Pharmacokinetics and safety of a single dose of the novel necrosis inhibitor LC28-0126 in healthy male subjects

AIMS

A novel necrosis inhibitor, LC28-0126, is expected to have a cellular protective effect from ischaemic reperfusion injury in acute myocardial infarction. The objective of this study was to investigate the safety, tolerability and pharmacokinetics of LC28-0126 after a single intravenous administration in healthy male subjects.

METHODS

The study was a dose-block-randomized, double-blind, placebo-controlled, single ascending dose, first-in-human trial. Subjects were randomly assigned to receive 0.3, 1, 3, 10, 25, 50, 100 or 200 mg of LC28-0126. LC28-0126 was infused for 30 min and 5 min in cohorts 1 and 2, respectively. An interim analysis to assess the tolerability and pharmacokinetics was conducted in each dose group. Blood samples were taken to determine plasma LC28-0126 concentrations from predose to 48 or 144 h postdose, and urine samples were taken from predose to 48 or 72 h postdose.

RESULTS

Overall, 89 subjects were randomly assigned to the dose groups of the two cohorts. LC28-0126 was well tolerated, and no serious adverse events were reported. LC28-0126 showed rapid disposition in the distribution phase. Overall, the fraction of unchanged LC28-0126 excreted during the 48 or 72 h after administration was below 5%. The systemic exposure of LC28-0126 tends to be increased in a dose-proportional manner in the dose range of 0.3-200 mg.

CONCLUSIONS

A single intravenous dose of LC28-0126 was safe and well tolerated up to 200 mg. Furthermore, LC28-0126 demonstrated a predictable pharmacokinetic profile after a single intravenous infusion of doses ranging from 0.3 to 200 mg.

Clinical implications of serum galactomannan measurement in patients with acute invasive fungal rhinosinusitis

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is an aggressive opportunistic infection with a high mortality rate. Recently, non-invasive techniques have been introduced for diagnosis of invasive fungal disease. The purpose of this study is to evaluate the diagnostic significance of serum galactomannan measurement in patients with AIFR.

METHODOLOGY

We conducted a retrospective case-control study of 28 patients with AIFR and 36 fungus ball (FB) patients. We evaluated clinical, laboratory, and pathologic findings along with disease course.

RESULTS

In 28 patients with AIFR, there were 21 cases of invasive aspergillosis (IA) and 7 cases of invasive mucormycosis (IM). The control group was comprised of 36 patients with FB. The three-group analysis showed a statistically significant difference among the groups. At the cut-off value of 0.48, the sensitivity and specificity were 71.4% and 93.0%, respectively. Comparison of mean serum galactomannan levels in 5 non-survivors and 9 survivors at initial measurement showed no significant difference, but that became significantly different 1 week later. Statistical analysis showed that the levels of serum galactomannan decreased significantly according to the measurement-point in within survivor-group analysis. The difference in between survivor-groups analysis was also significant.

CONCLUSION

Serum galactomannan measurement seems useful for early diagnosis and discrimination of fungal species in patients with AIFR. In addition, clinical outcomes may be related to the levels and patterns of serum galactomannan, especially in IA. The appropriate measurement of galactomannan might be helpful in treating the patients at high risk for AIFR.

Prevalence and socio-economic burden of heart failure in an aging society of South Korea

BACKGROUND

Heart failure (HF) is one of the leading causes of morbidity and mortality in South Korea. With the rapidly aging population in the country, the prevalence of HF and its associated costs are expected to rise continuously. This study was carried out to estimate the prevalence and economic burden of HF in order to understand its impact on our society.

METHODS

A prevalence-based, cost-of-illness study was conducted using the 2014 Health Insurance Review and Assessment Service-National Patients Sample (HIRA-NPS) data. Adult HF patients were defined as those aged ≥19 years who had at least one insurance claim record with a primary or secondary diagnosis of HF (ICD-10 codes of I11.0, I13.0, I13.2, and I50.x). The costs consist of direct costs (i.e., medical and non-medical costs) and indirect costs (i.e., productivity loss cost due to morbidity and premature death). Subgroup analyses were conducted by age group, history of HF hospitalization, and type of universal health security program enrolled in.

RESULTS

A total of 475,019 adults were identified to have HF in 2014. The estimated prevalence rate of HF was 12.4 persons per 1,000 adults. According to the base cases and the extended definition of the cases, the annual economic burden of HF from a societal perspective ranges from USD 1,414.0 to 1,560.5 for individual patients, and from USD 752.8 million to 1,085.6 million for the country. A high percentage (68.5 %) of this socioeconomic burden consist of medical costs, followed by caregiver's cost (13.2 %), productivity loss costs due to premature death (10.8 %) and morbidity (4.2 %), and transportation costs (3.4 %). The HF patients with prior hospitalization due to HF annually spent 9.7 times more for National-Health-Insurance-covered medical costs compared to HF patients who were not previously hospitalized.

CONCLUSIONS

In the present study, HF patients who were older and had a history of prior hospitalization for HF as well as an indigent status were shown at high risk of spending more for healthcare to treat their HF. An effective disease management protocol should be employed to target this patient group.

Discrepancy between short-term and long-term effects of bone marrow-derived cell therapy in acute myocardial infarction: a systematic review and meta-analysis

Background

Bone marrow-derived cell therapy has been used to treat acute myocardial infarction. However, the therapeutic efficacy of this approach remains controversial. Here, we performed a systematic review and meta-analysis to evaluate short-term and long-term effectiveness of bone marrow-derived therapy.

Methods

We searched eight databases (Ovid-Medline, Ovid-EMBASE, Cochrane Library, KoreaMed, KMBASE, KISS, RISS, and KisTi) up to December 2014. Demographic characteristics, clinical outcomes, and adverse events were analyzed. We identified 5534 potentially relevant studies; 405 were subjected to a full-text review. Forty-three studies with 2635 patients were included in this review.

Results

No safety issues related to cell injection were reported during follow-up. At 6 months, cell-injected patients showed modest improvements in left ventricular ejection fraction (LVEF) compared with the control group. However, there were no differences between groups at other time points. In the cardiac MRI analysis, there were no significant differences in infarct size reduction between groups. Interestingly, mortality tended to be reduced at the 3-year follow-up, and at the 5-year follow-up, cell injection significantly decreased all-cause mortality.

Conclusions

This meta-analysis demonstrated discrepancies between short-term LV functional improvement and long-term all-cause mortality. Future clinical trials should include long-term follow-up outcomes to validate the therapeutic efficacy of cell therapy.

Twenty-Year Experience of Heart Transplantation: Early and Long-Term Results

Background

We evaluated early and long-term results after heart transplantation (HTPL).

Methods

One hundred five consecutive patients (male:female=80:25) who underwent HTPL between 1994 and 2013 were enrolled. Based on the changes in immunosuppressive regimen, the study patients were divided into two groups. Early and long-term clinical outcomes were evaluated and compared between the patients who underwent HTPL before (group E, n=41) and after July 2009 (group L, n=64). The group L patients were older (p<0.001), had higher incidence of hypertension (p=0.001) and chronic kidney disease (p<0.001), and more frequently needed preoperative mechanical ventilation (p=0.027) and mechanical circulatory support (p=0.014) than the group E patients.

Results

Overall operative mortality was 3.8%, and postoperative morbidities included acute kidney injury (n=31), respiratory complications (n=16), reoperation for bleeding (n=15) and wound complications (n=10). There were no significant differences in early results except acute kidney injury between group E and group L patients. Overall survival rates at 1, 5, and 10 years were 83.8%, 67.7%, and 54.9%, respectively, with no significant difference between the two patient groups. Rejection-free rates at 1 and 5 years were 63.0% and 59.7%, respectively; rates were significantly higher in group L than in group E (p<0.001).

Conclusion

Despite increased preoperative comorbidities, group L patients showed similar early and long-term outcomes and significantly higher rejection-free rates when compared with group E patients.

Pure non-gestational choriocarcinoma arising in the ovary

Non-gestational choriocarcinoma (NGCO) is a rare primary ovarian cancer with poor prognosis. It is important to distinguish it from gestational ovarian choriocarcinoma (GCO), because there are different treatment options. However, it is difficult to distinguish the two types by routine histologic, ultrastructural, or immunohistochemical examination. The authors present NGCO in a 41-year-old woman, which was confirmed by DNA polymorphism analysis. All tested microsatellite markers had identical DNA profiles with the same allelic sizes between tumor and normal myometrium of the patient, indicating that both tissues originated from the same person. The results confirmed that the tumor was non-gestational in origin. Although the tumor was large, the authors performed hand- assisted laparoscopic surgical (HALS) staging. After three cycles of combination chemotherapy and surgery, the patient has not had any evidence of disease 48 months after treatment. This case demonstrates the usefulness of HALS staging and DNA polymorphism analysis in NGCO.

Abstract 65: Latrophilin-2 is a Specific Cell-surface Marker for Cardiac Progenitor Cells and Specifies Cardiac Lineage Commitment and Development

Backgrounds: The identification of a lineage-specific marker plays a pivotal role in understanding developmental process and is utilized to isolate a certain cell type with high purity for the therapeutic purpose. We here report a new cardiac-specific marker, and demonstrate its functional significance in the cardiac development.

Methods and Results: When mouse pluripotent stem cells (ES and iPS cells) were stimulated with BMP4, Activin A, bFGF and VEGF, they differentiated into cardiac cells. To screen cell-surface expressing molecules on cardiac progenitor cells compared to undifferentiated mouse iPS and ES cells, we isolated Flk1+/PDGFRa+ cells at differentiation day 4 and performed microarray analysis. Among candidates, we identified a new G protein-coupled receptor, Latrophilin-2 (LPHN2) whose signaling pathway and its effect on cardiac differentiation is unknown. In sorting experiments under cardiac differentiation condition, LPHN2+ cells derived from pluripotent stem cells strongly expressed cardiac-related genes (Mesp1, Nkx2.5, aMHC and cTnT) and exclusively gave rise to beating cardiomyocytes, as compared with LPHN2- cells. LPHN2-/- mice revealed embryonically lethal and huge defects in cardiac development. Interestingly, LPHN2+/- heterozygotes were alive and fertile. For the purpose of cardiac regeneration, we transplanted iPS-derived LPHN2+ cells into the infarcted heart of adult mice. LPHN2+ cells differentiated into cardiomyocytes, and systolic function of left ventricle was improved and infarct size was reduced. We confirmed LPHN2 expression on human iPS and ES cell-derived cardiac progenitor cells and human heart.

Conclusions: We demonstrate that LPHN2 is a functionally significant and cell-surface expressing marker for both mouse and human cardiac progenitor and cardiomyocytes. Our findings provide a valuable tool for isolating cardiac lineage cells from pluripotent stem cells and an insight into cardiac development and regeneration.

Early Parasympathetic Reinnervation Is Not Related to Reconnection of Major Branches of the Vagus Nerve after Heart Transplantation

Background and Objectives

Bicaval heart transplantation (HTx) may promote parasympathetic reinnervation. However, the prevalence and timing of reinnervation have not been fully investigated. Heart rate variability (HRV) and direct vagal stimulation were used to evaluate the presence of parasympathetic reinnervation after bicaval HTx.

Subjects and Methods

A total of 21 patients (time after HTx 0.52-4.41 years, mean 1.8±1.2 years) who received a bicaval HTx was enrolled. Reinnervation was evaluated using HRV values from 24-hour Holter recordings. A cross-sectional analysis of the HRV at 0.5-1, 1-2, and >2 years after HTx was performed. We also applied high-frequency electrical stimulation (16.7 Hz, 1 msec pulse width, ≤10 V) to the cardiac branches of the vagus nerve at the level of the superior vena cava in eight patients at 6 and 12 months after HTx.

Results

The degree of parasympathetic reinnervation corresponded to the time after HTx. The HRV analysis revealed that the root mean square of the successive differences between consecutive RR-intervals (RMSSD) and high-frequency power were significantly higher during the late period (>2 years) compared with the early period (0.5-1 year) after HTx. None of the eight patients who underwent direct vagal stimulation responded during the stimulation at 6 and 12 months, whereas incremental trends in HRV parameters were observed, which indicated that parasympathetic reinnervation began within 1 year after HTx.

Conclusion

Parasympathetic reinnervation seemed to begin in the early period (<1 year) after bicaval HTx. Reconnection of major branches of the vagus nerve may not be related to early reinnervation.

Abstract P119: Human Podoplanin+/vegfr-3+/lyve-1+ Monocytes are Lymphatic Endothelial Precursors

Lymphatic vessels are involved in the development of various inflammatory disorders, and lymphatic vessel regeneration has been increasingly investigated to develop therapies for lymphatic diseases. Here we report that Podoplanin+/VEGFR-3+/LYVE-1+ is a valid marker for human lymphatic endothelial precursors and the triple-positive cells can be used in lymphatic regeneration. During 5-day culture on an ultra-low attachment surface dish, human peripheral blood mononuclear cells (PBMCs) underwent exponential growth, aggregating into a sphere-like structure and expressing several lymphatic endothelial cell (LEC) markers and lymphangiogenic transcription factors. When dissociated from the aggregate and cultured on a gelatin-coated dish, the cells were attached to the surface. The attached cells were triple positive for LEC markers e.g. Podoplanin, LYVE-1, VEGFR-3. Furthermore, seeded in Matrigel with LECs, the 5-day aggregate-derived cells were incorporated into lymphatic endothelial network. The 5-day aggregates were largely positive for CD14+, a monocyte marker. The CD14+ population was sorted into Podoplanin-positive and negative group for further characterization. Notably, CD14+/Podoplanin+ cells showed increased expression of lymphangiogenic molecules (e.g. VEGFR-3, LYVE-1) both at the genetic and protein levels. Also, CD14+/Podoplanin+ cells secreted higher levels of lymphangiogenic cytokines (VEGF, HGF, PDGF-BB). ELISA results showed that CD14+/Podoplanin+ cells produced more lymphangiogenic cytokines than CD14+/Podoplanin- cells. Local injection of monocyte aggregates significantly increased lymphatic neovascularization and facilitated healing of the skin wound model of nude mice, with CD14+/Podoplanin+ group showing the most dramatic result. Our data suggests that Podoplanin-positive monocytes can be transdifferentiated into lymphatic endothelial precursor cells, and cells with triple positivity for Podoplanin, VEGFR-3, and LYVE-1 can be a promising cell source for therapy against human lymphatic vessel diseases.

Abstract P120: Improving the Angiogenic Abilities of Mobilized Peripheral Blood Stem Cells Achieved by Priming with Activated Platelet Supernatant for Regenerative Cell Therapy

Platelets play a critical role in hemostasis and also have ability to promote angiogenesis and tissue repair by secreting of numerous cytokine and making angiogenic condition. We investigated whether autologous ‘activated platelet supernatant (APS)’ has effect on enhancing pro-angiogenic potential of peripheral blood stem cells (PBSC) for stem cell-based therapy for ischemic diseases. Granulocyte-colony stimulating factor (G-CSF) mobilized peripheral blood stem cells (mobPBSC) were isolated from healthy volunteers, while APS was collected from platelet rich plasma by thrombin activation. mobPBSCs were primed with APS (APS primed mobPBSCs) for 6 hours, and APS primed mobPBSCs characterized their angiogenic ability. For the safety analysis, we estimated the thrombogenicity of platelets in whole blood mixed with APS primed mobPBSCs by expression of glycoprotein IIb and IIIa on platelets. APS had a higher level of various cytokines, such as IL8, IL17, PDGF and VEGF than naïve platelet supernatants. And APS primed mobPBSCs had more expression of angiogenic factors, surface markers (i.e. CD34, CD31, and CXCR4) and integrins (integrin α5, β1 and β2) than Veh primed and Pre primed mobPBSC. Also APS primed mobPBSCs were polarized toward CD14++/CD16+ pro-angiogenic monocytes. And result in adhesion to endothelial cells and fibronectin which represents cell to cell and cell to extracellular matrix adhesion, respectively. The culture supernatant of APS-primed mobPBSCs contained high levels of IL8, IL10, IL17 and TNFα, and augmented proliferation and capillary network formation of HUVEC. In-vivo transplantation of APS-primed mobPBSC into athymic mice ischemic hindlimbs and Matrigel plugs elicited vessel differentiation and tissue repair. In thrombogenicity test, platelet activity increased after mixing whole blood with mobPBSC regardless of the priming agent. However, this was reduced by pretreatment of aspirin, which is an antiplatelet agent prescribed to patients with ischemic diseases. Our data demonstrate that mobPBSCs primed with APS improve angiogenic potential, and that can be adjunctive strategy to enhance the efficiency of stem cell therapy for ischemic diseases.

Intravitreal anti-vascular endothelial growth factor monotherapy for large submacular hemorrhage secondary to neovascular age-related macular degeneration

PURPOSE

To evaluate the efficacy of anti-vascular endothelial growth factor (VEGF) monotherapy for large submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD).

METHODS

A total of 49 treatment-naive patients (49 eyes) with large SMH (more than five disc areas (DAs)) secondary to nAMD were retrospectively included. All patients were treated with an initial series of 3 monthly intravitreal anti-VEGF injections, followed by as-needed injections. At the 12-month follow-up, changes in best-corrected visual acuity (BCVA), hemorrhage area, central foveal thickness, and development of vitreous hemorrhage after treatment were evaluated.

RESULTS

The mean SMH area was 13.9 ± 8.8 disk areas (DAs) and mean symptom duration was 7.25 ± 5.9 days at baseline. The mean number of injections was 4.49 ± 1.61. Twelve months after treatment, the mean BCVA significantly improved from 1.14 ± 0.61 logarithm of the minimum angle of resolution (logMAR; 20/276, Snellen equivalent) to 0.82 ± 0.53 logMAR (20/132; P = 0.002). Twenty-four eyes (49%) showed improvement of more than three lines of BCVA at 12 months after treatment. Baseline BCVA (odds ratio (OR), 5.119; 95% confidence interval (CI), 1.993-9.545; P = 0.004), duration of symptoms (OR, 0.727; 95% CI, 0.332-0.952; P = 0.024), hemorrhage area (OR, 0.892; 95% CI, 0.721-0.965; P = 0.011), and baseline central foveal thickness (OR, 0.881; 95% CI, 0.722-0.945; P = 0.032) were significantly associated with good visual acuity 12 months after treatment.

CONCLUSIONS

Intravitreal anti-VEGF monotherapy is a valuable treatment option for large SMH secondary to nAMD.

Abstract 263: Therapeutic Potential of a Novel Necrosis Inhibitor in Myocardial Ischemia-reperfusion Injury

Background: Reperfusion, although essential for salvage of ischemic myocardium, paradoxically causes a wide variety of injuries. Opening of mitochondrial permeability transition pore (mPTP) and Ca 2+ overload contribute to myocardial ischemia-reperfusion (I/R) injury. We aimed to investigate the protective role of a novel necrosis inhibitor (NecroX-7; NecX) against myocardial I/R injury, using in vitro and in vivo models.

Methods and Results: In H9C2 rat cardiomyoblasts exposed to hypoxia-reoxygenation stress, the main mechanism of cell death was not apoptosis but necrosis, which was prevented mainly by NecX, the necrosis inhibitor, but not by Z-VAD-fmk, the apoptosis inhibitor. The protective effect of NecX was based on its potent ROS scavenging activity, especially on mitochondrial ROS which is one of the major inducers of mPTP opening. NecX preserved mitochondrial membrane potential, mitochondrial structure, through prevention of Ca 2+ influx and inhibition of the opening of mPTP. Inhibition of necrosis by NecX was accompanied by reduction of phospho-p38 MAPK and phospho-JNK, and decrease of HMGB1. Using Sprague-Dawley rats exposed to myocardial ischemia for 45 minutes followed by reperfusion, we compared therapeutic efficacies of NecX and Ciclosporin A (CsA) with 5% dextrose (control), each administrated 5 minutes before reperfusion. NecX markedly inhibited myocardial necrosis, reduced fibrotic area and attenuated the release of cardiac enzymes, compared to dextrose and CsA. Additionally, NecX preserved systolic function and prevented pathologic dilatory remodeling of left ventricle.

Conclusion: The novel necrosis inhibitor has a significant protective effect against myocardial I/R injury, indicating that it is a promising candidate for cardioprotective adjunctive measure on top of reperfusion therapy.

Clinical implication: We are trying to translate this experimental data into patients. A phase I clinical trial confirmed the safety profiles of NecX [NCT01737424] and a phase II trial for STEMI patients (NEXsteMI trial) is ongoing [NCT02070471].

The reliability and accuracy of measuring anteversion of the acetabular component on plain anteroposterior and lateral radiographs after total hip arthroplasty

There is no single standardised method of measuring the orientation of the acetabular component on plain radiographs after total hip arthroplasty. We assessed the reliability and accuracy of three methods of assessing anteversion of the acetabular component for 551 THAs using the PolyWare software and the methods of Liaw et al, and of Woo and Morrey. All measurements of the three methods had excellent intra- and inter-observer reliability. The values of the PolyWare software, which determines version of the acetabular component by edge detection were regarded as the reference standard. Although the PolyWare software and the method of Liaw et al were similarly precise, the method of Woo and Morrey was significantly less accurate (p < 0.001). The method of Liaw et al seemed to be more accurate than that of Woo and Morrey when compared with the measurements using the PolyWare software. If the qualified lateral radiograph was selected, anteversion measured using the method of Woo and Morrey was considered to be relatively reliable.

Role of Zscan4 in secondary murine iPSC derivation mediated by protein extracts of ESC or iPSC

Previously, we found that the delivery of mouse ES (mES) cell-derived proteins to adult fibroblasts enables the full reprogramming of these cells, converting them to mouse pluripotent stem cells (protein-iPS cells) without transduction of defined factors. During reprogramming, global gene expression and epigenetic status such as DNA methylation and histone modifications convert from somatic to ES-equivalent status. mES cell extract-derived iPS cells are biologically and functionally indistinguishable from mES cells in its potential in differentiation both in vitro and in vivo. Furthermore, these cells show complete developmental potency. However, the efficiency of generating iPS by treatment with extract from mES cells is still low. In this report, we demonstrated that protein extracts of mouse iPS cells that were previously generated by mES cell extract treatment were able to reprogram somatic cells to become ES-like cells (secondary protein-iPS cells). We confirmed that fetal animals (E12.5) could be derived from these cells. Surprisingly, the efficiency of forming Oct4-positive colonies was remarkably improved by treatment of somatic cells with mouse iPS cell extract in comparison to treatment with mES cell extract. By screening the genes differentially expressed between mouse iPS and mES cells, Zscan4, which is known to enhance telomere elongation and stabilize genomic DNA, was identified as a strong candidate to promote efficiency of reprogramming. Interestingly, treatment with protein extracted from mES cells overexpressing Zscan4 enhanced formation of Oct4-positive colonies. Our results provide an efficient and safe strategy for reprogramming somatic cells by using mouse iPS cell extract. Zscan4 might be a key molecule involved in the demonstrated improvement of reprogramming efficiency.

Left ventricular non-compaction progression to dilated cardiomyopathy following acute myocarditis in an early infant twin

Left ventricular non-compaction (LVNC), previously termed "spongy myocardium", is an abnormal interruption of myocardial compaction in early embryogenesis. It is now considered to be an important etiology of pediatric cardiomyopathy. Here, we report a case of 3-month-old twins with acute viral myocarditis, in which one of the twins, who had LVNC that progressed rapidly to dilated cardiomyopathy (DCMP) even after maximal medical therapy. The twin without LVNC recovered almost completely after supportive medical therapy. Although several reports have suggested that genetic abnormalities are associated with this disease, genetic research is needed to confirm this. This is the first report of LVNC in twins at 3 months of age who developed DCMP following acute fulminant myocarditis. In addition, this report highlights the fact that LVNC can be an important cause of DCMP, which can be rapidly aggravated after acute viral myocarditis during early infancy.

Beyond consolidation: auto-SCT and immunotherapy for plasma cell myeloma

Autologous hematopoietic cell transplantation (auto-HCT) is the standard consolidation therapy for plasma cell myeloma patients following induction therapy. Auto-HCT improves disease-free survival (DFS), but is generally not curative. The allogeneic HCT experience demonstrated that T-cell immunotherapy can confer long-term DFS. Preclinical and clinical data indicate that myeloma-associated Ags elicit humoral and cellular immune responses (IRs) in myeloma patients. These findings strongly suggest that the immunotherapeutic strategies, including immune checkpoint inhibitors, therapeutic cancer vaccines and adoptive cellular therapies, are promising avenues of clinical research that may be most applicable in the minimal residual disease state following auto-HCT. These strategies are designed to prime or augment antimyeloma IRs and promote a 'host-vs-myeloma' effect that may result in durable DFS. Innovative clinical trials investigating immune checkpoint inhibitors and cancer vaccines have demonstrated that robust immunity against myeloma-associated Ags can be elicited in the setting of auto-HCT. A diverse array of immunotherapeutic strategies have entered clinical trials in myeloma, including PD-1/PD-L1 inhibitors, DC/myeloma cell fusion vaccines and adoptive chimeric Ag receptor T-cell therapy, and further investigation of combinations of immunologic and pharmaceutical agents are expected in the near future. In this review, we will discuss the preclinical data supporting immunotherapy in auto-HCT for myeloma, clinical investigation of these strategies and the future prospects of immunotherapy in pursuit of the goal of curative therapy.

Heart transplantation in a patient with persistent left superior vena cava

A 56-year-old male presented with severe exertional dyspnea and pitting edema in the lower extremities. The pre-operative evaluation demonstrated biventricular dysfunction associated with severe tricuspid valve regurgitation and a persistent left superior vena cava. He was registered as a transplantation candidate, and orthotopic heart transplantation was performed using the standard bicaval technique. The left superior vena cava was connected to the right atrial appendage after the construction of a conduit using the recipient’s autologous coronary sinus tissue. One-month postoperatively, computed tomography imagery demonstrated a patent conduit between the left superior vena cava and right atrial appendage.

Concomitant ALK translocation and EGFR mutation in lung cancer: a comparison of direct sequencing and sensitive assays and the impact on responsiveness to tyrosine kinase inhibitor

BACKGROUND

Epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) translocation are considered mutually exclusive in nonsmall-cell lung cancer (NSCLC). However, sporadic cases having concomitant EGFR and ALK alterations have been reported. The present study aimed to assess the prevalence of NSCLCs with concomitant EGFR and ALK alterations using mutation detection methods with different sensitivity and to propose an effective diagnostic and therapeutic strategy.

PATIENTS AND METHODS

A total of 1458 cases of lung cancer were screened for EGFR and ALK alterations by direct sequencing and flourescence in situ hybridization (FISH), respectively. For the 91 patients identified as having an ALK translocation, peptide nucleic acid (PNA)-clamping real-time PCR, targeted next-generation sequencing (NGS), and mutant-enriched NGS assays were carried out to detect EGFR mutation.

RESULTS

EGFR mutations and ALK translocations were observed in 42.4% (612/1445) and 6.3% (91/1445) of NSCLCs by direct sequencing and FISH, respectively. Concomitant EGFR and ALK alterations were detected in four cases, which accounted for 4.4% (4/91) of ALK-translocated NSCLCs. Additional analyses for EGFR using PNA real-time PCR and ultra-deep sequencing by NGS, mutant-enriched NGS increased the detection rate of concomitant EGFR and ALK alterations to 8.8% (8/91), 12.1% (11/91), and 15.4% (14/91) of ALK-translocated NSCLCs, respectively. Of the 14 patients, 3 who were treated with gefitinib showed poor response to gefitinib with stable disease in one and progressive disease in two patients. However, eight patients who received ALK inhibitor (crizotinib or ceritinib) showed good response, with response rate of 87.5% (7/8 with partial response) and durable progression-free survival.

CONCLUSIONS

A portion of NSCLC patients have concomitant EGFR and ALK alterations and the frequency of co-alteration detection increases when sensitive detection methods for EGFR mutation are applied. ALK inhibitors appear to be effective for patients with co-alterations.

Effects of intensive versus mild lipid lowering by statins in patients with ischemic congestive heart failure: Korean Pitavastatin Heart Failure (SAPHIRE) study

BACKGROUND/AIMS

This study was designed to evaluate the dose-effect relationship of statins in patients with ischemic congestive heart failure (CHF), since the role of statins in CHF remains unclear.

METHODS

The South koreAn Pitavastatin Heart FaIluRE (SAPHIRE) study was designed to randomize patients with ischemic CHF into daily treatments of 10 mg pravastatin or 4 mg pitavastatin.

RESULTS

The low density lipoprotein cholesterol level decreased by 30% in the pitavastatin group compared with 12% in the pravastatin (p < 0.05) group. Left ventricular systolic dimensions decreased significantly by 9% in the pitavastatin group and by 5% in the pravastatin group. Left ventricular ejection fraction (EF) improved significantly from 37% to 42% in the pitavastatin group and from 35% to 39% in the pravastatin group. Although the extent of the EF change was greater in the pitavastatin group (16% vs. 11%) than that in the pravastatin group, no significant difference was observed between the groups (p = 0.386). Exercise capacity, evaluated by the 6-min walking test, improved significantly in the pravastatin group (p < 0.001), but no change was observed in the pitavastatin group (p = 0.371).

CONCLUSIONS

Very low dose/low potency pravastatin and high dose/high potency pitavastatin had a beneficial effect on cardiac reverse remodeling and improved systolic function in patients with ischemic CHF. However, only pravastatin significantly improved exercise capacity. These findings suggest that lowering cholesterol too much may not be beneficial for patients with CHF.