Pain identifies squamous cell carcinoma in organ transplant recipients: the SCOPE-ITSCC PAIN study

Organ transplant recipients (OTR) are at high risk for cutaneous squamous cell carcinomas (SCC). We aimed to define clinically meaningful patient-reported warning signals predicting the presence of invasive SCC.Patient-reported signs and symptoms of 812 consecutively biopsied skin lesions from 410 OTR were determined by questionnaire and physical examination and related to the subsequent biopsy-proven diagnoses. Receiver-operating characteristic (ROC) curve analyses were used as a measure of distinction between the predictive values of patient-reported warning signals and the occurrence of SCC. Pain was an independent predictive patient-reported warning signal for a biopsy-proven invasive SCC. The odds ratio from the fully adjusted model predicting SCC was 4.4(95% confidence interval: 2.4–8.2). Higher scores on the visual analog scale (VAS) for pain were associated witha greater likelihood for the presence of SCC compared to none or mild pain. The for scores on the VAS from 1to 3, 4 to 6 and 7 to 10 were 4.9 (2.2–10.5), 2.3 (0.96–5.5)and 16.5 (3.6–75.8), respectively. Pain is the most powerful patient-reported warning signal for invasive cutaneous SCC in OTR. Empowerment of patients by education could accelerate diagnosis and treatment of cutaneous SCC.

Abstract P4-12-08: Final efficacy results from a single-arm multicenter phase II study evaluating first-line trastuzumab, bevacizumab, and capecitabine (HAX) therapy for HER2-positive locally recurrent/metastatic breast cancer (LR/mBC)

Background: After median follow-up of 8.8 months, the primary efficacy results from the HAX study [Martín et al., Oncologist 2012] demonstrated a 73% overall response rate (ORR) according to RECIST (primary endpoint), median progression-free survival (PFS) of 14.4 months and a safety profile typical of the component agents; overall survival (OS) data were immature at that time. We present final efficacy results.

Methods: Patients with measurable HER2-positive LR/mBC who had received no prior chemotherapy for LR/mBC received bevacizumab 15 mg/kg day 1, trastuzumab 6 mg/kg day 1 (8 mg/kg loading dose in cycle 1), and capecitabine 1000 mg/m2 bid days 1–14, repeated every 3 weeks until progression, unacceptable toxicity, or withdrawal of consent.

Results: At the time of data cut-off, median follow-up was 31.8 months (range 1.2–44.5 months). Median duration of study therapy was 9.0, 9.4, and 10.3 months for bevacizumab, capecitabine, and trastuzumab, respectively. More than 8 cycles were administered in 67%, 65%, and 70%, respectively. Efficacy results in the intent-to-treat population (n = 88) and clinically important subgroups are shown below.

Patient subgroupBest ORR,% (95% CI)PFS events, n (%)Median PFS, months (95% CI)Deaths, n (%)Median OS, months (95% CI)1-year OS rate,% (95% CI)All patients (n = 88)75 (65-84)70 (80)14.2 (10.5-14.9)40 (45)31.8 (26.3-38.2)94 (86-98)ER and/or PgR positive (n = 37)73 (56-86)32 (86)14.1 (8.5-17.0)19 (51)31.8 (24.4-42.6)100 (*-*)ER and PgR negative (n = 51)77 (63-87)38 (75)14.5 (10.5-18.9)21 (41)33.1 (23.6-44.5)90 (77-96)No prior chemotherapy (n = 37)81 (65-92)27 (73)14.9 (10.5-24.8)14 (38)31.8 (26.3-44.4)94 (80-99)Prior chemotherapy (n = 51)71 (56-83)43 (84)13.6 (8.5-14.8)26 (51)30.9 (24.3-42.1)94 (82-98)Taxane pretreated (n = 28)57 (37-76)26 (93)9.5 (5.2-14.0)17 (61)27.4 (21.4-33.2)93 (74-98)Prior anti-HER2 therapy (n = 22)73 (50-89)18 (82)12.1 (5.2-17.0)11 (50)30.9 (24.3-*)95 (72-99)Age >60 years (n = 25)72 (51-88)16 (64)14.2 (10.5-21.7)11 (44)33.2 (22.0-*)100 (*-*)*Not reached

The most common grade ≥3 adverse events were hand-foot syndrome (26% of patients), diarrhea (11%), and hypertension (11%). The majority of deaths (38/40) were from progressive/underlying disease. The cause of the two remaining deaths was described as unknown; one was reported at the primary analysis and the other occurred 19 months after last study drug administration, following progression. Detailed long-term safety results will be presented.

Conclusion: Long-term follow-up results from the HAX study show that this is an active and tolerable first-line triplet therapy for HER2-positive mBC, demonstrating median OS of 31.8 months.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-08.

Preventing congenital syphilis - a regional audit of syphilis in pregnant women seen in Genitourinary Medicine services

Genitourinary case records of 42 pregnant women with syphilis were reviewed as part of a regional audit following the re-emergence of congenital syphilis in the north east of England. National standards, from the British Association of Sexual Health and HIV guidelines on managing syphilis in pregnancy, were met in the majority of cases with 69% being treated according to national guidance and all cases completing treatment. Locally developed standards on multidisciplinary working and communication were met less well, with particular issues regarding the documentation of pregnancy outcomes in GUM records and communication between specialities being highlighted. A regional good practice guide has been developed and implemented to address standards not met, reduce adverse outcomes and prevent future cases of congenital syphilis.

A surveillance model for skin cancer in organ transplant recipients: a 22-year prospective study in an ethnically diverse population

Skin cancer is a frequent complication of organ transplantation. Current guidelines advise specialist skin surveillance but there are limited data on how these should be implemented. This study determines overall burden of cancer and relevant intervals for strategic surveillance in an ethnically diverse transplant population. Prospective data on time to first and subsequent cancers and cumulative burden with respect to defined risk factors were analyzed in a cohort of 1010 patients in a UK center over 22 years. Among 931 individuals transplanted >6 months (mean 10.3 years), 1820 skin cancers occurred in 267 (29%) individuals and were multiple in 66%. Cumulative incidence at 5, 10, 20 and 30 years was 11%, 25%, 54% and 74%, with median time to second, third and fourth cancers of 24, 14.7 and 8.4 months, respectively. Tumors were overwhelmingly squamous and basal cell carcinomas (73% and 24%, respectively). Skin phototype, ultraviolet radiation exposure, age at transplant and duration of transplant were significant risk predictors and were used to construct clinically relevant surveillance intervals. This study provides a comprehensive, prospective analysis of skin cancer morbidity and risk in an ethnically diverse transplant population from which we derive an evidence-based skin cancer surveillance program.

Abstract OT1-1-02: A single-arm phase IIIb study of pertuzumab and trastuzumab with a taxane as first-line therapy for patients with HER2-positive advanced breast cancer (PERUSE)

Background: Pertuzumab (P), a humanized monoclonal antibody, inhibits signaling downstream of HER2 by binding to the dimerization domain of the receptor and preventing heterodimerization with other HER family members. The epitope recognized by P is distinct from that bound by trastuzumab (H) and so their complementary mechanisms of action result in a more comprehensive HER2 blockade. Data from the phase III trial CLEOPATRA showed significantly improved PFS in patients (pts) receiving P + H + docetaxel compared with H + docetaxel + placebo as first-line treatment for HER2-positive metastatic breast cancer (BC).

Trial design: PERUSE is a phase IIIb, multicenter, open-label, single-arm study in pts with HER2-positive metastatic or locally recurrent BC who have not been treated with systemic nonhormonal anticancer therapy for metastatic cancer. Pts will receive, P: 840 mg initial dose, 420 mg q3w IV; H: 8 mg/kg initial dose, 6 mg/kg q3w IV; taxane: docetaxel, paclitaxel, or nab-paclitaxel according to local guidelines. Treatment will be administered until disease progression or unacceptable toxicity. A planned protocol amendment will allow hormone receptor-positive pts to receive endocrine therapy alongside P+H after completion of taxane therapy, in line with clinical practice.

Eligibility criteria: At baseline, pts must have an LVEF of ≥50%, an ECOG PS of 0, 1, or 2, a disease-free interval of ≥6 months, and must not have received prior anti-HER2 agents for the treatment of metastatic BC. Prior H and/or lapatinib in the (neo)adjuvant setting is permitted, providing there was no disease progression during treatment. Pts must not have experienced other malignancies within the last 5 yrs other than carcinoma in situ of the cervix or basal cell carcinoma. There must be no clinical or radiographic evidence of CNS metastases or clinically significant cardiovascular disease.

Specific aims: As H was not widely available in the (neo)adjuvant setting prior to CLEOPATRA recruitment, a relatively low proportion of pts in CLEOPATRA had previously received H. PERUSE will assess the safety and tolerability of P+H + choice of taxane as first-line therapy for pts with HER2-positive metastatic or locally advanced BC in a pt population likely to have experienced wider exposure to prior H therapy.

Statistical methods: The primary endpoints of the PERUSE study are safety and tolerability. Secondary endpoints include PFS, OS, ORR, CBR, duration of response, time to response and QoL. The final analysis will be performed when 1500 pts have been followed up for at least 12 months after the last pt receives last study treatment unless they have been lost to follow-up, withdrawn consent, or died, or if the study is prematurely terminated by the sponsor. Safety analyses are planned after enrollment of ∼350, 700, and 1000 pts. Additionally, a data and safety monitoring board will review safety data after ∼50 pts have been enrolled and then every 6 months.

Current and target accrual: Enrollment of the first pt is expected in June 2012 with a total of 1500 pts planned to be recruited.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT1-1-02.

Exploiting parallel R in the cloud with SPRINT

BACKGROUND

Advances in DNA Microarray devices and next-generation massively parallel DNA sequencing platforms have led to an exponential growth in data availability but the arising opportunities require adequate computing resources. High Performance Computing (HPC) in the Cloud offers an affordable way of meeting this need.

OBJECTIVES

Bioconductor, a popular tool for high-throughput genomic data analysis, is distributed as add-on modules for the R statistical programming language but R has no native capabilities for exploiting multi-processor architectures. SPRINT is an R package that enables easy access to HPC for genomics researchers. This paper investigates: setting up and running SPRINT-enabled genomic analyses on Amazon's Elastic Compute Cloud (EC2), the advantages of submitting applications to EC2 from different parts of the world and, if resource underutilization can improve application performance.

METHODS

The SPRINT parallel implementations of correlation, permutation testing, partitioning around medoids and the multi-purpose papply have been benchmarked on data sets of various size on Amazon EC2. Jobs have been submitted from both the UK and Thailand to investigate monetary differences.

RESULTS

It is possible to obtain good, scalable performance but the level of improvement is dependent upon the nature of the algorithm. Resource underutilization can further improve the time to result. End-user's location impacts on costs due to factors such as local taxation.

CONCLUSIONS

Although not designed to satisfy HPC requirements, Amazon EC2 and cloud computing in general provides an interesting alternative and provides new possibilities for smaller organisations with limited funds.

Accelerating cardiac bidomain simulations using graphics processing units

Anatomically realistic and biophysically detailed multiscale computer models of the heart are playing an increasingly important role in advancing our understanding of integrated cardiac function in health and disease. Such detailed simulations, however, are computationally vastly demanding, which is a limiting factor for a wider adoption of in-silico modeling. While current trends in high-performance computing (HPC) hardware promise to alleviate this problem, exploiting the potential of such architectures remains challenging since strongly scalable algorithms are necessitated to reduce execution times. Alternatively, acceleration technologies such as graphics processing units (GPUs) are being considered. While the potential of GPUs has been demonstrated in various applications, benefits in the context of bidomain simulations where large sparse linear systems have to be solved in parallel with advanced numerical techniques are less clear. In this study, the feasibility of multi-GPU bidomain simulations is demonstrated by running strong scalability benchmarks using a state-of-the-art model of rabbit ventricles. The model is spatially discretized using the finite element methods (FEM) on fully unstructured grids. The GPU code is directly derived from a large pre-existing code, the Cardiac Arrhythmia Research Package (CARP), with very minor perturbation of the code base. Overall, bidomain simulations were sped up by a factor of 11.8 to 16.3 in benchmarks running on 6-20 GPUs compared to the same number of CPU cores. To match the fastest GPU simulation which engaged 20 GPUs, 476 CPU cores were required on a national supercomputing facility.

Dynamic respiratory endoscopy of Standardbred racehorses during qualifying races

REASON FOR PERFORMING STUDY

Examination of the equine upper airway during racing has not previously been documented.

OBJECTIVE

To describe the feasibility and appearance of the upper airways by overground respiratory endoscopic examination during racing conditions.

METHODS

Overground videoendoscopic examinations were performed on 46 Standardbred racehorses during qualifying races. Examined horses' speeds were recorded throughout the race with a portable GPS device.

RESULTS

The procedure did not interfere with performance as there were no significant differences in race times between races in which horses were examined with the endoscope in place and prior unexamined races. Airway obstructions during or after the race were documented in 21 horses. Most previously reported causes of upper airway obstruction were observed; surprisingly bilateral ventro-medial arytenoid displacement (VMAD; n = 5) was seen during exercise as frequently as dorsal displacement of the soft palate (DDSP). Although DDSP (n = 10) was the most common diagnosis made, many displacements (n = 5) occurred after the race. Horses that demonstrated DDSP after the race had slower speeds than unaffected horses during the race.

CONCLUSIONS

Racing endoscopy permits the diagnosis of upper airway obstructions without affecting performance. The occurrence of DDSP immediately after exercise may be clinically relevant. During racing VMAD may be an important anomaly.

POTENTIAL RELEVANCE

Racing endoscopy could be used to correlate the sensitivity of diagnostic endoscopy during race-training or treadmill examination. The pathogenesis and significance of VMAD deserves further investigation.

An audit highlighting a lack of awareness of the UK national guidelines for HIV testing, 2008

Following the publication of the UK national guidelines for HIV testing 2008, we carried out a local audit to determine the level of awareness of these guidelines among doctors working in Sunderland Royal Hospital, Sunderland, UK. An email questionnaire was distributed. Over two-thirds of respondents were unaware of the publication of the guidelines. Only 36% of respondents felt comfortable in offering a patient testing for HIV. The majority of doctors who responded lacked knowledge and confidence in issues surrounding HIV management and diagnosis, suggesting that better dissemination of information and training is still needed.

Effects of nanomaterials on luciferase with significant protection and increased enzyme activity observed for zinc oxide nanomaterials

This principle goal of this research was to examine the effects of various nanomaterials on the activity and behavior of the firefly enzyme luciferase. Nanomaterials have been found to stabilize, and in some instances, shown to increase the activity of enzymes. In this study gold, manganese oxide (MnO), and zinc oxide (ZnO) nanomaterials were utilized in order to test their effects on enzyme activity. Luciferase was used because its activity is easy to analyze, as it typically produces a large amount of bioluminescence easily detected by a Microtiter plate reader. Following incubation with the various nanomaterials, luciferase was subjected to degradation by several protein denaturing agents, such as heat, SDS, urea, ethanol, protease, hydrogen peroxide, and pH changes. Results indicated that luciferase activity is indeed affected when combined with nanomaterials, accompanied by both increases and decreases in enzyme activity depending on the type of nanomaterial and denaturing agent used. In most of the experiments, when incubated with ZnO nanomaterials, luciferase depicted significant increases in activity and bioluminescence. Additional experiments, in which human A375 cells were treated with luciferase-nanomaterial mixtures, also depicted increased enzyme activity and bioluminescence for luciferase incubated with ZnO nanomaterials. Ultimately, our findings indicated that when luciferase was subjected to multiple types of denaturation, zinc oxide nanomaterials dramatically preserved and increased enzyme activity and bioluminescence.

Screening for alcohol use disorders in a genitourinary medicine setting

The new National Institute for Health and Clinical Excellence (NICE) guidance cites genitourinary (GU) medicine clinics as one setting where screening for alcohol-use disorders should be part of routine clinical practice. Northumberland GU medicine service has routinely used the Fast Alcohol Screening Tool (FAST) since June 2009. An audit of all first attendees to the service in April 2010 (n = 256) was carried out. This audit found that the FAST questionnaire was acceptable to both patients and staff (uptake of 95.7%). Statistically significant associations between excessive alcohol and higher rates of unprotected sex (P < 0.01), an increased number of sexual partners (P < 0.01) and higher rates of sexually transmitted infection (STI) diagnosis (P < 0.05) were also demonstrated.

Trichomonas vaginalis: an unusual presentation

We report a case of Trichomonas vaginalis (TV) presenting as vulval ulceration in a 41-year-old woman. There was complete resolution of her symptoms only after oral tinidazole. The delayed diagnosis and importance of using the correct tests for the diagnosis of TV are discussed.

Population pharmacokinetics of enoxaparin in infants, children and adolescents during secondary thromboembolic prophylaxis: a cohort study

BACKGROUND

Enoxaparin has been extensively studied in adults on its safety and efficacy during prevention of symptomatic thromboembolism when acute anticoagulation or secondary prevention is required as a result of venous thrombosis or stroke. In children, it is still used off-label and little is known about the pharmacokinetics in children.

OBJECTIVES

The aim of the present study was to evaluate whether a once- or twice-daily dosing regimen would be feasible in children to achieve appropriate plasma levels of enoxaparin.

PATIENTS/METHODS

A population pharmacokinetic model was developed using anti-factor (F)Xa activity data from 126 children (median age: 5.9 years) receiving enoxaparin either as a once- or twice-daily dosing regimen.

RESULTS

A two-compartment model was adequate for describing the enoxaparin kinetics. Body weight proved to be the most predictive covariate for clearance and central volume of distribution: clearance 15 mL h⁻¹ kg⁻¹, central volume of distribution 169 mL kg⁻¹, intercompartmental clearance 58 mL h⁻¹, peripheral volume of distribution 10 L and absorption rate 0.414 h⁻¹. Interindividual variability was found to be 54% for clearance and 42% for volume of distribution.

CONCLUSION

The model is capable of describing all age groups and dosing levels of our population and predicts 12 h and 24 h enoxaparin activities sufficiently. According to our results, a once-daily enoxaparin dosing regimen with frequent monitoring is feasible. In 53.2% of the patients the median 24 h trough level was above the desired range of 0.1 IU mL⁻¹ anti-FXa activity for prophylaxis therapy.

322. PROTEOMIC AND FUNCTIONAL ANALYSIS OF HUMAN SPERM DETERGENT RESISTANT MEMBRANES

Mammalian spermatozoa attain the ability to fertilize an oocyte as they negotiate the female reproductive tract. This acquisition of functional competence is preceded by an intricate cascade of biochemical and functional changes collectively known as ‘capacitation’. Among the universal correlates of the capacitation process is a remarkable remodeling of the lipid and protein architecture of the sperm plasma membrane. While the fundamental mechanisms that underpin this dynamic reorganization remain enigmatic, emerging evidence has raised the prospect that it may be coordinated, at least in part, by specialized membrane microdomains, or rafts. In the studies described herein we have demonstrated that human spermatozoa express recognized markers of membrane rafts. Further, upon depletion of cellular cholesterol through either physiological (capacitation) or pharmacological (methyl-β-cyclodextrin) intervention, these membrane rafts appear to undergo a polarized redistribution to the peri-acrosomal region sperm head. The polarized targeting of membrane rafts to the sperm head encourages speculation that they represent platforms for the organization of proteins involved in sperm-oocyte interactions. Support for this notion rests with the demonstration that membrane rafts isolated on the basis of their biochemical composition in the form of detergent resistant membranes (DRMs), possess the ability to adhere to homologous zona pellucida. Furthermore a comprehensive proteomic analysis of the DRMs identified a number of proteins known for their affinity for the zona pellucida in addition to other candidates putatively involved in the mediation of downstream binding and/or fusion with the oolemma. Collectively these data afford novel insights into the sub-cellular localization and potential functions of membrane rafts in human spermatozoa.