OP0129 REPORTED CONGENITAL MALFORMATIONS AFTER EXPOSURE TO NON-TNF-Α INHIBITORS: A RETROSPECTIVE COMPARATIVE STUDY IN EUDRAVIGILANCE DATABASE

Background

Tumor necrosis factor-α inhibitors (TNFis) such as certolizumab pegol (CZP), are a subgroup of biologics, which have shown no increase in risk of congenital malformations (CMs) after use during pregnancy. (1) However, for the subgroup of non-TNFis, very scarce data is available.

Objectives

To evaluate the number and nature of reported CMs after intrauterine exposure to non-TNFis compared to CZP, in Eudravigilance database.

Methods

A retrospective comparative study in EudraVigilance database was conducted. Reports of all pregnancies exposed to non-TNFis and CZP, were extracted. Multiple versions of a unique case, pregnancies with unknown outcome, paternal exposures, CMs due to known genetic abnormalities, and cases exposed only via breast milk were excluded. Odd ratios for CMs were calculated for each non-TNFi, with CZP as reference group. Due to limitations of pharmacovigilance databases, such as possibility of under-reporting normal outcomes and information bias (2), in consultation with a clinical geneticist, CM patterns were compared between non-TNFi and CZP groups.

Results

In total 851 non-TNFi and 1179 CZP exposed pregnancy reports were included. Numerical differences for CMs after exposure to non-TNFis were not statistically significant except for belimumab and vedolizumab (Table 1).

Table 1.

Reported number, crude and adjusted ORs [95%CIs] for major and minor CMs and TOPFAs after intrauterine exposure to non-TNFis compared to CZP

MedicationReported CMs and TOPFAs, n/N (%)Crude ORs [95%CIs],Adjusted ORs (for maternal age) [95%CIs],Stratified ORs (teratogen unexposed cases only) [95%CIs] *Certolizumab pegol95/1179 (8.05)ReferenceReferenceReferenceAbatacept2/64 (3.12)0.36 [0.08, 1.52]0.35 [0.08, 1.47]0.69 [0.16, 2,96]Anakinra3/20 (15.00)2.01 [0.57, 6.99]2.81 [0.77, 10.20]3.39 [0.91, 12.63]Belimumab17/93 (18.27)2.55 [1.44, 4.49]2.63 [1.40, 4.93]2.65 [1.35, 5.20]Ixekizumab1/29 (3.44)0.40 (0.05, 3.02]0.39 [0.05, 2.96]0.42 [0.05, 3.16]Rituximab8/57 (14.03)1.86 [0.85, 4.04]2.47 [1.05, 5.80]2.55 [0.94, 6.95]Secukinumab4/128 (3.12)0.36 [0.13, 1.01]0.34 [0.10, 1.11]0.37 [0.11, 1.19]Tocilizumab10/124 (8.06)1.00 [0.50, 1.97]0.79 [0.37, 1.68]0.62 [0.22, 1.76]Ustekinumab19/215 (8.83)1.10 [0.66, 1.85]0.92 [0.51, 1.66]1.01 [0.56, 1.82]Vedolizumab23/113 (20.35)2.91 [1.76, 4.82]2.66 [1.53, 4.61]2.27 [1.24, 4.15]

OR: odds ratio; CI: confidence interval; CM: congenital malformation; TOPFA: termination of pregnancy due to foetal anomaly anomaly.

*After adjusting for maternal age, stratified ORs are presented for patients who had no reported teratogen exposure during pregnancy.

Pattern of CMs were reviewed by a clinical geneticist. Except for vedolizumab, no specific CM patterns were observed. For vedolizumab four cases of corpus callosum agenesis (CCA) were reported (versus null in CZP and other investigated non-TNFis). Three of the CCA cases were associated with other neurological CMs such as a neural tube defect, microcephaly and polymicrogyria. This indicates that the reported CCAs may have been related to undiagnosed genetic alterations or were associated with underlying maternal disease, although a definite relationship cannot be ruled out.

Conclusion

Except for vedolizumab, no special safety signal was identified regarding occurrence of CMs after exposure to non-TNFis. Based on available information, no firm conclusions can be made regarding observed CCA cases in vedolizumab group.

References

[1]EuropeanMedicinesAgency, Summary of Product Characteristics (SmPC) Certolizumab pegol (Cimzia). European Medicines Agency 2021. http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/001037/WC500069763.pdf.

[2]Klein K, Scholl JHG, De Bruin ML, van Puijenbroek EP, Leufkens HGM, Stolk P. When More Is Less: An Exploratory Study of the Precautionary Reporting Bias and Its Impact on Safety Signal Detection. Clin Pharmacol Ther. 2018;103(2):296-303.

Acknowledgements

We would like to thank C. Zaccaria and L. Piccolo for their contributions to access and interpreting data from EudraVigilance database. The views expressed in this article are the personal views of the author(s) and may not be understood or quoted as being made on behalf of or reflecting the position of the regulatory agency/agencies or organizations with which the author(s) is/are employed/affiliated.

Disclosure of Interests

Nafise Ghalandari: None declared, Hubertina Johanna Maria Josephina Crijns: None declared, Jorieke Bergman: None declared, Radboud Dolhain Speakers bureau: UCB, Roche, Abbvie, Genzyme, Novartis, Lilly, Grant/research support from: RJEM. Dolhain, MD, PhD received an unrestricted grant from UCB Pharma B.V, Dutch Arthritis Association and Galapagos., Eugène van Puijenbroek: None declared, Johanna Hazes: None declared

THC and CBD blood and brain concentrations following daily administration to adolescent primates

BACKGROUND

Cannabis availability with high concentrations of Δ-9-tetrahydrocannabinol (THC) and a range of THC to cannabidiol (CBD) ratios has increased in parallel with a rise in daily cannabis consumption by adolescents. Unanswered questions in adolescents include: 1) whether THC blood concentrations and THC metabolites remain stable or change with prolonged daily dosing, 2) whether CBD modulates THC pharmacokinetic properties and alters THC accumulation in brain, 3) whether blood THC levels reflect brain concentrations.

METHODS

In adolescent squirrel monkeys (Saimiri boliviensis), we determined whether a four-month regimen of daily THC (1 mg/kg) or CBD (3 mg/kg) + THC (1 mg/kg) administration (IM) affects THC, THC metabolites, and CBD concentrations in blood or brain.

RESULTS

Blood THC concentrations, THC metabolites and CBD remained stable during chronic treatment. 24 h after the final THC or CBD + THC injection, blood THC and CBD concentrations remained relatively high (THC: 6.0-11 ng/mL; CBD: 9.7-19 ng/mL). THC concentrations in cerebellum and occipital cortex were approximately twice those in blood 24 h after the last dose and did not significantly differ in subjects given THC or CBD + THC.

CONCLUSIONS

In adolescent monkeys, blood levels of THC, its metabolites or CBD remain stable after daily dosing for four months. Our model suggests that any pharmacological interactions between CBD and THC are unlikely to result from CBD modulation of THC pharmacokinetics. Finally, detection of relatively high brain THC concentrations 24 h after the final dose of THC suggests that the prolonged actions of THC may contribute to persistent cognitive and psychomotor disruption after THC- or cannabis-induced euphoria wane.

Effects of methamphetamine isomers on d-methamphetamine self-administration and food-maintained responding in male rats

RATIONALE

Methamphetamine (METH) abuse is generally attributed to the d-isomer. Self-administration of l-METH has been examined only in rhesus monkeys with a history of cocaine self-administration or drug-naïve rats using high toxic doses.

OBJECTIVES

In this study, the ability of l-METH and, for comparison, d-METH to engender self-administration in experimentally naïve rats, as well as to decrease d-METH self-administration and food-maintained responding, was examined.

METHODS

Male Sprague-Dawley rats were used in 3 separate experiments. In experiment 1, the acquisition of l- or d-METH self-administration followed by dose-response determinations was studied. In experiment 2, rats were trained to self-administer d-METH (0.05 mg/kg/infusion) and, then, various doses of l- or d-METH were given acutely prior to the session; the effect of repeated l-METH (30 mg/kg) also was examined. In experiment 3, rats were trained to respond for food reinforcement and, then, various doses of l- or d-METH were given acutely prior to the session; the effect of repeated l-METH (3 mg/kg) also was examined.

RESULTS

Reliable acquisition of l- and d-METH self-administration was obtained at unit doses of 0.5 and 0.05 mg/kg/infusion respectively. The dose-response function for l-METH self-administration was flattened and shifted rightward compared with d-METH self-administration, with peak responding for l- and d-METH occurring at unit doses of 0.17 and 0.025 respectively. l-METH also was approximately 10-fold less potent than d-METH in decreasing d-METH self-administration and 2-fold lower in decreasing food-maintained responding. Tolerance did not occur to repeated l-METH pretreatments on either measure.

CONCLUSIONS

As a potential pharmacotherapeutic, l-METH has less abuse liability than d-METH and its efficacy in decreasing d-METH self-administration and food-maintained responding is sustained with repeated treatment.

Bisphosphonates and mortality: confounding in observational studies?

Numerous observational studies suggest that bisphosphonates reduce mortality. This study showed that bisphosphonate use is associated with lower mortality within days of treatment, although the association was not significant until the second week. Such an early association is consistent with confounding, although an early treatment effect cannot be ruled out.

INTRODUCTION

The purpose of this study was to examine whether confounding explains why numerous observational studies show that bisphosphonate use is associated with lower mortality. To this end, we examined how soon after treatment initiation a lower mortality rate can be observed. We hypothesized that, due to confounding, the association would be observed immediately.

METHODS

This was a retrospective cohort study of hip fracture patients discharged from Swedish hospitals between 1 July 2006 and 31 December 2015. The data covered 260,574 hip fracture patients and were obtained from the Swedish Hip Fracture Register and national registers. Of the 260,574 patients, 49,765 met all eligibility criteria and 10,178 were pair matched (bisphosphonate users to controls) using time-dependent propensity scores. The matching variables were age, sex, diagnoses, prescription medications, type of hip fracture, type of surgical procedure, known or suspected dementia, and physical functioning status.

RESULTS

Over a median follow-up of 2.8 years, 2922 of the 10,178 matched patients died. The mortality rate was 7.9 deaths per 100 person-years in bisphosphonate users and 9.4 deaths in controls, which corresponded to a 15% lower mortality rate in bisphosphonate users (hazard ratio 0.85, 95% confidence interval 0.79-0.91). The risk of death was lower in bisphosphonate users from day 6 of treatment, although the association was not significant until the second week.

CONCLUSION

Bisphosphonate use was associated with lower mortality within days of treatment initiation. This finding is consistent with confounding, although an early treatment effect cannot be ruled out.

Epidemiology of osteonecrosis among older adults in Sweden

This study estimated the incidence of osteonecrosis in a Swedish, nationwide cohort of older adults. Osteonecrosis was approximately 10 times more common than in previous studies. The strongest risk factors were dialysis, hip fracture, osteomyelitis, and organ transplantation, but only hip fractures could have contributed substantially to the disease burden.

INTRODUCTION

The aim of this study was to estimate the incidence of osteonecrosis in a Swedish, nationwide cohort of older adults and in a large number of risk groups in that cohort.

METHODS

In this retrospective cohort study, we included everyone who was aged 50 years or older and who was living in Sweden on 31 December 2005. We used Swedish national databases to collect data about prescription medication use, diagnosed medical conditions, and performed medical and surgical procedures. The study outcome was diagnosis of primary or secondary osteonecrosis at any skeletal site. The strength of risk factors was assessed using age- and sex-standardized incidence ratios (SIRs).

RESULTS

The study cohort comprised 3,338,463 adults. The 10-year risk of osteonecrosis was 0.4% (n = 13,425), and the incidence rate was 4.7 cases/10000 person-years (95% confidence interval [CI], 4.6 to 4.7 cases). The strongest risk factors for osteonecrosis were hip fracture (SIR, 7.98; 95% CI, 7.69-8.27), solid organ transplantation (SIR, 7.14; 95% CI, 5.59-8.99), dialysis (SIR, 6.65; 95% CI, 5.62-7.81), and osteomyelitis (SIR, 6.43; 95% CI, 5.70-7.23). A history of hip fracture was present in 21.7% of cases of osteonecrosis, but osteomyelitis, dialysis, and solid organ transplantation were present in only 0.5 to 2% of cases.

CONCLUSIONS

Osteonecrosis was approximately 10 times more common than a small number of previous population-based studies have suggested. The strongest risk factors for osteonecrosis were dialysis, hip fracture, osteomyelitis, and solid organ transplantation, but only hip fractures could have contributed substantially to the disease burden.

Bisphosphonate use after clinical fracture and risk of new fracture

Among older adults with a previous fracture, treatment for osteoporosis was initially associated with a higher risk of new fracture. However, the relative risk of new fracture decreased over time, a trend that is consistent with a beneficial effect, as treatment for osteoporosis is prescribed to reduce high fracture risks.

INTRODUCTION

The purpose of this study was to examine whether bisphosphonate use is associated with a lower risk of new fracture after a clinical fracture in older adults.

METHODS

Data were available for 3,329,400 adults in Sweden who were aged ≥ 50 years between 2006 and 2011. During this period, 260,353 sustained a clinical fracture and were naïve to bisphosphonates at the time. Those who subsequently received a bisphosphonate were matched to up to three others on sex, year of birth, and type and year of initial fracture. The final cohort comprised 83,104 adults (26.3% bisphosphonate users).

RESULTS

During the period from initial fracture to initiation of bisphosphonate treatment, the incidence rate of any new clinical fracture was higher in those who later became bisphosphonate users than in those who remained nonusers (175.1 vs. 75.9 per 1000 person-years; hazard ratio 2.30, 95% confidence interval 2.19 to 2.41). Similarly, during the first 6 months of treatment, the incidence rate was higher in bisphosphonate users than in nonusers (128.8 vs. 90.2 per 1000 person-years; hazard ratio 1.41, 95% confidence interval 1.32 to 1.51). However, this difference decreased over time: by months 12 to 18, the incidence rate was similar in users and nonusers (59.3 vs. 55.3 per 1000 person-years; hazard ratio 1.03, 95% confidence interval 0.91 to 1.16).

CONCLUSIONS

There was a decrease in the relative risk of new fracture during bisphosphonate treatment, a trend that is consistent with a beneficial treatment effect, as bisphosphonates are prescribed to reduce high fracture risks.

Thoracolaparoscopic dissection of esophageal lymph nodes without esophagectomy is feasible in human cadavers and safe in a porcine survival study

High-risk early esophageal adenocarcinoma (i.e. submucosal invasion >500 nm, poor differentiation, and/or presence of lymphovascular invasion) is currently treated with esophagectomy with lymph node (LN) dissection given the high rates of LN metastases. However, esophagectomy is associated with substantial morbidity and mortality. Endoscopic radical resection followed by thoracolaparoscopic LN dissection without concomitant esophagectomy could be an alternative. The study aim was to evaluate the feasibility and safety of thoracolaparoscopic dissection of esophageal LNs in a preclinical setting. (i) In human cadavers, thoracolaparoscopic dissection of LNs involved in drainage of the esophagus was performed. Subsequently, esophagectomy was performed to be able to detect retained LNs. Outcome parameters included the number of dissected LNs, the number of retained LNs in the esophagectomy specimen (ES), and technical success. (ii) In swine, thoracolaparoscopic LN dissection was also performed. After the procedure, the swine survived for 28 days. Thereafter, the swine were sacrificed and esophagectomy was performed. Outcome parameters included the presence of ischemia and/or stenosis in the ES and other complications. (i) In five human cadavers, a median of 26 LNs (interquartile range 22-46) were dissected. In two ES, one retained LN was found: one high paraesophageal, one low paraesophageal. Technical success rate was 100%. (ii) None of the seven porcine ES showed signs of ischemia or stenosis. One swine died because of ventricular fibrillation during surgery; during follow up no complications were observed. Thoracolaparoscopic dissection of LNs involved in the drainage of the esophagus is feasible in human cadavers and swine. The porcine survival study suggests that the esophageal vascularity is not severely compromised by the procedure. As anatomy differs between swine and humans, safety of the procedure will have to be investigated thoroughly before applying this new technique as the treatment of choice.

Characterization of transient noise in Advanced LIGO relevant to gravitational wave signal GW150914

On September 14, 2015, a gravitational wave signal from a coalescing black hole binary system was observed by the Advanced LIGO detectors. This paper describes the transient noise backgrounds used to determine the significance of the event (designated GW150914) and presents the results of investigations into potential correlated or uncorrelated sources of transient noise in the detectors around the time of the event. The detectors were operating nominally at the time of GW150914. We have ruled out environmental influences and non-Gaussian instrument noise at either LIGO detector as the cause of the observed gravitational wave signal.

Properties of the Binary Black Hole Merger GW150914

On September 14, 2015, the Laser Interferometer Gravitational-Wave Observatory (LIGO) detected a gravitational-wave transient (GW150914); we characterize the properties of the source and its parameters. The data around the time of the event were analyzed coherently across the LIGO network using a suite of accurate waveform models that describe gravitational waves from a compact binary system in general relativity. GW150914 was produced by a nearly equal mass binary black hole of masses 36_{-4}^{+5}M_{⊙} and 29_{-4}^{+4}M_{⊙}; for each parameter we report the median value and the range of the 90% credible interval. The dimensionless spin magnitude of the more massive black hole is bound to be <0.7 (at 90% probability). The luminosity distance to the source is 410_{-180}^{+160}  Mpc, corresponding to a redshift 0.09_{-0.04}^{+0.03} assuming standard cosmology. The source location is constrained to an annulus section of 610  deg^{2}, primarily in the southern hemisphere. The binary merges into a black hole of mass 62_{-4}^{+4}M_{⊙} and spin 0.67_{-0.07}^{+0.05}. This black hole is significantly more massive than any other inferred from electromagnetic observations in the stellar-mass regime.

GW150914: First results from the search for binary black hole coalescence with Advanced LIGO

On September 14, 2015 at 09:50:45 UTC the two detectors of the Laser Interferometer Gravitational-wave Observatory (LIGO) simultaneously observed the binary black hole merger GW150914. We report the results of a matched-filter search using relativistic models of compact-object binaries that recovered GW150914 as the most significant event during the coincident observations between the two LIGO detectors from September 12 to October 20, 2015. GW150914 was observed with a matched filter signal-to-noise ratio of 24 and a false alarm rate estimated to be less than 1 event per 203000 years, equivalent to a significance greater than 5.1 σ.

GW150914: First results from the search for binary black hole coalescence with Advanced LIGO

On September 14, 2015 at 09:50:45 UTC the two detectors of the Laser Interferometer Gravitational-wave Observatory (LIGO) simultaneously observed the binary black hole merger GW150914. We report the results of a matched-filter search using relativistic models of compact-object binaries that recovered GW150914 as the most significant event during the coincident observations between the two LIGO detectors from September 12 to October 20, 2015. GW150914 was observed with a matched filter signal-to-noise ratio of 24 and a false alarm rate estimated to be less than 1 event per 203000 years, equivalent to a significance greater than 5.1 σ.

Tests of General Relativity with GW150914

The LIGO detection of GW150914 provides an unprecedented opportunity to study the two-body motion of a compact-object binary in the large-velocity, highly nonlinear regime, and to witness the final merger of the binary and the excitation of uniquely relativistic modes of the gravitational field. We carry out several investigations to determine whether GW150914 is consistent with a binary black-hole merger in general relativity. We find that the final remnant's mass and spin, as determined from the low-frequency (inspiral) and high-frequency (postinspiral) phases of the signal, are mutually consistent with the binary black-hole solution in general relativity. Furthermore, the data following the peak of GW150914 are consistent with the least-damped quasinormal mode inferred from the mass and spin of the remnant black hole. By using waveform models that allow for parametrized general-relativity violations during the inspiral and merger phases, we perform quantitative tests on the gravitational-wave phase in the dynamical regime and we determine the first empirical bounds on several high-order post-Newtonian coefficients. We constrain the graviton Compton wavelength, assuming that gravitons are dispersed in vacuum in the same way as particles with mass, obtaining a 90%-confidence lower bound of 10^{13}  km. In conclusion, within our statistical uncertainties, we find no evidence for violations of general relativity in the genuinely strong-field regime of gravity.

GW150914: Implications for the Stochastic Gravitational-Wave Background from Binary Black Holes

The LIGO detection of the gravitational wave transient GW150914, from the inspiral and merger of two black holes with masses ≳30M_{⊙}, suggests a population of binary black holes with relatively high mass. This observation implies that the stochastic gravitational-wave background from binary black holes, created from the incoherent superposition of all the merging binaries in the Universe, could be higher than previously expected. Using the properties of GW150914, we estimate the energy density of such a background from binary black holes. In the most sensitive part of the Advanced LIGO and Advanced Virgo band for stochastic backgrounds (near 25 Hz), we predict Ω_{GW}(f=25  Hz)=1.1_{-0.9}^{+2.7}×10^{-9} with 90% confidence. This prediction is robustly demonstrated for a variety of formation scenarios with different parameters. The differences between models are small compared to the statistical uncertainty arising from the currently poorly constrained local coalescence rate. We conclude that this background is potentially measurable by the Advanced LIGO and Advanced Virgo detectors operating at their projected final sensitivity.

GW150914: The Advanced LIGO Detectors in the Era of First Discoveries

Following a major upgrade, the two advanced detectors of the Laser Interferometer Gravitational-wave Observatory (LIGO) held their first observation run between September 2015 and January 2016. With a strain sensitivity of 10^{-23}/sqrt[Hz] at 100 Hz, the product of observable volume and measurement time exceeded that of all previous runs within the first 16 days of coincident observation. On September 14, 2015, the Advanced LIGO detectors observed a transient gravitational-wave signal determined to be the coalescence of two black holes [B. P. Abbott et al., Phys. Rev. Lett. 116, 061102 (2016)], launching the era of gravitational-wave astronomy. The event, GW150914, was observed with a combined signal-to-noise ratio of 24 in coincidence by the two detectors. Here, we present the main features of the detectors that enabled this observation. At full sensitivity, the Advanced LIGO detectors are designed to deliver another factor of 3 improvement in the signal-to-noise ratio for binary black hole systems similar in mass to GW150914.

Observation of Gravitational Waves from a Binary Black Hole Merger

On September 14, 2015 at 09:50:45 UTC the two detectors of the Laser Interferometer Gravitational-Wave Observatory simultaneously observed a transient gravitational-wave signal. The signal sweeps upwards in frequency from 35 to 250 Hz with a peak gravitational-wave strain of 1.0×10(-21). It matches the waveform predicted by general relativity for the inspiral and merger of a pair of black holes and the ringdown of the resulting single black hole. The signal was observed with a matched-filter signal-to-noise ratio of 24 and a false alarm rate estimated to be less than 1 event per 203,000 years, equivalent to a significance greater than 5.1σ. The source lies at a luminosity distance of 410(-180)(+160)  Mpc corresponding to a redshift z=0.09(-0.04)(+0.03). In the source frame, the initial black hole masses are 36(-4)(+5)M⊙ and 29(-4)(+4)M⊙, and the final black hole mass is 62(-4)(+4)M⊙, with 3.0(-0.5)(+0.5)M⊙c(2) radiated in gravitational waves. All uncertainties define 90% credible intervals. These observations demonstrate the existence of binary stellar-mass black hole systems. This is the first direct detection of gravitational waves and the first observation of a binary black hole merger.

Prospects for Observing and Localizing Gravitational-Wave Transients with Advanced LIGO and Advanced Virgo

We present a possible observing scenario for the Advanced LIGO and Advanced Virgo gravitational-wave detectors over the next decade, with the intention of providing information to the astronomy community to facilitate planning for multi-messenger astronomy with gravitational waves. We determine the expected sensitivity of the network to transient gravitational-wave signals, and study the capability of the network to determine the sky location of the source. We report our findings for gravitational-wave transients, with particular focus on gravitational-wave signals from the inspiral of binary neutron-star systems, which are considered the most promising for multi-messenger astronomy. The ability to localize the sources of the detected signals depends on the geographical distribution of the detectors and their relative sensitivity, and 90% credible regions can be as large as thousands of square degrees when only two sensitive detectors are operational. Determining the sky position of a significant fraction of detected signals to areas of 5 deg2 to 20 deg2 will require at least three detectors of sensitivity within a factor of ∼ 2 of each other and with a broad frequency bandwidth. Should the third LIGO detector be relocated to India as expected, a significant fraction of gravitational-wave signals will be localized to a few square degrees by gravitational-wave observations alone.

Discovery of AZD8165 – a clinical candidate from a novel series of neutral thrombin inhibitors

A novel series of neutral thrombin inhibitors has been developed using a selection process based on docking experiments and property calculations and predictions.

Targeting histone deacetylase 6 mediates a dual anti-melanoma effect: Enhanced antitumor immunity and impaired cell proliferation

The median survival for metastatic melanoma is in the realm of 8-16 months and there are few therapies that offer significant improvement in overall survival. One of the recent advances in cancer treatment focuses on epigenetic modifiers to alter the survivability and immunogenicity of cancer cells. Our group and others have previously demonstrated that pan-HDAC inhibitors induce apoptosis, cell cycle arrest and changes in the immunogenicity of melanoma cells. Here we interrogated specific HDACs which may be responsible for this effect. We found that both genetic abrogation and pharmacologic inhibition of HDAC6 decreases in vitro proliferation and induces G1 arrest of melanoma cell lines without inducing apoptosis. Moreover, targeting this molecule led to an important upregulation in the expression of tumor associated antigens and MHC class I, suggesting a potential improvement in the immunogenicity of these cells. Of note, this anti-melanoma activity was operative regardless of mutational status of the cells. These effects translated into a pronounced delay of in vivo melanoma tumor growth which was, at least in part, dependent on intact immunity as evidenced by the restoration of tumor growth after CD4+ and CD8+ depletion. Given our findings, we provide the initial rationale for the further development of selective HDAC6 inhibitors as potential therapeutic anti-melanoma agents.

A multicenter validation of an endoscopic classification with narrow band imaging for gastric precancerous and cancerous lesions

BACKGROUND AND STUDY AIM

The reliability and external validity of narrow band imaging (NBI) in the stomach have not been described consistently. The aim of the current study was to describe and estimate the accuracy and reliability of a simplified classification system for NBI in the diagnosis of gastric lesions.

METHODS

Consecutive patients undergoing NBI endoscopy at two reference centers (n=85, 33% with dysplasia) were included in two studies. In total, 224 different areas were biopsied and recorded onto video. In the derivation study, previously described NBI features were analyzed in order to develop a simplified classification. In the validation study the accuracy and reliability of this classification were estimated among three groups of endoscopists with different levels of expertise in NBI.

RESULTS

The reliability/accuracy results from the derivation study allowed the creation of a simplified NBI classification. In the validation study, "regular vessels with circular mucosa" (pattern A) was associated with normal histology (accuracy 83%; 95% confidence interval [CI] 75 %-90%); "tubulo-villous mucosa" (pattern B) was associated with intestinal metaplasia (accuracy 84%; 95CI 77%-91%; positive likelihood ratio [LR+]=4.75); and "irregular vessels and mucosa" (pattern C) was associated with dysplasia (accuracy 95%; 95CI 90%-99%; LR+=44.33). The reproducibility of these patterns was high (k=0.62). "Light-blue crest" was moderately reliable (k=0.49) but specific (87%) for intestinal metaplasia. A variable vascular density (additional pattern+) was the best feature for Helicobacter pylori gastritis (accuracy 70%; 95CI 59%-80%) but showed only fair reliability (k=0.38). Non-experienced endoscopists presented lower agreement (k=0.6 vs. k=0.75) and accuracy (74% vs. 86%) than international experts/experienced endoscopists.

CONCLUSION

A simplified NBI classification is accurate and reliable for the diagnosis of intestinal metaplasia and dysplasia. The classification should be further assessed and validated on a per-patient assessment of NBI, and by comparing NBI with other imaging technologies.

Surface-enhanced Raman spectroscopy analysis of house paint and wallpaper samples from an 18th century historic property

Conservation efforts for heritage buildings require a substantial knowledge of the chemical makeup of materials that were used throughout the lifetime of the property. In particular, conservators are often concerned with the identification of colorants used in both interior and exterior wall treatments (paint, wallpaper, etc.) in order to gain perspective into how the building may have appeared during a certain time period in its existence. Ideally, such an analysis requires a technique that provides molecular level information as to the identity of the colorant as well as other sample components (binders, fillers, etc.), which is useful for dating purposes. In addition, the technique should be easily applied to paint layer samples which can be extremely thin and fragile. Herein we report the surface-enhanced Raman spectroscopy (SERS) analysis of paint and wallpaper samples taken from exterior and interior surfaces of a historic building. Several pigments were identified in the samples, which ranged from early inorganic pigments (lead white, barium sulfate, calcium carbonate, anhydrous chromium(III) oxide) which have been used in house paints for centuries, to a more modern pigment (phthalocyanine blue), developed in the middle of the 20th century. This analysis highlights the usefulness of SERS in such a conservation effort, and demonstrates for the first time pigment identification in house paints and wallpaper using SERS, which has far-reaching implications not only in the field of conservation, but also in forensics, industrial process control, and environmental health and safety.

Hospice utilization by men dying of prostate cancer

9501

Background: The 25,000 American men who die of prostate cancer each year often suffer from fatigue, bone pain, and weight loss. Enrollment in hospice programs improves both the quality of life and the quality of death for this cohort. However, previous data suggest that hospice is often used inappropriately, either through underuse or through improperly timed referral. We sought to characterize sociodemographic and clinical factors that affect appropriate and inappropriate utilization of hospice services by men with metastatic prostate cancer in a population-based dataset. Methods: We used linked data from Surveillance, Epidemiology, and End Results and Medicare data to identify a cohort of beneficiaries who died of prostate cancer between 1992 and 2005. We then evaluated the bivariate association between sociodemographic and clinical data and any hospice enrollment. Hospice referrals within 7 days of death or more than 180 days before dying were considered inappropriate. Results: Of the 14,521 men dying of prostate cancer, 7,646 (53%) utilized hospice resources. Enrollment within 7 days of death was noted in 1699 subjects (22% of hospice users), and enrollment more than 180 days prior to death was seen in 717 participants (9% of hospice users). Subjects who utilized hospice within the appropriate time frame were enrolled for a mean of 47 days (S.D. 41, range 7–180 days) prior to death, with a median of 31 days. In our bivariate analysis, white ethnicity, partnered status, and achieving at least a high school diploma were significantly associated with hospice use ( Table ). Conclusions: Hospice utilization rates in our cohort compared favorably with previous analyses, but the frequency of improperly timed hospice referrals was similar to prior reports and provides an opportunity for improvement.

[Table: see text]

No significant financial relationships to disclose.

Complications of laparoscopic renal surgery

Initial excitement for laparoscopy's potential to decrease patient morbidity and convalescence by avoiding a flank incision was initially tempered by concerns for increased operative time, technical complexity and the suitability of laparoscopy approaches to oncologic surgery. With experience, the benefits of laparoscopic approaches to renal surgery have become clear. As laparoscopic techniques are mastered and the indications expanded, it is important to remember that minimally invasive surgery remains associated with significant risks and potential complications. Several complications are theoretically more difficult to control laparoscopically than with open exposure. Control of bleeding, identification of injury to solid organs, and positive margins due to the lack of haptic feedback have been of special concern during the rapid advancement of laparoscopic surgical technique between 1991 and today. It is critical for the urologist to be familiar with these complications in order to maximize patients' clinical outcomes through appropriate patient selection and intraoperative planning. Know-ledge of the complications of laparoscopic renal surgery will also aid in providing patients with true informed consent and realistic surgical expectations. The purpose of this manuscript is to review the complications associated with laparoscopic renal surgery in general, with specific attention paid to laparoscopic radical, partial, pediatric, and donor nephrectomy.

Utilization of photon orbital angular momentum in the low-frequency radio domain

We show numerically that vector antenna arrays can generate radio beams that exhibit spin and orbital angular momentum characteristics similar to those of helical Laguerre-Gauss laser beams in paraxial optics. For low frequencies (< or = 1 GHz), digital techniques can be used to coherently measure the instantaneous, local field vectors and to manipulate them in software. This enables new types of experiments that go beyond what is possible in optics. It allows information-rich radio astronomy and paves the way for novel wireless communication concepts.