm and 69.2% (95% CI: 56.6-80.1) of those in the LET + ZOL arm (P = 0.106). A multivariate model showed an OR of 1.72 (95% CI: 0.83-3.59) for the experimental arm. Conclusion: No increase in the clinical response rate was observed with the addition of ZOL to a neoadjuvant treatment regimen with LET. However a trend towards a better reponse in the LET + ZOL arm could be observed. This trend is consistent with previous studies that have investigated the addition of ZOL to chemotherapy, and it may support the evidence for a direct antitumor action of zoledronic acid