Quantitative measurement of HER3 total protein (H3T) and association with clinical outcome in HER2-positive metastatic breast cancer patients treated with trastuzumab

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Background: The heterodimerization of HER3, with HER2 and the subsequent activation of the AKT pathway, has been implicated in both regulation of tumor cell growth and in resistance to HER2 targeted therapies such as trastuzumab. Currently available methods of measuring H3T in formalin-fixed, paraffin-embedded (FFPE) samples are insufficiently sensitive or specific; thus the impact of quantitative measurement of H3T expression on clinical response to trastuzumab has not been evaluated. Methods: We have developed a highly quantitative, accurate, precise, sensitive, and reproducible H3T assay in FFPE samples based on the VeraTag technology platform. Consequently, the H3T assay displays ∼5-fold greater sensitivity than conventional IHC measurements. Additionally, the rank order and accuracy of the H3T measurements were preserved over a wide dynamic range in well-characterized cell line panels. Intra- and inter-assay reproducibility measurements demonstrated 7–11 %CV and 8–16 % CV, respectively. Results: Quantitative levels of HER2 total protein (H2T) and H3T expression were determined by the VeraTag technology in 81 tumors from patients with trastuzumab-treated metastatic breast cancer. A previously reported H2T cutoff was used to sub-divide the patients into HER2-normal (N = 26, median TTP = 4.1 mos) and HER2-overexpressing (N = 55, median TTP = 11.1 mos, HR = 0.43, p = 0.0002) groups. In the HER2-overexpressing group, high H3T expression, as defined by a positional scanning cutoff analysis, predicted shorter median time to progression (N = 25, median TTP = 6.1 mos) compared with low H3T expression (N = 30, median TTP = 13.1 mos, HR = 2.7, p = 0.0002). Univariate Cox proportional hazards analyses examining the HER2-overexpressing subgroup identified H3T (high vs. low) as the most significant predictor of TTP (HR = 2.98, p = 0.0004). Conclusions: These results demonstrate that the accurate and sensitive measurement of H3T in a cohort of patients with HER-2 positive breast cancer predicts TTP in response to trastuzumab and could indicate a population of patients with worse outcome requiring additional therapeutic intervention.

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The acceptability to patients of computerized cognitive behaviour therapy for depression: a systematic review

BACKGROUND

Cognitive behaviour therapy (CBT) is widely used to treat depression. However, CBT is not always available to patients because of a shortage of therapists and long waiting times. Computerized CBT (CCBT) is one of several alternatives currently available to treat patients with depression. Evidence of its clinical effectiveness has led to programs being used increasingly within the UK and elsewhere. However, little information is available regarding the acceptability of CCBT to patients.

METHOD

A systematic review of sources of information on acceptability to patients of CCBT for depression.

RESULTS

Sources of information on acceptability included: recruitment rates, patient drop-outs and patient-completed questionnaires. We identified 16 studies of CCBT for the treatment of depression that provided at least some information on these sources. Limited information was provided on patient take-up rates and recruitment methods. Drop-out rates were comparable to other forms of treatment. Take-up rates, when reported, were much lower. Six of the 16 studies included specific questions on patient acceptability or satisfaction although information was only provided for those who had completed treatment. Several studies have reported positive expectancies and high satisfaction in routine care CCBT services for those completing treatment.

CONCLUSIONS

Trials of CCBT should include more detailed information on patient recruitment methods, drop-out rates and reasons for dropping out. It is important that well-designed surveys and qualitative studies are included alongside trials to determine levels and determinants of patient acceptability.

The auxin influx carrier LAX3 promotes lateral root emergence

Lateral roots originate deep within the parental root from a small number of founder cells at the periphery of vascular tissues and must emerge through intervening layers of tissues. We describe how the hormone auxin, which originates from the developing lateral root, acts as a local inductive signal which re-programmes adjacent cells. Auxin induces the expression of a previously uncharacterized auxin influx carrier LAX3 in cortical and epidermal cells directly overlaying new primordia. Increased LAX3 activity reinforces the auxin-dependent induction of a selection of cell-wall-remodelling enzymes, which are likely to promote cell separation in advance of developing lateral root primordia.

Circulating endothelial progenitor cell numbers are not associated with donor organ age or allograft vasculopathy in cardiac transplant recipients

INTRODUCTION

Increasing age is associated with reduced numbers of circulating endothelial progenitor cells (EPCs). It is unclear whether this relates to depletion or impairment of bone marrow progenitors, or to deficient mobilization signals from aging tissues. In cardiac transplant patients, one previous study has reported an association between circulating EPCs and the risk of cardiac allograft vasculopathy (CAV). We investigated whether increased donor heart age, a strong risk factor for CAV, was associated with reduced circulating EPC numbers in a group of cardiac transplant recipients matched for factors which influence EPC numbers, but with maximally discordant donor heart ages.

METHODS

We identified 32 patient pairs, matched for factors known to influence EPC numbers, but who had discordant donor heart ages by at least 20 years. EPCs were quantified using flow cytometry for absolute counts of cells expressing all the combinations of CD45, CD34, CD133 and the kinase domain receptor (KDR).

RESULTS

There were no significant differences in the numbers of circulating EPCs between patients with old or young donor heart age. There was no association between the presence of CAV and circulating EPC numbers.

CONCLUSIONS

We suggest that the increased susceptibility to CAV of older donor hearts is not mediated via circulating EPCs. Our results are consistent with the theory that the normal age-related decline in EPC numbers relates to bone marrow aging rather than failure of target tissues to induce EPC mobilization.

Smoking after cardiac transplantation

Although smoking cessation is a prerequisite prior to listing for cardiac transplantation, some patients return to smoking after recovery. We have covertly assessed the smoking habits of our cardiac transplant recipients (with ethical approval) since 1993 by measuring urinary cotinine: a level of >500 ng/mL signifying continued tobacco use. We retrospectively analyzed survival, causes of death and the development of graft coronary artery disease (GCAD) with respect to the number of positive and negative cotinine levels. One hundred four of 380 (27.4%) patients tested positive for active smoking at some point posttransplant, and 57 (15.0%) tested positive repeatedly. Smokers suffered significantly more deaths due to GCAD (21.2% vs. 12.3%, p < 0.05), and due to malignancy (16.3% vs. 5.8%, p < 0.001). In univariate analysis, smoking after heart transplantation shortened median survival from 16.28 years to 11.89 years. After correcting for the effects of pretransplant smoking in time-dependent multivariate analysis, posttransplant smoking remained the most significant determinant of overall mortality (p < 0.00001). We conclude that tobacco smoking after cardiac transplantation significantly impacts survival by accelerating the development of graft vasculopathy and malignancy. We hope that this information will deter cardiac transplant recipients from relapsing, and intensify efforts in improving cessation rates.

Multicenter experience of ABO-incompatible pediatric cardiac transplantation

Although ABO blood group incompatible cardiac transplantation in neonates and infants reduces waiting list mortality without compromising outcome, the technique has not been adopted by all centers, and to date Toronto remains the only center to have published results from a large case series. We present a review of ABO-incompatible heart transplantation in the United Kingdom (UK) where current recipient selection criteria differ somewhat from those used in the United States (US) and Canada. Between February 2000 and November 2006, 21 ABO-incompatible cardiac transplants were performed in children aged 2-40 months (median 10.0). Immunosuppression followed standard regimens. Pretransplant donor-specific isohemagglutinins of >1:4, (the UNOS cutoff), were present in five patients and reduced by plasma exchange. After transplantation, 19/21 recipients demonstrated persisting deficiency of donor-specific isohemagglutinins. Significant donor-specific isohemagglutinins levels were detected repeatedly in 2/21 recipients who have shown no clinical or biopsy evidence of rejection. All recipients survive without retransplantation and there have been no episodes of humoral rejection. We conclude it is possible for other centers to replicate the excellent results achieved in Toronto and that ABO-incompatible transplantation may be performed successfully in some patients beyond infancy with established isohemagglutinin production providing preoperative antibody removing strategies are used.

Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation

OBJECTIVES

To evaluate computerised cognitive behaviour therapy (CCBT) for the treatment of anxiety, depression, phobias, panic and obsessive-compulsive behaviour (OCD). The software packages to be considered include Beating the Blues (BtB), Overcoming Depression: a five areas approach, FearFighter (FF), Cope and BT Steps. Other packages or programmes incorporating CCBT were also considered.

DATA SOURCES

Electronic databases from 1966 to March 2004. Evidence submitted by sponsors for CCBT products.

REVIEW METHODS

A systematic review was a review of the literature and the evidence submitted by sponsors for each of the products. A series of cost-effectiveness models was developed and run by the project team for the five CCBT products across the three mental health conditions.

RESULTS

Twenty studies were identified in the clinical effectiveness review. The analysis of these results showed some evidence that CCBT is as effective as therapist-led cognitive behaviour therapy (TCBT) for the treatment of depression/anxiety and phobia/panic and is more effective than treatment as usual (TAU) in the treatment of depression/anxiety. CCBT also appears to reduce therapist time compared with TCBT. When reviewing cost-effectiveness studies, only one published economic evaluation of CCBT was found. This was an economic evaluation of the depression software BtB alongside a randomised controlled trial (RCT), which found that BtB was cost-effective against TAU in terms of cost per quality-adjusted life-year (QALY) (less than 2000 pounds), however it contained weaknesses that were then addressed in the cost-effectiveness model developed for the study. The results of the model for the depression software packages in terms of incremental cost per QALY compared with TAU and the chance of being cost-effective at 30,000 pounds per QALY were for BtB 1801 pounds and 86.8%, for Cope 7139 pounds and 62.6% and for Overcoming Depression 5391 pounds and 54.4%. The strength of the BtB software being that it has been evaluated in the context of an RCT with a control group. The subgroup analysis found no differences across the severity groupings. For phobia/panic software, the model showed an incremental cost per QALY of FF over relaxation was 2380 pounds. Its position compared with TCBT is less clear. When modelling OCD packages, using the practice-level licence cost meant that BT Steps was dominated by TCBT, which had significantly better outcomes and was cheaper. However, the cheaper PCT licence resulted in the incremental cost-effectiveness of BT Steps over relaxation being 15,581 pounds and TCBT over BT Steps being 22,484 pounds.

CONCLUSIONS

The study findings are subject to substantial uncertainties around the organisational level for purchasing these products and the likely throughput. This is in addition to concerns with the quality of evidence on response to therapy, longer term outcomes and quality of life. The position of CCBT within a stepped care programme needs to be identified, as well as its relationship to other efforts to increase access to CBT and psychological therapies. Research is needed to compare CCBT with other therapies that reduce therapist time, in particular bibliotherapy and to explore the use of CCBT via the Internet. Independent research is needed, particularly RCTs, that examine areas such as patient preference and therapist involvement within primary care.

Stability diagram of unilateral buckling patterns of strip-delaminated films

Thin films deposited on substrates are usually submitted to large residual compression stresses, causing delamination and buckling of the film into various patterns. The present study is focused on the different equilibria arising on strip-shaped delaminated areas. The three most common types of buckling patterns observed on such strips are known as the straight-sided wrinkles, bubble pattern, and telephone cord blisters. The stability of those equilibria as a function of the two stress components of the loading is investigated. The Föppl-Von Karman model for elastic plates is used for theoretical aspects. The post-critical equilibrium paths of the buckling patterns are investigated numerically by means of the finite-element method. The substrate is assumed to be rigid and the contact to be frictionless. The equilibrium solutions can be classified into families of homologous equilibria allowing the identification of dimensionless parameters for the study of stability. A mapping of the different stable post-critical equilibria is given. It is shown that the straight-sided wrinkles and the bubbles are associated with anisotropy of stresses and/or of elastic properties, whereas the telephone cords are stable at high isotropic stresses. The morphological transitions are experimentally evidenced by in situ atomic force microscopy observations of a nickel 50-nm-thick film under stress.

Psychological therapies including dialectical behaviour therapy for borderline personality disorder: a systematic review and preliminary economic evaluation

OBJECTIVES

To summarise the available evidence on the clinical effectiveness and cost-effectiveness of psychological therapies including dialectical behaviour therapy (DBT) for borderline personality disorder (BPD).

DATA SOURCES

Electronic databases were searched up to March 2005.

REVIEW METHODS

Relevant studies were assessed using standard checklists and data were abstracted by two reviewers using standardised forms. Separate economic evaluations were undertaken for six selected randomised controlled trials (RCTs). Cost-effectiveness was assessed in terms of cost per parasuicide event avoided in all six trials and cost per quality-adjusted life-year (QALY) in four of them. All results are at 2003-4 prices and for 12 months follow-up.

RESULTS

Nine RCTs and one non-RCT of moderate to poor quality were identified in the clinical effectiveness review. They provided some evidence that DBT is more effective than treatment as usual (TAU) for the treatment of chronically parasuicidal and drug-dependent borderline women; that DBT-orientated therapy is more effective than client-centred therapy (CCT) for the treatment of BPD; and that DBT is as effective as comprehensive validation therapy plus 12-Step for the treatment of opioid-dependent borderline women. There was also some evidence that partial hospitalisation is more effective than TAU in the treatment of BPD, good evidence that manual-assisted cognitive behavioural therapy (MACT) is no more effective than TAU in the treatment of BPD and some evidence that interpersonal group therapy is no more effective than individual mentalisation-based partial hospitalisation (MBT) for the treatment of BPD. However, these results should be interpreted with caution as not all studies were primarily targeted to borderline symptoms and there were considerable differences between the studies. The assessment of cost-effectiveness found a mix of results in the four trials of DBT, along with the high levels of uncertainty and the limitations in the analyses. The findings do not support the cost-effectiveness of DBT though they suggest it has the potential to be cost-effective. The results for MBT are promising, though again surrounded by a high degree of uncertainty and for MACT, the analysis suggests that the intervention is unlikely to be cost-effective.

CONCLUSIONS

The overall efficacy of psychological therapies is promising; however, at this stage the evidence is inconclusive. The cost-effectiveness of the intervention in six RCTs examined, however, does not support the cost-effectiveness of DBT although potential is suggested. There is a need for considerable research in this area. This research should involve appropriately powered head-to-head RCTs of psychological therapies; a survey of current practice and the use of the full range of services by people with BPD to inform future economic analyses; full resource-use data collected in the context of pragmatic clinical trials; psychometric assessment of the validity of the EQ-5D or other generic and condition-specific preference-based measures in BPD, and the development of a more formal cost-effectiveness model using the above data.

The Arabidopsis SUPPRESSOR OF AUXIN RESISTANCE proteins are nucleoporins with an important role in hormone signaling and development

Nucleocytoplasmic transport of macromolecules is regulated by a large multisubunit complex called the nuclear pore complex (NPC). Although this complex is well characterized in animals and fungi, there is relatively little information on the NPC in plants. The suppressor of auxin resistance1 (sar1) and sar3 mutants were identified as suppressors of the auxin-resistant1 (axr1) mutant. Molecular characterization of these genes reveals that they encode proteins with similarity to vertebrate nucleoporins, subunits of the NPC. Furthermore, a SAR3-green fluorescent protein fusion protein localizes to the nuclear membrane, indicating that SAR1 and SAR3 are Arabidopsis thaliana nucleoporins. Plants deficient in either protein exhibit pleiotropic growth defects that are further accentuated in sar1 sar3 double mutants. Both sar1 and sar3 mutations affect the localization of the transcriptional repressor AXR3/INDOLE ACETIC ACID17, providing a likely explanation for suppression of the phenotype conferred by axr1. In addition, sar1 sar3 plants accumulate polyadenylated RNA within the nucleus, indicating that SAR1 and SAR3 are required for mRNA export. Our results demonstrate the important role of the plant NPC in hormone signaling and development.

Moderately premature infants at Kaiser Permanente Medical Care Program in California are discharged home earlier than their peers in Massachusetts and the United Kingdom

OBJECTIVE

To compare gestational age at discharge between infants born at 30-34(+6) weeks gestational age who were admitted to neonatal intensive care units (NICUs) in California, Massachusetts, and the United Kingdom.

DESIGN

Prospective observational cohort study.

SETTING

Fifty four United Kingdom, five California, and five Massachusetts NICUs.

SUBJECTS

A total of 4359 infants who survived to discharge home after admission to an NICU.

MAIN OUTCOME MEASURES

Gestational age at discharge home.

RESULTS

The mean (SD) postmenstrual age at discharge of the infants in California, Massachusetts, and the United Kingdom were 35.9 (1.3), 36.3 (1.3), and 36.3 (1.9) weeks respectively (p = 0.001). Compared with the United Kingdom, adjusted discharge of infants occurred 3.9 (95% confidence interval (CI) 1.4 to 6.5) days earlier in California, and 0.9 (95% CI -1.2 to 3.0) days earlier in Massachusetts.

CONCLUSIONS

Infants of 30-34(+6) weeks gestation at birth admitted and cared for in hospitals in California have a shorter length of stay than those in the United Kingdom. Certain characteristics of the integrated healthcare approach pursued by the health maintenance organisation of the NICUs in California may foster earlier discharge. The California system may provide opportunities for identifying practices for reducing the length of stay of moderately premature infants.