Ramucirumab combined with FOLFOX as front-line therapy for advanced esophageal, gastroesophageal junction, or gastric adenocarcinoma: a randomized, double-blind, multicenter Phase II trial

BACKGROUND

We report the first randomized, Phase II trial of ramucirumab, an anti-vascular endothelial growth factor receptor-2 monoclonal antibody, as front-line therapy in patients with advanced adenocarcinoma of the esophagus or gastric/gastroesophageal junction (GEJ).

PATIENTS AND METHODS

Patients from the USA with advanced esophageal, gastric, or GEJ adenocarcinoma randomly received (1:1) mFOLFOX6 plus ramucirumab (8 mg/kg) or mFOLFOX6 plus placebo every 2 weeks. The primary end point was progression-free survival (PFS) with 80% power to detect a hazard ratio (HR) of 0.71 (one-sided α = 0.15). Secondary end points included evaluation of response and overall survival (OS); an exploratory ramucirumab exposure-response analysis was undertaken.

RESULTS

Of 168 randomized patients, 52% of tumors were located in the stomach/GEJ and 48% in the esophagus. The trial did not meet the primary end point of PFS [6.4 versus 6.7 months, HR 0.98 (95% confidence interval 0.69-1.37)] or the secondary end point of OS (11.7 versus 11.5 months) in the intent-to-treat (ITT) population. Objective response rates (45.2% versus 46.4%) were similar between arms. Most Grade ≥3 toxicities did not differ significantly between arms, yet premature discontinuation of FOLFOX and ramucirumab (for reasons other than progressive disease) was more common among ramucirumab- versus placebo-treated patients. In an exploratory analysis that censored for premature discontinuation, the HR for PFS favored the ramucirumab arm (HR 0.76), particularly in patients with gastric/GEJ cancer. An exploratory exposure-response analysis indicated that patients with higher ramucirumab exposure had longer OS.

CONCLUSION

The addition of ramucirumab to front-line mFOLFOX6 did not improve PFS in the ITT population.

CLINICALTRIALSGOV IDENTIFIER

NCT01246960.

184 PRELIMINARY FINDINGS ON CARBOHYDRATE METABOLISM OF INTACT EQUINE CUMULUS-OOCYTE COMPLEXES DURING IN VITRO MATURATION

Production of equine embryos in vitro is gaining popularity, and many differences exist in composition of in vitro maturation (IVM) media. Metabolism of the cumulus-oocyte complex (COC) is essentially unknown in the horse. Here, we describe preliminary data on carbohydrate metabolism of the equine COC during IVM. COC, collected by scraping of the granulosa layer of all visible follicles of abattoir-derived ovaries, were held overnight (12–18 h) at room temperature (~20°C) and then placed in Maturation Medium (M199 with Earle’s salts, 10% FBS, with 25 μg mL–1 gentamicin and 5 mU mL–1 FSH). They were incubated singly in 10-μL droplets under mineral oil for 30 h at 38.3°C in 5% CO2 in air. Control droplets without COC were incubated in the same dish. After incubation, COC were removed and spent media kept at –80°C for later analysis. Oocytes were denuded of cumulus cells by pipetting in the presence of hyaluronidase and evaluated by light microscopy at 500×. Those with a visible polar body were classified as metaphase II (MII); oocytes with an intact oolemma and no polar body were classified as immature intact (INT) and those with an irregular or unapparent oolemma, or shrunken cytoplasm, were classed as degenerating (DEG). To adjust for variation in cumulus cell number, the stripped cumulus cells were frozen at –20°C and later analysed for DNA content using Picogreene. The spent media was analysed for depletion of glucose and appearance of lactate on a BMG Fluostar spectrophotometer using an enzyme-linked ultrafluorometric method. Data were expressed as pmol/ng DNA/hr and analysed by t-test, x2 and logistic regression. Thirty COC were cultured and analysed; 14 were classified as MII, 2 INT and 14 DEG. Seven COC (23%) depleted all the available glucose, indicating that the rate of glucose consumption in those 7 complexes was ≥1866 pmol/COC per hour. DNA content was positively correlated with glucose depletion (P = 0.02). In the COC that did not deplete available glucose, the ratio of glucose consumption:lactate production was 1.82, indicating that the major fate of exogenous glucose was production of lactate by glycolysis. In the 7 oocytes that depleted all the glucose, the ratio of glucose consumption:lactate production was 1.22. One explanation for this may be that when glucose was no longer available, it was conserved for other pathways. It was noteworthy that these COC had more cumulus cells (P < 0.01) and the maturation rate was 4/7 (57%). In the group of COC that did not deplete all of the glucose, there was no significant difference in glucose consumption (13.17 v. 12.25 pmol/ng DNA per hour; P > 0.4) or lactate production (21.48 v. 20.28 pmol/ng DNA per hour; P > 0.4) between COC in which the oocyte reached MII (10/23; 43%), and those which contained a degenerated oocyte at the end of culture, respectively. To the best of our knowledge, this is the first report documenting the metabolism of equine COC. These data underline the importance of further studies to determine optimal conditions for in vitro maturation of equine COC, especially in terms of glucose availability.

An Epizootiological Report of the Re-emergence and Spread of a Lineage of Virulent Newcastle Disease Virus into Eastern Europe

A number of contemporary outbreaks of Newcastle disease (ND) in Israel, Turkey, Georgia and Bulgaria have all been caused by a very similar viruses related to lineage 5a (genotype VIIa). Comparison with published ND virus (NDV) sequences suggests that this virus strain originated in South-East Asia and on introduction has circulated widely in backyard poultry in the Middle East and into Eastern Europe. An intracerebral pathogenicity index of 1.9 was obtained for a representative isolate from Bulgaria. In addition, the International Reference Laboratory for ND has characterized a molecular epidemiologically linked virus that has been reported to have caused disease in well-vaccinated broiler chickens in Pakistan. In the 1990s, another strain from the 5a lineage NDV was introduced into Europe and spread across the continent causing numerous outbreaks up to 1999. Despite improved controls, including good diagnostic tests and widespread vaccination, in commercial poultry, the novel circulating NDV strains described here have been established widely in the region and represent an increased risk for similar disease outbreak events to reoccur within the EU.

Assessment of Effectiveness of Control Strategies Against Simulated Outbreaks of Highly Pathogenic Avian Influenza in Ontario, Canada

The North American Animal Disease Spread Model (NAADSM) is a stochastic model framework developed to simulate the spread of highly contagious diseases of livestock and poultry, such as foot-and-mouth disease and highly pathogenic avian influenza (HPAI). The objective of this study was to make recommendations on the most effective HPAI control policy for Canada, specifically, on the effect of different speeds of detection, effectiveness of movement restrictions and stamping-out and ring-culling strategies on the magnitude of an HPAI outbreak. In addition, the effect of introduction of infection in a range of multiple farms simultaneously was also evaluated. A total of 21 060 scenarios, defined as different combinations of parameters for various epidemiological conditions and control measures, were created to simulate the number of poultry flocks that would become infected as a result of an incursion of HPAI. Each scenario was parameterized in NAADSM and replicated 1000 times, generating the median number of flocks infected at the end of the simulated outbreak for each scenario. Negative binomial regression analysis was used to model significant explanatory variables of the median number of flocks infected at the end of each simulated outbreak for each of the 21 060 scenarios. The final model included the following explanatory variables: number and type initially infected flock(s), density of flocks within the county where the initially infected flock(s) was located, probability of transmission through indirect contact, subclinical spread of the infection, speed of detection and a two-way interaction between intensity of bird destruction strategy and movement restriction effectiveness to reduce transmission through direct and indirect contacts. The modelling results suggested that stamping out of the detected infected flocks, without ring culling, in combination with effective movement restrictions on direct and indirect contacts, would be the most appropriate policy for Ontario.

Colonisation of dentures by Staphylococcus aureus and MRSA in out-patient and in-patient populations

Methicillin-resistant Staphylococcus aureus (MRSA) is an important human pathogen, and colonisation with this organism can result in localised or systemic infections which may be fatal. One hundred in-patients admitted to a London teaching hospital and 100 out-patients attending prosthetic dentistry clinics were recruited into this study. Of the 100 out-patients, 27 % harboured S. aureus on their dentures, compared to 33 % of in-patients. Only one out-patient had MRSA colonising their dentures whereas 12 % of the in-patients harboured MRSA. The median total bacterial count of the denture plaque samples was 6.2 × 10(7) cfu/sample and 6.9 × 10(7) cfu/sample for the out-patient and in-patient populations, respectively. In most instances, where present, S. aureus comprised less than 1 % of the total viable denture microbiota. Phage typing demonstrated that EMRSA-15 and non-typeable strains were harboured on dentures. The results of this study have revealed that dentures are a potential reservoir of MRSA and so account should be taken of these findings when planning decontamination procedures for elimination of this pathogen.

Use of complementary markers in assessing glycaemic control in people with diabetic kidney disease undergoing iron or erythropoietin treatment

AIMS

HbA(1c) values are unreliable in patients with diabetes who have chronic kidney disease who receive iron and/or erythropoiesis stimulating agents. The study aimed to evaluate the utility of the complementary glycaemic markers glycated albumin, fructosamine and 1,5 anhydroglucitol in this group of patients.

METHODS

A prospective study of patients with Type 2 diabetes and chronic kidney disease stage IIIB/IV undergoing intravenous iron or erythropoiesis-stimulating agent therapy. Glycaemic control was monitored using HbA(1c), seven-point daily glucose thrice weekly, continuous glucose monitoring, glycated albumin, fructosamine and 1,5 anhydroglucitol.

RESULTS

Fifteen patients [9 men; median age 72 years (interquartile range 68-74), follow-up period (16.4 ± 3.7 weeks)] received parenteral iron; 15 patients [11 men; 70 years (interquartile range 62-75), (17.3 ± 3.3 weeks)] received erythropoiesis-stimulating agent. HbA(1c) fell following treatment with both iron [57 mmol/mol (7.4%) to 53 mmol/mol (7.0%), P < 0.001] and erythropoiesis-stimulating agent [56 mmol/mol (7.3%) to 49 mmol/mol (6.6%), P = 0.01] despite mean blood glucose remaining unchanged (iron: 9.55 to 9.71 mmol/l, P = 0.07; erythropoiesis-stimulating agent: 8.72 to 8.78 mmol/l, P = 0.89). Unlike HbA1c , the glycated albumin, fructosamine and 1,5 anhydroglucitol levels did not change following iron [glycated albumin (16.8 to 16.3%, P = 0.10); fructosamine (259.5 to 256 μmol/l, P = 0.89); 1,5 anhydroglucitol (54.2 to 50.9 μmol/l, P = 0.89)] or erythropoiesis-stimulating agent [glycated albumin (17.9 to 17.5%, P = 0.29), fructosamine (324.3 to 306.0 μmol/l, P = 0.52), 1,5 anhydroglucitol (58.2 to 46.7 μmol/l, P = 0.35)]. Despite this, HbA(1c) was consistently the marker most closely related to mean blood glucose before and after each treatment (R range 0.7-0.88).

CONCLUSIONS

These data indicate that HbA(1c) was statistically most closely related to mean blood glucose, but clinical trends in glycaemia in patients undergoing iron or erythropoiesis-stimulating agent therapy are likely best assessed by including one of these additional glycaemic markers.

Epidemiology of Burkitt's lymphoma in Northwest Province, Cameroon, 2003-2010

BACKGROUND

Burkitt's lymphoma (BL) is an aggressive non-Hodgkin's lymphoma endemic to regions of Africa. Cases are thought to be typically found in low-lying, humid regions where malaria is rife.

AIMS AND OBJECTIVES

To investigate the clinical characteristics of BL, its incidence and relationship with malarial incidence in Northwest (NW) Province, Cameroon.

METHODS

Data on BL were collected from the three tertiary referral centres for BL treatment in NW Province, Cameroon. Data on malaria were collected from the Delegation of Public Health in Bamenda, NW Province. Data were collected between March and May 2010.

RESULTS

471 cases of BL were identified. The St Jude's stage of patients at presentation was as follows: stage I, 14.4% (43/299); stage II, 8.4% (25/299); stage III, 69.9% (209/299); stage IV, 7.4% (22/299). The incidences of BL per 100,000 children <15 years of age from 2005 to 2009 were as follows: 2005, 3.01 (29); 2006, 2.02 (20); 2007, 2.45 (25); 2008, 2.38 (25); 2009, 3.06 (33). The average incidence in NW Province was 2.58. In the Ndop plain, Ngo-Ketunjia, the incidences of BL were as follows: 2005, 10.3 (10); 2006, 3.00 (3); 2007, 1.95 (2); 2008, 2.84 (3); 2009, 4.60 (5). The average incidence was 4.54/100,000 children <15 years of age. Statistical analysis demonstrated a sinusoidal distribution of malaria cases throughout the year (P<0.00), with a peak incidence on 10 April. Conversely, no sinusoidal distribution of BL cases was demonstrated throughout the year (P = 0.09).

CONCLUSION

No relationship was demonstrated between an acute malarial infection and BL. Significant clustering was found, with the low-lying Ndop plain of Ngo-Ketunjia having an incidence of BL nearly twice that elsewhere in the region. The study demonstrates that the incidence of BL in NW Province, Cameroon remains one of the highest documented in the world.