Abstract P2-15-02: The efficacy of recruitment and retention strategies for research subjects in an early phase investigator-initiated breast cancer trial

Background: One of the biggest challenges faced by investigators is the implementation of effective strategies to improve the recruitment and retention of research participants. This is especially true for investigator-initiated, federally funded (e.g. NIH and DOD), early phase clinical trials that involve the treatment of serious diseases such as metastatic breast cancer (MBC). These studies may face additional barriers to participation since patients have often already undergone maximal treatment and are usually not in a financial position that for allows the travel and lodging necessary to receive further investigative treatment. Moreover, efficacy and toxicology in early phase clinical trials are unknown. Thus, when study budget constraints do not allow monetary incentives to participation, it is difficult to provide motivation for patients to enroll and remain adherent to the protocol requirements. However, many MBC patients are motivated to join clinical trials for altruistic purposes alone, and evidence supports that the researcher-patient relationship may be the most important factor in clinical trial participation. Recognizing that many patients are willing to participate if provided the appropriate resources despite limited monetary incentives, we developed a system to improve patient recruitment and retention to our studies, which are primarily federally funded. We report here on the strategies developed and used by our group to recruit and retain patients in a federally-funded investigator-initiated phase I/II vaccine study in MBC patients.

Methods: This study was funded by the NIH/NCI and involved infusion of HER2 specific T cells in HER2+ MBC patients after completing in vivo priming with a HER2 vaccine. It required 11 visits to Seattle, Washington. Working with agencies that offer free services to patients enrolled in clinical trials, a list of available resources was compiled and a visit flowchart with specific information on travel and lodging resources (e.g. Angel Flights and ACS sponsorship), local transportation and entertainment was developed. During screening, patients were given the list of resources and trial information. An email system was used to quickly communicate and follow-up with patients. Eligible patients were given the visit flowchart to help with their planning of study visits. An enrollment packet was provided at the first visit with a calendar to keep track of the visit schedule. Coordination of care between the patient's primary oncologist and the research staff was maintained throughout the study.

Results: 17 of 19 patients enrolled were not from Washington State. Two out-of-state patients withdrew early from the trial for reasons unrelated to disease progression or toxicity; one subject completed 8 visits and enrolled in another study and the other completed 2 visits and discontinued the trial to resume chemotherapy.

Conclusion: We have developed a successful system to enroll and retain patients in a trial requiring multiple study visits. Development and implementation of site-specific standard procedures are critical to improve study participation and retention, especially when patients receive no financial benefit.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-15-02.

Abstract OT3-1-02: Phase II randomized study of combination immunotherapy with or without Polysaccharide Krestin (PSK®) concurrently with a HER2 ICD peptide-based vaccine and trastuzumab in patients with stage IV breast cancer

Background: Endogenous immunity in patients with HER2+ metastatic breast cancer (MBC) is likely dampened by an immune-suppressive tumor microenvironment and not sufficient to control tumor growth. Thus, most patients have disease relapse after achieving complete remission with standard therapies. Immunomodulation directed at enhanced stimulation of tumor specific immunity could result in immunologic eradication of residual HER2+ tumor cells and prevent BC relapse. We have shown PSK to be a potent TLR-2 agonist that stimulates both innate and adaptive immunity in a BC mouse model. Additionally, we have shown combination immunotherapy with HER2 peptide vaccines and trastuzumab (TRAZ) to be safe and able to elicit HER2 specific Th1 immunity and epitope spreading (ES) which has been associated with survival in vaccinated patients. Lastly, decreased serum TGF-β elicited by HER2 vaccination correlates with Th1 ES and may serve as a biomarker to predict cancer vaccine efficacy. We hypothesize that PSK, when given with TRAZ can augment vaccine induced HER2 specific TH1 immunity and prevent disease relapse in patients with optimally treated HER2+ MBC.

Trial design: Phase II randomized two-arm clinical trial. Patients will be enrolled and randomly assigned in equal numbers to 1 of 2 arms (15 patients/arm) as follows: Arm 1:HER2 ICD vaccine, TRAZ and placebo or Arm 2:HER2 ICD vaccine, TRAZ and PSK. All patients will receive 3 monthly HER2 ICD vaccines plus TRAZ and 4 months of concomitant PSK or placebo. Serial blood draws for immunologic monitoring will be done.

Eligibility criteria: Patients with Stage IV HER2+ BC who have been treated with definitive therapy and are: (1) without evidence of disease or have stable-bone only disease, (2) receiving TRAZ monotherapy, and (3) without clinically significant autoimmune disease. Patients must have normal LVEF per MUGA scan or echocardiogram.

Aims: (1) Evaluate safety of PSK when given with a HER2 vaccine and TRAZ (2) Evaluate the effect of PSK on serum TGF-β levels when given with a HER2 vaccine and TRAZ and (3) Evaluate the effect of PSK on intermolecular ES when given with a HER2 vaccine and TRAZ. A secondary objective is to evaluate progression free survival (PFS) and overall survival (OS).

Statistical methods: (1) Toxicity will be determined by clinical and chemical parameters and grading will be done per CTEP CTCAE 4.0.; (2) Evaluation of TGF-β levels, pre and post-PSK treatment will be assessed with linear regression models; and analysis of multiple post-baseline measurements will be performed using generalized estimating equations; (3) A positive antigen-specific immune response will be defined as a precursor frequency >1:20,000 antigen-specific peripheral blood mononuclear cells. Differences in the levels of HER2 immunity will be evaluated between arms using a two-tailed T test. The degree of ES in each arm will be evaluated with generalized linear modeling; (4) Large differences in PFS and OS observed between groups will be noted and described.

Target accrual: 30 patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT3-1-02.

The ontogeny of New Zealand groper (Polyprion oxygeneios) lymphoid organs and IgM

This study investigates the ontogeny of New Zealand groper (Polyprion oxygeneios) immune system, a new species for aquaculture in the Southern Pacific Ocean. In the eggs, both lysozyme and IgM were detected. Egg IgM was found at 1.07-1.56 μg/g wet weight and consisted of monomers compared to the polymerized IgM found in adult serum. In larvae, the head-kidney (HK) was first observed at 6 dph, followed by the spleen at 16 dph, and thymus at 20 dph, and within these organs IgM(+) cells were first detected in the HK (12 dph), then the spleen (32 dph) and finally in the thymus and the gastrointestinal tract (45 dph). Low levels of Igμ heavy chain transcripts were detected at 2 and 3 dph and they increased at 9 dph. Igμ expression further increased from day 45 onwards. In juveniles (115 dph), the HK and blood showed similar percentages of IgM(+) cells as the adult groper. These results highlight the important maturation steps that occur during the development of the immune system in the marine teleost P. oxygeneios.

Routine group and save unnecessary for gastric band surgery: a retrospective case review audit of 1018 bariatric patients

What is already known about this subject •  The demand for bariatric surgery is increasing. •  NHS Trusts are expected to instigate cost-efficiency measures. •  Previous articles have discussed the need for routine preoperative cross-match. What this study adds •  No gastric band patient suffered a significant drop in haemoglobin or needed a blood transfusion. •  Group and save samples could be safely stored in the laboratory and only sent for analysis if clinically indicated. •  Even greater cost savings could be achieved if prudent use of perioperative blood testing and blood transfusion was implemented.

SUMMARY

Current guidance at our Trust is that all bariatric surgical patients should have preoperative group and save (G&S) and full blood count (FBC) tests, as well as a FBC check 1 d post-operatively. Our aim was to investigate blood transfusion requirements of these patients and whether we could reduce the number of investigations requested. 1018 consecutive elective laparoscopic gastric band and laparoscopic Roux-en-Y gastric bypass patients who were operated on in our bariatric unit from March 2000 until January 2011 were identified. Patients' haemoglobin levels, G&S status and blood transfusion requirements were analyzed using our online pathology system. 607 patients had a laparoscopic gastric band, with 411 undergoing a laparoscopic Roux-en-Y gastric bypass. None of our gastric band patients required a transfusion; however, nine patients (2.2%) undergoing a gastric bypass needed a transfusion. Two patients required transfusion within 24 h of surgery while six of the remaining seven patients received blood 3-4 d post-operatively. Costs incurred on FBC and G&S tests during this time were estimated to exceed £15 700. G&S and post-operative FBC tests could be abandoned for laparoscopic gastric band patients with significant financial and person-time savings. However, given that 2.2% of laparoscopic Roux-en-Y gastric bypass patients needed a blood transfusion, we believe that post-operative FBC tests are still warranted in this patient group, with a G&S sample stored in pathology. Much greater financial savings could be achieved if prudent use of preoperative investigations, including storing G&S samples in the laboratory, was adopted for all elective operations.

P1-13-04: Phase II Study of Topical Imiquimod and Abraxane for Treatment of Breast Cancer Cutaneous Metastases

Background: Breast cancer (BC) cutaneous lesions can present as local chest wall recurrence or isolated sites of metastatic disease. Current treatments with full thickness chest wall resection, radiation therapy and chemotherapy are not curative; and have significant morbidity and poor overall response rates. Combining local immunomodulation and systemic chemotherapy may be more effective in treating cutaneous disease. Topical imiquimod (IMQ), a TLR-7 agonist, has shown clinical activity against cutaneous metastasis. Pre-clinical studies have shown IMQ to stimulate Th1 cytokine secretion and up-regulate immune co-stimulatory molecules at the tumor site; resulting in augmented tumor specific T cell immunity and tumor growth inhibition. Use of paclitaxel in BC, has demonstrated immunostimulatory effects of increased serum IFN-γ and enhanced NK/LAK cell activity. Abraxane (albumin-bound paclitaxel) may be used in conjunction with IMQ as steroid pre-treatment is not required. We hypothesize the immune effects of Abraxane may synergize and augment the IMQ anti-tumor effects, resulting in greater clinical response. A phase II single-arm study of chemoimmunotherapy with topical IMQ and Abraxane was initiated to determine its safety and therapeutic efficacy; and examine its effect on augmenting endogenous tumor specific immunity and inducing tumor molecular alterations associated with inhibition of tumor growth and/or common pathways of BC immune escape.

Materials and Methods: Up to 15 BC patients with cutaneous lesions no longer amenable to standard therapy are enrolled and receive 3 treatment cycles. A treatment cycle consist of topical 5% IMQ to target lesions 4 days/week (wk.) and Abraxane 100 mg/m2 on Days 1, 8, 15 every 28 Days. Toxicity is evaluated per CTCAE v3.0 on Days 1, 8, 15 of each cycle and wks. 13, 16, 20, 24. Target lesion antitumor activity is assessed per modified WHO criteria (Complete response (CR); Partial response (PR); Stable disease (SD); Progressive disease (PD)) at baseline, wks. 4, 8, 12, 16, 20, 24. 2-mm target lesion skin biopsies are obtained pre-and post-treatment for histologic analysis and RT-PCR analysis of a 7 IFN-related gene signature associated with tumor inhibition. Immunity to HER2, IGFBP-2, TOPO-IIα, p53 and serum TGF-β levels are evaluated at baseline and wks. 12, 24 with IFN-γ ELISPOT and ELISA, respectively.

Results: 10 patients have been enrolled. Median (range) values include: age, 54 years (48-92), time from metastatic diagnosis, 134 months (58-728), prior chemotherapy regimens, 5 (2-10). 5/10 patients had received prior local therapy, e.g., radiation. 5/10, 4/10, and 2/10 patients had triple negative, HER2+ and ER+/PR+ tumors, respectively. In 5 patients completing 3 treatment cycles, overall response rate (ORR) = 100% (3 CR, 2 PR). In the 5 patients who completed 1–2 treatment cycles, ORR = 80% (2 PR, 2 SD, 1 PD). Treatment related toxicity is primarily grade I/II neutropenia, anemia; grade I skin toxicity. Immunologic analyses are ongoing and will be presented with completed clinical data on all patients.

Conclusions: Chemoimmunotherapy with topical IMQ and Abraxane is well-tolerated and shows excellent clinical efficacy in treating metastatic cutaneous lesions in heavily pretreated BC patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-13-04.

OT3-01-19: Phase II Study of Topical Imiquimod and Weekly Abraxane for the Treatment of Breast Cancer Cutaneous Metastases

Background

Breast cancer (BC) cutaneous lesions present as local chest wall recurrence or as isolated sites of metastatic disease. The treatment of cutaneous lesions is challenging and includes chest wall resection, local radiation therapy, and/or salvage chemotherapy which is not curative, associated with significant morbidity, and results in overall response rates of 20–30%. Thus, investigation of novel treatment strategies is warranted. This study incorporates multimodality treatment with topical imiquimod, a TLR-7agonist which generates an immune signal similar to that of pathogenic bacteria and Abraxane, a conventional systemic chemotherapy with potential immunostimulatory effects. Combined, these two agents provide local and systemic strategies which are potentially synergistic; and more effective than as single-agents in treating and controlling cutaneous disease.

Trial design: A Phase II single arm, non-randomized study. Patients will be sequentially enrolled and receive a maximum of 3 treatment cycles. A treatment cycle consists of topical imiquimod daily to target lesions for 4 days/week for 4 weeks in addition to Abraxane on Days 1, 8, and 15 every 28 days. Toxicity will be evaluated weekly during treatment then monthly for four months. Defined lesions are assessed at baseline and monthly. Skin biopsies are obtained pre and post treatment for histologic analysis and RT-PCR analysis of a 7 IFN-related gene signature previously associated with tumor inhibition. Immunity to BC antigens and serum TGF-β levels are also evaluated.

Aims: To evaluate the safety and anti-tumor effects of chemoimmunotherapy with topical imiquimod and Abraxane.

Eligibility criteria: Patients with progressive or relapsed BC after standard therapy who 1) have measurable cutaneous metastatic lesions, 2) are at least 7 days from last chemotherapy, 30 days from local radiotherapy and/or systemic steroids, 3) have adequate blood counts and 4) no history of active autoimmune disease. Bisphosphonates, trastuzumab, and/or hormonal therapy is allowed.

Statistical methods: Antitumor activity of target lesions will be assessed per modified WHO criteria. Complete response (CR)-complete clearance of lesions; Partial response (PR) ≥ 50% decrease in lesion size; Stable disease (SD) < 50% decrease in lesion size; Progressive disease (PD) increase in ≥ 25% lesion size). Historical overall response rates (ORR) with second and third line salvage chemotherapy range from 20–30%, with CR rates less than 2%. Based on these numbers, an ORR of 50% or a CR rate of 10% will be used as benchmarks for success (i.e., ≥8 responses or ≥2 CRs among 15 patients (observed ORR of ≥ 53% or observed CR rate of ≥ 13%) to consider the treatment worthy of further study. As a measure of the precision of the estimate of ORR achievable with 15 patients, if the response rate is 60%, we will be 80% confident that the observed RR is within 0.16 of the true RR with 15 patients treated. Toxicity will be evaluated by CTCAE v. 3.0 and descriptive statistics will be used to summarize changes from baseline and for reporting of immunological parameters.

Accrual: 10 patients received treatment with a target accrual of 15.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT3-01-19.

OT1-02-10: Phase I-II Study of HER2 Vaccination with Poly(I) • Poly(C12U) (Ampligen®) as an Adjuvant in Optimally Treated Breast Cancer Patients

Background

Despite improved response rates and overall survival, many HER2+ breast cancer (BC) patients have disease relapse suggesting residual microscopic disease. HER2 vaccines given with adjuvants that can enhance, sustain, and skew antigen immunogenicity toward a Th1 phenotype could induce robust tumor-specific Th1 immunity resulting in immunologic eradication of residual tumor cells and potentially prevent relapse. One such adjuvant is Ampligen which is highly selective as a TLR-3 agonist. Our pre-clinical studies show a dose effect in the tumor prevention efficacy of Ampligen when given as an adjuvant with vaccines. We hypothesize HER2 peptide vaccination given with standard adjuvant 100mcg GMCSF and Ampligen can induce a higher incidence and magnitude of protective HER2−specific Th1 immunity than with GMCSF alone.

Trial design: Phase I-II randomized 2-stage HER2 vaccine study. Stage I will enroll 40 patients (10/arm) into one of 4 Ampligen dose arms (4, 20, 79, or 495 mcg + HER2 vaccine). The Ampligen “maximum biologic dose” (MBD), the dose with the highest incidence/magnitude of immune response and lowest incidence of toxicity will be defined. Stage II will enroll 48 patients (24/arm) receiving Ampligen MBD + HER2 vaccine + GMCSF or HER2 vaccine + GMCSF to evaluate if Ampligen MBD increases the incidence and magnitude of immunity vs HER2 vaccine + GMCSF alone. Patients will be enrolled sequentially and randomized equally into all arms via a permuted block design. Patients will receive 3 monthly vaccines. Toxicity and immune response will be assessed.

Aims: 1) To evaluate toxicity and define the MBD of Ampligen as an adjuvant with HER2 vaccination 2) determine if Ampligen MBD when combined with GMCSF as adjuvant and HER2 vaccination increases incidence/magnitude of HER2 Th1 immunity compared to standard GMCSF alone.

Eligibility criteria: Stage II–IV HER2+ BC patients who: 1) have completed definitive standard treatment, and in clinical remission 2) 14 days post chemotherapy and steroids 3) have adequate blood counts 4) are off trastuzumab 5) have no active autoimmune disease.

Statistical methods: In aim 1, we expect mild toxicity between the 4 dose arms, thus lack of efficacy based on incidence of immune response will be evaluated. Six responses must be observed within a dose arm to move forward based on historical 60% response rate (RR) with standard GMCSF (probability of continuing if true RR is 40% and 70% is 0.17, 0.85, respectively). In aim 2, 24 patients/arm provides 80% power to detect 40% difference in incidence of immune response between the 2 groups (Pearson chi-square test, two-sided alpha of 0.05) and 82% power to assess a 0.85 SD unit difference in change between control and MBD, based on a 2-sample t-test (p=0.05) and effect size defined as the difference in the means divided by the common SD. Incidences of HER2 Th1 immunity will be compared across treatment arms via Pearson chi-square test; magnitude of immune response will be compared across groups via linear regression model.

Study Accrual: Target accrual is 88 patients: Stage 1 (n=40) and Stage II (n=48). There has been no accrual at this time.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT1-02-10.

Faecal incontinence in men

AIM

A few studies have specifically addressed faecal incontinence (FI) in men. We sought to describe patterns of male FI, assess treatment outcome and compare some aspects of FI between men and women, including quality of life.

METHOD

Prospectively recorded data on 85 consecutive male patients evaluated for FI at our pelvic floor centre in 2004 and 2005 were reviewed and compared with a cohort of 408 female patients. Treatment outcome in men was assessed by questionnaire.

RESULTS

The aetiology of FI could be determined in 61 (72%) men and was most commonly related to anal surgery (n = 23), prostate cancer therapy (n = 9) and spinal injury (n = 9). Eight patients had idiopathic soiling only. Mean age, Fecal Incontinence Severity Index (FISI) and quality of life scores were similar between men and women. Maximal mean resting pressure (MRP) and squeeze pressure (MSP) were on average higher in men than in women [MRP 56.9 (26.2) vs 40 (20.4) mmHg; P < 0.0001]; [MSP 98.1 (67.3) vs 39.4 (28.5) mmHg; P < 0.0001]. Sphincter defects involved the external sphincter less often in men (35 vs 70%, P = 0.004). Differences in faecal incontinence quality of life (FIQL) and SF-36 scores between men and women were minimal. After a median follow up of 2 years, complete resolution of symptoms was reported in 17% and improvement of symptoms in another 48% of men.

CONCLUSION

Although physiological and anatomical features of FI differ between men and women, its severity and impact on quality of life are similar. External sphincter defects are less common in men; hence, direct sphincter repair is less frequently an option. Evaluation and treatment improves symptoms in more than half of male patients.

Clinical and Pharmacokinetic Study of Ixabepilone (IXA) Plus Epirubicin (EPI) as Therapy for Women with Advanced Breast Cancer (BC)

Background: IXA and EPI have established single agent activity in early and late stage BC, however, safety and pharmacokinetics (PK) of the combination are unknown. This study aimed to determine the dose-limiting toxicities (DLT), define the maximum tolerated dose (MTD), investigate PK, and evaluate safety and activity of the combination of IXA and EPI in women with advanced BC.Patients and Methods: Women with locally advanced, recurrent or metastatic BC with ≤ 1 prior chemotherapy regimen as 1st line therapy, a maximum cumulative dose of ≤ 450 mg/m2 for EPI, or ≤300 mg/m2 for doxorubicin were eligible. A short IV infusion of EPI was followed by a 3-hour IV infusion of IXA given every 3 weeks. Three cohorts (3 to 6 patients (pts) per cohort) received IXA/EPI at 25/75, 30/75 and 35/75 mg/m2 respectively. An additional 24 pts were enrolled at the MTD. Blood samples for PK analysis of IXA, EPI and epirubicinol (EOL, major metabolite of EPI) were collected from all pts during cycle 1 and analyzed using LC/MS/MS. PK samples were collected out to 120 h for ixabepilone and 24 h for EPI/EOL. PK parameters were generated by non-compartmental methods.Results: Forty-two pts, median age of 57 (33-69) yrs were treated, 6 at 25/75 mg/m2, 6 at 35/75 mg/m2 and 30 at 30/75 mg/m2, receiving a total of 249 cycles (median 6, range 1-10). All pts were evaluable for safety and efficacy and 38 were evaluable for PK. Two DLTs, febrile neutropenia and grade 3 vomiting, occurred at the 35/75 mg/m2 dose level; therefore 30/75 mg/m2 (IXA/EPI) was defined as the MTD. No deaths or grade 4 non-hematological toxicities were reported. Neutropenia was the most frequent treatment related severe toxicity.Objective responses were seen at all dose levels in 18/32 pts (56%) with measurable disease. In addition, 2/10 pts (17%) with non-measurable disease had complete response. PFS was ≥6 mo in 27 (64%) pts and ≥ 9 mo in 18 (43%). IXA plasma concentrations declined rapidly in the first 24 hrs, followed by a slower elimination phase. Observed means of both elimination half-life (34-52 h) and clearance (25-27 L/h) within each cohort indicate a slow elimination of IXA from plasma. The IXA Cmax and AUC were linear across the 3 dose levels evaluated. With the EPI dose remaining at 75mg/m2, no alteration in EPI AUC was observed across dose levels. Exposure to EOL decreased with increasing IXA dose (Geo Mean AUC: 575.48, 314.46 and 204.46 in each dose group respectively). This may be due to altered metabolism of EPI in the presence of IXA or Cremophor in the IXA formulation. No relationship was observed between PK parameters of IXA, EPI or EOL and nausea, vomiting, and neutropenia.Conclusions: The combination of IXA/EPI is feasible, efficacious and has an acceptable safety profile at the studied dose levels. No clinically relevant PK interactions were observed. The observed effect on EOL exposure deserves further investigation.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2097.

Increased humoral and cellular immunity in patients (pts) with advanced melanoma treated with ipilimumab

3031

Background: Ipilimumab is an anti-CTLA-4 monoclonal antibody (Ab) that overcomes T-cell suppression. In this phase II study (CA184004), humoral and cellular responses were assessed in ipilimumab-treated pts with unresectable stage III/IV melanoma. Methods: Ipilimumab 3 or 10 mg/kg was given every 3 weeks x 4. Tetanus boosters were given ≤10 days pre-treatment. Influenza and pneumococcal vaccines were given 5 days after first ipilimumab dose. Tetanus, anti-influenza, and anti-pneumococcal Ab levels were assessed at pre-dose and Wk 7. Humoral response to 5 tumor antigens (Ag) and a control Ag (DHFR) were examined at baseline (BL) and at Wks 4, 8–9, and 12. DTH skin tests were given at pre-dose and Wk 4, with responses recorded 15 minutes (min) and 24–72 hours (hrs) post-test. Peripheral T-cell populations were evaluated through flow cytometry at BL, Wk 4, and Wk 12. Results: Pts received ipilimumab 3 (n = 40) or 10 mg/kg (n = 42). Increases from BL in humoral responses to pneumococcal (40–50/78 pts, depending on Ab) and tetanus (58/78 pts) vaccines were noted, even in pts who did not receive on-study pneumococcal (4–9 pts) or tetanus (7 pts) vaccines. Increased humoral response to influenza only occurred in pts receiving the influenza vaccine. Maximum increase from BL of ≥ 5-fold titer (clinically meaningful threshold) in humoral response to tumor Ag MELANA (23.2% of pts), SSX2 (20.3%), NYES01 (18.8%), MAGEA4 (10.1%), and P53 (4.3%) (DHFR, 4.3%) was noted without tumor vaccines. Tumor Ag response was not associated with clinical activity (complete or partial response, or stable disease ≥ 24 wks). Increased DTH reactions were noted for tetanus, 24–72 hrs (3 mg/kg: 5/7 pts; 10 mg/kg: 3/6 pts); tuberculin, 15 min (3 mg/kg: 7/15 pts; 10 mg/kg: 4/15 pts); Candida, 15 min (3 mg/kg: 4/6 pts; 10 mg/kg: 2/7 pts); and Trichophyton, 15 min (3 mg/kg: 3/4 pts; 10 mg/kg: 2/5 pts). Significant increases from BL in percents of HLA-DR+ CD4+ (p = 9.3x10-7), HLA-DR+ CD8+ (p = 0.018), and ICOS+ CD4+ (p = 0.0027) effector T cells were noted. Conclusions: Humoral immunity in ipilimumab-treated pts increased (± vaccination) in an Ag-dependent manner and cellular immunity was enhanced. Change in tumor Ag response was not associated with clinical activity.

[Table: see text]

A case of amyoplasia in a monochorionic twin pregnancy: a sequela from twin-twin transfusion syndrome?

OBJECTIVE

To present and discuss the sonographic and clinical findings in one twin of a monochorionic pair affected by amyoplasia.

METHODS

On ultrasound examination at 21 weeks in a monochorionic twin pregnancy, twin I was smaller, hydropic, with multiple contractures consistent with amyoplasia and oligohydramnios. Twin II was anatomically normal with polyhydramnios.

RESULTS

The twins were delivered at 28 weeks' gestation. The clinical findings were consistent with twin-twin transfusion syndrome (TTTS).

CONCLUSION

It is postulated that TTTS may be a causative factor in the excessive incidence of amyoplasia in monozygotic twin pregnancy.

The methodological soundness of literature reviews addressing three potential zoonotic public health issues

Literature reviews are important information sources for multiple stakeholders in zoonotic public health with limited time to keep up with the rapid increase in primary research in this field. However, their validity depends on their methodological soundness. The study purpose was to evaluate the methodological soundness of literature reviews in zoonotic public health. Relevant reviews (n = 132) published between January 2000 and August 2006 were identified on three issues: Mycobacterium avium ssp paratuberculosis as a potential cause of Crohn's disease in humans (30 reviews); antimicrobial use in animals as a risk factor for antimicrobial resistance in human pathogens (36); and the zoonotic potential of transmissible spongiform encephalopathies (66). The zoonotic aspect of the issue was the focus of 59 reviews and a subsection of 73 reviews. Two independent reviewers evaluated reviews using 13 criteria: 10 previously validated in the medical field, and three applicable to aetiology research. No review met more than eight of 13 criteria for methodological soundness; two articles met only one criterion. Two reviews described methods for identifying relevant primary research. In only two and four reviews respectively, authors conducted quantitative syntheses of research evidence or reported summarized measures of effect for the zoonotic risk to humans. Recommendations for future research and economic impact were provided in 64 and 10 reviews respectively. In 14 reviews, conclusions exceeded evidence presented. The various review authors' position on the evidence for the zoonotic association and the zoonotic risk to public health were inconsistent for all three issues. Reviews addressing potential zoonotic public health issues lack structured and transparent methodology preventing the end user from assessing the review's validity. These reviews should adhere to structured scientific principles similar to what is used for primary research articles.

Antenatal diagnosis of anophthalmia by three-dimensional ultrasound: a novel application of the reverse face view

The prenatal diagnosis of anophthalmia can be made on the demonstration of absent eye globe and lens on the affected side(s) on two-dimensional ultrasound examination, but when the fetal head position is unfavorable three-dimensional (3D) ultrasound may reveal additional diagnostic sonographic features, including sunken eyelids and small or hypoplastic orbit on the affected side(s). We present two cases of isolated anophthalmia diagnosed on prenatal ultrasound examination in which 3D ultrasound provided additional diagnostic information. The reverse face view provides valuable information about the orbits and the eyeballs for prenatal diagnosis and assessment of anophthalmia.

Does incontinence severity correlate with quality of life? Prospective analysis of 502 consecutive patients

OBJECTIVE

The Fecal Incontinence Severity Index (FISI) is widely used in the assessment of patients with faecal incontinence, but the relationship between FISI and the measurements of quality of life, such as the Fecal Incontinence Quality of Life Scale (FIQL) and the Medical Outcomes Survey (SF-36) has not been evaluated previously. The aim of the present study was to evaluate the relationship between disease severity and quality of life in a large cohort of patients.

METHOD

Five hundred and two consecutive patients (84.4% female, mean age 56 years) were evaluated for faecal incontinence between May 2004 and October 2005. Patients completed FISI, FIQL and SF-36 questionnaires. Pearson's coefficients were determined for the relationships between FISI and subscales of FIQL and SF-36. Quality of life scores were compared between groups of patients with different levels of incontinence severity (mild, moderate, severe) using Student's t-test.

RESULTS

Sixty-eight per cent of patients were incontinent of solid stool, 62% of liquid stool, and 90% of gas or mucus. The average FISI score was 36 (0-61). Moderate correlations were found between FISI and all subscales in FIQL (negative 0.29 to 0.41; P < 0.0001). Weak correlations were found between FISI and the social functioning (-0.21) and mental health (-0.17) scales in SF-36 (P < 0.05). Scores on the FIQL differed significantly between mild, moderate and severe incontinence.

CONCLUSION

FISI was only moderately correlated with a disease-specific quality of life measurement (FIQL). Even though this supports the common assumption that the quality of life in the patients with faecal incontinence worsens with an increase in disease severity, it also stresses the need of measuring both variables to determine the true impact of any treatment.

Complete validation of a unique digestion assay to detect Trichinella larvae in horse meat demonstrates the reliability of this assay for meeting food safety and trade requirements

A tissue digestion assay using a double separatory funnel procedure for the detection of Trichinella larvae in horse meat was validated for application in food safety programs and trade. The assay consisted of a pepsin-HCl digestion step to release larvae from muscle tissue and two sequential sedimentation steps in separatory funnels to recover and concentrate larvae for detection with a stereomicroscope. With defined critical control points, the assay was conducted within a quality assurance system compliant with International Organization for Standardization-International Electrotechnical Commission (ISO/IEC) 17025 guidelines. Samples used in the validation were obtained from horses experimentally infected with Trichinella spiralis to obtain a range of muscle larvae densities. One-, 5-, and 10-g samples of infected tissue were combined with 99, 95, and 90 g, respectively, of known negative horse tissue to create a 100-g sample for testing. Samples of 5 and 10 g were more likely to be positive than were 1-g samples when larval densities were less than three larvae per gram (lpg). This difference is important because ingested meat with 1 lpg is considered the threshold for clinical disease in humans. Using a 5-g sample size, all samples containing 1.3 to 2 lpg were detected, and 60 to 100% of samples with infected horse meat containing 0.1 to 0.7 lpg were detected. In this study, the double separatory funnel digestion assay was efficient and reliable for its intended use in food safety and trade. This procedure is the only digestion assay for Trichinella in horse meat that has been validated as consistent and effective at critical levels of sensitivity.

Surgical laser use in implantology and endodontics

The use of surgical lasers has been advocated to aid in the placement and second stage recovery of dental implants, together with soft tissue contouring. In addition, laser use has been suggested as an aid in decontamination of the implant surface in cases of peri-implantitis. In endodontics, the association of laser energy with dentine hypersensitivity, bacteriocidal action and pulp-capping, has led to a growing number of reports as to its beneficial use, together with claims of morphological changes in the canal wall, to enhance endodontic treatment success.

A systematic review of the effectiveness of magnetic resonance imaging (MRI) as an addition to mammography and ultrasound in screening young women at high risk of breast cancer

Breast magnetic resonance imaging (MRI) has been proposed as an additional screening test for young women at high risk of breast cancer in whom mammography alone has poor sensitivity. We conducted a systematic review to assess the effectiveness of adding MRI to mammography with or without breast ultrasound and clinical breast examination (CBE) in screening this population. We found consistent evidence in 5 studies that adding MRI provides a highly sensitive screening strategy (sensitivity range: 93-100%) compared to mammography alone (25-59%) or mammography plus ultrasound+/-CBE (49-67%). Meta-analysis of the three studies that compared MRI plus mammography versus mammography alone showed the sensitivity of MRI plus mammography as 94% (95%CI 86-98%) and the incremental sensitivity of MRI as 58% (95%CI 47-70%). Incremental sensitivity of MRI was lower when added to mammography plus ultrasound (44%, 95%CI 27-61%) or to the combination of mammography, ultrasound plus CBE (31-33%). Estimates of screening specificity with MRI were less consistent but suggested a 3-5-fold higher risk of patient recall for investigation of false positive results. No studies assessed as to whether adding MRI reduces patient mortality, interval or advanced breast cancer rates, and we did not find strong evidence that MRI leads to the detection of earlier stage disease. Conclusions about the effectiveness of MRI therefore depend on assumptions about the benefits of early detection from trials of mammographic screening in older average risk populations. The extent to which high risk younger women receive the same benefits from early detection and treatment of MRI-detected cancers has not yet been established.

Lasers and soft tissue: 'loose' soft tissue surgery

Oral soft tissue is composed of collagen, water, pigmented connective tissue, blood and lymphatic vessels. In that each may be considered target chromophores, all commercially available laser wavelengths in dentistry will interact with these component elements to a greater or lesser extent. What is of prime importance is that consideration is given to the predominant chromophore in any target tissue and the laser wavelength matched to achieve maximum absorption of light energy. Laser surgery can offer haemostasis, fewer post-operative complications and greater patient acceptance. This article examines the common 'loose' soft tissue management procedures in general dental practice and how the use of lasers can enable the clinician to deliver responsible care.

Laser regulation and safety in general dental practice

Laser devices, instruments and machines vary in their potential for light energy emission from low-powered hand-held or integrated devices, to high-powered units capable of cutting and ablating tissue and materials. The safe use of lasers in dentistry extends to all personnel who might be exposed, either deliberately or by accident, and demands of the lead clinician an approach to their use in order that risk of accidental exposure to laser light is minimised. The scope for regulations extends in similar ways to those imposed on the use of ionising radiation in the dental practice. Laser safety measures in the dental surgery are often drawn from the safe approach to the use of lasers in general and other specialties in medicine and surgery. This article serves to examine the risks involved in laser use in dentistry, the regulations governing safe use and the responsibilities of personnel involved in providing treatment to patients.

Translational mini-review series on vaccines: The Edward Jenner Museum and the history of vaccination

Edward Jenner's discovery of vaccination must rank as one of the most important medical advances of all time and is a prominent example of the power of rational enquiry being brought to bear during the Age of Enlightenment in 18th century Europe. In the modern era many millions of lives are saved each year by vaccines that work essentially on the same principles that were established by Edward Jenner more than 200 years ago. His country home in Berkeley, Gloucestershire, is where he carried out his work and where he spent most of his life. The building is now a museum in which the life and times of Jenner are commemorated including not only the discovery of smallpox vaccination but also his other important scientific contributions to natural history and medicine. The trustees of the Edward Jenner museum are committed to promoting the museum as a real and "virtual" educational centre that is both entertaining and informative.

Surgical lasers and hard dental tissue

The cutting of dental hard tissue during restorative procedures presents considerable demands on the ability to selectively remove diseased carious tissue, obtain outline and retention form and maintain the integrity of supporting tooth tissue without structural weakening. In addition, the requirement to preserve healthy tissue and prevent further breakdown of the restoration places the choice of instrumentation and clinical technique as prime factors for the dental surgeon. The quest for an alternative treatment modality to the conventional dental turbine has been, essentially, patient-driven and has led to the development of various mechanical and chemical devices. The review of the literature has endorsed the beneficial effects of current laser machines. However utopian, there is additional evidence to support the development of ultra-short (nano- and femto-second) pulsed lasers that are stable in use and commercially viable, to deliver more efficient hard tissue ablation with less risk of collateral thermal damage. This paper explores the interaction of laser energy with dental hard tissues and bone and the integration of current laser wavelengths into restorative and surgical dentistry.

Lasers and soft tissue: periodontal therapy

Periodontology exists as a major specialty within clinical dentistry that has developed through the extensive research carried out into all parameters pertaining to a 'best practice' approach. With the advent of surgical lasers into clinical dentistry, considerable interest has been shown in the possible benefits that might be derived from the adjunctive effects of bacterial control and haemostasis that are associated with laser use. Despite the number of publications on the subject, there is still controversy over the use of lasers in periodontology. The following paper will outline the procedures that have been advocated for laser use and provide a review of the literature.

Lasers and soft tissue: 'fixed' soft tissue surgery

Within a general practice setting, there are few benign pathological conditions of the attached or keratinised gingival complex that are not amenable to simple surgical intervention. The majority of surgical procedures are adjunctive to the delivery of restorative dentistry. There is an understandable dogma worldwide towards the management of soft tissues as they interface with restorative procedures. Contemporary teaching, both at undergraduate and postgraduate level, would recognise the need for a period of wound healing and stability, based on scalpel-induced incisional therapy. The use of laser wavelengths, based on predictable evidence-based protocols, has re-defined the surgical management of keratinised mucosa that is bound to the underlying periosteum and bone. This can be seen as being of benefit to the clinician in determining the outcome, and the patient in achieving quality results.

Verifiable CPD paper: laser-tissue interaction

The oral cavity is a unique and complex environment, where hard and soft tissues exist in close proximity, within bacteria-laden saliva. All oral tissues are receptive to laser treatment, but the biophysics governing laser-tissue interaction demands a knowledge of all factors involved in delivery of this modality; through this knowledge, correct and appropriate treatment can be delivered in a predictable manner.

Low-level laser use in dentistry

The use of laser light at power levels below that capable of direct tissue change (protein denaturation, water vaporisation and tissue ablation), has been advocated in diverse branches of medicine and veterinary practice, yet its acceptance in general dental practice remains low. However, the scope for using low-level laser light (LLLT) has emerged through many applications, either directly or indirectly tissue-related, in delivering primary dental care. The purpose of this article is to explain the mechanisms of action and to explore the uses of this group of lasers in general dental practice.

Verifiable CPD paper: introduction, history of lasers and laser light production

The word laser conjures in the mind's eye many aspects of what might be described as 'modern' life. The words 'powerful', 'precise' and 'innovative' complement our conception of the world in terms of technology, whereas patients often associate the words 'magical' and 'lightening quick' with the use of lasers in medical practice. The purpose of this series of articles is to explore the history and development of lasers, the integration of lasers into clinical dentistry and the safeguards as to their regulated use.

A software framework for solving problems of bioelectricity applying high-order finite elements

Electrical activity in biological media can be described in a mathematical way, which is applicable to computer-based simulation. Biophysically mathematical descriptions provide important insights into the electrical and electrophysiological properties of cells, tissues, and organs. Examples of these descriptions are Maxwell's and Poisson's equations for electromagnetic and electric fields. Commonly, numerical techniques are applied to calculate electrical fields, e.g. the finite element method. Finite elements can be classified on the order of the underlying Interpolation. High-order finite elements provide enhanced geometric flexibility and can increase the accuracy of a solution. The aim of this work is the design of a framework for describing and solving high-order finite elements in the SCIRun/BioPSE software system, which allows geometric modeling, simulation, and visualization for solving bioelectric field problems. Currently, only low-order elements are supported. Our design for high-order elements concerns interpolation of geometry and physical fields. The design is illustrated by an implementation of one-dimensional elements with cubic interpolation of geometry and field variables.

Further characterization of a rat model of varicella zoster virus-associated pain: Relationship between mechanical hypersensitivity and anxiety-related behavior, and the influence of analgesic drugs

Persistent herpes zoster-associated pain is a significant clinical problem and an area of largely unmet therapeutic need. Progress in elucidating the underlying pathophysiology of zoster-associated pain and related co-morbidity behavior, in addition to appropriately targeted drug development has been hindered by the lack of an appropriate animal model. This study further characterizes a recently developed rat model of zoster-associated hypersensitivity and investigates (a) response to different viral strains; (b) relationship between viral inoculum concentration ('dose') and mechanical hypersensitivity ('response'); (c) attenuation of virus-associated mechanical hypersensitivity by clinically useful analgesic drugs; and (d) measurement of pain co-morbidity (anxiety-like behavior) and pharmacological intervention in the open field paradigm (in parallel with models of traumatic peripheral nerve injury). Varicella zoster virus was propagated on fibroblast cells before s.c. injection into the glabrous footpad of the left hind limb of adult male Wistar rats. Control animals received injection of uninfected fibroblast cells. Hind-limb reflex withdrawal thresholds to mechanical, noxious thermal and cooling stimuli were recorded at specified intervals post-infection. Infection with all viral strains was associated with a dose-dependent mechanical hypersensitivity but not a thermal or cool hypersensitivity. Systemic treatment with i.p. morphine (2.5 mg/kg), amitriptyline (10 mg/kg), gabapentin (30 mg/kg), (S)-(+)-ibuprofen (20 mg/kg) and the cannabinoid WIN55,212-2 (2 mg/kg) but not the antiviral, acyclovir (50 mg/kg), was associated with a reversal of mechanical paw withdrawal thresholds. In the open field paradigm, virus-infected and nerve-injured animals demonstrated an anxiety-like pattern of ambulation (reduced entry into the central area of the open arena) which was positively correlated with mechanical hypersensitivity. This may reflect pain-related co-morbidity. Further, anxiety-like behavior was attenuated by acute i.p. administration of gabapentin (30 mg/kg) in nerve-injured, but not virus-infected animals. This model will prove useful in elucidating the pathophysiology of zoster-associated pain and provide a tool for pre-clinical screening of analgesic drugs.

Characterisation of some experimental silicones

Release of antimicrobials/antibacterials like chlorhexidine diacetate (CHD) has proved successful in inhibiting Candidal colonisation of silicone-based biomaterials. However, their addition will increase water uptake and may compromise the mechanical integrity. Two experimental silicones (S1 and S2) differing only in the surface treatment of the filler, were investigated. Ultimate tensile strength (UTS), % elongation at break (Eb), Shore A hardness and, when doped with 1% CHD, water uptake and CHD release were measured. Elastic modulus (E) was calculated from the hardness measurements. There was no significant difference in UTS and Eb between the two materials. However S1 had a higher hardness (30.6 +/- 0.97) and thus E (0.76 MPa) than S2 (hardness = 23.8 +/- 0.48, E = 0.45 MPa). Water uptake for S2 (0.6%) was higher than for S2 (0.1) and addition of CHD dramatically increased the uptake of both (S1 = 3.1%, S2 = 4.0%). Release of CHD was higher for S2 (30%) than S1 (27%). Equating osmotic pressure within the droplets with elastic restraining force gave an extension ratio of 1.95 for S1 and 5.39 for S2. Thus, addition of a hydrophilic agent can compromise the mechanical integrity of low modulus silicones.

Vorinostat (suberoylanilide hydroxamic acid, SAHA) is clinically active in advanced cutaneous T-cell lymphoma (CTCL): Results of a phase IIb trial

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Background: Vorinostat is a histone deacetylase inhibitor that has demonstrated clinical activity at tolerable dose levels in patients (pts) with advanced CTCL in phase I and IIa trials. Methods: Open-label, single-arm, nonrandomized phase IIb trial of oral vorinostat 400 mg daily until disease progression or intolerable toxicity. Eligibility: advanced CTCL; ≥ 2 prior systemic therapies which must have included bexarotene unless unable to tolerate; adequate hematologic, hepatic and renal function. Planned sample size: ≥ 50 evaluable pts with clinical stage ≥ IIB. Primary endpoint: objective response rate (OR = CR + PR) as measured by a modified skin severity weighted assessment tool. The study would be positive if OR in ≥ stage IIB pts was ≥ 20%. Secondary endpoints: assessment of response duration (DOR), time to progression (TTP), time to response (TTR), pruritus relief and safety. Results: Seventy-four pts (median age, 60 y [range, 39–83]; median 3 prior systemic therapies) were enrolled (61 pts ≥ stage IIB) from 9/04 to 5/05 at 18 centers. Data cut-off was 11/05 with a median follow-up of 4 months. Efficacy data are shown in Table 1 . The OR was 29.5% (18 PR including 1 with later CR) in ≥ stage IIB pts. Median TTP was 148 d for all pts and 203.5+ d for responders. The most common drug-related adverse experiences (AE) were diarrhea (49%), fatigue (46%), nausea (43%) and anorexia (26%), and were mostly ≤ Grade 2. Drug-related ECG changes were Grade 1 in 5 pts (7%) and Grade 2 in 1 pt (1%), but not associated with cardiac symptoms. Seven pts discontinued and 10 had dose modification due to drug-related AE. Drug-related AE ≥ Grade 3 included fatigue (5%), pulmonary embolism (5%), nausea (4%) and thrombocytopenia (4%). Twenty-five pts discontinued due to progressive disease. Causes of the 3 deaths on study were: unknown (d 2), ischemic stroke (d 227) and disease progression (d 52). Conclusion: Oral vorinostat is effective in the treatment of advanced CTCL with an acceptable safety profile.

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