Phase II trial of extended dose anti-CTLA-4 antibody ipilimumab (formerly MDX-010) with a multipeptide vaccine for resected stages IIIC and IV melanoma

9023

Background: Ipilimumab is a human anti-CTLA-4 antibody shown to have clinical activity in melanoma that is associated with immune-related adverse events (IrAEs). Methods: 50 HLA A*0201 positive patients with resected stages IIIC/IV melanoma received MART-1/gp100/tyrosinase peptides with adjuvant Montanide ISA 51 12 times subcutaneously with Ipilimumab at 3 or 10 mg/kg intravenously every 8 weeks for 12 months, and 25 HLA A *0201 negative patients received Ipilimumab alone at 10 mg/kg. Primary endpoints were toxicity and the achievement of a 40% rate of tolerable IrAEs. Immune responses measured by ELISPOT and tetramer assays, and time to relapse were also assessed. 3 melanoma peptides were administered at 1000 mcg/dose each. Results: Median age was 58, with 44 men and 31 women. 46 patients had stage IV, and 29 had stage IIIC resected disease. 19/75 (25%) patients had grades 3–4 IrAEs that were dose-limiting. No patient with dose limiting toxicity required hospitalization and all returned to baseline status with the use of systemic steroids. Assays of induction of IL-17 secreting T cells showed a positive association with freedom from relapse (p=0.049). Change in slope of the increase in total lymphocyte count at four weeks was also associated with a trend toward freedom from relapse and development of an IrAE. 27 of 75 patients have relapsed with a median of 23 months of follow-up. 10 were again rendered NED surgically and are alive without disease. 68 patients are alive, 10 with disease. Only 1/19 patients with grade 3/4 IrAE has died of disease, compared to 6/56 without a dose limiting IBE. 23 of 27 relapses occurred without a grade 3/4 IrAE, compared with 15 IrAEs in 48 patients without a relapse. ELISPOT assays showed that patients at 10 mg/kg actually had decreased responsiveness in fresh PBMC to PHA and the CEF (CMV, EBV, FLU) pool of peptides. Conclusions: IrAEs are associated with clinical benefit in patients with resected high-risk melanoma receiving Ipilimumab with or without a peptide vaccine. Increases in IL-17 secreting CD4 T cells and the slope of increase in total lymphocytes over 4 weeks are associated with freedom from relapse. These data support testing the current regimen at 10 mg/kg in a larger randomized trial.

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Multi-site, multi-country evaluation of analytical and operational performance of a low-mid volume chemiluminescent immunoassay analyzer

BACKGROUND

A new automated immunoassay low-mid volume (< or = 250 immunoassays/day) chemiluminescent analyzer, Abbott Architect i1000sR, was evaluated by seven laboratories around the world (4 in Europe, one each in Canada, Japan, and the U.S.A.) to demonstrate equivalent performance for key operating characteristics (e.g., precision, turn around time, limit of detection, functional sensitivity, and linearity).

METHODS

The laboratories followed standard protocols to assess precision, limit of detection (LoD), functional sensitivity, assay linearity, method comparison, and sample carryover. Turn around time for three stat assays (beta-hCG, BNP, and CK-MB) and the time required to complete workloads of 50 and 100 tests with a mixture of 75% routine tests and 25% stat tests was also evaluated.

RESULTS

Total precision was typically < 5% CV for nine immunoassays. Analytical performance met design goals and demonstrated equivalency to package insert data for assays on market and in use for an existing high volume immunoassay system. Stat turn around times were consistent with the fixed analytical time of 15.6 minutes and met the expectations of the laboratories. Measured test throughput ranged from 47 - 54 tests per hour and demonstrated that the analyzer was fit for the intended purpose of supporting a laboratory that performs < or = 250 immunoassays per day.

CONCLUSIONS

A multisite, international analyzer familiarization study is a practical means of confirming that a new instrument meets both a manufacturer's design specifications and users' real world expectations and provides a pragmatic test for the system. The experience of investigators at seven sites around the world indicates that a new fully automated chemiluminescent system is suitable for use.

The value of the D-Dimer assay for predicting vein thrombosis in rehabilitation patients receiving prophylactic low molecular weight heparin doses

PURPOSE

Early diagnosis and treatment of venous thrombosis biocontact="no" are essential in preventing pulmonary embolism (PE) and reducing the risk of recurrence. The objective was to assess the usefulness of the D-Dimer testing to rule out symptomatic VT in populations of patients receiving heparin in prophylactic doses.

METHODS

One hundred and twenty-three rehabilitation patients with medium or high risk for VT were investigated. Patients were affected by acquired cerebral diseases (n=31), severe brain damage (n=32) or orthopaedic surgical sequelae for major joint replacement or multiple limb fractures (n=60). All patients were receiving prophylactic heparin doses. D-Dimer levels were assessed using Dimertest Latex Agglutination Assay in citrated plasma. Single blinded compression Doppler Ultrasound (DUS) examination was performed in conformity with international standards.

RESULTS

In this specific setting, good sensitivity and specificity of the D-Dimer test was confirmed in patients with acquired cerebral diseases during rehabilitation, whereas false positive results were found in most patients who had undergone major joint replacement, until several weeks after surgery.

CONCLUSIONS

In rehabilitation patients receiving prophylactic heparin doses, the D-Dimer test seems to confirm high sensitivity and high negative predictive value for VT and PE. Relevant clinical variables seem to reduce the usefulness of the D-Dimer test as a screening tool for VT, at least in orthopaedic patients with joint prosthesis.

Soil radon monitoring in the NE flank of Mt. Etna (Sicily)

Soil radon has been monitored at a fixed location on the northeastern flank of Mt. Etna, a high-risk volcano in Sicily. The aim of this study was to evaluate the effects of the recent volcanic activity on soil radon concentration. Continuous radon measurements have been performed since July 2001. While comparison between the trend in in-soil radon concentration and the acquired meteorological series (temperature, humidity and pressure) appear to confirm a general seasonal correlation, nevertheless particular anomalies suggest a possible dependence of the radon concentration on volcanic dynamics.

Prognostic factors in multidisciplinary rehabilitation treatment in multiple sclerosis: an outcome study

The aim of this outcome study was to evaluate the effectiveness and prognostic factors of inpatient multidisciplinary rehabilitation treatment in patients with multiple sclerosis (MS). We analysed 230 consecutive inpatients with MS admitted to an MS rehabilitation ward who followed an individualized, goal-oriented, multidisciplinary rehabilitation program. Every patient was submitted to a neurological examination and evaluated by means of Kurtzke's Expanded Disability Status Scale (EDSS), with its functional systems (FS), Barthel Index (BI) and the Rivermead Mobility Index (RMI). We observed an effectiveness (percentage of potential improvement achieved during rehabilitation) of nearly 16% on BI and 8% on RMI, corresponding to an improvement in 124 patients (54%) on BI and 113 patients (49%) on RMI. Basal EDSS (beta = -0.32, P <0.001), cognitive status (beta = -0.15, P <0.05) and disease duration (beta = -0.13, P <0.05) were negatively associated with effectiveness of treatment on BI (adjusted R2 = 0.176), whereas effectiveness on RMI was correlated only with the EDSS score (beta = -0.34, P <0.001, adjusted R2 = 0.113). In the logistic regression analysis, the absence of severe sphincteric disturbances was correlated with the probability of improvement on BI that was nearly twice as high (OR =2.25, 95% CI 1.24-4.08) as that of other patients. Moreover, patients without severe cognitive deficits showed a similar probability (OR =2.37, 95% CI 1.05-5.33) of improvement on RMI. The results of this study provide further evidence that intensive multidisciplinary rehabilitation in MS is effective in the majority of MS patients and that early treatment may favour functional recovery.

Field vaccination of cattle using a bivalent modified-live vaccine against bluetongue virus serotypes 2 and 9: effect on milk production

To evaluate the effect of bluetongue (BT) vaccination on milk production in cattle, 30 cows at various stages of gestation were vaccinated using a bivalent bluetongue virus serotype 2 (BTV-2) and BTV-9 modified-live vaccine produced by Onderstepoort Biological Products in South Africa. A second group of 30 pregnant cows was used unvaccinated controls. Blood samples were taken from all animals three times a week for two months. Virus titres were determined and the daily milk production of each cow was quantitatively and qualitatively evaluated. From 27 of the 30 vaccinated cows, BTV was isolated from day 4 to day 28 post vaccination. BTV vaccination had no effect on milk production, somatic cell count, pH, milk fat, protein and lactose content. It is concluded that the bivalent BTV-2/BTV-9 modified-live vaccine does not affect milk production in cows.

Virological and serological response of cattle following field vaccination with bivalent modified-live vaccine against bluetongue virus serotypes 2 and 9

Following the bluetongue (BT) epidemic in Italy, the government initiated a vaccination campaign involving all domestic ruminants (cattle, sheep and goats) in the affected and adjacent areas to create a resistant population and to reduce virus circulation. Based on the serotypes circulating in the affected areas, monovalent BT virus (BTV) serotype 2 (BTV-2), or bivalent BTV-2 and BTV-9, modified-live vaccines were used. These are manufactured by Onderstepoort Biological Products in South Africa and, because they are recommended for use in sheep only, very little data exists on their use in cattle under field conditions. To evaluate duration and levels of viraemia and the antibody response following vaccination, 30 cattle in various stages of pregnancy were selected and vaccinated with a bivalent BTV-2/BTV-9 vaccine. Blood samples were taken from the animals three times a week for two months and screened using the competitive enzyme-linked immunosorbent assay (c-ELISA) and the virus neutralisation (VN) test. Intravenous egg inoculation, followed by two blind passages in Vero cells, was used to isolate BTV-2 and BTV-9 from ethylene-diaminetetra-acetic acid (EDTA) blood samples, and virus titres determined in viraemic animals. Titres against BTV were detected in 27 animals between days 4 and 35 post vaccination (pv). Viraemia peaked on day 9 pv with average viral titres of 10(4.5)TCID50/ml. From day 9 pv, the c-ELISA detected antibodies in all animals while low VN titres were observed commencing on day 18 pv. Furthermore, VN antibody to BTV-2 was detected in only 17 of the animals vaccinated and to BTV-9 in 27 animals.

Antibody response after vaccination with antigen-pulsed dendritic cells

Dendritic cells (DCs) are the most potent antigen-presenting cells of the immune system capable of initiating immune responses to antigens. It is also well documented that cancer patients often experience anergy against tumor antigens. In this study we selected the best protocol for inducing the production of antibodies against the HER2 oncoprotein using DCs to overcome anergy. Murine DCs were pulsed in vitro, using different protocols, with recombinant HER2 fused to a human Fc (in order to improve DC antigen uptake) and were used to vaccinate mice. The obtained results indicate that antigen-pulsed DCs can induce an antibody response and that adding CpG after antigen pulsing greatly increases anti-HER2 antibody production.

Post-stroke depression, antidepressant treatment and rehabilitation results. A case-control study

The aim of this study was to assess the specific influence of poststroke depression (PSD) on both basal functional status and rehabilitation results. We performed a case-control study in 290 stroke inpatients, matched for age (+/-1 year) and onset admission interval (+/-3 days) and divided in two groups according to the presence (PSD+) or absence (PSD-) of PSD. All PSD+ patients were treated with antidepressants (AD), mainly with fluoxetine. PSD+ patients, despite similar severity of stroke, showed greater disability in coping with activities of daily living (ADL) on admission and greater disability both in ADL and mobility at discharge than PSD- patients. Although both groups exhibited similar average functional improvement during rehabilitation, PSD- patients were nearly twice as likely to show excellent recovery both on ADL and mobility as PSD+ patients (OR = 1.95, 95% CI = 1.01-3.75 and OR = 2.23, 95% CI = 1.14-4.35, respectively). All AD drugs improved depressive symptoms. Few relevant side effects were observed: fluoxetine was discontinued in 2 patients because of insomnia and in 2 patients because of nausea; paroxetine was stopped in 1 patient because of nausea and dry mouth. Our results confirm the unfavorable influence of PSD on functional outcome, despite pharmacological treatment.

Topical administration of a doxorubicin-specific monoclonal antibody prevents drug-induced mouth apoptosis in mice

One of the most severe side effects of anti-tumour chemotherapy is mucositis due to drug toxicity for rapidly dividing cells. We show here that anti-DXR monoclonal antibodies can prevent DXR-induced damage. Indeed, apoptosis, confined to the proliferative compartment of the basal mucosa, observed in the tongue of DXR-treated mice was completely inhibited by topical application of the anti-DXR antibodies.

Mobility status after inpatient stroke rehabilitation: 1-year follow-up and prognostic factors

OBJECTIVES

To evaluate the stability of mobility status achieved by stroke patients during hospital rehabilitation treatment over time and to identify reliable prognostic factors associated with mobility changes.

DESIGN

Follow-up evaluation in consecutive first-ever stroke patients 1 year after hospital discharge. Multiple logistic regressions were used to analyze increases and decreases in Rivermead Mobility Index (RMI) scores (dependent variables) between discharge and follow-up. Independent variables were medical, demographic, and social factors.

SETTING

Rehabilitation hospital.

PATIENTS

A cohort of 155 patients with sequelae of first stroke, with a final sample of 141.

MAIN OUTCOME MEASURES

Mobility status at 1-year follow-up, as measured by the RMI, and odds ratios (OR) for improvement and decline in mobility.

RESULTS

Functionally, 19.9% improved the mobility levels achieved during the inpatient rehabilitation treatment; levels of 42.6% worsened. Patients with global aphasia (OR = 5.66; 95% confidence interval [CI], 1.50-21.33), unilateral neglect (OR = 3.01; 95% CI, 1.21-7.50), and age 75 years or older (OR = 5.77; 95% CI, 1.42-23.34) had a higher probability of mobility decline than the remaining patients. Postdischarge rehabilitation treatment (PDT), received by 52.5% of the final sample, was significantly and positively associated with mobility improvement (OR = 5.86; 95% CI, 2.02-17.00). Absence of PDT was associated with a decline in mobility (OR = 3.73; 95% CI, 1.73-8.04).

CONCLUSIONS

In most cases, mobility status had not yet stabilized at hospital discharge. PDT was useful in preventing a deterioration in mobility improvement achieved during inpatient treatment and in helping increase the likelihood of further mobility improvement.

Early versus delayed inpatient stroke rehabilitation: a matched comparison conducted in Italy

OBJECTIVE

To assess the specific influence of onset-admission interval (OAI) on rehabilitation results.

DESIGN

A case-control study in consecutive stroke inpatients, enrolled in homogeneous subgroups, matched for age (within 1 year) and Barthel Index (BI) score at admission, and different for OAI to the rehabilitation ward. The short OAI group began rehabilitation treatment within the first 20 days from stroke, medium OAI group between days 21 and 40, and long OAI between days 41 and 60.

SETTING

Rehabilitation hospital.

PATIENTS

One hundred forty-five patients with sequelae of first stroke.

MAIN OUTCOME MEASURES

Efficiency (average increase in BI per day), effectiveness (proportion of potential improvement achieved during rehabilitation) of treatment, and percentage of low- and high-response patients, calculated on BI, were evaluated. Odds ratios (ORs) of dropouts and of poor and excellent therapeutic response were also quantified.

RESULTS

The short OAI subgroup had significantly higher effectiveness of treatment than did the medium (p < .05) and the long OAI groups (p < .005). Beginning treatment within the first 20 days was associated with a significantly high probability of excellent therapeutic response (OR = 6.11; 95% confidence interval [CI], 2.03-18.36), and beginning later was associated with a similar risk of poor response (OR = 5.18; 95% CI, 1.07-25.00). On the other hand, early intervention was associated with a five times greater risk of dropout than that of patients with delayed start of treatment (OR = 4.99; 95% CI, 1.38-18.03). The three subgroups were significantly (p < .05) different regarding the percentage of low and high responders.

CONCLUSION

Our results showed a strong association between OAI and functional outcome.

One-year follow-Up in stroke patients discharged from rehabilitation hospital

This study was designed to evaluate functional status at a 1-year follow-up in consecutive first-stroke patients after discharge from rehabilitation hospital and to identify reliable prognostic factors associated with changes in their abilities. Functional evaluation was made of consecutive patients 1 year after discharge to their own homes. Two multiple logistic regressions (forward stepwise) were performed using both improvement and worsening of the Barthel Index score between discharge and follow-up as dependent variables. Independent variables were medical, demographic and social factors. The final sample included 157 out of 172 patients. During the follow-up, 10 patients (5.81%) died because of a new cerebrovascular event, 1 patient died of myocardial infarction, 2 patients had new strokes and 2 fractured their paretic legs. Functionally, 43.3% of the patients maintained the level they achieved during inpatient rehabilitation treatment, 23.6% improved and the remaining 33.1% worsened. Patients with hemineglect and aged >/=65 years had a higher probability of functional worsening (odds ratio, OR = 3.77, 95% confidence interval, CI = 1.42- 10.0 and OR = 3.93, 95% CI = 1. 72-8.95, respectively). Postdischarge rehabilitation (performed for 46.5% of the final sample) was significantly and positively associated with functional improvement (OR = 7.23, 95% CI = 2.89-18. 05), and its absence with functional worsening (OR = 12.32, 95% CI = 4.47-37.01). In conclusion, in nearly half of the cases, functional status was still not stabilized at the time of discharge from the rehabilitation hospital. Postdischarge outpatient treatment was useful for preventing worsening of the functional ability achived during inpatient treatment and increased the possibility of further functional improvement. Age >/=65 years and hemineglect were predictors of functional worsening at follow-up.

High level antibody response to retrovirus-associated but not to melanocyte lineage-specific antigens in mice protected against B16 melanoma

Mice vaccinated with Mycobacterium tuberculosis Ag38 gene-transduced B16 melanoma cells showed significant protection from intravenous challenge with parental B16 melanoma cells. No cytotoxic T-cell activity was found against melanoma cells, although the endogenous presence of the mycobacterial gene induced a preferential Th1 response. After immunization, a low serological response against melanoma cells was detected, while a high titer of antibodies directed to parental B16 cells, mainly of IgG2(a) isotype, was found in protected mice after challenge. These antibodies exhibited complement-dependent cytotoxicity against melanoma cells in vitro, while in vivo, used in passive immunization, they induced a decrease in a number of experimental B16 lung metastases. Most of the antibodies were directed against endogenous murine leukemia viruses. No reactivity against melanocyte lineage-specific antigens was observed. In particular, no reactivity was found in sera from protected mice against tyrosinase-related protein 2 (TRP-2), either stably expressed in a non-melanoma cell line or obtained by in vitro transcription-translation, or against tyrosinase, TRP-1 and gp100 antigens immunoprecipitated from B16 cells. Thus, in the B16 murine model, the presence of dominant viral antigens induces a very strong humoral response that might be protective and may inhibit or mask the presence of minor clonotypes.

Inhibition of fibronectin-activated migration of microvascular endothelial cells by interleukin-1alpha, tumour necrosis factor alpha and interferon gamma

The effect of interferon gamma (IFN) and the inflammatory cytokines tumour necrosis factor alpha (TNF) and interleukin 1alpha (IL-1) on micro- and macrovascular endothelial cell (EC) proliferation and migration was analysed. Whereas both micro- and macrovascular EC were growth-inhibited in response to the aforementioned cytokines, only microvascular EC were sensitive to TNF, IL-1 and IFN as inhibitors of fibronectin-activated cell migration. In addition, because microvascular EC play a crucial role in angiogenesis, and the formation of new capillaries depends upon the presence of angiogenic polypeptides, we evaluated the synthesis of fibroblast growth factor (FGF) type 1 and 2, Vascular Endothelial Growth Factor (VEGF) and Hepatocyte Growth Factor (HGF) in our system. Both micro- and macrovascular EC produce large amounts of FGF-2, which is mainly localized in the nucleus, and almost undetectable levels of FGF-1. In addition, the two cell types synthesize notable levels of VEGF and no HGF. Whether these findings are relevant to the different in vivo functions of EC residing different districts remains the focus of additional studies.

Segregation of type 1 cytokine production in human peripheral blood lymphocytes: phenotypic differences between IFN-gamma and IL-2-producing cells in the CD8+ T cell subset

T cell clones are classified as type 0, 1 or 2 depending on the lymphokines they produce. However, it has remained unclear whether single cells of a given type produce one or several cytokine species. Flow cytometric analysis of peripheral blood lymphocytes (PBL) obtained from 20 healthy donors for the production of the type 1 cytokines IFN-gamma and IL-2 revealed very few cells that co-expressed both cytokines independently of the mitogenic stimulus used for PBL activation. Similarly, kinetic studies of cytokine synthesis indicated a low percentage of IFN-gamma/IL-2 double-positive T cells at all time points. Reverse transcription-PCR analysis of sorted IL-2- and IFN-gamma-positive T cells showed the presence of IL-2- or IFN-gamma-specific mRNA only in those cells expressing the corresponding cytokine. This segregation of the two type 1 cytokines was lost in long-term cultured T cells and in T cell clones. A high percentage of cells expressing only IL-2 or IFN-gamma was observed even when the production of these cytokines was evaluated on CD4- and CD8+ subsets. Moreover, in some healthy individuals, IFN-gamma and IL-2 production by CD8+ T cells was related to CD8+ expression levels and cell size, i. e. IL-2-expressing cells were generally smaller with more intense CD8+ staining as compared with IFN-gamma-producing T cells. These data indicate that activated T lymphocytes are strongly committed in vivo to produce IFN-gamma or IL-2 and emphasizes the independent regulation of the two cytokine genes.