Efficacy and safety of ripretinib in patients with KIT-altered metastatic melanoma

BACKGROUND

Ripretinib, a broad-spectrum KIT and platelet-derived growth factor receptor A switch-control tyrosine kinase inhibitor, is approved for the treatment of adult patients with advanced gastrointestinal stromal tumor as ≥ fourth-line therapy. We present the efficacy and safety of ripretinib in patients with KIT-altered metastatic melanoma enrolled in the expansion phase of the ripretinib phase I study.

PATIENTS AND METHODS

Patients with KIT-altered metastatic melanoma were enrolled and treated with ripretinib at the recommended phase II dose of 150 mg once daily in 28-day cycles. Investigator-assessed responses according to Response Evaluation Criteria In Solid Tumors version 1.1 were carried out on day 1 of cycles 3, 5, 7, every three cycles thereafter, and at a final study visit.

RESULTS

A total of 26 patients with KIT-altered metastatic melanoma (25 with KIT mutations, 1 with KIT-amplification) were enrolled. Patients had received prior immunotherapy (n = 23, 88%) and KIT inhibitor therapy (n = 9, 35%). Confirmed objective response rate (ORR) was 23% [95% confidence interval (CI) 9%-44%; one complete and five partial responses] with a median duration of response of 9.1 months (range, 6.9-31.3 months). Median progression-free survival (mPFS) was 7.3 months (95% CI 1.9-13.6 months). Patients without prior KIT inhibitor therapy had a higher ORR and longer mPFS (n = 17, ORR 29%, mPFS 10.2 months) than those who had received prior KIT inhibitor treatment (n = 9, ORR 11%, mPFS 2.9 months). The most common treatment-related treatment-emergent adverse events (TEAEs) of any grade in ≥15% of patients were increased lipase, alopecia, actinic keratosis, myalgia, arthralgia, decreased appetite, fatigue, hyperkeratosis, nausea, and palmar-plantar erythrodysesthesia syndrome. There were no grade ≥4 treatment-related TEAEs.

CONCLUSIONS

In this phase I study, ripretinib demonstrated encouraging efficacy and a well-tolerated safety profile in patients with KIT-altered metastatic melanoma, suggesting ripretinib may have a clinically meaningful role in treating these patients.

Links between oral health-related quality of life in US adults and type 2 diabetes: structural equation modeling analysis

OBJECTIVES

To analyze the effects of type 2 diabetes mellitus (T2DM), need for dental care, personal health practices and use of services on oral health-related quality of life (OHRQoL) in US adults.

BASIC RESEARCH DESIGN

The sample included 2,945 participants (aged ≥ 20) selected from the National Health and Nutrition Examination Survey (NHANES) 2003-2004 stratified probability sample that represented 124,525,899 individuals in the weighted sample. Two-stage structural equation modelling (SEM) assessed interrelationships between T2DM regressions on factors associated with OHRQoL in a simplified three-factor Andersen Behavioral Model (ABM).

RESULTS

SEM supported the hypotheses that T2DM directly predicted need (perceived need, evaluated need, general health condition) with a significant path coefficient of 0.49 (β=0.49, p⟨0.05). Need had direct (77%) and indirect (23%) effects on OHRQoL (βdirect=0.30, βindirect=0.09, p⟨ 0.001). Need predicted personal health practices including use of services (reason for dental visit, frequency of dental visits, smoking status) (β=0.46, p⟨0.001). Need, in turn, predicted OHRQoL (β=0.19, p⟨0.001). In the model, 23.8%, 59.7%, and 18.1% of the variance was explained by need, personal health practices including use of services, and OHRQoL, respectively.

CONCLUSIONS

The results confirmed T2DM predicted need, which in sequence had direct and indirect effects on OHRQoL.

PMMA Bone Cement in Interventional Oncology

Polymethylmethacrylate (PMMA) bone cement is increasingly being used for percutaneous minimally invasive treatments of patients suffering from bone malignancies. PMMA is composed of a polymeric powder and a monomeric liquid. Once mixed, the polymerization process begins and leads to a viscous fluid that can be injected through a bone trocar. Cement progressively hardens within the bone, leading to a viscoelastic solid material. PMMA interacts with the surrounding cancellous bone through mechanical interlocking via interdigitations in trabecular bone. It can also bond with hardware, such as titanium screws, as it penetrates the macro- and micro-irregularities of the hardware. PMMA itself has no antineoplastic effects but may be used as a stand-alone treatment to provide pain palliation and bone consolidation through mechanical reinforcement, notably in areas with high compression load. It can also be used to reinforce the anchorage of screws in case of a landing zone with poor bone quality due to underlying malignant osteolysis.

Grazing management of mixed alfalfa bermudagrass pastures

Rotational grazing management is commonly recommended to improve persistence of legumes interseeded into bermudagrass, but impacts on animal performance are poorly understood. Steers (n = 365, BW = 249 ± 22.9 kg) grazed mixed alfalfa (Medicago sativa L.)/bermudagrass (Cynodon dactylon [L.] Pers.) pastures (n = 10; 1.6-ha) with either continuous grazing (CONT) or rotational grazing (ROT) management over 3 yr. Initial stocking rate was set at 6.25 steers/ha. When forage allowance of CONT became limiting in mid-July each year, 2 randomly selected steers were removed from all pastures to maintain equal stocking rates in CONT and ROT. Rotational grazing pastures were divided into 8 paddocks with 3-d grazing and 21-d rest between grazing events. Initial, final, and interim (28-d) BW were collected following a 16-h removal from feed and water. Data were analyzed as a repeated measures experiment with completely random design using the mixed procedure of SAS (SAS Inst. Inc., Cary, NC) using pasture within treatment by year in the random statement. Across years, steer BW did not differ (P ≥ 0.47) at the midpoint or end of the grazing season. Daily BW gains during the early summer period tended (P = 0.10) to be 0.11 kg greater for CONT than ROT in yr 1, but did not differ (P ≥ 0.24) in yr 2 and 3. In the late summer, ADG was 0.15 kg less (P < 0.01) for CONT than ROT in yr 1, were not different (P = 0.23) in yr 2, and were 0.29 kg less (P < 0.01) for CONT than ROT in yr 3. Over the entire experimental period, ADG did not differ (P ≥ 0.67) in yr 1 or 2, but tended (P = 0.09) to be 0.10 kg greater for ROT than CONT in yr 3. Forage mass of ROT was greater (P < 0.01) than CONT throughout the grazing season. Because stocking rates were maintained at the same level, ROT pastures provided greater (P < 0.01) forage allowance during the grazing season than CONT explaining differences in ADG between treatments. Alfalfa stand percentage did not differ (P = 0.79) at the beginning of the experiment, but was less (P ≤ 0.03) for CONT than ROT at all other sampling dates. These data indicate that at equal stocking rates, ROT can maintain greater alfalfa persistence, forage nutritive quality, and forage allowance compared with continuous grazing and provided increased animal performance during the late summer when the alfalfa stand was reduced in CONT pastures.

Replacing synthetic N with clovers or alfalfa in bermudagrass pastures. 2. Herbage nutritive value for growing beef steers

The objective of this study was to evaluate the effects of including alfalfa (ALF, Medicago sativa L.) or a combination of white (Trifolium repens L.) and red (Trifolium pretense L.) clovers (CLVR) inter-seeded into bermudagrass (Cynodon dactylon L. Pers.) on herbage nutritive value compared with monocultures of bermudagrass fertilised with 0 (0N), 56 (56N), or 112 (112N) kg nitrogen (N)/ha over four grazing seasons. At the end of the fourth year (during the winter), legume plants in ALF and CLVR were killed and the carryover N benefit on bermudagrass nutritive value was evaluated during the fifth year. Pre-grazing herbage of all pastures exceeded the dietary recommendations for growing steers to maintain 0.9 kg/day average daily liveweight gain for crude protein and total digestible nutrients, 118 and 617 g kg/DM, respectively. Post-grazing herbage in ALF was below 600 g/kg total digestible nutrients at all times during the grazing season, post-grazing total digestible nutrients of CLVR was below 600 g/kg during the late summer and autumn. Post-grazing herbage of monoculture bermudagrass pastures fell below 600 g/kg in the middle of summer regardless of N fertilisation. Carryover N benefits of legumes were similar to 112N in the early summer, but were not different than 0N and 56N during the late summer and autumn. Replacing applications of synthetic N in bermudagrass swards with inter-seeding of either clovers or alfalfa produce herbage with equivalent nutritive value to heavily N fertilised monocultures of bermudagrass during the early summer, and similar to moderately N fertilised in the late summer and autumn. The inclusion of legumes in bermudagrass swards can reduce the reliance on synthetic N fertilisation with little overall effect on herbage nutritive quality possibly decreasing environmental impacts of grazing production systems.

Replacing synthetic N with clovers or alfalfa in bermudagrass pastures. 3. Performance of growing steers

The objective of this study was to evaluate the performance of steers (n = 590, 263 ± 30.6 kg) grazing alfalfa (ALF, Medicago sativa L.) or a combination of white (Trifolium repens L.) and red (Trifolium pretense L.) clovers (CLVR) inter-seeded into bermudagrass (Cynodon dactylon L. Pers.) pastures compared with fertilisation with 0 (0N), 56 (56N), or 112 (112N) kg nitrogen (N)/ha (n = 4, 0.8-ha pastures per treatment) in north-east Arkansas (USA) over 4 years. The carryover N benefit of CLVR or ALF was compared with N fertilisation rates during the fifth year on performance of growing steers (n = 120; 235 ± 22.6 kg). Average daily gain increased with N application rate and legume pastures were similar to 56N; but liveweight gain per steer grazing legume pastures tended to be greater than 112N. Steer grazing days per hectare and liveweight gain per hectare were greater for ALF and CLVR than bermudagrass monocultures regardless of N fertilisation rate. Steer average daily gain, grazing days per hectare and liveweight gain per hectare for carryover N from legumes did not differ from 56N. These results indicate that replacing synthetic N by inter-seeding legumes into bermudagrass swards has the potential to improve individual animal performance and production per unit area and carryover benefits of legume N may be equivalent to 56 kg N/ha.

Replacing synthetic N with clovers or alfalfa in bermudagrass pastures. 1. Herbage mass and pasture carrying capacity

The objective of this study was to evaluate the effects of including alfalfa (ALF, Medicago sativa L.) or a combination of white (Trifolium repens L.) and red (Trifolium pretense L.) clovers (CLVR) inter-seeded into bermudagrass (Cynodon dactylon L. Pers.) on herbage nutritive value compared with monocultures of bermudagrass fertilised with 0 (0N), 56 (56N), or 112 (112N) kg nitrogen (N)/ha over four grazing seasons. In autumn, at the end of the fourth year and in the spring before the fifth grazing season, alfalfa and clover plants were killed and the carryover N benefit of CLVR or ALF was compared with N fertilisation rates during the fifth year. Across years, N fertilisation rate increased herbage mass and carrying capacity linearly; whereas herbage production from CLVR and ALF swards was equivalent to 56N, were greater than 0N and less than 112N. Herbage mass in CLVR and ALF swards was greater than fertilised bermudagrass swards in the spring and did not differ from fertilised bermudagrass in the early summer. In late summer herbage accumulation of CLVR and ALF swards appeared to decrease, limiting the herbage mass in the legume pastures compared with 56N and 112N. Carrying capacity of CLVR and ALF swards was greater than fertilised bermudagrass in the spring and early summer, but did not differ from fertilised swards in the late summer. The N benefit of including legumes in bermudagrass swards can alleviate the reliance on synthetic N fertilisation with little overall effect on pasture carrying capacity.

How does dense phase CO2 influence the phase behaviour of block copolymers synthesised by dispersion polymerisation?

Using a CO₂ continuous phase for dispersion synthesis of block copolymers can provide a useful handle to control phase behaviour.

Block copolymer synthesis by controlled/living radical polymerisation in heterogeneous systems

We review the range of CLRP-controlled syntheses of block copolymer particles in dispersed systems, which are being exploited to create new opportunities for the design of nanostructured soft materials.

Neurological consequences of diabetic ketoacidosis at initial presentation of type 1 diabetes in a prospective cohort study of children

OBJECTIVE

To investigate the impact of new-onset diabetic ketoacidosis (DKA) during childhood on brain morphology and function.

RESEARCH DESIGN AND METHODS

Patients aged 6-18 years with and without DKA at diagnosis were studied at four time points: <48 h, 5 days, 28 days, and 6 months postdiagnosis. Patients underwent magnetic resonance imaging (MRI) and spectroscopy with cognitive assessment at each time point. Relationships between clinical characteristics at presentation and MRI and neurologic outcomes were examined using multiple linear regression, repeated-measures, and ANCOVA analyses.

RESULTS

Thirty-six DKA and 59 non-DKA patients were recruited between 2004 and 2009. With DKA, cerebral white matter showed the greatest alterations with increased total white matter volume and higher mean diffusivity in the frontal, temporal, and parietal white matter. Total white matter volume decreased over the first 6 months. For gray matter in DKA patients, total volume was lower at baseline and increased over 6 months. Lower levels of N-acetylaspartate were noted at baseline in the frontal gray matter and basal ganglia. Mental state scores were lower at baseline and at 5 days. Of note, although changes in total and regional brain volumes over the first 5 days resolved, they were associated with poorer delayed memory recall and poorer sustained and divided attention at 6 months. Age at time of presentation and pH level were predictors of neuroimaging and functional outcomes.

CONCLUSIONS

DKA at type 1 diabetes diagnosis results in morphologic and functional brain changes. These changes are associated with adverse neurocognitive outcomes in the medium term.

Clinical characteristics and therapeutic responses in patients with germ-line AIP mutations and pituitary adenomas: an international collaborative study

CONTEXT

AIP mutations (AIPmut) give rise to a pituitary adenoma predisposition that occurs in familial isolated pituitary adenomas and less often in sporadic cases. The clinical and therapeutic features of AIPmut-associated pituitary adenomas have not been studied comprehensively.

OBJECTIVE

The objective of the study was to assess clinical/therapeutic characteristics of AIPmut pituitary adenomas.

DESIGN

This study was an international, multicenter, retrospective case collection/database analysis.

SETTING

The study was conducted at 36 tertiary referral endocrine and clinical genetics departments.

PATIENTS

Patients included 96 patients with germline AIPmut and pituitary adenomas and 232 matched AIPmut-negative acromegaly controls.

RESULTS

The AIPmut population was predominantly young and male (63.5%); first symptoms occurred as children/adolescents in 50%. At diagnosis, most tumors were macroadenomas (93.3%); extension and invasion was common. Somatotropinomas comprised 78.1% of the cohort; there were also prolactinomas (n = 13), nonsecreting adenomas (n = 7), and a TSH-secreting adenoma. AIPmut somatotropinomas were larger (P = 0.00026), with higher GH levels (P = 0.00068), more frequent extension (P = 0.018) and prolactin cosecretion (P = 0.00023), and occurred 2 decades before controls (P < 0.000001). Gigantism was more common in the AIPmut group (P < 0.000001). AIPmut somatotropinoma patients underwent more surgical interventions (P = 0.00069) and had lower decreases in GH (P = 0.00037) and IGF-I (P = 0.028) and less tumor shrinkage with somatostatin analogs (P < 0.00001) vs. controls. AIPmut prolactinomas occurred generally in young males and frequently required surgery or radiotherapy.

CONCLUSIONS

AIPmut pituitary adenomas have clinical features that may negatively impact treatment efficacy. Predisposition for aggressive disease in young patients, often in a familial setting, suggests that earlier diagnosis of AIPmut pituitary adenomas may have clinical utility.

Lessons learnt about effectively applying participatory action research: a case study from the New South Wales dairy industry

A participatory action research (PAR) project was implemented in the New South Wales dairy industry. Six regional dairy groups were given funding to investigate issues relating to management of the feedbase. Facilitated meetings in the regions identified limitations to local systems and how these limitations could be addressed. Local groups then implemented research of relevance to their systems. Activities varied but groups were guided by the principles of PAR. Regional groups consisted of farmers, government extension and/or research staff, processors and other stakeholders. A leadership team, consisting of representatives from each of the regional groups and other stakeholders, was formed to administer the project and assist groups in using the PAR approach. Evaluation of the project indicated high levels of participation in all regions and a strong sense of ownership of the project and/or project work. The most commonly mentioned outcome in the groups was what they learned as a result of involvement. The project and its evaluation are discussed in relation to PAR principles, the outcomes from the approach, and lessons learnt for improving the success of PAR.

MRI and 2D-CSI MR spectroscopy of the brain in the evaluation of patients with acute onset of neuropsychiatric systemic lupus erythematosus

MRI and 2D-CSI spectroscopy were performed in eight patients with systemic lupus erythematosus who presented with acute onset of neuropsychiatric lupus (NP-SLE), and in seven normal controls to evaluate for differences in metabolic peaks and metabolic ratios between the two groups. Also, the interval change of the metabolic peaks and their ratios during treatment in the NP-SLE patient group was evaluated. Metabolic peaks for N-acetyl-aspartate (NAA), choline (Cho), creatine (Cr), and lactate/lipids (LL) and their ratios (NAA/Cr, NAA/Cho, Cho/Cr, LL/Cr) were determined at initial presentation and 3 and 6 months later. In the eight lupus patients compared to the seven normal controls, NAA/Cho ratios were lower at presentation (1.05 vs 1.25; p = 0.004) and decreased even further at the three month follow-up (0.92 vs 1.05; p = 0.008). In contrast, both Cho/Cr (1.42 vs 1.26; p = 0.026) and LL/Cr ratios (0.26 vs 0.19; p = 0.002) were higher in the lupus patients at presentation compared to the controls and did not significantly change at three and six months follow-up. The NAA/Cr ratios were lower in the lupus patients compared to the controls at presentation but the difference was not statistically significant. However, the mean NAA/Cr significantly decreased from the initial examination to the three month follow-up (1.42 vs 1.32; p = 0.049) but did not significantly change from the three to the six month follow-up examinations. The NAA/Cr, Cho/Cr, and NAA/Cho ratios varied significantly (p < 0.05, p < 0.05, p < 0.05, respectively) between the 17 different locations measured in the brain in all eight patients and seven controls. Both the NAA/Cr ratios and the Cho/Cr ratios were also significantly lower in the gray matter than in the white matter (p < 0.0001) in both patients and controls, whereas the LL/Cr and NAA/Cho ratios were not significantly different. In conclusion, 2D-CSI MR spectroscopy may be useful in the early detection of metabolic CNS changes in NP-SLE patients with acute onset of new neurological symptoms as well as in the follow-up after treatment to assess presence and changes in metabolic brain injury. However, although there are detectable differences between normal individuals and lupus patients it is currently unclear whether these relate to the acute episode. Future studies are needed comparing NP-SLE patients with active CNS involvement with those inactive disease.

Search for the decay KL --> pi(0)e+e-

We report on a search for the decay KL-->pi(0)e+e- carried out by the KTeV/E799 experiment at Fermilab. This decay is expected to have a significant CP violating contribution and the measurement of its branching ratio could support the Cabibbo-Kobayashi-Maskawa mechanism for CP violation or could point to new physics. Two events were observed in the 1997 data with an expected background of 1.06+/-0.41 events, and we set an upper limit B(KL-->pi(0)e+e-)<5.1 x 10(-10) at the 90% confidence level.

Implementing and maintaining school-based mental health services in a large, urban school district

The Dallas (Texas) Public Schools established the first school-based health center in the United States in 1969. In 1993 a partnership between two school principals, a school mental health professional, and the medical director of the county mental health center was the impetus for the first comprehensive school-based mental health center in Texas. In 1995 the programs joined together as Youth and Family Centers (YFCs) to provide physical health, mental health, and other support services to students and their families. The 10 strategically located school-based centers are directed by licensed mental health professionals employed by the district who lead a multidisciplinary team of physical health and mental health providers. Students served by the YFCs have fewer discipline problems, course failures, and school absences.

Evaluation of New York State's Child Health Plus: methods

BACKGROUND

The State Children's Health Insurance Program (SCHIP) is the largest public investment in child health care in 30 years, targeting 11 million uninsured children, yet little is known about the impact of health insurance on uninsured children. In 1991 New York State implemented Child Health Plus (CHPlus), a health insurance program that was a prototype for SCHIP. A study was designed to measure the association between CHPlus and access to care, utilization of services, and quality of care.

METHODS

The setting was a 6-county region in upstate New York (population 1 million) around and including the city of Rochester. A before-and-during design was used to compare children's health care for the year before they enrolled in CHPlus versus the first year during CHPlus, for 1828 children (ages 0-6.99 years at enrollment) who enrolled between November 1, 1991 and August 1, 1993. An additional study involved 187 children 2 to 12.99 years old who had asthma. Parents were interviewed to assess demographic characteristics, sources of health care, experience with CHPlus, and impact of CHPlus on their children's quality of care and health status. Medical charts were reviewed to measure utilization and quality of care, for 1730 children 0 to 6.99 years and 169 children who had asthma. Charts were reviewed at all primary care offices and at the 12 emergency departments and 6 public health department clinics in the region. CHPlus claims files were analyzed to determine costs during CHPlus and to impute costs before CHPlus from utilization data.

ANALYSES

Logistic regression and Poisson regression were used to compare the means of dependent measures with and without CHPlus coverage, while controlling for age, prior insurance type, and gap in insurance coverage before CHPlus.

CONCLUSIONS

This study developed and implemented methods to evaluate the association between enrollment in a health insurance program and children's health care. These methods may also be useful for evaluations of SCHIP.

Intracytoplasmic sperm injection overcomes previous fertilization failure with conventional in vitro fertilization

OBJECTIVE

To evaluate the outcome of intracytoplasmic sperm injection (ICSI) in patients with previous idiopathic fertilization failure (< or =20% fertilization rate) after conventional IVF.

DESIGN

Retrospective analysis.

SETTING

IVF program at a university medical center.

PATIENT(S)

Twenty-five patients who underwent 38 ICSI cycles after experiencing unexplained fertilization failure with conventional IVF (group A) and 87 patients who underwent 118 ICSI cycles for male factor indications during the same period (group B).

INTERVENTION(S)

Intracytoplasmic sperm injection was performed in a subsequent cycle after fertilization failure with conventional IVF.

MAIN OUTCOME MEASURE(S)

Outcomes of IVF were compared between groups A and B.

RESULT(S)

Fertilization was achieved with ICSI in all patients with previous fertilization failure. The mean (+/- SD) fertilization rate (68%+/-21% vs. 64%+/-22%), implantation rate per embryo (22.6% vs. 20%), and delivery rate per cycle (47.3% vs. 49.1%) did not differ significantly between groups A and B. Overall, 72% of patients with previous unexplained fertilization failure had a successful pregnancy after ICSI.

CONCLUSION(S)

Intracytoplasmic sperm injection can overcome unexplained fertilization failure caused by a potentially occult gamete abnormality, with the same fertilization, implantation, and pregnancy rates as are seen in patients with abnormal sperm parameters.