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Background Ang‐(1‐12) is a primary non‐renin dependent substrate for direct tissue angiotensin II (Ang II) formation by chymase. This discovery challenges conventional thinking and explains the large residual risk of cardiovascular events in patients medicated with blockers of the renin angiotensin system (RAS). Here we report the first demonstration of circulating Ang‐(1‐12) as a biomarker of essential hypertension (EH) and cardio‐renal remodeling. Methods The cohort of patients from Olmsted County MN included 52 healthy adult volunteers (21 females), age 54 ± 8 years, and 23 essential hypertensive (EH) patients (14 females) age 61 ± 8 years with systolic blood pressure (SBP) ≥140 mm Hg prior to recruitment. Clinical examination, standardized BP measurements, and venous blood were obtained for measurements of plasma concentrations of angiotensinogen (AGT), Ang‐(1‐12), Ang II, aldosterone, renin activity, N‐terminal pro–B‐type natriuretic peptide (NT‐proBNP) and atrial and brain natriuretic peptides (ANP and BNP, respectively). All values are Means ± SD. Data were analyzed by 2‐way ANOVA for sex and hypertension. Results Plasma Ang‐(1‐12) levels in EHs [SBP: 134 ± 14 mm Hg; Ang‐(1‐12): 1,463 ± 446] were higher than normotensives [SBP: 117 ± 13 mm Hg; Ang‐(1‐12): 1,353 ± 379 fmol/mL, hypertension effect: P<0.05], irrespective of sex. Hypertension associated with increases in pulse pressure, PRA, and plasma AGT and NT‐proBNP concentrations (see Figure ). The elevation in circulating NT‐proBNP levels with hypertension was accounted for by a 4.6‐fold increase in hypertensive males (165 ± 134 pg/mL) while the 1.5‐fold rise in plasm NT‐proBNP did reach significance (134 ± 127 pg/mL, p> 0.05). Conclusions We show for the first time that Ang‐(1‐12) circulates in humans and its concentrations are elevated by chronic hypertension. We further demonstrate a sexual dimorphic pattern in hypertensives with respect to NT‐proBNP, the latter a biomarker for cardiac remodeling. Whether this represents a natriuretic system‐related compensatory mechanism, or worsening pathology, due to an elevated noncanonical RAS specific to male hypertensives remains to be studied. Further investigation to fully define the role of Ang‐(1‐12) as a cardiac disease biomarker in a larger, gender and ethnic diverse population and its relationship to hypertension and myocardial structure is warranted. Support or Funding Information Supported by grant HL‐051952 from the NHLBI of the NIH Lines are means ± SD Figure 1

Enteric glia are important components of the enteric nervous system (ENS) that control critical functions of the alimentary canal including motility, fluid and ion transport, and immune barrier. Anatomical assessments of enteric glia to date have utilized microdissected whole‐mount tissue or thin sections to visualize cells in the optically dense matrix of the bowel. The aim of this study was to assess the morphological features of enteric glia throughout the small and large intestines of the mouse in intact full‐thickness preparations. B6.Cg‐Polr2atm1(CAG‐GCaMP5g,‐tdTomato)Tvrd/J mice were bred to homozygosity with B6.Cg‐Tg(SOX10‐cre/ERT2)Vpa mice which were maintained as hemizygous. Mice received a gavage of tamoxifen (5mg in 0.2ml corn oil) for five days at seven to eight weeks of age to induce tdTomato (tdT) expression in glia. Mice were euthanized by CO2 inhalation at 10–20 weeks of age. Jejunum and mid colon segments were opened on the mesenteric border, fixed in 4% paraformaldehyde, immunostained for anti‐S100β, and cleared with Ce3D solution. Tissues were imaged using confocal microscopy and 3D reconstructions were made using Analyze. SOX10‐tdT cells were found in the bowel throughout all layers. In the muscularis externa of both the jejunum and colon, there were extensive networks within myenteric ganglia, intraganglionic fiber tracts, within the circular muscle layer, along fiber tracts ascending through the circular muscle, and rare cells were observed in the longitudinal muscle layer. In the submucosal layer of both the jejunum and colon, SOX‐tdT cells were in submucosal ganglia, along intraganglionic fibers and formed a regular network of processes that extended within the lamina propria surrounding the base of intestinal crypts. In the mucosa, SOX10‐tdT distribution differed between the jejunum and colon. In the colonic mucosa, there were two distinct bands of SOX10‐tdT networks oriented perpendicular to and surrounding all colonic glands which were approximately 120μm in height. These bands were located approximately 20μm and 60μm from the base of the glands. SOX10‐tdT cells were very rarely observed near the luminal surface of the colonic glands. In the jejunal mucosa, there were extensive SOX10‐tdT networks throughout the lamina propria surrounding crypts and extending to the tips of villi. Overlap of SOX10‐tdT and S100β immunoreactivity was nearly 100% throughout all glial populations with two exceptions, only 10–20% of SOX10‐tdT cells had S100β immunoreactivity in the jejunum mucosa and there were submucosal neurons that expressed S100β that did not contain SOX10‐tdT. Collectively, these data demonstrate significant complexity of the glial networks of the intestines with distinct morphological differences between mucosal glia of the colon and jejunum that may implicate different functions of enteric glia in the small and large intestines. Support or Funding Information Supported by NIH grants R01DK106011, P30DK084567 and DP2AT010875 and Department of Defense grant W81XWH‐18‐1‐0218. Representative SOX10‐tdT fluorescence in projections of 409 or 139 1.22μm‐thick confocal images through the full thickness of either jejunum (left) or colon (right), respectively. Figure 1

Abstract All-trans retinoic acid (ATRA) syndrome is a complex constellation of symptoms that arise in about 15% of patients who receive retinoic acid as therapy for acute promyelocytic leukemia (PML). This syndrome typically consists of fever, dyspnea, weight gain, pulmonary infiltrates, pleural or pericardial effusions, episodic hypotension, renal dysfunction, and leukocytosis. Rarely does this entity present as typical chest pain suggestive of an acute myocardial infarction. A 39-year-old man diagnosed with acute PML treated with idarubicin and ATRA was admitted for febrile neutropenia, nausea, vomiting, cough, and epigastric pain despite being on ciprofloxacin and metronidazole at home. He continued to have low-grade fevers despite being on antibiotics and antifungals. On hospital day three, he was transferred to the CCU for worsening non-radiating left substernal chest pain associated with nausea and vomiting, new inferior lead 2 mm ST segment elevation, lateral lead T wave inversion, troponin and CKMB elevation, and hypotension not responding to frequent fluid boluses. A Swan-Ganz catheter was placed and pressors were started. The patient was found to have a dramatic neutrophil-predominant leukocytosis only hours after a CBC showed neutropenia. He also developed anuric acute renal failure. A cardiac catheterization was considered but could not be performed because of thrombocytopenia and the patient’s renal status. Subsequent EKG’s revealed more impressive changes. New 3 mm ST segment elevations and T wave inversions were noted in the lateral leads, the inferior lead ST segment elevations persisted and new inferior lead T wave inversions were present. An emergent echocardiogram was obtained which showed a significantly decreased LVEF at 36% and global LV hypokinesis without pericardial effusion. The constellation of symptoms was more suggestive of ATRA syndrome versus acute coronary syndrome and intravenous dexamethasone was started. The patient’s chest pain resolved spontaneously over the next three hours, the dramatic EKG findings and elevated cardiac enzymes resolved over the next few days, and the patient was transferred back to the admitting hematology service. A follow-up echocardiogram before discharge revealed a normal LVEF at 74% and no residual wall motion abnormalities. He eventually required hemodialysis for continued renal failure, which was continued as an outpatient after discharge. Of note, the patient’s fever resolved after beginning dexamethasone and multiple blood, urine, stool, and sputum cultures obtained remained negative throughout the hospital stay. This clinical situation presents a very distinct dilemma in how to proceed with clinical care. The presenting symptoms, signs, diagnostics, and imaging alone were all suggestive of a worsening ischemic cardiac process. But in considering the clinical presentation as a whole, especially the concomitant renal failure, fever in the setting of broad-spectrum coverage, and dramatic leukocytosis, we were more convinced of a systemic reaction to recent ATRA use. We maintained a low threshold for beginning an acute coronary syndrome protocol involving antiplatelet agents but were supported in our diagnosis by the patient’s remarkable recovery shortly after beginning intravenous steroids.

Abstract T is a Farnesyltransferase inhibitor with clinical activity in elderly adults with newly diagnosed AML who are not candidates for TCC. For adults ≥ age 65 with poor-risk AML, T 600 mg BID for 21 out of every 28–63 days induces complete remissions (CR) in 15%, median duration 7.3 mos, median survival 18 mos. In vitro, T+E exhibits synergistic anti-AML effects. In an attempt to increase CR rates in elderly AML pts, we are conducting a Phase I trial of oral T+E, with escalating doses of both drugs and 14 vs. 21 days of T every 28–63 days (median time to beginning cycle 2 is Day 31, range 29–43). To date, 60 adults ≥ age 70 (median 77, range 71–91) have been treated at 10 dose levels of T (300, 400 or 600 mg BID, 14 or 21 days) + E (100, 150 or 200 mg daily days 1–3 and 8–10) and have received 145 cycles (median 3, range 1–7). A total of 35 (58%) have had secondary AML and 31 (52%) have had adverse cytogenetics. Marrow blast percent was median 55% (range 20–96%), with 75% &gt;30,000 blasts. Nonhematologic toxicities include oropharyngeal mucositis (15% ≥ grade 2), CNS (overall 30%, with 80% of those ≤ grade 2), renal (6%), hyperbilirubinemia (6%), rash (20%) and fatigue (20%). Toxicities occurred across all T+E dose levels tested to date. Documented infections occurred in 16 (27%) pts during cycle 1 and 22/145 (14%) cycles. Twenty six pts (43%) required hospitalization during cycle 1 for median 7 days (range 2–28). Overall hospitalization rate for all cycles was 28% (41/145). Ten pts (17%) died on study: 6 during cycle 1 (4 infection, 1 emphysema, 1 cerebrovascular) and 4 during cycles 2–4 (3 acute myocardial infarctions, 1 ventricular arrhythmia). For 56 evaluable pts, 12 (21%) have achieved CR and 11(20%) have achieved partial remission/hematologic improvement (PR/HI). All pts achieving CR have done so within 2 cycles (9/12 after cycle 1). Eight of 30 pts (27%) receiving T ≥ 400 mg BID have achieved CR. Median age of CR pts is 79 (range 71–86), 8 (67%) have secondary AML, and 5 (42%) have complex cytogenetics. CR durations to date range from 2+ to 13.5+ mos, with median 7+ months. Three of 12 have relapsed at 3, 10, and 11 mos, 2 have been retreated with T+E, and both have achieved 2nd CRs. In sum, the oral regimen of T+E is tolerable and feasible on an outpatient basis for elderly adults with newly diagnosed AML who are not candidates for TCC, with the suggestion of improvement of CR rates over T alone.

Abstract Background: Responses to the novel HDAC inhibitor romidepsin were observed in patients (pts) with T-cell lymphoma in a phase 1 NCI trial. Aims: To evaluate the efficacy and tolerability of romidepsin in the treatment of advanced cutaneous T-cell lymphoma (CTCL). As an exploratory endpoint, to examine the molecular effects of romidepsin in both CTCL and peripheral T-cell lymphoma (PTCL). Methods: This Phase 2, open-label, multi-arm, multicenter study enrolled 71 CTCL pts from the NCI and 9 extramural sites. PTCL pts were also enrolled. Clinical results for pts with CTCL and biomarker analyses for both PTCL and CTCL are presented here; clinical results for the PTCL pts are presented elsewhere. This study is now closed to accrual. Pts with recurrent CTCL (Stages IA-IVB) received romidepsin at 14 mg/m2 as a 4-hr infusion on days 1, 8 and 15 q 28 days. Responses were assessed using a composite endpoint that evaluated overall changes in skin (modified Physicians Global Assessment), lymph nodes, extranodal visceral lesions and abnormal circulating T-cells. Molecular endpoints evaluated in NCI pts were: histone acetylation in peripheral blood mononuclear cells (PBMCs); MDR-1 gene expression in PBMCs and in biopsy samples; and blood fetal hemoglobin levels. Results: 71 pts (48 men and 23 women) with a mean age of 56 yrs (range 28–84) were enrolled and received romidepsin; 63 pts received ≥2 cycles of therapy. Mean number of prior therapies was 3.4 (range 1–10). Objective disease response rates (ORR) are presented in the table. Overall disease control (CR+PR+SD90) was 62% in all pts and 70% in pts who received ≥2 cycles. Target skin lesions were followed and changes were generally similar to overall skin changes. Median duration of response (DOR) was 11 months (mo) and the maximum DOR as of data cut-off was 5.5+ yrs. The most frequent drug-related AEs (all grades, all cycles) were generally mild, including nausea (82%; 4% ≥grade 3), fatigue (73%; 14% ≥ grade 3), electrocardiogram T-wave amplitude decreased (69%, 0% ≥grade 3); hemoglobin decreased (59%, 9% ≥grade 3), and platelet count decreased (59%; 13% ≥grade 3). Six pts died within 30 days of study drug administration: 2 after salvage chemotherapy, 1 with ARDS due to PD, 2 with infection, and 1 of unknown cause; 2 of these deaths were considered possibly related to treatment. An increase in all biomarkers measured was observed, although not in all pts. Correlation between global histone H3 acetylation (AcH3) at the 24-hr time point and Cmax, AUC, and clearance was observed (r = 0.37, 0.36, and −0.44, respectively, p = 0.03). Pts with major responses were more likely to have higher levels of AcH3 at 24 hr. Conclusions: This study demonstrates tolerability and durable clinical benefit (ORR of 35% and median DOR of 11 mo in all pts) of romidepsin in pts with recurrent CTCL. Significant responses were observed at all stages of disease, including an ORR of 32% in all pts with stage ≥IIB and 20% in all pts with stage IV. Time to response was rapid, within 2 mo in most pts, and responses were durable, &gt;6 mo in most pts. Molecular analyses confirmed that romidepsin inhibits its target deacetylases in pts. Increases were not observed in all pts, perhaps reflecting, in part, variable drug exposure or variable response to HDAC inhibition. Correlation of global acetylation with PK parameters suggests that increased drug exposure results in increased global acetylation. All Pts N=71 Pts ≥ 2 cycles N=63 ORR (CR+PR), n (%) 25 (35%) 25 (40%) PR, n (%) 21 (30%) 21 (33%) CR, n (%) 4 (6%) 4 (6%) SD90, n(%) 19 (27%) 19 (30%) Overall disease control (CR+PR+ SD90) 44 (62%) 44 (70%) DOR 11 (1+ mo, 5.5+ yrs) 11 (1+ mo, 5.5+ yrs) OR for pts with stage ≥ IIB, n (%) 20/62 (32%) 20/55 (36%) SD90= stable disease for ≥90 days

Abstract Background: The histone deacetylase (HDAC) inhibitors are a class of epigenetic agents undergoing clinical testing. HDAC inhibitors modulate expression of genes involved in cell cycle regulation, leading to induction of differentiation or apoptosis. Romidepsin, a novel, HDAC inhibitor, has previously demonstrated activity as a single agent in patients (pts) with T-cell lymphoma in a phase 1 NCI study. Aims: To evaluate the efficacy and tolerability of romidepsin in the treatment of advanced PTCL and as an exploratory endpoint, to examine the molecular effects of romidepsin in both PTCL and cutaneous T-cell lymphoma (CTCL). Methods: This Phase 2, open-label, multi-arm, multicenter study enrolled 43 PTCL pts from the NCI and 9 extramural sites. CTCL pts were also enrolled in this study. The clinical results for pts with PTCL are presented here; the clinical results for the pts with CTCL and the biomarker analyses for both PTCL and CTCL are presented elsewhere. This study is now closed to accrual. Pts with relapsed or refractory PTCL or primary cutaneous anaplastic large cell lymphoma were eligible. Pts received romidepsin 14 mg/m2 as a 4-hr infusion on days 1, 8 and 15 every 28 days. Responses were assessed using elements of the IWG criteria and RECIST, as appropriate, for pts with lymph node involvement and extranodal disease. Results: 43 pts (23[53%] men and 20 [47%] women) with a mean age of 58.1 (range: 27 to 84) years were treated with romidepsin. 31 pts received ≥ 2 cycles of therapy. Mean number of prior therapies was 3.9 (range 1 to 12). Objective disease response rates (ORR) are summarized in the table. The mean number of cycles of treatment was 6.8 (range 1–37) and the overall median duration of response was 8.3 months (range 1.6 months to 4.8+ yrs) for all pts. The median duration of response for the 7 pts who achieved CR was 8.5 months (range 4.6 months to 4.8+yrs). The most frequent drug-related AEs (all grades, all cycles) were generally mild and included: nausea (86%; 0% ≥grade 3), fatigue (79%; 0% ≥grade 3), decreased platelets (70%; 7% ≥grade 3), and decreased AGC (63%; 5% ≥grade 3). One death, in a pt with significant cardiovascular disease who had achieved a CR, was considered possibly related to treatment. Conclusions: This study demonstrates tolerability and durable clinical benefit (ORR of 39% and median duration of response of 8.3 months) of romidepsin in pts with recurrent or refractory PTCL. Based on these promising results, a Phase 2B protocol investigating romidepsin in pts with progressive or relapsed PTCL is ongoing at multiple international centers. All Pts N=43 Pts ≥ 2 cycles N=31 ORR (CR+PR), n (%) 17 (39%) 17 (55%) PR, n (%) 10 (23%) 10 (32%) CR, n (%) 7 (16%) 7 (23%)

Importance Black individuals are more likely than white individuals to develop dementia. Whether higher blood pressure (BP) levels in black individuals explain differences between black and white individuals in dementia risk is uncertain. Objective To determine whether cumulative BP levels explain racial differences in cognitive decline. Design, Setting, and Participants Individual participant data from 5 cohorts (January 1971 to December 2017) were pooled from the Atherosclerosis Risk in Communities Study, Coronary Artery Risk Development in Young Adults Study, Cardiovascular Health Study, Framingham Offspring Study, and Northern Manhattan Study. Outcomes were standardized as t scores (mean [SD], 50 [10]); a 1-point difference represented a 0.1-SD difference in cognition. The median (interquartile range) follow-up was 12.4 (5.9-21.0) years. Analysis began September 2018. Main Outcomes and Measures The primary outcome was change in global cognition, and secondary outcomes were change in memory and executive function. Exposures Race (black vs white). Results Among 34 349 participants, 19 378 individuals who were free of stroke and dementia and had longitudinal BP, cognitive, and covariate data were included in the analysis. The mean (SD) age at first cognitive assessment was 59.8 (10.4) years and ranged from 5 to 95 years. Of 19 378 individuals, 10 724 (55.3%) were female and 15 526 (80.1%) were white. Compared with white individuals, black individuals had significantly faster declines in global cognition (−0.03 points per year faster [95% CI, −0.05 to −0.01]; P = .004) and memory (−0.08 points per year faster [95% CI, −0.11 to −0.06]; P &amp;lt; .001) but significantly slower declines in executive function (0.09 points per year slower [95% CI, 0.08-0.10]; P &amp;lt; .001). Time-dependent cumulative mean systolic BP level was associated with significantly faster declines in global cognition (−0.018 points per year faster per each 10–mm Hg increase [95% CI, −0.023 to −0.014]; P &amp;lt; .001), memory (−0.028 points per year faster per each 10–mm Hg increase [95% CI, −0.035 to −0.021]; P &amp;lt; .001), and executive function (−0.01 points per year faster per each 10–mm Hg increase [95% CI, −0.014 to −0.007]; P &amp;lt; .001). After adjusting for cumulative mean systolic BP, differences between black and white individuals in cognitive slopes were attenuated for global cognition (−0.01 points per year [95% CI, −0.03 to 0.01]; P = .56) and memory (−0.06 points per year [95% CI, −0.08 to −0.03]; P &amp;lt; .001) but not executive function (0.10 points per year [95% CI, 0.09-0.11]; P &amp;lt; .001). Conclusions and Relevance These results suggest that black individuals’ higher cumulative BP levels may contribute to racial differences in later-life cognitive decline.

Abstract Aims Small-interfering RNA (siRNA)-based targeting of proprotein convertase subtilisin/kexin type 9 (PCSK9) represents a novel therapeutic approach that may provide a convenient, infrequent, and safe dosing schedule to robustly lower low-density lipoprotein cholesterol (LDL-C). Given the long duration of action, however, establishing safety in particular with respect to immunogenicity is of paramount importance. In earlier clinical studies of other RNA-targeted treatment approaches (antisense oligonucleotide therapy) immunological and haematological adverse effects, in particular thrombocytopenia and pro-inflammatory effects, have been reported. Here, we present the pre-specified safety analysis from ORION-1 evaluating platelets, immune cells, immunological markers, antidrug antibodies, and clinical immunogenicity adverse events (AEs) under PCSK9 siRNA treatment with inclisiran. Methods and results The pre-specified safety analysis from ORION-1 was performed in six different inclisiran dosing regimens in patients at high risk of cardiovascular disease with elevated LDL-C levels. Patients received either a single dose (SD: 200 mg, n = 60; 300 mg, n = 62 or 500 mg, n = 66) or double-dose starting regimen (DD: 100 mg, n = 62; 200 mg, n = 63; or 300 mg, n = 61 on days 1 and 90) of inclisiran or placebo (SD: n = 65; DD: n = 62). The effects of inclisiran on haematological parameters including platelet counts, lymphocytes, and monocytes as well as on the immune markers interleukin 6 (IL-6) and tumour necrosis factor-α (TNF-α) were examined after 180 days. Immunogenicity was further evaluated by analysis of anti-drug-antibodies (ADAs) towards inclisiran in 6068 study samples and by careful analysis of immunogenicity AEs as part of the pharmacovigilance strategy. At day 180, no significant alterations of platelet counts were observed in any of the dosing groups (change from baseline, SD: 200 mg: 0.8%; 300 mg: −0.5%; 500 mg: −1.8%; DD: 100 mg: 1.3%; 200 mg: −0.5%; 300 mg: 1.0%; no significant difference for any group as compared with placebo). No significant effects on other immune cells, including leucocytes, monocytes, or neutrophils were detected. Notably, no significant increase of inflammatory biomarkers (IL-6 or TNF-α) with either the SD or DD regimen became evident. There was no evidence for immunogenicity based on ADA level analysis and careful review of clinical immunogenicity AEs in none of the treatment regimens. Conclusion In this pre-specified safety analysis of ORION-1 for the siRNA therapeutic inclisiran, no adverse effects on measures of inflammation or immune activation nor adverse effects on platelets or clinical immunogenicity AEs were observed over at least 6-month treatment. These safety findings in the largest analysis of an RNAi study in humans to date provide strong reassurance about the safety of inclisiran and the potential of cardiovascular RNA-targeted therapies.

Abstract Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is an uncommon histologic variant, and the optimal treatment of stage I-II NLPHL is undefined. We conducted a multicenter retrospective study including patients ≥16 years of age with stage I-II NLPHL diagnosed from 1995 through 2018 who underwent all forms of management, including radiotherapy (RT), combined modality therapy (CMT; RT+chemotherapy [CT]), CT, observation after excision, rituximab and RT, and single-agent rituximab. End points were progression-free survival (PFS), freedom from transformation, and overall survival (OS) without statistical comparison between management groups. We identified 559 patients with median age of 39 years: 72.3% were men, and 54.9% had stage I disease. Median follow-up was 5.5 years (interquartile range, 3.1-10.1). Five-year PFS and OS in the entire cohort were 87.1% and 98.3%, respectively. Primary management was RT alone (n = 257; 46.0%), CMT (n = 184; 32.9%), CT alone (n = 47; 8.4%), observation (n = 37; 6.6%), rituximab and RT (n = 19; 3.4%), and rituximab alone (n = 15; 2.7%). The 5-year PFS rates were 91.1% after RT, 90.5% after CMT, 77.8% after CT, 73.5% after observation, 80.8% after rituximab and RT, and 38.5% after rituximab alone. In the RT cohort, but not the CMT cohort, variant immunoarchitectural pattern and number of sites &gt;2 were associated with worse PFS (P &lt; .05). Overall, 21 patients (3.8%) developed large-cell transformation, with a significantly higher transformation rate in those with variant immunoarchitectural pattern (P = .049) and number of involved sites &gt;2 (P = .0006). OS for patients with stage I-II NLPHL was excellent after all treatments.