An Evaluation of the Safety and Efficacy of Lapatinib Plus Trastuzumab Plus Paclitaxel in First-Line HER2+ Metastatic Breast Cancer

Background: Trastuzumab given concomitantly with paclitaxel is an established first-line metastatic breast cancer (MBC) treatment; however, approximately 30% to 40% of patients show no response as defined by RECIST to this combination. Lapatinib is an oral dual tyrosine kinase inhibitor of EGFR and HER2 and approved, in combination with capecitabine, after trastuzumab-based therapy for HER2+ MBC. The differing mechanisms of action may allow synergy between lapatinib and trastuzumab when given concurrently with paclitaxel for MBC.Methods: This is an open-label phase I safety study. The primary objective of the study was to assess the safety and tolerability of lapatinib when administered with concurrent paclitaxel and trastuzumab. Patients were enrolled into 1 of 3 cohorts. Cohort 1 received lapatinib (1000 mg/d), paclitaxel (80 mg/m2 weekly for 3 weeks of a 4-week cycle), and the standard weekly dose of trastuzumab. Cohort 2 received lapatinib (1000 mg/d), paclitaxel (70 mg/m2), and trastuzumab. Cohort 3 received lapatinib (750 mg/d), paclitaxel (80 mg/m2), and trastuzumab. Patients: were 3+ by IHC or FISH amplified for HER2; had not received prior treatment in the metastatic setting; and had an ECOG performance status of 0 or 1. Safety was assessed weekly and tumor response per RECIST every 8 weeks. Treatment continued until disease progression or toxicity. All patients received prophylactic loperamide per protocol amendment.Results: Open-label safety enrollment is complete and preliminary safety data are available for all 63 patients. The most frequently reported AEs for all cohorts were diarrhea (81%), fatigue (71%), rash (68%), nausea (59%), alopecia (56%), and vomiting (37%). Dehydration was the most frequently reported serious AE (SAE) (n=6; 10%) and most were in cohort 1 (5 patients). Diarrhea of any grade was reported for 97% of patients in cohort 1, 93% of patients in cohort 2, and 50% of patients in cohort 3. No grade 4 or 5 diarrhea events were reported. The proportion of patients with a maximum toxicity of grade 3 diarrhea was 62% in cohort 1, 43% in cohort 2, and 20% in cohort 3. Two patients (both in cohort 1) reported diarrhea as a serious AE and a total of 4 patients (6%) had lapatinib withdrawn due to diarrhea (none in cohort 3).Conclusions: Preliminary safety results show a high incidence of grade 3 diarrhea when lapatinib was given at a dose of 1000 mg/d concurrently with paclitaxel and trastuzumab. This incidence was significantly reduced with a lapatinib dose of 750 mg/d in combination with paclitaxel and trastuzumab when given with loperamide. Final safety and efficacy data, including overall response and progression-free survival, from this open-label safety study will be presented.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5085.

Crenarchaeota affiliated with group 1.1b are prevalent in coastal mineral soils of the Ross Sea region of Antarctica

The objective of this study was to examine the presence and diversity of Archaea within mineral and ornithogenic soils from 12 locations across the Ross Sea region. Archaea were not abundant but DNA sufficient for producing 16S rRNA gene clone libraries was extracted from 18 of 51 soil samples, from four locations. A total of 1452 clones were analysed by restriction fragment length polymorphism and assigned to 43 operational taxonomic units from which representatives were sequenced. Archaea were primarily restricted to coastal mineral soils which showed a predominance of Crenarchaeota belonging to group 1.1b (> 99% of clones). These clones were assigned to six clusters (A through F), based on shared identity to sequences in the GenBank database. Ordination indicated that soil chemistry and water content determined archaeal community structure. This is the first comprehensive study of the archaeal community in Antarctic soils and as such provides a reference point for further investigation of microbial function in this environment.

Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study

OBJECTIVES

To estimate clinical and dipstick predictors of infection and develop and test clinical scores; to compare management using clinical and dipstick scores with commonly used alternative strategies; to estimate the cost-effectiveness of each strategy; and to understand the natural history of urinary tract infection (UTI) and women's concerns about its presentation and management.

DESIGN

There were six studies: (1) validation development for diagnostic clinical and dipstick scores; (2) validation of the scores developed; (3) observation of the natural history of UTI; (4) randomised controlled trial (RCT) of scores developed in study 1; (5) economic analysis of the RCT; (6) qualitative study of patients in the RCT.

SETTING

Primary care.

PARTICIPANTS

Women aged 17-70 with suspected UTI.

INTERVENTIONS

Patients were randomised to five management approaches: empirical antibiotics; empirical delayed antibiotics; target antibiotics based on a higher symptom score; target antibiotics based on dipstick results; or target antibiotics based on a positive mid-stream specimen of urine (MSU).

MAIN OUTCOME MEASURES

Antibiotic use, use of MSUs, rates of reconsultation and duration, and severity of symptoms.

RESULTS

(1) 62.5% of women had confirmed UTI. Only nitrite, leucocyte esterase and blood independently predicted diagnosis of UTI. A dipstick rule--based on having nitrite or both leucocytes and blood--was moderately sensitive (77%) and specific (70%) [positive predictive value (PPV) 81%, negative predictive value (NPV) 65%]. A clinical rule--based on having two of urine cloudiness, offensive smell, reported moderately severe dysuria, moderately severe nocturia--was less sensitive (65%) (specificity 69%, PPV 77%, NPV 54%). (2) 66% of women had confirmed UTI. The predictive values of nitrite, leucocyte esterase and blood were confirmed. The dipstick rule was moderately sensitive (75%) but less specific (66%) (PPV 81%, NPV 57%). (3) Symptoms rated as moderately bad or worse lasted 3.25 days on average for infections sensitive to antibiotics; resistant infections lasted 56% longer, infections not treated with antibiotics 62% longer and symptoms associated with urethral syndrome 33% longer. Symptom duration was shorter if the doctor was perceived to be positive about prognosis, and longer with frequent somatic symptoms, previous history of cystitis, urinary frequency and more severe symptoms at baseline. (4) 66% of the MSU group had laboratory-confirmed UTI. Women suffered 3.5 days of moderately bad symptoms if they took antibiotics immediately but 4.8 days if they delayed taking antibiotics for 48 hours. Taking bicarbonate or cranberry juice had no effect. (5) The MSU group was more costly over 1 month but not over 1 year. Cost-effectiveness acceptability curves showed that for a value per day of moderately bad symptoms of over 10 pounds, the dipstick strategy is most likely to be cost-effective. (6) Fear of spread to the kidneys, blood in the urine, and the impact of symptoms on vocational and leisure activities were important triggers for seeking help. When patients are asked to delay taking antibiotics the uncomfortable and worrying journey from 'person to patient' needs to be acknowledged and the rationale behind delaying the antibiotics made clear.

CONCLUSIONS

To achieve good symptom control and reduce antibiotic use clinicians should either offer a 48-hour delayed antibiotic prescription to be used at the patient's discretion or target antibiotic treatment by dipsticks (positive nitrite or positive leucocytes and blood) with the offer of a delayed prescription if dipstick results are negative.

The validity and reliability of diagnoses of work-related mental ill-health

OBJECTIVES

To establish the reliability and validity of work-related mental ill-health diagnoses.

BACKGROUND

A UK-based surveillance scheme for work-related ill-health involving occupational physicians (OPs) reporting suggests that mental ill-health incidence is increasing by around 13% per year, with anxiety, depression and "other work-related stress" being the most common diagnoses. There have been no studies of the validity and reliability of such diagnoses. Given the existence of a large network of psychiatrists (PSYs) also involved in surveillance of work-related ill-health, an opportunity arose to measure the concurrent validity and reliability of work-related mental ill-health diagnoses.

METHODS

100 anonymised summaries of cases previously reported by OPs or PSYs were collected; each was sent to 5 PSYs and 5 OPs, who assigned a diagnosis and judged whether the case was work-related. Concurrent validity of the ill-health aspect of the diagnoses, and of the opinion as to work-relatedness, was assessed by comparing the overall classifications of cases by OPs and PSYs. Reliability of the diagnostic classification was measured by kappa matrices.

RESULTS

Diagnostic proportions for PSYs and OPs demonstrated good agreement for anxiety, depression, anxiety plus depression and "stress" (11%, 34%, 27%, 14%) and (14%, 30%, 27%, 17%), respectively. In both groups, kappa coefficients were high for a psychotic diagnosis (0.78, 95% CI: 0.74 to 0.83), but not as high for anxiety (0.27, 95% CI: 0.23 to 0.32), depression (0.34, 95% CI: 0.29 to 0.38) and "stress" (0.15, 95% CI: 0.10 to 0.19). The odds ratio of classifying a case as work-related among PSYs compared to OPs was 2.39 (95% CI: 1.68 to 3.38), p<0.001.

CONCLUSIONS

The overall agreement between OPs and PSYs on mental ill-health diagnoses suggests that OP diagnoses are valid for epidemiological purposes. However, the within-group reliability of the diagnosis "stress" is low. Given differences in judgements about work-relatedness, further research is needed to investigate this aspect of a diagnosis.

Increased detections of leptomeningeal presentations in men with hormone refractory prostate cancer: an effect of improved systemic therapy?

Metastases from prostate cancer occur largely in bone through a haematogenous route. Metastatic spread of prostate cancer to the leptomeninges was rarely seen in the past. However, there has been a recent increase in presentations of leptomeningeal spread from prostate cancer in our institutions. Between 2004 and 2006, four patients were diagnosed with metastatic prostate cancer with leptomeningeal metastases in our centres. All four patients had hormone refractory prostate cancer and had previously had chemotherapy. The median survival of these patients was approximately 15 months from the time of hormone refractoriness. The prognosis of leptomeningeal metastasis secondary to metastatic prostate cancer is poor, ranging from 2 to 7 months as seen in our series. New cases of leptomeningeal metastases seen in our series are hypothesized to be secondary to the use of effective modern systemic treatments. A parallel might be drawn with the increased rate of central nervous system metastases in breast cancer since the introduction of effective cytotoxic treatments and more recently targeted therapies. We suggest the clinicians to be aware of the potential change of natural history and pattern of progression in metastatic prostate cancer.

Bacterial diversity associated with ornithogenic soil of the Ross Sea region, AntarcticaThis article is one of a selection of papers in the Special Issue on Polar and Alpine Microbiology

In the Ross Sea region of Antarctica, ornithogenic soils form on land under Adélie Penguin rookeries. Compared with mineral soils of the Ross Sea region, ornithogenic soils are generally high in microbial biomass, organic carbon, and total nitrogen and phosphorus, with high electrical conductivity and large variations in pH. The objective of this study was to assess the bacterial composition of ornithogenic soils from Cape Hallett and Cape Bird in the Ross Sea region using culture-independent methods. Soil clone libraries were constructed and those clones that occurred ≥3 times were sequenced. The bacterial diversity of the soils was dependent on the presence of penguins. Firmicutes most closely related to the endospore-formers (e.g., Oceanobacillus profundus and Clostridium acidurici ) and (or) Gammaproteobacteria belonging to the genus Psychrobacter dominated soils currently occupied with penguins. In contrast, Gammaproteobacteria, closely related to cultured members of the genera Rhodanobacter , Psychrobacter , Dokdonella , and Lysobacter , dominated the soils previously colonized by penguins. Results of this study indicate that despite relatively high nutrient levels and microbial biomass, bacterial communities of ornithogenic soils were not more diverse than those of mineral soils of the Ross Sea region of Antarctica.

Prescribing trends in asthma: a longitudinal observational study

BACKGROUND

Inhaled corticosteroids (ICS) are effective treatment for childhood asthma. Cross-sectional studies indicate that some asthmatic children are treated with excessively high doses of ICS and are at risk of serious adverse effects.

OBJECTIVE

To describe longitudinal trends in asthma prescribing for children, with particular reference to very-high-dose (unlicensed) ICS prescribing.

DESIGN

Retrospective, cross-sectional, observational study of general practitioner prescribing for asthma drugs in children aged under 12 years with a recorded asthma diagnosis between 1992 and 2004 using the General Practice Research Database (GPRD).

RESULTS

Data were available for an average of 357,956 children per year. The percentage of children prescribed ICS increased from 2.7 in 1992 to 7.0 in 1997 and 1998 and then fell to 3.3 in 2004. In children under 5 years with asthma, very-high-dose ICS prescriptions (>400 microg/day) fell from 10.6% of all ICS prescriptions in 1992 to 4.5% by 2004. In contrast, very-high-dose ICS prescriptions (>800 microg/day) for asthmatic children aged 5-11 years rose from 1.1% in 1992 to 4.6% in 2004. Oral corticosteroid prescribing in under 5-year-olds who had been prescribed ICS fell from 37.1% in 1992 to 21.7% 1999 and remained constant thereafter; the respective percentages for those aged 5-11 years olds were 20.1 and 12.4.

CONCLUSIONS

Trends for corticosteroid prescribing in childhood asthma changed dramatically between 1992 and 2004. There are several plausible reasons for this.

Changing clinicians' behavior: a randomized controlled trial of fees and education

The fissure-sealing of newly erupted molars is an effective caries prevention treatment, but remains underutilized. Two plausible reasons are the financial disincentive produced by the dental remuneration system, and dentists' lack of awareness of evidence-based practice. The primary hypothesis was that implementation strategies based on remuneration or training in evidence-based healthcare would produce a higher proportion of children receiving sealed second permanent molars than standard care. The four study arms were: fee per sealant treatment, education in evidence-based practice, fee plus education, and control. A cost-effectiveness analysis was conducted. Analysis was based on 133 dentists and 2833 children. After adjustment for baseline differences, the primary outcome was 9.8% higher when a fee was offered. The education intervention had no statistically significant effect. 'Fee only' was the most cost-effective intervention. The study contributes to the incentives in health care provision debate, and led to the introduction of a direct fee for this treatment.

Seasonal changes in circadian peripheral plasma concentrations of melatonin, serotonin, dopamine and cortisol in aged horses with Cushing's disease under natural photoperiod

Equine pituitary pars intermedia dysfunction (PPID) is a common and serious condition that gives rise to Cushing's disease. In the older horse, it results in hyperadrenocorticism and disrupted energy metabolism, the severity of which varies with the time of year. To gain insight into the mechanism of its pathogenesis, 24-h profiles for peripheral plasma melatonin, serotonin, dopamine and cortisol concentrations were determined at the winter and summer solstices, and the autumn and spring equinoxes in six horses diagnosed with Cushing's disease and six matched controls. The nocturnal rises in plasma melatonin concentrations, although different across seasons, were broadly of the same duration and similar amplitude in both groups of animals (P > 0.05). The plasma concentrations of cortisol did not show seasonal variation and were different in diseased horses only in the summer when they were higher across the entire 24-h period (P < 0.05). Serotonin concentrations were not significantly affected by time of year but tended to be lower in Cushingoid horses (P = 0.07). By contrast, dopamine output showed seasonal variation and was significantly lower in the Cushing's group in the summer and autumn (P < 0.05). The finding that the profiles of circulating melatonin are similar in Cushingoid and control horses reveals that the inability to read time of year by animals suffering from Cushing's syndrome is an unlikely reason for the disease. In addition, the results provide evidence that alterations in the dopaminergic and serotoninergic systems may participate in the pathogenesis of PPID.

Repeat testing for congenital hypothyroidism in preterm infants is unnecessary with an appropriate thyroid stimulating hormone threshold

BACKGROUND

Revised UK neonatal screening guidelines recommend that a second blood sample for assay of thyroid stimulating hormone (TSH) be taken when preterm infants reach a postmenstrual age of 36 weeks.

OBJECTIVE

To examine the results of a regional screening programme to see whether a rise in TSH concentration was observed in some preterm infants between the first sample taken around 5 days after delivery and the second sample taken at around 36 weeks.

METHODS

Whole-blood TSH concentrations in preterm infants born over a 2-year period (April 2005 to March 2007) were assessed, and the number of infants in whom there was a fall or rise to values below or above the local screening threshold (6 mU/l) was determined.

RESULTS

Baseline TSH samples were obtained from 2238 preterm infants (median gestational age 32 weeks, range 21-35) with second samples obtained from 2039 (median gestational 32 weeks, range 23-35). In 19 infants, TSH concentrations fell from above to below the screening threshold, and in five infants values rose from below the screening threshold to 6-10 mU/l. However, TSH concentrations fell to <6 mU/l on a further blood spot in four of these infants, and the remaining infant had a serum TSH of 6.8 mU/l. Three infants had raised TSH concentrations on both occasions with unequivocal hypothyroidism (serum TSH >80 mU/l). The initial TSH concentration in one of these infants was 6-10 mU/l.

CONCLUSIONS

No infant with a normal TSH concentration on first sampling had a TSH concentration that rose above 10 mU/l on second sampling, and no infants with a normal TSH concentration on first screening are receiving long-term thyroxine treatment. This study suggests that a second sample may not be necessary with a screening threshold of 6 mU/l.

Predictors of academic attainments of young people with Down's syndrome

BACKGROUND

Earlier studies of young people with Down's syndrome have investigated a relatively limited range of variables which may influence their academic attainment. The relative strength of such influences and how they may vary during the school career, has also been under-researched.

AIMS

The aim of the paper is to identify the contemporary and antecedent predictors of the level of academic attainment achieved by a representative sample of young people with Down's syndrome. Sample The paper reports data from three studies of 71 young people with Down's syndrome and their families. Mean IQ at the time of the first study (t1) was 40.4. Mean chronological age was 9 years at t1, 14 at t2, and 21 at t3, when all the young people had left school.

METHODS

The outcome measure was the 58-item Academic Attainments Index (AAI), comprising three sub-scales covering reading, writing and numeracy. Predictors of the outcome were derived from questionnaires and interviews from tutors, mothers and fathers. A path analysis approach was used to investigate the pattern of predictors of the outcome over the three studies.

RESULTS

Factors predicting greater progress in this measure between t2 and t3 were lower chronological age and attendance at mainstream school. Progress from t1 to t2 was also associated with attendance at mainstream school, as well as with higher t1 mental age, mother's practical coping style and higher child attentiveness. Background factors predicting higher t1 AAI scores were higher mental age, attendance at mainstream school and father's internal locus of control. The path analysis model predicted 48% of the variance in t3 outcome scores. Severity of intellectual impairment was by far the most significant predictor.

CONCLUSION

Limitations to the study include evidence of attrition bias towards more able children, and the need to obtain the t3 outcome measure from tutors for some young people and parents for others. Parents may have over-estimated abilities. Results are broadly in agreement with other studies, and confirm the pattern reported earlier with this group. Mainstream school attendance had a modest beneficial effect on AAI scores throughout the school career of the children, independently of level of intellectual disability. Identification of predictors of attainment levels and of improvement over time may help parents, teachers and other professionals involved with families of children and young people with Down's syndrome optimise the attainment of such skills.

Non-progressive periorbital necrotising fasciitis

Necrotising fasciitis is a potentially devastating soft tissue infection with a significant fatality rate. Streptococcus is commonly associated, although the cause may be polymicrobial. Early recognition is essential and aggressive surgical intervention may be required to prevent the rapid spread of infection along fascial planes. We report an unusual case of necrotising fasciitis of the eyelids with spontaneous limitation of the area of necrosis.