Efficacy and Safety of Teprotumumab in Patients With Thyroid Eye Disease of Long Duration and Low Disease Activity

CONTEXT

Early inflammatory thyroid eye disease (TED) can lead to symptomatic chronic disease, including disabling proptosis. Teprotumumab, an insulin-like growth factor-1 receptor (IGF-1R) inhibitor, previously demonstrated efficacy in acute, high-inflammation TED trials.

OBJECTIVE

We present data from the first placebo-controlled trial with teprotumumab in chronic/low disease activity TED.

METHODS

This randomized double-masked, placebo-controlled trial, conducted at 11 US centers, enrolled adult participants with TED duration of 2 to 10 years, Clinical Activity Score (CAS) ≤ 1 or no additional inflammation or progression in proptosis/diplopia for ≥1 year, proptosis ≥3 mm from before TED and/or from normal, euthyroid/mildly hypo/hyperthyroid, no prior teprotumumab, and no steroids within 3 weeks of baseline. Patients received (2:1) intravenous teprotumumab or placebo once every 3 weeks (total 8 infusions). The primary endpoint was proptosis (mm) improvement at Week 24. Adverse events (AEs) were assessed.

RESULTS

A total of 62 (42 teprotumumab and 20 placebo) patients were randomized. At Week 24, least squares mean (SE) proptosis improvement was greater with teprotumumab (-2.41 [0.228]) than with placebo (-0.92 [0.323]), difference -1.48 (95% CI -2.28, -0.69; P = .0004). Proportions of patients with AEs were similar between groups. Hyperglycemia was reported in 6 (15%) vs 2 (10%) and hearing impairment in 9 (22%) vs 2 (10%) with teprotumumab and placebo, respectively. AEs led to discontinuation in 1 teprotumumab (left ear conductive hearing loss with congenital anomaly) and 1 placebo patient (infusion-related). There were no deaths.

CONCLUSION

Teprotumumab significantly improved proptosis vs placebo in longstanding/low inflammation TED, demonstrating efficacy regardless of disease duration/activity. The safety profile was comparable to that previously reported.

Tweeting for Success: The Role of Twitter in Enhancing SCImago Journal Rank for Specialty Surgical Journals

Background The cornerstone of surgical education and practice is the surgical journal, but the ability to disperse the vital information within their pages had previously been limited. The use of Twitter by surgical journals has increased in recent years and has allowed these journals to reach a wider audience than they previously could. In this article, we discuss the role Twitter engagement has on a journal's impact factor, visibility, and prestige. Methods The authors compiled a list of journals using the SciMago Journal and Country rank platform. Included journals' Twitter profiles were then assessed using Twitonomy, an online platform that collects and processes data regarding individual Twitter profiles. Statistical analysis was conducted to determine the relationship between Twitter use and SCImago Journal Rank (SJR). Results Simple linear regression and multiple linear regression models determined that the only variables that had a statistically significant impact on all journals were the age of the Twitter account (p=0.003) and the percentage of retweets (p=0.001). When it comes to specialty-specific journals, further analysis showed that the only significant factor regarding its impact on SJR was the percentage of retweets (p=0.007). Conclusions Surgical journals' regular use of Twitter is important in the dissemination of important information to a wide audience. This article shows that the most important variable to determine the impact and visibility of a surgical journal is the percentage of retweets. Further research should be performed to better understand how to use Twitter and other social media platforms to reach a larger audience.

Post-traumatic subdural hygromas: observations concerning a surgical enigma

Four per cent (38) of 881 head injured patients developed known subdural hygromas. Their times of onset and course were variable. However, only two large hygromas seemed clinically significant. Hygromas were more frequent when intracranial pressure monitors were placed, possibly due to opening of the arachnoid, particularly if intracranial pressure was low. But, of course, monitors were only inserted in more severely injured patients. The use of Richmond bolts to drain subdural hygromas in a controlled fashion while monitoring intracranial pressure is suggested.

Use of prognostic factors in improving the design and efficiency of clinical trials in childhood leukemia: Children's Cancer Study Group Report

Prognostic factors are exerting an increasingly apparent and important influence on the results of comparative treatment regimens in childhood leukemia. Since February 1975, 883 previously untreated children with acute lymphocytic leukemia were entered in a protocol designed to evaluate prognostic factors that influence induction rate, remission duration, and survival and to identify subsets of patients with a high risk of early failure. Stratification was based upon the initial wbc count, and standard and more intensive induction and maintenance therapy programs were compared. The combination of older age (> 10 years), high initial wbc counts (greater than or equal to 20 x 10(9)/liter), and low serum IgG is associated with a significantly lower rate of induction of complete remission. The following factors were associated with an unfavorable prognosis with regard to bone marrow relapse and death: wbc count of greater than or equal to 20 x 10(9)/liter; age > 7 years old; CNS disease at diagnosis; L2 lymphoblasts; hemoglobin level greater than or equal to 11 g/dl; decreased concentration of serum immunoglobulin; and M3 marrow on Day 14 of induction. None of the 41 patients in the low-risk prognostic group (3-7 years old with an initial wbc count of < 10 x 10(9)/liter) with L1 blast cells, normal Ig, and M1 marrow on Day 14 has sustained an adverse event. Identification of prognostic factors should permit more efficient and effective design of future protocols by refining the classification of acute lymphocytic leukemia, decreasing the toxic risk to patients with a better prognosis, and improving the relatively poor remission duration and survival for patients with a poor prognosis.

L-Asparaginase, vincristine, and prednisone for induction of first remission in acute lymphocytic leukemia

L-Asparaginase was added to vincristine and prednisone for induction of first remission in 815 children with acute lymphocytic or acute undifferentiated leukemia. This combination resulted in an overall remission rate of 93%. The addition of L-asparaginse to the standard induction regimen using prednisone and vincristine did not significantly increase the morbidity or mortality rate during the induction period. The most common side effect was transient L-asparaginase-induced hyperglycemia. The safe administration of L-asparaginase i.m. and the dose efficacy of 6000 I.U./sq m were confirmed. For these reasons, L-asparaginase should be combined with vincristine and prednisone for the initial induction of children with acute lymphocytic or acute undifferentiated leukemia.

Effect of adriamycin on DNA, RNA, and protein synthesis in cell-free systems and intact cells

The effect of adriamycin on DNA, RNA, and protein synthesis was investigated in cell-free systems and intact cells. In studies with purified mammalian cell enzymes, adriamycin produced a greater inhibition of DNA-dependent DNA polymerase than of RNA polymerase. The extent of inhibition of both these enzymes was decreased by increasing the concentration of the DNA template in the reaction mixture. In studies with isolated nuclei, adriamycin was also a more potent inhibitor of DNA synthesis than RNA synthesis. However, with intact cells, adriamycin inhibited both DNA and RNA synthesis to about the same extent. The inhibition produced by adriamycin on RNA synthesis in intact cells was greater than that observed in the cell-free systems. Adriamycin inhibited protein synthesis in a cell-free system consisting of polyribosomes, transfer RNA, and enzymes but did not inhibit protein synthesis in intact cells. These differences in the pattern of inhibition may be due to biotransformation of the drug and/or preferential binding to chromosomal DNA in the intact cell.

Detection of bacterial endotoxin in antitumor agents

The Limulus amebocyte lysate assay was used to detect the presence of bacterial endotoxin in a variety of chemotherapeutic agents currently in use. Results were quantitated using a standard Escherichia coli endotoxin curve. Relative concentrations of endotoxin ranging from 0.1 to 63 ng/ml were detected in individual lots of L-asparaginase, 5-azacytidine, bleomycin, DTIC, actinomycin D, adriamycin, and vinblastine diluted to normal concentrations for injection. When multiple lots of a given drug were tested, at least one lot produced a negative assay, indicating less than 0.1 ng/ml of endotoxin in 50% of these drugs. All lots of cytosine arabinoside, cyclophosphamide, daunorubicin, vincristine, and streptozotocin tested had less than 0.1 ng/ml of endotoxin. Inactivation kinetics of the Limulus-positive drug material in dilute alkali solutions were identical to those of E. coli endotoxin. The Limulus lysate test is a rapid and specific method for the detection of small amounts of bacterial endotoxin contaminating parenteral preparations of antitumor agents.

Intensive chemotherapy as primary treatment for rhabdomyosarcoma of the pelvis

Twenty-six cases of childhood rhabdomyosarcoma involving the pelvis were treated at Childrens Hospital of Los Angeles between 1950 and 1972. The median survival of 17 patients treated up to 1970 was 6 months. Of a group of 9 patients treated with intensive chemotherapy (ICG) prior to surgery and/or x-ray therapy, 5 are surviving from 12 to 60 months and have a relative survival rate of 4.5 times that of the mixed therapy group (MTG) (p = 0.01). Deaths have occurred only in patients with Stage IV disease. The use of preoperative chemotherapy with or without x-ray therapy followed by local surgical excision when necessary can be as effective in prolonging the survival of children with pelvic rhabdomyosarcoma as those obtained with more traditional approaches; this limitation in use of surgery is likely to preserve the quality of life, should the child live to adulthood.

In vitro biochemical and cytotoxicity studies with 1-beta-D-arabinofuranosylcytosine and 5-azacytidine in combination

The effect of 1-beta-D-arabinofuranosylcytosine (ara-C) and 5-azacytidine (5-aza-C), alone and in combination, on DNA synthesis and cytotoxicity in hamster fibrosarcoma cells has been studied. After a 2-hr exposure of S-phase cells to ara-C at concentrations of 2 to 200 muM, the cells required about 4 to 6 hr to recover from inhibition of DNA synthesis. When 2 exposures to ara-C were used, maximal cytotoxicity occurred when the 2nd dose of ara-C was administered at the time when the cells recovered from the inhibition of DNA synthesis. When the S-phase cells were exposed to ara-C, the maximal killing effect of 5-aza-C occurred when this agent was administered 6 hr later, at the time when the cells had recovered from the inhibition of DNA synthesis. When S-phase cells were exposed to 5-aza-C, the maximal cell kill produced by ara-C also occurred 5 to 6 hr later. When the S-phase cells were exposed simultaneously to both ara-C and 5-aza-C, significant antagonism with respect to cytotoxicity was observed between these 2 agents. When cells in G1 were exposed to 5-aza-C, the cytotoxicity produced by ara-C on these cells when they entered S phase was additive with respect to the cytotoxicity produced by 5-aza-C exposure alone.

BCG in the treatment of acute lymphocytic leukemia

Children with acute lymphocytic leukemia, who were in remission after induction with prednisone and vincristine and consolidation with intravenous methotrexate, were randomized into three groups receiving (1) no further therapy, (2) BCG, and (3) chemotherapy with biweekly methotrexate and monthly prednisone and vincristine. Children continuing in remission after 8 mo on chemotherapy in group 3 were rerandomized into three similar groups, i.e., no therapy, BCG, and chemotherapy. In the primary randomization, the median duration of remission was identical in the groups receiving no therapy or BCG, (4 and 4.3 mo respectively), and both were significantly less than the median duration of remission on chemotherapy which had not been reached prior to secondary randomization at 8 mo. Results of secondary randomization were similar to those of primary randomization. As used in this study, BCG was ineffective in prolonging drug-induced remissions either early in remission or when the leukemic cell population might have been further reduced after 8 mo of maintenance chemotherapy.

Cellular phosphorylation of 1-beta-D-arabinofuranosylcytosine 5-azacytidine with intact fibrosarcoma and leukemic cells

The phosphorylation of 1-beta-D-arabinofuranosylcytosine (ara-C) and 5-azacytidine (5-aza-C) by A(T1)C1-3 hamster fibrosarcoma cells and L5178Y murine leukemic cells was studied, using intact cells. The cellular phosphorylation of both these nucleoside analogs appears to follow Michaelis-Menton kinetics. The apparent Km value for ara-C in the fibrosarcoma and leukemic cells was about 40 muM, whereas the apparent Km values for 5-aza-C in these cells were about 1.3 and 0.41 mM, respectively. Deoxycytidine and cytidine were found to be potent competitive inhibitors of the phosphorylation of ara-C and 5-aza-C, respectively, ara-C and 5-aza-C were found to be weak competitive inhibitors of the phosphorylation of deoxycytidine and cytidine, respectively. A clone isolated from the fibrosarcoma cells that was partially resistant to the cytotoxic effects of ara-C exhibited a higher Km value for both ara-C and deoxycytidine than the wild-type fibrosarcoma cells.

Dibromodulcitol (NSC-104800) compared with cyclophosphamide (NSC-26271) as remission maintenance therapy in previously treated children with acute lymphoblastic leukemia or acute undifferentiated leukemia: possible effectiveness in reducing the incidence of central nervous system leukemia

Dibromodulcitol and cyclophosphamide are both alkylating agents. In this study, these two drugs were compared for their effectiveness as remission maintenance therapy for childhood acute lymphoblastic leukemia or acute undifferentiated leukemia. Toxic effects were similar in both groups of patients although cystitis did not occur with the dibromodulcitol treatment. The duration of remission was slightly shorter for dibromodulcitol than for cyclophosphamide (P = 0.04). There was, however, a lower incidence of CNS leukemia in the patients treated with dibromodulcitol, which did not seem to be related to a basic difference in the patient groups.

Inhibitory effects of mitogens on adenoidal lymphocytes in vitro

Cultures of human adenoidal lymphocytes exposed briefly to either phytohemagglutinin (PHA), Staphylococcus filtrate (Staph-F), concanavalin-A (Con-A), or pokeweed mitogen (PWM) incorporate increased amounts of thymidine earlier than replicate cultures exposed continuously to the mitogens. These effects can begin in the first 24 hr of culture and are seen maximally between 36 and 72 hr. Once a blastogenic response is established, PHA or PWM can diminish that response. Inhibition with PWM requires that the initial stimulation was with this mitogen, while PHA can inhibit blastogenesis to both PHA and PWM-stimulated cells. Because these mitogens can have a paradoxical effect on adenoidal lymphocytes, being capable of both initiating and inhibiting DNA synthesis, this phenomena should be kept in mind when such systems are utilized for the evaluation of antigens and drug effects.

The treatment of acute childhood leukemia: predictions for the future based on extrapolations from the past

Further progress in the treatment of acute leukemia involves a careful assessment of host and disease factors in each child and the selection of a therapeutic regimen which interacts with these factors to provide the maximum chance for survival. For some children, this therapy can be carried out in the community by expertly trained hematologist-oncologists; for others, the best treatment will involve clinical research at a center. Such a general approach has the best chance of fulfilling the optimistic survival projections made by the President's Cancer Panel in 1973 for acute lymphocytic leukemia.

1-beta-D-arabinofuranosylcytosine-induced chromatid breakage: effect of inhibition of DNA synthesis

The frequency of chromatid breakage induced by 1-beta-D-arabinofuranosylcytosine was decreased when hamster cell fibroblasts were treated with chemical agents that interferred with DNA synthesis immediately before addition of the analog. This phenomenon occurred in both the S and G2 phases of the cell cycle.

Chromatid breakage: differential effect of inhibitors of DNA synthesis during G 2 phase

The cell cycle specificity of chromatid breakage induced by inhibitors of DNA synthesis depends on the mechanism of drug action. 5-Hydroxy-2-formylpyridine thiosemicarbazone, hydroxyurea, and guanazole, compounds that inhibit ribonucleotide reductase, do not cause chromatid breakage during G(2) phase. In contrast, two active antitumor agents, arabinosylcytosine and 5-azacytidine, which are either incorporated into polynucleotides or affect DNA polymerase, produce chromatid breakage during G(2) phase. All of these agents except guanazole also induce breakage in S phase.

Effective combination treatment of advanced acute lymphocytic leukemia with cytosine arabinoside (NSC-63878) and L-asparaginase (NSC-109229)

The combination of cytosine arabinoside and L-asparaginase induced remission in 15 of 22 children (68%) with previously treated acute lymphocytic leukemia (ALL). Eight of these patients were in remission after the second week of treatment and seven were in remission after the fourth week. The combination was well tolerated. These preliminary results suggest that these two agents have an additive therapeutic effect in inducing remissions in children with advanced ALL.

Chromatid breakage: cytosine arabinoside-induced lesions inhibited by ultraviolet irradiation

Exposure to ultraviolet light can reduce the frequency of chromatid breaks induced by cytosine arabinoside in the DNA synthetic and post-DNA synthetic phases of the cell cycle. This effect can be correlated temporally with a decrease in the uptake of tritiated thymidine after ultraviolet treatment, implying that the genesis of such breakage is intimately related to DNA synthesis and that such synthesis is not confined to the DNA synthetic phase.

Effect of 1-beta-D-arabinofuranosylcytosine on cell cycle passage time

1-beta-D-Arabinofuranosylcytosine (ara-C) affects the passage rate of cells from S to G2 phase to a greater extent than from G1 to S. This finding is consistent with the fact that the compound may have its major biological effect during the latter part of S and the early part of G2. The magnitude of these effects is related to the dose and duration of ara-C administration. Inhibition of DNA synthesis can occur without disturbances in transit time.

An approach to the emotional support of fatally ill children

When children with leukemia were en couraged to ask questions about their ill ness, they asked many. These questions were straightforward, demonstrating their interest in learning about their illness, and emphasiz ing their need to place events in perspective. Much of the staff's initial fear and appre hension regarding their ability to deal with problems centering around life and death were gradually resolved as they began to ap proach these problems with the information gathered from the children rather than with the preconceived prejudices obtained from other adults.