First-in-human, open-label dose-escalation and dose-expansion study of the safety, pharmacokinetics, and antitumor effects of an oral ALK inhibitor ASP3026 in patients with advanced solid tumors

Abstract Background ASP3026 is a second-generation anaplastic lymphoma kinase (ALK) inhibitor that has potent in vitro activity against crizotinib-resistant ALK-positive tumors. This open-label, multicenter, first-in-human phase I study ( NCT01284192 ) assessed the safety, pharmacokinetic profile, and antitumor activity of ASP3026. Methods Advanced solid tumor patients received oral ASP3026 in 3 + 3 dose-escalation cohorts at doses of 25–800 mg once daily in 28-day cycles. The endpoints were to identify the maximum tolerated dose (MTD), the recommended phase II dose (RP2D), and the pharmacokinetic profile of ASP3026. A phase Ib expansion cohort enrolled patients with metastatic, crizotinib-resistant ALK-positive solid tumors at the RP2D, and response was evaluated by RECIST 1.1. Results The dose-escalation cohort enrolled 33 patients, including three crizotinib-resistant, ALK-positive patients, and the dose-expansion cohort enrolled another 13 crizotinib-resistant, ALK-positive non-small cell lung cancer (NSCLC) patients. ASP3026 demonstrated both linear pharmacokinetics and dose-proportional exposure for area under the plasma concentration–time curve and maximum concentration observed with a median terminal half-life of 35 h, supporting the daily dosing. Grade 3 rash and elevated transaminase concentrations were dose-limiting toxicities observed at 800 mg; hence, 525 mg daily was the MTD and RP2D. The most common treatment-related adverse events were nausea (38 %), fatigue (35 %), and vomiting (35 %). Among the 16 patients with crizotinib-resistant ALK-positive tumors (15 NSCLC, 1 neuroblastoma), eight patients achieved partial response (overall response rate 50 %; 95 % confidence interval 25–75 %) and seven patients (44 %) achieved stable disease. Conclusions ASP3026 was well tolerated and had therapeutic activity in patients with crizotinib-resistant ALK-positive advanced tumors. Trial registration ClinTrials.gov: NCT0128419

Selective inhibition of FLT3 by gilteritinib in relapsed or refractory acute myeloid leukaemia: a multicentre, first-in-human, open-label, phase 1-2 study.

BackgroundInternal tandem duplication mutations in FLT3 are common in acute myeloid leukaemia and are associated with rapid relapse and short overall survival. The clinical benefit of FLT3 inhibitors in patients with acute myeloid leukaemia has been limited by rapid generation of resistance mutations, particularly in codon Asp835 (D835). We aimed to assess the highly selective oral FLT3 inhibitor gilteritinib in patients with relapsed or refractory acute myeloid leukaemia.MethodsIn this phase 1-2 trial, we enrolled patients aged 18 years or older with acute myeloid leukaemia who either were refractory to induction therapy or had relapsed after achieving remission with previous treatment. Patients were enrolled into one of seven dose-escalation or dose-expansion cohorts assigned to receive once-daily doses of oral gilteritinib (20 mg, 40 mg, 80 mg, 120 mg, 200 mg, 300 mg, or 450 mg). Cohort expansion was based on safety and tolerability, FLT3 inhibition in correlative assays, and antileukaemic activity. Although the presence of an FLT3 mutation was not an inclusion criterion, we required ten or more patients with locally confirmed FLT3 mutations (FLT3mut+) to be enrolled in expansion cohorts at each dose level. On the basis of emerging findings, we further expanded the 120 mg and 200 mg dose cohorts to include FLT3mut+ patients only. The primary endpoints were the safety, tolerability, and pharmacokinetics of gilteritinib. Safety and tolerability were assessed in the safety analysis set (all patients who received at least one dose of gilteritinib). Responses were assessed in the full analysis set (all patients who received at least one dose of study drug and who had at least one datapoint post-treatment). Pharmacokinetics were assessed in a subset of the safety analysis set for which sufficient data for concentrations of gilteritinib in plasma were available to enable derivation of one or more pharmacokinetic variables. This study is registered with ClinicalTrials.gov, number NCT02014558, and is ongoing.FindingsBetween Oct 15, 2013, and Aug 27, 2015, 252 adults with relapsed or refractory acute myeloid leukaemia received oral gilteritinib once daily in one of seven dose-escalation (n=23) or dose-expansion (n=229) cohorts. Gilteritinib was well tolerated; the maximum tolerated dose was established as 300 mg/day when two of three patients enrolled in the 450 mg dose-escalation cohort had two dose-limiting toxicities (grade 3 diarrhoea and grade 3 elevated aspartate aminotransferase). The most common grade 3-4 adverse events irrespective of relation to treatment were febrile neutropenia (97 [39%] of 252), anaemia (61 [24%]), thrombocytopenia (33 [13%]), sepsis (28 [11%]), and pneumonia (27 [11%]). Commonly reported treatment-related adverse events were diarrhoea (92 [37%] of 252]), anaemia (86 [34%]), fatigue (83 [33%]), elevated aspartate aminotransferase (65 [26%]), and increased alanine aminotransferase (47 [19%]). Serious adverse events occurring in 5% or more of patients were febrile neutropenia (98 [39%] of 252; five related to treatment), progressive disease (43 [17%]), sepsis (36 [14%]; two related to treatment), pneumonia (27 [11%]), acute renal failure (25 [10%]; five related to treatment), pyrexia (21 [8%]; three related to treatment), bacteraemia (14 [6%]; one related to treatment), and respiratory failure (14 [6%]). 95 people died in the safety analysis set, of which seven deaths were judged possibly or probably related to treatment (pulmonary embolism [200 mg/day], respiratory failure [120 mg/day], haemoptysis [80 mg/day], intracranial haemorrhage [20 mg/day], ventricular fibrillation [120 mg/day], septic shock [80 mg/day], and neutropenia [120 mg/day]). An exposure-related increase in inhibition of FLT3 phosphorylation was noted with increasing concentrations in plasma of gilteritinib. In-vivo inhibition of FLT3 phosphorylation occurred at all dose levels. At least 90% of FLT3 phosphorylation inhibition was seen by day 8 in most patients receiving a daily dose of 80 mg or higher. 100 (40%) of 249 patients in the full analysis set achieved a response, with 19 (8%) achieving complete remission, ten (4%) complete remission with incomplete platelet recovery, 46 (18%) complete remission with incomplete haematological recovery, and 25 (10%) partial remission INTERPRETATION: Gilteritinib had a favourable safety profile and showed consistent FLT3 inhibition in patients with relapsed or refractory acute myeloid leukaemia. These findings confirm that FLT3 is a high-value target for treatment of relapsed or refractory acute myeloid leukaemia; based on activity data, gilteritinib at 120 mg/day is being tested in phase 3 trials.FundingAstellas Pharma, National Cancer Institute (Leukemia Specialized Program of Research Excellence grant), Associazione Italiana Ricerca sul Cancro

Gilteritinib or chemotherapy for relapsed or refractory FLT3-mutated AML

BACKGROUND: Patients with relapsed or refractory acute myeloid leukemia (AML) with mutations in the FMS-like tyrosine kinase 3 gene (FLT3) infrequently have a response to salvage chemotherapy. Gilteritinib is an oral, potent, selective FLT3 inhibitor with single-agent activity in relapsed or refractory FLT3-mutated AML. METHODS: In a phase 3 trial, we randomly assigned adults with relapsed or refractory FLT3-mutated AML in a 2:1 ratio to receive either gilteritinib (at a dose of 120 mg per day) or salvage chemotherapy. The two primary end points were overall survival and the percentage of patients who had complete remission with full or partial hematologic recovery. Secondary end points included event-free survival (freedom from treatment failure [i.e., relapse or lack of remission] or death) and the percentage of patients who had complete remission. RESULTS: Of 371 eligible patients, 247 were randomly assigned to the gilteritinib group and 124 to the salvage chemotherapy group. The median overall survival in the gilteritinib group was significantly longer than that in the chemotherapy group (9.3 months vs. 5.6 months; hazard ratio for death, 0.64; 95% confidence interval [CI], 0.49 to 0.83; P\u3c0.001). The median event-free survival was 2.8 months in the gilteritinib group and 0.7 months in the chemotherapy group (hazard ratio for treatment failure or death, 0.79; 95% CI, 0.58 to 1.09). The percentage of patients who had complete remission with full or partial hematologic recovery was 34.0% in the gilteritinib group and 15.3% in the chemotherapy group (risk difference, 18.6 percentage points; 95% CI, 9.8 to 27.4); the percentages with complete remission were 21.1% and 10.5%, respectively (risk difference, 10.6 percentage points; 95% CI, 2.8 to 18.4). In an analysis that was adjusted for therapy duration, adverse events of grade 3 or higher and serious adverse events occurred less frequently in the gilteritinib group than in the chemotherapy group; the most common adverse events of grade 3 or higher in the gilteritinib group were febrile neutropenia (45.9%), anemia (40.7%), and thrombocytopenia (22.8%). CONCLUSIONS: Gilteritinib resulted in significantly longer survival and higher percentages of patients with remission than salvage chemotherapy among patients with relapsed or refractory FLT3-mutated AML. (Funded by Astellas Pharma; ADMIRAL ClinicalTrials.gov number, NCT02421939.)

Resistance, Outcome and the Development of Mutations with Dasatinib in Patients with Chronic-Phase Chronic Myeloid Leukemia (CML-CP).

Abstract Abstract 1122 Poster Board I-144 Dasatinib is an FDA approved tyrosine kinase inhibitor (TKI) targeted at BCR-ABL for the treatment of CML after imatinib resistance or intolerance. A phase III dose-optimization study of dasatinib in CML-CP, where patients received either 100 mg or 140 mg of dasatinib on a once- or twice-daily schedule, indicated that 100 mg once daily dasatinib provided durable disease control with an estimated progression-free survival (PFS) of 73% at 36 months. We conducted a retrospective analysis to expand on these results to determine if earlier cytogenetic response (CyR) predicts superior outcomes within this dosing arm and also to quantify progression to advanced-phase CML and characterize the quality of BCR-ABL mutations associated with loss of response to dasatinib. Our landmark analysis demonstrated that 90% of patients receiving dasatinib 100 mg once daily who achieved complete cytogenetic response (CCyR) at 12 months were progression-free at 36 months, a considerable improvement over those without CCyR at 12 months (Table 1). Of the 164 patients receiving dasatinib 100 mg once daily, 59 had attained CCyR at 6 months of therapy. The rate of PFS after 36 months within this cohort was 93%, whereas those with partial CyR or those without major cytogenetic response (MCyR) at 6 months had 36-month PFS rates of 76% and 54%, respectively. A total of 36 subjects experienced progression events while receiving dasatinib 100 mg once daily: 8 due to death, 5 due to development of advanced phases of CML, 3 due to increases ≥30% in Ph+ metaphases, 9 due to increasing white blood-cell count, 4 due to loss of complete hematologic response, 4 due to loss of MCyR, and 3 for unknown reason. The majority (86%) of patients who do progress while receiving dasatinib remain in CP at 36 months. The development of mutations in BCR-ABL is a known mechanism of loss of response to dasatinib. In participants with loss of response to dasatinib who have available mutation data (n=61), the incidence of developing mutations during dasatinib therapy (at any dose) is 19% (5/27) in patients without baseline mutations, and 47% (16/34) in those with mutations at initiation of dasatinib. Of the patients who lost response to dasatinib and developed new mutations during therapy, 13 patients harbored T315I, 6 possessed F317L, 3 had V299L, and 1 acquired E255K. Three other patients developed mutations not associated with resistance to dasatinib (Table 2). New mutations that emerged in the 100 mg once daily arm and 70 mg twice daily arm were of similar frequency. In conclusion, patients who achieve early and complete CyRs to second-line dasatinib exhibit reduced rates of long-term progression versus those without CCyR at 6 months. Of the patients who do progress while receiving dasatinib, the majority remain in CP at 36 months. Of patients treated with 100 mg once daily, only 3% progressed to accelerated or blast phase with 36 months of follow-up. This transformation-free survival rate favors the use of dasatinib following imatinib failure in patients who have the option of pursuing allogeneic stem cell transplantation. Finally, the development of new mutations leading to resistance during dasatinib therapy is uncommon, and the lower total daily dose employed by the 100 mg once daily regimen does not appear to select for a greater variety of mutations than have been previously identified in patients treated with 70 mg twice daily. In patients who lose response to dasatinib and develop new mutations, a switch to an alternate TKI or stem-cell transplantation may be appropriate. Table 1. Progression-free survival of subjects with or without cytogenetic responses receiving dasatinib 100 mg once daily Cytogenetic Response PFS (95% CI) 12 months CCyR (n=55) 90% (81–100) partial CyR (n=23) 77% (60–95) minimal/minor/none (n=33) 63% (43–83) 6 months CCyR (n=59) 93% (85–100) partial CyR (n=26) 76% (59–93) minimal/minor/none (n=53) 54% (36–73) Abbreviation: CI, confidence interval. Table 2. Subjects developing new mutations during dasatinib by select dosing arms All subjects* (n=61) 100 mg once daily* (n=13) 70 mg twice daily* (n=14) M244V 1 0 0 E255K 1 0 1 V299L 3 2 1 F311L 1 0 1 T315I 13 3 3 F317L 6 3 1 M351T 1 0 0 * Subjects with loss of response to dasatinib and available baseline and progression/end-of-treatment mutation data. Disclosures Shah: Bristol-Myers Squibb: Consultancy; Novartis: Consultancy. Bahceci:Bristol-Myers Squibb: Employment. Lambert:Bristol-Myers Squibb: Employment. Ploughman:Bristol-Myers Squibb: Employment. Radich:Bristol-Myers Squibb: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding. </jats:sec

Improvement of Selective Depletion of Alloreactive T Cells.

Abstract Severe T cell depletion required for allogeneic hematopoietic stem cell transplantation from haplo-identical donors results in poor immune reconstitution and leads to high rates of mortality from infections, and relapse. One approach to overcome this problem is to infuse T cells depleted of alloreactivity. Selective depletion (SD) of alloreactive T cells is achieved by elimination of activated T cells after ex-vivo stimulation with recipient cells. To determine optimum selective depletion conditions, we have investigated the factors that modify alloreactivity of T cells. Methods: Alloreactivity was measured by one-way mixed lymphocyte reaction (MLR) using 3H thymidine uptake. PBMCs were used as responders and either irradiated expanded T cells (expT) or dendritic cells (DCs) as stimulators. T cells were expanded using anti-CD3 coated beads. DCs were generated from monocytes by GM-CSF and IL-4 stimulation. Selective depletion was performed by co-incubation of responder and stimulator cells for 72 hours and depletion of activated cells by an immunotoxin, LMB-2 (Anti-Tac (Fv)-PE-38), which was added to the culture at 24 and 48 hours. Effectiveness of the depletion was tested by a secondary MLR utilizing the original stimulator cells and unrelated third part cells. Results: Expansion of T cells has resulted in increase of HLA-DR, CD80 and CD86 expression compared to resting T cells (52.5% vs. 6%, 20.9% vs. 0.9%, and 32.9% vs. 20.9%, respectively), resulting in better stimulation in MLR (6505 cpm vs 1620 cpm). In one-way MLR using either PBMCs or CD25 depleted PBMCs as responders and expanded T cells and DCs as targets, with or without anti-CD28 in the culture media. DCs were better stimulators than expT cells (6636 vs. 4308). However, most dramatic effect was seen when anti-CD28 was added to the culture, increasing response to both expT cells and to a lesser extent DCs (40,169 and 19,303). Removal of CD25 positive cells also improved alloreactivity in all culture conditions (6636 in expT, 16,644 in DC, 57,363 in expT+CD28, and 30,943 in DC+CD28). To better define the effect of the target, we have performed Vbeta repertoire analysis of responding cells after expT cell, DC and expT cell+anti-CD28 stimulation. Flow cytometry revealed expansion of discrete Vbeta families, in addition to shared ones. We have then performed selective depletion using PBMCs or CD 25 depleted PBMCs as stimulators and expT cells, expT cell+anti-CD28, and DCs as stimulators. Residual alloreactivity after expT cell stimulation against original stimulators, DCs and third party cells were 7%, 147% and 99% respectively. Interestingly, after SD utilizing DCs as stimulators, there was substantial residual activity against expT cells (69%). When SD was performed using expT cells as stimulators with anti-CD28, combined with CD25 depletion, the depletion against both original stimulators and DCs was improved (2% and 54%, respectively). Conclusion: Depletion of regulatory T cells, and co-stimulation with ant-CD28 improves alloreactivity and selective depletion. Whether improvement in in-vitro selective depletion will result in better clinical outcome will be tested in a clinical trial.</jats:p

Predictors of Long-Term Cytogenetic Response Following Dasatinib Therapy of Patients with Chronic-Phase Chronic Myeloid Leukemia (CML-CP).

Abstract Abstract 3296 Poster Board III-184 BACKGROUND Achievement of major and complete cytogenetic response on imatinib in newly diagnosed CML-CP has been associated with excellent survival. Dasatinib is a potent oral tyrosine kinase inhibitor with marked activity and good tolerability in patients with any-phase CML who have failed prior therapy, including imatinib. AIM To investigate factors predictive of cytogenetic response and survival outcomes for patients who receive dasatinib after imatinib failure. METHODS Collated patient data from trials of dasatinib (START-C, START-R, and CA180-034) in patients with CML-CP were analyzed. All patients had failed prior treatment with imatinib as a result of resistance or intolerance. Patients with highly imatinib-insensitive BCR-ABL mutations (L248V, G250E, Q252H/R, Y253H/F, E255K/V, T315I/D, F317L, and H369P/R) were ineligible for START-R. Across the three trials, patients were administered dasatinib 50 (n=167) or 70 (n=655) mg twice daily, or 100 (n=165) or 140 (n=163) mg once daily. Analysis of efficacy parameters was performed on all patients receiving at least one dose of dasatinib (n=1150). A multivariate logistic regression model was applied to evaluate patient treatment characteristics as predictive factors for cytogenetic response. RESULTS After a median follow-up of 26 months, the rate of major cytogenetic response (MCyR) was 62% and of complete cytogenetic response (CCyR) was 51%. By multivariate analysis, the following were selected as independent favorable prognostic factors for achievement of MCyR: younger age, lower percentage of Ph+ cells, absence of the T315I mutation, prior MCyR with imatinib, imatinib intolerance (vs. resistance), no prior stem cell transplantation (SCT), shorter time from CML diagnosis to dasatinib therapy (Table 1). The same baseline factors independently predicted CCyR. CONCLUSION This study confirms the clinical efficacy of dasatinib among patients with CML-CP who have failed prior therapy. Furthermore, we identified baseline factors associated with improved response to dasatinib. Work to determine additional predictive factors for survival outcome with dasatinib is ongoing. The subgroups of patients who may not respond optimally to dasatinib are small, and a modification to their treatment regimen may be called for. Disclosures Jabbour: Bristol-Myers Squibb: Speakers Bureau; Novartis: Speakers Bureau. Bahceci:Bristol-Myers Squibb: Employment. Zhu:Bristol-Myers Squibb: Employment. Lambert:Bristol-Myers Squibb: Employment. Cortes:Bristol-Myers Squibb: Research Funding. </jats:sec

Value of Survival Gains In Chronic Myelogenous Leukemia

Abstract Abstract 4736 Background: Tyrosine Kinase Inhibitors (TKI) are the first line therapies for patients with chronic myelogenous leukemia (CML). The value of survival gains to patients associated with TKI treatment—in aggregate or relative to the cost of treatment—is unknown. Methods: Multivariate Cox proportional hazard models are used to construct real-world, community-based estimates of survival improvements in CML associated with the introduction of first-line TKI therapy, controlling for characteristics of patients which may independently affect survival. We then employ an economic framework following Becker, Philipson and Soares (2005) to calculate social value of infra-marginal improvements in survival gains due to treatment with TKIs. Finally, the value of community-based improvements in CML survival from treatment by newer TKIs used in second line is estimated by combining community-based survival data for first-line TKIs, along with clinical data on health improvements for CML patients receiving a TKI in second line. Results: Introduction of first-line TKIs in 2001 is associated with a real-world decrease in the all-cause mortality hazard rate of 0.183 (p &lt; 0.01) for CML patients. A decrease of this magnitude is associated with an increase in life expectancy from 60 to 110 months for treated CML patients with median survival length in 2001. We estimate that patients place an annual value of $110,000 on first-line treatment with TKIs. This implies that for all patients in present and future CML cohorts, the present social value of first-line TKI therapy is$88bn. The present value of costs is estimated to be $8bn, suggesting that more than 90$47bn in social value, of which roughly 88% is retained by patients. This estimated value of the newer TKIs does not incorporate possible benefits in first-line therapy. Conclusions: In total, the TKI class in first and second-line theray has created over $135bn in social value. Approximately 90% of this value is retained by patients; approximately 10% is recouped by manufacturers. These estimates suggest that at current price levels, the vast majority of value created by new therapies in CML is appropriated by patients. In addition, since our estimates of survival community-based improvements are somewhat smaller than those contained in clinical trial estimates, this suggests the potential value of addressing real-world obstacles to efficacy, such as poor adherence. Disclosures: Yin: Precision Health Economics: Consultancy. Penrod:Bristol-Myers Squibb: Employment. Maclean:Bristol-Myers Squibb: Employment. Humphrey:Bristol-Myers Squibb: Employment. Bahceci:Bristol-Myers Squibb: Employment. Lakdawalla:Bristol-Myers Squibb: Consultancy; Precision Health Economics: Equity Ownership. </jats:sec

Immunotherapy of B Cell Malignancies Using Transiently Redirected Cytotoxic T Cells.

Abstract Current treatment approaches for B-cell malignancies such as non-Hodgkin’s lymphoma and chronic lymphocytic leukemia are initially effective, but most patients ultimately relapse. Thus, there is a compelling need to develop novel therapies. One promising approach is immunotherapy using cytotoxic T cells (CTL). The major limitation of immunotherapy is the availability of large number of high-affinity autologous CTLs. Retargeting of T cells by genetic modification to introduce chimeric receptors can overcome this problem. Since infusion of permanently modified CTLs may not be desirable, we have developed a new method of transfecting CTLs using mRNA, which results in nearly universal but transient expression of a chimeric receptor targeting CD19. The chimeric immunoreceptor used for transfection was composed of anti-CD19 single chain antibody, CD3ζ and 4-1BB signaling domain (anti-CD19-CIR). mRNA was produced by in vitro transcription of PCR generated templates followed by poly(A) addition. CD8+ CTLs were isolated from expanded or resting T cells from healthy volunteers using magnetic beads. T cells were expanded using magnetic beads conjugated with anti-CD28 and anti-CD3. mRNA transfection was performed by electroporation using Amaxa nucleofector. The cytotoxicity was evaluated by a standard 51Cr release method. To test the in vivo function, CD19+ lymphoma cells expressing firefly luciferase (ffLuc) was injected to NOD/scid mice intraperitoneally. Intra peritoneal tumors have established by day 3, and anti-CD19-CIR or mock transfected T cells were injected intraperitoneally at days 3 and 6. The mice were imaged using IVIS biophotonic imaging system. When transfected with anti-CD19-CIR mRNA, more than 90% of the CD3+ T lymphocytes expressed the receptor on their surface. Both the CD4+ and the CD8+ subpopulations were transfected equally and the anti-CD19-CIR expression was sustained for a minimum of 3 days. T cells transfected with anti-CD19-CIR effectively lysed CD40L expanded autologous or allogeneic B cell lymphoblasts and multiple B-cell lymphoma cell lines (Daudi, SKI-DLCL-1 and CRL-2261). T cells expressing low, medium or high levels of anti-CD19-CIR effectively lysed the targets regardless of the level of expression. In vivo, anti-CD19-CIR transfected T cells were able to treat established tumors as demonstrated by non-invasive serial imaging of luciferase-mediated bioluminescence (Figure). Our data provide a rationale for developing methods for large-scale electroporation of chimeric receptors in CTLs, in support of clinical application of this treatment modality in patients with high-risk B-cell malignancies. Figure: In vivo activity of Anti-CD19-CIR transfectedCTLs.A) Pseudocolorimage representing light intensity and anatomic localization of the ffLuc-derived lymphoma signal in two representative mice. B) Longitudinal monitoring of the bioluminescent signals of ffLuc+ Daudi cells in NOD/scid mice. Points, mean photon flux (in p/s/cm2/sr); bars, SE. Figure:. In vivo activity of Anti-CD19-CIR transfectedCTLs.A) Pseudocolorimage representing light intensity and anatomic localization of the ffLuc-derived lymphoma signal in two representative mice. B) Longitudinal monitoring of the bioluminescent signals of ffLuc+ Daudi cells in NOD/scid mice. Points, mean photon flux (in p/s/cm2/sr); bars, SE.</jats:p