Continuing Education Evaluations of an Internal Medicine and a Pediatric Podcast

INTRODUCTION

This study aimed to characterize practitioners who use podcasts as a form of continuing education (CE), evaluate attitudes regarding podcasting as a medium for CE, and assess intended practice change after listening to podcasts for CE.

METHODS

We examined CE data from a mandatory postpodcast evaluation collected between February 2021 and August 2021 for two free podcasts. We analyzed linked episode data containing podcast downloads.

RESULTS

Listeners downloaded 972,691 episodes and claimed 8182 CE credits (less than 1% of total downloads) over 7 months. CE credit was claimed by physicians, physician assistants, nurses, and pharmacists. Most listeners claiming CE credit were not affiliated with an academic institution. Motivation for listening to episodes included a topic of interest, relevance to a patient, and a topic of less comfort. Of individuals obtaining CE, 98% intended to implement change after listening.

DISCUSSION

Although only a small number of podcast listeners claim CE credit, those who claim credit represent a diverse and interprofessional audience. Listeners select podcasts to fill self-identified learning needs. Overwhelmingly, listeners report podcast CE changes intended practice. Podcasts may be an effective modality for CE and practice change; further research should focus on facilitators and barriers to CE uptake and on patient health outcomes.

Prediction of post-partum depression and anxiety based on clinical interviews and symptom self-reports of depression and anxiety during pregnancy

Introduction

The tools used to evaluate mental health during pregnancy matter. Their efficacy in identifying symptom severity enables better predictions of postpartum mental health. The Mother & Youth: Research on Neurodevelopment & behaviour (MYRNA) cohort is an NIH funded longitudinal cohort from Sherbrooke, Canada studying the effects of pregnant women’s mental health.

Objectives

We examine which mental health tools will better gauge depression and anxiety during pregnancy based on predicting postpartum outcomes. Our hypothesis is that an approach combining a clinical interview with self-report questionnaires may predict mental health in postpartum women.

Methods

Participants’ mental health is evaluated by the SCID-5-RV, a lifetime interview administered at 30 weeks and monthly questionnaires including PHQ-9 and GAD-7. Participants are in the depression/anxiety group if they either pass all the criteria in the SCID during pregnancy or have an average PHQ-9 or GAD-7 score greater than 7. The Edinburgh Postnatal Depression Scale (EPDS) and the Perceived Stress Scale (PSS) are the outcome variables.

Results

PHQ-9 was correlated with EPDS, r(220)= .38, p< .01, and GAD-7 was correlated with PSS, r(213)= .56, p< .01. SCID results only had a significant effect on PSS, F(3,220)= 3.77, p= .01 and not with EPDS, F(3,219)= 1.08, p= .36. When the self-report measures and interview were combined significant effects were seen for both the EPDS, F(1,222)= 18.71, p< .01 and the PSS, F(1,223)= 34.94, p<.01.

Conclusions

Preliminary results show significant associations between measures administered during pregnancy and postpartum measures. Prediction models based on classification will be analyzed once more data is collected.

Disclosure

No significant relationships.

White matter microstructure associated with the range of attentional and impulsive performance in school-aged children

Introduction

Inhibition capabilities have been shown to be a strong predictor of social and educational life outcomes (Mischel & Ebbesen, 1970; Shoda et al., 1990). Inhibition capabilities have an enormous impact on attention and impulsivity (Bari & Robbins, 2013). These two executive functions are associated with numerous psychiatric disorders but are not well understood in terms of white matter (WM) connectivity (Puiu et al., 2018). Novel techniques and statistical approaches in neuroimaging bring us closer to a biologically sustained model.

Objectives

This research aims to: 1) identify WM connections associated with attention/impulsivity performance and 2) characterize the differences in WM microstructure associated with the variation of the performance.

Methods

157 children (GESTE cohort, 8-12 years, 27 Dx ADHD, 2 Dx ASD) with b=1500mm²/s, 2mm isotropic dMRI acquisitions were included. Tractography was performed with TractoFlow pipeline (Theaud et al., 2020). Dimensionality reduction of diffusion metrics yielded two components : microstructural complexity (DTI Metrics, AFD & NuFo) and axonal density (AFD_fixel) (Chamberland et al., 2019). Attention/impulsivity were evaluated with the CPT3. Multivariate linear regression was performed in python.

Results

Lower microstructural complexity was associated with poorer attentional performance on regions of the parietal lobe to the occipital gyrus (P-O, p=0.044, R²=0.14, Figure 1.) and the Broadman’s area 8 to area 6 (SF8-SF6, p=0.002, R²=0.12, Figure 1.). Lower axonal density was associated with a less impulsive pattern on SF8-SF6 (p=0.001, R²=0.13, Figure 1.). Results remained significant when removing children with an ADHD or ASD diagnosis.

Conclusions

We identified underlying difference in WM microstructure that may be associated with the variation in attention/impulsivity performance in school-aged children.

Disclosure

No significant relationships.

Procedural Training in Pediatric Emergency Medicine Fellowship: What Are We Teaching and What Do Fellows Need to Learn?

BACKGROUND

Life-saving procedures are rarely performed on children in the emergency department, making it difficult for trainees to acquire the skills necessary to provide proficient resuscitative care for children. Studies have demonstrated that residents in general pediatrics and emergency medicine lack exposure to procedures in the pediatric context, but no studies exist regarding procedural training in pediatric emergency medicine (PEM). Although the Accreditation Council for Graduate Medical Education (ACGME) provides a list of procedures in which PEM fellows must be competent, the relevance of this procedure list to actual PEM practice has not been studied.

OBJECTIVES

This study sought to determine whether PEM fellowships currently provide sufficient exposure to the skills most relevant for practicing PEM physicians.

STUDY DESIGN

Data were collected via anonymous electronic survey from physicians who graduated from PEM fellowship between 2012 and 2016. Survey items measured respondents' comfort with performing critical procedures, and their perceptions of the necessity of knowing how to perform each procedure in their current practice environment.

RESULTS

A total of 133 individuals responded to the survey. Respondents unanimously agreed that 18 of the 36 procedures required by the ACGME are necessary to know in their current practice environment. For the remaining 18 mandated procedures, there was significant disagreement among respondents both as to the necessity of the procedure in current practice and respondents' degree of comfort with performing each procedure.

CONCLUSIONS

Among recent PEM fellowship graduates, there is significant variation in comfort with performing ACGME-mandated procedures. These data highlight important opportunities for curricular enhancement in the procedural training of PEM physicians.

"What Do You Want to Learn or Work on Today?": Benefits and Barriers to Asking Residents for Self-identified Learning Goals

BACKGROUND

In the emergency department (ED), residents and attendings may have a short-term relationship, such as a single shift. This poses challenges to learner assessment, instructional strategy selection, and provision of substantive feedback. We implemented a process for residents to identify goals for ED shifts; characterized residents' goals; and determined how goal identification affected learning, teaching, and feedback.

METHODS

This was an observational study in a large, tertiary pediatric ED using mixed methods. Residents were asked to identify learning goals for each shift and were asked postshift if they had identified, accomplished, and/or received feedback on these goals. Goals were categorized by Accreditation Council for Graduate Medical Education Core Competencies. Predictors of goal identification, accomplishment, and receipt of feedback were determined. Residents and attendings were interviewed about their experiences.

RESULTS

We collected 306 end-of-shift surveys (74% response rate) and 358 goals and conducted 29 interviews. We found that: 1) Goal setting facilitated perceived learning. Residents identified goals 54% of the time. They accomplished 89% of and received feedback on 76% of goals. 2) Residents' perceived weaknesses, future practice settings, and available patients informed their goals. Most goals mapped to patient care (59%) or medical knowledge (37%) competencies. 3) Goal identification helped attendings determine residents' needs. 4) Ideal goals were specific and achievable. 5) Common barriers were busyness of the ED and difficulty creating goals. Residents were less likely to identify goals (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.41 to 0.94) and receive feedback on busy evening shifts (OR = 0.19, 95% CI = 0.10 to 0.37) and were most likely to receive feedback overnight (OR = 3.66, 95% CI = 1.87 to 7.14).

CONCLUSIONS

Asking residents to identify goals for ED shifts as an instructional strategy facilitated perceived learning, goal accomplishment, and receipt of feedback. Resident-driven goal identification is a simple and effective instructional strategy that physicians can incorporate into their precepting in the ED.

Influence of simulation on electronic health record use patterns among pediatric residents

Objective

Electronic health record (EHR) simulation with realistic test patients has improved recognition of safety concerns in test environments. We assessed if simulation affects EHR use patterns in real clinical settings.

Materials and Methods

We created a 1-hour educational intervention of a simulated admission for pediatric interns. Data visualization and information retrieval tools were introduced to facilitate recognition of the patient's clinical status. Using EHR audit logs, we assessed the frequency with which these tools were accessed by residents prior to simulation exposure (intervention group, pre-simulation), after simulation exposure (intervention group, post-simulation), and among residents who never participated in simulation (control group).

Results

From July 2015 to February 2017, 57 pediatric residents participated in a simulation and 82 did not. Residents were more likely to use the data visualization tool after simulation (73% in post-simulation weeks vs 47% of combined pre-simulation and control weeks, P <. 0001) as well as the information retrieval tool (85% vs 36%, P < .0001). After adjusting for residents' experiences measured in previously completed inpatient weeks of service, simulation remained a significant predictor of using the data visualization (OR 2.8, CI: 2.1-3.9) and information retrieval tools (OR 3.0, CI: 2.0-4.5). Tool use did not decrease in interrupted time-series analysis over a median of 19 (IQR: 8-32) weeks of post-simulation follow-up.

Discussion

Simulation was associated with persistent changes to EHR use patterns among pediatric residents.

Conclusion

EHR simulation is an effective educational method that can change participants' use patterns in real clinical settings.

Abstract P4-21-08: A phase I/II of S-222611, a reversible EGFR and HER2 inhibitor, combined with trastuzumab +/- chemotherapy in patients with HER2-positive metastatic breast cancer

Background: S-222611, an oral, reversible EGFR and HER2 inhibitor, has been shown to be well-tolerated as monotherapy at a dose of 800mg daily with good anti-tumor activity in patients previously treated with other anti-HER2-based regimens. This study evaluated the tolerability and safety of daily oral administration of S-222611 (S) in combination with trastuzumab (T), trastuzumab + vinorelbine (T+V) and trastzumab + capecitabine (T+C) in HER2-positive (HER2+) metastatic breast cancer (MBC) with or without brain metastases.

Methods: This study was performed as a 3+3 dose escalation followed by expansion to examine the tolerability and safety of S in combination with T, T+V and T+C in Arms A, B and C, respectively. S was administered orally once daily, starting at a dose of 400mg in Arm A, and 200mg in Arms B and C. The dosing of T was 8mg/kg loading followed by 6mg/kg or fixed dose of 600mg subcutaneously every 21 days as recommended. V was administered at 60mg/m2 orally on Day 1 and 8 of a 21-day cycle, and C 1000mg/m2 orally daily for 14 days followed by a 7-day rest period. All patients had HER2+ MBC and were required to have progressed following at least one prior line of anti-HER2 therapy. Prior treatments with V and C were permitted. Anti-diarrhea prophylaxis with loperamide was not required.

Results: A total of 45 patients were enrolled. All patients had received prior anti-tumor regimens including T (n=45), T-DM1 (n=26), pertuzumab (n=9) and lapatinib (n=12). The clinically recommended doses of S at which most adverse events were manageable,were determined as:600mg in Arm A, 200mg in Arm B and 400mg in Arm C. Dose limiting toxicities included Grade 3 diarrhea for Arm A; and Grade 4 neutropenia, Grade 3 Hypokalemia and Hypophosphatemia for Arm B. As of 13 May 2016, treatment is ongoing in 2 patients. No other Grade 4 AEs related to S-222611 have been observed. Grade 3 bilirubin elevation was observed in 5/45 patients, probably due to transporter (UGT1A1) inhibition, while no G3/4 liver dysfunction was reported. RECIST partial responses (PR) were observed in 6 of 9 patients in Arm A and 5 of 9 patients in Arm C, at respective clinically recommended doses. Nine of 45 patients had brain metastases; 4 of these patients showed RECIST PR including an intracranial tumor response in one patient (400mg in Arm C) who had prior treatments with paclitaxel, T+C, T-DM1 and V after diagnosis of BM.

Conclusions: The clinically recommended doses of S-222611 combined with T, T +V and T+C were determined for further clinical studies. Clinical benefit (PR and SD &gt;6 month) was seen with each combination even in heavily pre-treated HER2+ MBC patients.

Summary of the safety and efficacy of S-222611 (S) combination. Dose (mg)nDLT (1st cycle)G3 Diarrhea during study (N of patients)RECIST tumor response, PR n/ SD ≥6M nORR n (%)CBR n (%)Arm A: S + T4005010/10/5 (0%)1/5 (20%)Arm A: S + T6009036/06/9 (67%)6/9 (67%)Arm A: S + T8007141/11/7 (14%)2/7 (29%)Arm B: S + T + V2005020/40/5 (0%)4/5 (80%)Arm B: S + T + V4002211/01/2 (50%)1/2 (50%)Arm C: S + T + C2004010/10/4 (0%)1/4 (25%)Arm C: S + T + C4009025/05/9 (56%)5/9 (56%)Arm C: S + T + C6004022/12/4 (50%)3/4 (75%)

Citation Format: Rafii S, Macpherson I, Baird R, Saggese M, Spiliopoulou P, Kumar S, Italiano A, Bonneterre J, Campone M, Cresti N, Posner J, Takeda Y, Arimura A, Spicer J. A phase I/II of S-222611, a reversible EGFR and HER2 inhibitor, combined with trastuzumab +/- chemotherapy in patients with HER2-positive metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-08.

Abstract P3-08-08: Preferences for breast cancer risk reduction among BRCA1 and BRCA2 mutation carriers: A discrete choice experiment

This abstract was withdrawn by the authors.

Alterations in amygdala-prefrontal circuits in infants exposed to prenatal maternal depression

Prenatal exposure to maternal depression is common and puts offspring at risk for developing a range of neuropsychiatric disorders. Despite its prevalence and adverse associations, neurobiological processes by which prenatal maternal depression (PMD) confers risk remain poorly understood. Maternal mood and fetal behavior were assessed between 34 and 37 gestational weeks. Using resting-state functional magnetic resonance imaging (fMRI) and diffusion MRI, we examined functional and structural connectivity within amygdala-prefrontal circuits in 64 infants (mean age=5.8±1.7 weeks) with (n=20) and without (n=44) in utero exposure to PMD. Resting fMRI and diffusion MRI both indicated atypical amygdala-prefrontal connectivity in PMD-exposed infants: Resting fMRI indicated increased inverse, or negative, functional connectivity between the amygdala and the dorsal prefrontal cortex (PFC), bilaterally, and diffusion MRI indicated decreased structural connectivity between the right amygdala and the right ventral PFC. Spectral dynamic causal modeling supported these findings suggesting altered amygdala-PFC effective (or directed) connectivity in PMD-exposed infants. Last, path analyses supported a mechanistic account relating PMD to a third-trimester fetal behavior: PMD alters amygdala-PFC connectivity, which in turn, is associated with an increase in fetal heart rate reactivity to in utero perturbation. These data suggest that the maturation and coordination of central and peripheral physiology are altered by prenatal exposure to maternal depression. To the best of our knowledge, this is the first study to directly associate infant MRI measures with a behavior-fetal heart rate response, and supports hypotheses that PMD-associated variations in the development of amygdala-PFC circuits are relevant for future neurobehavioral maturation.

Comparing preferences for outcomes of psoriasis treatments among patients and dermatologists in the U.K.: results from a discrete-choice experiment

BACKGROUND

Plaque psoriasis can have a significant negative effect on patients' quality of life, and treatments can result in serious toxicities. Although there have been several studies of patients' and physicians' relative preferences for the benefits and risks of psoriasis treatments, it is unclear how and whether patients' and physicians' preferences for the outcomes of psoriasis treatments differ.

OBJECTIVES

To quantify patient and dermatologist preferences for improvements in psoriasis symptoms and for increases in the risk of treatment-related serious adverse events.

METHODS

Members of the U.K. Psoriasis Association and U.K. dermatologists with experience prescribing biologics completed a web-enabled discrete-choice experiment survey in which they evaluated efficacy and safety features of biological treatments for psoriasis. Choices between hypothetical treatment options were used to estimate preference weights indicating respondents' relative trade-off preferences among treatment outcomes. These outcomes included improvements in the severity and coverage of psoriatic plaques and treatment-related risks of tuberculosis, serious infections and lymphoma. Preference estimates were used to derive the maximum level of side-effect risks that respondents would accept for improvements in psoriasis symptoms.

RESULTS

Respondents' tolerance for side-effect risks varied with side-effect severity and location of plaques, and risk tolerance for serious side-effects was greater for patients than for dermatologists.

CONCLUSIONS

Estimates of patients' risk tolerance for serious side-effects indicate that patients valued psoriasis symptom control highly and suggest that psoriasis symptoms have a significant effect on patients' quality of life. In light of research showing increased treatment satisfaction and improved treatment adherence among patients who receive therapies that are consistent with their preferences, our findings suggest that greater communication between dermatologists and patients about risk tolerance could help improve patient care.

Abstract P4-14-26: Phase I expansion of S-222611, a reversible inhibitor of EGFR and HER2, in advanced solid tumors, including HER2-positive breast cancer patients with brain metastases

BACKGROUND

S-222611 is an oral, reversible ErbB tyrosine kinase inhibitor of EGFR and HER2 with potent pre-clinical activity. MTD was not reached during the dose-escalation phase, (maximum dose 1600 mg QD). PK and efficacy data supported a daily dose of 800 mg. An expansion cohort of patients has been treated to further explore safety and efficacy.

METHODS

Subjects with advanced solid tumors expressing EGFR and/or overexpressing HER2 were enrolled. S-222611 800 mg daily was administered until disease progression or unacceptable toxicity.

RESULTS

76 patients were included in this phase 1 expansion cohort with a variety of tumor types. Dose reduction was required because of adverse events in 15 patients; the most frequent of which being diarrhea and elevated bilirubin. Two patients discontinued treatment due to drug- related adverse events. Of the 25 patients with HER2-positive metastatic breast cancer (MBC), 4 partial responses were observed, and prolonged stable disease (≥ 6 months) was observed in 3 additional patients. These 25 patients had received prior HER2-directed therapy as shown in Table 1.

Table 1. Prior therapies received by patients with HER2-positive MBCPrior therapyn (%)Trastuzumab22 (88)T-DM13 (12)Lapatinib16 (64)Chemotherapy23 (92)

Six of these patients had brain metastases, in whom 1 intracranial response and 2 prolonged stable disease (≥ 6 months) were observed (Table 2).

Table 2. HER2-positive MBC patients with brain metastases - best overall response to S-222611Pts #HER2 IHCBrain metastasesBest overall response (RECIST 1.1)Patient 13+Target lesionPRPatient 23+Target lesionSD (≥12 M)Patient 33+Target lesionSD (6.0 M)Patient 43+Non-target lesionSD (4.7 M)Patient 53+Non-target lesionSD (3.3 M)Patient 63+Non-target lesionNE

The patient showing intracranial response was previously treated with lapatinib and capecitabine after diagnosis of BM.

CONCLUSIONS

S-222611 was well tolerated at a dose of 800 mg once daily. Anti-tumour activity, including shrinkage of brain metastases, was evident in a heavily pre-treated population of patients with HER2-positive breast cancer.

Citation Format: Baird RD, Arkenau H-T, Deva S, Cresti N, Garcia-Corbacho J, Hogarth L, Frenkel E, Kawaguchi K, Arimura A, Donaldson K, Posner J, Sarker D, Jodrell D, Plummer R, Spicer J, Italiano A. Phase I expansion of S-222611, a reversible inhibitor of EGFR and HER2, in advanced solid tumors, including HER2-positive breast cancer patients with brain metastases. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-14-26.

Physician preferences for bone metastasis drug therapy in Canada

BACKGROUND

Currently in Canada, several bone-targeted agents (btas) with varying characteristics are available for the prevention of skeletal-related events (sres) in patients with bone metastasis secondary to solid tumours. In the present study, we evaluated the preferences of physicians in Canada for the various attributes of the available btas.

METHODS

Physicians treating patients with bone metastasis from solid tumours were invited to complete an online discrete-choice experiment. Respondents were asked to choose between pairs of hypothetical medications for virtual patients. Each hypothetical medication was described based on predefined key attributes: time until first sre, time until worsening of pain, medication-related annual risk of osteonecrosis of the jaw (onj), medication-related annual risk of renal impairment, and mode of administration. A random-parameters logit model was used to analyze the choices between hypothetical medications and thus infer physician preferences for medication attributes.

RESULTS

Responses from the 200 physicians who completed the discrete-choice experiment suggested that months until first sre, risk of renal impairment, and months until worsening of pain were considered the most important attributes affecting choice of bta. The annual risk of onj was considered the least important attribute.

CONCLUSIONS

When making treatment decisions about the choice of bta for patients with bone metastasis from solid tumours, delaying sres and worsening of pain, and reducing the risk of renal impairment are primary considerations for physicians in Canada.

Phase 1 dose-escalation study of S-222611, an oral reversible dual tyrosine kinase inhibitor of EGFR and HER2, in patients with solid tumours

BACKGROUND

S-222611 is a reversible inhibitor of EGFR, HER2 and HER4 with preclinical activity in models expressing these proteins. We have performed a Phase 1 study to determine safety, maximum tolerated dose (MTD), pharmacokinetic profile (PK) and efficacy in patients with solid tumours expressing EGFR or HER2.

PATIENTS AND METHODS

Subjects had advanced tumours not suitable for standard treatment, expressing EGFR or HER2, and/or with amplified HER2. Daily oral doses of S-222611 were escalated from 100mg to 1600 mg. Full plasma concentration profiles for drug and metabolites were obtained.

RESULTS

33 patients received S-222611. It was well tolerated, and the most common toxicities, almost all mild (grade 1 or 2), were diarrhoea, fatigue, rash and nausea. Only two dose-limiting toxicities occurred (diarrhoea and rash), which resolved on interruption. MTD was not reached. Plasma exposure increased with dose up to 800 mg, exceeding levels eliciting pre-clinical responses. The plasma terminal half-life was more than 24h, supporting once daily dosing. Responses were seen over a wide range of doses in oesophageal, breast and renal tumours, including a complete clinical response in a patient with HER2-positive breast carcinoma previously treated with lapatinib and trastuzumab. Four patients have remained on treatment for more than 12 months. Downregulation of pHER3 was seen in paired tumour biopsies from a responding patient.

CONCLUSIONS

Continuous daily oral S-222611 is well tolerated, modulates oncogenic signalling, and has significant antitumour activity. The recommended Phase 2 dose, based on PK and efficacy, is 800 mg/day.

Abstract P4-12-24: Phase I trial of S-222611, a dual tyrosine kinase inhibitor of EGFR and HER2, with preliminary evidence of efficacy in patients (pts) with heavily-pretreated HER2-positive metastatic breast cancer

Background and rationale: S-222611 is a novel, oral, reversible inhibitor of EGFR, HER2 and HER4 with an improved preclinical profile compared with first-generation pan-HER inhibitors.

Research objectives: We conducted a phase I study to determine safety, maximum tolerated dose (MTD), pharmacokinetics (PK), pharmacodynamics (PD) and preliminary efficacy in pts with solid tumors expressing EGFR or HER2.

Patients and methods: Pts with advanced solid tumors and biopsies confirming EGFR and/or HER2 expression were treated with continuous daily oral doses of S-222611. The dose of S-222611 was escalated in cohorts of at least 3 pts from 100mg to 1600mg. PK profiles were obtained in all pts, and PD assays for pEGFR, pHER2 and pHER3 were performed on paired tumor biopsies in selected pts.

Results: A total of 50 pts have been treated to-date; age 25-80y; 20 female; 13 with HER2-positive metastatic breast cancer (HER2+ MBC). S-222611 was generally well tolerated with two dose-limiting toxicities in the dose-escalation phase: rash at 1200mg; diarrhea at 1600mg. MTD was not defined. Diarrhea was the most frequent toxicity, but was rarely worse than grade 1/2. Nausea, rash, anorexia and fatigue were also seen. Bilirubin rises with normal transaminases were observed. Plasma concentrations of S-222611 increased with dose up to 800mg, which was the dose selected for the expansion phase. Steady state values of Cmax and AUC0-24 at this dose were in the effective range of concentrations in mouse models. Average t½ of 33h was consistent with once daily dosing. Tumor responses were seen over the full dose range tested (100-1600mg), with four pts on treatment for &gt;12 months. Out of 13 HER2+ MBC pts, one clinical complete response (CR) was observed for &gt;12 months, and four partial responses (PRs) were also seen (2 confirmed, 2 unconfirmed), yielding an overall response rate of 38% in this small group (Table 1). All 5 responding patients had previously progressed on trastuzumab (T); 4 of them had also progressed on lapatinib (L); and one patient had progressed on T, L and T-DM1. Out of 6 breast patients with PD results available, the 3 pts with a decrease in pHER3 all responded, whereas the 3 pts with no change or increase in pHER3 all had disease progression.

Conclusion: S-222611 was well tolerated in doses up to 1600mg daily with diarrhea, nausea and rash being readily manageable. Significant antitumor activity has been observed in patients with heavily pre-treated HER2+ MBC, including those progressing on prior T, L and T-DM1. Rates of grade 3 diarrhea appear markedly lower than those reported for other second-generation pan-HER TKIs. The recommended phase 2 dose, based on PK and clinical activity, is 800mg/day.

Table 1. HER2+ MBC pts with tumor shrinkage after S-222611 treatmentPatient numberPrior progression on trastuzumab-based regimenPrior progression on lapatinib-based regimenBest responseMonths on treatment (at time of data lock)S01014YYclinical CR20.3m (ongoing)S03034YNconfirmed PR11.5m (ongoing)S04046YYconfirmed PR6.0m (ongoing)S01030YYunconfirmed PRwithdrawn at 3.7m with progressionS01047YYunconfirmed PR4.8m (ongoing)

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-24.

Development of leadership self-efficacy and collective efficacy: adolescent girls across castes as peer educators in Nepal

Adolescent girls in Nepal face enormous social barriers to accessing education and health services due to exclusionary socio-religious traditions and years of conflict. The programme and study reported here address two issues that a national assembly of in-school and out-of-school adolescent girls, who had completed a basic life skills class, and, in the case of unschooled girls, an intensive literacy course, identified as important to their well-being - menstrual restrictions and HIV awareness and prevention. Local non-governmental organizations developed a peer education programme in three districts of Nepal that paired girls from different castes and different educational levels. The programme sought to increase peer educators' (PE) leadership and collective efficacy for informing peers and adults in their communities about the effects that these issues have on women and girls. In total, 504 girls were selected and trained as PEs. They conducted targeted discussion sessions with other girls and organised mass awareness events, reaching 20,000 people. Examination of the effects of participating in the programme on key outcome measures showed that leadership self-efficacy, which was a central theoretical construct for the programme, provided a strong predictor of both increased HIV knowledge and of practicing fewer menstrual restrictions at endline. The project demonstrated that girls from different caste and educational backgrounds are able to work together to change individual behaviour and to address socio-cultural norms that affect their lives and well-being within their communities.

SOX2 antibody responses in patients with various tumor types and SCLC with and without paraneoplastic neurologic syndromes

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Background: SOX2, a member of the SOX Group B family of transcription factors, is expressed in normal adult brain, testis and prostate as well as in many SCLC cell lines. Spontaneous antibody responses to SOX2 have previously been shown to be detectable in SCLC patients. We undertook a retrospective study to determine whether antibody responses were detectable in patients with other malignancies and in patients with paraneoplastic neurologic syndromes (PND/PNS). Methods: Previously obtained serum samples from patients with no known disease (n = 84), breast and ovarian cancer (n = 35 each), melanoma (n = 42), NSCLC (n = 150), and SCLC patients, 90 from Turkey and 68 patients studied for PND, were tested by ELISA using serial 4-fold dilutions for anti-SOX2 and anti-HuD antibody. Results: Preliminary data shows SOX2 reactivity in 5/84 (6%) normal volunteer sera, 8/35 (23%) in both breast and ovarian cancer patients, 4/42 (9%) melanoma patients, 20/150 (13.3%) NSCLC patients, and 56/158 (35.4%) SCLC patients. Compared to controls, there was a statistically significant difference in SOX2 immunoreactivity in breast, ovarian (p = 0.007 for both) and SCLC patients (p < 0.001), and a trend was noted in NSCLC patients (p = 0.080). No breast, ovarian, melanoma or normal patient had SOX2 antibody titers ≥1:6400, compared with 32/56 (57.1%) of SCLC (p < 0.01) and 6/20 (30%) NSCLC patients (p < 0.16). Nine SCLC patients had neurologic symptoms and were previously found to have anti-HuD antibodies, associated with a diagnosis of PND. This was confirmed in 8/9 patients in our assay. However, none of the nine patients displayed anti-SOX2 reactivity. Eleven additional SCLC patients were found to be HuD positive by our ELISA. Conclusions: Anti-SOX2 responses are found in a significant proportion of patients with SCLC, breast and ovarian cancer, but not in melanoma patients compared to normal controls. Patients with SCLC have higher titer antibodies when compared with the other groups, and anti-SOX2 antibodies do not appear to associate with anti-HuD responses, supporting the hypothesis that SOX2 immune responses are not associated with PND and may be useful as a vaccine target. Supported by the Cancer and Leukemia Group B/Aventis Oncology Award and the Steps for Breath Foundation.

No significant financial relationships to disclose.

Impact of Preferential Flow at Varying Irrigation Rates by Quantifying Mass Fluxes

Solute concentration and soluble dye studies inferring that preferential flow accelerates field-scale contaminant transport are common but flux measurements quantifying its impact are essentially nonexistent. A tile-drain facility was used to determine the influence of matrix and preferential flow processes on the flux of mobile tracers subjected to different irrigation regimes (4.4 and 0.89 mm h(-1)) in a silt loam soil. After tile outflow reached steady state either bromide (Br; 280 kg ha(-1)) or pentafluorobenzoic acid (PFBA; 121 kg ha(-1)) was applied through the irrigation system inside a shed (3.5 x 24 m). Bromide fluxes were monitored at an irrigation rate of 4.4 mm h(-1) while PFBA fluxes were monitored at an irrigation rate of 0.89 mm h(-1). At 4.4 mm h(-1) nearly one-third of the surface-applied Br was recovered in the tile line after only 124 mm of irrigation and was poorly fit by the one-dimensional convective-dispersive equation (CDE). On the other hand, the one-dimensional CDE fit the main PFBA breakthrough pattern almost perfectly, suggesting the PFBA transport was dominated by matrix flow. Furthermore, after 225 mm of water had been applied, less than 2% of the applied PFBA had been leached through the soil compared with more than 59% of the applied Br. This study demonstrates that the methodology of applying a narrow strip of chemical to a tile drain facility is appropriate for quantifying chemical fluxes at the small-field scale and also suggests that there may be a critical input flux whereby preferential flow is initiated.

Clinical pharmacology studies in UK Phase 1 units: an AHPPI survey 1999-2000

AIMS

This study, conducted by the Association for Human Pharmacology in the Pharmaceutical Industry (AHPPI), was designed to determine the amount of Phase 1 activity in the UK in the period 1999-2000, the timelines involved for submissions to ethics committee and responses from ethics committees.

METHODS

A questionnaire was completed by AHIPPI members from pharmaceutical companies with in-house phase 1 units, by Clinical Research Organizations (CRO's) and by academic centres. A few responses were also vailable from organisations that were not AHPPI members. Results were rendered anonymous and grouped by category.

RESULTS

The response rate was > 98% and indicated that the vast majority of early drug research in humans is now CRO-based (82%). The total number of studies (as indicated by protocol numbers) was notably similar across the 2 years--629 in 1999 and 606 in 2000. Turnaround time for ethics committee review was a mean of 14 days.

CONCLUSIONS

These data set important benchmarks for early-phase drug research in the UK where regulatory approval is not currently required. Furthermore, the information should be used as a guide if the competitive nature of such work in the UK is to be maintained as new national legislation is implemented following publication of the European Union (EU) Clinical Trials Directive.

Multiple interactions of cimetidine and probenecid with valaciclovir and its metabolite acyclovir

The effects of probenecid and cimetidine on the pharmacokinetics of valaciclovir and its metabolite acyclovir have been investigated. Twelve healthy male volunteers participated in this open single-dose study with a four-way-crossover randomized and balanced design. At the first of four administrations, volunteers in four groups received 1 g of valaciclovir alone, valaciclovir with 1 g of probenecid, valaciclovir with 800 mg of cimetidine, or valaciclovir with a combination of probenecid and cimetidine. At three subsequent administrations, drug regimens were alternated among groups so that each group received each regimen. Probenecid and cimetidine increased the mean maximum concentrations in serum (C(max)) of valaciclovir by 23 and 53% and the areas under the concentration-time curves (AUC) for valaciclovir by 22 and 73%, respectively; probenecid and cimetidine also increased the mean acyclovir C(max) by 22 and 8% and its AUC by 48 and 27%, respectively. The combination had a greater effect than either drug alone. Their effects may be due to competitive inhibition of membrane transport of valaciclovir and acyclovir in the liver and kidney. Neither cimetidine nor probenecid affected the absorption of valaciclovir. Both probe drugs reduced the rate of valaciclovir metabolism but not its extent. These pharmacokinetic modifications did not affect the tolerability of valaciclovir.

Stroke in young adults and children

Data from studies of 337 children and 1606 young adults are summarized to identify the major causes of stroke in these age groups. In children under 15 years of age, stroke occurs in patients with congenital heart disease, nonatherosclerotic vasculopathies, infection, and hematologic defects like sickle cell disease. In patients 15 to 35 years of age, dissection, cardioembolism, nonatheroslerotic vasculopathies, and prothrombotic states cause a significant percentage of strokes. In adults over 35 years of age, traditional atherosclerotic risk factors predominate. Lifestyle choices (e.g., cigarette smoking, alcohol consumption, and illicit drug use) can significantly increase the rate of stroke among young adults in a community. Limited access to healthcare may increase the role of infectious disease and peripartum complications.

Who can give a pediatric trauma history for children injured in bicycle crashes?

Emergency Departments are important sites for injury surveillance but the quality of data collected has not been evaluated. This prospective cohort study assessed the ability of various respondents to provide circumstantial information following pediatric bicyclist trauma. A semi-structured survey tool was administered in the Emergency Department of a Level One Pediatric Trauma Center for 448 child bicyclists. The injured child provided more complete information when compared to witnesses and Emergency Medical Services personnel. No one respondent type provided the complete history. To obtain thorough injury circumstantial information, multiple respondents should be interviewed utilizing a semi-structured questionnaire.

Effects of lamotrigine on pain-induced chemo-somatosensory evoked potentials

Lamotrigine, a sodium channel blocker that selectively inhibits the neuronal release of glutamate, has been shown to produce analgesia in acute and chronic pain models in rats without causing noticeable sedation. After oral administration it also reduces pain scores, as assessed by the cold pain test, in volunteers. The purpose of this study was to determine the analgesic effect of lamotrigine given by mouth to healthy volunteers as evidenced by alterations in chemo-somatosensory evoked potentials. The following factors were measured: latency to N1 and P100 peak (ms); amplitude between the N1 and P100 peak (microV); visual analogue pain intensity scores. A double-blind, randomised and crossover design was used in which 12 volunteers received either placebo or lamotrigine 300 mg on separate occasions as determined by the randomisation schedule. Volunteers were tested before and 2 h after the treatment. The plasma lamotrigine concentration was measured immediately after the end of the experimental sessions. Lamotrigine produced a significantly higher latency to P100 values at 2 h postdrug than placebo (p < 0.05) but had no significant effects on the other factors. Although plasma concentrations were similar to those observed in the cold pain test, we conclude that lamotrigine 300 mg by mouth had no analgesic effect in this acute pain model.

Bilateral optic neuropathy with IgGkappa multiple myeloma improved after myeloablative chemotherapy

A 49-year-old woman with immunoglobulin GK multiple myeloma developed progressive visual loss with bilateral upper and lower central arcuate scotomas. Funduscopic and electrophysiologic studies indicated bilateral optic neuropathy. The immunoglobulin G fraction of the patient's serum reacted with retinal ganglionic cells in bovine retina. The visual abnormalities remitted after myeloablative chemotherapy and disappearance of the paraprotein.

Lack of an effect of zolmitriptan (Zomig, 311C90) on psychometric task performance: results of a placebo-controlled study in healthy volunteers

The novel selective 5-hydroxytryptamine (5-HT)1B/1D agonist, zolmitriptan (Zomig, formerly known as 311C90), has shown good efficacy in the acute oral treatment of migraine. Zolmitriptan acts both centrally and peripherally, therefore it is important to assess central nervous system effects. At single doses of 25-50 mg (up to 8 times the likely therapeutic dose), zolmitriptan can cause sedation; therefore, a study was designed to examine the dose-response. A double-blind, randomized, placebo-controlled, six-limb crossover study in 13 healthy volunteers compared the effects of single oral doses of zolmitriptan (5, 10, 15 or 20 mg) and lorazepam (2 mg) on various psychometric tests. Zolmitriptan doses less than 20 mg had no statistically significant effects on choice reaction time, the Stroop test, visual analog scale (VAS) assessments of physical sedation, tranquilization and other types of feelings, the logical reasoning test or the adaptive tracking test. There was a mild transient increase in the subjective assessment on VAS of mental sedation which was dose related and occurred mainly with the highest zolmitriptan dose and were not reflected in objective measures of drug effects. In contrast, lorazepam (used as a positive control) was associated with statistically significant impairment in all tests (except tranquilization) for up to 10 h after dosing. The results demonstrate that therapeutic doses of zolmitriptan are unlikely to cause clinically significant impairment in psychometric performance.

Perceptions of danger: a psychological mediator of neighborhood demographic characteristics

Associations between neighborhood characteristics and adjustment of 168 urban fifth-grade children were explored. High neighborhood risk was associated with parent and teacher reports of child misconduct, and with parent and child reports of child psychological distress, while child and parent perceptions of neighborhood dangers appeared to mediate these associations. Specific neighborhood aspects were also related to child adjustment: higher violent crime rates with higher child misconduct rates, and lower neighborhood incomes with greater child psychological distress. Implications for research and intervention are discussed.

Median cleft lip with associated midline sinuses

Midline upper lip sinuses alone are rare entitities, with less than 25 cases reported previously. Midline upper lip sinuses with associated cleft lip are even more rare. A patient report of median cleft lip with associated upper lip sinuses in a 16-year-old boy is presented. Controversy exists as to whether these abnormalities are related. This report demonstrates the plausibility of a cause-and-effect relationship between midline clefts and sinuses.

Effect of food and gender on the pharmacokinetics of tucaresol in healthy volunteers

AIMS

The potential effects of food and gender on the pharmacokinetics of tucaresol were investigated in healthy volunteers.

METHODS

Ten males (mean weight 76.5 kg, age 27-42 years) and eight females (mean weight 58.9 kg, age 18-44 years) received a single oral dose of 200 mg tucaresol on two occasions in random order. On one occasion, tucaresol was given after an overnight fast and on the other, immediately after ingestion of a standard breakfast.

RESULTS

There were no significant differences in standard pharmacokinetic parameters between the two occasions but the rate of tucaresol absorption was faster after food intake. Female subjects had higher Cmax (ratio 1.25 with 95% CI 1.10-1.44) and AUC (ratio 1.25 with 95% CI 1.05-1.49) values than males but the differences were due to the higher body weights of the males; weight-adjusted apparent total clearance values (CL/F) were not different between genders (ratio 1.03 with 95% CI 0.87-1.21).

CONCLUSIONS

Food intake and gender have no significant effect on the exposure to orally administered tucaresol.

The pharmacodynamics and pharmacokinetics of the 5HT1B/1D-agonist zolmitriptan in healthy young and elderly men and women

OBJECTIVE

Zolmitriptan is a selective 5HT1B/1D-agonist for the treatment of migraine. In this study we investigated the cardiovascular and central nervous system effects and the pharmacokinetics of zolmitriptan in young and elderly adults.

METHODS

Twelve young adult and 12 elderly volunteers received single doses of 5, 10, and 15 mg zolmitriptan during a randomized, double-blind, placebo-controlled study. Blood pressure, heart rate, ECG, and central nervous system effects were monitored, and pharmacokinetic parameters of zolmitriptan and its metabolites calculated.

RESULTS

Zolmitriptan did not affect heart rate and had little effect on systolic blood pressure in the young adults. In the elderly, mean peak supine systolic blood pressure values were 9 to 16 mm Hg higher after zolmitriptan than after placebo. Mean peak diastolic pressure was 6 to 10 mm Hg higher in both age groups. These changes were transient. Postural changes in blood pressure were unaffected. There was a dose-related increase in sedation, but the magnitude of the effects was small. Mean observed peak plasma concentration (Cmax) and area under the plasma concentration-time profile [AUC(0-infinity)] for zolmitriptan and its active N-desmethyl metabolite were similar in both age groups but higher in young women than in young men. Metabolite/parent ratios probably the result of greater first-pass metabolism in young men. Zolmitriptan half-life was 2.8 to 3.6 hours in the elderly compared with 2.7 to 2.9 hours in young adults. Mean Cmax and AUC(0-infinity) for the inactive, N-oxide, and the indole acetic acid metabolites were higher in the elderly, associated with lower renal clearance.

CONCLUSIONS

Zolmitriptan was well tolerated, with an effect of age on its effects on blood pressure and the pharmacokinetics of its metabolites. The data suggest no need for dose adjustment for age. In young subjects, concentrations were higher in women than in men, but the differences were insufficient to justify dosage adjustment.

The novel anti-migraine compound zolmitriptan (Zomig 311C90) has no clinically significant interactions with paracetamol or metoclopramide

OBJECTIVE

This study investigated potential pharmacokinetic or pharmacodynamic interactions between the novel anti-migraine compound zolmitriptan (Zomig, formerly 311C90) and paracetamol and/or metoclopramide.

METHODS

In an open-label, randomised, crossover study, 15 healthy volunteers received single oral doses of 10 mg zolmitriptan alone, 1 g paracetamol alone, 10 mg zolmitriptan + 1 g paracetamol, 10 mg zolmitriptan + 10 mg metoclopramide or 10 mg zolmitriptan + 1 g paracetamol + 10 mg metoclopramide on five separate occasions.

RESULTS

Metoclopramide had no significant effects on the pharmacokinetics of zolmitriptan or the active zolmitriptan metabolite 183C91, nor did it affect interactions between zolmitriptan and paracetamol. Paracetamol marginally increased the maximum plasma concentration (Cmax) (11%) and the area under the curve (AUC) (11%) and reduced the renal clearance of zolmitriptan (9%); similar small effects were seen on 183C91. The AUC, Cmax and half-life of paracetamol were reduced by concomitant zolmitriptan (by 11%, 31% and 8%, respectively), whilst the mean residence time showed a small increase (+0.7 h). There was a trend towards a transient increase in blood pressure following all regimens containing zolmitriptan; this effect was small, was consistent between all zolmitriptan regimens as well as with previous studies, and was considered to be clinically insignificant. Zolmitriptan was well tolerated after all treatment regimens.

CONCLUSION

Concomitant administration of zolmitriptan and paracetamol resulted in a slight increase in bioavailability of zolmitriptan and a reduced rate and extent of paracetamol absorption. These findings are considered to be of no clinical significance and there is no reason to avoid concomitant administration of paracetamol and/or metoclopramide with zolmitriptan.

Lack of interaction between valaciclovir, the L-valyl ester of aciclovir, and digoxin

AIMS

Changes in both digoxin and aciclovir renal clearance following coadministration with some other renally eliminated drugs have been reported. The potential interaction of valaciclovir, with its antiherpetic metabolite aciclovir, and digoxin was investigated.

METHODS

Twelve healthy volunteers (seven males, five females) participated in an open, randomized, four-period crossover study. Valaciclovir, 1000 mg, was given alone on one occasion, and on another, after the second of two 0.75 mg digoxin doses administered 12 h apart. Blood samples and all urine were collected up to 12 h following the valaciclovir dose for aciclovir radioimmunoassay. On a third occasion, digoxin was given alone and on a fourth, with 1000 mg valaciclovir three times/day for 8 days starting 12 h before the first digoxin dose. Blood samples were taken up to 168 h and all urine collected up to 24 h following the second dose for digoxin radioimmunoassay.

RESULTS

There were no clinically significant differences in digoxin or aciclovir pharmacokinetic parameters when digoxin or valaciclovir was given alone or in combination.

CONCLUSIONS

No dosage adjustment is required when valaciclovir and digoxin are coadministered.

The interaction between propranolol and the novel antimigraine agent zolmitriptan (311C90)

AIMS

Zolmitriptan (Zomig, formerly known as 311C90), a selective 5HT1B/1D agonist is under development as an acute oral treatment for migraine. Despite the use of prophylactic medication, such as propranolol, breakthrough attacks often occur in patients. Consequently we investigated the effects of propranolol on the pharmacokinetics of, and cardiovascular responses to, zolmitriptan.

METHODS

A double-blind, randomized, crossover study of the effects of pre-treatment with propranolol 160 mg daily for 7 days or placebo on the pharmacokinetics and effects on blood pressure of a single 10 mg dose of zolmitriptan in 12 healthy volunteers.

RESULTS

Propranolol increased mean zolmitriptan Cmax and AUC by 56% and 37% respectively; mean t1/2 was prolonged from 3.1 to 4.0 h. Mean Cmax and AUC of the pharmacologically active N-desmethyl metabolite were reduced by 24% and 11% respectively and the metabolite:parent AUC ratio (AUCm/AUCp) fell from 0.46 to 0.26. Mean Cmax and AUC for the inactive indole acetic acid metabolite were both reduced by 13% and AUCm/AUCp from 1.04 to 0.59. A small pressor effect of short duration was observed following zolmitriptan with mean peak rises of 13 and 11 mmHg in systolic and diastolic pressures respectively; propranolol had no effect on the pressor response.

CONCLUSIONS

The results suggest that propranolol inhibits biotransformation of zolmitriptan but with no change in the small pressor response to zolmitriptan. It is therefore unlikely that the pharmacokinetic changes will lead to clinically important changes in pharmacological effects and dosage adjustment of zolmitriptan is not required in patients taking propranolol for migraine prophylaxis.

Quality improvement in neurology residency programs. Report of the Quality Improvement Committee of the Association of University Professors of Neurology

The neurology residency programs in the United States are facing a crisis of quality. The Association of University Professors of Neurology (AUPN) approved the Quality Improvement Committee to examine this situation and make recommendations, which have been accepted by the AUPN. The recommendations are (1) that the educational goals of neurology residency training be dissociated from patient-care needs in academic medical centers and (2) that minimum levels of quality be applied to residents in neurology residency programs and to these programs themselves. These minimum criteria should include minimum educational criteria for entry into the program, minimum criteria for advancement from one year to the next in the program, and minimum criteria for performance of the graduates of neurology residency programs for program accreditation. The implementation of these recommendations will require a shift of funding of the care of indigent patients from the graduate medical education budget to direct patient-care sources. These recommendations will significantly improve the quality of neurologists and neurologic care in the United States.

Peripheral vascular effects and pharmacokinetics of the antimigraine compound, zolmitriptan, in combination with oral ergotamine in healthy volunteers

Members of the new class of antimigraine compounds, 5HT1B/1D agonists, as well as ergotamine, may cause vasoconstriction through stimulation of 5HT receptors on peripheral vessels. The cardiovascular effects of 20 mg oral zolmitriptan (Zomig, formerly 311C90), 2 mg oral ergotamine and the combination were assessed in a randomized double-blind, placebo-controlled crossover study in 12 healthy subjects. Pharmacodynamic measures included oscillometric blood pressure, systolic blood pressure at the toe and arm using a strain gauge technique, stroke volume and cardiac output using bioimpedance cardiography, high-resolution ultrasound to measure brachial arterial diameter and a novel Doppler method to measure blood flow velocity. Both drugs produced small degrees of peripheral vasoconstriction, including increases in diastolic blood pressure and blood flow velocity and decreases in arterial diameter and toe-arm systolic pressure gradient. These effects were generally additive with the combination but of no clinical importance. There were no significant changes in cardiac output, stroke volume heart rate or ECG. Zolmitriptan, at eight times the likely therapeutic dose, was generally well tolerated both alone and in combination with ergotamine. Ergotamine had no clinically important effects on zolmitriptan pharmacokinetics.

1457 years of microsurgical experience

Microsurgery is a relatively new field of surgery involving various methods and practices that are currently evolving. Our goal was to register the current practices employed by the members of the American Society for Reconstructive Microsurgery. A survey was mailed to the 319 members of the society, resulting in a response rate of 33 percent (106 of 319). The data reflect the combined experience of 10,839 free-tissue transfers and 3487 digital and upper and lower extremity replants over a 4-year period between 1990 and 1994. Practices employed, such as pharmacologic adjuvant therapy, monitoring techniques, flap types, and success rates reported by the members of the American Society for Reconstructive Microsurgery, were analyzed.

The absolute bioavailability and metabolic disposition of the novel antimigraine compound zolmitriptan (311C90)

AIMS

Two open studies in healthy volunteers were conducted to determine the absolute bioavailability and metabolic disposition of zolmitriptan (311C90), a novel 5HT1D agonist for the acute treatment of migraine.

METHODS

After an initial test i.v. infusion, bioavailability was assessed by comparison of AUC after an i.v. infusion (3.5 mg) and an oral tablet (10 mg), in six men and six women using a randomised, crossover design. Disposition was studied by administration of a 25 mg capsule, labelled with 100 microCi [14C]-zolmitriptan, to five men and one woman on a single occasion.

RESULTS

Zolmitriptan was well tolerated by both i.v. and oral routes. Adverse events were mostly mild, consistent with earlier studies and characteristic of this class of drug. Reports were similar in nature and number after both oral and i.v. dosing. Mean +/- s.d. oral bioavailability was 0.49 +/- 0.24 (0.38 +/- 0.16 in men and 0.60 +/- 0.28 in women). After oral dosing, Cmax and AUC values in women were approximately double those in men. Relative to zolmitriptan concentrations, metabolite concentrations were higher after oral dosing than after i.v., and higher in men compared with women. Half-life was significantly longer after oral dosing (mean 22%, 95% CI 6-35%). Mean +/- s.d. values for CL, V2 and t1/2,z after i.v. dosing (all subjects) were 8.7 +/- 1.7 ml min-1 kg-1, 122 +/- 321 and 2.30 +/- 0.59 h respectively. Following administration of 25 mg [14C]-zolmitriptan, 91.5% of the dose was recovered in 7 days, 64.4 +/- 6.5% in urine and 27.1 +/- 6.0% in faeces. Less than 10% was recovered unchanged in urine, with 31.1 +/- 6.4% recovered as the inactive indole acetic acid metabolite. Most of the faecal material was unchanged zolmitriptan, representing unabsorbed drug. Plasma concentrations of [14C] were slightly higher than those of the summed concentrations of known analytes zolmitriptan, the active N-desmethyl metabolite (183C91), the inactive N-oxide (1652W92) and indole acetic acid (2161W92) metabolites, which accounted for 86% of total plasma radioactivity. No other significant metabolites were detected in plasma. Some minor additional metabolites were detected in urine, none of which contributed more than 5% of the dose.

CONCLUSIONS

The data suggest that zolmitriptan undergoes first-pass metabolism and this is more extensive in men than in women. Zolmitriptan has suitable bioavailability for an acute oral migraine treatment and there are no significant unidentified metabolites in man.

Disposition of atovaquone in humans

Atovaquone is an antiprotozoal compound with good in vitro stability against metabolic inactivation. Previous human studies which did not involve radiolabelling had not accounted for a substantial proportion of the dose. The possible metabolism of atovaquone in men was examined in a radiolabelling study involving four healthy male volunteers. Radioactivity was eliminated almost exclusively via the feces. All radioactivity in plasma, urine, and feces was accounted for by atovaquone, with no evidence of metabolites. Radiolabelled atovaquone was administered to a patient with an indwelling biliary tube after surgery. Biliary radioactivity was approximately 10- to 40-fold higher than that in plasma and was accounted for by atovaquone. Atovaquone is not significantly metabolized in humans but is excreted into bile against a high concentration gradient.

Population pharmacokinetics of lamotrigine monotherapy in patients with epilepsy: retrospective analysis of routine monitoring data

AIMS

To examine the population pharmacokinetics of lamotrigine in patients newly diagnosed with epilepsy and receiving oral lamotrigine monotherapy for up to 48 weeks.

METHODS

The population consisted of 158 Caucasians and 5 Asians of whom 81 were males and 82 females. Age and weight ranged between 14 and 76 years and 41-107 kg, respectively. A one-compartment compartment model with first-order absorption and elimination was fitted to plasma lamotrigine concentration-time profiles from retrospective drug monitoring, using non-linear mixed effect modelling (NONMEM), with first-order estimation. Oral clearance (CLo), apparent volume of distribution (V/F) and absorption rate constant (Ka) were the main pharmacokinetic parameters.

RESULTS

CLo was not significantly influenced by body weight, age, gender, oral contraceptives and dose. However, due to auto-induction CLo increased by 17.3% during the 48 weeks of therapy, from 1.94 to 2.28 l h(-1), and was 28.7% lower in Asians than Caucasian. The final magnitude in interpatient variability was 32%. The effect of the covariates weight, age, race and gender on V/F was examined and none was statistically significant. The final population estimate of V/F was 77.4 l with an interpatient variability of 34%.

CONCLUSIONS

In view of the wide therapeutic margin of lamotrigine and the 21% residual variability in plasma concentrations, the modest significant effects of race and auto-induction on clearance are unlikely to be clinically significant and, thus, no dosage adjustment is warranted for these effects.

The pharmacokinetics and effects on blood pressure of multiple doses of the novel anti-migraine drug zolmitriptan (311C90) in healthy volunteers

AIMS

Zolmitriptan (311C90), a novel, selective, centrally and peripherally acting 5-HT1D-receptor agonist is under development as an acute treatment for migraine. The tolerability, pharmacokinetics and effects on blood pressure and heart rate of multiple doses of 5 or 10 mg (5 doses administered over 24 h) were compared, in healthy adult volunteers, with those after placebo and single doses of zolmitriptan.

METHODS

Twelve subjects participated in a randomized, balanced, crossover comparison. Plasma and urine concentrations of zolmitriptan and its metabolites, pulse rate and blood pressure were measured at intervals after drug. Ten volunteers completed the study.

RESULTS

Zolmitriptan was well tolerated after single and multiple doses throughout the study. There was no evidence of significant changes in the pharmacokinetic parameters of zomitriptan or its metabolites after the last dose compared to the first, except for an expected rise in peak concentrations and a small, apparent increase in the amount of drug excreted in urine and hence in CLR. After the last 10 mg dose, mean dosing interval zolmitriptan AUC was 80.3 ng ml-1 h compared with 86.5 ng ml-1 h after the single 10 mg dose (95% CI for ratio 0.76-1.13). There was no evidence of changes in the pharmacokinetic parameters of zolmitriptan and its metabolites after 10 mg compared with 5 mg, except a small increase in zolmitriptan CLR. There were no statistically significant increases in peak systolic or diastolic blood pressure after the last doses of zolmitriptan compared to placebo or in peak blood pressure after the last dose compared to the first. There were no significant differences between blood pressure immediately before the first and last doses of each multiple dose regimen. Peak erect systolic blood pressure after the last 10 mg dose (137 mmHg) was significantly lower than that after placebo (147 mmHg, 95% CI for difference -18, -2) and that after the last 5 mg dose (148 mmHg, 95% CI -19, -3).

CONCLUSIONS

Repeated doses of 5 or 10 mg zolmitriptan are well tolerated despite higher plasma concentrations than expected from single doses.

Comparison of the pharmacokinetics of lamotrigine in patients with chronic renal failure and healthy volunteers

AIMS

The aim of this study was to compare the pharmacokinetics of the anti-epileptic agent, lamotrigine, in patients with chronic renal failure and healthy volunteers.

METHODS

Non-compartmental pharmacokinetics of a single oral dose (200 mg) of the anti-epileptic agent, lamotrigine, and its main metabolite, lamotrigine N2-glucuronide, were determined for 10 patients with chronic renal failure of mean estimated creatinine clearance 18 ml min-1 and a control group of 11 healthy volunteers, matched for age and gender.

RESULTS

For lamotrigine, there were no significant differences in Cmax, tmax, AUC, t1/2,z, CL/F and amount excreted in urine although t1/2,z tended to be longer for the renal failure group with a mean (+/-s.d.) of 35.9 +/- 10.7 h vs 27.8 +/- 4.3 h for the control group. For the renal failure group. VZ/F was 18% higher (95% CI 1% to 39%) compared with controls and CLR was reduced to 61% (95% CI 46% to 80%) of the control group value. For lamotrigine glucuronide, Cmax was increased 4-fold (95% CI 3.1 to 5.3) and AUC 7.8-fold (95% CI 6.0 to 10.1) in the renal failure group compared with controls. CLR was approximately 9-fold lower and apparent t1/2 was increased by 53% (95% CI 27% to 84%). Concentrations of an N2-methylated cardio-active metabolite, previously observed in dogs, were below the limit of detection (2 ng ml-1) of the ASTED/h.p.l.c. assay in the renal failure group as well as controls.

CONCLUSIONS

These results indicate that impaired renal function will have little effect on the plasma concentrations of lamotrigine achieved for a given dosing regimen.

The HuD paraneoplastic protein shares immunogenic regions between PEM/PSN patients and several strains and species of experimental animals

Patients with small-cell carcinoma of the lung and paraneoplastic encephalomyelitis develop antibodies (anti-Hu) against HuD, a member of a family of neuronal specific RNA-binding proteins, which are also expressed by the tumor. In order to determine if the human HuD paraneoplastic antigen shares immunogenic regions between patients and several strains and species of animals, we immunized animals with HuD and several deletion constructs of this protein. All immunized animals developed high titers of anti-HuD antibodies, comparable to the antibody titers found in paraneoplastic patients. Using immunohistochemistry and Western blot analysis of human and mouse cerebral cortex, the pattern of reactivity of these antibodies could not be differentiated from the human paraneoplastic anti-Hu antibodies. None of the immunized animals developed neurologic symptoms. Western blot analysis of HuD deletion constructs demonstrated that the first and second RNA binding domains were the main immunodominant regions, and that the animal immune response was both strain and species dependent.

Evaluation of non-invasive techniques to assess vasoconstriction in healthy volunteers using methoxamine as a probe drug

Non-invasive methods for assessment of the vascular effects of antimigraine drugs were evaluated with respect to their utility, variability and sensitivity in a double-blind, placebo-controlled, three-period crossover study in six healthy volunteers using an intravenous vasoconstrictor, methoxamine, as a probe drug. Changes in the internal diameter of the brachial and radial arteries were measured using ultrasound which had low between-day and within-day coefficients of variation. Peak systolic velocity (PSV), time-averaged velocity (TAV), total flow, resistance (RI) and pulsatility indices (PI) were measured by Doppler from one arterial wave form. Whilst PSV and TAV increased with methoxamine, because of bradycardia, changes in PI and RI were difficult to interpret. An automatic oscillometric cuff, a mercury-in-silastic strain gauge method and the "Finapres", finger arterial blood pressure monitor were used to follow changes in systolic blood pressure (SBP). The strain gauge technique underestimated arm SBP compared to the oscillometric method but clearly showed drug-related increases whilst the Finapres did not reflect changes in blood pressure detected by the other methods.

Atovaquone has no effect on the pharmacokinetics of phenytoin in healthy male volunteers

The potential pharmacokinetic interaction between atovaquone and phenytoin was investigated in 12 healthy male volunteers. Each volunteer received a single 600 mg oral dose of phenytoin in the two treatment periods. On one occasion phenytoin was taken alone and on the other pre-treatment with 2000 mg atovaquone taken as two doses of 1000 mg as a microfluidized suspension. The mean (+/- s.d.) peak plasma concentrations (Cmax), apparent total clearance (CL/F) and terminal half-life (t1/2) for phenytoin when administered alone were 10.6(1.8) mg 1(-1), 24.3 (7.7) ml min-1 and 25(8) h, respectively. When administered together with atovaquone, phenytoin Cmax, CL/F and t1/2,z were 10.9 (2.0) mg 1(-1), 23.8 ml min-1 and 24(6) h, respectively. There were no statistically significant differences in any of these plasma pharmacokinetic parameters. There were also no statistically significant differences in the fraction of circulating drug not bound to plasma protein or urinary excretion of 5-hydroxyphenyl-phenyl-hydantoin. In conclusion, there was no effect of atovaquone on the pharmacokinetics of phenytoin or its major metabolite after a single dose.

Tucaresol increases oxygen affinity and reduces haemolysis in subjects with sickle cell anaemia

The primary pathophysiological event in sickling is the intracellular polymerization of deoxygenated haemoglobin S. Tucaresol (589C80;4[2-formyl-3-hydroxyphenoxymethyl] benzoic acid), a substituted benzaldehyde, was designed to interact with haemoglobin to increase oxygen affinity and has been shown to inhibit sickling in vitro. We administered tucaresol to sickle cell patients in the steady state to examine the anti-sickling effect in vivo. Oral doses of tucaresol or placebo were given to nine stable sickle cell patients (aged 17-39 years; tucaresol, six; placebo, three) for 10 d. The first two patients on tucaresol were scheduled to receive a loading dose of 800 mg or 1200 mg (depending on bodyweight) for the first 4 d, followed by maintenance doses of 200 or 300 mg for the next 6 d. Due to concerns over the sharp rise in haematocrit in one patient, subsequent cohorts received 300 mg tucaresol daily throughout the dosing period. The oxygen affinity of haemoglobin S was increased in all patients receiving tucaresol, with between 10% and 24% of the haemoglobin modified, dependent on dose. In all patients on tucaresol, haemolysis was reduced with rises in haemoglobin of 0.9- 3.7 g/dl (mean 2.2 g/dl), falls in lactate dehydrogenase of 16-52%, and a halving of the irreversibly sickled cell counts. These effects were apparent within a few days and persisted for 1-2 weeks following discontinuation of the drug. Three of the six patients on tucaresol developed fever and cervical lymphadenopathy, with onset between days 7 and 11 from start of drug. Further evaluation of the tolerability and efficacy of tucaresol in sickle cell patients is necessary.