CPX-351 Pharmacokinetics and Safety in Adults with Hematologic Malignancies and Renal Function Impairment: Phase 1 Trial

This open-label phase 1 study (clinicaltrials.gov, NCT03555955) assessed CPX-351 pharmacokinetics (PK) and safety in patients with hematologic malignancies with normal or impaired renal function. Patients were enrolled into three cohorts based on their creatinine clearance (CrCl): ≥90 mL/min (Cohort 1, normal renal function, n = 7), 30 to <59 mL/min (Cohort 2, moderate renal impairment, n = 8), or <30 mL/min (Cohort 3, severe renal impairment, n = 6). Patients received intravenous CPX-351 for initial induction; blood and urine samples were collected for PK analysis. The primary objective was to assess the PK parameters for cytarabine, daunorubicin, and their respective metabolites, arabinosyluracil (Ara-U) and daunorubicinol. Renal impairment did not significantly impact the cytarabine, daunorubicin, or daunorubicinol exposure, but it caused a slight increase in the Ara-U exposure. The CPX-351 side effect profile was similar in patients with impaired renal function compared to those with normal renal function. All the patients reported ≥1 treatment-emergent adverse event (TEAE), most commonly febrile neutropenia and nausea (57% each) and hyperglycemia (43%); no patients discontinued treatment due to TEAEs. These data suggest that CPX-351 dose adjustment is not required for patients with hematologic malignancies with moderate or severe renal impairment.

The influence of body painting on L4 spinous process palpation accuracy in novice palpators

OBJECTIVES

Current literature remains inconclusive regarding the best methodology to accurately palpate lumbar spinous processes (SP). Body painting (BP) uses markers to draw anatomical structures on the skin's surface. While BP can be a useful tool for engaging learners, it is unknown whether it improves palpation accuracy. The purpose of this study was to investigate whether the addition of body painting to palpation education improves lumbar spinous process palpation accuracy in first-year Doctor of Physical Therapy (DPT) students.

METHODS

Thirty-eight DPT students were randomized into a traditional palpation group and a body painting (BP) group. Each group received identical instruction on palpating the lumbar spine, with the BP group additionally drawing lumbar SPs on their laboratory partner with a marker. Students were then assessed on their ability to accurately palpate the L4 SP on randomly assigned subjects. Two Certified Registered Nurse Anesthetists (CRNAs) used ultrasound imaging to confirm the location of each student's palpation. Palpation time was also recorded. The BP group also completed a survey on the learning experience.

RESULTS

Forty-five percent of students were able to accurately palpate the L4 SP. There was no significant difference (p = 0.78) in palpation accuracy between the traditional and BP group, although students in the BP group were randomly assigned subjects with a significantly (p = 0.005) higher BMI. Ninety-five percent of students were able to palpate within one spinal level of the L4 SP. Students in the BP group reported that the BP activity facilitated learning and active participation. There was no significant difference in palpation time (p = 0.98) between groups. There was a fair correlation (r=-0.41) between palpation accuracy and subject BMI.

DISCUSSION/CONCLUSION

While body painting was an enjoyable activity to incorporate into palpation laboratory, it is unclear whether it enhanced lumbar SP palpation accuracy in first-year DPT students.

Real-World Treatment Patterns and Clinical Outcomes in Canadian Patients with AML Unfit for First-Line Intensive Chemotherapy

Acute myeloid leukemia (AML) is a hematological malignancy that predominantly affects the elderly. Prognosis declines with age. For those who cannot tolerate intensive chemotherapy, historically established treatment options have been hypomethylating agents (HMAs), low dose cytarabine (LDAC), and best supportive care (BSC). As the standard of care evolves for those unfit for intensive chemotherapy, there is a need to understand established treatment pathways, clinical outcomes and healthcare resource utilization in Canada. The CURRENT study was a retrospective chart review of AML patients not eligible for intensive chemotherapy who initiated first-line treatment between 1 January 2015 and 31 December 2018. Data were collected from 170 Canadian patients treated at six hematology centers, of whom 118 received systemic therapy and 52 received BSC as first-line treatment. Median overall survival was 8.58 months and varied from 2.96 months for BSC to 13.31 months for HMAs. Over 80% of patients had at least one outpatient visit, and 67% of patients receiving systemic therapy and 71% of those receiving BSC had at least one admission to hospital, during their first line of therapy. A total of 96 (81.4%) patients receiving first line systemic therapy and 39 (75.0%) of those receiving first line BSC had at least one red blood cell or platelet transfusion. These findings highlight the unmet need for novel therapies for patients ineligible for intensive chemotherapy.

Healthcare resource utilization trends in patients with acute myeloid leukemia ineligible for intensive chemotherapy receiving first-line systemic treatment or best supportive care: A multicenter international study

Objectives

This retrospective chart review examined real‐world healthcare resource utilization (HRU) in patients with AML ineligible for intensive therapy who received first‐line systemic therapy or best supportive care (BSC).

Methods

Data were collected anonymously on patients with AML who initiated first‐line hypomethylating agents (HMA), low‐dose cytarabine (LDAC), other systemic therapy, or BSC. HRU endpoints included hospitalizations, outpatient consultations, transfusions, and supportive care.

Results

Of 1762 patients included, 46% received HMA, 11% received LDAC, 17% received other systemic therapy, 26% received BSC; median treatment durations were 118, 35, 33, and 57 days, respectively. Most patients were hospitalized, most commonly for treatment administration, transfusion, or infection (HMA 82%, LDAC 93%, other systemic therapy 83%, BSC 83%). A median number of hospitalizations were 2–6 across systemic groups and two for BSC, with median durations of 8–18 days. Transfusion rates and outpatient consultations were highest for HMA (80% and 79%) versus LDAC (57% and 53%), other systemic therapy (57% and 63%), and BSC (71% and 66%). Antivirals/antibiotics and antifungals were used more frequently than growth factors (72–92%, 34–63%, and 7–27%, respectively).

Conclusion

Patients with AML ineligible for intensive therapy have high HRU; novel therapies are needed to alleviate this burden.

Real-world treatment patterns and clinical outcomes in patients with AML unfit for first-line intensive chemotherapy. Leuk Lymphoma 2022;63:928-938. [PMID: 35147482 DOI: 10.1080/10428194.2021.2002321]

Acute myeloid leukemia (AML) predominantly affects the elderly, and prognosis declines with age. Induction chemotherapy plus consolidation therapy is standard of care for fit patients; options for unfit patients include hypomethylating agents (HMA), low-dose cytarabine (LDAC), targeted therapies, and best supportive care (BSC). This retrospective chart review evaluated clinical outcomes in unfit patients with AML who initiated first-line treatment or BSC 01/01/2015-12/31/2018. Overall survival (OS), progression-free survival (PFS), time-to-treatment failure (TTF), and response rates were assessed. Of 1762 patients, 1310 received systemic therapies: 809 HMA, 199 LDAC, and 302 other therapies; 452 received BSC. Median OS was 9.9, 7.9, 5.4, and 2.5 months for HMA, LDAC, other, and BSC, respectively. Median PFS was 7.5, 5.3, 4.1, and 2.1 months for HMA, LDAC, other, and BSC, respectively; median TTF was 4.9, 2.1, 2.2, and 2.1 months, respectively. Our findings highlight the unmet need for novel therapies for unfit patients.

Abstract 1866: Pharmacokinetics and biodistribution of formatted Affimer® biotherapeutics targeting PD-L1

Programmed Cell Death-Ligand 1 (PD-L1) is part of the immune checkpoint system involved in preventing autoimmunity. PD-L1 is upregulated on tumors cells and binds to its receptor, PD-1, expressed by immune cells in the tumor microenvironment. Anti-PD-L1 immunotherapies have shown to be effective treatments both as monotherapies and in combinations with chemotherapies and radiotherapies, providing long term responses in a subset of patients. We have developed a PD-L1 Affimer antagonist that could differentiate itself from the current clinically approved mAbs due to its smaller size, improved tissue penetration and alternative routes of delivery such as a subcutaneous injection. It also opens up the possibility of generating additional PD-L1 antagonist therapeutics such as bispecifics and cytokine fusions. The Affimer biotherapeutic scaffold is a 14kDa monomeric protein based on the human protease inhibitor Stefin A, lacking post-translational modifications such as disulfide bonds and glycosylation. We have identified a range of high-affinity competitive binders to human PD-L1 confirmed by SPR using Fc formatted antigen, competition ELISA and blockade of PD-L1/PD-1 axis using various cell-based assays. We demonstrated efficacy in a humanized PD-L1 MC38 tumor growth inhibition model and compared it to approved PD-L1 antibody therapies. Pharmacokinetics (PK) and biodistribution are key parameters that influence the efficacy and safety of therapeutic proteins. Half-life extension of lead Affimer proteins was achieved by fusing to a human Fc region of an IgG (designated AVA004).Pharmacokinetic analysis of AVA004 Fc molecules were performed in C57Bl/6, humanized FcRn/HSA mice and cynomolgus after single intravenous administration. Tissue distribution following intravenous administration of AVA004 Fc to humanized NOG mice bearing orthotopic MDA-MB-231 tumor cells was evaluated using radiolabeled 125I- AVA004 Fc. Biodistribution imaging studies were conducted in mice bearing A375 tumor cells using IRDye800 conjugated to AVA004 Fc followed by ex vivo imaging. A more quantitative biodistribution study was conducted in the same model using SPECT imaging DOTAGA bioconjugated AVA004 Fc molecules radiolabeled with 111Indium. The imaging biodistribution allowed us to select the most favorable molecule based on its tumor/plasma and tumor/liver ratios.

Citation Format: Estelle Adam, Emma Jenkins, Floriane Laurent, Jennifer Hillman, Maureen West, Emma Stanley, David Sanford, Agnieszka Kownacka, Céline Mothes, Alexandra Oudot, Vincent Matthew, David Gilfoyle, Barry Jones, William Bachovchin, Amrik Basran, Cyril Berthet. Pharmacokinetics and biodistribution of formatted Affimer® biotherapeutics targeting PD-L1 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1866.

Rotation of a strongly coupled dust cluster in plasma by the torque of an electron beam

A 1-mm-size cluster composed of 10 dust particles immersed in plasma is rotated by the torque of a pulsed electron beam with energy in the range 8-12 keV. The dust particles are electrically charged spheres with radius 5.9 μm and are levitated in the plasma sheath, forming a round, planar, Coulomb-coupled cluster. The electron beam irradiates the dust cluster passing slightly off its center, and sets the particles in motion by the action of the electron drag force. The total torque at 12 keV is 4.9±0.2×10^{-11} Nm at an angular speed 1.41±0.05 rad s^{-1}. The main dynamical features of the cluster such as intershell rotation and itinerancy of the dust particles inside the cluster are simulated by using a molecular dynamics code.

Mortality from Multiple Myeloma Within One Year Following Autologous Stem Cell Transplantation: Defining an Ultra-high Risk Population

Despite improvements in therapy, approximately 5% of patients who undergo autologous stem cell transplantation (ASCT) experience early mortality (EM), death within 1 year of transplant (EM post-ASCT). Such patients tend to have few comorbidities suggesting their EM is owing to aggressive underlying disease. We sought to characterize this ultra-high risk population through a retrospective review of patients with newly diagnosed multiple myeloma (MM) treated with first-line ASCT. Patients who died within 1 year of ASCT were matched for age, sex, and year of transplant in a 1:2 fashion with a control group. Of 962 transplants performed between January 1, 2007, and May 1, 2019, 41 patients (4.3%) died within 1 year of ASCT from MM-related causes. In a multivariate analysis, anemia, hypercalcemia, high-risk cytogenetics, and elevated lactate dehydrogenase were associated with EM post-ASCT. Forty patients (97.6%) received at least 1 novel agent. Most patients with EM post-ASCT received second-line chemotherapy (80.5%), although survival from initiation of second-line chemotherapy was only 2.1 months. The primary reason for not receiving second-line therapy was rapid relapse. Clinical parameters reflecting disease burden, as well as high-risk cytogenetics, are associated with EM post-ASCT. These patients have a dismal overall survival despite significant advances in treatment of patients with relapsed or refractory myeloma. Further study of these ultra-high risk patients is required to improve disease management and may give further insights into the biology of relapse and resistance in myeloma.

Day 14 Bone Marrow Evaluation During Acute Myeloid Leukemia Induction in a Real-world Canadian Cohort

INTRODUCTION

The 2017 National Comprehensive Cancer Network guidelines for acute myeloid leukemia have recommended performing bone marrow (BM) aspiration and BM trephine biopsy (BMTB) 14 to 21 days after starting induction therapy (commonly referred to as "day 14 [D14] marrow"). Those who do not achieve a hypoplastic marrow, with cellularity < 20% and blasts < 5%, are recommended to undergo 2-cycle induction (2CI). We performed a retrospective analysis to determine the impact of D14 BM characteristics in predicting for remission, association with overall survival (OS), and the effect of 2CI according to the D14 BM results.

PATIENTS AND METHODS

Patients aged 18 to 70 years undergoing induction therapy with standard "7 + 3" regimens were included. D14 cellularity was determined from BMTB samples and the blast percentage was assessed by morphology on BM aspiration and BMTB samples. The outcomes evaluated included the rates of complete remission (CR) and OS.

RESULTS

A total of 486 patients with results from D14 BM evaluation were included in the present study. On multivariate analysis, cytogenetic risk and D14 blasts < 5% were predictive of CR/CR with incomplete count recovery (P < .001). Cytogenetic risk (P < .001), age < 60 years (P = .001), and D14 blasts < 5% (P = .045) predicted for OS. 2CI was performed in 131 patients (27%). Patients with hypocellular D14 BM but residual blasts (n = 106) underwent 2CI in 46% of cases, with improved remission rates (43.9% vs. 72.0%; P = .004) but no difference in OS.

CONCLUSIONS

The results from D14 BM evaluations are predictive of subsequent remission and OS. Our findings did not show a survival benefit with D14 BM-driven 2CI.

Management of cardiovascular health in acute leukemia: a national survey

Cardiovascular (CV) disease is a common comorbidity in acute leukemia (AL) patients and can be worsened by the use of anthracyclines. Interruptions and underutilization of CV medications during AL treatments may negatively impact the CV health of these patients. A 30-question electronic survey was distributed to Canadian hematologists who treat adults with AL to determine the frequency, timing and rationale for interruptions in statins, antiplatelets and angiotensin antagonists in patients undergoing intensive chemotherapy. Strategies for mitigating anthracycline cardiotoxicity, methods of establishing baseline CV risk and utilization of clinical pharmacists were also assessed. Results indicate that it is common for AL patients undergoing intensive chemotherapy to require CV medication interruptions. This highlights the need for collaboration between hematology and cardiology healthcare teams and utilization of multidisciplinary healthcare professionals to improve CV care during AL.

Comparison of a pediatric-inspired treatment protocol versus standard-intensity chemotherapy for young adults with standard-risk BCR-ABL negative acute lymphoblastic leukemia

We investigated the utility of a pediatric-inspired protocol in adults aged 18-40 years with standard-risk BCR-ABL negative acute lymphoblastic leukemia (ALL). Retrospective outcomes of 25 patients treated with a pediatric protocol between 2008 and 2014 were compared with 22 similarly aged patients treated with an adult protocol between 2003 and 2008. Twenty-five (100%) and 19 (86%) patients achieved complete remission, respectively. At median follow-up of 36.8 months, 3-year event-free survival was increased in patients on the pediatric protocol at 80% versus 45% (p = .019). There was a trend toward improved overall survival at 80% versus 59% (p = .12). Treatment-related toxicity was not increased despite the increased treatment intensity. Patients with BCR and/or ABL copy number variation demonstrated comparatively poorer outcomes in both cohorts. In our experience with this cohort of patients, pediatric-based protocols are safe and effective, justifying their use in younger adults with ALL.

Management of Newly Diagnosed Acute Myeloid Leukemia in the Elderly: Current Strategies and Future Directions

The incidence of acute myeloid leukemia (AML) increases with age, and the majority of cases occur in adults aged >55 years. The prognosis of AML in older adults is generally poor; however, AML is a heterogeneous disease regardless of age, and prognosis depends on cytogenetic changes, genetic mutations, and patient characteristics. Several lines of evidence support offering treatment to the vast majority of older patients, and the survival benefit associated with this approach generally outweighs the risk of toxicity. Response and long-term survival using intensive induction regimens are significantly lower in older patients, although a small proportion of patients can achieve durable remissions. Selection of patients for intensive induction therapy requires comprehensive assessment of disease characteristics, performance status, and comorbidities. In unfit patients, options for treatment include hypomethylating agents, low-dose ara-C, or consideration of a clinical trial if available. The incorporation of novel therapies into treatment, such as FLT3 inhibitors and antibody-drug conjugates, offers significant promise in older patients, although, thus far, increased responses using novel agents have often not translated to improved survival outcomes. The development of reduced-intensity conditioning regimens and improvements in supportive care has increased the use of allogeneic stem cell transplant (ASCT) in older patients. Selection of patients for ASCT requires an estimation of the trade-off between toxicity and risk of relapse.

Jumping Translocations in Myeloid Malignancies Associated With Treatment Resistance and Poor Survival

BACKGROUND

Jumping translocations (JT) are uncommon cytogenetic abnormalities involving nonreciprocal translocations of a single donor chromosome onto 2 or more chromosomes. The clinical characteristics and prognosis of JTs in patients with myeloid malignancies are not well described.

MATERIALS AND METHODS

We searched our cytogenetic database from 2003 to 2014 to identify cases of myeloid malignancies associated with a JT. These cases were cross-referenced with our clinical databases to determine patient characteristics, response to treatment and overall survival.

RESULTS

We identified 10 patients with myeloid malignancies and a JT: 4 cases of acute myeloid leukemia with myelodysplastic syndrome-related changes, 4 cases of myelodysplastic syndrome, and 2 cases of postpolycythemia myelofibrosis. The donor segment was derived from chromosome 1 in every case. The acquisition of a JT was a late occurrence, with a median time to JT development of 24.9 months (range, 0-248 months) from diagnosis. The overall response to treatment was poor, with no patients experiencing a response to conventional chemotherapy or hypomethylating agents. The median overall survival for the group was 9 months (95% confidence interval, 2.5-15.5) after identification of a JT.

CONCLUSION

The acquisition of a JT in patients with myeloid malignancies appears to be a late event and is associated with myelodysplasia. In our series, this was associated with a poor prognosis with a poor response to treatment, disease transformation to acute myeloid leukemia, and short overall survival.

Tamibarotene in patients with acute promyelocytic leukaemia relapsing after treatment with all-trans retinoic acid and arsenic trioxide

Treatment of acute promyelocytic leukaemia (APL) with arsenic trioxide (ATO) and all-trans retinoic acid (ATRA) is highly effective first-line therapy, although approximately 5-10% of patients relapse. Tamibarotene is a synthetic retinoid with activity in APL patients who relapse after chemotherapy and ATRA, but has not been studied in relapse after treatment with ATO and ATRA. We report on a phase II study of tamibarotene in adult patients with relapsed or refractory APL after treatment with ATRA and ATO (n = 14). Participants were treated with tamibarotene (6 mg/m(2) /d) during induction and for up to six cycles of consolidation. The overall response rate was 64% (n = 9), the rate of complete cytogenetic response was 43% (n = 6) and the rate of complete molecular response was 21% (n = 3). Relapse was frequent with 7 of 9 responders relapsing after a median of 4·6 months (range 1·6-26·8 months). The median event-free survival (EFS) was 3·5 months [95% confidence interval (CI) 0-8·6 months] and the median overall survival (OS) was 9·5 months (95% CI 5·9-13·1 months). These results demonstrate that tamibarotene has activity in relapsed APL after treatment with ATO and ATRA and further studies using tamibarotene as initial therapy and in combination with ATO are warranted.

A case of transfusion independence in a patient with myelodysplastic syndrome using deferasirox, sustained for two years after stopping therapy

Patients with myelodysplastic syndrome (mds) experience clinical complications related to progressive marrow failure and have an increased risk of developing acute myeloid leukemia. Frequent red blood cell transfusion can lead to clinical iron overload and is associated with decreased survival in mds patients. Iron chelation therapy reduces markers of iron overload and prevents end-organ damage. Here, we present the case of a patient with low-risk mds with transfusional iron overload. He was treated for 2 years with an oral iron chelator, deferasirox, and after 12 months of treatment, he experienced a hemoglobin increase of more than 50 g/L, becoming transfusion-independent. He has remained transfusion-independent, with a normal hemoglobin level, for more than 2 years since stopping chelation therapy. Hematologic and erythroid responses have previously been reported in mds patients treated with iron chelation. The durability of our patient's response suggests that iron chelation might alter the natural history of mds in some patients.

Response to "Need to minimize bias when surveying patient attitudes to stopping cml treatment"

We thank Villemagne et al. for their comments, and we will address some of the issues that they raised.[...]

The effect of low molecular weight heparin on survival in cancer patients: an updated systematic review and meta-analysis of randomized trials

BACKGROUND

Tumors may exploit the coagulation system to enhance the survival and dissemination of cancer cells. Some studies have suggested that heparin and low molecular weight heparin (LMWH) have antitumor effects. We reported a previous meta-analysis that suggested a modest improvement in overall survival with the use of LMWH in patients with cancer. Herein, we present the results of an updated systematic review and meta-analysis.

OBJECTIVE

To evaluate the effect of LMWH as compared with placebo or no anticoagulant on the overall survival in patients with solid cancers.

METHODS

We conducted a systematic review and meta-analysis of randomized trials evaluating the use of LMWH vs. placebo or no anticoagulant in cancer patients without venous thrombosis. A meta-analysis was conducted with a random-effects model, and data were analyzed by the use of odds ratios (ORs) and relative risks (RRs) calculated for 1-year overall mortality.

RESULTS

We identified 724 potentially relevant studies, nine of which met our inclusion criteria, and reported data on 1-year overall mortality. Studies were heterogeneous regarding types of cancer and interventions, and included 5987 patients, 98.4% of whom had advanced-stage disease (III and IV). There was no discernible effect on mortality with the use of LMWH (pooled OR 0.87, 95% CI 0.70-1.08; RR 0.94, 95% CI 0.86-1.04).

CONCLUSIONS

In contrast to the previous study, these results did not show a survival benefit in cancer patients receiving LMWH. The effect of LMWH on overall survival in patients with limited-stage disease still is unknown.

Development of Myasthenia Gravis in a Patient with Chronic Myeloid Leukemia during Treatment with Nilotinib

We report on a patient diagnosed with chronic myeloid leukemia (CML) who developed myasthenia gravis while on treatment with nilotinib. Autoimmune disease, including the development of myasthenia gravis, has been described in association with CML as well as the use of tyrosine kinase inhibitors. Second generation tyrosine kinase inhibitors are highly effective in the treatment of CML, although can result in adverse effects related to off-target kinase inhibition, and longer term reporting of adverse effects is required.

Patient preferences for stopping tyrosine kinase inhibitors in chronic myeloid leukemia

BACKGROUND

We used an interview-assisted survey of patients with chronic myeloid leukemia (cml) at a single tertiary care centre to explore patient reactions to and preferences for, and the risk-acceptability of, stopping tyrosine kinase inhibitor (tki) treatment.

METHODS

The study included patients with confirmed cml currently being treated with a tki. The survey was conducted by structured interview using a standard form. Patient preferences were explored in a case-based scenario using 0%-100% visual analog scales and 5-point Likert scales. Data were analyzed using proportions for dichotomous variables and medians and interquartile ranges for continuous variables.

RESULTS

Of 63 patients approached, 56 completed the survey. Participant responses suggest that the idea of stopping tki use is appealing to many patients if there is a chance of long-term stable disease and a high probability of response upon restarting a tki. Participants were more likely to stop their tki as the risk of relapse decreased. Participants reported loss of disease control and failure of disease to respond to treatment as important concerns if they chose to stop their tki.

CONCLUSIONS

Given the current 60% estimated rate of relapse after discontinuation of tki therapy, most patients with cml chose to continue with tki. However, at the lower relapse rates reported with second-generation tkis, participants were more undecided, demonstrating a basic understanding of risk. Contrary to our hypothesis, neither compliance nor occurrence of side effects significantly affected patient willingness to stop their tki.

Opioid use is associated with decreased quality of life in patients with Crohn's disease

BACKGROUND/AIMS

Quality of life is an important consideration in the management of patients with Crohn's disease. Previous studies suggest that Crohn's disease patients using opioids may have decreased quality of life and increased risk of mortality. Our aim was to determine the association between health-related quality of life (HRQoL) and opioid use in patients with Crohn's disease while controlling for disease severity.

PATIENTS AND METHODS

We conducted a cross-sectional study recruiting Crohn's disease patients at our center. Disease activity was measured using the Harvey-Bradshaw Index (HBI), and HRQoL was measured using the Inflammatory Bowel Disease Questionnaire (IBDQ).

RESULTS

We enrolled 38 Crohn's disease patients using opioids and 62 patients not using opioids. Patients using opioids had an increased duration of disease (median 18.5 vs. 9 years, P = 0.005), increased surgeries related to Crohn's disease (median 3 vs. 0, P < 0.001), and increased prednisone use (29% vs. 11.3%, P = 0.03). Patients using opioids had increased disease activity (median HBI score 9.0 vs. 3.0, P < 0.001). Quality of life was lower in patients using opioids (mean IBDQ score 109.3 vs. 162.9, P < 0.001). This finding was significant when controlling for HBI scores, number of previous surgeries, and prednisone use (P = 0.003).

CONCLUSIONS

Opioid use in Crohn's disease patients appears to be associated with disease activity and severity. HRQoL is markedly decreased in patients using opioids and this association is significant even when controlling for variables reflecting disease severity. Our findings suggest that Crohn's disease patients using opioids are likely to be significantly impacted by their disease.

Custom cerium oxide nanoparticles protect against a free radical mediated autoimmune degenerative disease in the brain

Cerium oxide nanoparticles are potent antioxidants, based on their ability to either donate or receive electrons as they alternate between the +3 and +4 valence states. The dual oxidation state of ceria has made it an ideal catalyst in industrial applications, and more recently, nanoceria's efficacy in neutralizing biologically generated free radicals has been explored in biological applications. Here, we report the in vivo characteristics of custom-synthesized cerium oxide nanoparticles (CeNPs) in an animal model of immunological and free-radical mediated oxidative injury leading to neurodegenerative disease. The CeNPs are 2.9 nm in diameter, monodispersed and have a -23.5 mV zeta potential when stabilized with citrate/EDTA. This stabilizer coating resists being 'washed' off in physiological salt solutions, and the CeNPs remain monodispersed for long durations in high ionic strength saline. The plasma half-life of the CeNPs is ∼4.0 h, far longer than previously described, stabilized ceria nanoparticles. When administered intravenously to mice, the CeNPs were well tolerated and taken up by the liver and spleen much less than previous nanoceria formulations. The CeNPs were also able to penetrate the brain, reduce reactive oxygen species levels, and alleviate clinical symptoms and motor deficits in mice with a murine model of multiple sclerosis. Thus, CeNPs may be useful in mitigating tissue damage arising from free radical accumulation in biological systems.

Three-loop corrections to the Higgs boson mass and implications for supersymmetry at the LHC

In supersymmetric models with minimal particle content and without left-right squark mixing, the conventional wisdom is that the 125.6 GeV Higgs boson mass implies top squark masses of O(10)  TeV, far beyond the reach of colliders. This conclusion is subject to significant theoretical uncertainties, however, and we provide evidence that it may be far too pessimistic. We evaluate the Higgs boson mass, including the dominant three-loop terms at O(αtαs2), in currently viable models. For multi-TeV top squarks, the three-loop corrections can increase the Higgs boson mass by as much as 3 GeV and lower the required top-squark masses to 3-4 TeV, greatly improving prospects for supersymmetry discovery at the upcoming run of the LHC and its high-luminosity upgrade.

Modulation of fine specificity of anti-DNA antibody by CDR3L residues

The light chain of 2C10, an anti-double stranded DNA (dsDNA) autoantibody, is not favorable for DNA binding and it was suggested that the light chain might modulate the specificity of the antibody in DNA binding. We studied several mutant scFvs expressing mutated VL and normal VH of 2C10 to explore the role of the light chain in determining the fine specificity of the antibody, which we define as the preferential binding to a specific sequence of bases or a helical conformation compared to dsDNA from calf thymus. The wild-type Fab and scFv of 2C10 bind to poly(dA-dC).(dG-dT) better than to dsDNA. However, in the absence of the light chain domain, the VH domain bound dsDNA better than poly(dA-dC).(dG-dT), indicating the possible involvement of the light chain in determining the fine specificity in DNA binding. The mutations we studied were located in either CDR1L or CDR3L of the antibody. The CDR1 mutants, D28A, D30A, D31A, and D32A have been previously shown to cause an increase in the affinity of 2C10 scFv to DNA. The fine specificity of 2C10 was not affected by the CDR1 mutants which bound to poly(dA-dC).(dG-dT) better than dsDNA. However, CDR3L mutants, D92A and N93A, which had been shown to be involved in direct interaction with DNA, preferred dsDNA to poly(dA-dC).(dG-dT) in their binding. Our results indicate that the fine specificity of 2C10 in DNA binding is modulated primarily by Asp at 92 and Asn at 93 in CDR3L. The effects of CDR1L mutations indicate that this region affects only the affinity but not the fine specificity of 2C10.

A human mitochondrial ferritin encoded by an intronless gene

Ferritin is a ubiquitous protein that plays a critical role in regulating intracellular iron homoeostasis by storing iron inside its multimeric shell. It also plays an important role in detoxifying potentially harmful free ferrous iron to the less soluble ferric iron by virtue of the ferroxidase activity of the H subunit. Although excess iron is stored primarily in cytoplasm, most of the metabolically active iron in cells is processed in mitochondria. Little is yet known of how these organelles regulate iron homeostasis and toxicity. Here we report an unusual intronless gene on chromosome 5q23.1 that encodes a 242-amino acid precursor of a ferritin H-like protein. This 30-kDa protein is targeted to mitochondria and processed to a 22-kDa subunit that assembles into typical ferritin shells and has ferroxidase activity. Immunohistochemical analysis showed that it accumulates in high amounts in iron-loaded mitochondria of erythroblasts of subjects with impaired heme synthesis. This new ferritin may play an important role in the regulation of mitochondrial iron homeostasis and heme synthesis.

Prednisolone plus albuterol versus albuterol alone in mild to moderate bronchiolitis

To evaluate combination therapy of mild to moderate bronchiolitis with bronchiodilators and corticosteroids, we treated 51 young children with first-time wheezing and symptoms of respiratory tract infection with albuterol plus either prednisolone or placebo for 5 days. Disease severity was scored on days 0, 2, 3, and 6. On day 2, prednisolone resulted in significantly lower scores (2.7 +/- 1.4 vs. 4.0 +/- 1.5 in all patients evaluated, p < 0.05) than placebo, whereas there was no detectable difference on day 6, suggesting that addition of prednisolone to albuterol transiently accelerates recovery from bronchiolitis. The clinical significance of this effect needs to be evaluated in further studies.

The structural basis for DNA binding by an anti-DNA autoantibody

We have used single and multiple site-directed mutagenesis, and molecular modeling, to identify critical residues in the DNA binding site of MAb 2C10, an IgG anti-dsDNA autoantibody from an MRL/lpr lupus mouse. Simultaneous replacement of four Arg residues in the CDR3H abolished binding activity. With one exception, replacement of any one of these Arg residues reduced the activity to 20-50% of the unmutated scFv activity. Arg to Asp replacements had a slightly greater effect than Arg to Ala replacements. In the one exceptional case, replacement of Arg99 with Ala actually increased DNA binding five-fold and replacement by Asp had little effect. Mutation of Phe32 and Asn35 to A1a in CDRIH decreased DNA binding, whereas replacement of Arg31 with A1a had negligible effect. Ala substitution of any one of a cluster of Asp residues in CDR1L increased DNA binding three to six-fold, confirming previous findings that the L-chain of MAb 2C10 is not favorable for DNA binding. The L-chain does participate in shaping the selectivity of antigen binding, and mutation of CDR3L residue Asp92 or Asn93 caused a decrease in DNA binding activity. Directed mutagenesis, consistent with a molecular model, indicates that: several CDR amino acids contribute to DNA binding, without one residue dominating; both VH and VL CDR3 domains contribute to specificity of binding whereas the CDR1L hinders DNA binding. The results suggest a significant role for electrostatics in the interaction of DNA with MAb 2C10.

NMR analysis of interactions of a phosphatidylinositol 3'-kinase SH2 domain with phosphotyrosine peptides reveals interdependence of major binding sites

The interactions of the N-terminal src homology (SH2) domain (N-SH2) of the 85 kDa subunit of phosphatidylinositol 3'-kinase (PI-3K) with phosphotyrosine (ptyr) and a series of ptyr-containing peptides have been examined by NMR spectroscopy. HSQC (heteronuclear single-quantum coherence) NMR spectra of 15N-labeled SH2 were used to evaluate its interactions with ptyr-containing ligands. The ability of ligands to cause chemical shift changes was compared to their potency as competitors in in vitro binding experiments using polyoma virus middle T antigen (MT). The results suggest the interdependence of SH2 binding elements. Chemical shifts of residues involved in the ptyr binding were altered by variations of the sequence of the bound peptide, suggesting that the ptyr fit can be adjusted by the peptide sequence. Perturbations of chemical shifts of residues coordinating the methionine three residues C-terminal to the ptyr (the +3 residue) were affected by substitution in the binding peptide at +1 and vice versa. Such results show synergistic interplay between regions of the SH2 binding residues C-terminal to the ptyr.

Participants and nonparticipants of a mass media self-help smoking cessation program

Differences in demographic and smoking-related characteristics were examined among an ethnically heterogeneous sample of participants and nonparticipants of a self-help media-enhanced smoking cessation program which had been aired in seven cities in California. Subjects had been prompted or not prompted to view the mass media smoking cessation broadcast as an experimental manipulation. Written self-help smoking cessation materials were provided as supplements in local Sunday newspapers. Predictors of viewing the smoking cessation broadcasts and reading the self-help manual were examined separately. Across conditions, more smokers read the manual than viewed the broadcast. Nonredundant predictors of viewing the smoking cessation broadcasts included being prompted to view the broadcast, and self-reports of a tendency to read or listen to self-help material. Nonredundant predictors of reading the self-help smoking cessation manual included city of residence, older age, being a heavier smoker, planning to quit in the next 3 months, and receiving a newspaper at home (in which the self-help material appeared). Apparently, a televised cessation program can reach smokers who vary widely in characteristics. Prompting viewing increases participation, but only to a limited extent. Distribution of a written cessation manual in Sunday newspapers tends to be utilized by a relatively larger population, but especially by those persons who are motivated to quit.

A continuously variable field of view surface coil

A new type of surface coil is described which allows the user to continuously vary the size of the field of view. This utilizes a modified radiofrequency trombone for size adjustment that results in a stable frequency over a wide range of dimensions. Results show that the coil may be increased in area by as much as 60% while maintaining frequency stability to ca. 1 MHz at 63.5 MHz. Images of the human spine are presented to demonstrate the clinical utility of the new design.

Epicardial electrical activation analyzed via frequency-wavenumber spectrum estimation for the characterization of arrhythmiagenic states

The application of a new signal processing methodology to the analysis of epicardial array ECG signals is presented as an alternative to isopotential or isochrones mapping by the use of a zero-delay wavenumber spectrum (ZDWS) estimation technique. The methodology "explains" the array data as the sum of modulated wideband (non-sinusoidal) propagating waves projected onto the array plane and provides an accurate estimate of their number and bearing. The slowness distribution of each of the waves is then obtained by estimating their temporal spectrum. In this experimental study the effects of localized noninfarcting reversible low flow ischemia, digoxin toxicity and verapamil reversal of digoxin toxicity are quantified via the ZDWS methodology and are compared with the information that can be extracted from isopotential mapping. It is demonstrated that the ZDWS methodology permits the epicardial electric activation to be decomposed into a number of quantification parameters which possess a hierarchical "tree" structure and therefore provide a means for an objective and robust characterization of the effects of agents which alter myocardial conduction and arrhythmia generation.