QT Interval Shortening With Isavuconazole: In Vitro and In Vivo Effects on Cardiac Repolarization

The effects of isavuconazole (active moiety of isavuconazonium sulfate) on cardiac ion channels in vitro and cardiac repolarization clinically were assessed in a phase I, randomized, double-blind study in healthy individuals who received isavuconazole (after 2-day loading dose), at therapeutic or supratherapeutic doses daily for 11 days, moxifloxacin (400 mg q.d.), or placebo. A post-hoc analysis of the phase III SECURE trial assessed effects on cardiac safety. L-type Ca2+ channels were most sensitive to inhibition by isavuconazole. The 50% inhibitory concentrations for ion channels were higher than maximum serum concentrations of nonprotein-bound isavuconazole in vivo. In the phase I study (n = 161), isavuconazole shortened the QT interval in a dose- and plasma concentration-related manner. There were no serious treatment-emergent adverse events; palpitations and tachycardia were observed in placebo and supratherapeutic isavuconazole groups; no cardiac safety signals were detected in the SECURE study (n = 257). Isavuconazole was associated with a shortened cardiac QT interval.

A Case of Chylothorax in a Hemodialysis Patient with Left Innominate Venous Stenosis

Chylothorax is defined as accumulation of chyle-containing lymphatic fluid within the pleural space. Chylothorax is very rarely seen in hemodialysis patients. We report a case of a patient on hemodialysis who developed chylothorax secondary to left innominate vein stenosis, with other features of venous hypertension such as arm edema successfully treated with angioplasty and pigtail drainage.

Displaced intracapsular neck of femur fractures: Outcome of 810 hydroxyapetite coated (HAC) uncemented hemiarthroplasties

A Cochrane review influenced new NICE guidelines, which recommended surgeons: Offer cemented implants to patients undergoing surgery with arthroplasty. However our trust routinely uses HAC uncemented stem (Taperloc^®, Biomet) hemiarthroplasties. A review of a consecutive series of uncemented HAC stem hemiarthroplasties including measures such as intro-operative complications, mortality and revision surgery. Prospectively collected data between January 2008 and June 2014 was used, with medical record and radiographic reviews performed. 810 consecutive Taperloc uncemented hemiarthroplasty with monopolar heads were performed in 763 patients, with a minimum 12 month follow-up (12-90) follow-up. Mean age 83yrs; 71% female. Meantime to operation was 28.5h. 30day mortality: 4.4% (33/763). One year mortality was 11.2% (89/763). 2.5% (20/810) were admitted on a separate admission with the periprosthetic fracture. 0.6% (5/810) were revised to total hip replacement for subsidence and associated pain. Only 1% (8/810) had intraoperative calcar fractures, all of which were treated with intraoperative cabling with no evidence of clinically relevant subsidence or medium term complications requiring revision surgery within a year. To the author's knowledge this is largest outcome series for modern design uncemented hemiarthroplasty. Our study shows comparable data to cemented hemiarthroplasty but no deaths in the first 2days post-op. Our series also demonstrates a well below average mortality figures which are clearly multifactorial but believe uncemented prosthesis play a role. We believe that uncemented proven stem design hemiarthroplasty remains a safe and good surgical option for displaced intracapsular fractures.

Conversion of gestational diabetes mellitus to future Type 2 diabetes mellitus and the predictive value of HbA1c in an Indian cohort

AIM

To investigate the distribution of and risk factors for dysglycaemia (Type 2 diabetes and prediabetes) in women with previous gestational diabetes mellitus in India.

METHODS

All women (n = 989) from two obstetric units in New Delhi and Hyderabad with a history of gestational diabetes were invited to participate, of whom 366 (37%) agreed. Sociodemographic, medical and anthropometric data were collected and 75-g oral glucose tolerance test were carried out.

RESULTS

Within 5 years (median 14 months) of the pregnancy in which they were diagnosed with gestational diabetes, 263 (72%) women were dysglycaemic, including 119 (32%) and 144 (40%) with Type 2 diabetes and prediabetes, respectively. A higher BMI [odds ratio 1.16 per 1-kg/m² greater BMI (95% CI 1.10, 1.28)], presence of acanthosis nigricans [odds ratio 3.10, 95% CI (1.64, 5.87)], postpartum screening interval [odds ratio 1.02 per 1 month greater screening interval 95% CI (1.01, 1.04)] and age [odds ratio 1.10 per 1-year older age 95% CI (1.04, 1.16)] had a higher likelihood of having dysglycaemia. The American Diabetes Association-recommended threshold HbA_1c value of ≥ 48 mmol/mol (6.5%) had a sensitivity and specificity of 81.4 and 90.7%, respectively, for determining the presence of Type 2 diabetes postpartum.

CONCLUSION

The high post-pregnancy conversion rates of gestational diabetes to diabetes reported in the present study reinforce the need for mandatory postpartum screening and identification of strategies for preventing progression to Type 2 diabetes. Use of the American Diabetes Association-recommended HbA_1c threshold for diabetes may lead to significant under-diagnosis.

Osteochondral fractures of the knee in skeletally immature patients: short term results of operative fixation using Omnitech screws

PURPOSE

Osteochondral fractures in skeletally immature patients are rare. A retrospective case series is reported looking at the use of Omnitech compression screws for these injuries.

METHOD

Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months.

RESULTS

The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively.

CONCLUSION

The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

Outcome of operable oral cavity cancer and impact of maintenance metronomic chemotherapy: A retrospective study from rural India

BACKGROUND

Oral cavity cancer is the most common cancer among rural India. There is a paucity of data for outcomes of operable oral cavity cancer from rural India. Use of maintenance metronomic may delay or avoid relapse.

AIM

To evaluate outcomes of operable oral cavity carcinoma and evaluate impact of maintenance metronomic chemotherapy.

OBJECTIVES

To evaluate disease-free survival (DFS), overall survival (OS), and factors affecting the outcome in operable oral cavity cancer.

MATERIALS AND METHODS

Data of patients diagnosed with oral cavity cancer registered between May 2008 and May 2014 were retrieved. Only those patients with operable oral cavity cancer and upfront definitive surgery were included in the study. Demographic profile, stage, tobacco consumption, adjuvant therapy, and pattern of failure were collected. Kaplan-Meir survival analysis was used to determine DFS and OS. Log-rank test was used to evaluate factors affecting outcome.

RESULTS

Median follow-up is 24 months. Out of 335 patients, 225 (67%) had advanced operable cancer with 42/225 (18%) and 183/225 (82%) as Stages III and IVA, respectively. Buccal mucosa was the most common subsite (178/335, 53%) followed by tongue (63/335, 19%). Ninety-two percent patients were addicted to smokeless tobacco, whereas 27% were smokers. Median DFS is 13 months with 2 years relative DFS 32%. Median OS is 30 months, with 2 years OS of 54%. Metronomic adjuvant oral chemotherapy was given in 130/225 (58%); Stage III and IVA patients with median of 14 months (3-18 months). Use of metronomic chemotherapy improved DFS (8 vs. 14 months, P = 0.22) and OS (14 vs. 26 months, P = 0.04).

CONCLUSION

Oral cavity cancer is a major health care problem in rural India. Presentation at advanced stage leads to suboptimal outcomes. Benefit of metronomic maintenance chemotherapy in locally advanced oral cavity needs to be further evaluated prospectively.

Regional uptake an variations in orthopaedic enhanced recovery pathways in knee and hip total arthroplasty

The use of enhanced recovery (ER) pathways for hip and knee arthroplasty has increased over the last decade, and the adoption within orthopaedics is becoming more common. We have demonstrated a regional variation and institutional inconsistency of uptake and delivery of ER pathways in our region. Units that have a unified pathway were more likely to have consistency in treatment and early analgesia for patients. We would advocate that units use an agreed enhanced recovery pathway to optimise patient recovery from hip and knee arthroplasties.

Regional and seasonal variations in ultraviolet B irradiation and vitamin D synthesis in India

Evaluation of ultraviolet B index (UVBI) and its impact on vitamin D synthesis is important. We observed the maximum UVBI between 11 am and 1 pm. There was no increase in serum 25(OH)D levels following sun exposure during winter as the UVBI was significantly low, emphasizing the need for vitamin D supplementation during these months.

INTRODUCTION

The amount of vitamin D3 synthesizing UVB irradiation (290-320 nm) reaching the earth's surface at different altitudes and seasons in different parts of India and it's impact on vitamin D synthesis has not been well studied.

METHODS

The hourly UVB index (UVBI) from 10 am to 3 pm everyday for 12 months was measured by a solar meter in 4 different zones (North, Northeast, West and South) of the country. To study the impact of sun light exposure on vitamin D synthesis during winter, healthy school children aged 10-15 years were exposed to sunlight for a period of 30 min per day, between 11 am to 12 noon with 10 % body surface area, for 4 weeks. The main outcome measures were serum 25(OH)D, PTH, calcium, phosphate, and alkaline phosphatase levels before and after sun exposure.

RESULTS

The mean UVBI was highest between 11 am and 1 pm throughout the year in all locations. The highest UVBI was recorded from the North zone (4.5 ± 2.7 μW/Cm(2)), while the least was recorded in the Northeast zone (2.1 ± 1.2 μW/Cm(2)). UVBI readings in the Northeast zone were consistently low throughout the year, while all the other three zones showed significant seasonal fluctuations. Surprisingly, we observed a significant decrease in serum 25(OH)D levels from baseline (6.3 ± 4.6 to 5.1 ± 2.7 ng/mL; p < 0.001) despite sun exposure.

CONCLUSION

The mean UVBI was highest between 11 am and 1 pm throughout the year in all locations. No increase in the serum 25(OH)D levels was observed following sun exposure in winter, emphasizing the need for vitamin D supplementation during these months.

Abstract PD2-02: NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early breast cancer

COX2 has been implicated in breast tumorigenesis, tumour proliferation & invasion. The role of COX2 in carcinogenesis is thought to be related to its abilities to increase production of prostaglandins, convert pro-carcinogens to carcinogens, inhibit apoptosis, promote angiogenesis, modulate inflammation & immune function & increase tumour cell invasiveness. COX2 inhibition may synergise with aromatase inhibition in controlling endocrine responsive breast cancer. The COX2 product prostaglandin E2 (PGE2) & cytokines such as interleukin-6 (IL6) can up regulate aromatase expression suggesting that aromatase inhibition may be more effective in combination with a COX2 inhibitor. There may be additional COX2 mediated anticancer activity. The hypothesis addressed is that activity of aromatase inhibitors(AI) as neoadjuvant endocrine therapy for early breast cancer may be enhanced by the addition of a COX2 inhibitor.

TRIAL OBJECTIVES

To determine whether the activity of AIs as neo-adjuvant endocrine therapy for ER positive breast cancer in postmenopausal women may be enhanced by the addition of the selective COX2 inhibitor celecoxib.

TRIAL DESIGN

Prospective phase III multicentre randomised trial. Patients were randomised to receive 16 weeks of exemestane 25 mg daily or letrozole 2.5 mg daily (open label) and celecoxib 400 mg twice daily or matched placebo (double blinded). Translational research tumour samples were collected before, during & after therapy.

KEY ELIGIBILITY CRITERIA

Post menopausal, ER positive, invasive cancer, 2cms or greater with calipers & visible on USS.

PRIMARY OUTCOME MEASURE

Objective clinical response to neoadjuvant treatment by RECIST criteria.

RESULTS

Primary Outcome; Response to treatment has been calculated for 266 patients (Table 1). Response rate was 73% in the celecoxib arm & 55% in the placebo arm (p=0.0022). The response rates 4 arm comparison are shown in Table 2. After adjustment for AI effect the significant difference in response rates remained (p=0.0023); the difference in response rates was greater in the exemestane treated group (29%) compared to the letrozole group (7%) although heterogeneity between AI arms was statistically non-significant (p=0.06).

Table 1 Primary Outcome Results: response ratesOUTCOMEPLACEBO N (%)CELECOXIB N (%)TOTAL N (%)X2statisticP-valueRESPONSE73(55)97(73%)170 (64%)9.38820.0022NO RESPONSE60 (45%)36 (27%)96 (36%)  TOTAL133133266  

Table 2: Response Rates 4 Arm Comparison EXEMESTANELETROZOLERESPONSEPLACEBO n(%)CELECOXIB n(%)TOTAL n(%)PLACEBO n(%)CELECOXIB n(%)TOTAL n(%)RESPONSE33 (49)52(78)85(63)40(61)45(68)85(64)NO RESPONSE34(51)15(22)49(37)26(39)21(32)47(36)TOTAL67671346666132

Secondary outcome; There was an USS response rate of 42% v 37% for celecoxib & placebo arms respectively (p=0.2513)

CONCLUSION

The addition of the COX2 inhibitor celecoxib to an AI significantly & substantially increased the clinical response from 55% to 73%. Effect on tumour size assessed with USS is less marked with a non-significant increase in responses from 37% to 42%.

This work was supported by CRUK: CRUK/06/005 and Pfizer.

Citation Format: Rea D, Francis A, Poole C, Brookes C, Stein R, Bartlett J, Dunn J, Canney P, Sutton R, Daoud R, Hallissey M, Achuthan R, Grant M, Babrah J, Smith S, Fraser J, Desai A, Al Dubaisi M, Patel A, Bristol J, Chandrasekharan S, Prest C, Jewkes A. NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early breast cancer. [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 PD2-02.

Resectable extra-pleural and extra-meningeal solitary fibrous tumours: A multi-centre prognostic study

BACKGROUND

Extra-pleural and extra-meningeal solitary fibrous tumour (SFT) is a rare sarcoma histotype curable with surgery in the majority of patients. The behaviour of these tumours ranges from indolent/very low grade to malignant/high grade but it is still not possible to accurately predict prognosis after surgery. We have investigated a multi-centre series to stratify the risk of recurrence to patients with SFTs.

METHODS

We retrospectively analysed the data from 243 patients who underwent surgery (2002-2011) at four sarcoma referral centres.

RESULTS

Upon univariate analysis, hypercellularity, atypia, necrosis, high mitotic rate (ie >4 mitoses/10 HPF) were associated with both disease-free and overall survival. Surgical margins were a significant prognostic factor for disease-free (P = 0.007) but not for overall survival. Unexpectedly, larger tumour size was associated with a better prognosis (P = 0.038) and fewer recurrences (P = 0.024). Upon multivariable analysis, high mitotic rate (hazard ratio, HR = 2.85, P = 0.002), cellular atypia (HR = 1.62, P = 0.015) and hypercellularity (HR = 1.82, P = 0.031) were significantly associated with recurrences. A SFT recurrence score has been provided to stratify risk of recurrence.

CONCLUSION

This study provides a prognostic model to stratify risk of recurrence in patients with resectable SFTs. This allows clinician to decide on an optimal follow-up strategy and to select patients that may benefit from adjuvant treatments.

Osteochondral Fractures of the Knee in Skeletally Immature Patients: Short-Term Results of Operative Fixation using Omnitech Screws

PURPOSE OF THE STUDY

Retrospective case series looking at the use of Omnitech compression screws for the management of osteochondral fractures in skeletally immature patients.

MATERIAL AND METHODS

Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months.

RESULTS

The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively.

CONCLUSION

The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

Molecular Mechanism Linking BRCA1 Dysfunction to High Grade Serous Epithelial Ovarian Cancers with Peritoneal Permeability and Ascites

Ovarian cancer constitutes the second most common gynecological cancer with a five-year survival rate of 40%. Among the various histotypes associated with hereditary ovarian cancer, high-grade serous epithelial ovarian carcinoma (HGSEOC) is the most predominant and women with inherited mutations in BRCA1 have a lifetime risk of 40-60%. HGSEOC is a challenge for clinical oncologists, due to late presentation of patient, diagnosis and high rate of relapse. Ovarian tumors have a wide range of clinical presentations including development of ascites as a result of deregulated endothelial function thereby causing increased vascular permeability of peritoneal vessels. The molecular mechanisms remain elusive. Studies have shown that fallopian tube cancers develop in women with BRCA1 gene mutations more often than previously suspected. Recent studies suggest that many primary peritoneal cancers and some high-grade serous epithelial ovarian carcinomas actually start in the fallopian tubes. In this article we have addressed the molecular pathway of a recently identified potential biomarker Ubc9 whose deregulated expression due to BRCA1 dysfunction can result in HGSEOC with peritoneal permeability and formation of ascites. We also discuss the role of downstream targets Caveolin-1 and Vascular Endothelial Growth Factor (VEGF) in the pathogenesis of ascites in ovarian carcinomas. Finally we hypothesize a signaling axis between Ubc9 over expression, loss of Caveolin-1 and induction of VEGF in BRCA1 mutant HGSEOC cells. We suggest that Ubc9-mediated stimulation of VEGF as a novel mechanism underlying ovarian cancer aggressiveness and ascites formation. Agents that target Ubc9 and VEGF signaling may represent a novel therapeutic strategy to impede peritoneal growth and spread of HGSEOC.

Differentiating Tumor Progression from Pseudoprogression in Patients with Glioblastomas Using Diffusion Tensor Imaging and Dynamic Susceptibility Contrast MRI

BACKGROUND AND PURPOSE

Early assessment of treatment response is critical in patients with glioblastomas. A combination of DTI and DSC perfusion imaging parameters was evaluated to distinguish glioblastomas with true progression from mixed response and pseudoprogression.

MATERIALS AND METHODS

Forty-one patients with glioblastomas exhibiting enhancing lesions within 6 months after completion of chemoradiation therapy were retrospectively studied. All patients underwent surgery after MR imaging and were histologically classified as having true progression (>75% tumor), mixed response (25%-75% tumor), or pseudoprogression (<25% tumor). Mean diffusivity, fractional anisotropy, linear anisotropy coefficient, planar anisotropy coefficient, spheric anisotropy coefficient, and maximum relative cerebral blood volume values were measured from the enhancing tissue. A multivariate logistic regression analysis was used to determine the best model for classification of true progression from mixed response or pseudoprogression.

RESULTS

Significantly elevated maximum relative cerebral blood volume, fractional anisotropy, linear anisotropy coefficient, and planar anisotropy coefficient and decreased spheric anisotropy coefficient were observed in true progression compared with pseudoprogression (P < .05). There were also significant differences in maximum relative cerebral blood volume, fractional anisotropy, planar anisotropy coefficient, and spheric anisotropy coefficient measurements between mixed response and true progression groups. The best model to distinguish true progression from non-true progression (pseudoprogression and mixed) consisted of fractional anisotropy, linear anisotropy coefficient, and maximum relative cerebral blood volume, resulting in an area under the curve of 0.905. This model also differentiated true progression from mixed response with an area under the curve of 0.901. A combination of fractional anisotropy and maximum relative cerebral blood volume differentiated pseudoprogression from nonpseudoprogression (true progression and mixed) with an area under the curve of 0.807.

CONCLUSIONS

DTI and DSC perfusion imaging can improve accuracy in assessing treatment response and may aid in individualized treatment of patients with glioblastomas.