Identification and validation of potential targets for the diagnosis and therapy of chronic lymphocytic leukaemia

Treatment of chronic lymphocytic leukaemia (CLL) has greatly improved with the use of combination chemo-immunotherapy but the treatment of relapsed and fludarabine refractory CLL is still challenging with the current agents. Large amounts of mRNA expression data are publicly available but identifying suitable targets requires validation at the protein level. I used available RNA expression data to identify candidate antigens that could be screened for protein level expression using commercially available monoclonal/polyclonal antibodies. To test new molecules I optimised an in-vitro viability assay system using mononuclear cells and standard viability assessments. To study pathway interactions, B-cell receptor (BCR) was stimulated using goat F(ab’)2 anti-human IgM or IgD and signalling responses were assessed by SYK-phosphorylation (SYK pY348PE) and calcium-flux measured by ratiometric difference in florescent intensity of Fluo-3/Fura-red. I assessed 84 antigens and 15 showed binding on CLL cells and/or normal B-cells but not other leucocytes. I found that 7 of the 15 molecules have a recognised role in neurotransmission, such as the nicotinic acetyl choline receptor subunit β4 and dopamine receptor D4. This observation indicated that these molecules and pathways were potentially involved in the pathophysiology of CLL and I therefore further investigated their importance. In exploring the newly identified targets, I found that dopamine and D2 antagonist domperidone reduced CLL cell survival in vitro, in a dose dependent manner. While elucidating the downstream mechanisms for the above effect, I observed that dopamine significantly reduced SYK phosphorylation and calcium flux induced by stimulation of the BCR pathway using goat F(ab’)2 anti-human IgD. In vitro testing also demonstrated a synergistic effect in blocking of the D2 and the BCR pathways as a combination of PI3-kinase δ inhibitor (GS-1101) with domperidone reduced CLL cell viability more efficiently than either agent alone. Therefore I have identified a number of novel molecules expressed in CLL and further investigated their biological importance in the disease pathophysiology. These novel molecules provide several potential untested therapeutic targets in CLL

Thigh-length compression stockings and DVT after stroke

Controversy exists as to whether neoadjuvant chemotherapy improves survival in patients with invasive bladder cancer, despite randomised controlled trials of more than 3000 patients. We undertook a systematic review and meta-analysis to assess the effect of such treatment on survival in patients with this disease

Azithromycin in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Background Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatory actions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19. Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospital with COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients were randomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once per day by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatment groups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment and were twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants and local study staff were not masked to the allocated treatment, but all others involved in the trial were masked to the outcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treat population. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936. Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) were eligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was 65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomly allocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall, 561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days (rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median 10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days (rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, no significant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilation or death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24). Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or other prespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restricted to patients in whom there is a clear antimicrobial indication. Funding UK Research and Innovation (Medical Research Council) and National Institute of Health Research