Abstract P3-09-01: NEPA, a fixed-dose combination of netupitant and palonosetron, prevents chemotherapy-induced nausea and vomiting (CINV) more effectively and reduces the impact on daily living for breast cancer patients compared with palonosetron

Background:

Breast cancer (BC) patients receiving anthracycline-cyclophosphamide (AC) chemotherapy (CT) are at risk for developing CINV due not only to the emetogenicity of the CT but also to young age and gender. As recommended by international antiemetic guidelines, targeting multiple molecular pathways involved in emesis related to AC is important for maximizing control of CINV and improving the functional status of BC patients during CT. NEPA is a fixed-dose combination of netupitant (NETU), a highly-selective NK1 receptor antagonist (RA), and palonosetron (PALO), a pharmacologically distinct 5-HT3 RA, that targets dual antiemetic pathways with a convenient single day dose.

Methods:

This was a multinational, randomized, double-blind, phase 3 study evaluating the efficacy and safety of a single oral dose of NEPA (NETU 300 mg + PALO 0.50 mg) versus a single oral 0.50 mg dose of PALO in chemotherapy-naïve patients receiving AC. All patients received oral dexamethasone (DEX) on day 1 (12 mg NEPA arm; 20 mg PALO arm). The primary efficacy endpoint was complete response (CR: no emesis, no rescue medication) in the delayed phase, 25-120h after CT. The Functional Living Index-Emesis (FLIE) questionnaire with a 5-day recall period was used to assess the impact of CINV on patients’ daily lives as a secondary endpoint. The FLIE consists of 9 nausea-specific (nausea domain) and 9 vomiting-specific (vomiting domain) items that address the effect of nausea and vomiting on daily life. Each item is scored on a 7-point 100 mm visual analog scale with anchors of “none/not at all” and “a great deal”. The proportion of patients with an average item score >6 reflecting “no impact on daily life” (NIDL) (ie, total FLIE score >108, nausea/vomiting domain score >54) was compared for NEPA vs PALO using a Cochran-Maentel-Haenszel test stratified by age class and region.

Results:

1455 patients with a mean age of 54 were randomized to receive NEPA or PALO. Treatment groups were similar; 98% were females with BC (97%).

As previously reported (ASCO 2013), NEPA showed superior CR rates compared to PALO for the acute 0-24h (88% vs 85%; p = 0.047), delayed (77% vs 70%; p = 0.001) and overall 0-120h (74% vs 67%; p = 0.001) phases.

A greater proportion of NEPA-treated patients reported NIDL for nausea, vomiting and combined domains compared to PALO.

% Patients with NIDL (Overall 0-120h)NEPA (N = 724)PALO (N = 725)p-valueNausea domain72%66%0.015Vomiting domain90%84%0.001Overall combined79%72%0.0056 patients excluded who did not receive AC or study drug

The adverse event (AE) profile was comparable between groups. Most frequently reported treatment-related AEs for NEPA and PALO, respectively, were headache (3.3%, 3.0%) and constipation (2.1%, 2.1%).

Conclusions:

In this large Phase 3 study of predominantly females with BC receiving AC, NEPA was superior to PALO in preventing CINV and reducing the negative impact of CINV on patients’ daily lives. As a fixed-dose antiemetic drug combination including an NK1 RA and 5-HT3 RA, NEPA offers improved efficacy over PALO alone, with a convenient single-day dose, and oral DEX only on day 1.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-09-01.

The inhibitory circuit architecture of the lateral hypothalamus orchestrates feeding

The growing prevalence of overeating disorders is a key contributor to the worldwide obesity epidemic. Dysfunction of particular neural circuits may trigger deviations from adaptive feeding behaviors. The lateral hypothalamus (LH) is a crucial neural substrate for motivated behavior, including feeding, but the precise functional neurocircuitry that controls LH neuronal activity to engage feeding has not been defined. We observed that inhibitory synaptic inputs from the extended amygdala preferentially innervate and suppress the activity of LH glutamatergic neurons to control food intake. These findings help explain how dysregulated activity at a number of unique nodes can result in a cascading failure within a defined brain network to produce maladaptive feeding.

Phase-contrast microtomography of thin biomaterials

Phase-contrast microtomography, performed at the beamline ID 22 of the European Synchrotron Radiation Facility (ESRF, Grenoble, France), is demonstrated for high-resolution 3-D imaging of a hydroxyapatite sample. The technique, which relies on phase contrast imaging, gives the possibility to observe features inside samples with negligible absorption contrast. The positive results obtained suggest a possible future investigation of the influence of the distribution of pores and defects inside biomaterial coatings, on the growth of osteoblast cells.

Biologic effects of surface roughness and fluorhydroxyapatite coating on osteointegration in external fixation systems: an in vivo experimental study

The concomitant influence of surface roughness and fluorhydroxyapatite (FHA) coating of titanium (Ti) implants on bone response was investigated. For this purpose, titanium screw-shaped implants with a lower degree (Y371) and a higher degree (TiPore300) of surface roughness, coated with FHA and uncoated, were transversally inserted into the diaphyses of sheep tibiae for 12 weeks. Four sheep received Y371 (group A) and Y371 + FHA (group B) screws and four sheep received TiPore300 (group C) and TiPore300 + FHA (group D) screws. For each type of material, the morphology and microstructure of implant-facing bone were evaluated. The host bone of each tibia was used as a control. In all groups the bone tissue did not reach a complete maturation. The higher degree of roughness, perhaps due to an excessive irregularity of the surface, induced the worst osteointegration: a fibrous tissue layer between screw and new bone tissue was often present. Nevertheless, as viewed by XRD, no crystallographic change of the apatite lattice was observed in any of the implants. In contrast, the microhardness value, an index of bone mineralization, was higher in the uncoated screws and decreased progressively in the following order: group C > group A > group B > group D. The association of plasma spraying with roughness treatment constitutes a complex system that seems to interfere with bone mineralization. A chemical change of the surface, perhaps with more Ti release or more coating degradation, could be responsible for such impairment. The authors emphasize the necessity for simultaneous evaluation of surface topography and chemistry as well as an improvement in plasma-spraying and post-processing techniques and in standard procedures for materials characterization.

Biomechanical and histomorphometric investigations on two morphologically differing titanium surfaces with and without fluorohydroxyapatite coating: an experimental study in sheep tibiae

The influence of fluorohydroxyapatite (FHA) coating and surface roughness of Ti6Al4V implants on bone response was investigated. Uncoated and FHA-coated screws with lower (LR and LR+FHA; Ra: 5.7+/-0.2 microm) and higher (HR and HR+FHA; Ra: 21.8+/-0.9 microm) surface roughness, were inserted into the diaphyses of 8 sheep tibiae. Twelve weeks after implantation, extraction torque and bone-to-implant contact were evaluated. The smoothest surfaces showed an improved extraction torque and significant differences were observed between LR and HR (-24.6%, p<0.0005), LR and HR+FHA (-30.7%, p<0.0005), LR+FHA and HR (-17.4%, p<0.005), and LR+FHA and HR+FHA (-24.0%, p<0.005). The bone-to-implant contact data paralleled the biomechanical data: the smoother the surface, the greater the bone-to-implant contact. Significant (p<0.0005) decreases in bone-to-implant contact were observed between LR+FHA and HR (-24.2%), and between LR+FHA and HR+FHA (-29.2%). The current findings suggest that LR surfaces significantly improve the osteointegration rate of implanted cortical screws independently of the FHA coating.

Design, characterization, and structure of a biologically active single-chain mutant of human IFN-gamma

A mutant form of human interferon-gamma (IFN-gamma SC1) that binds one IFN-gamma receptor alpha chain (IFN-gamma R alpha) has been designed and characterized. IFN-gamma SC1 was derived by linking the two peptide chains of the IFN-gamma dimer by a seven-residue linker and changing His111 in the first chain to an aspartic acid residue. Isothermal titration calorimetry shows that IFN-gamma SC1 forms a 1:1 complex with its high-affinity receptor (IFN-gamma R alpha) with an affinity of 27(+/- 9) nM. The crystal structure of IFN-gamma SC1 has been determined at 2.9 A resolution from crystals grown in 1.4 M citrate solutions at pH 7.6. Comparison of the wild-type receptor-binding domain and the Asp111-containing domain of IFN-gamma SC1 show that they are structurally equivalent but have very different electrostatic surface potentials. As a result, surface charge rather than structural changes is likely responsible for the inability of the His111-->Asp domain of to bind IFN-gamma R alpha. The AB loops of IFN-gamma SC1 adopt conformations similar to the ordered loops of IFN-gamma observed in the crystal structure of the IFN-gamma/IFN-gamma R alpha complex. Thus, IFN-gamma R alpha binding does not result in a large conformational change in the AB loop as previously suggested. The structure also reveals the final six C-terminal amino acid residues of IFN-gamma SC1 (residues 253-258) that have not been observed in any other reported IFN-gamma structures. Despite binding to only one IFN-gamma R alpha, IFN-gamma SC1 is biologically active in cell proliferation, MHC class I induction, and anti-viral assays. This suggests that one domain of IFN-gamma is sufficient to recruit IFN-gamma R alpha and IFN-gamma R beta into a complex competent for eliciting biological activity. The current data are consistent with the main role of the IFN-gamma dimer being to decrease the dissociation constant of IFN-gamma for its cellular receptors.

Ambulatory 24-hour blood pressure monitoring: correlation between blood pressure variability and left ventricular hypertrophy in untreated hypertensive patients

BACKGROUND

Left ventricular hypertrophy (LVH) appears to be poorly correlated with clinical measurements of blood pressure: a better correlation may be observed with data from 24 h ambulatory blood pressure monitoring (ABPM). The aim of this study was to compare the results of non-invasive ABPM in a population of patients with essential hypertension who had never been treated, subdividing them based on the presence or absence of LVH in the transthoracic echocardiogram (LVMI, left ventricular mass index > 135 g/m2 in males and > 110 g/m2 in females).

METHODS

Eighty hypertensive patients with mild or moderate hypertension underwent routine blood tests, a 24 h ABPM and a transthoracic echocardiogram. Based on the ABPMs, we analyzed average 24 h systolic and diastolic blood pressure (BP), average daytime (6 a.m.-10 p.m.) and nighttime (10 p.m.-6 a.m.) systolic and diastolic BP, average morning (6-12 a.m.) BP and the number of dipper or non-dipper patients. The echocardiographic study included the calculation of left ventricular mass using Devereux's formula according to the Penn convention, analysis of the patterns of left ventricular geometry and a study of left ventricular diastolic function.

RESULTS

Thirty-five (43.7%) patients had LVH at the echocardiographic study. In 52 subjects, the clinical history showed at least one BP measurement > 140/90 mmHg in the year prior to our observation. The average age was 48 +/- 11, without any significant correlation to LVMI (r = 0.13). The magnitude of the S-wave in V1 and the R-wave in V5 and the magnitude of the tallest R-wave and S-wave in the electrocardiogram analysis had a significant correlation with LVMI (r = 0.23 and r = 0.26, respectively). The echocardiogram revealed a normal left ventricular geometry in 43.8% of hypertensive patients, concentric remodeling in 13.8%, concentric hypertrophy in 16.2% and eccentric hypertrophy in 26.2%. The isovolumic relaxation time (IVRT) and A-wave were significantly correlated with LVMI (r = 0.49 and r = 0.33, respectively). LVMI had a significant correlation with systolic BP at ABPM (24 h systolic BP r = 0.34; daytime systolic BP r = 0.35; nighttime systolic BP r = 0.28; 6-12 systolic BP r = 0.29) but not with diastolic BP. Dipper patients represented 76.3% of the population, without any difference in LVMI between dippers and non-dippers (p = 0.09). Dipper patients had a higher prevalence of normal left ventricles as compared with non-dippers (p < 0.0001). White-coat hypertension was observed in 7.5% of hypertensive patients.

CONCLUSIONS

The prevalence of LVH in our population was high (43.7%) and some parameters related to diastolic left ventricular function (IVRT, A-wave) were correlated with LVMI. Systolic ambulatory BP was significantly correlated with LVMI, while diastolic BP was not.

Short-term administration of intranasal or oral Hexarelin, a synthetic hexapeptide, does not desensitize the growth hormone responsiveness in human aging

The function of the growth hormone-insulin-like growth factor I (GH-IGF-I) axis is reduced in aging, although the secretory capacity of somatotrope cells is preserved. Previous studies have suggested that continuous administration of GH-releasing peptides (GHRPs) results in homologous desensitization to the GH-releasing effect of the peptides. In the present study we have studied whether healthy elderly subjects would remain responsive to short-term, intermittent treatment with Hexarelin (HEX), a GHRP, and whether this treatment would result in an increase in serum IGF-I. In study I, the effect of an 8-day treatment with intranasal administration of 1.25 mg (about 18 micrograms/kg) t.i.d. HEX on the acute GH response to the hexapeptide and on serum IGF-I, IGF binding protein 3 (IGFBP-3), prolactin and cortisol levels was studied in seven elderly subjects (four males and three females, aged 67-80 years). In study II, the same parameters were studied before and after a 15-day treatment with oral administration of 20 mg (about 300 micrograms/kg) t.i.d. HEX in seven elderly women (aged 63-80 years). The GH response to the intranasal HEX administration was not significantly higher than that induced by 1 microgram/kg iv GHRH (229.4 +/- 35.9 vs 145.8 +/- 26.9 micrograms.l-1.h-1) and was maintained with a trend towards increase after an 8-day treatment with the peptide (342.5 +/- 199.3 micrograms.l-1.h-1). On the other hand, HEX treatment did not significantly modify IGF-I (138.7 +/- 11.1 vs 122.4 +/- 14.1 micrograms/l) but increased IGFBP-3 levels (2.4 +/- 0.2 vs 1.6 +/- 0.2 mg/l, p < 0.02). The GH response to the oral HEX administration was also not significantly higher than that to iv GHRH (257.6 +/- 72.0 vs 179.0 +/- 42.8 micrograms.l-1.h-1) and did not change after a 15-day treatment with the peptide (237.8 +/- 42.8 micrograms.l-1.h-1). Both IGF-I and IGFBP-3 levels were slightly but significantly increased by oral HEX treatment (156.0 +/- 10.7 vs 141.6 +/- 13.6 micrograms/l, p < 0.03, 3.4 +/- 0.2 vs 3.1 +/- 0.2 mg/l, p < 0.03, respectively). Neither intranasal nor oral HEX treatment modified PRL or cortisol levels and did not induce any side effect. In conclusion, these results indicate that chronic but intermittent treatment with HEX, administered either by intranasal or oral route, does not desensitize the GH response to the peptide. Moreover, after HEX treatment a trend towards increase was shown for IGF-I and IGFBP-3 levels. Thus, our findings strengthen the hypothesis that prolonged treatment with HEX may restore the reduced GH release in aging.

Arterial baroreceptors are not essential for low frequency oscillation of arterial pressure

Cardiovascular parameters exhibit spontaneous oscillations at the respiratory frequency, and in the low frequency range (LF < 0.20 Hz). Although LF is attributed to the sympathetic control, the mechanism responsible for the oscillation, whether instability of the baroreflex loop, or activity of a central nervous system pattern generator, is controversial. To answer this question, time series of arterial blood pressure, heart period and left external iliac blood flow from chloralose-anaesthetised dogs were examined by standard statistics as well as by autoregressive spectral and cross-spectral analysis. The circulation to the left hind-limb was isolated and connected to a constant-pressure perfusing system, to obtain mechanical uncoupling from the central circulation. Three steady-state conditions were studied. A device inserted into the common carotid arteries allowed the carotid sinus region to be in continuity with the animal's arterial system (CONTROL) or perfused at constant pressure by an external source (CAROTID BUFFER); bilateral cervical vagotomy was also performed (VAGI CUT). Intra-individual (beat-to-beat) variability of each parameter was evaluated by standard deviation (SD) of time series in the three conditions. The average SD of heart period was reduced in CAROTID BUFFER and in VAGI CUT; the SDs of arterial pressure and iliac flow were not changed by these interventions. Autospectra of iliac flow time series in CONTROL showed a prominent peak at 0.05 +/- 0.04 Hz (mean +/- SD of all experiments), accounting for 90 +/- 11% of the total variance.(ABSTRACT TRUNCATED AT 250 WORDS)

Growth hormone-releasing activity of growth hormone-releasing peptide-6 is maintained after short-term oral pretreatment with the hexapeptide in normal aging

The reduced activity of the growth hormone (GH)-insulin-like growth factor I (IGF-I) axis in aging may contribute to changes in body composition. As this GH insufficiency is due to hypothalamic pathogenesis, the availability of GH-releasing peptides (GHRPs), such as GHRP-6 (His-D-Trp-Ala-Trp-D-Phe-Lys-NH2) which is active even after oral administration, might be useful to restore it. The aim of our study was to verify the effectiveness of oral administration of GHRP-6 in normal elderly subjects and to investigate whether its GH-releasing activity is maintained or vanishes after short-term oral treatment. Seven normal elderly women (aged 65-82 years) were studied. The effect of oral administration of 300 micrograms/kg GHRP-6 on GH secretion was investigated before and after 4 days of treatment with the hexapeptide given twice daily. The GH response to the maximal effective dose of GHRH (1 microgram/kg i.v.) also was studied. Before treatment, oral administration of 300 micrograms/kg GHRP-6 elicited a clear GH rise (peak 10.7 +/- 3.3 micrograms/l; AUC 353.1 +/- 90.6 micrograms.l-1.h-1), which was significantly higher (p < 0.01) than that induced by intravenous GHRH (peak 5.1 +/- 1.5 micrograms/l; AUC 106.5 +/- 43.9 micrograms.l-1.h-1). After 4 days of treatment with GHRP-6, the GH response to the hexapeptide was maintained, with a trend towards an increase (peak 16.8 +/- 2.9 micrograms/l; AUC 499.8 +/- 107.2 micrograms.l-1.h-1). The IGF-I levels were not increased significantly after treatment (77.1 +/- 8.4 vs 84.1 +/- 12.2 micrograms/l).(ABSTRACT TRUNCATED AT 250 WORDS)

Arginine enhances the growth hormone-releasing activity of a synthetic hexapeptide (GHRP-6) in elderly but not in young subjects after oral administration

In man the GH-releasing hexapeptide His-DTrp-Ala-Trp-DPhe-Lys-NH2 (GHRP-6) has been shown to be active even after oral administration. On the other hand, it has been shown that arginine (ARG) totally restores the reduced somatotropic responsiveness to GHRH observed in aging. Based on the foregoing, in this study we verified the GH-releasing activity of oral GHRP-6 (300 micrograms/kg) in normal aging and the possible enhancing effect of 8 g oral ARG on the GH-releasing effect of GHRP-6. Eight young (age 24-32 yr) and 8 elderly (age 66-85 yr) subjects were studied. In all the GH response to GHRH (1 microgram/kg iv) was also studied. Both IGF-I levels and the GH response to iv GHRH were lower in elderly than in young subjects (mean +/- SE, IGF-I: 65.1 +/- 9.1 vs 142.9 +/- 9.4 micrograms/L, p < 0.0001; GH peak: 5.4 +/- 1.0 vs 13.6 +/- 0.8 micrograms/L, p < 0.0001). Oral GHRP-6 administration induced a GH rise in elderly which was lower, though not significantly, than that in young subjects (GH peak: 9.9 +/- 2.0 vs 16.2 +/- 5.4 micrograms/L). Oral ARG administration enhanced the GHRP-6-induced GH rise in elderly (GH peak: 22.1 +/- 3.3 micrograms/L, p < 0.01 vs GHRP-6 alone) while failed to modify it in young subjects (GH peak: 13.5 +/- 3.4 micrograms/L). The GH response to oral ARG+GHRP-6 in elderly was higher than that to all stimuli in young adults (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Carcinoma of the parathyroid glands. Apropos of a case associated with thyroid struma]

The paper reports a case of carcinoma of the parathyroid associated with thyroid struma and underlines the difficulties of intraoperative diagnosis and the surgical approach which should be adopted on the basis of this finding. Often the diagnosis of the malignant nature of the neoplasia is based on the possible appearance of local or distant recurrence rather than histological examination.

[Treatment of hypopituitarism]

The hipopituitarim's treatment is in want to use the hormonal replacement with corticosteroid and l-tiroxine in all patients. The exogenous gonadotropin or sexual hormones are administrated in both sexes in different way for different ages. The pituitary dwarfism secondary to GH deficiency is now cured with the syntetic GH use. The DDAVP is the drug of choice in the therapy of diabetes insipidus.

[Comparison of MR and CT in a radiological study of Cushing's syndrome. A report on 16 cases]

In 16 patients with high cortisol plasma levels MRI and CT investigation of adrenal gland region was performed; 13 also had the pituitary region examined. CT and MRI results in Cushing's Syndrome due to adrenal glands etiology (8 cases) are overlapping. The morphological criteria utilized consist in the radiological finding of bilateral adrenal hyperplasia or adrenal mass (adenoma, carcinoma). The great amount of retroperitoneal fat increases the normal contrast with both techniques. In the pituitary Cushing's Syndrome MRI was more sensible than CT as far as it concerns ACTH producing pituitary lesion assessment; this technique may show 5 mm diameter adenomas for their high signal intensity.

[Normal human gingiva. In vitro observations]

By comparing human embrional gum fragments cultivated in vitro using the technique of Wolff and Haffen with adult gum fragments, the advantages of the fetal gum are evident; and this could serve as a point of departure for an analysis of the differentiation and the cytophysiology of this structure, which is still not very well known.

[Control of postoperative pain in periodontology]

In periodontal surgery 2 long acting local anaesthetics, Bupivacaine and Etidocaine, have been compared to Mepivacaine and Lidocaine with regard to effect upon the immediate postoperative pain. Both long acting solutions were significantly superior to Lidocaine and Mepivacaine.

Enhancement of cholinergic tone by pyridostigmine promotes both basal and growth hormone (GH)-releasing hormone-induced GH secretion in children of short stature

Increased cholinergic tone induced by pyridostigmine (PD) increases basal plasma GH levels and potentiates the GH response to GHRH in normal adults. In this study the effects of PD (60 mg, orally) on both basal and GHRH (1 microgram/kg)-induced GH secretion in seven children with familial short stature (FSS), six with GH deficiency (GHD) and 10 with constitutional growth delay (CGD) were studied and compared with results obtained by stimulation with insulin-induced hypoglycemia (IH) and GHRH alone. The mean peak plasma GH levels were variable, but individual values were frequently low in all groups after both IH [FSS, 9.7 +/- 1.3 (+/- SEM) ng/mL; GHD, 1.6 +/- 0.4 ng/mL; CGD, 7.0 +/- 0.8 ng/mL] and GHRH (FSS, 23.8 +/- 6.6 ng/mL; GHD, 11.1 +/- 5.8 ng/mL; CGD, 15.1 +/- 4.5 ng/mL) administration. PD induced GH responses (FSS, 14.5 +/- 1.6 ng/mL; GHD, 3.8 +/- 0.8 ng/mL; CGD, 18.3 +/- 3.2 ng/mL) that in many children in the FSS and CGD groups were higher than those after IH and GHRH treatment. PD clearly increased the GH response to GHRH in all children [FSS, 69.5 +/- 9.4 ng/mL (P less than 0.01 vs. other stimuli); GHD, 18.0 +/- 7.5 ng/mL; CGD, 50.0 +/- 8.5 ng/mL (P less than 0.01 vs. other stimuli)]. We conclude that in children with short stature, as in adults, enhancement of cholinergic tone increases both basal and GHRH-induced GH secretion, and that PD plus GHRH is the best provocative stimulus for evaluating the somatotroph response.