A phase 1b dose escalation study to evaluate safety, tolerability and pharmacokinetics of oral monotherapy with KX2-391 in elderly subjects with acute myeloid leukemia who are refractory to or have declined standard induction therapy

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Background: Treatment of elderly AML patients is complicated by poor tolerance to standard therapies and multi-drug resistance. It is imperative to explore novel agents which are tolerable and target alternative pathways. KX2-391 is an oral non-ATP-competitive inhibitor of Src kinase and tubulin polymerase. We conducted a phase I open-label safety and activity study in elderly subjects with AML who were refractory to or declined standard induction chemotherapy. Five dose levels were tested from 40 to 160 mg daily. Methods: 24 subjects were recruited from 3 institutions with an average age of 74 years (range 63-86). The majority had previously received HMAs. 1 subject was treated at 40 mg, 2 at 80 mg, 8 at 120 mg, 12 at 140 mg, and 1 at 160 mg. Of the 24 subjects enrolled, 7 (29%) were on treatment for 12 days or less; 9 (38%) from 15 to 29 days, 5 (21%) from 33 to 58 days and 3 (13%) from 77 to 165 days. One subject treated at 120 mg for 165 days had a reduction in splenomegaly from 16 cm to 4 cm BLCM, and survived 373 days. A second subject was treated at 120 mg for 154 days until disease progression. One subject was dosed at 160 mg for 12 days and remained treatment-free for about 18 months. Results: DLTs occurred in 8 subjects at: 120mg (AST/ALT, elevated bilirubin); 140 mg (Mucositis, Allergic Reaction, 2 elevated LFTs, acute kidney injury) and 160 mg (Mucositis). The most common (≥ 25%) treatment-related adverse events were nausea/vomiting; diarrhea; anorexia; fatigue/weakness; increase ALT/AST; hypokalemia; hypotension; febrile neutropenia; dyspnoea; abdominal pain; constipation; dizziness. The RPTD for KX2-391 is 120 mg given once daily. KX2-391 bone marrow concentrations are similar to the target IC50 of 142 ng/mL. Conclusions: This is the first study conducted to determine whether KX01 can be safely given to this high risk, frail AML patient population. The data from this study support proceeding with further studies including alternative dosing phase 1 studies (higher dose, shorter course followed by drug-free intervals) and phase 2 studies to assess efficacy. Clinical trial information: NCT01397799.

En Bloc Liver Kidney Transplantation Using Donor Splenic Artery as Inflow to the Kidney: Report of Two Cases

The number of simultaneous liver-kidney transplants has been increasing. This surgery is associated with an increased risk of complications, longer duration of surgery and longer ischemia time for the renal allograft. Two patients listed for liver-kidney transplant at our center underwent en bloc combined liver-kidney transplantation using donor splenic artery as inflow. Patient 1 previously underwent cardiac catheterization that was complicated by a bleeding pseudoaneurysm of the right external iliac artery that required endovascular stenting of the external iliac artery and embolization of the inferior epigastric artery. Patient 2 was on vasopressor support and continuous renal replacement therapy at the time of transplant. In this paper, we described a novel technique of en bloc liver-kidney transplant with simultaneous reperfusion of both allografts using the donor splenic artery for renal inflow. This technique is useful for decreasing cold ischemia time and total operative time by simultaneous reperfusion of both allografts. It is a useful technical variant that can be used in patients with severe disease of the iliac arteries.

Standardizing terms, definitions and concepts for describing and interpreting unwanted immunogenicity of biopharmaceuticals: recommendations of the Innovative Medicines Initiative ABIRISK consortium

Biopharmaceuticals (BPs) represent a rapidly growing class of approved and investigational drug therapies that is contributing significantly to advancing treatment in multiple disease areas, including inflammatory and autoimmune diseases, genetic deficiencies and cancer. Unfortunately, unwanted immunogenic responses to BPs, in particular those affecting clinical safety or efficacy, remain among the most common negative effects associated with this important class of drugs. To manage and reduce risk of unwanted immunogenicity, diverse communities of clinicians, pharmaceutical industry and academic scientists are involved in: interpretation and management of clinical and biological outcomes of BP immunogenicity, improvement of methods for describing, predicting and mitigating immunogenicity risk and elucidation of underlying causes. Collaboration and alignment of efforts across these communities is made difficult due to lack of agreement on concepts, practices and standardized terms and definitions related to immunogenicity. The Innovative Medicines Initiative (IMI; http://www.imi-europe.org), ABIRISK consortium [Anti-Biopharmaceutical (BP) Immunization Prediction and Clinical Relevance to Reduce the Risk; http://www.abirisk.eu] was formed by leading clinicians, academic scientists and EFPIA (European Federation of Pharmaceutical Industries and Associations) members to elucidate underlying causes, improve methods for immunogenicity prediction and mitigation and establish common definitions around terms and concepts related to immunogenicity. These efforts are expected to facilitate broader collaborations and lead to new guidelines for managing immunogenicity. To support alignment, an overview of concepts behind the set of key terms and definitions adopted to date by ABIRISK is provided herein along with a link to access and download the ABIRISK terms and definitions and provide comments (http://www.abirisk.eu/index_t_and_d.asp).

A pro-apoptotic function of iASPP by stabilizing p300 and CBP through inhibition of BRMS1 E3 ubiquitin ligase activity

The p53 family and its cofactors are potent inducers of apoptosis and form a barrier to cancer. Here, we investigated the impact of the supposedly inhibitory member of the apoptosis-stimulating protein of p53, iASPP, on the activity of the p53 homolog TAp73, and its cofactors p300 and CBP. We found that iASPP interacted with and stabilized the histone acetyltransferase p300 and its homolog CBP upon cisplatin treatment. Vice versa, iASPP depletion by shRNA resulted in decreased amounts of p300 and CBP, impaired binding of p300 and TAp73 to target site promoters, reduced induction of pro-apoptotic TAp73 target genes, and impaired apoptosis. Mechanistically, we observed that the p300-regulatory E3 ubiquitin ligase BRMS1 could rescue the degradation of p300 and CBP in cisplatin-treated, iASPP-depleted cells. This argues that iASPP stabilizes p300 and CBP by interfering with their BRMS1-mediated ubiquitination, thereby contributing to apoptotic susceptibility. In line, iASPP overexpression partially abolished the interaction of BRMS1 and CBP upon DNA damage. Reduced levels of iASPP mRNA and protein as well as CBP protein were observed in human melanoma compared with normal skin tissue and benign melanocytic nevi. In line with our findings, iASPP overexpression or knockdown of BRMS1 each augmented p300/CBP levels in melanoma cell lines, thereby enhancing apoptosis upon DNA damage. Taken together, destabilization of p300/CBP by downregulation of iASPP expression levels appears to represent a molecular mechanism that contributes to chemoresistance in melanoma cells.

Laboratory diagnosis of paraneoplastic pemphigus

BACKGROUND

Paraneoplastic pemphigus (PNP) is a multiorgan disease characterized by antibodies against plakins, desmogleins and the α2-macroglobulin-like-1 (A2ML1) protein, in association with an underlying neoplasm. Accurate diagnosis relies on the demonstration of these autoantibodies in serum.

OBJECTIVES

To evaluate the value of different laboratory techniques in the serological diagnosis of PNP.

METHODS

We performed immunoblotting, envoplakin (EP) enzyme-linked immunosorbent assay (ELISA), indirect immunofluorescence (IIF) on rat bladder, radioactive immunoprecipitation and a nonradioactive combined immunoprecipitation-immunoblot assay. Additional assays included BP180 ELISA and BP230 ELISA. We included the sera of 19 patients with PNP and 40 control subjects.

RESULTS

The sensitivities were 63% for anti-EP ELISA, 74% for rat bladder IIF, 89% for immunoblotting, 95% for radioactive immunoprecipitation and 100% for nonradioactive immunoprecipitation. Specificities ranged from 86% to 100%. The BP180 and BP230 ELISAs had low sensitivity and specificity for PNP. The combination of rat bladder IIF and immunoblot showed 100% sensitivity and specificity. The analysis of sequential PNP sera showed that antibody titres may decrease over time, possibly resulting in negative outcomes for EP ELISA and rat bladder IIF studies.

CONCLUSIONS

The detection of autoantibodies against EP and periplakin, or A2ML1 by immunoprecipitation is most sensitive for PNP. The combination of rat bladder IIF and immunoblotting is equally sensitive and highly specific, and represents an alternative valuable and relatively easy approach for the serological diagnosis of PNP.

Social neighborhood environment and sports participation among Dutch adults: does sports location matter?

Studies on the relation between the social neighborhood environment and sports participation have produced inconsistent results. Use of generic sports outcomes may have obscured associations only apparent for sports at certain locations. This study aims to assess the association between the social neighborhood environment and three location-specific sports outcomes. Repeated cross-sectional data on sports participation (any type of sports, sports at indoor sports clubs, sports at outdoor sports clubs, sports on streets) were obtained from 20 600 adults using the Dutch national health survey 2006-2009. Data on neighborhood social safety and social capital were obtained using the Dutch Housing Research 2006. Over 40% of Dutch adults participated in any type of sports. Indoor sports clubs were most popular. Multilevel logistic regression analyses revealed that neighborhood social safety was positively associated with sports at indoor sports clubs [odds ratio (OR) = 1.25, 95% confidence interval (CI) = 1.06-1.48), but not with the other sports outcomes. Contrary, neighborhood social capital was positively associated with sports on streets only (OR = 1.69, 95% CI = 1.17-2.44). The results suggest that a positive social neighborhood environment enhances sports participation, but that this impact depends on the location of the sports activity. This study highlights the importance of using location-specific sports outcomes when assessing environmental determinants.

The medical alliance: from placebo response to alliance effect

The natural human response to illness is to seek to understand what is happening and to look for help from others. In all cultures, one finds healers, who provide explanations and offer care. Their interventions often have a placebo effect through activation of natural healing processes in the patient. Although placebo effects are relatively large and robust, physicians generally consider placebo treatment prescientific and deceptive. We review the determinants of the placebo response and show how a particular professional alliance between a patient and a caregiver is apt to equally affect treatment outcome. We distinguish the alliance effect from the placebo effect. We develop a comprehensive model of the medical alliance, on the basis of the concept of concordance, and review its relevance for clinical practice and medical education. The alliance effect represents a professional and ethical way of activating a patient's natural healing mechanisms.