Nanoghosts: Mesenchymal Stem cells derived nanoparticles as a unique approach for cartilage regeneration

Osteoarthritis (OA) is a chronic degenerative disease, which affects the joints and is characterized by inflammation, cartilage loss and bone changes. Nowadays, there are no treatments for OA, and current therapies are focused on relieving the symptoms. As a new therapy approach, micro and nanoparticles have been extensively explored and among all the studied particles, the use of cell-membrane-based particles is expanding. Another promising approach studied to treat OA, is the use of mesenchymal stem cells (MSCs) which play an important role modulating inflammation. We developed a novel kind of MSCs' cytoplasmic-membrane-based nanoparticles, termed nano-ghosts (NGs). Retaining MSCs' surface properties and lacking cells' internal machinery allow the NGs to have immunomodulatory capacity and to be immune-evasive while not susceptible to host-induced changes. In this study, we demonstrate NGs' ability to target cartilage tissues, in vitro and in vivo, while modulating the inflammatory process. In vivo studies demonstrated NGs ability to act as an immunomodulatory drug slowing down cartilage degeneration process. Our proof-of-concept experiments show that NGs system is a versatile nano-carrier system, capable of therapeutics loading, with targeting capabilities towards healthy and inflamed cartilage cells. Our results, along with previously published data, clearly reveal the NGs system as a promising nano-carrier platform and as a potential immunomodulatory drug for several inflammation-related diseases.

Natalizumab induced blood eosinophilia: A retrospective pharmacovigilance cohort study and review of the literature

OBJECTIVE

To describe frequency of natalizumab related eosinophilia and clinical symptoms of eosinophilic disease in our monocentric cohort.

METHODS

Comparison of clinical characteristics of 115 natalizumab treated and 116 untreated RRMS patients and review of literature.

RESULTS

38% of natalizumab treated patients had eosinophilia, which occurred significantly more frequently compared to untreated MS patients (3%, p-value<0.001). In symptomatic patients, mean eosinophil counts were significantly higher than in asymptomatic patients and symptoms developed within one year.

DISCUSSION

Eosinophilia is a side effect of natalizumab and mostly asymptomatic. However, few patients develop within one year after start of natalizumab an eosinophilic disease as severe side effect.

Prognostic utility of differential contrast-enhancement patterns on late gadolinium enhancement cardiac MRI (LGE-CMR) in patients with cancer-associated cardiac masses

Background

LGE-CMR tissue characterization is widely used to identify cardiac masses (CMASS) in cancer patients – including neoplasm (NEO) and thrombus (THR). Prognostic utility of their differential LGE patterns is unknown.

Purpose

To determine incremental prognostic utility of LGE patterns in CMASS

Methods

The population comprised of cancer patients with CMASS on LGE-CMR, for which etiology was classified based on presence (NEO) or absence (THR) of enhancement, and controls matched for cancer type/stage. LGE-CMR tissue properties of NEO was classified based on extent of contrast enhancement – diffusely enhancing (DE), mixed (ME), and predominantly avascular (PA). Clinical follow up was performed for embolic events within 6 months of CMR and all-cause mortality.

Results

330 cancer patients (55% M; 55±16yo) with an array of cancer diagnoses (19% sarcoma, 17% GI, 13% GU) were studied. Among CMASS+ pts (n=190), 66% had NEO and 34% had THR on LGE. All THR were non-enhancing. Among NEO, LGE pattern was variable (46% DE, 41% ME, 13% PA); ME lesions were larger than other groups (Fig. 1A). Quantitative tissue properties were consistent with qualitative groups, as evidenced by stepwise variation in signal intensity and CNR. Cumulative embolic events were 3-fold higher in CMASS+ than controls (All: 20% vs. 7%, p=0.001; PE: 13% vs. 5%, p=0.02; CVA/systemic embolism: 10% vs. 3%, p=0.01). Median time to event was 1.3 months [IQR 0.1–2.3] from CMR. Aggregate events were similar between NEO and THR, reflecting similar rates of PE and CVA (p=NS). Among CMASS pts with embolic events, 56% were on anticoagulation at time of event (59% NEO, 50% THR, p=0.61). Regarding CMASS morphology, emboli were 3-fold higher among intracavitary (IC) or highly mobile (HM) CMASS (IC: 25% vs 7%, p&lt;0.001; HM: 38% vs 12%, p=0.001). Regarding location, right sided CMASS were associated with a 3–5 fold increase in PE (IC: 19% vs 6%; HM: 35% vs 7%, both p&lt;0.001) and similar CVA events among left sided CMASS (IC: 17% vs. 6%, p=0.02; HM: 33% vs 6%, p=0.05). Embolic events were similar when partitioned based on quantitative LGE patterns between patients with and without embolic events. As for all-cause mortality, NEO on CMR conferred increased mortality than THR (HR 3.06 [CI=1.84–5.1], p&lt;0.001) and matched controls (HR 2.08 [CI=1.42–3.04], p&lt;0.001) during a median follow-up of 9.4 months [IQR 3.6–23.2]. Among NEO subgroups (Fig. 1B), survival was lower in patients with heterogeneous LGE patterns vs matched controls: the lowest survival in ME (p=0.002) suggests increased vascularity and tumor hypoxia/necrosis associated with aggressive tumors and hence larger lesions.

Conclusions

Among cancer patients, CMR-evidenced CMASS confers high short-term embolic risk, which are equivalently common between NEO and THR. Intra-cavitary location and increased mobility augment embolic risk irrespective of CMASS tissue properties whereas differential LGE patterns on CMR strongly impact prognosis.

Funding Acknowledgement

Type of funding source: None

Improved tolerability of neratinib in patients with HER2-positive early-stage breast cancer: the CONTROL trial

BACKGROUND

Neratinib is an irreversible pan-HER tyrosine kinase inhibitor approved for extended adjuvant treatment in early-stage HER2-positive breast cancer based on the phase III ExteNET study. In that trial, in which no antidiarrheal prophylaxis was mandated, grade 3 diarrhea was observed in 40% of patients and 17% discontinued due to diarrhea. The international, open-label, sequential-cohort, phase II CONTROL study is investigating several strategies to improve tolerability.

PATIENTS AND METHODS

Patients who completed trastuzumab-based adjuvant therapy received neratinib 240 mg/day for 1 year plus loperamide prophylaxis (days 1-28 or 1-56). Sequential cohorts evaluated additional budesonide or colestipol prophylaxis (days 1-28) and neratinib dose escalation (DE; ongoing). The primary end point was the incidence of grade ≥3 diarrhea.

RESULTS

Final data for loperamide (L; n = 137), budesonide + loperamide (BL; n = 64), colestipol + loperamide (CL; n = 136), and colestipol + as-needed loperamide (CL-PRN; n = 104) cohorts, and interim data for DE (n = 60; completed ≥six cycles or discontinued; median duration 11 months) are available. No grade 4 diarrhea was observed. Grade 3 diarrhea rates were lower than ExteNET in all cohorts and lowest in DE (L 31%, BL 28%, CL 21%, CL-PRN 32%, DE 15%). Median number of grade 3 diarrhea episodes was one; median duration per grade 3 episode was 1.0-2.0 days across cohorts. Most grade 3 diarrhea and diarrhea-related discontinuations occurred in month 1. Diarrhea-related discontinuations were lowest in DE (L 20%, BL 8%, CL 4%, CL-PRN 8%, DE 3%). Decreases in health-related quality of life did not cross the clinically important threshold.

CONCLUSIONS

Neratinib tolerability was improved with preemptive prophylaxis or DE, which reduced the rate, severity, and duration of neratinib-associated grade ≥3 diarrhea compared with ExteNET. Lower diarrhea-related treatment discontinuations in multiple cohorts indicate that proactive management can allow patients to stay on neratinib for the recommended time period. CLINICALTRIALS.GOV: NCT02400476.

A real-world assessment of procalcitonin combined with antimicrobial stewardship in a community ICU

PURPOSE

We evaluated the feasibility and impact of PCT-guided antibiotic duration combined with an established antibiotic stewardship program (ASP) in a community hospital intensive care unit (ICU).

METHODS

We implemented daily PCT levels for ICU patients receiving antibiotics. Our protocol recommended stopping antibiotic therapy if PCT met an absolute or relative stopping threshold. We evaluated the adherence to stopping criteria within 48 h, antibiotic use [days of therapy (DOT) per 1000 patient-days (PD)], length of stay and ICU-mortality. We performed interrupted time series analysis to compare 24 months before and 12 months after implementation.

RESULTS

A total of 297 antibiotic courses were monitored with PCT in 217 patients. Protocol adherence was 34% (absolute threshold: 39%, relative threshold: 12%). Antibiotic use pre-PCT was 935 DOTs/1000 PDs and post-PCT was 817 DOTs/1000 PDs (RR_adj 0.73, 95% CI: 0.62 to 0.86). No statistically significant changes in clinical outcomes were noted.

CONCLUSION

In the context of an established ASP in a community hospital ICU, PCT monitoring was feasible and associated with an adjusted overall decrease of 27% in antibiotic use with no adverse impact on clinical outcomes. Incorporating PCT testing to guide antibiotic duration can be successful if integrated into workflow and paired with ASP guidance.

Afatinib versus methotrexate as second-line treatment in Asian patients with recurrent or metastatic squamous cell carcinoma of the head and neck progressing on or after platinum-based therapy (LUX-Head & Neck 3): an open-label, randomised phase III trial

BACKGROUND

Treatment options are limited for patients with recurrent or metastatic squamous cell carcinoma of the head and neck (HNSCC) following progression after first-line platinum-based therapy, particularly in Asian countries.

PATIENTS AND METHODS

In this randomised, open-label, phase III trial, we enrolled Asian patients aged ≥18 years, with histologically or cytologically confirmed recurrent/metastatic HNSCC following first-line platinum-based therapy who were not amenable for salvage surgery or radiotherapy, and had an Eastern Cooperative Oncology Group (ECOG) performance status of 0/1. Patients were randomised (2 : 1) to receive oral afatinib (40 mg/day) or intravenous methotrexate (40 mg/m2/week), stratified by ECOG performance status and prior EGFR-targeted antibody therapy. The primary end point was progression-free survival (PFS) assessed by an independent central review committee blinded to treatment allocation.

RESULTS

A total of 340 patients were randomised (228 afatinib; 112 methotrexate). After a median follow-up of 6.4 months, afatinib significantly decreased the risk of progression/death by 37% versus methotrexate (hazard ratio 0.63; 95% confidence interval 0.48-0.82; P = 0.0005; median 2.9 versus 2.6 months; landmark analysis at 12 and 24 weeks, 58% versus 41%, 21% versus 9%). Improved PFS was complemented by quality of life benefits. Objective response rate was 28% with afatinib and 13% with methotrexate. There was no significant difference in overall survival. The most common grade ≥3 drug-related adverse events were rash/acne (4% with afatinib versus 0% with methotrexate), diarrhoea (4% versus 0%), fatigue (1% versus 5%), anaemia (<1% versus 5%) and leukopenia (0% versus 5%).

CONCLUSIONS

Consistent with the phase III LUX-Head & Neck 1 trial, afatinib significantly improved PFS versus methotrexate, with a manageable safety profile. These results demonstrate the efficacy and feasibility of afatinib as a second-line treatment option for certain patients with recurrent or metastatic HNSCC.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01856478.

pH-responsive poly(lactide-co-glycolide) nanoparticles containing near-infrared dye for visualization and hyaluronic acid for treatment of osteoarthritis

This study focuses on intra-articular (IA) drug delivery system for the treatment of knee osteoarthritis (OA). In osteoarthritic condition the synovial fluid presents pockets with lower pH environment. To take advantage of these pH differences, poly(lactic-co-glycolic acid (PLGA) nanoparticles (NPs) and pH- responsive PLGA NPs encapsulated with ammonium bicarbonate (NH₄HCO₃) were generated. The nanoparticles were loaded with hyaluronic acid (HA) as a possible model drug for OA and with near-infrared dye (NIR) that was used to visualize the NPs with molecular imaging techniques. These NPs were characterized by dynamic light scattering, transmission electron microscopy and compared in in vitro, in vivo and ex vivo experiments in the treatment of OA. The results indicate that the NPs were sufficiently small, displayed a uniform size distribution and were non-toxic both in vitro and in vivo. Both NPs treatment seem to induced a reduction in OA progression, with pH- responsive NPs showing the more pronounced effect. This is probably because the pockets of low pH environment in the synovial fluid trigger a burst release of the pH-responsive NPs. This result is corroborated by in vitro experiments since the pH- responsive NPs showed an extracellular burst release behavior and higher chondrocyte vitality than non-responsive NPs. This study demonstrates that PLGA NPs containing HA and NH₄HCO₃ are candidates for the treatment of knee OA.