Activity and safety of radiotherapy with anti-PD-1 drug therapy in patients with metastatic melanoma

The anti-PD-1 antibodies nivolumab and pembrolizumab are active in metastatic melanoma; however, there is limited data on combining anti-PD-1 antibody and radiotherapy (RT). We sought to review clinical outcomes of patients receiving RT and anti-PD-1 therapy. All patients receiving anti-PD-1 antibody and RT for metastatic melanoma were identified. RT and systemic treatment, clinical outcome, and toxicity data were collected. Fifty-three patients were included; 35 patients received extracranial RT and/or intracranial stereotactic radiosurgery (SRS) and 21 received whole brain radiotherapy (WBRT) (three of whom also received SRS/extracranial RT). Patients treated with extracranial RT or SRS received treatment either sequentially (RT then anti-PD-1, n = 11), concurrently (n = 16), or concurrent "salvage" treatment to lesions progressing on anti-PD-1 therapy (n = 15). There was no excessive anti-PD-1 or RT toxicity observed in patients receiving extracranial RT. Of six patients receiving SRS, one patient developed grade 3 radiation necrosis. In 21 patients receiving WBRT, one patient developed Stevens-Johnson syndrome, one patient developed acute neurocognitive decline, and one patient developed significant cerebral edema in the setting of disease. Response in irradiated extracranial/intracranial SRS lesions was 44% for sequential treatment and 64% for concurrent treatment (p=0.448). Likewise there was no significant difference between sequential or concurrent treatment in lesional response of non-irradiated lesions. For progressing lesions subsequently irradiated, response rate was 45%. RT and anti-PD-1 antibodies can be safely combined, with no detectable excess toxicity in extracranial sites. WBRT and anti-PD-1 therapy is well tolerated, although there are rare toxicities and the role of either anti-PD-1 or WBRT in the etiology of these is uncertain.

Electromyography characterization of stretch responses in hemiparetic stroke patients and their relationship with the Modified Ashworth Scale

Objectives: To determine the validity of the Modified Ashworth Scale as a measure of spasticity by determining its relationship to surface electromyography activity and contracture.

Design: A controlled study of hemiparetic stroke patients with spasticity.

Setting: A physiotherapy department in a secondary care hospital.

Subjects: Thirty-one stroke patients and 20 healthy volunteers.

Main measures: The resistance to passive movement around the knee and ankle of the affected and unaffected legs was rated using the Modified Ashworth Scale. Passive range of movement was measured with a goniometer. Surface electromyography recordings of four lower limb muscles were taken during passive stretches of the knee and ankle.

Results: Hemiparetic patients produced surface electromyography responses to stretch that were of greater amplitude (unaffected limbs: mean = 25.82 mV (43.85), affected limbs: mean = 24.77 mV (35.46)) than those of healthy volunteers (mean = 15.85 (29.96)). The affected muscles of hemiparetic patients were more likely to produce surface electromyography responses to stretch of a sustained duration (45% of cases) compared with unaffected limbs (24% of cases) and those of healthy volunteers (16% of cases). The Modified Ashworth Scale showed a positive correlation with the magnitude ( p &lt 0.05) and duration ( p &lt 0.001) of the surface electromyography response. High scores on the Modified Ashworth Scale were associated with contracture ( p &lt 0.001). Contracted muscles produced significantly greater surface electromyography reflex responses compared with noncontracted muscles ( p &lt 0.05).

Conclusion: The Modified Ashworth Scale reflects spasticity in terms of surface electromyography stretch responses produced by passive movement, but the relationship of spasticity to contracture remains unclear.

What PASSes for good? Experience-based Swedish and hypothetical British EuroQol 5-Dimensions preference sets yield markedly different point estimates and patient acceptable symptom state cut-off values in chronic arthritis patients on TNF blockade

OBJECTIVES

Health utilities derived from answers to generic health-related quality of life (HRQoL) questionnaires such as the EuroQol 5-Dimensions (EQ-5D) are often used in cost-utility analyses (CUAs) of new and expensive treatments. Different preference sets (tariffs) used in the computation of utility values and quality-adjusted life-years (QALYs) from questionnaire responses (health states) yield varying results, potentially affecting decisions of resource allocation. The objective of the present study was to compare British (UK), hypothetical, and Swedish (SE), experience-based, EQ-5D utilities using data from clinical practice.

METHOD

UK and SE EQ-5D utilities were computed in an observational cohort of patients with rheumatoid arthritis (RA), spondyloarthritis (SpA), and psoriatic arthritis (PsA) treated with tumour necrosis factor (TNF) blockers, comparing point estimates and patient acceptable symptom state (PASS) cut-off levels.

RESULTS

SE utilities were found to be consistently higher than UK utilities, and PASS cut-offs were essentially stable over time.

CONCLUSIONS

With higher baseline utilities, there may be less room for improvement after an intervention and thus less accumulation of QALYs in CUAs applying the SE, as opposed to the UK, EQ-5D tariff.

FRAX-based assessment and intervention thresholds--an exploration of thresholds in women aged 50 years and older in the UK

Under current guidelines, based on prior fracture probability thresholds, inequalities in access to therapy arise especially at older ages (≥70 years) depending on the presence or absence of a prior fracture. An alternative threshold (a fixed threshold from the age of 70 years) reduces this disparity, increases treatment access and decreases the need for bone densitometry.

INTRODUCTION

Several international guidelines set age-specific intervention thresholds at the 10-year probability of fracture equivalent to a woman of average BMI with a prior fracture. At older ages (≥70 years), women with prior fracture selected for treatment are at lower average absolute risk than those selected for treatment in the absence of prior fracture, prompting consideration of alternative thresholds in this age group.

METHODS

Using a simulated population of 50,633 women aged 50-90 years in the UK, with a distribution of risk factors similar to that in the European FRAX derivation cohorts and a UK-matched age distribution, the current NOGG intervention and assessment thresholds were compared to one where the thresholds remained constant from 70 years upwards.

RESULTS

Under current thresholds, 45.1% of women aged ≥70 years would be eligible for therapy, comprising 37.5% with prior fracture, 2.2% with high risk but no prior fracture and 5.4% selected for treatment after bone mineral density (BMD) measurement. Mean hip fracture probability was 11.3, 23.3 and 17.6%, respectively, in these groups. Under the alternative thresholds, the overall proportion of women treated increased from 45.1 to 52.9%, with 8.4% at high risk but no prior fracture and 7.0% selected for treatment after BMD measurement. In the latter group, the mean probability of hip fracture was identical to that observed in women with prior fracture (11.3%). The alternative threshold also reduced the need for BMD measurement, particularly at older ages (>80 years).

CONCLUSIONS

The alternative thresholds equilibrate fracture risk, particularly hip fracture risk, in those with or without prior fracture selected for treatment and reduce BMD usage at older ages.

Enhanced enzymatic degradation resistance of plasmid DNA in ionic liquids

Buffered ionic liquids can substantially enhance enzymatic degradation resistance of plasmid DNA, indicating the potential to serve as next-generation biological storage buffer at ambient temperature.

Maggots as a wound debridement agent for chronic venous leg ulcers under graduated compression bandages: A randomised controlled trial

Objectives

Slough in chronic venous leg ulcers may be associated with delayed healing. The purpose of this study was to assess larval debridement in chronic venous leg ulcers and to assess subsequent effect on healing.

Methods

All patients with chronic leg ulcers presenting to the leg ulcer service were evaluated for the study. Exclusion criteria were: ankle brachial pressure indices <0.85 or >1.25, no venous reflux on duplex and <20% of ulcer surface covered with slough. Participants were randomly allocated to either 4-layer compression bandaging alone or 4-layer compression bandaging + larvae. Surface areas of ulcer and slough were assessed on day 4; 4-layer compression bandaging was then continued and ulcer size was measured every 2 weeks for up to 12 weeks.

Results

A total of 601 patients with chronic leg ulcers were screened between November 2008 and July 2012. Of these, 20 were randomised to 4-layer compression bandaging and 20 to 4-layer compression bandaging + larvae. Median (range) ulcer size was 10.8 (3–21.3) cm2 and 8.1 (4.3–13.5) cm2 in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Mann–Whitney U test, P = 0.184). On day 4, median reduction in slough area was 3.7 cm2 in the 4-layer compression bandaging group ( P < 0.05) and 4.2 cm2 ( P < 0.001) in the 4-layer compression bandaging + larvae group. Median percentage area reduction of slough was 50% in the 4-layer compression bandaging group and 84% in the 4-layer compression bandaging + larvae group (Mann–Whitney U test, P < 0.05). The 12-week healing rate was 73% and 68% in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Kaplan–Meier analysis, P = 0.664).

Conclusions

Larval debridement therapy improves wound debridement in chronic venous leg ulcers treated with multilayer compression bandages. However, no subsequent improvement in ulcer healing was demonstrated.

Use of dermal injection of activated protein C for treatment of large chronic wounds secondary to pyoderma gangrenosum

BACKGROUND

Pyoderma gangrenosum (PG) is a systemic disease that presents with cutaneous necrotizing ulceration, producing deep necrotic ulcers, usually with a raised, undermined, violaceous border. Treatment typically involves high dose immunosuppressive drugs, but more recently anti-tumour necrosis factor and monoclonal antibodies have been used. Activated protein C (APC) stimulates wound healing in patients with treatment-refractory skin ulcers, possibly by stimulating angiogenesis and re-epithelialization, and preventing inflammation.

AIM

To investigate whether APC may be beneficial as a treatment for ulcers related to cutaneous PG.

METHODS

Two patients were recruited with a clinical history and physical and histopathological evidence of acute PG. A total of 400 μg (1.0 mL) of APC was injected subcutaneously into the dermal edge of necrotic PG ulcers weekly for a total treatment period of 6 weeks. Photographs were taken, and clinical progress, ulcer size and pain score were monitored during this period and after the cessation of treatment, at weeks 8 and 12.

RESULTS

Over the 12 weeks of the trial, APC led to a reduction in wound size from 3.8 cm(2) to 0.8 cm(2) in patient 1 (78.9% decrease) and from 41 cm(2) to 16 cm(2) in patient 2 (70.0% decrease, respectively), and a reduction in pain scores from 10 to 0 (100% decrease) in both patients.

CONCLUSION

Although this study has limited because of its small sample size and lack of a true placebo group, it does indicate that APC has potential as a therapeutic option for patients with chronic skin ulcers from PG.

Murray J. 226 HUMAN LACTOFERRIN EXPRESSED IN COW MILK CAN EXTEND THE SHELF LIFE OF MILK

Lactoferrin (LF) is an antimicrobial protein that is produced at high levels in human secretions, including milk, but is present at very low levels in the milk of ruminants. Lactoferrin is an iron-binding protein, and because iron is required by some bacteria to grow, lactoferrin can reduce the growth of certain bacteria. Lactoferrin can inhibit the growth of gram-negative bacteria, gram-positive bacteria, yeast, and some antibiotic-resistant pathogens. Lactoferrin also has bacteriocidal activity, killing the organism by inducing membrane perturbations often in conjunction with other antimicrobial agents such as lysozyme. Due to these properties, lactoferrin has the potential to increase the health of lactating animals as well as extend the shelf life of the milk. A herd of cows were genetically engineered to produce milk containing recombinant human lactoferrin (rhLF-milk) at approximately the same concentration found in human milk. In this study, growth of bacteria in raw milk samples from 2 control cows was compared with that from 2 cows that produce rhLF-milk. The experiment examined the shelf life of milk at room temperature over a 72-h period and the shelf life of milk left at 4°C over 3 weeks by plating aliquots on agar plates and counting the number of bacterial colonies that grew on plates after 24 and 48 h. The milk left at room temperature was plated at 0, 24, 48, and 72 h. The milk left in at 4°C was measured at 0, 4, 7, 11, 14, 18, and 21 days. Statistical evaluations were conducted using SAS statistical software, version 9.3 (SAS Institute Inc., Cary, NC, USA). Bacterial data were compared using the repeated-measures function in SAS and the Greenhouse-Geisser epsilon test to determine differences. For all tests, P-values <0.05 were considered statistically significant. The rhLF-milk showed less bacteria growth than control milk over the 4 time periods when left at room temperature (P = 0.0029), but did not inhibit the growth of bacteria when held for longer periods at 4°C (P = 0.6031). This shows that rhLF-milk may have an extended shelf life at room temperature and thus may be a means to increase food availability in developing countries. The next step in this research will be examining the populations of bacteria in the milk to determine how rhLF alters the populations of bacteria growing in milk over time, the different types of bacteria populations between the rhLF and control milk and what their effects are.

Design of surface sites for the selective hydrogenation of 1,3-butadiene on Pd nanoparticles: Cu bimetallic formation and sulfur poisoning

Control of selectivity in the hydrogenation of 1,3-butadiene is achieved by tuning the graphite-supported Pd catalyst’s properties.