Abstract: The protein design problem is to identify an amino acid sequence that folds to a desired structure. Given Anfinsen’s thermodynamic hypothesis of folding, this can be recast as finding an amino acid sequence for which the desired structure is the lowest energy state. As this calculation involves not only all possible amino acid sequences but also, all possible structures, most current approaches focus instead on the more tractable problem of finding the lowest-energy amino acid sequence for the desired structure, often checking by protein structure prediction in a second step that the desired structure is indeed the lowest-energy conformation for the designed sequence, and typically discarding a large fraction of designed sequences for which this is not the case. Here, we show that by backpropagating gradients through the transform-restrained Rosetta (trRosetta) structure prediction network from the desired structure to the input amino acid sequence, we can directly optimize over all possible amino acid sequences and all possible structures in a single calculation. We find that trRosetta calculations, which consider the full conformational landscape, can be more effective than Rosetta single-point energy estimations in predicting folding and stability of de novo designed proteins. We compare sequence design by conformational landscape optimization with the standard energy-based sequence design methodology in Rosetta and show that the former can result in energy landscapes with fewer alternative energy minima. We show further that more funneled energy landscapes can be designed by combining the strengths of the two approaches: the low-resolution trRosetta model serves to disfavor alternative states, and the high-resolution Rosetta model serves to create a deep energy minimum at the design target structure.

Abstract: Introduction: It is anticipated that many patients with hemophilia are likely to switch from one coagulation factor product to a newer agent within the next few years. New replacement factor formulations have been developed using several approaches that have theoretical benefit. However, except for pharmacokinetic properties, it may be difficult to determine whether they are superior to current clinically successful preparations. Rurioctocog alfa pegol (Adynovate®), a pegylated, extended half-life factor VIII (FVIII) concentrate, received United States Food and Drug Administration approval in 2015. Its efficacy and safety for the treatment of hemophilia A have been demonstrated in multiple studies (Konkle et al. 2015; Gruppo et al. 2019; Mullins et al. 2017). The ATHN 2: Factor Switching Study provided the opportunity to longitudinally observe previously treated hemophilia patients switching to rurioctocog alfa pegol to identify dosing regimens, patient satisfaction with the change in therapy, impact on health states and productivity. Methods: The ATHN 2: Factor Switching Study is sponsored by the American Thrombosis and Hemostasis Network (ATHN) and is being conducted at ATHN-affiliated sites in the US. This multi-center, longitudinal, observational study enrolled male and female children and adults with moderate or severe congenital hemophilia A or B (factor VIII or IX clotting activity ≤5% of normal) who were previously treated with plasma-derived or recombinant factor replacement products with ³50 exposure days. Patients receiving care from one of 30 hemophilia treatment centers were enrolled into 2 arms: 1) a prospective arm including those switching factor replacement products who were followed for & lt;1 year; and 2) a retrospective arm including those who had switched factor replacement products within the past 50 weeks at the time of enrollment. Patients were assessed retrospectively or followed prospectively for & lt;1 year. Treatment administered in ATHN 2 was at the discretion of the patient's provider. Each patient was seen during a study visit or contacted by telephone at least once every 3 months. A product-specific module developed for rurioctocog alfa pegol included assessment of dosing and treatment satisfaction vs prior therapy; adherence to therapy assessed using Validated Hemophilia Regimen Treatment Adherence Scale-Prophylaxis (VERITAS-Pro), a validated instrument with 6 subscales (timing, dosing, planning, remembering, skipping, communication); health states measured by the EQ-5D-DL; work productivity assessed by the Work Productivity Activity Impairment Questionnaire (WPAI); and overall satisfaction with therapy. Results: Patients (n=59) with hemophilia A were enrolled into the rurioctocog alfa pegol sub-study by May 1, 2020. Mean (± standard deviation [SD]) age was 25 ± 18 years (range = 4-77 years); 72.9% (n=43) were in the prospective arm and 27.1% (n=16) in the retrospective arm; 11.9% (n=7) had moderate hemophilia A and 88.1% (n=52) had severe disease. All were taking rurioctocog alfa pegol as prophylaxis. At study end, results for dosing (Table 1) indicated the most common treatment regimen was twice weekly (45.1%, n=23), and mean nominal dose was 50 ± 10 U/kg. Patients were highly adherent to prophylaxis with rurioctocog alfa pegol with a mean total VERITAS-Pro score of 31.4 ± 8.4; adherence improved slightly over time (32.6 ± 9.0 at baseline vs 29.2 ± 4.2 at month 12). Patients strongly preferred rurioctocog alfa pegol vs all prior factor products for controlling bleeding, convenience, finding time to take and ease of administering FVIII, and how often they were required to take factor (Table 1). Overall, 76.5% of patients were very satisfied or satisfied with rurioctocog alfa pegol. Assessment of health states indicated that patients generally had no or slight problems with mobility, activities, or self-care; and were not in pain or anxious/depressed. Patients generally missed no time from work or school. Overall health was self-rated at 89.0 ± 13.0 on a scale from 0 (worst health) to 100 (best health) and remained stable from baseline (88.0 ± 14.0) to month 12 (87.8 ± 15.3). Conclusions: Moderate and severe hemophilia A patients enrolled in ATHN 2 who received rurioctocog alfa pegol for prophylaxis enjoyed excellent health, had little to no school or work impairment and were adherent to, and satisfied with, their treatment regimen. Disclosures Recht: Spark: Research Funding; CSL Behring: Consultancy, Other: personal fees; Novo Nordisk: Consultancy, Other: personal fees, Research Funding; Genentech: Consultancy, Other: personal fees, Research Funding; Pfizer: Consultancy, Other: personal fees; BioMarin: Research Funding; Takeda: Consultancy, Other: personal fees, Research Funding; uniQure: Consultancy, Other: personal fees, Research Funding. Guelcher:Novo-Nordisk: Consultancy; Octapharma: Consultancy; Genentech, Octapharma, CSL Behring, Takeda, Pfizer, Novo Nordisk: Consultancy; Takeda: Consultancy. Neufeld:Bayer: Other: DSMB; genetech: Consultancy; Novo Nordsik: Consultancy; Octapharma: Consultancy; Takeda: Consultancy; Imara Pharma: Other: DSMB service; ApoPharma/Chiezi: Other: DSMB service; Pfizer: Membership on an entity's Board of Directors or advisory committees; BMS: Consultancy; Acceleron Pharma: Consultancy, Other: DSMB. Ragni:Alnylam/Sanofi, ATHN, BioMarin, Bioverativ, Sangamo, Spark: Research Funding; Alnylam/Sanofi, BioMarin, Bioverativ, Spark: Consultancy; BioMarin: Consultancy, Research Funding; Bioverativ: Consultancy, Research Funding; Spark: Consultancy, Research Funding; Takeda: Research Funding; Sangamo: Consultancy, Research Funding; Alnylam Pharmaceuticals Inc., Baxalta/Takeda, BioMarin, Bioverativ, and Spark Therapeutics: Membership on an entity's Board of Directors or advisory committees; American Thrombosis Hemostasis Network: Other: Committee work; Baxalta/Takeda, CSL Behring, Genentech, a member of the Roche Group, OPKO Biologics, and Vascular Medicine Institute: Research Funding. Sidonio:Biomarin: Consultancy, Honoraria, Speakers Bureau; Sanofi: Consultancy, Honoraria, Research Funding, Speakers Bureau; Grifols: Research Funding; Spark: Consultancy, Honoraria; Uniqure: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Novo Nordisk: Consultancy, Honoraria; Octapharma: Consultancy, Honoraria, Research Funding; Roche: Consultancy, Honoraria; Genentech: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria; Bayer: Consultancy, Honoraria. Takemoto:Novartis: Other: DMBC; Genentech: Consultancy. Tarantino:Spark: Membership on an entity's Board of Directors or advisory committees; CDC: Membership on an entity's Board of Directors or advisory committees; Dova: Membership on an entity's Board of Directors or advisory committees; Biomarin: Membership on an entity's Board of Directors or advisory committees; NovoNordisk: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Research Funding; Octapharma: Membership on an entity's Board of Directors or advisory committees; Grifols: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Genentech: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; HRSA: Membership on an entity's Board of Directors or advisory committees; Pfizer: Other; Sobi: Membership on an entity's Board of Directors or advisory committees. Caicedo:Takeda: Current Employment. Denne:Takeda: Current Employment.

Abstract: The aim of this two-center, all-comers registry was to compare the effectiveness and safety of intravascular lithotripsy (IVL) to that of modified balloon angioplasty (MB). MB angioplasty using a cutting or scoring balloon is commonly used in patients with calcified coronary arteries. IVL is a new technology for lesion preparation. This is the first study to compare MB with IVL. Methods The cohort included all patients treated by MB angioplasty or IVL between 2019 and 2021. The primary endpoint was strategy success ( & lt;20% residual stenosis). The secondary endpoint was long-term safety outcomes [cardiac death, acute myocardial infarction (AMI), target lesion failure/revascularization (TVR)]. Quantitative coronary angiography (QCA) was performed in all patients. Primary and secondary endpoints were compared using inverse probability of treatment weighting (IPTW) for treatment effect estimation. Results A total of n  = 86 patients were treated by IVL and n  = 92 patients by MB angioplasty. The primary endpoint was reached in 152 patients (85.4%). Patients in the IVL group had less residual stenosis (5.8% vs. 22.8%; p  = 0.001) in QCA. Weighted multivariable regression analysis revealed that IVL had a significant positive effect on reaching the primary endpoint of strategy success [odds ratio (OR) 24.58; 95% confidence interval (95% CI) 7.40–101.86; p  = 0.001]. In addition, severe cal cification was shown to result in a lower probability of achieving the primary endpoint (OR 0.08; 95% CI 0.02–0.24; p  = 0.001). During the follow-up period (450 days) there was no difference in cardiovascular mortality rate [IVL ( n  = 5) 2.8% vs. MB ( n  = 3) 1.7%; p  = 0.129]. Patients with unstable angina at the time of the index procedure had the highest probability of cardiovascular death [hazard ratio (HR) 7.136; 95% CI 1.248–40.802; p  = 0.027]. No differences were found in long-term rates of AMI (IVL 1.7% vs. MB 2.8%; p  = 0.399; IVL HR 2.73; 95% CI 0.4–17.0; p  = 0.281) or TVR (IVL 5.6% vs. MB 9%; p  = 0.186; IVL HR 0.78; 95% CI 0.277–2.166; p  = 0.626). Conclusion IVL leads to a significantly better angiographic intervention outcome compared to MB angioplasty in our cohort. During long-term follow-up, no differences in cardiovascular mortality, rate of acute myocardial infarction, or target lesion failure/revascularization were observed.

Abstract: GOAL‐Hēm is a novel, haemophilia‐specific, patient‐centred outcome measure (PCOM) based on goal attainment scaling, allowing people with haemophilia (PwH) to set and monitor the attainment of individualized goals for treatment. Aim To provide a thorough overview of the creation, validation, and development of GOAL‐Hēm. Methods Clinician workshops were held to develop a haemophilia‐specific goal menu. Qualitative data from semistructured interviews with PwH and their caregivers guided further revisions to the goal menu (i.e., goal domains and descriptors). A feasibility study was performed including a 12‐week, prospective, noninterventional evaluation involving clinicians and PwH at four US haemophilia treatment centres. Finally, the Patient Voice Study gathered feedback from PwH and their caregivers via an online survey, interviews, and a focus group. Results The feasibility study validated GOAL‐Hēm with successful outcomes in construct/content validity and responsiveness, including a large effect in patient‐ and clinician‐rated goal attainments. The Patient Voice Study led to significant refinement of GOAL‐Hēm goals and descriptors, resulting in a more straightforward and relatable menu for PwH and their caregivers. Overall, GOAL‐Hēm captured qualitative data in areas important to PwH and employed quantitative methods to evaluate meaningful changes in those areas. The individualized tool was well equipped to handle the complex and chronic nature of haemophilia and was endorsed by PwH, their caregivers, and clinicians. Conclusion The GOAL‐Hēm development journey may serve as a roadmap for other PCOMs in a variety of settings, including clinical studies, haemophilia treatment centres for care planning, and as a tool to gather real‐world evidence.

Abstract: Polyethylene glycol (PEG) is an inert, water soluble polymer, used for decades in pharmaceuticals. Although PEG is considered safe, concerns persist about the potential adverse effects of long-term exposure to PEG-containing therapies, specifically in children, following the introduction of PEGylated recombinant factor products used for the treatment of hemophilia. Given the absence of long-term surveillance data, and to evaluate the potential risk, we estimated PEG exposure in the pediatric population receiving PEGylated therapies with pediatric indications administered intravenously or intramuscularly. We used a range of pediatric weights and doses based on prescribing information (PI) or treatment guidelines. PIs and reporting websites were searched for information about adverse events (AEs). For a child weighing 50 kg on the highest prophylactic dose of a FVIII product, the range of total PEG exposure was 40–21,840 mg/year; for factor IX (FIX) products, the range was 13–1342 mg/year; and for other products, the range was 383–26,743 mg/year, primarily as a derivative excipient. No AE patterns attributable to PEG were found for any of these products, including potential renal, neurological, or hepatic AEs. Our analyses suggest the pediatric population has had substantial exposure to PEG for several decades, with no evidence of adverse consequences.