Panobinostat plus lenalidomide and dexamethasone phase I trial in multiple myeloma (MM)

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Background: Panobinostat (LBH589) is a highly potent pan-deacetylase inhibitor (pan-DACi), affecting with epigenetic and non-epigenetic pathways of cancer. In vivo experiments demonstrated potent MM cytotoxicity of the triplet panobinostat + lenalidomide + dexamethasone. Methods: Trial started with 5 mg panobinostat (po, TIW) combined with fixed doses of lenalidomide (25 mg po, QD, Days 1–21) and dexamethasone (40 mg po, Days 1–4, 9–12, 17–20, Cycles 1–4), in a 28-day cycle. MTD of panobinostat in this combination for second-line MM will be established based on data from cohorts of ≥6 evaluable patients (pts). Safety, tolerability, PK/PD, and preliminary efficacy will be assessed. Results: Twenty-two pts with relapsed or relapsed refractory MM were treated in three dose levels to date. Dose escalation started at 5 mg panobinostat (po, thrice weekly) combined with fixed doses of 25 mg lenalidomide (po, qd, Days 1–21) and 40 mg of dexamethasone (po, Days 1–4, 9–12, 17–20, Cycles 1–4), in a 28-day cycle. Data from all eight patients in Cohort 1 were evaluated. The median number of prior lines of therapy was two (range 1–3). Six out of eight patients in Cohort 1 remain on therapy. Median follow-up is six cycles (range 4–8+). No DLT was observed. In Cohort 2, eight patients were treated at the dose level of 10 mg of panobinostat, with one single DLT: a Gr 1 increase of QT interval duration was detected on Day 3, persisting on Day 8 with therapy withheld, meeting DLT definition although not deemed clinically relevant. Cohort 3 is enrolling with six patients at 20 mg of panobinostat, thus far. SAEs included fever (two pts), anxious depressive syndrome, respiratory infection, atrial fibrillation, exertional dyspnea, cellulitis, superficial blood clot of thigh, phlebitis, hypokalemia. All, but fever in one patient, were assessed by the investigator as not study drug related. Conclusions: The potential for anti-myeloma activity of this triple combination is strongly supported by in vivo preclinical data. In this first clinical trial assessing this triple oral combination, the 5 and 10 mg dose level of panobinostat appear safe. Updated safety, early efficacy, and subsequent dose-level patient data will be presented.

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Patient preference as a determinant of breast cancer adjuvant chemotherapy use in older women: CALGB #369901

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Background: Decisions about use of breast cancer chemotherapy in women 65 and older (“older”) can be complex due to comorbidity, uncertain efficacy and limited data on patient preference. Methods: Older women diagnosed with invasive, non-metastatic breast cancer between 2004 and 2008 were recruited from 53 CALGB sites for an observational study of preferences and chemotherapy use. Data on preferences and other factors were collected from patient interviews and clinical data were abstracted from charts. Generalized estimating equation regression was used to assess associations between chart-reported chemotherapy and independent variables; associations were also evaluated in 2 subgroups: “chemotherapy indicated” (estrogen receptor [ER] negative and/or node positive) and “consider chemotherapy” (ER positive and node negative). Results: Among 935 eligible women registered, 815 (87.2%) completed interviews. The mean age of the cohort was 73 years (range 65–100); 38% were node positive, 82% were ER positive and all had tumors ≥ 1 cm (44% were AJCC stage 1, 44% stage 2 and 12% stage 3). Based on ER and nodal status, chemotherapy was “indicated” for 47% and could be “considered” for 53%. Crude chemotherapy rates were 70% in the “indicated” group and 17% in the “considered” group, for an overall rate of 42%. Women who would choose chemotherapy for an increase in survival of ≤12 months were 4.1 times (95% CI 2.5–6.7, p<.0001) more likely to receive chemotherapy than women who would only choose chemotherapy if it added more than 12 months, controlling for age, tumor factors, comorbidity and other covariates. Stronger preferences were seen among women with “indications” for chemotherapy (OR 7.9, 95% CI 3.7–17.0, p<.001) than in those where treatment might be “considered” (OR 1.8, 95% CI 0.9–3.4, p=.08). Higher patient rating of communication with providers was independently related to a decision to use chemotherapy among women where chemotherapy could be “considered” but not among those where chemotherapy was “indicated”. Conclusions: Beyond clinical indications, older women's preferences and communication with providers are important correlates of chemotherapy use.

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Influence of magnetic cohesion on the stability of granular slopes

We use a molecular dynamics model to simulate the formation and evolution of a granular pile in two dimensions in order to gain a better understanding of the role of magnetic interactions in avalanche dynamics. We find that the angle of repose increases only slowly with magnetic field; the increase in angle is small even for intergrain cohesive forces many times stronger than gravity. The magnetic forces within the bulk of the pile partially cancel as a result of the anisotropic nature of the dipole-dipole interaction between grains. However, we show that this cancellation effect is not sufficiently strong to explain the discrepancy between the angle of repose in wet systems and magnetically cohesive systems. In our simulations we observe shearing deep within the pile, and we argue that it is this motion that prevents the angle of repose from increasing dramatically. We also investigate different implementations of friction with the front and back walls of the container, and conclude that the nature of the friction dramatically affects the influence of magnetic cohesion on the angle of repose.

Ethical and governance challenges in human fetal tissue research

Genetics holds the key to understanding normal human biology and possibly many of the major causes of human disease and impairment. Research into human developmental genetics seems, therefore, to be both necessary and justified. However, such research requires the use of embryonic and fetal tissue obtained from spontaneous abortions and elective termination of pregnancy. This paper examines the arguments in favour of using tissue from elective terminations and the evolution of regulatory frameworks for this research. The paper argues that the recent statutory and regulatory reforms in the UK have not properly addressed the issue of ethically obtaining postimplantation human embryos for research. It is argued that the recent reforms have left the Polkinghorne guidelines untouched but that these are now unequal to the task. A practical suggestion for reform of the approach to the informing and consent of potential donors is offered.

UK national curriculum for undergraduate oral surgery subgroup for teaching of the Association of British Academic Oral and Maxillofacial Surgeons

This article describes a curriculum in oral surgery for undergraduate dental education in the United Kingdom prepared by the Education Subgroup of The British Academic Oral and Maxillofacial Surgeons. This group is made up of representatives from each of the 13 UK Dental Schools, one Irish Dental School and one Post-graduate Institute. The document represents a group consensus of an undergraduate UK oral surgery curriculum that is founded on the frameworks outlined by the General Dental Council, the Quality Assurance Agency for Higher Education and the Association for Dental Education in Europe. Our curriculum document is more prescriptive than the information available in the aforementioned documents. It is based on UK undergraduate oral surgery experience and thus attempts to set achievable core competencies and, in a few areas, challenges the available curriculum and related documentation.

Obstetric skills drills: evaluation of teaching methods

OBJECTIVE

To determine the most effective method of delivering training to staff on the management of an obstetric emergency.

SUBJECTS

The research was conducted in a District General Hospital in the UK, delivering approximately 3500 women per year. Thirty-six staff, comprising of junior and senior medical and midwifery staff were included as research subjects. Each of the staff members were put into one of six multi-professional teams. Effectively, this gave six teams, each comprising of six members.

METHOD

Three teaching methods were employed. Lecture based teaching (LBT), simulation based teaching (SBT) or a combination of these two (LAS). Each team of staff were randomly allocated to undertake a full day of training in the management of Post Partum Haemorrhage utilising one of these three teaching methods. Team knowledge and performance were assessed pre-training, post training and at three months later. In addition to this assessment of knowledge and performance, qualitative semi-structured interviews were carried out with 50% of the original cohort one year after the training, to explore anxiety, confidence, communication, knowledge retention, enjoyment and transferable skills.

RESULTS

All teams improved in their performance and knowledge. The teams taught using simulation only (SBT) were the only group to demonstrate sustained improvement in clinical management of the case, confidence, communication skills and knowledge. However, the study did not have enough power to reach statistical significance. The SBT group reported transferable skills and less anxiety in subsequent emergencies. SBT and LAS reported improved multidisciplinary communication. Although tiring, the SBT was enjoyed the most.

CONCLUSION

Obstetrics is a high risk speciality, in which emergencies are to some extent, inevitable. Training staff to manage these emergencies is a fundamental principal of risk management. Traditional risk management strategies based on incident reporting and event analysis are reactive and not always effective. Simulation based training is an appropriate proactive approach to reducing errors and risk in obstetrics, improving teamwork and communication, whilst giving the student a multiplicity of transferable skills to improve their performance.

Patients’ preferences for adjuvant radiation therapy in early breast cancers

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Background: Adjuvant radiation therapy (ART) reduces the risk of local recurrence in women with breast cancers. In good prognosis tumours in older women the absolute benefits are small. The aim of this study is to determine the smallest improvement in local recurrence rates that women would consider sufficient to make their adjuvant therapy worthwhile. Methods: 95 women who had completed ART 2–4 years earlier for T1N0M0 breast cancers had their preferences elicited by 1 of 3 interviewers. Women were presented 3 sets of hypothetical scenarios about the risks of recurrence with and without radiation using baseline risks of 5%, 10%,and 20%without ART. The order scenarios were presented was allocated randomly. Results: The women’s median age was 63 years 54% had dependants, and 58% travelled 20km or less to their ART centre. A 1% reduction in risk of local recurrence was judged sufficient to to make ART worthwhile by 77% of the women. More than half the women judged ART worthwhile even if it conferred no benefit. 3–8% of the women judged even the maximum possible benefits insufficient to make ART worthwhile. Women’s preferences were almost identical for all 3 scenarios(Spearman’s rank correlations of 0.89 to 0.94). Preferences were unaffected by the order of scenario presentation, interviewer, participants age, cancer recurrence prior to interview,support during ART, dependants, distance to travel to ART, or time since completing ART. Conclusions: Most women judged small benefits in local recurrence sufficient to make ART worthwhile. Many women judged negligible benefits sufficient suggesting the importance of considerations other than the trade-off between direct benefits and harms.

No significant financial relationships to disclose.

β-Defensin evolution: selection complexity and clues for residues of functional importance

We have examined the evolution of the genes at the major human beta-defensin locus and the orthologous loci in a range of other primates and mammals. For the first time, these data allow us to examine selective episodes in the more recent evolutionary history of this locus as well as in the ancient past. We have used a combination of maximum-likelihood-based tests and a maximum-parsimony-based sliding window approach to give a detailed view of the varying modes of selection operating at this locus. We provide evidence for strong positive selection soon after the duplication of these genes within an ancestral mammalian genome. During the divergence of primates, however, variable selective pressures have acted on beta-defensin genes in different evolutionary lineages, with episodes of both negative and, more rarely, positive selection. Positive selection appears to have been more common in the rodent lineage, accompanying the birth of novel rodent-specific beta-defensin gene clades. Sites in the second exon have been subject to positive selection and, by implication, are important in functional diversity. A small number of sites in the mature human peptides were found to have undergone repeated episodes of selection in different primate lineages. Particular sites were consistently implicated by multiple methods at positions throughout the mature peptides. These sites are clustered at positions that are predicted to be important for the function of beta-defensins.

Circulating levels and clinical significance of soluble CD86 in myeloma patients

Circulating soluble CD86 (sCD86) levels are elevated in a number of leukaemias and are an independent prognostic factor in acute myeloid leukaemia. We investigated the clinical significance of circulating sCD86 in 299 patients from the UK Medical Research Council myeloma VIth trial, where patients received ABCM [adriamycin, carmustine (BCNU), cyclophosphamide, melphalan] either alone or with prednisolone (ABCM + P). Serum levels of sCD86 were significantly elevated (P = 0.0001) in myeloma patients and using the median normal donor level (0.621 ng/ml) as a cut-off point, 70% of patients had elevated levels (range = 0.015-15.87 ng/ml, median = 1.1 ng/ml). In univariate analysis elevated sCD86 levels were associated with significantly shorter (P < 0.001) survival (median = 22 vs. 51 months) and event-free survival (median = 14 vs. 31 months) in ABCM + P but not ABCM patients. Multivariate analysis demonstrated that sCD86 was a significant, independent prognostic marker of both overall [risk ratio (RR) = 2.04, P = 0.0006] and event-free (RR = 1.95, P = 0.0004) survival in ABCM + P patients. In conclusion, this study demonstrated that sCD86 levels are a significant independent prognostic marker in at least some myeloma treatment groups and its biological role and prognostic value should be further investigated.

Levels of the soluble forms of CD80, CD86, and CD83 are elevated in the synovial fluid of rheumatoid arthritis patients

The release of soluble forms of CD80 (sCD80), CD86 (sCD86), and CD83 (sCD83) provide a potentially powerful immunoregulatory mechanism. We therefore investigated the potential presence and relative levels of these molecules in the synovial fluid (SF) and serum of patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Serum and SF levels were measured by enzyme-linked immunosorbent assay. Serum levels of sCD80, sCD86, and sCD83 in RA and OA patients were similar to those present in normal donor serum (NDS) and the SF of OA patients. In contrast, when compared with NDS and OA SF levels, almost all RA SF samples had elevated sCD83 levels (32/35, >0.63 ng/ml) and a substantial proportion had elevated sCD80 (13/29, >0.22 ng/ml) or sCD86 (16/33, >2.31 ng/ml) levels. Analysis of matched pairs of serum and SF from RA patients demonstrated that the SF/serum ratio for sCD80 (95% CI = 1.7-3), sCD86 (95% CI = 1.5-3.1), and sCD83 (95% CI = 3.6-7.8) levels was >1 in almost all patients. In conclusion, this study shows that the SF from almost all RA patients contain elevated levels of sCD83 and the majority of these samples also contain elevated levels of sCD80 and/or sCD86. These molecules may play a role in modulating immune responses within the rheumatoid joint.

Day-long subcutaneous infusion of exenatide lowers glycemia in patients with type 2 diabetes

Exenatide (exendin-4) is an incretin mimetic with potential antidiabetic activity. This study examined the effects of a continuous subcutaneous (SC) infusion of exenatide (0.2, 0.4, 0.6, or 0.8 microg/kg/day) or placebo (PBO) on glycemic control over 23 h intervals. Twelve subjects with type 2 diabetes treated with metformin and/or diet received 10 infusions (4 exenatide, 6 PBO) on consecutive days. Exenatide was given in a dose-increasing design with at least one placebo infusion between each exenatide infusion, and with meals and a snack provided during the first 14 h of infusion. Plasma exenatide concentrations were dose-proportional. Plasma glucose (4-23 h) was lower in all exenatide arms compared to placebo (p<0.0001). The change in insulin/glucagon ratio and amylin concentrations from pre-infusion to post-infusion was increased (p<0.005, p<0.05, respectively) in the combined exenatide arms, but remained unchanged in the placebo groups. Nausea and vomiting were the most common treatment emergent adverse events. Exenatide infusion also appeared to have positive effects on beta-cell and alpha-cell function as measured by proinsulin/insulin ratios and mean glucagon concentrations. In summary, exenatide lowered plasma glucose during both prandial and fasting states when delivered as a continuous SC infusion over twenty-three hours, suggesting that exenatide can provide day-long glycemic control in patients with type 2 diabetes.

PATIENTS AT HIGH RISK FOR UPPER TRACT UROTHELIAL CANCER: EVALUATION OF HYDRONEPHROSIS USING HIGH RESOLUTION MAGNETIC RESONANCE UROGRAPHY

PURPOSE

We assessed the potential of magnetic resonance urography (MRU) in the evaluation of hydronephrosis not explained by standard investigation in patients at high risk for upper tract urothelial cancer.

MATERIALS AND METHODS

A total of 23 consecutive patients in a specialist urological unit with unexplained hydronephrosis prospectively underwent MRU which comprised overview heavily T2-weighted MR urographic images followed by focused high resolution turbo spin echo T2-weighted sequences obtained in an axial and coronal oblique plane through the level of urinary obstruction. All were at high risk for urothelial cancer and had either contraindications to or problems with standard investigations including poor contrast excretion due to obstruction or renal failure, failed ureteral cannulation or contrast allergy. Clinical events and imaging followup, subsequent endoscopic/surgical findings and histopathology validated MR findings.

RESULTS

In 23 patients with a high clinical suspicion of upper tract transitional cell tumors (TCC), 8 ureteral and 5 renal pelvic TCCs (2 bilateral) were diagnosed by MR, and confirmed histologically. In a further 5 patients benign causes for the hydronephrosis were found. No intrinsic or extrinsic pathology was demonstrable in 5 patients whose imaging findings were stable during 1 year of followup.

CONCLUSIONS

MRU is a valuable noninvasive investigation for evaluating hydronephrosis in this group of patients with suspected urothelial cancer in which routine investigation had failed to provide clinically important information. Focused high resolution T2-weighted images were reliable in the diagnosis of ureteral and renal pelvic TCCs, and were valuable in excluding these and other mass lesions as the cause of hydronephrosis.

Antimicrobial activity of murine lung cells against Staphylococcus aureus is increased in vitro and in vivo after elafin gene transfer

Staphylococcus aureus is a pathogen often found in pneumonia and sepsis. In the context of the resistance of this organism to conventional antibiotics, an understanding of the regulation of natural endogenous antimicrobial molecules is of paramount importance. Previous studies have shown that both human and mouse airways express a variety of these molecules, including defensins, cathelicidins, and the four-disulfide core protein secretory leukocyte protease inhibitor. We demonstrate here by culturing mouse tracheal epithelial cells at an air-liquid interface that, despite the production of Defb1, Defb14, and Defr1 in this system, these cells are unable to clear S. aureus when exposed to this respiratory pathogen. Using an adenovirus (Ad)-mediated gene transfer strategy, we show that overexpression of elafin, an anti-elastase/antimicrobial molecule (also a member of the four-disulfide core protein family), dramatically improves the clearance of S. aureus. In addition, we also demonstrate that this overexpression is efficient in vivo and that intratracheal instillation of Ad-elafin significantly reduced the lung bacterial load and demonstrates concomitant anti-inflammatory activity by reducing neutrophil numbers and markers of lung inflammation, such as bronchoalveolar lavage levels of tumor necrosis factor and myeloperoxidase. These findings show that an increased antimicrobial activity phenotype is provided by the elafin molecule and have implications for its use in S. aureus-associated local and systemic infections.