Safety and immunogenicity of ChAdOx1 85A prime followed by MVA85A boost compared with BCG revaccination among Ugandan adolescents who received BCG at birth: a randomised, open-label trial

Background BCG confers reduced, variable protection against pulmonary tuberculosis. A more effective vaccine is needed. We evaluated the safety and immunogenicity of candidate regimen ChAdOx1 85A–MVA85A compared with BCG revaccination among Ugandan adolescents. Methods After ChAdOx1 85A dose escalation and age de-escalation, we did a randomised open-label phase 2a trial among healthy adolescents aged 12–17 years, who were BCG vaccinated at birth, without evident tuberculosis exposure, in Entebbe, Uganda. Participants were randomly assigned (1:1) using a block size of 6, to ChAdOx1 85A followed by MVA85A (on day 56) or BCG (Moscow strain). Laboratory staff were masked to group assignment. Primary outcomes were solicited and unsolicited adverse events (AEs) up to day 28 and serious adverse events (SAEs) throughout the trial; and IFN-γ ELISpot response to antigen 85A (day 63 [geometric mean] and days 0–224 [area under the curve; AUC). Findings Six adults (group 1, n=3; group 2, n=3) and six adolescents (group 3, n=3; group 4, n=3) were enrolled in the ChAdOx1 85A-only dose-escalation and age de-escalation studies (July to August, 2019). In the phase 2a trial, 60 adolescents were randomly assigned to ChAdOx1 85A–MVA85A (group 5, n=30) or BCG (group 6, n=30; December, 2019, to October, 2020). All 60 participants from groups 5 and 6 were included in the safety analysis, with 28 of 30 from group 5 (ChAdOx1 85A–MVA85A) and 29 of 30 from group 6 (BCG revaccination) analysed for immunogenicity outcomes. In the randomised trial, 60 AEs were reported among 23 (77%) of 30 participants following ChAdOx1 85A–MVA85A, 31 were systemic, with one severe event that occurred after the MVA85A boost that was rapidly self-limiting. All 30 participants in the BCG revaccination group reported at least one mild to moderate solicited AE; most were local reactions. There were no SAEs in either group. Ag85A-specific IFN-γ ELISpot responses peaked on day 63 in the ChAdOx1 85A–MVA85A group and were higher in the ChAdOx1 85A-MVA85A group compared with the BCG revaccination group (geometric mean ratio 30·59 [95% CI 17·46–53·59], p<0·0001, day 63; AUC mean difference 57 091 [95% CI 40 524–73 658], p<0·0001, days 0–224). Interpretation The ChAdOx1 85A–MVA85A regimen was safe and induced stronger Ag85A-specific responses than BCG revaccination. Our findings support further development of booster tuberculosis vaccines. Funding UK Research and Innovations and Medical Research Council. Translations For the Swahili and Luganda translations of the abstract see Supplementary Materials section

Safety of a controlled human infection model of tuberculosis with aerosolised, live-attenuated Mycobacterium bovis BCG versus intradermal BCG in BCG-naive adults in the UK: a dose-escalation, randomised, controlled, phase 1 trial

Background: Mycobacterium tuberculosis is the main causative agent of tuberculosis. BCG, the only licensed vaccine, provides inadequate protection against pulmonary tuberculosis. Controlled human infection models are useful tools for vaccine development. We aimed to determine a safe dose of aerosol-inhaled live-attenuated Mycobacterium bovis BCG as a surrogate for M tuberculosis infection, then compare the safety and tolerability of infection models established using aerosol-inhaled and intradermally administered BCG. Methods: This phase 1 controlled human infection trial was conducted at two clinical research facilities in the UK. Healthy, immunocompetent adults aged 18–50 years, who were both M tuberculosis-naive and BCG-naive and had no history of asthma or other respiratory diseases, were eligible for the trial. Participants were initially enrolled into group 1 (receiving the BCG Danish strain); the trial was subsequently paused because of a worldwide shortage of BCG Danish and, after protocol amendment, was restarted using the BCG Bulgaria strain (group 2). After a dose-escalation study, during which participants were sequentially allocated to receive either 1 × 103, 1 × 104, 1 × 105, 1 × 106, or 1 × 107 colony-forming units (CFU) of aerosol BCG, the maximum tolerated dose was selected for the randomised controlled trial. Participants in this trial were randomly assigned (9:12), by variable block randomisation and using sequentially numbered sealed envelopes, to receive aerosol BCG (1 × 107 CFU) and intradermal saline or intradermal BCG (1 × 106 CFU) and aerosol saline. Participants were masked to treatment allocation until day 14. The primary outcome was to compare the safety of a controlled human infection model based on aerosol-inhaled BCG versus one based on intradermally administered BCG, and the secondary outcome was to evaluate BCG recovery in the airways of participants who received aerosol BCG or skin biopsies of participants who received intradermal BCG. BCG was detected by culture and by PCR. The trial is registered at ClinicalTrials.gov, NCT02709278, and is complete. Findings: Participants were assessed for eligibility between April 7, 2016, and Sept 29, 2018. For group 1, 15 participants were screened, of whom 13 were enrolled and ten completed the study; for group 2, 60 were screened and 33 enrolled, all of whom completed the study. Doses up to 1 × 107 CFU aerosol-inhaled BCG were sufficiently well tolerated. No significant difference was observed in the frequency of adverse events between aerosol and intradermal groups (median percentage of solicited adverse events per participant, post-aerosol vs post-intradermal BCG: systemic 7% [IQR 2–11] vs 4% [1–13], p=0·62; respiratory 7% [1–19] vs 4% [1–9], p=0·56). More severe systemic adverse events occurred in the 2 weeks after aerosol BCG (15 [12%] of 122 reported systemic adverse events) than after intradermal BCG (one [1%] of 94; difference 11% [95% CI 5–17]; p=0·0013), but no difference was observed in the severity of respiratory adverse events (two [1%] of 144 vs zero [0%] of 97; 1% [−1 to 3]; p=0·52). All adverse events after aerosol BCG resolved spontaneously. One serious adverse event was reported—a participant in group 2 was admitted to hospital to receive analgesia for a pre-existing ovarian cyst, which was deemed unrelated to BCG infection. On day 14, BCG was cultured from bronchoalveolar lavage samples after aerosol infection and from skin biopsy samples after intradermal infection. Interpretation: This first-in-human aerosol BCG controlled human infection model was sufficiently well tolerated. Further work will evaluate the utility of this model in assessing vaccine efficacy and identifying potential correlates of protection

Nanovesicle-bioactive conjugates to be used as nanomedicines, prepared by a one-step scalable method using CO2-expanded solvents

The application of innovative nanotechnologies to medicine has shown a great potential to significantly benefit clinical practice, offering solutions to many of the current limitations in diagnosis, treatment and management of human diseases. Among the various approaches for exploiting developments in nanotechnology for biomedical applications, drug delivery systems (DDS) have already had an enormous impact on medical technology, improving the performance of many existing drugs and enabling the use of entirely new therapies.The fact that DDSs can protect sensitive biomolecules, such as enzymes and proteins, from degradation and the in vivo attack of the immune system providing longer blood circulation times, have been used to improve the effectiveness and delivery of these drugs. Particularly vesicles have served as convenient delivery vehicles for biologically active compounds because they are non-toxic, biodegradable and non immunogenic. Contrary to products where the active substance is in solution, the pharmacological properties of vesicle-based delivery systems, such as stability, kinetic release of the encapsulated substance and response to external stimuli, are strongly dependent on the structural characteristics of the conjugates. Indeed, a high degree of structural homogeneity regarding size, morphology and lipid organization in the membrane is crucial for their optimum performance as functional entities. Conventional methodologies to produce vesicles, usually present difficulties in controlling the self-assembling of the molecules constituting the system, leading to materials with high structural heterogeneity. Therefore additional operations are needed in order to achieve the desired structures. In order to be able to commercially exploit the enormous potential of these DDS as nanomedicines, it is necessary the development of new, efficient and environmentally respectful methodologies that allow the manufacturing of these materials with controlled nanostructures, and that are amenable to be scalable. Recently Nanomol group has developed a process called DELOS-SUSP (Depresurization of an Expanded Liquid Organic Solution-Suspension) for the preparation of dispersed systems based on the use of compressed fluids (CFs). This eco-efficient one-step methodology allows the obtaining of uniform, unilamellar and nanoscopic cholesterol-rich vesicles with large structural homogenity and great stability along time. Taken advantage of the enormous potential of CF-based technologies for the production of nanostructured materials, this PhD Thesis has been devoted to demonstrate the goodness of such methodologies for the direct, robust and scalable encapsulation of biomolecules in cholesterol-rich vesicles. Another important objective has been the development of reproducible and scalable methodologies in order to functionalize those vesicles with targeting/protective units enabling greater selectivity of the therapeutic targets and therefore more effective treatments; and finally the use of the biomolecules-vesicles conjugates prepared by DELOS-SUSP in the treatment of different diseases. Concretely, the first part of this work has been focused on the integration of different proteins such as GFP, BSA, GLA and EGF in vesicles of different compositions obtaining nanovesicle-biomolecule conjugates with good physicochemical characteristics, homogeneous morphologies and high protein loadings. Likewise RGD targeting peptides and protective units such as PEG, have been successfully incorporated into the membrane of the vesicles. Importantly is have been prove that the biomolecules activity is unaffected after processing with compressed fluids and in the case of some proteins, the biological activity is enhance when the biomolecules were associated to the vesicles. The latter reinforce the importance of the nanostructuration in the efficacy of nanomedicines. In further steps to demonstrate the potential of the nanoconjugates prepared by DELOS-SUSP to be used as nanomedicines, GLA loaded liposomes-RGD and rhEGF loaded quatsomes conjugates were prepared by DELOS-SUSP and applied for the treatment of the Fabry’s disease and complex wounds, respectively. All the physicochemical characterizations as well as the in-vitro and in-vivo biological assays carried out in the frame of this Thesis have demonstrated that both nanoconjugates can be considered as future potential nanomedicines that could provide safer, more efficacious drugs, site-specific delivery, improved patient compliance, and favorable clinical outcomes. The results obtained in this Thesis contribute to demonstrate that DELOS-SUSP methodology is a strong and robust platform for the production of nanovesicle-bioactive conjugates to be used as nanomedicine

Nanovesicle-bioactive conjugates to be used as nanomedicines, prepared by a one-step scalable method using CO₂-expanded solvents

The application of innovative nanotechnologies to medicine has shown a great potential to significantly benefit clinical practice, offering solutions to many of the current limitations in diagnosis, treatment and management of human diseases. Among the various approaches for exploiting developments in nanotechnology for biomedical applications, drug delivery systems (01S) have already had an enormous impact on medical technology, improving the performance of many existing drugs and enabling the use of entirely new therapies.The fact that 01Ss can protect sensitive biomolecules, such as enzymes and proteins, from degradation and the in vivo attack of the immune system providing longer blood circulation times, have been used to improve the effectiveness and delivery of these drugs. Particularly vesicles have served as convenient delivery vehicles for biologically active compounds because they are non-toxic, biodegradable and non immunogenic. Contrary to products where the active substance is in solution, the pharmacological properties of vesicle-based delivery systems, such as stability, kinetic release of the encapsulated substance and response to external stimuli, are strongly dependent on the structural characteristics of the conjugates. Indeed, a high degree of structural homogeneity regarding size, morphology and lipid organization in the membrane is crucial for their optimum performance as functional entities. Conventional methodologies to produce vesicles, usually present difficulties in controlling the self-assembling of the molecules constituting the system, leading to materials with high structural heterogeneity. Therefore additional operations are needed in order to achieve the desired structures. In order to be able to commercially exploit the enormous potential of these 01S as nanomedicines, it is necessary the development of new, efficient and environmentally respectful methodologies that allow the manufacturing of these materials with controlled nanostructures, and that are amenable to be scalable. Recently Nanomol group has developed a process called DELOS-SUSP (Depresurization of an Expanded Liquid Organic Solution-Suspension) for the preparation of dispersed systems based on the use of compressed fluids (CFs). This eco-efficient one-step methodology allows the obtaining of uniform, unilamellar and nanoscopic cholesterol-rich vesicles with large structural homogenity and great stability along time. Taken advantage of the enormous potential of CF-based technologies for the production of nanostructured materials, this PhD Thesis has been devoted to demonstrate the goodness of such methodologies for the direct, robust and scalable encapsulation of biomolecules in cholesterol-rich vesicles. Another important objective has been the development of reproducible and scalable methodologies in order to functionalize those vesicles with targeting/protective units enabling greater selectivity of the therapeutic targets and therefore more effective treatments; and finally the use of the biomolecules-vesicles conjugates prepared by DELOS-SUSP in the treatment of different diseases. Concretely, the first part of this work has been focused on the integration of different proteins such as GFP, BSA, GLA and EGF in vesicles of different compositions obtaining nanovesicle-biomolecule conjugates with good physicochemical characteristics, homogeneous morphologies and high protein loadings. Likewise RGD targeting peptides and protective units such as PEG, have been successfully incorporated into the membrane of the vesicles. Importantly is have been prove that the biomolecules activity is unaffected after processing with compressed fluids and in the case of some proteins, the biological activity is enhance when the biomolecules were associated to the vesicles. The latter reinforce the importance of the nanostructuration in the efficacy of nanomedicines. In further steps to demonstrate the potential of the nanoconjugates prepared by DELOS-SUSP to be used as nanomedicines, GLA loaded liposomes-RGD and rhEGF loaded quatsomes conjugates were prepared by DELOS-SUSP and applied for the treatment of the Fabry's disease and complex wounds, respectively. All the physicochemical characterizations as well as the in-vitro and in-vivo biological assays carried out in the frame of this Thesis have demonstrated that both nanoconjugates can be considered as future potential nanomedicines that could provide safer, more efficacious drugs, site-specific delivery, improved patient compliance, and favorable clinical outcomes. The results obtained in this Thesis contribute to demonstrate that DELOS-SUSP methodology is a strong and robust platform for the production of nanovesicle-bioactive conjugates to be used as nanomedicine

Digital dermoscopy monitoring in patients with multiple nevi: How many lesions should we monitor per patient?

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Effects of once-weekly exenatide on cardiovascular outcomes in type 2 diabetes

BACKGROUND: The cardiovascular effects of adding once-weekly treatment with exenatide to usual care in patients with type 2 diabetes are unknown. METHODS: We randomly assigned patients with type 2 diabetes, with or without previous cardiovascular disease, to receive subcutaneous injections of extended-release exenatide at a dose of 2 mg or matching placebo once weekly. The primary composite outcome was the first occurrence of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. The coprimary hypotheses were that exenatide, administered once weekly, would be noninferior to placebo with respect to safety and superior to placebo with respect to efficacy. RESULTS: In all, 14,752 patients (of whom 10,782 [73.1%] had previous cardiovascular disease) were followed for a median of 3.2 years (interquartile range, 2.2 to 4.4). A primary composite outcome event occurred in 839 of 7356 patients (11.4%; 3.7 events per 100 person-years) in the exenatide group and in 905 of 7396 patients (12.2%; 4.0 events per 100 person-years) in the placebo group (hazard ratio, 0.91; 95% confidence interval [CI], 0.83 to 1.00), with the intention-to-treat analysis indicating that exenatide, administered once weekly, was noninferior to placebo with respect to safety (P<0.001 for noninferiority) but was not superior to placebo with respect to efficacy (P=0.06 for superiority). The rates of death from cardiovascular causes, fatal or nonfatal myocardial infarction, fatal or nonfatal stroke, hospitalization for heart failure, and hospitalization for acute coronary syndrome, and the incidence of acute pancreatitis, pancreatic cancer, medullary thyroid carcinoma, and serious adverse events did not differ significantly between the two groups. CONCLUSIONS: Among patients with type 2 diabetes with or without previous cardiovascular disease, the incidence of major adverse cardiovascular events did not differ significantly between patients who received exenatide and those who received placebo