Preclinical Development of Brain Permeable ERβ Agonist for the Treatment of Glioblastoma

Glioblastoma (GBM) is the most prevalent and aggressive type of adult brain tumors with low 5-year overall survival rates. Epidemiologic data suggest that estrogen may decrease brain tumor growth, and estrogen receptor beta (ERβ) has been demonstrated to exert antitumor functions in GBM. The lack of potent, selective, and brain permeable ERβ agonist to promote its antitumor action is limiting the therapeutic promise of ERβ. In this study, we discovered that Indanone and tetralone-keto or hydroxyl oximes are a new class of ERβ agonists. Because of its high activity in ERβ reporter assays, specific binding to ERβ in polar screen assays, and potent growth inhibitory activity in GBM cells, CIDD-0149897 was discovered as a possible hit by screening a library of compounds. CIDD-0149897 is more selective for ERβ than ERα (40-fold). Treatment with CIDD-0149897 markedly reduced GBM cell viability with an IC50 of ∼7 to 15 μmol/L, while having little to no effect on ERβ-KO cells and normal human astrocytes. Further, CIDD-0149897 treatment enhanced expression of known ERβ target genes and promoted apoptosis in established and patient-derived GSC models. Pharmacokinetic studies confirmed that CIDD-0149897 has systemic exposure, and good bioavailability in the brain. Mice tolerated daily intraperitoneal treatment of CIDD-0149897 (50 mg/kg) with a 7-day repeat dosage with no toxicity. In addition, CIDD-0149897 treatment significantly decreased tumor growth in U251 xenograft model and extended the survival of orthotopic GBM tumor-bearing mice. Collectively, these findings pointed to CIDD-0149897 as a new class of ERβ agonist, offering patients with GBM a potential means of improving survival.

Oxamniquine derivatives overcome Praziquantel treatment limitations for Schistosomiasis

Human schistosomiasis is a neglected tropical disease caused by Schistosoma mansoni, S. haematobium, and S. japonicum. Praziquantel (PZQ) is the method of choice for treatment. Due to constant selection pressure, there is an urgent need for new therapies for schistosomiasis. Previous treatment of S. mansoni included the use of oxamniquine (OXA), a drug that is activated by a schistosome sulfotransferase (SULT). Guided by data from X-ray crystallography and Schistosoma killing assays more than 350 OXA derivatives were designed, synthesized, and tested. We were able to identify CIDD-0150610 and CIDD-0150303 as potent derivatives in vitro that kill (100%) of all three Schistosoma species at a final concentration of 71.5 μM. We evaluated the efficacy of the best OXA derivates in an in vivo model after treatment with a single dose of 100 mg/kg by oral gavage. The highest rate of worm burden reduction was achieved by CIDD -150303 (81.8%) against S. mansoni, CIDD-0149830 (80.2%) against S. haematobium and CIDD-066790 (86.7%) against S. japonicum. We have also evaluated the ability of the derivatives to kill immature stages since PZQ does not kill immature schistosomes. CIDD-0150303 demonstrated (100%) killing for all life stages at a final concentration of 143 μM in vitro and effective reduction in worm burden in vivo against S. mansoni. To understand how OXA derivatives fit in the SULT binding pocket, X-ray crystal structures of CIDD-0150303 and CIDD-0150610 demonstrate that the SULT active site will accommodate further modifications to our most active compounds as we fine tune them to increase favorable pharmacokinetic properties. Treatment with a single dose of 100 mg/kg by oral gavage with co-dose of PZQ + CIDD-0150303 reduced the worm burden of PZQ resistant parasites in an animal model by 90.8%. Therefore, we conclude that CIDD-0150303, CIDD-0149830 and CIDD-066790 are novel drugs that overcome some of PZQ limitations, and CIDD-0150303 can be used with PZQ in combination therapy.

A protocol for the management of pediatric type I open fractures

BACKGROUND

The management of pediatric type I open fractures remains controversial. There has been no consistent protocol established in the literature for the non-operative management of these injuries.

METHODS

A protocol was developed at our institution for the non-operative management of pediatric type I open forearm fractures. Each patient was given a dose of intravenous antibiotics at the time of the initial evaluation in the emergency department. The wound was then irrigated and a closed reduction performed in the emergency department. The patient was admitted for three doses of intravenous antibiotics (over approximately a 24-h period) and then discharged home without oral antibiotics.

RESULTS

In total, 45 consecutive patients were managed with this protocol at our hospital between 2004 and 2008. The average age was 10 (range 4-17) years. The average number of doses of intravenous antibiotics was 4.06 per patient. Thirty patients (67 %) received cefazolin (Ancef®) as the treating medication and 15 patients received clindamycin (33 %). There were no infections in any of the 45 patients.

CONCLUSION

In this study we outline a consistent management protocol for type I open pediatric forearm fractures that has not previously been documented in the literature. Our results corroborate the those reported in the literature that pediatric type I open fractures may be managed safely in a non-operative manner. There were no infections in our prospective series of 45 consecutive type I open pediatric forearm fractures using our protocol. Using a protocol of only four doses of intravenous antibiotics (one in the emergency department and three additional doses during a 24-h hospital admission) is a safe and efficient method for managing routine pediatric type I open fractures non-operatively.

Frequency of rare cytogenetic abnormalities at relapse in acute myeloid leukemia (AML) with FLT3 internal tandem duplication (ITD) and normal karyotype at diagnosis: Evidence for genomic instability?

7049

Background: FLT3-ITD mutations are present in AML in 30% of patients, most commonly with a normal karyotype, and are associated with short disease-free survival. In vitro and in vivo studies of FLT3-ITD cell lines and patient samples have demonstrated DNA double-strand break repair by an alternative highly error-prone form of non-homologous end-joining (ALT NHEJ), resulting in illegitimate ligation of non-contiguous DNA breaks, causing DNA deletions and translocations that may contribute to disease progression. To look for clinical evidence of genomic instability, we reviewed cytogenetic changes at relapse. Methods: Charts of patients with cytogenetically normal AML with FLT3-ITD treated at the University of Maryland Greenebaum Cancer Center were reviewed along with metaphase analysis results at diagnosis and relapse. Results: Cytogenetic data were available from first and, when applicable, subsequent relapses for 12 patients with cytogenetically normal AML with FLT3-ITD who relapsed, including 5 following allogeneic hematopoietic stem cell transplantation (allo HSCT). Ten patients acquired cytogenetic changes, many of them rare translocations and inversions (Table). Conclusions: AML with FLT3-ITD and normal karyotype at diagnosis has a high frequency of rare cytogenetic abnormalities at relapse, providing clinical evidence for genomic instability. These data may support the potential therapeutic role of inhibitors of ALT NHEJ repair proteins, such as PARP1 and DNA ligase IIIa, in AML with FLT3-ITD. [Table: see text]

Disease response and survival outcomes in acute myeloid leukemia (AML) patients unfit for chemotherapy treated with 10-day decitabine as initial therapy

6611

Background: AML is primarily a disease of older adults, with a median age of 67 years at diagnosis. Many patients are considered unfit for chemotherapy due to poor performance status and/or comorbidities, prompting investigation of less intensive approaches. A clinical trial in which 10-day courses of decitabine 20mg/m2 were given every 28 days as initial therapy demonstrated a promising complete remission (CR) rate and disease-free survival (DFS). We used this regimen to treat AML patients unfit for chemotherapy outside of a clinical trial. Methods: Charts of 32 newly diagnosed AML patients treated with 10-day courses of decitabine 20mg/m2 as initial therapy at the University of Maryland Greenebaum Cancer Center between September 2010 and November 2011 were retrospectively reviewed. If patients attained bone marrow blasts <5%, 5-day courses were administered subsequently and were continued until disease progression. Results: Median age at diagnosis was 74 years (range, 52-86). 18 patients were male and 14 female. 23 were Caucasian, 7 African-American and 1 Hispanic. 10 patients (31%) had performance status ≥ 2. All had significant cardiac, pulmonary and/or renal disease. Karyotype risk group was unfavorable in 17 patients, intermediate in 14 and unknown in one. There were 9 CRs and 1 partial remission, for an overall response rate of 31%, following a median of 2 (range, 1 to 4) courses. 21 patients did not respond to treatment following 1 to 6 courses, and one died within 29 days of treatment initiation. 21 patients (65%) were hospitalized at least once for fever or infection during treatment. Of the 9 patients who achieved CR, 5 had normal, 3 complex and 1 unknown karyotypes. Median DFS was 390 days (range, 87+-468+) and median OS 180 days (range, 15-623+). Six-month OS was 37.5% and 1-year OS 16.5%. Conclusions: AML patients unfit for chemotherapy treated with 10-day decitabine 20mg/m2 outside of a clinical trial had a higher response rate than reported for 5-day decitabine, but a lower response rate than in the reported clinical trial of the 10-day regimen. Additional novel treatment approaches are needed for these patients.

Risk assessment in human immunodeficiency virus-associated acute myeloid leukemia

CD4 count ≤200×10(6) cells/L has been identified as a predictor of short survival in HIV-associated acute myeloid leukemia (HIV-AML), but karyotype, which is the best predictor of survival in AML, has not been evaluated in HIV-AML patients. A retrospective cohort of 31 patients was created from 9 local cases and 22 published cases. HIV-AML karyotypes were heterogeneous and were similar in distribution to those in HIV-negative AML. Among intensively treated patients, most achieved complete remission, but succumbed to infectious complications, mostly non-opportunistic, during consolidation therapy. Median survival for intensively-treated patients with CD4 counts ≤200×10(6) cells/L was 8.5 months, compared to 48 months for those with >200×10(6) CD4 cells/L (p=0.03). In contrast, AML karyotype did not predict survival (p=0.43), albeit with small numbers in each karyotype group. Thus, CD4 count is a strong predictor of short survival in HIV-AML patients regardless of karyotype. Studies evaluating innovative strategies for infection prophylaxis and for improving immune reconstitution are needed.

Protein expression of PDZ-binding kinase is up-regulated in hematologic malignancies and strongly down-regulated during terminal differentiation of HL-60 leukemic cells

PBK/TOPK is a recently identified 322 amino acid serine/threonine kinase that is phosphorylated during mitosis and may include p38 MAPK among its targets. Previous work has shown up-regulated expression of PBK/TOPK mRNA in a variety of tumor cell lines and fetal tissues, suggesting a role for this kinase in malignant cell proliferation. In this paper, PBK/TOPK protein expression was examined in a variety of primary hematologic neoplasms: PBK/TOPK was readily detected in 9 of 12 AML samples (75%), in 3 of 3 ALL samples, and in 1 sample each of a plasmacytoma and blastic type mantle cell lymphoma where it was strongly expressed. In contrast, PBK/TOPK was only weakly expressed in 2 samples of G-CSF-mobilized peripheral blood stem cells that were enriched in CD34+ progenitors by immunoselection. Furthermore, when HL-60 myeloid leukemic cells were differentiated with phorbol ester (TPA), PBK/TOPK protein expression was strongly down-regulated by 24 h. Under these same conditions, phosphorylated c-Myc was rapidly down-regulated (by 4 h), while the levels of cyclin D1 and phosphorylated p38 were constant. Notably, of 5 clinical samples that strongly expressed PBK/TOPK, 4 also strongly expressed phosphorylated c-Myc, while only 1 of 3 PBK/TOPK negative samples expressed phosphorylated c-Myc. These data show that PBK/TOPK protein is up-regulated in a variety of hematologic malignancies and may be involved in leukemic cell growth. Additional studies are warranted to determine if PBK/TOPK would be a valuable target for novel therapeutics. To this end, we also describe the derivation of clones of 293 (human embryonic kidney) cells, which carry an inducible kinase-defective mutant of PBK/TOPK. This model may be useful for studying the effects of down-regulated PBK/TOPK function.

Health-care charges generated by patients with diabetes

For assessment of health-care charges generated by patients with diabetes, 50 patients (25 who were older than 65 years and 25 who were age 65 or younger) whose primary care had been delivered between 1990 and 1995 by a single diabetologist were randomly selected. Institutional health-care bills were accessed from all but three medical center billing offices (dermatology, psychiatry, and radiation oncology areas did not respond). For each dollar billed by endocrinology, the hospital billed 25.90 dollars, other medical specialties 2.70 dollars, surgery 1.10 dollars, radiology 0.70 dollars and pathology 0.60 dollars. The charges generated by the endocrinologist-diabetologist account for approximately 3% of the total charges for the care of the patient with diabetes mellitus in a fee-for-service practice. Although the endocrinologist-diabetologist provides the most cost-effective medical service for patients with diabetes, low reimbursement jeopardizes the practice of this subspecialty.

Targeting Vascular Endothelial Growth Factor for Relapsed and Refractory Adult Acute Myelogenous Leukemias

PURPOSE

Vascular endothelial growth factor (VEGF) promotes acute myelogenous leukemia (AML) cell growth and survival and may contribute to drug resistance. bevacizumab, an anti-VEGF monoclonal antibody, exhibits clinical activity against diverse malignancies when administered with cytotoxic chemotherapy. We conducted a Phase II clinical trial of bevacizumab administered after chemotherapy to adults with refractory or relapsed AML, using a timed sequential therapy (TST) approach.

EXPERIMENTAL DESIGN

bevacizumab 10 mg/kg was administered on day 8 after 1-beta-d-arabinofuranosylcytosine 2 g/m(2)/72 h beginning day 1 and mitoxantrone 40 mg/m(2) beginning day 4. In vivo laboratory correlates included AML cell VEGF receptor-1 (FLT-1) expression, marrow microvessel density, and free serum VEGF before and during TST with bevacizumab.

RESULTS

Forty-eight adults received induction therapy. Myelosuppression occurred in all of the patients similar to other TST regimens. Toxicities were decreased ejection fraction (6%), cerebrovascular bleed (4%), and mortality of 15%. Overall response was 23 of 48 (48%), with complete response (CR) in 16 (33%). Eighteen (14 CR and 4 partial response) underwent one consolidation cycle and 5 (3 CR and 2 partial response) underwent allogeneic transplant. Median overall and disease-free survivals for CR patients were 16.2 months (64%, 1 year) and 7 months (35%, 1 year). Marrow blasts demonstrated FLT-1 staining before bevacizumab and marked decrease in microvessel density after bevacizumab. VEGF was detected in pretreatment serum in 67% of patients tested, increased by day 8 in 52%, and decreased in 93% (67% undetectable) 2 h after bevacizumab.

CONCLUSIONS

In this single arm study, cytotoxic chemotherapy followed by bevacizumab yields a favorable CR rate and duration in adults with AML that is resistant to traditional treatment approaches. The clearance of marrow blasts in some patients after bevacizumab suggests that VEGF neutralization might result directly in leukemic cell death. The potential biological and clinical activity of bevacizumab in AML warrants additional clinical and laboratory study.

Femur fracture in infants: a possible accidental etiology

Femoral fractures in nonambulating infants are generally felt to be attributable to abuse in the absence of significant trauma or underlying organic pathology. The investigation of such fractures includes a report to appropriate social service and law enforcement agencies, and legal involvement. This paper describes 2 nonambulatory infants who sustained identical oblique distal femoral metaphyseal fractures extending through the growth plate after playing in an infant stationary activity center called an Exersaucer. It is possible that the twisting motion provided by the Exersaucer (Evenflo, Picqua, OH) might be consistent with the generation of forces necessary to cause these fractures.

Improving shoulder and elbow function in children with Erb's palsy

Many children who sustain birth injuries to the brachial plexus suffer significant functional limitations due to various sequelae affecting the shoulder and elbow or forearm. The maintenance of full passive mobility during the period of neurological recovery is essential for normal joint development. Early surgical correction of shoulder contractures and subluxations reduces permanent deformity. Reconstruction of forearm rotation contractures significantly improves the appearance and use of the extremity for many basic activities. Each child must be carefully evaluated, therapy maximized, and the surgical approach individualized to obtain the best result.

[Surgical treatment of children with brachial plexus paralysis]

OBJECTIVE AND METHODS

A variety of surgical procedures exist for early repair of the nerve injury in obstetrical brachial plexus palsy, including neuroma excision and nerve grafting, neurolysis and neurotization. Secondary deformities of the shoulder, forearm, and hand can similarly be reconstructed using soft tissue and skeletal procedures. This review describes our surgical approach to maximize the ultimate functional outcome in infants and children with obstetrical brachial plexus palsy.

Lysosomal enzyme cytochemistry of human RPE, Bruch's membrane and drusen

Twenty-five human eyes of various ages from eye bank donors and surgical enucleations were obtained for ultrastructural cytochemical demonstration of acid phosphatase (AcPase) and arylsulfatase B (ASB) in the retinal pigment epithelium (RPE) and Bruch's membrane. Results with post-mortem (less than 10 hr) tissues were comparable to those of fresh specimens. Vigorous reactivity was demonstrated in lysosomes of RPE and choriocapillary endothelium but no reactive sites were found in Bruch's membrane, although many lysosome-like dense bodies occurred in eyes greater than 20 yr of age. Granular drusen of 30-70-yr-olds contained no reactive bodies. In eyes greater than 80 years old blebs of RPE basal cytoplasm protruding into Bruch's membrane contained reactive lysosomes. We conclude that the RPE ordinarily does not extrude or exocytose active lysosomes (ie, phagolysosomes, other secondary lysosomes, residual bodies, lipofuscin) or lysosomal enzymes. Aged RPE, however, extrudes cytoplasm with active lysosomes into Bruch's membrane. The possible impact of this process on the extracellular connective tissue is discussed, particularly with regard to age-related deterioration of Bruch's membrane and neovascularization.

Experimental ocular malignant melanoma in Sinclair swine

An animal model of malignant melanoma of the eye was established by transplanting a cell suspension from cutaneous melanomas into the anterior chamber of the eye in Sinclair Farm miniature swine. The frequency of tumor takes in the eye was increased from 8.9% to 22% by treating the animals simultaneously with subconjunctival triamcinolone acetonide. As an animal model for hematoporphyrin derivative--photoradiation treatment of human malignant melanoma of the eye, this does not appear to be a good research tool because of the sporadic incidence of tumor takes, the rapid growth of tumor within the eye causing glaucoma, and the dark iris pigmentation of successful tumor takes, which hides extensive underlying ciliary body tumor.

Susceptibility of laboratory primates to infection with Mansonella ozzardi from man

The study was undertaken to determine primates were susceptible to infection with Caribbean and/or Amazon strains of Mansonella ozzardi of man. Twenty-three animals including three chimpanzees, four squirrel monkeys, one capuchin, five rhesus and 10 patas monkeys each received, by subcutaneous or intraperitoneal injection, 25-170 infective larvae of M. ozzardi harvested either from infected Culicoides furens collected in Haiti or Simulium sp. (sanguineum complex) collected in the Colombian Amazon and transported to our laboratories in Louisiana. Patent infections were obtained in seven of 10 patas monkeys but not in any other species of primates. The prepatent period ranged in duration from 149-186 days with a mean of 168 days. All of the patas monkeys developed modest microfilaremias that persisted for as long as 1 year, the duration of our observations. Adult worms were obtained at necropsy from three of four patas monkeys. The worms were recovered from soakings of the carcass and skin rather than from the abdominal cavity and mesenteries. However, their precise habitat was not determined.

Role of nurse clinician in urologic oncology

The incorporation of single and combination chemotherapy into the therapeutic regimen for some advanced genitourinary tumors has greatly added to the myriad of medical and psychologic problems already present in these patients. Working closely with a urologist, a nurse clinician can be of significant help in the total care of this group of patients. Due to the seriousness and chronicity of the neoplastic process, the emotional and social impact as well as physical factors affect all phases of the patient's life, as well as the lives of family members. The incorporation of traditional nursing values into the medical education of nurse clinicians helps to prepare them to deal with these problems, and their participation serves to make the medical team more complete.