Pacritinib is a potent ACVR1 inhibitor with significant anemia benefit in patients with myelofibrosis

In patients with cytopenic myelofibrosis, treatment with the JAK2/IRAK1 inhibitor pacritinib was associated with anemia benefit in the phase 3 PERSIST-2 study. The impact of pacritinib on transfusion independence (TI) has not been previously described, nor has the mechanism by which pacritinib improves anemia been elucidated. Because it has been previously postulated that inhibition of activin A receptor, type 1 (ACVR1)/activin receptor-like kinase-2 improves anemia in patients with myelofibrosis via suppression of hepcidin production, we assessed the relative inhibitory potency of pacritinib compared with other JAK2 inhibitors against ACVR1. Pacritinib inhibited ACVR1 with greater potency (half-maximal inhibitory concentration [IC50] = 16.7 nM; Cmax:IC50 = 12.7) than momelotinib (IC50 = 52.5 nM; Cmax:IC50 = 3.2), fedratinib (IC50 = 273 nM; Cmax:IC50 = 1.0), or ruxolitinib (IC50 > 1000; Cmax:IC50 < 0.01). Pacritinib's inhibitory activity against ACVR1 was corroborated via inhibition of downstream SMAD signaling in conjunction with marked suppression of hepcidin production. Among patients on PERSIST-2 who were not transfusion independent at baseline based on Gale criteria, a significantly greater proportion achieved TI on pacritinib compared with those treated on best available therapy (37% vs 7%, P = .001), and significantly more had a ≥50% reduction in transfusion burden (49% vs 9%, P < .0001). These data indicate that the anemia benefit of the JAK2/IRAK1 inhibitor pacritinib may be a function of potent ACVR1 inhibition.

Retrospective analysis of pacritinib in patients with myelofibrosis and severe thrombocytopenia

Thrombocytopenia is common in patients with myelofibrosis and is a well-established adverse prognostic factor. Both of the approved Janus kinase (JAK) inhibitors, ruxolitinib and fedratinib, can worsen thrombocytopenia and have not been evaluated in patients with severe thrombocytopenia (.

Determining the recommended dose of pacritinib: results from the PAC203 dose-finding trial in advanced myelofibrosis

PAC203 is a randomized dose-finding study of pacritinib, an oral JAK2/IRAK1 inhibitor, in patients with advanced myelofibrosis who are intolerant of or resistant to ruxolitinib. Patients were randomized 1:1:1 to pacritinib 100 mg once per day, 100 mg twice per day, or 200 mg twice per day. Enhanced eligibility criteria, monitoring, and dose modifications were implemented to mitigate risk of cardiac and hemorrhagic events. Efficacy was based on ≥35% spleen volume response (SVR) and ≥50% reduction in the 7-component total symptom score (TSS) through week 24. Of 161 patients, 73% were intolerant of and 76% had become resistant to ruxolitinib; 50% met criteria for both. Severe thrombocytopenia (platelet count <50 × 103/μL) was present in 44%. SVR rates were highest with 200 mg twice per day (100 mg once per day, 0%; 100 mg twice per day, 1.8%; 200 mg twice per day, 9.3%), particularly among patients with baseline platelet counts <50 × 103/μL (17%; 4 of 24). Although TSS response rate was similar across doses (100 mg once per day, 7.7%; 100 mg twice per day, 7.3%; 200 mg twice per day, 7.4%), median percent reduction in TSS suggested a dose-response relationship (-3%, -16%, and -27%, respectively). Pharmacokinetic and pharmacodynamic modeling based on all available data showed greatest SVR and TSS reduction at 200 mg twice per day compared with lower doses. Common adverse events were gastrointestinal events, thrombocytopenia, and anemia. There was no excess of grade ≥3 hemorrhagic or cardiac events at 200 mg twice per day. Pacritinib 200 mg twice per day demonstrated clinical activity and an acceptable safety profile and was selected as the recommended dose for a pivotal phase 3 study in patients with myelofibrosis and severe thrombocytopenia. This trial was registered at www.clinicaltrials.gov as #NCT03165734.

Synthesis of a Vocal Sound from the 3,000 year old Mummy, Nesyamun 'True of Voice'

The sound of a 3,000 year old mummified individual has been accurately reproduced as a vowel-like sound based on measurements of the precise dimensions of his extant vocal tract following Computed Tomography (CT) scanning, enabling the creation of a 3-D printed vocal tract. By using the Vocal Tract Organ, which provides a user-controllable artificial larynx sound source, a vowel sound is synthesised which compares favourably with vowels of modern individuals.

A comparison of patients with acute myeloid leukemia and high-risk myelodysplastic syndrome treated on versus off study

Patients with newly diagnosed (ND) and relapsed/refractory (RR) acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS, ≥10% blasts) often receive intensive chemotherapy at diagnosis and relapse. We retrospectively identified 365 patients and categorized the reasons for receiving treatment off study (medical, logistical, or unclear). The pretreatment characteristics of the on and off study groups were similar. Rates of the complete remission (CR) without measurable residual disease were significantly higher for ND patients treated on versus off study (61% versus 35%), but CR rates and survival were low for all RR patients regardless of study assignment. The subset of ND patients treated off study for medical reasons had significantly decreased overall survival and relapse-free survival. Standard, stringent study eligibility criteria may delineate a population of ND, but not RR, patients with improved outcomes with intensive induction chemotherapy.

Ibopamine: A New Preoperative Mydriatic for Cataract Surgery

Ibopamine is a dopaminergic mydriatic of proven use for fundoscopy. This double-blind prospective trial assessed its efficacy and safety as a preoperative mydriatic agent. 105 patients undergoing extracapsular cataract surgery were randomly allocated to receive Ibopamine 1%, Ibopamine 1% with Cyclopentolate 1%, or the control Phenylephrine 10% with Cyclopentolate 1%. Ibopamine alone achieved good mydriasis prior to anaesthesia, but this was not maintained intraoperatively. Cyclopentolate combined with Ibopamine, produced consistently greater mydriasis than when combined with Phenylephrine, but the difference became less marked as surgery continued. Analysis in relation to the stage of surgery showed that the greatest stimulus to miosis occurred during expression of the nucleus. Pulse rate and blood pressure in the 51 local anaesthetic cases showed no significant difference between the treatment groups, and there was no significant variation from baseline. The incidence of local side effects was similar in the three groups, and there were no systemic symptoms attributable to the drops. In conclusion, Ibopamine is a safe and effective mydriatic agent for cataract surgery, when used in combination with Cyclopentolate.

Successful Treatment of Cannabinoid Hyperemesis Syndrome with Topical Capsaicin

Cannabinoid hyperemesis syndrome (CHS) is a clinical entity in which marijuana users develop nausea, vomiting, and abdominal pain that improves with hot water bathing or cannabis cessation. Previous models suggest that CHS arises solely from the derangement of cannabinoid receptor type 1 signaling. However, involvement of transient receptor potential vanilloid subtype 1 (TRPV1) receptor, which is activated by marijuana, capsaicin, and heat, could fill gaps in existing models, including the enigmatic role of hot water bathing. We propose that chronic cannabis use decreases TRPV1 signaling and alters gastric motility, and we report the case of a CHS patient whose symptoms improved after topical capsaicin.

Quality of life from the perspective of the patient with acute myeloid leukemia

BACKGROUND

Although outcomes for acute myeloid leukemia (AML) have improved over time, they remain poor overall, and toxicity from both the disease and its treatment can affect quality of life (QOL). One barrier to including QOL endpoints in clinical trials is the lack of a disease-specific QOL instrument that can efficiently capture the major QOL deficits in this population.

METHODS

A cross-sectional study was performed to elicit concepts for inclusion in a new AML-specific QOL instrument called the AML-QOL. Eighty-two patients at various stages of disease were interviewed about sources of support (positive concepts) and problems and symptoms (negative concepts) experienced over the past week, and they were asked to grade how much each affected their QOL. In addition, patients were asked to complete 2 validated instruments: the Functional Assessment of Cancer Therapy with the leukemia and transplant modules and the 29-item Patient-Reported Outcomes Measurement Information System questionnaire.

RESULTS

With data from the open-ended and questionnaire-based portions of the interview, 7 positive concepts and 64 negative concepts were elicited. From these, 5 positive concepts and 21 negative concepts were selected for inclusion in the preliminary AML-QOL on the basis of concept prevalence and the impact on QOL.

CONCLUSIONS

These concepts will form the basis of a new QOL instrument specific to AML. Cancer 2018;124:145-52. © 2017 American Cancer Society.

Patient-reported outcomes in acute myeloid leukemia: Where are we now?

Outcomes for acute myeloid leukemia remain poor, and treatment decisions must consider not just quantity, but also quality of life (QOL). We conducted a systematic review of studies in patients with acute myeloid leukemia or high-risk myelodysplastic syndrome that incorporated patient-reported outcome (PRO) measures. PubMed and PsycINFO were searched for articles published from January 2000 through June 2016. Forty-one were relevant for our review with more published in recent years. There was considerable inter-study heterogeneity in which instruments were used, and many studies employed multiple (often overlapping) instruments. Longitudinal studies in particular suffered from both high attrition rates due to disease-related mortality as well as waning compliance with questionnaire completion. There remain significant challenges to incorporation of PROs into leukemia trials. Despite these limitations, however, well-implemented PROs can provide important information beyond objective response outcomes and highlight areas of focus for clinicians caring for patients and for future research endeavors.

Mitoxantrone, etoposide and cytarabine following epigenetic priming with decitabine in adults with relapsed/refractory acute myeloid leukemia or other high-grade myeloid neoplasms: a phase 1/2 study

DNA methyltransferase inhibitors sensitize leukemia cells to chemotherapeutics. We therefore conducted a phase 1/2 study of mitoxantrone, etoposide, and cytarabine following “priming” with 5-10 days of decitabine (dec/MEC) in 52 adults (median age 55 [range: 19-72] years) with relapsed/refractory acute myeloid leukemia (AML) or other high-grade myeloid neoplasms. During dose escalation in cohorts of 6-12 patients, all dose levels were well-tolerated. As response rates appeared similar with 7 and 10-days of decitabine, a 7-day course was defined as the recommended phase 2 dose (RP2D). Among 46 patients treated at/above the RP2D, 10 (22%) achieved a complete remission (CR), 8 without measurable residual disease; five additional patients achieved CR with incomplete platelet recovery, for an overall response rate of 33%. Seven patients (15%) died within 28 days of treatment initiation. Infection/neutropenic fever, nausea, and mucositis were the most common adverse events. While the CR rate compared favorably to a matched historic control population (observed/expected CR ratio=1.77), CR rate and survival were similar to two contemporary salvage regimens used at our institution (G-CLAC and G-CLAM). Thus, while meeting the pre-specified efficacy goal, we found no evidence that dec/MEC is substantially better than other cytarabine-based regimens currently used for relapsed/refractory AML.

Determinants of quality of life in patients with acute myeloid leukemia

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Background: There is growing interest in quantifying quality of life (QOL) effects of acute myeloid leukemia (AML) therapy. As there are no AML-specific QOL instruments available, we conducted a cross-sectional study to elicit concepts for the development of such an instrument, the AML-QOL. Methods: Adults with AML at various time points during the course of participated in an open-ended interview and completed the FACT-G, -LEU, -BMT and the PROMIS-29 questionnaires in order to elicit concepts impacting QOL. In addition, patients were asked to quantify the degree to which each impacted their QOL on a 3-point scale (little, some, large impact). Positive concepts (i.e., sources of support) were included in the AML-QOL based on prevalence; negative concepts were included based on both prevalence and the percent of cases in which the concept had high impact on QOL. Results: Among 82 patients, commonly described positive concepts were family support (85%), maintaining a positive attitude (63%), friends or community (52%), and trust in the medical team (52%). Negative concepts with the highest prevalence and impact product are shown in the Table. After completing FACT and PROMIS, 22% of patients reported confusion with items querying functional status because of ambiguity between temporary functional restrictions (e.g., inability because of an inpatient stay) and functional limitations (e.g., inability due to weakness). Conclusions: Our interviews identified concepts most important to patients during AML therapy and allowed development of a 40-item survey that is now undergoing validation. [Table: see text]

Minimal residual disease prior to allogeneic hematopoietic cell transplantation in acute myeloid leukemia: a meta-analysis

Minimal residual disease prior to allogeneic hematopoietic cell transplantation has been associated with increased risk of relapse and death in patients with acute myeloid leukemia, but detection methodologies and results vary widely. We performed a systematic review and meta-analysis evaluating the prognostic role of minimal residual disease detected by polymerase chain reaction or multiparametric flow cytometry before transplant. We identified 19 articles published between January 2005 and June 2016 and extracted hazard ratios for leukemia-free survival, overall survival, and cumulative incidences of relapse and non-relapse mortality. Pre-transplant minimal residual disease was associated with worse leukemia-free survival (hazard ratio=2.76 [1.90-4.00]), overall survival (hazard ratio=2.36 [1.73-3.22]), and cumulative incidence of relapse (hazard ratio=3.65 [2.53-5.27]), but not non-relapse mortality (hazard ratio=1.12 [0.81-1.55]). These associations held regardless of detection method, conditioning intensity, and patient age. Adverse cytogenetics was not an independent risk factor for death or relapse. There was more heterogeneity among studies using flow cytometry-based than WT1 polymerase chain reaction-based detection (I²=75.1% vs. <0.1% for leukemia-free survival, 67.8% vs. <0.1% for overall survival, and 22.1% vs. <0.1% for cumulative incidence of relapse). These results demonstrate a strong relationship between pre-transplant minimal residual disease and post-transplant relapse and survival. Outcome heterogeneity among studies using flow-based methods may underscore site-specific methodological differences or differences in test performance and interpretation.

Lymphomatoid granulomatosis associated with azathioprine use for immune-mediated neuropathy

Lymphomatoid granulomatosis (LG) is a rare Epstein-Barr virus-driven lymphoproliferative disorder that generally arises in immunosuppressed patients and which can be life-threatening. Here we describe the development of pulmonary LG in a patient on long-term azathioprine for immune-mediated neuropathy. Although azathioprine carries a boxed warning for malignancy, its association specifically with LG, an otherwise rare entity, is poorly recognised. Early recognition of drug-induced LG is critical, since discontinuation of the offending agent, and implementation of effective therapy can provide rapid clinical benefit in some patients. In this case, rituximab was used as an effective treatment for LG, which also provided an additional benefit of controlling the patient's underlying neuropathy. Further research is needed to identify vulnerable patients who are at high risk of developing drug-induced LG.

Outpatient care of patients with acute myeloid leukemia: Benefits, barriers, and future considerations

Patients with acute myeloid leukemia (AML) who receive intensive induction or re-induction chemotherapy with curative intent typically experience prolonged cytopenias upon completion of treatment. Due to concerns regarding infection and bleeding risk as well as significant transfusion and supportive care requirements, patients have historically remained in the hospital until blood count recovery-a period of approximately 30 days. The rising cost of AML care has prompted physicians to reconsider this practice, and a number of small studies have suggested the safety and feasibility of providing outpatient supportive care to patients following intensive AML (re-) induction therapy. Potential benefits include a significant reduction of healthcare costs, improvement in quality of life, and decreased risk of hospital-acquired infections. In this article, we will review the currently available literature regarding this practice and discuss questions to be addressed in future studies. In addition, we will consider some of the barriers that must be overcome by institutions interested in implementing an "early discharge" policy. While outpatient management of selected AML patients appears safe, careful planning is required in order to provide the necessary support, education and rapid management of serious complications that occur among this very vulnerable patient population.

Update on antigen-specific immunotherapy of acute myeloid leukemia

Among the few drugs that have shown a benefit for patients with acute myeloid leukemia (AML) in randomized clinical trials over the last several decades is the CD33 antibody-drug conjugate, gemtuzumab ozogamicin (GO). Undoubtedly, this experience has highlighted the value of antigen-specific immunotherapy in AML. A wide variety of therapeutics directed against several different antigens on AML cells are currently explored in preclinical and early clinical studies. On the one hand, these include passive strategies such as unconjugated antibodies targeting one or more antigens, antibodies armed with drugs, toxic proteins, or radionuclides, or adoptive immunotherapies, in particular utilizing T cells engineered to express chimeric antigen receptors (CARs) or modified T cell receptor (TCR) genes; on the other hand, these include active strategies such as vaccinations. With the documented benefit for GO and the emerging data with several classes of therapeutics in other leukemias, in particular small bispecific antibodies and CAR T cells, the future is bright. Nevertheless, a number of important questions related to the choice of target antigen(s), patient population, exact treatment modality, and supportive care needs remain open. Addressing such questions in upcoming studies will ultimately be required to optimize the clinical use of antigen-specific immunotherapies in AML and ensure that such treatments become an effective, versatile tool for this disease for which the outcomes have remained unsatisfactory in many patients.

A phase I/II study of oral clofarabine plus low-dose cytarabine in previously treated acute myeloid leukaemia and high-risk myelodysplastic syndrome patients at least 60 years of age

Outcomes for older adults with acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS) are generally poor, and new effective therapies are needed. We investigated oral clofarabine combined with low-dose cytarabine (LDAC) in patients aged 60 years and above with relapsed or refractory AML or high-risk MDS in a phase I/II trial. A 3 + 3 dose escalation of oral clofarabine was followed by a phase II expansion with the aim of obtaining a complete response (CR) rate ≥30%. We identified 20 mg/d for 5 d as the maximum tolerated dose (MTD) of oral clofarabine. A total of 35 patients, with a median age of 72 years, were treated. Of 26 patients enrolled at the MTD, 4 had treatment-related grade 3-4 non-haematological toxicities, but none died within 28 d. The observed CR rate and median survival were 34% [95% confidence interval (CI), 18-50%] and 6.8 months overall and 38% [95% CI, 19-57%] and 7.2 months at the MTD. The median disease-free survival was 7.4 months. Fifty-two percent (23/44) of cycles administered at the MTD were done without hospital admission. This combination of oral clofarabine and LDAC demonstrated efficacy with a CR rate of >30% and acceptable toxicity in older patients.

Antigen-specific immunotherapies for acute myeloid leukemia

Antigen-specific immunotherapies have emerged as important components of curative treatment algorithms for many cancers. In acute myeloid leukemia (AML), success has been less obvious. Nonetheless, among the few drugs shown to improve survival in recent randomized trials is the CD33 antibody-drug conjugate gemtuzumab ozogamicin. Significant antileukemic activity is also well documented for radioimmunoconjugates targeting CD33, CD45, or CD66. These therapeutics can intensify conditioning before hematopoietic cell transplantation, but their effect on patient outcomes needs clarification. Emerging data now suggest clinical antileukemic activity of several novel antibodies and perhaps some adoptive T-cell immunotherapies and vaccines. In parallel, numerous other agents targeting a wider variety of antigens are currently being explored. However, the antigenic heterogeneity characteristic of AML is a considerable limitation for all these therapeutics, and many important questions related to the ideal target antigen(s), disease situation in which to use these therapies, most suitable patient populations, exact treatment modalities, and details of supportive care needs remain open. Addressing such questions in upcoming studies will be required to ensure that antigen-directed therapies become an effective tool in AML, a disease for which outcomes with standard "3 + 7"-based chemotherapy have remained unsatisfactory in many patients.

Comparison of minimal residual disease as outcome predictor for AML patients in first complete remission undergoing myeloablative or nonmyeloablative allogeneic hematopoietic cell transplantation

Minimal residual disease (MRD) is associated with adverse outcome in AML after myeloablative (MA) hematopoietic cell transplantation (HCT). We compared this association with that seen after nonmyeloablative (NMA) conditioning in 241 adults receiving NMA (n=86) or MA (n=155) HCT for AML in first remission with pre-HCT bone marrow aspirates assessed by flow cytometry. NMA patients were older and had more comorbidities and secondary leukemias. Three-year relapse estimates were 28% and 57% for MRD^neg and MRD^pos NMA patients, and 22% and 63% for MA patients. Three-year overall survival (OS) estimates were 48% and 41% for MRD^neg and MRD^pos NMA patients and 76% and 25% for MA patients. This similar OS after NMA conditioning was largely accounted for by higher non-relapse mortality (NRM) in MRD^neg (30%) compared to MRD^pos (10%) patients, whereas the reverse was found for MRD^neg (7%) and MRD^pos (23%) MA patients. A statistically significant difference between MA and NMA patients in the association of MRD with OS (P<0.001) and NRM (P=0.002) but not relapse (P=0.17) was confirmed. After adjustment, the risk of relapse was 4.51-times (P<0.001) higher for MRD^pos patients. These data indicate that the negative impact of MRD on relapse risk is similar after NMA and MA conditioning.

Prediction of adverse events during intensive induction chemotherapy for acute myeloid leukemia or high-grade myelodysplastic syndromes

Intensive chemotherapy for newly diagnosed acute myeloid leukemia (AML) or myelodysplastic syndromes (MDS) is associated with significant treatment-related morbidity and mortality. Herein, we investigate how pretreatment characteristics relate to early adverse outcomes in such patients, studying 205 consecutive individuals receiving curative-intent induction chemotherapy with cytarabine and an anthracycline ("7 + 3"; n = 175) or a "7 + 3"-like regimen (n = 30). Among the entire cohort, baseline grade 4 neutropenia (i.e., absolute neutrophil count <500 cells/µL) was associated with development of fever (P = 0.04), documented infection (P < 0.0001), and bacteremia (P = 0.002) but not requirement for intensive care unit-level care; after exclusion of the 30 patients who received "7 + 3"-like induction, baseline grade 4 neutropenia remained associated with documented infection (P < 0.0001) and bacteremia (P = 0.0005). Among patients achieving a complete remission with the initial treatment cycle, grade 4 neutropenia was associated with delayed neutrophil count recovery (P < 0.0001). Low monocyte and lymphocyte counts at baseline were similarly associated with increased risk of documented infection or bacteremia. After adjustment for age, gender, disease type, cytogenetic/molecular risk, and performance status, the risk of fever, documented infection, or bacteremia was 1.87 (95% confidence interval: 1.04-3.34; P=0.04)-fold, 4.95 (2.20-11.16; P<0.001)-fold, and 3.14 (0.99-9.98; P=0.05)-fold higher in patients with initial grade 4 neutropenia. Together, our studies identify severe baseline neutropenia as a risk factor for infection-associated adverse events after induction chemotherapy and may provide the rationale for the risk-adapted testing of myeloid growth factor support in this high-risk AML/MDS patient subset.

Height as an explanatory factor for sex differences in human cancer

BACKGROUND

Most cancers occur more frequently in men. Numerous explanations for this excess risk have been proposed, yet no study has quantified the degree to which height explains the sex difference even though greater height has been associated with increased risk for many cancers.

METHODS

During the period from 2000 to 2002, 65308 volunteers aged 50 to 76 years were recruited to the Vitamins And Lifestyle (VITAL) study. Cancers of shared anatomic sites (n = 3466) were prospectively identified through 2009 through the Surveillance, Epidemiology, and End Results cancer registry. Age- and race-adjusted hazard ratios (HRs) for the associations between sex and incident cancers were estimated using Cox proportional hazards models, with and without adjustment for height and height squared as measures of body size.

RESULTS

Men had a 55% increased risk of cancer at shared sites (HR = 1.55; 95% confidence interval [CI] = 1.45 to 1.66). When height was accounted for, 33.8% (95% CI = 10.2% to 57.3%) of the excess risk for men was explained by the height differences between sexes. The proportion mediated by height was 90.9%, 57.3%, and 49.6% for kidney, melanoma, and hematologic malignancies, respectively, with little evidence that height mediates the sex difference for gastrointestinal tract, lung, and bladder cancers. For comparison, more than 35 lifestyle and medical risk factors only explained 23.1% of the sex difference in cancer risk at shared sites.

CONCLUSIONS

Height is an important explanatory factor for the excess risk for men for many shared-site cancers. This suggests that some of the excess risk is due to factors associated with height (eg, number of susceptible cells in a specific organ or growth-influencing exposures in childhood).

Regular recreational physical activity and risk of hematologic malignancies: results from the prospective VITamins And lifestyle (VITAL) study

BACKGROUND

Conflicting evidence exists on the relationship between physical activity (PA) and incident hematologic malignancies. Herein, we used a large cohort study to examine this association.

PATIENTS AND METHODS

Sixty-five thousand three hundred twenty-two volunteers aged 50-76 years were recruited from 2000 to 2002. Incident hematologic malignancies (n = 666) were identified through 2009 by linkage to the Surveillance, Epidemiology, and End Results cancer registry. Hazard ratios (HRs) for hematologic malignancies associated with PA averaged over 10 years before baseline were estimated with Cox proportional hazards models, adjusting for factors associated with hematologic cancers or PA.

RESULTS

There was a decreased risk of hematologic malignancies associated with PA (HR = 0.66 [95% confidence interval, 95% CI 0.51-0.86] for the highest tertile of all PA, P-trend = 0.005, and HR = 0.60 [95% CI 0.44-0.82] for the highest tertile of moderate/high-intensity PA, P-trend = 0.002). These associations were strongest for myeloid neoplasms (HR = 0.48 [95% CI 0.29-0.79] for the highest tertile of all PA, P-trend = 0.013, and HR = 0.40 [95% CI 0.21-0.77] for the highest tertile of moderate/high-intensity PA, P-trend = 0.016). There were also significant associations between PA and chronic lymphocytic leukemia/small lymphocytic lymphoma or other mature B-cell lymphomas except plasma cell disorders.

CONCLUSIONS

Our study offers the strongest epidemiological evidence, to date, to suggest an association between regular PA and dose-dependent risk reduction for most hematologic malignancies, particularly myeloid neoplasms.

The impact of interventions on provider and treatment delays in head and neck cancer patients

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Background: Diagnosis and management of squamous cell carcinoma of head and neck (SCCHN) involves a multidisciplinary approach. Navigation at a public hospital can be difficult and lead to delays. In a previous study, we reported English-speaking and employed patients having longer provider delays (Lai 2011). In July 2010, we instituted the use of patient navigators, bimonthly management conferences, and improved inter-disciplinary communication in order to improve the patient experience. Aims: 1. Study differences in “provider delay” (time between first contact with health care provider and positive biopsy) between patients in cohort A (diagnosed between 1/2007 and 6/2010) and cohort “B” (diagnosed between 7/2010 and 6/ 2011). 2. Study differences in “treatment delay” (time between biopsy and initiation of treatment) between the two cohorts. 3. Determine what factors influence delays in both cohorts. Methods: The delays of the two cohorts were compared using the student t-test. Independent t-test and chi-square tests were used to examine associations between delays and the following characteristics: language, employment, presence of partner, gender, ethnicity, age, cancer sub-site, staging, number of co-morbidities, tobacco use, and alcohol use. The likelihood ratio test was used for multivariate analysis. Results: 133 patients in cohort A and 20 patients in cohort B were evaluable. Both provider and treatment delays in cohort B (50.5 and 39.3 days, respectively) were shorter than cohort A (60.2 and 41.6 days), but this was not statistically significant. The standard deviations of both delays were lower in cohort B, pointing towards a greater consistency in this group. In cohort A, provider delay was significantly shorter (p-value=0.003) for non-English speakers than English speakers on univariate and multivariate analysis. Other trends were not observed. Conclusions: Simple interventions can reduce provider and treatment delays. Our observations suggest that these interventions can mitigate the effect of patient factors on provider and treatment delay. However, our results may be affected by small sample size and demographic shifts. With time, we will accrue more patients to address these issues.

Effect of oral sodium chlorate administration on Escherichia coli O157:H7 in the gut of experimentally infected pigs

Strategies are sought to reduce pathogenic Escherichia coli concentrations in food animals. Because E. coli possess respiratory nitrate reductase activity, which also reduces chlorate to cytotoxic chlorite, we tested and found that oral sodium chlorate administration reduced gut concentrations of E. coli O157:H7 in experimentally infected pigs and wildtype E. coli concentrations in nonchallenged pigs. Mean +/- S.E. concentrations (log10 CFU/g) of E. coli O157:H7 in ileal, cecal, colonic and rectal contents from placebo-treated pigs were 4.03 +/- 0.66, 3.82 +/- 0.24, 4.42 +/- 0.25 and 4.03 +/- 0.16, respectively. In contrast, E. coli O157:H7 concentrations were reduced (P < 0.05) in ileal (1.56 +/- 0.22) cecal (2.65 +/- 0.38), colonic (3.05 +/- 0.38) and rectal (3.00 +/- 0.29) contents from pigs orally administered three successive (8 h apart) 10-ml doses of 100 mM chlorate. Wildtype E. coli concentrations in gut contents of non-E. coli O157:H7-challenged pigs likewise treated with chlorate were reduced by 1.1 to 4.5 log10 units compared to concentrations in placebo-treated pigs, which exceeded 6.0 log10 CFU/g. As before, the reductions were greater in anterior regions of the gut than regions more caudal. Similar treatment of E. coli O157:H7-challenged pigs with 200 mM chlorate caused reductions in gut concentrations of E. coli O157:H7; however, the reductions were not necessarily greater than those achieved with the 100 mM chlorate treatment.

Organic chemistry of embalming agents in Pharaonic and Graeco-Roman mummies

Chemical treatments were an essential element of ancient Egyptian mummification. Although the inorganic salt natron is recognized as having a central role as a desiccant, without the application of organic preservatives the bodies would have decomposed in the humid environment of the tombs. The nature of the organic treatments remains obscure, because the ancient Egyptians left no written record of the process. Secondary textual evidence for mummification is provided by Herodotus, Diodorus Siculus, Strabo and Pliny. The most important account is that of Herodotus (about 450 yr bc), although archaeological evidence shows that by this time the process had declined significantly and the best results had been achieved centuries before. His account mentions myrrh, cassia, palm wine, 'cedar oil' (still widely disputed) and 'gum'; however, it is vague with respect to the specific natural products used. Here we report the results of chemical investigations of a substantial collection of samples of tissues, wrappings and 'resinous/bituminous' materials from provenanced and dated Egyptian mummies. We focused on examples of the 'classic' mummy-making culture of the Pharaonic or dynastic period, from which we can begin to track the development of mummification chronologically.

Prevalence of antimicrobial resistance in Salmonellae isolated from market-age swine

Antimicrobial resistance levels were examined for 365 Salmonella isolates recovered from the lymph nodes (n = 224) and cecal contents (n = 141) of market-age swine at slaughter. Antimicrobial resistance testing was performed by disk diffusion using 13 antibiotics common in the treatment of disease in human and veterinary medicine. Although none of the antibiotics tested were used subtherapeutically within the last 5 years on the farms sampled, resistance to chlortetracycline, penicillin G, streptomycin, and sulfisoxazole was common. Penicillin G resistance was significantly more frequent (P = 0.03) and sulfisoxazole resistance was significantly less frequent (P < 0.01) in lymph node versus cecal isolates. Multidrug resistance was observed among 94.7% of the lymph node isolates and 93.5% of the cecal isolates. The most frequent multidrug resistance pattern included three antibiotics-penicillin G, streptomycin, and chlortetracycline. Isolates in somatic serogroup B, and more specifically, Salmonella Agona and Salmonella Schwarzengrund isolates, were often resistant to a greater number of antibiotics than were isolates in the other serogroups. Streptomycin, sulfisoxazole, ampicillin (lymph node isolates), and nitrofurantoin (cecal isolates) resistance levels differed significantly between somatic serogroups. The prevalence of penicillin G-, streptomycin-, and sulfisoxazole-resistant isolates differed significantly between serovars for both lymph node and cecal isolates. Results of this study suggest that a correlation exists between the somatic serogroup or serovar of a Salmonella isolate and its antimicrobial resistance status, which is specific to the antibiotic of interest and the source of the isolate (lymph node versus cecal contents).

Determination of fluoroquinolones in serum using an on-line clean-up column coupled to high-performance immunoaffinity-reversed-phase liquid chromatography

A simple, rapid and reliable method for the simultaneous analysis of the fluoroquinolones ciprofloxacin, enrofloxacin, sarafloxacin, and difloxacin in bovine serum has been developed. Upon injection of serum samples, an on-line protein G-linked column was employed to automatically remove serum components that otherwise would interfere with analyses. A high-performance immunoaffinity chromatography (HPIAC) column containing covalently bound anti-sarafloxacin antibodies was then used to capture the fluoroquinolones while allowing the remainder of the serum components to elute to waste. After binding to the HPIAC column, the fluoroquinolones were eluted directly onto a reversed-phase (RP) column for final separation of the compounds prior to fluorescence detection at excitation and emission wavelengths of 280 and 444 nm, respectively. Due to use of a clean-up column in tandem with a highly selective HPIAC column, the only off-line sample preparation required was dilution (10-fold) in phosphate buffered saline (PBS) and passage of the samples through a 0.2-microm filter to remove particulate matter prior to injection. No significant interferences from the sample matrix were observed, indicating good selectivity with the HPIAC column. The method yielded high recoveries from fortified bovine serum that were >95% for all four fluoroquinolones with good reproducibility (C.V. values <7.0%). The on-line, automated method described here provides a simple, sensitive and specific assay for multiresidue detection of fluoroquinolones in serum.

Effect of sodium chlorate on Salmonella typhimurium concentrations in the weaned pig gut

Salmonella cause economic losses to the swine industry due to disease and compromised food safety. Since the gut is a major reservoir for Salmonella, strategies are sought to reduce their concentration in pigs immediately before processing. Respiratory nitrate reductase activity possessed by Salmonella also catalyzes the intracellular reduction of chlorate (an analog of nitrate) to chlorite, which is lethal to the microbe. Since most gastrointestinal anaerobes lack respiratory nitrate reductase, we conducted a study to determine if chlorate may selectively kill Salmonella within the pig gut. Weaned pigs orally infected with 8 x 10(7) CFU of a novobiocin- and nalidixic acid-resistant strain of Salmonella Typhimurium were treated 8 and 16 h later via oral gavage (10 ml) with 0 or 100 mM sodium chlorate. Pigs were euthanized at 8-h intervals after receiving the last treatment. Samples collected by necropsy were cultured qualitatively and quantitatively for Salmonella and for most probable numbers of total culturable anaerobes. A significant (P < 0.05) chlorate treatment effect was observed on cecal concentrations of Salmonella, with the largest reductions occurring 16 h after receiving the last chlorate treatment. An observed treatment by time after treatment interaction suggests the chlorate effect was concentration dependent. Chlorate treatment may provide a means to reduce foodborne pathogens immediately before harvest.

Inhibition of in vitro Salmonella Typhimurium colonization in porcine cecal bacteria continuous-flow competitive exclusion culturest

Continuous-flow (CF) chemostate cultures were used as models to determine the potential usefulness of undefined porcine cecal bacteria as competitive exclusion (CE) cultures against colonization by Salmonella Typhimurium. One culture, pCF1, was derived from cecal bacteria of an animal maintained on antibiotic-free feed, while the other culture, pCF4, was derived from cecal bacteria of an animal maintained on feed containing chlortetracycline. The effectiveness against a chlortetracycline-resistant Salmonella Typhimurium was examined in CF cultures maintained in the absence (pCF1 and pCF4) and presence (cpCFl and cpCF4) of chlortetracycline. CF cultures were inoculated with each of 10(2), 10(4), and 10(6) Salmonella Typhimurium CFU/ml. Chemostat inocula of 10(2) Salmonella CFU/ml resulted in no Salmonella Typhimurium being detected at 2 and 3 days postinoculation in pCF1 and pCF4, respectively, and after 2 days in both cpCF1 and cpCF4. Inoculations of 10(4) Salmonella Typhimurium CFU/ml resulted in clearance from pCF1 and pCF4 within 4 days and within 3 days from cpCF1 and cpCF4. Following inoculation with 10(6) CFU/ml, no Salmonella Typhimurium were detected in all CF cultures by 6 days postinoculation. The results indicated that in vitro CF cultures of porcine cecal bacteria were able to inhibit the growth of Salmonella Typhimurium. The ability to limit Salmonella Typhimurium growth was not restricted by prior exposure of the cecal bacteria to the feed additive chlortetracycline. The present study demonstrates the potential application of CF cultures as models to aid in the identification of CE cultures against salmonellosis in pigs.

Bactericidal effect of sodium chlorate on Escherichia coli O157:H7 and Salmonella typhimurium DT104 in rumen contents in vitro

Escherichia coli O157:H7 and Salmonella Typhimurium DT104 are important foodborne pathogens affecting the beef and dairy industries and strategies are sought to rid these organisms from cattle at slaughter. Both pathogens possess respiratory nitrate reductase that also reduces chlorate to the lethal chlorite ion. Because most anaerobes lack respiratory nitrate reductase, we hypothesized that chlorate may selectively kill E. coli O157:H7 and Salmonella Typhimurium DT104 but not potentially beneficial anaerobes. In support of this hypothesis, we found that concentrations of E. coli O157:H7 and Salmonella Typhimurium DT104 were reduced from approximately 1,000,000 colony forming units (CFU) to below our level of detection (< or = 10 CFU) following in vitro incubation (24 h) in buffered ruminal contents (pH 6.8) containing 5 mM added chlorate. In contrast, chlorate had little effect on the most probable number (mean +/- SD) of total culturable anaerobes (ranging from 9.9 +/- 0.72 to 10.7 +/- 0.01 log10 cells/ml). Thus, chlorate was bactericidal to E. coli O157:H7 and Salmonella Typhimurium DT104 but not to potentially beneficial bacteria. The bactericidal effect of chlorate was concentration dependent (less at 1.25 mM) and markedly affected by pH (more bactericidal at pH 6.8 than pH 5.6).

A preliminary survey of antibiotic resistance of Salmonella in market-age swine

We conducted an epidemiological survey of antibiotic resistance in Salmonella recovered from market-age swine at five different Texas farms. These farms, which were visited between October 1997 and June 1998, were completely integrated, farrow-to-finish operations. Samples were taken from the lymph nodes and cecal contents at the time of slaughter. The Salmonella samples that were recovered were sent to the National Veterinary Services Laboratory for serotyping. Antibiotic resistance was determined using the Dispens-O-Disc Susceptibility Test System using 13 different antimicrobial agents that have been utilized in either veterinary medicine, human medicine, or both. Preliminary analysis of the first 183 samples out of approximately 400 Salmonella samples recovered indicated that 183 (100%) of the Salmonella samples were resistant to penicillin G, and 122 (66.7%) were resistent to chlortetracycline. Six (3.3%) were resistant to four antibiotics (chlortetracycline, penicillin G, streptomycin, and sulfisoxazole), and 25 (13.7%) were resistant to three antibiotics (chlortetracycline, penicillin G, and either streptomycin, sulfisoxazole, or ampicillin). Variation was seen between serotypes, with four out of five S. agona samples (80.0%) and two out of eight S. derby samples (25.0%) resistant to four antibiotics. Variation in antibiotic resistance also was seen between farms. There is an increasing concern about the prevalent usage of antibiotics in medicine and agriculture and the relationship this may have on emerging microbial resistance patterns; therefore, continued surveillance on antibiotic resistance in animal production is warranted.

Development of a monoclonal antibody-based cELISA for the analysis of sulfadimethoxine. 2. Evaluation of rapid extraction methods and implications for the analysis of incurred residues in chicken liver tissue

Several rapid extraction methods were evaluated for use with a monoclonal antibody-based competitive inhibition ELISA (cELISA) to detect sulfadimethoxine (SDM) in chicken liver tissue. These methods included extraction of the samples with (1) aqueous buffer with or without ultrafiltration, (2) acetonitrile/water, (3) methanol/water, or (4) acetone. The organic extraction methods were evaluated with or without solvent evaporation prior to dilution into assay buffer for the cELISA. The aqueous-based extraction methods were compatible with the cELISA. However, of the organic extraction methods, only the acetone liver extract with solvent evaporation prior to analysis was compatible with the cELISA. The cELISA method coupled to aqueous- or acetone-based sample extraction as well as an HPLC method was evaluated for the analysis of chicken liver tissues fortified with SDM at levels from 0.2 to 0.025 ppm. Mean SDM recoveries for the HPLC method and for the cELISA method using samples prepared by aqueous extraction, aqueous extraction and ultrafiltration, or acetone extraction, evaporation, and reconstitution were 68.9, 95.7, 60.1, and 52.5%, respectively. For the analysis of samples obtained from an SDM incurred residue study, HPLC and cELISA analysis of the same organic extract gave results that were highly correlated (R(2) = 0.976; p < 0.0001). However, results obtained from the analysis of aqueous extracts by cELISA did not correlate well with those obtained by HPLC (R(2) = 0.61, p > 0. 0006). This was attributed to the coextraction of cross-reactive SDM-related residues that were not quantified by the HPLC method. The presence of these residues should be considered during data interpretation when ELISA methods coupled with rapid aqueous extraction of samples are used in SDM residue monitoring programs.

Effects of long-term feeding of diets containing moniliformin, supplied by Fusarium fujikuroi culture material, and fumonisin, supplied by Fusarium moniliforme culture material, to laying hens

Beginning at 24 wk of age, control diets or diets containing 50 or 100 mg/kg moniliformin (M), 100 or 200 mg/kg fumonisin B1 (FB1), or a combination of 50 mg M and 100 mg FB1/kg of diet were fed to White Leghorn laying hens for 420 d. The hens were then fed the control diet for an additional 60 d. At the beginning of the experiment, each treatment consisted of four replicates of six hens. Egg production was reduced by approximately 50% by the end of the second 28-d laying period and remained at approximately this level for the 420 d in only the hens fed the diet containing 100 mg M/kg feed. Production returned to control levels or above within 60 d after hens were fed the control diet. Egg weights were reduced by the 100-mg M diet during the first three 28-d laying periods before returning to weights comparable with controls. The hens in this group also had significantly lower body weights than the other treatments. Mortality was minimal except in hens fed the 100 mg M/kg diet and the 100 mg FB1/kg diet, on which approximately 20% of the hens died. The hens were artificially inseminated with semen from males fed control diets, and fertility was not affected by the dietary treatments. Importantly, toxic synergy between M and FB1 was not observed for any of the parameters measured. Results indicate that laying hens may be able to tolerate relatively high concentrations of M and FB1 for long periods of time without adversely affecting health and performance. Interestingly, hens fed the 100-mg M/kg diet were able to recover when returned to control diets. The likelihood of encountering M or FB1 at these concentrations in finished feed is small.

Immunosorbents coupled on-line with liquid chromatography for the determination of fluoroquinolones in chicken liver

Four fluoroquinolones were analyzed in fortified chicken liver using an automated, on-line immunoaffinity extraction method. The fluoroquinolones were extracted from the liver matrix using an immunoaffinity capture column containing anti-sarafloxacin antibodies covalently cross-linked to protein G. After interfering liver matrix components had been washed away, the captured fluoroquinolones were automatically eluted directly onto a reversed phase column. Liquid chromatographic analyses were performed by isocratic elution using 2% acetic acid/acetonitrile (85:15) as the mobile phase and an Inertsil phenyl column with fluorescence detection at excitation and emission wavelengths of 280 and 444 nm, respectively. No significant interferences from the sample matrix were observed, indicating good selectivity with the immunoaffinity column. Overall recoveries from fortified liver samples (20, 50, and 100 ng/g) ranged between 85.7 and 93.5% with standard deviations of <5%. The limit of quantification for each fluoroquinolone was 1 ng/mL. The limits of detection, based on a signal-to-noise ratio of 5:1, were 0.47, 0.32, 0.87, and 0.53 ng/mL for ciprofloxacin, enrofloxacin, sarafloxacin, and difloxacin, respectively.

Determination of four fluoroquinolones in milk by on-line immunoaffinity capture coupled with reversed-phase liquid chromatography

An automated, on-line immunoaffinity extraction method was developed for the analysis of 4 fluoroquinolones in milk: ciprofloxacin, difloxacin, enrofloxacin, and sarafloxacin. This method involves analyte extraction using an immunoaffinity capture column containing anti-fluoroquinolone antibodies coupled on-line with reversed-phase column chromatography. Liquid chromatographic analyses were performed by isocratic elution using a mobile phase of 2% acetic acid-acetonitrile (85 + 15) and an Inertsil phenyl column with fluorescence detection at excitation and emission wavelengths of 278 and 444 nm, respectively. No significant interferences from the sample matrix were observed, indicating good selectivity with the immunoaffinity column. Recoveries from fortified raw milk samples (5-50 ppb of each fluoroquinolone) ranged from 72 to 90%, with standard deviations of < or = 8%.

Studies of organic residues from ancient Egyptian mummies using high temperature-gas chromatography-mass spectrometry and sequential thermal desorption-gas chromatography-mass spectrometry and pyrolysis-gas chromatography-mass spectrometry

The techniques of gas chromatography-mass spectrometry (GC-MS) and sequential thermal desorption-gas chromatography-mass spectrometry (TD-GC-MS) and pyrolysis-gas chromatography-mass spectrometry (Py-GC-MS) have been utilised to characterise the constituents of tissue-derived or applied organic material from two Pharaonic Egyptian mummies with a view to identifying embalming practices/substances. The results obtained using TD-GC-MS revealed a series of monocarboxylic acids with the C16:0, C18:1 and C18:0 components dominating in both mummies. The thermal desorption products related to cholesterol, i.e., cholesta-3,5,7-triene and cholesta-3,5-diene (only in Khnum Nakht), were detected in both mummies. Khnum Nakht also contained a number of straight chain alkyl amides (C16-C18) and an alkyl nitrile (C18). Other products included the 2,5-diketopiperazine derivative (DKP) of proline-glycine (pro-gly) which was a major component (7.9%) in Khnum Nakht but only a very minor component in Horemkenesi. Py-GC-MS of samples of both specimens yielded a series of alkene/alkane doublets (Horemkenesi C6-C18, Khnum Nakht C6-C24) which dominated their chromatograms. Series of methyl ketones in the C9-C19 chain length range were also present, with C5-C7 cyclic ketones occurring in Horemkenesi only. These ketones are indicative of covalent bond cleavage, probably of polymerised acyl lipids. Nitrogenous products included nitriles (C9-C18) which were significant in both samples, and amides which were only detected in Khnum Nakht. Also present amongst the pyrolysis products were three steroidal hydrocarbons, cholest-(?)-ene, cholesta-3,5,7-triene and cholesta-3,5-diene. High temperature-GC-MS of trimethylsilylated lipid extracts yielded similar monocarboxylic acids to that obtained using TD-GC-MS, while a series of alpha, omega-dicarboxylic acids and a number of mono- and di-hydroxy carboxylic acids not seen in the thermal desorption or pyrolysis GC-MS analyses were significant constituents in both mummy samples. Overall, the use of GC-MS and sequential TD-GC-MS and Py-GC-MS has demonstrated in both mummies the presence of a complex suite of lipids and proteinaceous components whose compositions indicates extensive alteration via oxidative and hydrolytic processes during long-term interment. None of the classical embalming resins was detected but an exogenous origin for at least a proportion of these components cannot be discounted since fats, oils and gelatin have been proposed as embalming agents in mummification. The combined approach of sequential TD- and Py-GC-MS has potential for application to the characterisation of embalming materials in mummies. Most importantly these techniques virtually eliminate any destruction of the mummified bodies thereby allowing the scope of investigations of ancient Egyptian funerary practices to be significantly extended.

Efficacy of various inorganic sorbents to reduce the toxicity of aflatoxin and T-2 toxin in broiler chickens

Experiments were conducted to determine the efficacy of three inorganic sorbents, S1, S2, and S3, to reduce the toxicity of aflatoxins (AF) and T-2 toxin in male broiler chickens from day of hatch to 21 d of age. The compounds had been reported to bind to AF and T-2 toxin in vitro. S1 and S2 were the same basic compound that had been stored for different lengths of time following activation. In Experiments 1, 2, and 3, the appropriate diets were produced to contain no mycotoxins, the specific adsorbent at 0.5% of diet, AF alone at 5 mg/kg of diet, T-2 alone at 8 mg/kg of diet, AF at 5 mg/kg of diet plus the specific sorbent at 0.5% of diet, or T-2 at 8 mg/kg of diet plus the specific sorbent at 0.5% of diet. The specific sorbents used were: 1) Experiment 1, S1; 2) Experiment 2, S1 and S2; and 3) Experiment 3, S3. In Experiments 1 and 3, S1 and S3, respectively, showed no protection against AF or T-2 toxin as measured by BW gain, when compared to AF alone group. In Experiment 2, S1 showed no protection; however S2 reduced the effects of AF on BW gain by 25% as compared to AF alone diet. The data demonstrate that under the conditions of our experiment: 1) one of the sorbents provided some protection against aflatoxicosis; 2) there was variability in protection against aflatoxicosis between two different samples of the same sorbent that had been stored for different lengths of time following activation; 3) protection by the sorbents against the effects of T-2 toxin was not observed.