A Phase II trial of alternating osimertinib and gefitinib therapy in advanced EGFR-T790M positive non-small cell lung cancer: OSCILLATE

In this phase II, single arm trial (ACTRN12617000720314), we investigate if alternating osimertinib and gefitinib would delay the development of resistance to osimertinib in advanced, non-small cell lung cancer (NSCLC) with the epidermal growth factor receptor (EGFR) T790M mutation (n = 47) by modulating selective pressure on resistant clones. The primary endpoint is progression free-survival (PFS) rate at 12 months, and secondary endpoints include: feasibility of alternating therapy, overall response rate (ORR), overall survival (OS), and safety. The 12-month PFS rate is 38% (95% CI 27.5-55), not meeting the pre-specified primary endpoint. Serial circulating tumor DNA (ctDNA) analysis reveals decrease and clearance of the original activating EGFR and EGFR-T790M mutations which are prognostic of clinical outcomes. In 73% of participants, loss of T790M ctDNA is observed at progression and no participants have evidence of the EGFR C797S resistance mutation following the alternating regimen. These findings highlight the challenges of treatment strategies designed to modulate clonal evolution and the clinical importance of resistance mechanisms beyond suppression of selected genetic mutations in driving therapeutic escape to highly potent targeted therapies.

A Phase Ib/II Trial of Combined BRAF and EGFR Inhibition in BRAF V600E Positive Metastatic Colorectal Cancer and Other Cancers: The EVICT (Erlotinib and Vemurafenib In Combination Trial) Study

PURPOSE

BRAF V600E mutant metastatic colorectal cancer represents a significant clinical problem, with combination approaches being developed clinically with oral BRAF inhibitors combined with EGFR-targeting antibodies. While compelling preclinical data have highlighted the effectiveness of combination therapy with vemurafenib and small-molecule EGFR inhibitors, gefitinib or erlotinib, in colorectal cancer, this therapeutic strategy has not been investigated in clinical studies.

PATIENTS AND METHODS

We conducted a phase Ib/II dose-escalation/expansion trial investigating the safety/efficacy of the BRAF inhibitor vemurafenib and EGFR inhibitor erlotinib.

RESULTS

Thirty-two patients with BRAF V600E positive metastatic colorectal cancer (mCRC) and 7 patients with other cancers were enrolled. No dose-limiting toxicities were observed in escalation, with vemurafenib 960 mg twice daily with erlotinib 150 mg daily selected as the recommended phase II dose. Among 31 evaluable patients with mCRC and 7 with other cancers, overall response rates were 32% [10/31, 16% (5/31) confirmed] and 43% (3/7), respectively, with clinical benefit rates of 65% and 100%. Early ctDNA dynamics were predictive of treatment efficacy, and serial ctDNA monitoring revealed distinct patterns of convergent genomic evolution associated with acquired treatment resistance, with frequent emergence of MAPK pathway alterations, including polyclonal KRAS, NRAS, and MAP2K1 mutations, and MET amplification.

CONCLUSIONS

The Erlotinib and Vemurafenib In Combination Trial study demonstrated a safe and novel combination of two oral inhibitors targeting BRAF and EGFR. The dynamic assessment of serial ctDNA was a useful measure of underlying genomic changes in response to this combination and in understanding potential mechanisms of resistance.

Cost and cost-effectiveness of health behavior change interventions implemented with self-help groups in Bihar, India

Introduction

Health interventions implemented with self-help groups (SHGs) enhance the relevance and acceptability of the health services. The Parivartan program was implemented in eight districts of Bihar with women’s self-help groups to increase adoption of maternal and newborn health behaviors through layering health behavior change communication. This study estimates the cost and cost-effectiveness of a health behavior change program with SHGs in Bihar.

Methods

Cost analysis was conducted from a provider’s perspective. All costs have been presented in US dollars for the purpose of international comparisons and converted to constant values. The effectiveness estimate was based on the reported changes in select newborn care practices. A decision model approach was used to estimate the potential number of neonatal deaths averted based on adoption of key newborn care practices. Using India’s life expectancy of 65 years, cost per life year saved was calculated. A one-way sensitivity analysis was conducted using the upper and lower estimates for various variables in the model, and functionality of SHGs.

Results

The cost of forming an SHG group was US$254 and that of reaching a woman within the group was US$19. The unit cost for delivering health interventions through the Parivartan program was US$148 per group and US$11 per woman reached. During an 18 months period, Parivartan program reached around 17,120 SHGs and an estimated 20,544 pregnant women resulting in an estimated prevention of 23 neonatal deaths at a cost of US$3,825 per life year saved.

Conclusion

SHGs can be an effective platform to increase uptake of women’s health interventions and follow-up care, and also to broaden their utility beyond microfinance, particularly when they operate at a larger scale.

Correction of moderate to severe hallux valgus with combined proximal opening wedge and distal chevron osteotomies: a reliable technique

AIMS

The mainstay of surgical correction of hallux valgus is first metatarsal osteotomy, either proximally or distally. We present a technique of combining a distal chevron osteotomy with a proximal opening wedge osteotomy, for the correction of moderate to severe hallux valgus.

PATIENTS AND METHODS

We reviewed 45 patients (49 feet) who had undergone double osteotomy. Outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) and the Short Form (SF) -36 Health Survey scores. Radiological measurements were undertaken to assess the correction. The mean age of the patients was 60.8 years (44.2 to 75.3). The mean follow-up was 35.4 months (24 to 51).

RESULTS

The mean AOFAS score improved from 54.7 to 92.3 (p < 0.001) and the mean SF-36 score from 59 to 86 (p < 0.001). The mean hallux valgus and intermetatarsal angles were improved from 41.6(o) to 12.8(o) (p < 0.001) and from 22.1(o) to 7.1(o), respectively (p < 0.001). The mean distal metatarsal articular angle improved from 23(o) to 9.7(o). The mean sesamoid position, as described by Hardy and Clapham, improved from 6.8 to 3.5. The mean length of the first metatarsal was unchanged. The overall rate of complications was 4.1% (two patients).

CONCLUSION

These results suggest that a double osteotomy of the first metatarsal is a reliable, safe technique which, when compared with other metatarsal osteotomies, provides strong angular correction and excellent outcomes with a low rate of complications. Cite this article: Bone Joint J 2016;98-B:1202-7.

Visualizing skin effects in conductors with MRI: (7)Li MRI experiments and calculations

While experiments on metals have been performed since the early days of NMR (and DNP), the use of bulk metal is normally avoided. Instead, often powders have been used in combination with low fields, so that skin depth effects could be neglected. Another complicating factor of acquiring NMR spectra or MRI images of bulk metal is the strong signal dependence on the orientation between the sample and the radio frequency (rf) coil, leading to non-intuitive image distortions and inaccurate quantification. Such factors are particularly important for NMR and MRI of batteries and other electrochemical devices. Here, we show results from a systematic study combining rf field calculations with experimental MRI of (7)Li metal to visualize skin depth effects directly and to analyze the rf field orientation effect on MRI of bulk metal. It is shown that a certain degree of selectivity can be achieved for particular faces of the metal, simply based on the orientation of the sample. By combining rf field calculations with bulk magnetic susceptibility calculations accurate NMR spectra can be obtained from first principles. Such analyses will become valuable in many applications involving battery systems, but also metals, in general.

A comparitive evaluation of the marginal adaptation of zirconium coping and nickel-chromium coping using shoulder finish line design: an invitro study

Marginal adaptation is an important factor for long term clinical success of the restoration. This study aims to evaluate and compare the marginal adaptation of zirconium coping and nickel-chromium coping using the shoulder finish line design. For the purpose of this study 30 master dies were fabricated. A total of 30 copings were fabricated in which 15 zirconia copings and 15 Ni-Cr copings were fabricated. The copings obtained were seated on the die and marginal discrepancy between the metal die and the copings were then measured with Scanning electron microscope at magnification of ×50 and the findings were statistically analyzed. Mean and standard deviation values of marginal discrepancy of cervical margins of zirconia copings were 39.32 and 2.66 μm and Ni-Cr copings were 129.98 and 2.57 μm. Higher mean marginal gap (μm) is recorded in Ni-Cr copings compared to zirconia copings. The difference in mean marginal gap (μm) between the two copings is found to be statistically significant (P < 0.001). Within the limitation of this study it was concluded that higher mean marginal gap (μm) was recorded in Ni-Cr copings compared to zirconia copings. The difference in mean marginal gap (μm) between the two copings is found to be statistically significant (P < 0.001).

7Li MRI of Li batteries reveals location of microstructural lithium

There is an ever-increasing need for advanced batteries for portable electronics, to power electric vehicles and to facilitate the distribution and storage of energy derived from renewable energy sources. The increasing demands on batteries and other electrochemical devices have spurred research into the development of new electrode materials that could lead to better performance and lower cost (increased capacity, stability and cycle life, and safety). These developments have, in turn, given rise to a vigorous search for the development of robust and reliable diagnostic tools to monitor and analyse battery performance, where possible, in situ. Yet, a proven, convenient and non-invasive technology, with an ability to image in three dimensions the chemical changes that occur inside a full battery as it cycles, has yet to emerge. Here we demonstrate techniques based on magnetic resonance imaging, which enable a completely non-invasive visualization and characterization of the changes that occur on battery electrodes and in the electrolyte. The current application focuses on lithium-metal batteries and the observation of electrode microstructure build-up as a result of charging. The methods developed here will be highly valuable in the quest for enhanced battery performance and in the evaluation of other electrochemical devices.

Synthesis of uriedo and thiouriedo derivatives of peptide conjugated heterocycles - A new class of promising antimicrobials

Forty five new derivatives of ureas and thioureas were synthesized by the reaction of peptide conjugated heterocycles with isocyanates and isothiocyanates respectively. All the compounds have been characterized by IR, (1)H NMR, mass and elemental analysis. The compounds were evaluated for their ability to inhibit the growth of a panel of microorganisms and all the synthesized compounds displayed an excellent antimicrobial activity. From structure-activity relationship studies, it was apparent that thioureas infact is slightly more active than ureas. Also, substituents on the phenyl ring of the title compounds play a key role in the activity. Further, compound 40 is nearly twenty times more potent than the standard used. These results present a platform for the further studies in this line.

The effects of scale on the costs of targeted HIV prevention interventions among female and male sex workers, men who have sex with men and transgenders in India

Background

The India AIDS Initiative (Avahan) project is involved in rapid scale-up of HIV-prevention interventions in high-risk populations. This study examines the cost variation of 107 non-governmental organisations (NGOs) implementing targeted interventions, over the start up (defined as period from project inception until services to the key population commenced) and first 2 years of intervention.

Methods

The Avahan interventions for female and male sex workers and their clients, in 62 districts of four southern states were costed for the financial years 2004/2005 and 2005/2006 using standard costing techniques. Data sources include financial and economic costs from the lead implementing partners (LPs) and subcontracted local implementing NGOs retrospectively and prospectively collected from a provider perspective. Ingredients and step-down allocation processes were used. Outcomes were measured using routinely collected project data. The average costs were estimated and a regression analysis carried out to explore causes of cost variation. Costs were calculated in US$ 2006.

Results

The total number of registered people was 134 391 at the end of 2 years, and 124 669 had used STI services during that period. The median average cost of Avahan programme for this period was $76 per person registered with the project. Sixty-one per cent of the cost variation could be explained by scale (positive association), number of NGOs per district (negative), number of LPs in the state (negative) and project maturity (positive) (p<0.0001).

Conclusions

During rapid scale-up in the initial phase of the Avahan programme, a significant reduction in average costs was observed. As full scale-up had not yet been achieved, the average cost at scale is yet to be realised and the extent of the impact of scale on costs yet to be captured. Scale effects are important to quantify for planning resource requirements of large-scale interventions. The average cost after 2 years is within the range of global scale-up costs estimates and other studies in India.

Post lumbar puncture spinal subarachnoid hematoma causing paraplegia: a short report

A 53 year old male underwent total excision of a large sphenoidal wing meningioma. Patient was treated with cephalosporins and phenytoin for postoperative meningitis. Three weeks after surgery, a follow up lumbar puncture was done. The patient became paraplegic over a few hours. Imaging of the dorsolumbar spine and other investigations demonstrated a large intraspinal hematoma caused by thrombocytopenia which was probably drug induced. After normalising the platelet count surgical evacuation of the spinal subarachnoid hematoma was done. Relevant literature is reviewed.

Risk assessment in first degree female relatives of breast cancer patients using the alkaline Comet assay

First degree female relatives (FDFRs) of breast cancer patients have been reported to have a 2- to 3-fold increase in breast cancer risk as compared with the general population. Assessment of genetic instability (DNA damage and repair efficiency) is an important parameter concerning mutagenesis and carcinogenesis. In an attempt to identify individuals at high risk of breast cancer in the FDFRs of breast cancer patients, two tests were used: the alkaline Comet assay on leucocytes and the micronucleus test (MNT) on buccal epithelial cells. In addition to FDFRs, two other categories of subjects were included: breast cancer patients and controls. The Comet assay was used to study basal DNA damage, DNA susceptibility to a mutagen (N-methyl N-nitro N-nitrosoguanidine) and DNA repair efficiency. In addition, the MNT served as an indicator of chromosome breakage/aneuploidy. A significant increase in DNA damage (basal and after treatment with a mutagen, as well as after allowing repair to take place) and micronucleus frequency was observed from controls to FDFRs and from FDFRs to breast cancer patients. There was considerable variability in the subjects with respect to both of these parameters. Outliers identified among the FDFRs based on 3 SD limits of DNA damage and micronucleus frequency were considered as high risk individuals.

Socio-demographic and maternal determinants of low birth weight: a multivariate approach

A community based study was conducted in the rural areas of Udupi taluk, Karnataka state of South India to identify the socio-demographic, maternal and obstetric determinants of low birth weight. All singleton live births that occurred in the study area during a one year period (October 1991 to September 1992) were included. A total of 2919 singleton child-mother pairs formed the basis of the analysis. Information about social, demographic and economic conditions of the families; maternal factors such as age, parity, quality of antenatal care and previous obstetric history were collected by interviewing the mothers and family members and verifying the available medical records through the field investigators especially recruited and trained for this purpose. Data was analyzed using multiple logistic regression model. Primis, elderly mothers and mothers who had not received good quality antenatal care were found to be more at risk of having low birth weight babies. Other significant determinants were family custom, socio-economic status and environmental sanitation.

Knowledge of and attitudes to HIV/AIDS of senior secondary school pupils and trainee teachers in Udupi District, Karnataka, India

A cross-sectional descriptive study using a questionnaire with mostly closed-ended questions was carried out on 990 pupils and 46 trainee teachers to investigate their knowledge of and attitudes to HIV/AIDS. Pupils in one school were reassessed after a health talk and distribution of a handout. Despite having had no formal sex education, most respondents were reasonably well informed about the transmission of HIV. However, there were many misconceptions about transmission and prevention and 16.9% of pupils were found to possess very little knowledge of HIV/AIDS. Mass media, teachers and health workers were quoted as the main sources of knowledge. It was found that 24.3% pupils and 6.3% of trainee teachers thought there was a cure, and 27.4% of pupils and 14% of trainee teachers thought there was a vaccine to prevent HIV infection. Schools that were rural, private and English-speaking scored better, as did male students and schools teaching science. The necessity of formal sex education was expressed by 98.5% of pupils and all the trainee teachers. The pupils who were reassessed after receiving a talk and handout showed significant improvement in their knowledge and a change in attitude (p < 0.01). The mass media are important in disseminating knowledge on HIV/AIDS in India but due to the lack of inter-personal approaches to the education system, knowledge is inadequate and misconceptions exist.

Socio-demographic determinants of antenatal care

A large scale community-based study in South Kanara district of Karnataka state, India has revealed that, despite a low infant mortality rate (IMR), there is a clear association between IMR and lack of antenatal care (ANC) as well as IMR and poor quality ANC. We analyse the factors which determine the utilization of ANC and show the association between quality of ANC and maternal literacy, occupation, age and parity. Factors which are also significantly associated are socio-economic status, religion and matriarchal system. Characteristically, those who do not receive any ANC are poor, illiterate, multiparous unskilled mothers over 30 years of age and who live far away from a medical facility. This study conclusively demonstrates that even in regions where IMR is low there is enough scope to reduce it further by concentrating our efforts on the high risk population.

Perinatal mortality in a rural district of south India

Perinatal mortality is one of the most sensitive indices of maternal and child health. The perinatal mortality rate is an indicator of the extent of pregnancy wastage as well as of the quality and quantity of health care available to the mother and the newborn. A community based prospective study carried out on 13,214 births in South Kanara district between Oct. 1991-Sept. 1992 revealed a perinatal mortality rate (PNMR) of 44.65/1000 births. Among the various factors influencing perinatal mortality, breech deliveries and babies of multiple pregnancies had a very high perinatal mortality rate of 180.81/1000 births (adjusted odd's ratio: 4.90) and 128/1000 births (adjusted odd's ratio: 2.64). The previous bad obstetric history of the mother, parity and sex of the newborn were among the other important factors influencing the PNMR.

In vitro studies on extracellular matrix production by M.leprae infected murine neurofibroblasts

Fibroblasts and a host of macrophage secretory products have been implicated in a number of diseases where excess extracellular matrix (ECM) deposition is the main pathological feature. Fibrosis characterized by excessive deposition of collagen also contributes to the irreversible nerve damage observed in leprosy. Since M. leprae are seen within neurofibroblasts (Nf) in the advanced stages of the disease and macrophages form a common infiltrating cellular constituent of leprous nerves at all stages, secretion of ECM proteins by Nf was studied, in vitro following infection with M. leprae and in the presence of macrophage secretory products. These studies were compared in cells derived from two strains of mice, Swiss White (SW) and C57BL/6, as they differ in their response to M. leprae infection and parallel those observed in lepromatous and tuberculoid patients, respectively. On infection with M. leprae, Nfs showed a decrease in secretion of collagen type IV in SW and type I in C57Bl/6 strain. Macrophages caused a further decrease in the secretion of collagen types affected by M. leprae infection per se, while the other collagen types, viz. I and III in SW strain and III and IV in C57Bl/s strain, were unaffected. This study indicates that neural collagenization in nerves in advanced leprosy may be of Nf origin. However, unlike other diseases with excess collagen deposition, ECM proteins produced by Nfs in response to nerve damage may not be of prime importance in the progression of leprous neuropathy and occur as a general response to loss of cellular content in leprous nerves.

Schwann cell extracellular matrix protein production is modulated by Mycobacterium leprae and macrophage secretory products

Extracellular matrix (ECM) protein deposition is an important feature of leprous nerves, where Schwann cells (SCs) and macrophages are the main hosts for Mycobacterium leprae. Since, SCs are involved in the synthesis of ECM proteins and its production is regulated by macrophage secretory factors, the present study aimed to determine in vitro, the effect of M. leprae infection and macrophage secretory products on secretion of ECM proteins by SCs in two strains of mice, Swiss White (SW) and C57BL/6, that are known to differ in their nerve pathology and macrophage functions in response to infection. Following six days of M. leprae infection, SCs from SW mice responded with increased secretion of 14C-leucine radiolabelled proteins and a concomitant increase in laminin and collagens type I, III and IV, as determined by enzyme-linked immunosorbent assay. In contrast infected C57BL/6 SCs responded with decreased secretion of total proteins and fibronectin. Exposure of SCs to macrophage conditioned medium resulted in decreased ECM protein secretion in both strains of mice. This decrease was a function of protein breakdown by macrophage derived proteases and also active regulation by macrophage secreted cytokines. A similar effect of M. leprae and macrophage secretory products on SC metabolism in leprous nerves would have major ramifications on damage and repair activities. In addition ECM proteins would also influence the composition of the infiltrating cell population in lepromatous and tuberculoid nerves.

Infant feeding--knowledge and attitudes in a rural area of Karnataka

A study of the knowledge and attitude towards infant feeding was conducted in South India on a group of 300 mothers whose babies' ages from 3 days to 17 months. Most of the mothers opined that breast-feeding had to be initiated within 24 hours of birth. However, only 32% felt that breast milk should be the first feed, whereas 68% considered prelacteal feeds a necessity. 71% of the mothers considered 3 to 5 months to be the optimum duration of exclusive breast-feeding. 90% felt that cow's milk was an ideal supplement. 78.3% subscribed to the view that breast-feeding should continue beyond one year. A sizeable proportion expressed the need to discontinue breastfeeds during babies' or maternal illness, particularly diarrhoea. Our results will form the babies of the content and the target groups in our future health education programme.

Development of PCR assay for targeting partial <i>lipL21</i> and <i>lipL41</i> gene of <i>leptospira</i>

Leptospirosis is a bacterial zoonotic disease caused by spirochetes of the genus Leptospira that affects human and a wide range of animals. The direct method of diagnosis of leptospirosis, has been so far by culture isolation but it is time consuming and potentially biohazardous. Another traditional method is the detection of antibodies (Serological tests) which is also a time consuming method and fails to identify the infecting serovar. To overcome these limitations associated with the cultivation and serology, we developed PCR assay targeting partial lipL21 gene and lipL41 gene of Leptospires using in-house designed P28/29 and P30/31 primers, with a product size of 385bp and 427bp. The amplicons were subjected to restriction enzyme digestion using RsaI, Pvu II and HindIII for product of P28/29 and ClaI, TaqI and RsaI were used for product of P30/31. The protocols were standardized and the assay targeting the partial lipL21 and lipL41 gene was found to be specific for eight pathogenic Leptospires out of nine leptospires tested. The products were then cloned in pGEMT Easy vector and sequenced to facilitate further studies. PCR could detect the target bacterial gene without any ambiguity and showed good efficiency in detection of targeted species in the sample. This simple, rapid and cost-effective method can be applicable in a prediction system to prevent disease outbreak by these Leptospira species and can be considered as an effective tool for disease diagnosis of Leptospira species. Key words: PCR; lipL21; lipL41; Molecular Diagnostics; Transformation. Nepal Journal of Biotechnology. Jan. 2011, Vol. 1, No. 1 : 22-30