Safety and efficacy of gene replacement therapy for X-linked myotubular myopathy (ASPIRO): a multinational, open-label, dose-escalation trial

Background: X-linked myotubular myopathy is a rare, life-threatening, congenital muscle disease observed mostly in males, which is caused by mutations in MTM1. No therapies are approved for this disease. We aimed to assess the safety and efficacy of resamirigene bilparvovec, which is an adeno-associated viral vector serotype 8 delivering human MTM1. Methods: ASPIRO is an open-label, dose-escalation trial at seven academic medical centres in Canada, France, Germany, and the USA. We included boys younger than 5 years with X-linked myotubular myopathy who required mechanical ventilator support. The trial was initially in two parts. Part 1 was planned as a safety and dose-escalation phase in which participants were randomly allocated (2:1) to either the first dose level (1·3 × 1014 vector genomes [vg]/kg bodyweight) of resamirigene bilparvovec or delayed treatment, then, for later participants, to either a higher dose (3·5 × 1014 vg/kg bodyweight) of resamirigene bilparvovec or delayed treatment. Part 2 was intended to confirm the dose selected in part 1. Resamirigene bilparvovec was administered as a single intravenous infusion. An untreated control group comprised boys who participated in a run-in study (INCEPTUS; NCT02704273) or those in the delayed treatment cohort who did not receive any dose. The primary efficacy outcome was the change from baseline to week 24 in hours of daily ventilator support. After three unexpected deaths, dosing at the higher dose was stopped and the two-part feature of the study design was eliminated. Because of changes to the study design during its implementation, analyses were done on an as-treated basis and are deemed exploratory. All treated and control participants were included in the safety analysis. The trial is registered with ClinicalTrials.gov, NCT03199469. Outcomes are reported as of Feb 28, 2022. ASPIRO is currently paused while deaths in dosed participants are investigated. Findings: Between Aug 3, 2017 and June 1, 2021, 30 participants were screened for eligibility, of whom 26 were enrolled; six were allocated to the lower dose, 13 to the higher dose, and seven to delayed treatment. Of the seven children whose treatment was delayed, four later received the higher dose (n=17 total in the higher dose cohort), one received the lower dose (n=7 total in the lower dose cohort), and two received no dose and joined the control group (n=14 total, including 12 children from INCEPTUS). Median age at dosing or enrolment was 12·1 months (IQR 10·0–30·9; range 9·5–49·7) in the lower dose cohort, 31·1 months (16·0–64·7; 6·8–72·7) in the higher dose cohort, and 18·7 months (10·1–31·5; 5·9–39·3) in the control cohort. Median follow-up was 46·1 months (IQR 41·0–49·5; range 2·1–54·7) for lower dose participants, 27·6 months (24·6–29·1; 3·4–41·0) for higher dose participants, and 28·3 months (9·7–46·9; 5·7–32·7) for control participants. At week 24, lower dose participants had an estimated 77·7 percentage point (95% CI 40·22 to 115·24) greater reduction in least squares mean hours per day of ventilator support from baseline versus controls (p=0·0002), and higher dose participants had a 22·8 percentage point (6·15 to 39·37) greater reduction from baseline versus controls (p=0·0077). One participant in the lower dose cohort and three in the higher dose cohort died; at the time of death, all children had cholestatic liver failure following gene therapy (immediate causes of death were sepsis; hepatopathy, severe immune dysfunction, and pseudomonal sepsis; gastrointestinal haemorrhage; and septic shock). Three individuals in the control group died (haemorrhage presumed related to hepatic peliosis; aspiration pneumonia; and cardiopulmonary failure). Interpretation: Most children with X-linked myotubular myopathy who received MTM1 gene replacement therapy had important improvements in ventilator dependence and motor function, with more than half of dosed participants achieving ventilator independence and some attaining the ability to walk independently. Investigations into the risk for underlying hepatobiliary disease in X-linked myotubular myopathy, and the need for monitoring of liver function before gene replacement therapy, are ongoing. Funding: Astellas Gene Therapies

Towards the prevention of acute lung injury: a population based cohort study protocol

<p>Abstract</p> <p>Background</p> <p>Acute lung injury (ALI) is an example of a critical care syndrome with limited treatment options once the condition is fully established. Despite improved understanding of pathophysiology of ALI, the clinical impact has been limited to improvements in supportive treatment. On the other hand, little has been done on the prevention of ALI. Olmsted County, MN, geographically isolated from other urban areas offers the opportunity to study clinical pathogenesis of ALI in a search for potential prevention targets.</p> <p>Methods/Design</p> <p>In this population-based observational cohort study, the investigators identify patients at high risk of ALI using the prediction model applied within the first six hours of hospital admission. Using a validated system-wide electronic surveillance, Olmsted County patients at risk are followed until ALI, death or hospital discharge. Detailed in-hospital (second hit) exposures and meaningful short and long term outcomes (quality-adjusted survival) are compared between ALI cases and high risk controls matched by age, gender and probability of developing ALI. Time sensitive biospecimens are collected for collaborative research studies. Nested case control comparison of 500 patients who developed ALI with 500 matched controls will provide an adequate power to determine significant differences in common hospital exposures and outcomes between the two groups.</p> <p>Discussion</p> <p>This population-based observational cohort study will identify patients at high risk early in the course of disease, the burden of ALI in the community, and the potential targets for future prevention trials.</p

Improved Respiratory Outcomes for X-Linked Myotubular Myopathy (XLMTM) with Gene Replacement Therapy, Resamirigene Bilparvovec (ASPIRO): Preliminary Results from ASPIRO, a Phase 1/2/3 Study

Astelas Gene Therapies

State of the art of immunoassay methods for B-type natriuretic peptides: An update

The aim of this review article is to give an update on the state of the art of the immunoassay methods for the measurement of B-type natriuretic peptide (BNP) and its related peptides. Using chromatographic procedures, several studies reported an increasing number of circulating peptides related to BNP in human plasma of patients with heart failure. These peptides may have reduced or even no biological activity. Furthermore, other studies have suggested that, using immunoassays that are considered specific for BNP, the precursor of the peptide hormone, proBNP, constitutes a major portion of the peptide measured in plasma of patients with heart failure. Because BNP immunoassay methods show large (up to 50%) systematic differences in values, the use of identical decision values for all immunoassay methods, as suggested by the most recent international guidelines, seems unreasonable. Since proBNP significantly cross-reacts with all commercial immunoassay methods considered specific for BNP, manufacturers should test and clearly declare the degree of cross-reactivity of glycosylated and non-glycosylated proBNP in their BNP immunoassay methods. Clinicians should take into account that there are large systematic differences between methods when they compare results from different laboratories that use different BNP immunoassays. On the other hand, clinical laboratories should take part in external quality assessment (EQA) programs to evaluate the bias of their method in comparison to other BNP methods. Finally, the authors believe that the development of more specific methods for the active peptide, BNP1–32, should reduce the systematic differences between methods and result in better harmonization of results

Application for primary endpoint qualification of the 95th centile of stride velocity (SV95C) in Duchenne muscular dystrophy

peer reviewe

Recent progress in understanding and predicting Atlantic decadal climate variability

Recent Atlantic climate prediction studies are an exciting new contribution to an extensive body of research on Atlantic decadal variability and predictability that has long emphasized the unique role of the Atlantic Ocean in modulating the surface climate. We present a survey of the foundations and frontiers in our understanding of Atlantic variability mechanisms, the role of the Atlantic Meridional Overturning Circulation (AMOC), and our present capacity for putting that understanding into practice in actual climate prediction systems

Regionally aggregated, stitched and de‐drifted CMIP‐climate data, processed with netCDF‐SCM v2.0.0

The world's most complex climate models are currently running a range of experiments as part of the Sixth Coupled Model Intercomparison Project (CMIP6). Added to the output from the Fifth Coupled Model Intercomparison Project (CMIP5), the total data volume will be in the order of 20PB. Here, we present a dataset of annual, monthly, global, hemispheric and land/ocean means derived from a selection of experiments of key interest to climate data analysts and reduced complexity climate modellers. The derived dataset is a key part of validating, calibrating and developing reduced complexity climate models against the behaviour of more physically complete models. In addition to its use for reduced complexity climate modellers, we aim to make our data accessible to other research communities. We facilitate this in a number of ways. Firstly, given the focus on annual, monthly, global, hemispheric and land/ocean mean quantities, our dataset is orders of magnitude smaller than the source data and hence does not require specialized ‘big data’ expertise. Secondly, again because of its smaller size, we are able to offer our dataset in a text-based format, greatly reducing the computational expertise required to work with CMIP output. Thirdly, we enable data provenance and integrity control by tracking all source metadata and providing tools which check whether a dataset has been retracted, that is identified as erroneous. The resulting dataset is updated as new CMIP6 results become available and we provide a stable access point to allow automated downloads. Along with our accompanying website (cmip6.science.unimelb.edu.au), we believe this dataset provides a unique community resource, as well as allowing non-specialists to access CMIP data in a new, user-friendly way

Simulations of ocean deoxygenation in the historical era: insights from forced and coupled models

Ocean deoxygenation due to anthropogenic warming represents a major threat to marine ecosystems and fisheries. Challenges remain in simulating the modern observed changes in the dissolved oxygen (O2). Here, we present an analysis of upper ocean (0-700m) deoxygenation in recent decades from a suite of the Coupled Model Intercomparison Project phase 6 (CMIP6) ocean biogeochemical simulations. The physics and biogeochemical simulations include both ocean-only (the Ocean Model Intercomparison Project Phase 1 and 2, OMIP1 and OMIP2) and coupled Earth system (CMIP6 Historical) configurations. We examine simulated changes in the O2 inventory and ocean heat content (OHC) over the past 5 decades across models. The models simulate spatially divergent evolution of O2 trends over the past 5 decades. The trend (multi-model mean and spread) for upper ocean global O2 inventory for each of the MIP simulations over the past 5 decades is 0.03 ± 0.39×1014 [mol/decade] for OMIP1, −0.37 ± 0.15×1014 [mol/decade] for OMIP2, and −1.06 ± 0.68×1014 [mol/decade] for CMIP6 Historical, respectively. The trend in the upper ocean global O2 inventory for the latest observations based on the World Ocean Database 2018 is −0.98×1014 [mol/decade], in line with the CMIP6 Historical multi-model mean, though this recent observations-based trend estimate is weaker than previously reported trends. A comparison across ocean-only simulations from OMIP1 and OMIP2 suggests that differences in atmospheric forcing such as surface wind explain the simulated divergence across configurations in O2 inventory changes. Additionally, a comparison of coupled model simulations from the CMIP6 Historical configuration indicates that differences in background mean states due to differences in spin-up duration and equilibrium states result in substantial differences in the climate change response of O2. Finally, we discuss gaps and uncertainties in both ocean biogeochemical simulations and observations and explore possible future coordinated ocean biogeochemistry simulations to fill in gaps and unravel the mechanisms controlling the O2 changes