Unbound Bilirubin and Auditory Neuropathy Spectrum Disorder in Late Preterm and Term Infants with Severe Jaundice

OBJECTIVE

This study evaluates whether unbound bilirubin is a better predictor of auditory neuropathy spectrum disorder (ANSD) than total serum bilirubin (TSB) or the bilirubin:albumin molar ratio (BAMR) in late preterm and term neonates with severe jaundice (TSB ≥20 mg/dL or TSB that met exchange transfusion criteria).

STUDY DESIGN

Infants ≥34 weeks' gestation with severe jaundice during the first 2 weeks of life were eligible for the prospective observational study. A comprehensive auditory evaluation was performed within 72 hours of peak TSB. ANSD was defined as absent or abnormal auditory brainstem evoked response waveform morphology at 80-decibel click intensity in the presence of normal outer hair cell function. TSB, serum albumin, and unbound bilirubin were measured using the colorimetric, bromocresol green, and modified peroxidase method, respectively.

RESULTS

Five of 44 infants developed ANSD. By logistic regression, peak unbound bilirubin but not peak TSB or peak BAMR was associated with ANSD (OR, 4.6; 95% CI, 1.6-13.5; P = .002). On comparing receiver operating characteristic curves, the area under the curve for unbound bilirubin (0.92) was significantly greater (P = .04) compared with the area under the curve for TSB (0.50) or BAMR (0.62).

CONCLUSIONS

Unbound bilirubin is a more sensitive and specific predictor of ANSD than TSB or BAMR in late preterm and term infants with severe jaundice.

Prevalence of anemia and associations between neonatal iron status, hepcidin, and maternal iron status among neonates born to pregnant adolescents

BACKGROUND

Little is known about anemia and iron status in US newborns because screening for anemia is typically not undertaken until 1 y of age. This study was undertaken to characterize and identify determinants of iron status in newborns born to pregnant adolescents.

METHODS

Pregnant adolescents (≤ 18 y, n = 193) were followed from ≥ 12 wk gestation until delivery. Hemoglobin, ferritin, soluble transferrin receptor, serum iron, hepcidin, erythropoietin (EPO), IL-6, and C-reactive protein were assessed in maternal and cord blood.

RESULTS

At birth, 21% of the neonates were anemic (Hb < 13.0 g/dl) and 25% had low iron stores (ferritin < 76 µg/l). Cord serum ferritin concentrations were not significantly associated with gestational age (GA) at birth across the range of 37-42 wk. Neonates born to mothers with ferritin < 12 µg/l had significantly lower ferritin (P = 0.003) compared to their counterparts. Hepcidin and IL-6 were significantly (P < 0.05) higher in neonates born to mothers with longer durations of active labor.

CONCLUSION

Given the importance of the iron stores at birth on maintenance of iron homeostasis over early infancy, additional screening of iron status at birth is warranted among those born to this high risk obstetric population.

Central auditory processing disorder profile in premature and term infants

OBJECTIVE

The aim of this study is to compare central auditory processing disorder (CAPD) profile between children born prematurely and at term.

METHODS

A retrospective study involving children 7 to 13 years of age who were referred for CAPD evaluation over the past 3 years. Parental reports and medical records were used to collect information. Children with a score ≥ two standard deviations below the mean for at least one ear on at least two different CAPD tests were considered to have CAPD.

RESULTS

A total of 82 children were evaluated for CAPD of which 22 met exclusion criteria, resulting in 60 children with CAPD (15 premature and 45 term). Premature children had higher prevalence of cesarean section delivery and neonatal jaundice compared with term children. Premature children had a higher total number of failed CAPD tests compared with the term children. Among CAPD tests, there was an increased frequency of abnormal Phonemic Synthesis test (PST) and decreased frequency of abnormal Staggered Spondaic Word test (SSW) among premature children compared with term children.

CONCLUSION

Premature children differ in CAPD profile compared with term children. Findings suggest possible etiological differences for CAPD such as jaundice or differential susceptibility of premature children for altered PST and SSW performance when compared with the term children.

Maternal inflammation at delivery affects assessment of maternal iron status

Pregnant adolescents (aged ≤ 18 y, n = 253) were followed from ≥ 12 wk of gestation to delivery to assess longitudinal changes in anemia and iron status and to explore associations between iron status indicators, hepcidin, and inflammatory markers. Hemoglobin, soluble transferrin receptor (sTfR), ferritin, serum iron, erythropoietin (EPO), hepcidin, C-reactive protein, interleukin-6 (IL-6), folate, and vitamin B-12 were measured, and total body iron (TBI) (milligrams per kilogram) was calculated using sTfR and ferritin values. Anemia prevalence increased from trimesters 1 and 2 (3-5%, <28 wk) to trimester 3 (25%, 33.2 ± 3.7 wk, P < 0.0001). The prevalence of iron deficiency (sTfR > 8.5 mg/L) doubled from pregnancy to delivery (7% to 14%, P = 0.04). Ferritin and hepcidin concentrations at delivery may have been elevated as a consequence of inflammation because IL-6 concentrations at delivery were 1.6-fold higher than those obtained at 26.1 ± 3.3 wk of gestation (P < 0.0001), and a positive association was found between IL-6 and both hepcidin and ferritin at delivery (P < 0.01). EPO was consistently correlated with hemoglobin (r = -0.36 and -0.43, P < 0.001), ferritin (r = -0.37 and -0.32, P < 0.0001), sTfR (r = 0.35 and 0.25, P < 0.001), TBI (r = -0.44 and -0.37, P < 0.0001), and serum iron (r = -0.22 and -0.16, P < 0.05) at mid-gestation and at delivery, respectively. EPO alone explained the largest proportion of variance in hemoglobin at 26.0 ± 3.3 wk of gestation (R(2) = 0.13, P = 0.0001, n = 113) and at delivery (R(2) = 0.19, P < 0.0001, n = 192). Pregnant adolescents are at high risk of anemia. EPO is a sensitive indicator of iron status across gestation, is not affected by systemic inflammation, and may better predict risk of anemia at term. The trial was registered at clinicaltrials.gov as NCT01019902.

Auditory neural myelination is associated with early childhood language development in premature infants

BACKGROUND

Auditory neural myelination (ANM) as evaluated by auditory brainstem evoked response (ABR) during the neonatal period has been used as a surrogate outcome for long-term neurodevelopment. The validity of ANM as a surrogate outcome for long-term neurodevelopment has not been well studied.

AIM

Evaluate the association of ABR I-V interpeak latency (IPL), an index of ANM, at 35 week postmenstrual age (PMA) with language outcome at 3 years of age.

DESIGN

Prospective study.

SUBJECTS

24-33 week gestational age (GA) infants were eligible if they did not meet exclusion criteria: craniofacial malformation, chromosomal disorders, deafness, auditory dys-synchrony, TORCH infection, or non-English speaking parents. Infants with malignancy, head injury, encephalopathy, meningitis, blindness, or who died or relocated were also excluded.

OUTCOME MEASURES

ABRs were performed at 35 week PMA using 80 dB nHL and I-V IPL (ms) measured. Auditory Comprehension (AC) and Expressive Communication (EC) were evaluated by a speech-language pathologist at 3 years of age using Preschool Language Scale.

RESULTS

Eighty infants were studied. The mean GA and birth weight of infants were 29.2 weeks and 1336 g, respectively. There was association of worse ear I-V IPL and better ear I-V IPL with AC (Coefficient-5.4, 95% CI: -9.8 to -0.9 and Coefficient-5.5, 95% CI: -10 to-0.9, respectively) and EC (Coefficient-5.6, 95% CI: -9.5 to-1.8 and Coefficient-6.7, 95% CI: -10.6 to-2.7, respectively) after controlling for confounders.

CONCLUSION

The neonatal I-V IPL is a predictor of language development at 3 years of age in preterms.

Fabrication of biocompatible free-standing nanopatterned films for primary neuronal cultures

A novel nanopatterned biocompatible PCL film promotes the growth of primary hippocampal neurons (rendered in blue).

Optimum click rate for neurodevelopmental evaluation using auditory brainstem response in premature infants

OBJECTIVE

To determine the optimal click rate (CR) for neurodevelopmental assessment using auditory brainstem evoked response (ABR) in preterm infants.

STUDY DESIGN

A prospective study was performed in 17 preterm infants at 34 weeks' postmenstrual age. Three separate ABRs were performed a few minutes apart on each subject using three different click rates (CRs): 19.9/s, 29.9/s, and 69.9/s. An ABR response with waves I, III, and V identifiable and measurable was defined as a pass response. The CR associated with the highest frequency of pass responses was considered optimal, or if two CRs were tied for the highest frequency, then the faster of the two CR was deemed best.

RESULTS

The frequency of pass responses for 29.9/s and 19.9/s CR was 100% and was significantly higher compared with 82% frequency with 69.9/s CR. There was no difference in latencies, interpeak latencies, and amplitudes of waves between 19.9/s and 29.9/s CR; however, standard deviations of interpeak latencies were larger with 19.9/s compared with 29.9/s CR.

CONCLUSION

Our data suggest that 29.9/s is the optimal CR for neurodevelopmental assessment using ABR. Because of smallest variance in interpeak latencies, the sample size requirement will be lowest using 29.9/s CR with secondary reduction in cost and time.

Phase III trial of gemcitabine plus docetaxel versus capecitabine plus docetaxel with planned crossover to the alternate single agent in metastatic breast cancer

BACKGROUND

Safety and efficacy of gemcitabine plus docetaxel (GD) and capecitabine plus docetaxel (CD) were compared in patients with metastatic breast cancer, where the alternate crossover monotherapy (GD→C or CD→G) was predetermined.

PATIENTS AND METHODS

Patients were randomly assigned to 3-week cycles of either gemcitabine 1000 mg/m(2) on days 1 and 8 plus docetaxel 75 mg/m(2) on day 1 or capecitabine 1000 mg/m(2) twice daily on days 1-14 plus docetaxel 75 mg/m(2) day 1. Upon progression, patients received crossover monotherapy. Primary end point was time to progression (TtP). Secondary end points evaluated overall response rate (ORR), overall survival (OS), and adverse events (AEs).

RESULTS

Despite over-accrual of 475 patients, the trial matured with only 324 of 385 planned TtP events due to patient discontinuations. Human epidermal growth factor receptor 2 status was not captured in this study. More CD patients (28%) discontinued due to AEs than GD patients (18.0%, P = 0.009). TtP [hazard ratio (HR) = 1.101, 95% confidence interval (CI) 0.885-1.370, P = 0.387] and OS (HR = 1.031, 95% CI 0.830-1.280, P = 0.785) were not significantly different comparing GD and CD. ORR was not statistically different (P = 0.239) comparing GD (72 of 207, 34.8%) and CD (78 of 191, 40.8%). TtP, OS, and ORR were not significantly different comparing crossover groups. GD caused greater fatigue, hepatotoxicity, neutropenia, and thrombocytopenia but not febrile neutropenia; CD caused more hand-foot syndrome, gastrointestinal toxicity, and mucositis.

CONCLUSIONS

GD and CD produced similar efficacy and toxicity profiles consistent with prior clinical experience.

In utero iron status and auditory neural maturation in premature infants as evaluated by auditory brainstem response

OBJECTIVE

To determine whether cord ferritin (CF) concentration, an index of in utero iron status, is associated with auditory neural maturation in premature infants.

STUDY DESIGN

A prospective cohort study was performed to compare auditory neural maturation in infants with latent iron deficiency (CF 11-75 ng/mL) and infants with normal iron status (CF > 75 ng/mL) at birth. Our inclusion criteria were infants of 27-33 weeks gestational age who were admitted to the neonatal intensive care unit between July 2007 and November 2008 within 12 hours after birth and had cord blood collected. Infants with TORCH infections (toxoplasmosis, other infections, rubella, cytomegalovirus infection, and herpes simplex), chromosomal disorders, craniofacial anomalies, culture-proven sepsis, and/or unstable conditions were excluded. CF level was measured using a chemiluminescence immunoassay method. Bilateral monaural auditory brainstem evoked response (ABR) was assessed using 80-dB nHL click stimuli at a repetition rate of 29.9/seconds within 48 hours after birth.

RESULTS

Of the 80 infants studied, 35 had latent iron deficiency. After controlling for confounders, the infants with latent iron deficiency had significantly prolonged absolute wave latencies I, III, and V and decreased frequency of mature ABR waveforms compared with the infants with normal iron status.

CONCLUSION

Premature infants with in utero latent iron deficiency have abnormal auditory neural maturation compared with infants with normal in utero iron status.

Three-Year Follow-Up of Survival and Progression in a Phase II Trial of Gemcitabine Plus Carboplatin (Plus Trastuzumab in HER2+ Patients) in Metastatic Breast Cancer Patients

Background: We have previously reported (Loesch, et al. Clin Breast Cancer, 2008) the efficacy and safety of gemcitabine and carboplatin with or without trastuzumab in patients with metastatic breast cancer. We now report time-to-progression (TTP) and overall survival (OS) after up to 3.5 years of extended follow-up.Patients and Methods: Patients were stratified into 3 groups at registration; Group 1: HER2 positive (+) regardless of prior taxane; Group 2: HER2 negative (–) and taxane naïve or remote (no taxanes within the past 2 years); and Group 3: HER2– and taxane pretreated. Women ≥18 years of age, with ECOG performance status 0-2, with RECIST-defined measurable disease, and either HER2– or HER2+ (3+ score) by immunohistochemistry or fluorescence in situ hybridization were enrolled. Treatment: Day 1 gemcitabine 1500 mg/m2 over 30 minutes followed by carboplatin AUC=2.5 repeated every 14 days up to Cycle 9. Group 1 also received trastuzumab 8 mg/kg in Cycle 1 followed by 4 mg/kg in Cycles 2-9, followed thereafter by 6 mg/kg every 21 days until progression or intolerable toxicity.Results: A total of 150 patients were registered (50, 51, and 49 in Groups 1, 2, and 3, respectively). Median follow-up for surviving patients, calculated from registration, was 31.3, 27.1, and 25.4 months, respectively. Median TTP (calculated as progression-free survival), was 7.2, 5.6, and 4.6 months, respectively. Median OS (range) has not been reached for Group 1 (range, 1.2-46.9); for Group 2 was 21.7 months (&lt;1-44.3); and, for Group 3 was 11.9 months (&lt;1-33.6). At 24-months, survival rates were 73.3%, 41.4%, and 20.5%, respectively; at 36-months, survival rates were 60.6%, 25.7%, and ≤8.3%, respectively. For Group 1 only, the remaining 3 responding patients were followed for 3.5 years, at which time they were relapse-free.Conclusions: Gemcitabine plus carboplatin with or without trastuzumab has been shown to be highly active in metastatic breast cancer. HER2+ patients receiving trastuzumab had the highest TTP and survival rates of all treatment groups. As expected, taxane-pretreated patients had shortened TTP and decreased OS rates compared to taxane-naïve patients.Research support was provided, in part, by Lilly USA, LLC; Indianapolis, IN.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2105.

A phase III study comparing concurrent gemcitabine (Gem) plus cisplatin (Cis) and radiation followed by adjuvant Gem plus Cis versus concurrent Cis and radiation in patients with stage IIB to IVA carcinoma of the cervix

CRA5507

Background: Cervical cancer is the second-most common cancer among women worldwide, in both incidence and mortality. Current standard therapy for locally advanced disease consists of concurrent Cis and external-beam radiation (XRT). This multicenter, open-label, randomized, phase III trial aimed to improve outcomes, capitalizing on the synergistic activity of Gem, Cis, XRT, and the potential value of adjuvant therapy. Methods: Eligible patients (pts) with bulky stage IIB to IVA, 18–70 years of age, chemotherapy- and radiotherapy-naive, with a Karnofsky Performance Status score ≥70, were randomized to Arm A: Cis 40 mg/m2 followed by Gem 125 mg/m2 weekly × 6 doses with concurrent XRT (50.4 Gy: in 28 fractions: 1.8 Gy/day, 5 days/week), followed by brachytherapy (brachy) (30–35 Gy) and then 2 adjuvant 21-day cycles of Gem (1,000 mg/m2 on Days 1 and 8) plus Cis (50 mg/m2 on Day 1); or Arm B: Cis 40 mg/m2 weekly × 6 doses with concurrent XRT followed by brachy, given as in Arm A. Primary endpoint was progression-free survival (PFS) at 3 years, compared between arms using Kaplan-Meier methods and a Z-statistic. Results: 515 pts were enrolled between 5/02 and 3/04 (259 pts Arm A, 256 pts Arm B). Median age was 46 years; stage IIB/IIIB/IVA in 61/37/2% of pts. Compliance in the concurrent and brachy phase was >90% for both arms; adjuvant cycles were completed by >75% of pts in Arm A. PFS at 3 years was 74% in Arm A compared to 65% in Arm B, resulting in a statistically significant improvement (p = 0.029). Overall survival (log-rank p = 0.0224) and time to progressive disease (log-rank p = 0.0008) were also significantly improved. Significantly more pts in Arm A experienced grade 3/4 toxicities (86.5%), compared to pts in Arm B (46.3%; Fisher's p < 0.001). In Arm A, 2 pts died due to causes probably related to treatment compared to 0 pts in Arm B. Conclusions: This novel regimen of concurrent Gem plus Cis and XRT followed by brachy and adjuvant Gem plus Cis significantly improved outcomes in pts with locally advanced carcinoma of the cervix, at the expense of increased but acceptable toxicity, compared to the current standard of care.

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Combined modality treatment for organ preservation in patients with invasive bladder cancer

e16129

Purpose: To evaluate long term results of chemoradiation and organ preservation in invasive T2-T4a bladder carcinoma in a single institution with prolonged follow up. Methods: Sixty one patients with clinical stage II and III (T3N0) muscle invasive bladder carcinoma were treated between February 1991 and December 2007. Forty four received sequential treatment (chemo followed by radiation) and seventeen concurrent treatments. Chemotherapy was platinum based in all patients, fifth teen with Carboplatin. All underwent maximal citoreduction with TUR .First 20 patients received pelvic radiation (1991–1993),while the other 41 three-dimensional radiotherapy (median dose 60 Gy). Male/female 55/6: median age 64 (range 46–80); transitional type 58 and mixed-epidermoid 6. Grade II: 3, grade III: 48 and grade IV: 10. Clinical stage II:50 and III:11. Mean follow up 63 months. Results: The 5 year overall survival rate was 57%. Forty patients remained NED, with eight deaths due to second primary or cardiovascular disease. Twenty pts were treated more than 5 years ago, 16(80%) are alive, 14 NED,2 pts relapsed after 5 years. Of all predictive factors analyzed only clinical stage reached statistical significance for relapse (p=0.0029), and borderline significance for overall survival (p=0.064). Toxicity: Grade 3–4: 7%, with 3% of febrile neutropenia. No patient required cystectomy because of bladder morbidity. Conclusions: Trimodality treatment in selected patients offers rates of event free survival and overall survival similar to those reported for surgery with acceptable toxicity and no treatment related cystectomy. Relapse after 5 year is very uncommon. In this small group of patient results were similar with concurrent and sequential treatment. At present we treat our patients with concurrent chemoradiation with tridimensional technique.

No significant financial relationships to disclose.

A phase III study comparing concurrent gemcitabine (Gem) plus cisplatin (Cis) and radiation followed by adjuvant Gem plus Cis versus concurrent Cis and radiation in patients with stage IIB to IVA carcinoma of the cervix

CRA5507

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

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