Daratumumab: monoclonal antibody therapy to treat multiple myeloma

Daratumumab (Darzalex[TM]) is a human monoclonal antibody (MAb) that targets CD38; a surface protein highly expressed across multiple myeloma (MM) cells. Preclinical studies have shown daratumumab induces MM cell death through several mechanisms, including complement-dependent cytotoxicity (CDC) antibody-dependent cell-mediated cytotoxicity (ADCC), antibody-dependent cellular phagocytosis (ADCP), apoptosis upon secondary crosslinking and immunomodulatory effects via a decrease in immune suppressive cells. Daratumumab has a favorable toxicity profile and encouraging clinical activity as a single agent and in combination with lenalidomide in heavily pretreated, relapsed patients in whom other novel agents (such as bortezomib, thalidomide and lenalidomide) and stem cell transplant have already failed. Given the encouraging efficacy and acceptable safety profile, daratumumab has emerged as a novel treatment option for MM both as a monotherapy and in combination with conventional and novel anti-MM agents. This review will focus on preclinical pharmacology, pharmacokinetics, safety and clinical development of daratumumab in MM.

A facility for the analysis of the electronic structures of solids and their surfaces by synchrotron radiation photoelectron spectroscopy

A synchrotron radiation beamline in the photon energy range of 18-240 eV and an electron spectroscopy end station have been constructed at the 3 GeV Diamond Light Source storage ring. The instrument features a variable polarisation undulator, a high resolution monochromator, a re-focussing system to form a beam spot of 50 × 50 μm², and an end station for angle-resolved photoelectron spectroscopy (ARPES) including a 6-degrees-of-freedom cryogenic sample manipulator. The beamline design and its performance allow for a highly productive and precise use of the ARPES technique at an energy resolution of 10-15 meV for fast k-space mapping studies with a photon flux up to 2 ⋅ 10¹³ ph/s and well below 3 meV for high resolution spectra.

Help seeking behavior and onset-to-alarm time in patients with acute stroke: sub-study of the preventive antibiotics in stroke study

Background

Patients with acute stroke often do not seek immediate medical help, which is assumed to be driven by lack of knowledge of stroke symptoms. We explored the process of help seeking behavior in patients with acute stroke, evaluating knowledge about stroke symptoms, socio-demographic and clinical characteristics, and onset-to-alarm time (OAT).

Methods

In a sub-study of the Preventive Antibiotics in Stroke Study (PASS), 161 acute stroke patients were prospectively included in 3 Dutch hospitals. A semi-structured questionnaire was used to assess knowledge, recognition and interpretation of stroke symptoms. With in-depth interviews, response actions and reasons were explored. OAT was recorded and associations with socio-demographic, clinical parameters were assessed.

Results

Knowledge about stroke symptoms does not always result in correct recognition of own stroke symptoms, neither into correct interpretation of the situation and subsequent action. In our study population of 161 patients with acute stroke, median OAT was 30 min (interquartile range [IQR] 10–150 min). Recognition of one-sided weakness and/or sensory loss (p = 0.046) and adequate interpretation of the stroke situation (p = 0.003), stroke at daytime (p = 0.002), severe stroke (p = 0.003), calling the emergency telephone number (p = 0.004), and transport by ambulance (p = 0.040) were associated with shorter OAT.

Conclusion

Help seeking behavior after acute stroke is a complex process. A shorter OAT after stroke is associated with correct recognition of one-sided weakness and/or sensory loss, adequate interpretation of the stroke situation by the patient and stroke characteristics and logistics of stroke care, but not by knowledge of stroke symptoms.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0749-2) contains supplementary material, which is available to authorized users.

Quantifying the prevalence of frailty in English hospitals

OBJECTIVES

Population ageing has been associated with an increase in comorbid chronic disease, functional dependence, disability and associated higher health care costs. Frailty Syndromes have been proposed as a way to define this group within older persons. We explore whether frailty syndromes are a reliable methodology to quantify clinically significant frailty within hospital settings, and measure trends and geospatial variation using English secondary care data set Hospital Episode Statistics (HES).

SETTING

National English Secondary Care Administrative Data HES.

PARTICIPANTS

All 50,540,141 patient spells for patients over 65 years admitted to acute provider hospitals in England (January 2005-March 2013) within HES.

PRIMARY AND SECONDARY OUTCOME MEASURES

We explore the prevalence of Frailty Syndromes as coded by International Statistical Classification of Diseases, Injuries and Causes of Death (ICD-10) over time, and their geographic distribution across England. We examine national trends for admission spells, inpatient mortality and 30-day readmission.

RESULTS

A rising trend of admission spells was noted from January 2005 to March 2013 (daily average admissions for month rising from over 2000 to over 4000). The overall prevalence of coded frailty is increasing (64,559 spells in January 2005 to 150,085 spells by Jan 2013). The majority of patients had a single frailty syndrome coded (10.2% vs total burden of 13.9%). Cognitive impairment and falls (including significant fracture) are the most common frailty syndromes coded within HES. Geographic variation in frailty burden was in keeping with known distribution of prevalence of the English elderly population and location of National Health Service (NHS) acute provider sites. Overtime, in-hospital mortality has decreased (>65 years) whereas readmission rates have increased (esp.>85 years).

CONCLUSIONS

This study provides a novel methodology to reliably quantify clinically significant frailty. Applications include evaluation of health service improvement over time, risk stratification and optimisation of services.

Developing and validating a risk prediction model for acute care based on frailty syndromes

OBJECTIVES

Population ageing may result in increased comorbidity, functional dependence and poor quality of life. Mechanisms and pathophysiology underlying frailty have not been fully elucidated, thus absolute consensus on an operational definition for frailty is lacking. Frailty scores in the acute medical care setting have poor predictive power for clinically relevant outcomes. We explore the utility of frailty syndromes (as recommended by national guidelines) as a risk prediction model for the elderly in the acute care setting.

SETTING

English Secondary Care emergency admissions to National Health Service (NHS) acute providers.

PARTICIPANTS

There were N=2,099,252 patients over 65 years with emergency admission to NHS acute providers from 01/01/2012 to 31/12/2012 included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcomes investigated include inpatient mortality, 30-day emergency readmission and institutionalisation. We used pseudorandom numbers to split patients into train (60%) and test (40%). Receiver operator characteristic (ROC) curves and ordering the patients by deciles of predicted risk was used to assess model performance. Using English Hospital Episode Statistics (HES) data, we built multivariable logistic regression models with independent variables based on frailty syndromes (10th revision International Statistical Classification of Diseases, Injuries and Causes of Death (ICD-10) coding), demographics and previous hospital utilisation. Patients included were those>65 years with emergency admission to acute provider in England (2012).

RESULTS

Frailty syndrome models exhibited ROC scores of 0.624-0.659 for inpatient mortality, 0.63-0.654 for institutionalisation and 0.57-0.63 for 30-day emergency readmission.

CONCLUSIONS

Frailty syndromes are a valid predictor of outcomes relevant to acute care. The models predictive power is in keeping with other scores in the literature, but is a simple, clinically relevant and potentially more acceptable measurement for use in the acute care setting. Predictive powers of the score are not sufficient for clinical use.

Simple psoas cross-sectional area measurement is a quick and easy method to assess sarcopenia and predicts major surgical complications

AIM

Radiologically assessed muscle mass has been suggested as a surrogate marker of functional status and frailty and may predict patients at risk of postoperative complications. We hypothesize that sarcopenia negatively impacts on postoperative recovery and is predictive of complications.

METHOD

One hundred patients undergoing elective resection for colorectal carcinoma were included in this study. Lean muscle mass was estimated by measuring the cross-sectional area of the psoas muscle at the level of the third lumbar vertebra identified on a preoperative CT scan, normalizing for patient height. Perioperative morbidity was scored according to the Clavien-Dindo classification. All statistical data analyses were carried out using the Statistical Package for the Social Sciences (SPSS) version 20.0.

RESULTS

Fifteen per cent of patients were identified as sarcopenic. There were no deaths in the study group. Sarcopenia was associated with a significantly increased risk of developing major complications (Grade 3 or greater, OR = 5.41, 95% CI: 1.45-20.15, P = 0.01). Sarcopenia did not predict length of stay, critical care dependency or time to mobilization.

CONCLUSION

Sarcopenia, as a marker of frailty, is an important risk factor in surgical patients but difficult to estimate using bedside testing. CT scans, performed for preoperative staging, provide an opportunity to quantify lean muscle mass without additional cost or exposure to radiation and eliminate the inconvenience of further investigations.

Early parental physical punishment and emotional and behavioural outcomes in preschool children

OBJECTIVE

To determine whether there is an association between being smacked by your main caregiver in the first two years and emotional and behavioural problems at age four.

DESIGN

Secondary analysis of data from the Growing Up in Scotland Prospective Study (GUS).

SETTING

Scotland, UK.

PARTICIPANTS

GUS birth cohort children, whose main caregiver had no concerns about their behaviour at 22 months.

EXPOSURE

Ever smacked by main caregiver in first 22 months, as measured by caregiver self-report at 22 months.

MAIN OUTCOME

Emotional and behavioural problems as measured by parental assessment and the Strengths and Difficulties Questionnaire (SDQ) at 46 months.

RESULTS

Preschool children exposed to main caregiver smacking in the first two years were twice as likely to have emotional and behavioural problems as measured by parental assessment [odds ratio (OR) 2.5, 95% confidence interval (CI) 1.9-3.2; absolute risk reduction (ARR) 17.8%, 95% CI 12.1-23.5] and SDQ (OR 2.5, 95% CI 1.7-3.7; ARR 7.5%, 95% CI 3.7-11.5), as children never smacked by their main caregiver. The association remained significant after adjusting for child age and sex, caregiver age, sex, ethnicity, educational attainment and mental health status, sibling number, structural family transitions and socioeconomic status (adj. OR 2.4, 95% CI 1.8-3.2 for parental assessment and adj. OR 2.2, 95% CI 1.4-3.5 for SDQ).

CONCLUSIONS

Parental use of physical punishment in the first two years may be a modifiable risk factor for emotional and behavioural difficulties in preschool children.

Multidimensional Treatment Foster Care for Adolescents in English care: randomised trial and observational cohort evaluation

BACKGROUND

Children in care often have poor outcomes. There is a lack of evaluative research into intervention options.

AIMS

To examine the efficacy of Multidimensional Treatment Foster Care for Adolescents (MTFC-A) compared with usual care for young people at risk in foster care in England.

METHOD

A two-arm single (assessor) blinded randomised controlled trial (RCT) embedded within an observational quasi-experimental case-control study involving 219 young people aged 11-16 years (trial registration: ISRCTN 68038570). The primary outcome was the Child Global Assessment Scale (CGAS). Secondary outcomes were ratings of educational attendance, achievement and rate of offending.

RESULTS

The MTFC-A group showed a non-significant improvement in CGAS outcome in both the randomised cohort (n = 34, adjusted mean difference 1.3, 95% CI -7.1 to 9.7, P = 0.75) and in the trimmed observational cohort (n = 185, adjusted mean difference 0.95, 95% CI -2.38 to 4.29, P = 0.57). No significant effects were seen in secondary outcomes. There was a possible differential effect of the intervention according to antisocial behaviour.

CONCLUSIONS

There was no evidence that the use of MTFC-A resulted in better outcomes than usual care. The intervention may be more beneficial for young people with antisocial behaviour but less beneficial than usual treatment for those without.

Maternal mortality, birth with a health professional and distance to obstetric care in Indonesia and Bangladesh

OBJECTIVE

To examine the relationship between distance to a health facility, consulting a health professional and maternal mortality.

METHODS

Retrospective cohort study in Matlab, Bangladesh (1987-2005), to collect data on all pregnancies, births and deaths. In Java, Indonesia (2004-2005), an informant-based approach identified maternal deaths and a population-based survey sampled women who survived birth. Logistic regression was used to examine the influence of distance to a health facility and uptake of a health professional on odds of dying.

RESULTS

Maternal mortality was 320 per 100 000 births (95% CI: 290, 353) in Indonesia and 318 per 100 000 (95% CI: 272, 369) in Bangladesh. Women who lived further from health centres in both countries were less likely to have their births attended by health professionals than those who lived closer. For women who were assisted by a health professional, the odds of dying increased with increasing distance from a health centre [odds ratio per km; Indonesia: 1.07 (95% CI: 1.02-1.11), Bangladesh: 1.47 (95% CI: 1.22-1.78)]. There was no evidence for an association between distance to a health centre and maternal death for women who were not assisted by a health professional.

CONCLUSIONS

Even in settings where health services are relatively close to women's homes, distance to a health facility affects maternal mortality for women giving birth with a health professional. Women may only seek professional care in an emergency and may be unable to reach timely care when living far away from a health centre.

Phylogenetic and phylogeographic analysis of the genus Orestias (Teleostei: Cyprinodontidae) in the southern Chilean Altiplano: the relevance of ancient and recent divergence processes in speciation

This study presents phylogenetic molecular data of the Chilean species of Orestias to propose an allopatric divergence hypothesis and phylogeographic evidence that suggests the relevance of abiotic factors in promoting population divergence in this complex. The results reveal that diversification is still ongoing, e.g. in the Ascotán salt pan, where populations of Orestias ascotanensis restricted to individual freshwater springs exhibit strong genetic differentiation, reflecting putative independent evolutionary units. Diversification of Orestias in the southern Altiplano may be linked to historical vicariant events and contemporary variation in water level; these processes may have affected the populations from the Plio-Pleistocene until the present.

Formation and stability of impurity "snakes" in tokamak plasmas

New observations of the formation and dynamics of long-lived impurity-induced helical "snake" modes in tokamak plasmas have recently been carried out on Alcator C-Mod. The snakes form as an asymmetry in the impurity ion density that undergoes a seamless transition from a small helically displaced density to a large crescent-shaped helical structure inside q<1, with a regularly sawtoothing core. The observations show that the conditions for the formation and persistence of a snake cannot be explained by plasma pressure alone. Instead, many features arise naturally from nonlinear interactions in a 3D MHD model that separately evolves the plasma density and temperature.

Measuring the effects of alexithymia on perception of emotional vocalizations in autistic spectrum disorder and typical development

BACKGROUND

The results from recent studies suggest that alexithymia, a disorder characterized by impairments in understanding personal experiences of emotion, is frequently co-morbid with autism spectrum disorder (ASD). However, the extent that alexithymia is associated with primary deficits in recognizing external emotional cues, characteristic in ASD, has yet to be determined.

METHOD

Twenty high-functioning adults with ASD and 20 age- and intelligence-matched typical controls categorized vocal and verbal expressions of emotion and completed an alexithymia assessment.

RESULTS

Emotion recognition scores in the ASD group were significantly poorer than in the control group and performance was influenced by the severity of alexithymia and the psycho-acoustic complexity of the presented stimuli. For controls, the effect of complexity was significantly smaller than for the ASD group, although the association between total emotion recognition scores and alexithymia was still strong.

CONCLUSIONS

Higher levels of alexithymia in the ASD group accounted for some, but not all, of the group difference in emotion recognition ability. However, alexithymia was insufficient to explain the different sensitivities of the two groups to the effects of psycho-acoustic complexity on performance. The results showing strong associations between emotion recognition and alexithymia scores in controls suggest a potential explanation for variability in emotion recognition in non-clinical populations.

A new scheme for stigmatic x-ray imaging with large magnification

This paper describes a new x-ray scheme for stigmatic imaging. The scheme consists of one convex spherically bent crystal and one concave spherically bent crystal. The radii of curvature and Bragg reflecting lattice planes of the two crystals are properly matched to eliminate the astigmatism, so that the conditions for stigmatic imaging are met for a particular wavelength. The magnification is adjustable and solely a function of the two Bragg angles or angles of incidence. Although the choice of Bragg angles is constrained by the availability of crystals, this is not a severe limitation for the imaging of plasmas, since a particular wavelength can be selected from the bremsstrahlung continuum. The working principle of this imaging scheme has been verified with visible light. Further tests with x rays are planned for the near future.

The Aarhus statement: improving design and reporting of studies on early cancer diagnosis

Early diagnosis is a key factor in improving the outcomes of cancer patients. A greater understanding of the pre-diagnostic patient pathways is vital yet, at present, research in this field lacks consistent definitions and methods. As a consequence much early diagnosis research is difficult to interpret. A consensus group was formed with the aim of producing guidance and a checklist for early cancer-diagnosis researchers. A consensus conference approach combined with nominal group techniques was used. The work was supported by a systematic review of early diagnosis literature, focussing on existing instruments used to measure time points and intervals in early cancer-diagnosis research. A series of recommendations for definitions and methodological approaches is presented. This is complemented by a checklist that early diagnosis researchers can use when designing and conducting studies in this field. The Aarhus checklist is a resource for early cancer-diagnosis research that should promote greater precision and transparency in both definitions and methods. Further work will examine whether the checklist can be readily adopted by researchers, and feedback on the guidance will be used in future updates.

Information needs across the colorectal cancer care continuum: scoping the literature

Because cancer care requires a multifaceted approach, providing useful and timely information to people with colorectal cancer may be fragmented and inconsistent. Our interest was in examining what has and has not captured the attention of researchers speaking to the information needs of people with colorectal cancer. We followed Arksey and O'Malley's framework for the methodology of scoping review. Focusing solely on colorectal cancer, we analysed 239 articles to get a picture of which information needs and sources of information, as well as the timing of providing information, were attended to. Treatment-related information received the most mentions (26%). Healthcare professionals (49%) were mentioned as the most likely source of information. Among articles focused on one stage of the care continuum, post-treatment (survivorship) received the most attention (16%). Only 27% of the articles consulted people with colorectal cancer and few attended to diet/nutrition and bowel management. This study examined the numerical representation of issues to which researchers attend, not the quality of the mentions. We ponder, however, on the relationship between the in/frequency of mentions and the actual information needs of people with colorectal cancer as well as the availability, sources and timing of information.

High-precision soft x-ray polarimeter at Diamond Light Source

The development and performance of a high-precision polarimeter for the polarization analysis in the soft x-ray region is presented. This versatile, high-vacuum compatible instrument is supported on a hexapod to simplify the alignment with a resolution less than 5 μrad, and can be moved with its own independent control system easily between different beamlines and synchrotron facilities. The polarimeter can also be used for the characterization of reflection and transmission properties of optical elements. A W/B(4)C multilayer phase retarder was used to characterize the polarization state up to 1200 eV. A fast and accurate alignment procedure was developed, and complete polarization analysis of the APPLE II undulator at 712 eV has been performed.