Diarrhea Morbidities in Small Areas: Accounting for Non-Stationarity in Sociodemographic Impacts using Bayesian Spatially Varying Coefficient Modelling

Model-based estimation of diarrhea risk and understanding the dependency on sociodemographic factors is important for prioritizing interventions. It is unsuitable to calibrate regression model with a single set of coefficients, especially for large spatial domains. For this purpose, we developed a Bayesian hierarchical varying coefficient model to account for non-stationarity in the covariates. We used the integrated nested Laplace approximation for parameter estimation. Diarrhea morbidities in Ghana motivated our empirical study. Results indicated improvement regarding model fit and epidemiological benefits. The findings highlighted substantial spatial, temporal, and spatio-temporal heterogeneities in both diarrhea risk and the coefficients of the sociodemographic factors. Diarrhea risk in peri-urban and urban districts were 13.2% and 10.8% higher than rural districts, respectively. The varying coefficient model indicated further details, as the coefficients varied across districts. A unit increase in the proportion of inhabitants with unsafe liquid waste disposal was found to increase diarrhea risk by 11.5%, with higher percentages within the south-central parts through to the south-western parts. Districts with safe and unsafe drinking water sources unexpectedly had a similar risk, as were districts with safe and unsafe toilets. The findings show that site-specific interventions need to consider the varying effects of sociodemographic factors.

Incidence and management of diarrhea in patients with HER2-positive breast cancer treated with pertuzumab

Background

Pertuzumab disrupts heterodimerization between human epidermal growth factor receptor 2 (HER2) and epidermal growth factor receptor (EGFR), HER3, and HER4. Thus, pertuzumab could result in adverse events similar to those observed with EGFR antagonists, such as diarrhea. We report the incidence and severity of diarrhea observed with pertuzumab in the CLEOPATRA, NeoSphere, and TRYPHAENA studies.

Patients and methods

Patients (n = 1443) had metastatic [CLEOPATRA (n = 804)] or early-stage breast cancer [NeoSphere (n = 416) and TRYPHAENA (n = 223)]. The incidence and severity of diarrhea were analyzed by treatment received. The incidence of febrile neutropenia concurrent with diarrhea and the effect of pre-existing gastrointestinal comorbidities were also evaluated. Subgroup analyses were carried out using CLEOPATRA data.

Results

The incidence of all-grade diarrhea across studies was generally greater for pertuzumab-based treatment, ranging from 28% to 72% (grade 1, 21%-54%; grade 2, 8%-37%; grade 3, 0%-12%; grade 4, 0%). Incidence was highest during the first pertuzumab-containing cycle, decreasing with subsequent cycles. Dose delays or discontinuations due to diarrhea were infrequent, ranging from 0% to 8%. Among pertuzumab-treated patients with diarrhea, 47%-67% received pharmacological intervention, most commonly with loperamide. Overlap between diarrhea and febrile neutropenia was uncommon, ranging from 0% to 11%. No relationship was observed between pre-existing gastrointestinal comorbidities and diarrhea. In CLEOPATRA, patients ≥65 years treated with pertuzumab had a higher incidence of grade 3 diarrhea than patients <65 years (19% versus 8%). All-grade diarrhea occurred at greater frequency among pertuzumab-treated Asian versus white patients with metastatic breast cancer (74% versus 63%); the corresponding rates in the control arm were 53% and 45%, respectively.

Conclusions

In both the metastatic and early-stage breast cancer settings, diarrhea was common but manageable for all pertuzumab-containing regimens. Diarrheal episodes were mainly low grade and occurred most often during the first treatment cycle. Diarrheal-related drug delays or discontinuations were uncommon.

ClinicalTrials.gov identifiers

NCT00567190 (CLEOPATRA), NCT00545688 (NeoSphere), NCT00976989 (TRYPHAENA).

Search for Electronic Recoil Event Rate Modulation with 4 Years of XENON100 Data

We report on a search for electronic recoil event rate modulation signatures in the XENON100 data accumulated over a period of 4 yr, from January 2010 to January 2014. A profile likelihood method, which incorporates the stability of the XENON100 detector and the known electronic recoil background model, is used to quantify the significance of periodicity in the time distribution of events. There is a weak modulation signature at a period of 431_{-14}^{+16} day in the low energy region of (2.0-5.8) keV in the single scatter event sample, with a global significance of 1.9σ; however, no other more significant modulation is observed. The significance of an annual modulation signature drops from 2.8σ, from a previous analysis of a subset of this data, to 1.8σ with all data combined. Single scatter events in the low energy region are thus used to exclude the DAMA/LIBRA annual modulation as being due to dark matter electron interactions via axial vector coupling at 5.7σ.

The association between maternal postnatal depressive symptoms and offspring sleep problems in adolescence

BACKGROUND

Sleep problems are associated with increased risk of physical and mental illness. Identifying risk factors is an important method of reducing public health impact. We examined the association between maternal postnatal depression (PND) and offspring adolescent sleep problems.

METHOD

The sample was derived from Avon Longitudinal Study of Parents and Children (ALSPAC) participants. A sample with complete data across all variables was used, with four outcome variables. A sensitivity analysis imputing for missing data was conducted (n = 9633).

RESULTS

PND was associated with increased risk of sleep problems in offspring at ages 16 and 18 years. The most robust effects were sleep problems at 18 years [adjusted odds ratio (OR) for a 1 s.d. increase in PND, 1.26, 95% confidence interval (CI) 1.15-1.39, p < 0.001] and waking more often (adjusted OR 1.14, 95% CI 1.05-1.25, p = 0.003). This remained after controlling for confounding variables including antenatal depression and early sleep problems in infancy.

CONCLUSIONS

PND is associated with adolescent offspring sleep problems. Maternal interventions should consider the child's increased risk. Early sleep screening and interventions could be introduced within this group.

Improved nutrition in adolescents and young adults after childhood cancer - INAYA study

BACKGROUND

Multimodality treatment improves the chance of survival but increases the risk for long-term side effects in young cancer survivors, so-called" Adolescents and Young Adults"(AYAs). Compared to the general population AYAs have a 5 to 15-fold increased risk of cardiovascular morbidity. Thus, improving modifiable lifestyle risk factors is of particular importance.

METHODS

The INAYA trial included AYAs between 18 and 39 years receiving an intensified individual nutrition counseling at four time points in a 3-month period based on a 3-day dietary record. At week 0 and 12 AYAs got a face-to-face counseling, at week 2 and 6 by telephone. Primary endpoint was change in nutritional behavior measured by Healthy Eating Index - European Prospective Investigation into Cancer and Nutrition (HEI-EPIC).

RESULTS

Twenty-three AYAs (11 female, 12 male, median age 20 years (range 19-23 years), median BMI: 21.4 kg/m2 (range: 19.7-23.9 kg/m2) after completion of cancer treatment for sarcoma (n = 2), carcinoma (n = 2), blastoma (n = 1), hodgkin lymphoma (n = 12), or leukemia (n = 6) were included (median time between diagnosis and study inclusion was 44 month). The primary endpoint was met, with an improvement of 20 points in HEI-EPIC score in 52.2 % (n = 12) of AYAs. At baseline, median HEI-EPIC score was 47.0 points (range from 40.0 to 55.0 points) and a good, moderate and bad nutritional intake was seen in 4.3, 73.9 and 21.7 % of AYAs. At week 12, median HEI-EPIC improved significantly to 65.0 points (range from 55.0 to 76.0 points) (p ≤ 0.001) and a good, moderate and bad nutritional intake was seen in 47.8, 52.2 and 0 % of AYAs. No change was seen in quality of life, waist-hip ratio and blood pressure.

CONCLUSION

Intensified nutrition counseling is feasible and seem to improve nutritional behavior of AYAs. Further studies will be required to demonstrate long-term sustainability and confirm the results in a randomized design in larger cohorts.

TRIAL REGISTRATION

Clinical trial identifier DRKS00009883 on DRKS.

Pseudosyndactyly and Musculoskeletal Contractures in Inherited Epidermolysis Bullosa: Experience of the National Epidermolysis Bullosa Registry, 1986–2002

Mitten deformities of the hands and feet occur in nearly every patient with the most severe subtype (Hallopeau-Siemens) of recessive dystrophic epidermolysis bullosa, and in at least 40–50% of all other recessive dystrophic epidermolysis bullosa patients. Smaller numbers of patients with dominant dystrophic, junctional, and simplex types of epidermolysis bullosa are also at risk of this complication. Surgical intervention is commonly performed to correct these deformities, but recurrence and the need for repeated surgery are common. Higher numbers of epidermolysis bullosa patients also develop musculoskeletal contractures in other anatomic sites, further impairing overall function. Lifetable analyses not only better project the cumulative risk of mitten deformities and other contractures but also emphasize the need for early surveillance and intervention, since both of these musculoskeletal complications may occur within the first year of life.

Selective directed self-assembly of coexisting morphologies using block copolymer blends

Directed self-assembly (DSA) of block copolymers is an emergent technique for nano-lithography, but is limited in the range of structures possible in a single fabrication step. Here we expand on traditional DSA chemical patterning. A blend of lamellar- and cylinder-forming block copolymers assembles on specially designed surface chemical line gratings, leading to the simultaneous formation of coexisting ordered morphologies in separate areas of the substrate. The competing energetics of polymer chain distortions and chemical mismatch with the substrate grating bias the system towards either line/space or dot array patterns, depending on the pitch and linewidth of the prepattern. This is in contrast to the typical DSA, wherein assembly of a single-component block copolymer on chemical templates generates patterns of either lines/spaces (lamellar) or hexagonal dot arrays (cylinders). In our approach, the chemical template encodes desired local spatial arrangements of coexisting design motifs, self-assembled from a single, sophisticated resist.

There is a limited range of structures available in nanolithography using directed self-assembled block copolymers. Here, Black and co-workers expand directed self-assembly chemical patterning by using a blend of lamellar and cylinder forming block copolymers on surface chemical line gratings.

A novel microfluidic platform for size and deformability based separation and the subsequent molecular characterization of viable circulating tumor cells

Circulating tumor cells (CTCs) were introduced as biomarkers more than 10 years ago, but capture of viable CTCs at high purity from peripheral blood of cancer patients is still a major technical challenge. Here, we report a novel microfluidic platform designed for marker independent capture of CTCs. The Parsortix™ cell separation system provides size and deformability-based enrichment with automated staining for cell identification, and subsequent recovery (harvesting) of cells from the device. Using the Parsortix™ system, average cell capture inside the device ranged between 42% and 70%. Subsequent harvest of cells from the device ranged between 54% and 69% of cells captured. Most importantly, 99% of the isolated tumor cells were viable after processing in spiking experiments as well as after harvesting from patient samples and still functional for downstream molecular analysis as demonstrated by mRNA characterization and array-based comparative genomic hybridization. Analyzing clinical blood samples from metastatic (n = 20) and nonmetastatic (n = 6) cancer patients in parallel with CellSearch(®) system, we found that there was no statistically significant difference between the quantitative behavior of the two systems in this set of twenty six paired separations. In conclusion, the epitope independent Parsortix™ system enables the isolation of viable CTCs at a very high purity. Using this system, viable tumor cells are easily accessible and ready for molecular and functional analysis. The system's ability for enumeration and molecular characterization of EpCAM-negative CTCs will help to broaden research into the mechanisms of cancer as well as facilitating the use of CTCs as "liquid biopsies."

Abstract OT3-01-04: An open-label, single-arm, phase II study of pertuzumab with high-dose trastuzumab for the treatment of central nervous system progression post-radiotherapy in patients with HER2-positive metastatic breast cancer (PATRICIA)

Background: Central nervous system (CNS) metastases are observed in up to half of patients with HER2-positive metastatic breast cancer (MBC), with incidence likely to continue to rise due to longer survival through improved systemic treatments. While radiotherapy-based approaches can be effective, there are potential short- and long-term toxicities, and patients frequently progress. CNS response to existing systemic therapies has been generally poor, and there is a high unmet need with no approved treatment for CNS metastases in HER2-positive MBC. Combination of the HER2-targeted monoclonal antibodies trastuzumab and pertuzumab provides a more comprehensive blockade of HER2 than either antibody alone, and data from the phase III CLEOPATRA trial suggest that adding pertuzumab to trastuzumab and docetaxel may delay onset of CNS disease. Trastuzumab concentrations in the CNS are increased under conditions of an impaired blood–brain barrier (BBB) and subtherapeutic levels in the CNS may be related to insufficient dosing rather than inability to cross the BBB. The PATRICIA trial is evaluating the addition of pertuzumab with high-dose trastuzumab to a patient's current systemic treatment for HER2-positive MBC patients with CNS progression post-radiotherapy and stable systemic disease.

Study design: In this US-based, phase II, open-label, single-arm study, patients will receive intravenous pertuzumab (840 mg loading dose followed by 420 mg every 3 weeks) in combination with intravenous high-dose trastuzumab (6 mg/kg weekly) in addition to their current systemic therapy (except for ado-trastuzumab emtansine or lapatinib) until disease progression or unacceptable toxicity.

Eligibility criteria: Patients aged ≥18 years with confirmed HER2-positive MBC with new and/or progressive CNS lesions &gt;60 days after whole-brain radiotherapy or stereotactic radiosurgery for CNS metastases, performance status 0–1, and stable systemic disease will be eligible. Patients must have a baseline left ventricular ejection fraction (LVEF) ≥50%, no significant history of cardiac disease or current use of anthracyclines, life expectancy &gt;12 weeks, and not be pregnant or lactating.

Aims: The primary efficacy endpoint will be objective response rate (ORR) in the CNS, assessed by the investigator using RANO–BM criteria. Secondary endpoints will include duration of CNS response, progression-free survival (CNS and/or non-CNS), overall survival, and safety. Pharmacokinetic and patient-reported outcomes will also be evaluated. LVEF will be assessed throughout treatment and follow-up. An interim analysis will be performed when 15 patients have completed 2 cycles, and the study will be stopped if no clinical benefit (complete response, partial response, or stable disease in the CNS) is seen or if two or more patients have congestive heart failure events related to trastuzumab or pertuzumab.

Statistical methods: The recruitment target is 40 patients; with 35 evaluable, the 95% confidence interval around an estimated ORR of 20% will be 8.4–36.9%. The trial opens for accrual in Q3 2015.

Citation Format: Lin NU, Pegram MD, Lai C, Lacasia A, Stein A, Yoo B, Perez EA. An open-label, single-arm, phase II study of pertuzumab with high-dose trastuzumab for the treatment of central nervous system progression post-radiotherapy in patients with HER2-positive metastatic breast cancer (PATRICIA). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-01-04.

Abstract P4-14-14: Incidence and management of diarrhea in patients with HER2-positive breast cancer treated with pertuzumab

BACKGROUND:

Pertuzumab (P) in combination with trastuzumab (T) and docetaxel (D) is the approved first line SOC in patients with HER2 positive metastatic breast cancer and is approved neoadjuvantly in patients with HER2 positive stage Ib-IIIc breast cancer. Because of its role in heterodimerization with EGFR, P may cause adverse events associated with EGFR antagonists. Diarrhea is the most commonly reported AE due to P. Increased usage of P has generated clinical questions regarding the incidence and management of diarrhea. Here we report safety analyses of diarrhea from three P containing studies.

METHODS: The safety population evaluated in this exploratory analysis included 804 patients from CLEOPATRA, 416 patients from NeoSphere, and 223 from TRYPHAENA. Diarrhea incidence, severity (NCI-CTCAE v3.0), and management in P containing arms were analyzed.

RESULTS: The incidence and management of diarrhea in MBC (Table 1), EBC (Table 2):

CLEOPATRA P+T+D n=408Pla+T+D n=396Incidence of Events n (%)All Grades279 (68)193 (49)≥ Grade 338 (9)20 (5)Median time to 1st event (days) all grades / Interquartile Range (IQR)8 (4,44)23 (6,82)Discontinuation of any study drug8 (0.2)2 (0.6)Treatment n (%)Antidiarrheal treatment164 (40)77 (19)

 NeoSphere X4 followed by adjuvant FECx3TRYPHAENANeoadjuvant tx followed by T up to 1 yearT+D n=107P+T+D n=107P+T n=108P+D n=94FEC+P+T x3→P+T+D x3 n=72FEC x3 →P+T+D x3 n=75TCH+P x6 n=76Incidence of Events n (%) (neoadjuvant + adjuvant exposure)All Grades41 (38)55 (51)46 (43)53 (56)46 (64)47 (63)55 (72)≥ Grade 34 (4)7 (7)3 (3)5 (5)3 (4)4 (5)9 (12)Median time to 1st event (days) all grades / Interquartile Range (IQR)7 (4,24)8 (3,26)19 (4,117)6 (3,21)9 (4,30)69 (64,82)6 (3,21)Discontinuation of any study drug0000000Treatment n (%)Antidiarrheal treatment13 (12)23 (22)20 (19)28 (30)23 (32)22 (29)31 (41)pertuzumab(P)+trastuzumab(T)+docetaxel(D) FEC= 5FU, epirubicin, cyclophosphamide TCH= docetaxel,(T)carboplatin(C), trastuzumab(H)

The overall incidence of diarrhea events is greatest in the first cycle containing P: in CLEOPATRA (P+T+D) 43%, in NeoSphere (P+T+D) 34%, (P+T) 21%, and in TRYPHAENA (FEC+P+T→P+T+D) 40%, (FEC→P+T+D c4) 46%, and (TCH+P) 55%. Of patients experiencing diarrhea, the median number of events (all grades) for patients receiving P+T+D in CLEOPATRA and NeoSphere was 2 and 1 respectively, and 2 for patients receiving TCH+P in TRYPHAENA.

CONCLUSIONS:

Diarrhea was common in all P containing arms but events were mostly low grade and occurred more often with the first cycle. Events and management were similar in the EBC and MBC setting. Approximately half of patients required antidiarrheal treatment. However, rates of study drug discontinuation due to diarrhea were low. Studies of treatment associated diarrhea management are planned.

Citation Format: Swain SM, Schneeweiss A, Gianni L, Stein A, McNally V, Heeson S, Portera C, Yoo B, Cortes JC, Baselga J. Incidence and management of diarrhea in patients with HER2-positive breast cancer treated with pertuzumab. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-14-14.

Reevaluation of possible outcomes of infections with human immunodeficiency virus

Several lines of evidence indicate that HIV infection can result in several possible incomes, including a very small proportion of individuals whose HIV replication is controlled after treatment interruption (known as HIV posttreatment controllers) or spontaneously without any treatment (known as HIV elite controllers). Both types of individuals are HIV RNA negative but HIV DNA positive, with living virus which can be stimulated ex vivo. A review was conducted to assess the literature on yet rarer cases with detectable integrated HIV DNA without HIV infectious virus in HIV-seropositive or -negative individuals. Three categories of patients were identified: (a) HIV-seropositive individuals with apparent spontaneous cure from their HIV infection, (b) HIV-seronegative children born to HIV-infected mothers and (c) highly exposed seronegative adults. Validity criteria were proposed to assess the presence of integrated HIV DNA as possible or unquestionable in these three categories. Only three articles among the 22 ultimately selected fulfilled these criteria. Among the highly exposed seronegative subjects, some individuals were described as being without integrated HIV DNA, probably because these subjects were not investigated using relevant, highly sensitive methods. Finally, we propose a definition of spontaneous cure of HIV infection based on clinical, immunologic and virologic criteria.

Maternal depression and anxiety predicts the pattern of offspring symptoms during their transition to adulthood

BACKGROUND

Episodes of depression and anxiety (D&A) during the transition from late adolescence to adulthood, particularly when persistent, are predictive of long-term disorders and associated public health burden. Understanding risk factors at this time is important to guide intervention. The current objective was to investigate the associations between maternal symptoms of D&A with offspring symptoms during their transition to adulthood.

METHOD

Data from a large population-based birth cohort study, in South Brazil, were used. Prospective associations between maternal D&A and offspring risk of these symptoms during the transition to adulthood (18/19, 24 and 30 years) were estimated.

RESULTS

Maternal D&A in adolescence was associated with offspring symptoms across the transition to adulthood, associations were consistently stronger for females than for males. Daughters whose mothers reported D&A were 4.6 times (95% confidence interval 2.71-7.84) as likely to report D&A at all three time-points, than daughters of symptom-free mothers.

CONCLUSIONS

Maternal D&A is associated with persistent D&A during the daughter's transition to adulthood. Intervention strategies should consider the mother's mental health.

The influence of mothers' and fathers' sensitivity in the first year of life on children's cognitive outcomes at 18 and 36 months

BACKGROUND

There has been increasing interest in the relative effects of mothers' and fathers' interactions with their infants on later development. However to date there has been little work on children's cognitive outcomes.

METHODS

We examined the relative influence of fathers' and mothers' sensitivity during interactions with their children at the end of the child's first year (10-12 months, n = 97), on child general cognitive development at 18 months and language at 36 months.

RESULTS

Both parents' sensitivity was associated with cognitive and language outcomes in univariate analyses. Mothers' sensitivity, however, appeared to be associated with family socio-demographic factors to a greater extent that fathers' sensitivity. Using path modelling the effect of paternal sensitivity on general cognitive development at 18 months and language at 36 months was significantly greater than the effect of maternal sensitivity, when controlling for socio-demographic background. In relation to language at 36 months, there was some evidence that sensitivity of one parent buffered the effect of lower sensitivity of the other parent.

CONCLUSIONS

These findings suggest that parental sensitivity can play an important role in children's cognitive and language development, and that higher sensitivity of one parent can compensate for the lower sensitivity of the other parent. Replication of these findings, however, is required in larger samples.

Foetal exposure to maternal depression predicts cortisol responses in infants: findings from rural South India

BACKGROUND

Maternal depression during pregnancy is associated with an increased risk of adverse child outcomes. One potential mechanism is the influence of antenatal depression on the foetal hypothalamic-pituitary-adrenal axis. This can be observed as disturbances in baseline cortisol secretion during childhood. The influence of antenatal depression on infant cortisol reactivity to a stressor may provide further insight into this association. In addition, the dose-response relationship between foetal exposure to antenatal depression and infant cortisol reactivity is unclear.

METHODS

A consecutive sample of 133 pregnant women in their third trimester was recruited from an antenatal clinic in Karnataka, South India. Women were assessed for depression before and after birth on the Edinburgh Postnatal Depression Scale (EPDS) and the Kessler 10 Scale. Salivary cortisol response to immunization was measured in 58 infants at 2 months of age. We aimed (i) to investigate the association between antenatal depression and infant cortisol reactivity to immunization and (ii) to explore whether the relationship is dose-dependent.

RESULTS

Exposure to antenatal depression independently predicted elevated infant cortisol responses to immunization (β = 0.53, P = 0.04). The association was found to be U-shaped, for antenatal depression measured on the EPDS, with the infants exposed to the highest and lowest levels of maternal antenatal EPDS scores during intra-uterine life showing elevated cortisol responses to immunization (R(2) = 0.20, P = 0.02). Infants exposed to moderate levels of maternal antenatal depression showed the lowest cortisol response to immunization.

CONCLUSIONS

These findings suggest that the association between antenatal depression and infant cortisol reactivity is dose-dependent and U-shaped, implying that infants exposed to both low and high levels of maternal depression showed greater reactivity. The study provides the first evidence of such an association from a low-income setting.