Floating-Harbor syndrome with chorioretinal colobomas

BACKGROUND

We present a case of a child with Floating-Harbor Syndrome (FHS) with bilateral chorioretinal coloboma (CC). To the best of our knowledge, this is the first case report of this association. Floating- Harbor syndrome is an extremely rare autosomal dominant genetic disorder with approximately 100 cases reported. It is characterized by a series of atypical features that include short stature with delayed bone age, low birth weight, skeletal anomalies, delayed speech development, and dysmorphic facial characteristics that typically portray a triangular face, deep-set eyes, long eyelashes, and prominent nose.

MATERIALS AND METHODS

Our patient was examined by a pediatric ophthalmologist for the time at age of 7. Visual acuity, optical coherence tomography (OCT) and Optos imaging were collected on every visit. The patient had whole genome sequencing ordered by a pediatric geneticist to confirm Floating-Harbor syndrome.

RESULTS

We present the patient's OCT and Optos images that illustrate the location of the patient's inferior chorioretinal coloboma in both eyes. The whole genome sequencing report collected revealed a heterozygous de novo pathogenic variant in the SRCAP gene, consistent with a Floating-Harbor syndrome diagnosis in the literature.

DISCUSSION

Both genetic and systemic findings are consistent with the diagnosis of Floating-Harbor syndrome in our patient. Rubenstein-Taybi and Floating-Harbor syndrome share a similarity in molecular and physical manifestations, but because of the prevalence in Rubenstein-Taybi diagnoses, it is a syndromic condition that includes coloboma and frequently associated with each other. Therefore, a retinal exam should become part of the standard protocol for those with FHS, as proper diagnosis, examination and treatment can prevent irreversible retinal damage.

Connected diagnostics: linking digital rapid diagnostic tests and mobile health wallets to diagnose and treat brucellosis in Samburu, Kenya

BACKGROUND

Despite WHO guidelines for testing all suspected cases of malaria before initiating treatment, presumptive malaria treatment remains common practice among some clinicians and in certain low-resource settings the capacity for microscopic testing is limited. This can lead to misdiagnosis, resulting in increased morbidity due to lack of treatment for undetected conditions, increased healthcare costs, and potential for drug resistance. This is particularly an issue as multiple conditions share the similar etiologies to malaria, including brucellosis, a rare, under-detected zoonosis. Linking rapid diagnostic tests (RDTs) and digital test readers for the detection of febrile illnesses can mitigate this risk and improve case management of febrile illness.

METHODS

This technical advance study examines Connected Diagnostics, an approach that combines the use of point-of-care RDTs for malaria and brucellosis, digitally interpreted by a rapid diagnostic test reader (Deki Reader) and connected to mobile payment mechanisms to facilitate the diagnosis and treatment of febrile illness in nomadic populations in Samburu County, Kenya. Consenting febrile patients were tested with RDTs and patient diagnosis and risk information were uploaded to a cloud database via the Deki Reader. Patients with positive diagnoses were provided digital vouchers for transportation to the clinic and treatment via their health wallet on their mobile phones.

RESULTS

In total, 288 patients were tested during outreach visits, with 9% testing positive for brucellosis and 0.6% testing positive for malaria. All patients, regardless of diagnosis were provided with a mobile health wallet on their cellular phones to facilitate their transport to the clinic, and for patients testing positive for brucellosis or malaria, the wallet funded their treatment. The use of the Deki Reader in addition to quality diagnostics at point of care also facilitated geographic mapping of patient diagnoses in relation to key risk areas for brucellosis transmission.

CONCLUSIONS

This study demonstrates that the Connected Dx approach can be effective even when addressing a remote, nomadic population and a rare disease, indicating that this approach to diagnosing, treatment, and payment for healthcare costs is feasible and can be scaled to address more prevalent diseases and conditions in more populous contexts.

Abstract OT2-07-04: A phase 1b study of poziotinib in combination with T-DM1 in women with advanced or metastatic HER2-positive breast cancer

Background:Poziotinib represents a new class of irreversible quinazoline inhibitors of ErbB receptor tyrosine kinases that inhibit the proliferation of tumor cells in culture and in vivo by inhibiting HER-1 (EGFR), HER-2, HER-4. ErbB signaling plays important roles in the progression of HER2+ breast cancer. Poziotinib has promising clinical activity in breast cancer, and other solid tumors including lung, gastric, and colorectal cancers.

Study SPI-POZ-101, is being conducted to evaluate the safety and efficacy of the combination of daily poziotinib and T-DM1, HER2 antibody-drug-conjugate every three weeks in patients with HER2+ advanced or metastatic breast cancer.

Trial Objectives and Design: The primary objectives of the study are to determine the maximum tolerated dose (MTD) or maximum administered dose (MAD) of daily poziotinib plus T-DM1 (every 3 weeks) in women with advanced or metastatic HER2 positive breast cancer; and to evaluate the Objective Response Rate (ORR) in these patients.

The secondary objectives include disease control rate (DCR), progression-free-survival (PFS), safety and pharmacokinetics at the MTD/MAD dose level of poziotinib plus T-DM1.

In Part 1, the dose of poziotinib plus standard dose of T-DM1 (3.6 mg/kg IV) on Day 1 of each cycle will be determined using a “3+3” design with up to 3 escalating dose levels, 8, 10 and 12 mg with no DLT or to de-escalate to 6 mg with DLT observed in Cycle 1. Patients in current dose cohort, if not discontinued, will continue treatment until discontinuation of therapy.

In Part 2 of the study, approximately 10 patients will be treated at the MTD/MAD to confirm dose for safety of the combination and to evaluate preliminary efficacy.

Eligibility Criteria: The study will enroll female patients between 18 and 90 years with confirmed HER2 overexpression or gene-amplified tumor via immunohistochemistry [IHC] with IHC 3+ or IHC 2+ with confirmatory fluorescence in situ hybridization [FISH]+ or [ISH]+ and must have had at least 2 lines of anti-HER2 directed therapies either in the metastatic or early-stage disease setting. Patients must have adequate hematologic, hepatic, cardiac and renal functions and have at least one measurable lesion per RECIST 1.1 criteria. Exclusion criteria includes unstable CNS metastases or seizure disorder; anticancer chemotherapy, TKIs, biologics, immunotherapy, radiotherapy, or investigational treatment within 15 days; ≥ Grade 2 adverse events; known hypersensitivity to receptor tyrosine kinase inhibitors or any of the components of poziotinib tablets or T-DM1 IV solution.

Statistical Methods: Part 1 of the study will enroll 3 to 6 patients at each dose using 3+3 design. Part 2 will enroll 10 patients at the MTD/MAD. The efficacy analysis will be conducted using the Evaluable Population based on RECIST 1.1. The Clopper-Pearson 95% confidence interval will be estimated using exact method based on binomial distribution.

Target Accrual:Part 1: 6-18 patients Part 2: 10 patients

ClinicalTrials.gov Identifier: NCT03429101

Contact Information: Spectrum Pharmaceuticals. SPI-POZ-101@sppirx.com

Poziotinib is currently under clinical investigation and has not been approved for use in breast cancer.

Citation Format: Bhat G, Potter D, Bharadwaj J, Khan N, Shabazz L, Tache J, Yang Z. A phase 1b study of poziotinib in combination with T-DM1 in women with advanced or metastatic HER2-positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-07-04.

Abstract P1-13-05: Efficacy and safety of eflapegrastim confirmed in reducing severe neutropenia in breast cancer patients treated with myelosuppressive chemotherapy in the second Phase 3 randomized controlled multinational trial compared to pegfilgrastim (RECOVER trial)

Background:

Eflapegrastim is a novel investigational biologic comprised of recombinant human G-CSF covalently linked to the human immunoglobulin G4FC fragment using proprietary LAPSCOVERY™ technology with potentially unique distribution to areas rich in FcRn receptors. RECOVER is the second Phase 3 study to investigate the non-inferiority (NI) of eflapegrastim to pegfilgrastim in patients receiving chemotherapy for breast cancer. The first Phase 3 study, ADVANCE, has demonstrated the non-inferiority of eflapegrastim comparing to pegfilgrastim in the duration of severe neutropenia (DSN) in breast cancer patients receiving docetaxel and cyclophosphamide (TC) and was previously published at ASCO 2018 meeting.

TrialDesign:

Patients with Stage I to Stage IIIA breast cancer from centers in the USA, Canada, Poland, Hungary, South Korea and India were treated on Day 1 of each of four 21-day cycles with adjuvant or neo-adjuvant TC. On Day 2 of each cycle, patients received a single subcutaneous dose of either eflapegrastim 13.2 mg/0.6 mL (equivalent to 3.6 mg G-CSF) or pegfilgrastim (6 mg) in a 1:1 ratio. Patients had CBCs drawn on Day 1 prior to chemotherapy and Days 4-15 daily or until recovery of neutropenia in Cycle 1. CBC was also collected on Days 1, 4, 7, 10 and 15 in Cycles 2-4. The primary endpoint was to demonstrate the non-inferiority of eflapegrastim comparing to pegfilgrastim as measured by the mean DSN in Cycle 1 with NI margin of <0.62 day.

Results:

In a total of 237 intent-to-treat patients (randomized to 118 eflapegrastim; 119 pegfilgrastim), median age was 59 years (range 29 to 88 years); mean (SD) DSN was 0.31 (0.688) days for eflapegrastim and 0.39 (0.949) days for pegfilgrastim, demonstrating the non-inferiority (95% CI of ΔDSN: [-0.292, 0.129]; p<0.0001). Non-inferiority of eflapegrastim for DSN was maintained across all 4 cycles. There were no statistically significant differences in secondary endpoints: time to ANC recovery, depth of ANC nadir and incidence of FN at Cycle 1. The common Grade 3/4 adverse events observed in≥5%of patients were similar across both arms and were mainly hematologic including neutropenia, lymphopenia, anemia and leukopenia. Grade 3/4 bone pain and febrile neutropenia rates were similar across both arms and were less than 5%.

Conclusions:

Eflapegrastim, a novel long acting G-CSF demonstrated non-inferiority to pegfilgrastim in the reduction of DSN in breast cancer patients treated with TC and has validated the results from the first Phase 3 ADVANCE study. Eflapegrastim was safe and well-tolerated with a similar safety profile to pegfilgrastim.

Citation Format: Schwartzberg L, Bhat G, Mezei K, Lang I, Moon YW, Senviratne L, Chawla S, Cobb P, Yang Z. Efficacy and safety of eflapegrastim confirmed in reducing severe neutropenia in breast cancer patients treated with myelosuppressive chemotherapy in the second Phase 3 randomized controlled multinational trial compared to pegfilgrastim (RECOVER trial) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-13-05.

Abstract OT1-02-10: A phase 2 study of poziotinib in patients with HER2-positive metastatic breast cancer (MBC) who have received prior HER2 regimens for MBC

Background: Poziotinib is a novel, oral, quinazoline-based pan-HER inhibitor that irreversibly blocks signaling through the epidermal growth factor receptor (EGFR) family of tyrosine-kinase receptors, including EGFR (HER1/ErbB1/EGFR), HER2 (ErbB2), and HER4 (ErbB4), as well as HER receptor mutations. This, in turn, leads to inhibition of the proliferation of tumor cells that overexpress these receptors. It is well established that breast cancers are associated with a mutation in, or overexpression of, members of the EGFR receptor family. The primary objective of this Phase 2 study is to evaluate the Objective Response Rate (ORR) of poziotinib in patients with human epidermal growth factor receptor 2 (HER2)-positive MBC. The secondary efficacy variables are Progression-Free Survival (PFS), Disease Control Rate (DCR), Overall Survival (OS), and Time to Progression (TTP).

Trial Design: This is a Phase 2, open-label, multicenter study to evaluate the efficacy, safety and tolerability of poziotinib in patients with HER2-positive MBC who have received at least 2 prior HER2- directed treatment regimens. Each treatment cycle is 21 days in duration. During each cycle, eligible patients receive 24 mg of poziotinib orally (as three 8-mg tablets) once daily for 14 days, followed by a 7 day treatment-free period.

Eligibility Criteria: Eligible patients are at least 18 years of age, have confirmed HER2 overexpression, adequate hematologic, renal and hepatic function, and have received at least 2 prior HER2-directed therapy regimens, including trastuzumab and trastuzumab emtansine (TDM-1). Patients are excluded if they have prior exposure to poziotinib, a history of congestive heart failure, left ventricular ejection fraction <50%, unable to take oral medications, or have conditions that cause malabsorption. A 30 day wash out period from previous chemotherapeutic or radiation therapies is required.

Statistical Methods: The purpose of this study is to evaluate the efficacy of poziotinib compared to the efficacy of other standard HER2-positive breast cancer treatments as reported in the literature. The ORR will be analyzed descriptively along with the 95% CI. The secondary efficacy variables will be analyzed descriptively.

Target Accrual: Approximately 70 patients. Enrollment began February 2016.

Contact Information: For more information or to refer a patient,

email: spi-poz-201@sppirx.com or fax: 1-949-398-9711.

Citation Format: Lathrop K, Lucas J, Vacirca JL, Bhat G, Choi MR, Naughton M. A phase 2 study of poziotinib in patients with HER2-positive metastatic breast cancer (MBC) who have received prior HER2 regimens for MBC [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 OT1-02-10.

Abstract OT1-01-11: Randomized phase 3 study of a novel, long-acting G-CSF (eflapegrastim) versus pegfilgrastim in the management of chemotherapy-induced neutropenia in early-stage breast cancer patients receiving docetaxel and cyclophosphamide (TC) (ADVANCE study)

Background: Eflapegrastim is a distinct biologic that uses an innovative, proprietary long-acting protein/peptide discovery technology (LAPSCOVERY™). Eflapegrastim consists of a novel, modified recombinant human G-CSF conjugated to the Fc fragment of IgG4 via a polyethylene glycol linker to produce a new, longer-acting G-CSF with a potentially unique distribution to areas rich in Fc receptors including its site of action in the bone marrow. A successful dose-finding Phase 2 trial including a pegfilgrastim control arm established the dose for a Phase 3 non-inferiority trial.

Trial Design: This is a randomized, open-label, active-controlled, multinational, multicenter, Phase 3 study comparing the efficacy and safety of eflapegrastim to pegfilgrastim. Patients (n=580) will be randomized in a 1:1 ratio to receive either eflapegrastim (equivalent to 3.6 mg G-CSF) or pegfilgrastim (equivalent to 6.0 mg G-CSF) once per chemotherapy cycle (up to 4 cycles), approximately 24 hours after chemotherapy. The primary endpoint is to compare the efficacy of a single dose of eflapegrastim with pegfilgrastim in patients with ESBC receiving TC, as measured by the Duration of Severe Neutropenia (DSN) in Cycle 1. Key secondary objectives include Time to Absolute Neutrophil Count (ANC) Recovery in Cycle 1; Depth of ANC Nadir in Cycle 1; incidence of Febrile Neutropenia. Safety and pharmacokinetics will also be assessed.

Eligibility Criteria: This study is enrolling histologically confirmed ESBC patients who are: eligible to receive adjuvant or neoadjuvant TC chemotherapy; at least 18 years of age, with adequate hematologic, renal and hepatic function. Patients will be excluded if they have: active concurrent malignancy or life-threatening disease; a known sensitivity or previous reaction to E. coli derived products or any of the products to be administered during study participation; concurrent adjuvant cancer therapy; locally recurrent/metastatic or contralateral breast cancer; previous exposure to filgrastim, pegfilgrastim, or other G-CSF products in clinical development prior to the administration of study drug; bone marrow or hematopoietic stem cell transplant or radiation therapy prior to enrollment, or are pregnant or breast-feeding.

Statistical Methods: The goal of this study is to demonstrate non-inferiority. For the Primary Efficacy Analysis, the mean DSN in Cycle 1 will be compared between the eflapegrastim and pegfilgrastim treatment arms. A 2-sided 95% confidence interval (CI) of the difference between the mean DSN of the eflapegrastim arm and the mean DSN of the pegfilgrastim arm will be calculated using bootstrap resampling with treatment as the only stratification factor. For the Secondary Efficacy Analyses, the results will each be summarized by treatment arm and cycle. The two-sided 95% CI for the difference between the treatment arms will be calculated.

Target Accrual: Approximately 580 patients. Enrollment began January 2016.

Contact Information: Spectrum Pharmaceuticals. advance@sppirx.com.

Citation Format: Schwartzberg LS, Bharadwaj J, Peguero JA, Vacirca JL, Ibrahim EN, Bhat G, Choi MR, McGregor K, Agajanian R. Randomized phase 3 study of a novel, long-acting G-CSF (eflapegrastim) versus pegfilgrastim in the management of chemotherapy-induced neutropenia in early-stage breast cancer patients receiving docetaxel and cyclophosphamide (TC) (ADVANCE study) [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 OT1-01-11.

Abstract OT3-02-13: Randomized phase 3 study of a novel, long-acting G-CSF (SPI-2012) versus pegfilgrastim in the management of chemotherapy-induced neutropenia in early-stage breast cancer patients receiving docetaxel and cyclophosphamide (TC) (ADVANCE study)

Background: SPI-2012 is a distinct biologic that uses the innovative, proprietary long-acting protein/peptide discovery technology (LAPSCOVERY™) to enhance the activity of G-CSF. SPI-2012 consists of a novel, modified recombinant human G-CSF conjugated to the Fc fragment of IgG4 via a polyethylene glycol linker to produce a new, more potent, longer-acting G-CSF with a potentially unique distribution to areas rich in Fc receptors. The primary endpoint of this Phase 3 study is to compare the efficacy of a single dose of SPI-2012 with pegfilgrastim in patients with early-stage breast cancer (ESBC) receiving TC chemotherapy, as measured by the Duration of Severe Neutropenia (DSN) in Cycle 1. Key secondary objectives include the comparison of SPI-2012 with pegfilgrastim during Cycle 1 in: Time to Absolute Neutrophil Count (ANC) Recovery; Depth of ANC Nadir and Incidence of Febrile Neutropenia. Safety and pharmacokinetics will also be assessed.

Trial Design: This is a randomized, open-label, active-controlled, multicenter study comparing the efficacy and safety of SPI-2012 to pegfilgrastim. Patients (n=506) will be randomized in a 1:1 ratio to receive either SPI-2012 (equivalent to 3.6 mg G-CSF) or pegfilgrastim (equivalent to 6.0 mg G-CSF) once per chemotherapy cycle (up to 4 cycles), approximately 24 hrs after chemotherapy.

Eligibility Criteria: This study will enroll histologically confirmed ESBC patients who are eligible to receive adjuvant or neoadjuvant TC chemotherapy and at least 18 years of age, with adequate hematologic, renal and hepatic function. Patients will be excluded if they have active concurrent malignancy or life-threatening disease; a known sensitivity or previous reaction to E. coli derived products or any of the products to be administered during study participation; concurrent adjuvant cancer therapy; locally recurrent/metastatic or contralateral breast cancer; previous exposure to filgrastim, pegfilgrastim, or other G-CSF products in clinical development prior to the administration of study drug; bone marrow or hematopoietic stem cell transplant or radiation therapy prior to enrollment or are pregnant or breast-feeding.

Statistical Methods: The goal of the study is to demonstrate non-inferiority of SPI-2012 to pegfilgrastim. For the Primary Efficacy Analysis, the mean DSN in Cycle 1 will be compared between the SPI-2012 and pegfilgrastim treatment arms. A 2-sided 95% confidence interval (CI) of the difference between the mean DSN of the SPI-2012 arm and the mean DSN of the pegfilgrastim arm will be calculated using bootstrap resampling with treatment as the only stratification factor. For the Secondary Efficacy Analyses, the results will each be summarized by treatment arm and Cycle. The two-sided 95% CI for the difference between the treatment arms will be calculated.

Target Accrual: Approximately 506 pts.

Citation Format: Schwartzberg L, Vacirca JL, Hager SJ, Adoo CS, Ibrahim EN, Bhat G, Choi MR, Allen LF, Tedesco KL, Agajanian R. Randomized phase 3 study of a novel, long-acting G-CSF (SPI-2012) versus pegfilgrastim in the management of chemotherapy-induced neutropenia in early-stage breast cancer patients receiving docetaxel and cyclophosphamide (TC) (ADVANCE study). [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 OT3-02-13.

Abstract P1-10-05: Randomized phase 2, open-label, dose-ranging study of a novel, long-acting G-CSF (SPI-2012) or pegfilgrastim for the management of neutropenia in patients with breast cancer (BC) treated with (Neo) adjuvant chemotherapy with docetaxel + cyclophosphamide (TC)

Background: SPI-2012 is a distinct biologic that uses the innovative proprietary long-acting protein/peptide discovery technology (LAPSCOVERY™) to enhance the activity of G-CSF. SPI-2012 consists of a novel, modified recombinant human G-CSF conjugated to the Fc fragment of IgG4 via a polyethylene glycol linker to produce a new, more potent, longer-acting G-CSF with a potentially unique distribution to areas rich in Fc receptors. To assess the effect of SPI-2012 in supporting patients with breast cancer receiving myelosuppressive chemotherapy with TC, we conducted a randomized Phase 2 study of 3 SPI-2012 doses versus pegfilgrastim.

Methods: This was an open-label, global, multicenter, dose-ranging study designed to compare the safety and efficacy of SPI-2012 relative to a fixed, standard dose of pegfilgrastim as a concurrent active control. The study included 4 treatment arms: 3 dose levels of SPI-2012 (45 μg/kg, 135 μg/kg, and 270 μg/kg) vs pegfilgrastim (6 mg,). The primary objective of the study was the Duration of Severe Neutropenia (DSN) during Cycle 1 in patients with BC who received adjuvant or neoadjuvant TC chemotherapy.

Results: A total of 147 evaluable patients were enrolled. Patient and tumor characteristics were comparable across all 4 treatment arms. Mean age was 58.2 years (range 32 to 77 years); most patients were <65 years (68%), female (98%) and white (95%). The study met its primary endpoint with DSN in patients treated in the 135 µg/kg and 270 µg/kg SPI-2012 treatment arms in Cycle 1 showing non-inferiority to the DSN in patients treated with pegfilgrastim (p=0.002 and p<0.001, respectively). In addition, superiority was demonstrated in patients treated with 270 µg/kg SPI-2012 compared to pegfilgrastim (p=0.023). Non-inferiority in DSN was also observed in Cycles 2 to 4 in both the 135 µg/kg and 270 µg/kg SPI-2012 treatment arms compared to pegfilgrastim.

Duration of Severe Neutropenia in Cycle 1 of TC chemotherapy by Treatment Arm  45 μg/kg SPI-2012 (N=39) 135 μg/kg SPI-2012 (N=36) 270 μg/kg SPI-2012 (N=36)Pegfilgrastim (N=36)DSN Mean (SD)(days)1.03 (1.5)0.44 (1.3)0.03 (0.2)0.31 (0.8)Difference with pegfilgrastim0.720.14-0.28NANon-inferiority p-value0.2960.002<0.001NASuperiority p-value0.0060.5280.023NASD=Standard Deviation; NA=Not Applicable

The common treatment-emergent adverse events observed in ≥20% of patients were similar across all 4 study arms with similar or lower incidence in the SPI-2012 treatment arms, and included fatigue, nausea, alopecia, diarrhea, and bone pain.

Conclusions: All doses of SPI-2012 administered in this Phase 2 study were well tolerated, and no new or significant dose-related toxicities were observed. Most reported adverse events were mild and similar to those previously reported in clinical trials with filgrastim and pegfilgrastim in patients receiving myelosuppressive chemotherapy. In Cycle 1, the 135 µg/kg dose of SPI-2012 was non-inferior compared to pegfilgrastim, and the 270 µg/kg dose was superior in terms of DSN. Additional efficacy and safety data for SPI-2012 will be collected in planned Phase 3 clinical trials.

Citation Format: Vacirca JL, Chan A, Mezei K, Adoo CS, Papai Z, McGregor K, Okera M, Horvath Z, Landherr L, Hanslik J, Hager SJ, Ibrahim EN, Ghazal H, Rostom M, Bhat G, Choi MR, Allen LF, Tedesco KL, Agajanian R, Lang I. Randomized phase 2, open-label, dose-ranging study of a novel, long-acting G-CSF (SPI-2012) or pegfilgrastim for the management of neutropenia in patients with breast cancer (BC) treated with (Neo) adjuvant chemotherapy with docetaxel + cyclophosphamide (TC). [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 P1-10-05.

Community-Acquired Methicillin Resistant Staphylococcus aureus Bacteremia: Case Series

Community-acquired methicillin resistant Staphylococcus aureus (MRSA) usually causes skin and soft tissue infections. However, community-acquired methicillin resistant S.aureus has been identified as a causative agent of many invasive infections like necrotizing fasciitis, pneumonia and bacteremia. Risk factors such as immunodeficiency and skin and soft tissue infections have been identified for acquiring bacteremia. We present four cases of bacteremia caused by community-acquired methicillin resistant S.aureus, risk factors and outcome.Kathmandu University Medical Journal Vol.13(1) 2015; 77-79

Survival on biventricular mechanical support with the Centrimag® as a bridge to decision: a single-center risk stratification

Objective:

Temporary mechanical assist devices are increasingly being used as a lifesaving bridge to decision in patients requiring cardiopulmonary resuscitation. We report our single-center experience with biventricular Centrimag® pumps over a five-year period.

Method:

Data was retrospectively collected in consecutive patients who required biventricular support from 2008 to 2013. Patients who were supported with central cannulation using the Centrimag® system were analyzed. In addition to demographic information, data pertaining to indications, outcomes and mortality were collected.

Results:

The cohort consisted of 48 patients (19 women and 29 men, mean age of 56 years). The median duration of support was 14 days. The median duration to patient expiration while still on the Centrimag® was 12 days. Thirty-day survival was 56% (27/48). Nine patients were explanted to recovery, while fourteen patients were converted to a durable LVAD, two of whom were then transplanted. We stratified patients into two groups. Group I comprised patients who were either explanted to recovery, converted to durable LVAD or transplanted (23/48) and Group II consisted of patients who either died on the Centrimag® or were explanted for withdrawal of care (25/48). Statistical analysis did not reveal any clinically significant differences between the two groups in terms of age, sex, etiology, hemodynamic, co-morbidities or laboratory parameters.

Conclusion:

The biventricular Centrimag® can be used as a bridge to decision in patients with thirty-day survival of >50%. Parameters to predict 30-day survival in this high-risk cohort continue to remain elusive.

Use of a single circuit to provide temporary mechanical respiratory and circulatory support in patients with LV apical thrombus and cardiogenic shock

Introduction:

Techniques to support patients with cardiogenic shock continue to improve. Patients with intracardiac thrombi pose a potential for additional complications. Novel methods of biventricular support are necessary to manage these patients.

Methods:

Two patients with refractory cardiogenic shock and left ventricular apical thrombi underwent mechanical circulatory support (MCS) as a bridge to decision, with a left ventricular assist device (LVAD) and extracorporeal mechanical oxygenation (ECMO). Instead of the conventional LV apical cannulation for LVAD, the left atrium (LA) was cannulated. The LA cannula was then integrated with the ECMO circuit via a ‘Y’ connection to a percutaneous right atrial cannula, enabling optimal drainage of both sides into one circuit through a single CentriMag® pump and ECMO into the aorta.

Results:

The first patient was converted to a durable LVAD and transplanted, while the second patient was explanted, after demonstrating significant LV recovery.

Conclusion:

We demonstrated the use of MCS as a bridge to decision in patients with LV thrombi, utilizing biatrial cannulation with a ‘Y’ connection to drain both right- and left-sided circulation through a single circuit and pump.

Colorectal neoplasia in long-standing ulcerative colitis - a prospective study from a low-prevalence area

AIM

Despite increasing recognition of ulcerative colitis (UC) in Asia in recent decades, reports on the occurrence of colorectal neoplasia (CRN) in UC are scarce and surveillance for this complication is not routinely practised in this region. We aimed to assess the outcome of a newly initiated pilot screening programme for screening CRN among UC patients in India.

METHOD

In this prospective study from an academic hospital setting, patients with UC at high risk of CRN were offered screening by magnifying chromocolonoscopy and the frequency of neoplastic lesions was assessed.

RESULTS

Twenty-nine (70.7%) of 41 eligible patients [a median age of 46 (interquartile range 36-54.5) years; 17 (58.6%) men] enrolled for surveillance; 41 colonoscopies were undertaken over 42 months. The median disease duration was 10 (interquartile range 7.5-14.5) years. Sixteen (55.1%) had extensive colitis. On initial screening, low-grade dysplasia (LGD) was seen in five (17.2%) and high-grade dysplasia (HGD) in three (10.3%). Of these three, one accepted proctocolectomy immediately, one underwent surgery for adenocarcinoma and one refused surgery. Twelve follow-up colonoscopies in nine patients revealed three new LGD.

CONCLUSIONS

High-grade dysplasia and subsequent adenocarcinoma can be detected with careful follow-up in Indian patients with long-standing UC but acceptance of surveillance and subsequent therapy are suboptimal. We found evidence that screening and surveillance programmes are useful for detecting neoplasias in UC, and need to be customized for this region.

Biomarker interactions are better predictors of spontaneous preterm birth

OBJECTIVE

The objective of this study was to assess the role of biomarker interactions as predictors of spontaneous preterm birth (PTB) using multifactor dimensionality reduction (MDR) analysis. With MDR, a nonparametric, unsupervised, model-free approach, we tested for biomarker interactions within maternal-fetal compartments in 2 racial groups: African Americans (AA) and Caucasians (C).

STUDY DESIGN

A total of 36 biomarkers from maternal plasma (MP), cord plasma (CP), and amniotic fluid (AF) were analyzed from 191 patients. The MDR combined attribute selection, construction, and classification to detect biomarker interactions that were assessed for generality and significance using 10× cross-validation and permutation testing. Selected significant interactive models were replicated with additional samples.

RESULTS

The interactive model containing interleukin (IL)-2, angiopoietin 2 (ANGPT-2), and IL-6 receptor was significant in AA MP. In AA CP, the IL-8 and tumor necrosis factor (TNF) receptor 1 model was significant. In AA AF, the ANGPT-2 and macrophage inflammatory protein 1 alpha model was significant. Replication of the AA MP model using 54 additional AA MP samples confirmed predictability of these biomarkers. In C AF, interaction was observed between ANGPT-2, monocyte chemotactic protein 3, and TNF-α, but no other interactions were significant in C.

CONCLUSIONS

Using MDR, we identified biomarker interactions that are predictors of PTB even in the absence of a main effect with a single biomarker.

Dysregulated biomarkers induce distinct pathways in preterm birth

OBJECTIVE

To document racial disparity in biomarker concentrations in maternal/fetal plasma and amniotic fluid between African Americans and European Americans with spontaneous preterm birth (PTB; cases) and normal term birth (controls), and their contribution to distinct pathophysiological pathways of PTB.

DESIGN

Nested case-control study.

SETTING

The Perinatal Research Center, Nashville, Tennessee, USA.

SAMPLE

Maternal and fetal plasma and amniotic fluid samples were collected from 105 cases (59 African American and 46 European American) and 86 controls (40 African American and 46 European American).

METHODS

Thirty-six biomarkers were analysed using the protein microarray approach.

MAIN OUTCOME MEASURES

Differences in biomarker concentrations between cases and controls of different races in maternal, fetal and intra-amniotic compartments, and the risk of PTB. Dysregulated biomarker-induced PTB pathways associated with PTB in each race were determined using ingenuity pathway analysis (IPA).

RESULTS

Racial disparity was observed in biomarker concentrations in each compartment between cases and controls: amniotic fluid, IL8 and MIP1α differed between case and controls in European Americans, whereas ANGPT2, Eotaxin, ICAM-1, IL-1β, IL1RA, RANTES and TNFα differed between case and controls in African Americans. In both races the FAS ligand, MCP-3 and TNFR-I differed between cases and controls. For fetal plasma, ANGPT2, Eotaxin, FGF basic, ICAM-1, IGF-I, IL10, IL-1β, IL2, IP10 KGF, MCP-3, MIP1α, PDGF-BB, TGFα, TGFβ1, TIMP1, TNFα, TNFR-I, TNFR-II and VEGF differed between cases and controls in European Americans, whereas only MMP7 differed between cases and controls in African Americans. IL-8 differed between cases and controls in both races. For maternal plasma, IL1RA, MMP7 and VEGF differed between cases and controls in European Americans, whereas ANGPT2, FGF basic, IL-1β, IL5, IL6R, KGF, MCP-3, MIP1α, TIMP1 and TNFα differed between cases and controls in African Americans. ANG, IL8 and TNFR-I differed between cases and controls in both races.

CONCLUSIONS

We conclude that: (1) biomarker concentrations in maternal, fetal and intra-amniotic compartments differ between cases and controls; (2) there is racial disparity in the biomarker profile in each of the compartments; (3) substantial numbers of dysregulated fetal plasma biomarkers contribute to PTB in European Americans, whereas maternal plasma biomarkers contribute to PTB in African Americans; and (4) both inflammation and haematological functions are associated with PTB in European Americans, but maternal proinflammatory changes dominate PTB in African Americans. Biomarker analyses document racial disparity and the distinct pathophysiological contributions from different compartments that can determine pregnancy outcome.