Genome-wide gene expression responses to experimental manipulation of Saccharomyces cerevisiae repressor activator protein 1 (Rap1) expression level

Precise regulation of transcription in gene expression is critical for all aspects of normal organism form, fitness, and function and even minor alterations in the level, location, and timing of gene expression can result in phenotypic variation within and between species including evolutionary innovations and human disease states. Eukaryotic transcription is regulated by a complex interplay of multiple factors working both at a physical and molecular levels influencing this process. In Saccharomyces cerevisiae, the TF with the greatest number of putative regulatory targets is the essential gene Repressor Activator Protein 1 (RAP1). While much is known about the roles of Rap1 in gene regulation and numerous cellular processes, the response of Rap1 target genes to systematic titration of RAP1 expression level remains unknown. To fill this knowledge gap, we used a strain with a tetracycline-titratable promoter replacing wild-type regulatory sequences of RAP1 to systematically reduce the expression level of RAP1 and followed this with RNA sequencing (RNA-seq) to measure genome-wide gene expression responses. Previous research indicated that Rap1 plays a significant regulatory role in particular groups of genes including telomere-proximal genes, homothallic mating (HM) loci, glycolytic genes, DNA repair genes, and ribosomal protein genes; therefore, we focused our analyses on these groups and downstream targets to determine how they respond to reductions in RAP1 expression level. Overall, despite being known as both an activator and as a repressor of its target genes, we found that Rap1 acts as an activator for more target genes than as a repressor. Additionally, we found that Rap1 functions as an activator of ribosomal protein genes and a repressor of the silent mating locus genes consistent with predictions from the literature. Unexpectedly, we found that Rap1 functions as a repressor of glycolytic enzyme genes contrary to prior reports of it having the opposite effect. We also compared the expression of RAP1 to five different genes related to DNA repair pathway and found that decreasing RAP1 downregulated four of those five genes. Finally, we found no effect of RAP1 depletion on telomere-proximal genes despite its functioning to silence telomeric repeat-containing RNAs. Together our results enrich our understanding of this important transcriptional regulator. The graphical abstract is provided as a supplementary fig. (S-Fig 1).

A phase 1 open-label study to assess the relative bioavailability of TAK-931 tablets in reference to powder-in-capsule in patients with advanced solid tumors

In this phase 1 open-label study, we assessed the relative bioavailability of a prototype tablet formulation of TAK-931, a cell division cycle 7 kinase inhibitor, in reference to the current powder-in-capsule (PIC) formulation in patients with advanced solid tumors for whom no effective standard treatment was available. Adult patients were randomized 1:1 in a crossover fashion to receive one dose of TAK-931 80 mg PIC on Day 1 and one dose of TAK-931 80 mg tablet on Day 3 (or the reverse sequence), followed by TAK-931 50 mg PIC once daily (QD) for 12 days starting from Day 5, before a 7-day rest period (Cycle 0). From Cycle 1, all patients received 50 mg PIC QD on Days 1-14 followed by a 7-day rest period. Twenty patients were enrolled. Median T_max was achieved approximately 2 h post-dose of TAK-931 80 mg for both tablet and PIC. Geometric mean C_max, AUC exposures, and T_1/2z of TAK-931 were similar for both formulations. Geometric mean C_max, AUC_last, and AUC_inf ratios were 0.936 (90% confidence interval [CI]: 0.808-1.084), 1.004 (90% CI: 0.899-1.120), and 1.007 (90% CI: 0.903-1.123), respectively, for TAK-931 tablet in reference to PIC. Discontinuation of TAK-931 due to treatment-emergent adverse events (TEAEs) occurred in 1 patient. Four (20%) patients experienced a serious TEAE; none were considered related to TAK-931. Pharmacokinetics and systemic exposure profiles were similar following administration of both formulations, supporting the transition from PIC to tablet in the clinical development of TAK-931. (Trial registration number ClinicalTrials.gov NCT03708211. Registration date October 12, 2018).

Safety, Tolerability, and Pharmacokinetics of TAK-931, a Cell Division Cycle 7 Inhibitor, in Patients with Advanced Solid Tumors: A Phase I First-in-Human Study

Purpose:

We conducted a first-in-human, dose-escalation study, to evaluate the safety, tolerability, pharmacokinetics, pharmacodynamics, and activity of TAK-931, a cell division cycle 7 inhibitor, in Japanese patients with advanced solid tumors.

Experimental Design:

Patients ages ≥20 years received oral TAK-931: once daily for 14 days in 21-day cycles (schedule A; from 30 mg); once daily or twice daily for 7 days on, 7 days off in 28-day cycles (schedule B; from 60 mg); continuous once daily (schedule D; from 20 mg); or once daily for 2 days on, 5 days off (schedule E; from 100 mg) in 21-day cycles.

Results:

Of the 80 patients enrolled, all had prior systemic treatment and 86% had stage IV disease. In schedule A, 2 patients experienced dose-limiting toxicities (DLTs) of grade 4 neutropenia and the maximum tolerated dose (MTD) was 50 mg. In schedule B, 4 patients experienced DLTs of grade 3 febrile neutropenia (n = 3) or grade 4 neutropenia (n = 1); the MTD was 100 mg. Schedules D and E were discontinued before MTD determination. The most common adverse events were nausea (60%) and neutropenia (56%). Time to maximum plasma concentration of TAK-931 was approximately 1–4 hours postdose; systemic exposure was approximately dose proportional. Posttreatment pharmacodynamic effects correlating to drug exposure were observed. Overall, 5 patients achieved a partial response.

Conclusions:

TAK-931 was tolerable with a manageable safety profile. TAK-931 50 mg once daily days 1–14 in 21-day cycles was selected as a recommended phase II dose and achieved proof of mechanism.

Trial registration ID:

NCT02699749

Significance:

This was the first-in-human study of the CDC7 inhibitor, TAK-931, in patients with solid tumors. TAK-931 was generally tolerable with a manageable safety profile. The recommend phase II dose was determined to be TAK-931 50 mg administered once daily on days 1–14 of each 21-day cycle. A phase II study is ongoing to confirm the safety, tolerability, and antitumor activity of TAK-931 in patients with metastatic solid tumors.

111 Adipose Tissue-Derived Mesenchymal Stem Cells as a Potential Restorative Treatment for Cartilage Defects: A PRISMA Review and Meta-Analysis

Aim

Joint damage through trauma or degeneration causes cartilage defects, leading to osteoarthritis (OA). Current therapies relieve symptoms or replaces damaged joint, which is costly and fraught with complications. Mesenchymal stem cells (MSCs) have immunomodulatory properties and low immunogenicity, making them a novel avenue for research for OA treatment. This systematic review investigates whether adipose derived MSC (AMSCs) can treat cartilage defects.

Method

A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science. Clinical, imaging, functional outcomes were extracted from nineteen included studies. Inclusion criteria was studies conducted on human populations that compared effects of AMSCs on cartilage regeneration to non-exposed controls. Studies conducted on animals, ex vivo studies, in vitro studies were excluded.

Results

Nine studies reported improved Visual Analogue Scale (VAS) scores (mean difference -3.30; 95% CI:-3.72,-2.89; p<0.001). Eight studies reported improved Knee injury and Osteoarthritis Outcome Score (KOOS) in five subscales. Pooled analysis of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in seven studies revealed an improvement (mean difference -25.52; 95% CI:-30.93,-20.10; p<0.001). Cartilage regeneration was assessed using Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. All studies reported improved regeneration, with a pooled end-point score of 68.12 (95% CI:62.18–74.05; p<0.001).

Conclusions

AMSCs are effective therapeutic agents for cartilage defects. We recommend researchers to determine roles of biochemical components that facilitate AMSC-mediated cartilage repair. Establishing the most efficient methods for MSC extraction, culture, delivery, and performing studies with long follow-up times enable future research to provide evidence needed to bring AMSC-based therapies into the market.

180 Retrograde Hindfoot Nailing for the Treatment of Acute Ankle Fractures in the Elderly - a Systematic Review and Meta-Analysis

Aim

Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation (ORIF). Tibiotalocalcaneal (TTC) nailing is an alternative option for the geriatric patient. This meta-analysis provides the most detailed analysis of hindfoot nailing for fragility ankle fractures.

Method

A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science, identifying fourteen studies for inclusion. Studies including patients over 60 with a fragility ankle fracture, treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded.

Meta-regression analyses were performed to explore sources of heterogeneity, and publication bias was assessed using Egger's test.

Results

312 ankle fractures were included. The mean age was 77.3 (32–101) years. 26.9% were male, and 41.9% were diabetics. The pooled proportion of superficial infection, deep infection, implant failure, malunion, and all-cause mortality was 0.10 (95%CI:0.06–0.16; I2=44%), 0.08 (95%CI:0.06–0.11, I2=0%), 0.11 (95%CI:0.07–0.15,I2=0%), 0.11 (95%CI:0.06–0.18; I2=51%), and 0.27 (95%CI:0.20–0.34; I2=11%), respectively. The pooled mean post-operative OMAS score was 54.07 (95%CI:48.98–59.16; I2=85%). The best-fitting meta-regression model included age and percentage of male patients as covariates (p=0.0263), and were inversely correlated with higher OMAS scores. Egger's test (p=0.56) showed no significant publication bias.

Conclusions

TTC nailing is an adequate alternative option for fragility ankle fracture management. However, current evidence includes mainly case series with inconsistent outcome measures reported and post-operative rehabilitation protocols. Prospective RCTs with long follow-up times and large cohort sizes are needed to clearly guide the use of TTC nailing for ankle fractures.

893 Predictors for Infection Severity in Open Tibial Fractures

Aim

Open tibial fractures can be difficult to manage - many factors could affect treatment and outcome, including being complicated by infection. We present a cohort of 244 patients and analyse which factors are significantly associated with infection outcome.

Method

Open tibia fractures treated at a major trauma centre between 2015–2021 were included.

Infection status was categorized into no infection, superficial infection, osteomyelitis. Data collected were Age, mode of injury, polytrauma, fibula status, Gustilo-Anderson (GA) classification, wound contamination, time to first procedure. time to definitive plastics procedure, time to definitive fixation, type of definitive fixation, smoking/diabetic status, and BMI.

Multicollinearity was calculated, with highly correlated factors removed. Multinomial logistic regression was performed. Chi-Squared test, with Post-Hoc Bonferroni correction was performed for complex categorical factors.

Results

244 patients were included. Polytrauma and fibula status, and type of definitive fixation were excluded from the multivariate model due to strong multicollinearity. Compared to non-infected outcome, patients with superficial infection had higher BMI (p<0.01), higher GA grade (p<0.01), and osteomyelitis patients had longer time to definitive fixation (p=0.049) and longer time to definitive plastics procedure (p=0.013), higher GA grade, and wound contamination.

Post-hoc analysis showed “no infection” was positively associated with GA-I (p=0.029) and GA-II (p<0.01), and negatively associated with GA-IIIC (p<0.01). Osteomyelitis was positively associated with GA-IIIc (p<0.01)

Conclusions

This study investigated associations between injury and presentation factors that may have been associated with infection. We suggest clinicians should give extra consideration to the factors highlighted during management and take preventative measures to mitigate the infection risk.

114 Bone Transport Using the Monorail External Fixator Over an Intramedullary Nail for Post-Traumatic Femoral Defects

Aim

The management of limb-length discrepancy secondary to traumatic bone loss poses a unique challenge for surgeons. The Ilizarov technique is popular but is associated with long external fixator time and many complications. This retrospective study assessed outcomes of post-traumatic femoral defects managed by monorail external fixation over an intramedullary nail.

Method

Eight patients were included from over a four-year period with post-traumatic femoral defects, that underwent treatment with monorail fixator-assisted intramedullary nailing. Mean follow-up time was 232.83 weeks. Five were open fractures (Gustilo-Anderson type 3A:n=4, 3B:n=1), one had closed fracture. Average bone defect size was 8cm. Primary outcomes were lengthening index, consolidation time and index, external fixator index. Secondary outcomes were time to full weight bearing(FWB), time to union, complications. Patient reported outcome measures including EQ-5D-5L, SF-36, Oxford knee scores(OKS), Oxford hip scores(OHS) were recorded after recovery.

Results

Average consolidation time and index were 11.35months and 1.24months/cm, respectively. Mean lengthening and external fixator index were 20.2days/cm and 23.88days/cm, respectively. On average, patients achieved FWB and bone union 56.25 weeks and 68.83 weeks after bone transport initiation, respectively. Two patients had docking site non-union, treated by reamed intramedullary exchange nailing. Two patients had osteomyelitis. EQ-5D-5L and EQ-VAS scores were compared to UK population norms (p=0.104, p=0.238, respectively). Average OKS was 32.17 and OHS was 34.00.

Conclusions

Monorail external fixation over an intramedullary nail is an effective option for post-traumatic femoral defects, reducing external fixator time, lowering complication rate, returning patients’ quality of life to a level comparable with the normal population.

245 Ankle Fusion with Tibiotalocalcaneal Retrograde Nail for Fragility Ankle Fractures: Outcomes at a Major Trauma Centre

Aim

Fragility ankles fractures in the geriatric population are challenging to manage, due to fracture instability, soft tissue compromise, and patient co-morbidities. Traditional management options include open reduction internal fixation, or conservative treatment, both of which are fraught with high complication rates. We aimed to present functional outcomes of elderly patients with fragility ankle fractures treated with retrograde ankle fusion nails.

Method

171 patients received a tibiotalocalcaneal nail over a six-year period, but only twenty met the inclusion criteria of being over sixty and having poor bone stock. Primary outcome was mortality risk from co-morbidities according to Charlson co-morbidity index (CCI), and patients’ post-operative mobility status compared to pre-operative mobility. Secondary outcomes include intra-operative and post-operative complications, six-month mortality rate, time to mobilisation and union.

Results

Mean age was 77.82 years old. The average CCI was 5.05. Thirteen patients returned to their pre-operative mobility state. Patients with low CCI are more likely to return to pre-operative mobility status (p=0.16;OR=4.00).

Average time to bone union and mobilisation were 92.5 days and 7.63 days, respectively. Mean post-operative AOFAS ankle-hindfoot and Olerud-Molander scores were 53.0 and 50.9, respectively. There were four cases of superficial infection. Patients with high CCI were more likely to acquire superficial infections (p=0.264,OR=3.857). There were no deep infections, periprosthetic fractures, nail breakages, non-unions. Average follow-up time was 499.3 days.

Conclusions

Tibiotalocalcaneal nailing is an effective and safe option for managing fragility ankle fractures in the elderly. This technique leads to lower complication rates and earlier mobilisation than traditional fixation methods.

537 Open vs Closed Pilon Fractures: Comparison of Management, Outcomes, and Complications

Aim

Despite the low incidence of pilon fractures, their high impact nature presents difficulties in surgical management/recovery. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences in treatment, outcomes, complications between open and closed pilon fractures.

Method

This retrospective study was conducted at a major trauma centre, including patients over 5-year period. 135 patients were included (open:48, closed:87). Primary outcome was AOFAS score at 3-, 6- and 12-months post-injury. Secondary outcomes include time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, follow-up time. Post-operative complications were collected.

Results

Open fractures had lower AOFAS score 3 months post-injury, longer bone union time, and time to FWB. For both open and closed fractures, compared to ORIF patients, those treated with fine wire fixator (FWF) had lower AOFAS scores 3- and 6-months post-injury. Closed fracture patients treated with ORIF had shorter bone union time, time to PWB and FWB. Patients with AO/OTA 43A fractures needed shorter time to PWB and FWB than those with 43C fractures. Common complications (closed:open) were superficial infection (22%:54%), post-traumatic arthritis (25%:16%), non-union (11%:24%).

Conclusions

Open fractures, with more extensive soft tissue damage, were likely more suited for FWF, rather than ORIF (18% of open vs 72% of closed were treated with ORIF). Due to greater associated trauma, more frequent complications, and delayed definitive fixation, open fractures had lower AOFAS scores. Nevertheless, use of staged approach involving temporary external fixation, followed with ORIF or FWF achieved low complication rates and good functional recovery.

OPTIC primary analysis: A dose-optimization study of 3 starting doses of ponatinib (PON)

7000

Background: PON, a third-generation tyrosine kinase inhibitor (TKI), demonstrated deep and long-lasting responses and survival in patients (pts) with chronic-phase chronic myeloid leukemia (CP-CML) resistant/intolerant to second-generation TKI therapy (PACE; NCT01207440); post hoc analysis suggested a relationship between dose and both adverse events and response. Here we present the primary analysis of OPTIC (NCT02467270), an ongoing, randomized, phase 2 trial with a novel response-based dosing regimen of PON in pts with resistant/intolerant CP-CML. Methods: Pts with CP-CML resistant/intolerant to ≥2 TKIs or with the BCR-ABL1 T315I mutation were randomized to PON starting doses of 45 mg (cohort A; 45 mg → 15 mg), 30 mg (B; 30 mg →15 mg), and 15 mg (C) once daily. Doses were reduced to 15 mg with achievement of ≤1% BCR-ABL1IS in cohorts A and B. The primary endpoint is ≤1% BCR-ABL1IS at 12 mo; secondary endpoints include cytogenetic and molecular responses and safety outcomes. AOEs were adjudicated prospectively by an independent review committee. Results: 283 pts were randomized (A/B/C: n=94/95/94) and had the following baseline characteristics: median age 48 y (18‒81 y); 98% received ≥2 (55% ≥3) TKIs; 99% had resistant disease; 40% had ≥1 baseline mutations (23% T315I). At the primary analysis with 32 mo median follow-up, 134 pts (47%; n=50/41/43) remained on treatment and 204 pts (72%) had PON exposure ≥12 mo. At 12 mo, 44% (41/93) in A, 29% (27/93) in B, and 23% (21/91) in C achieved ≤1% BCR-ABL1IS (Table); primary endpoint was met by cohort A. Dose reductions to 15 mg after achieving response (A/B) were 48/29%. Most common grades ≥3 TEAEs were thrombocytopenia, 27%; neutropenia, 17%; and anemia, 7%. AOEs/serious AOEs were reported in cohorts A (10%/4%), B (5%/4%), and C (3%/3%). Dose reductions or discontinuations for TEAEs (A/B/C) were 46/35/32% and 19/16/14%, respectively. Conclusions: The OPTIC primary analysis demonstrates the optimal benefit:risk profile for PON was achieved with a response-based dosing regimen starting with 45 mg/d, followed by dose reduction to 15 mg/d upon achieving ≤ 1% BCR-ABL1IS; 30 mg→15 mg and 15 mg cohorts may provide benefit, especially in pts without T315I mutation (Table). The observed ≤1% BCR-ABL1IS responses are supported by robust survival outcomes in pts with CP-CML resistant to second-generation BCR-ABL1 TKI therapy, both with and without BCR-ABL1 mutations. Clinical trial information: NCT02467270. [Table: see text]

Feasibility of Long-term Proteasome Inhibition in Multiple Myeloma by in-class Transition From Bortezomib to Ixazomib

BACKGROUND

The ongoing US MM-6 study is investigating in-class transition (iCT) from parenteral bortezomib-based induction to all-oral IRd (ixazomib-lenalidomide-dexamethasone) with the aim of increasing proteasome inhibitor (PI)-based treatment adherence and duration while maintaining patients' health-related quality of life (HRQoL) and improving outcomes.

PATIENTS AND METHODS

US community sites are enrolling non-transplant-eligible patients with newly diagnosed multiple myeloma (MM) with no evidence of progressive disease after 3 cycles of bortezomib-based therapy to receive IRd (up to 39 cycles or until progression or toxicity). The patients use mobile or wearable digital devices to collect actigraphy (activity and sleep) data and electronically complete HRQoL, treatment satisfaction and medication adherence questionnaires. The primary endpoint is progression-free survival. The key secondary endpoints include response rates and therapy duration.

RESULTS

At the data cutoff, 84 patients had been treated (median age 73 years; 44% aged ≥ 75 years; 49% men; 15% Black or African American; and 10% Hispanic or Latino). Of the 84 patients, 62% were continuing therapy. The mean duration of total PI therapy was 10.1 months and for the IRd regimen was 7.3 months. With an 8-month median follow-up, the 12-month progression-free survival rate was 86% (95% confidence interval, 73%-93%) from both the start of bortezomib-based treatment and the start of IRd. The overall response rate was 62% (complete response, 4%; very good partial response, 25%; partial response, 33%) after bortezomib-based induction and 70% (complete response, 26%; very good partial response, 29%; partial response, 15%) after iCT. The IRd safety profile was consistent with previous clinical trial data, and HRQoL and treatment satisfaction were maintained.

CONCLUSION

The patients included in the US MM-6 study are representative of the real-world US MM population. The use of iCT might permit prolonged PI-based therapy with promising efficacy, without impacting patients' HRQoL or treatment satisfaction.

New Service Model for Common Mental Disorders in Hong Kong: a Retrospective Outcome Study

OBJECTIVE

To review the first 8-month outcome of the Common Mental Disorder Clinic model in Hong Kong in terms of patient exit status and improvement in depressive and anxiety symptoms.

METHODS

During the first appointment, patients were interviewed by a multidisciplinary team comprising a psychiatrist, a psychiatric nurse, and an occupational therapist. A multidisciplinary case conference was conducted to discuss clinical observations, diagnosis, issues of concern, and the optimal individualised treatment plan. Low-intensity interventions by nurses and/or occupational therapists were provided, as were optional, time-limited, protocol-based interventions by clinical psychologists for those with mild to moderate depressive and anxiety symptoms. Pharmacological intervention may be used when indicated. Upon completion of the treatment plan, patients were reassessed by the treating psychiatrist. Discharge options included discharge without psychiatric follow-up, step-up to psychiatric outpatient clinics, and step-down services. The self-administered Patient Health Questionnaire-9 (PHQ-9) and Generalised Anxiety Disorder 7-item scale (GAD-7) were used to assess the past 2 weeks' depressive and anxiety symptoms, respectively, at baseline and at each session.

RESULTS

From July 2015 to February 2016, 1325 Chinese patients received the new service. Of them, 170 men and 363 women (mean age, 52.6 years) completed the treatment plan. After treatment, their mean PHQ-9 score decreased from 11.06 to 7.55 (p < 0.001), and the mean GAD-7 score decreased from 9.94 to 6.54 (p < 0.001). After treatment, 42.4% and 48.2% of the patients were within the normal range of PHQ-9 and GAD-7 scores, respectively, compared with 16.9% and 20.8% before treatment. The mean time to implementation of the individualised treatment plan was 82.33 days. Of the patients, 54.4% were discharged without any need for medical or psychiatric follow-up; 28% were stepped up to psychiatric outpatient clinics; and 17.3% were stepped down. The predictors of exit status were whether psychiatric medication was prescribed during initial intake (p = 0.011), whether psychiatric medication was prescribed at last follow-up (p < 0.001), the service period (p = 0.010), and the GAD-7 final score (p = 0.005).

CONCLUSIONS

The first 8-month outcome of the new service model was encouraging, with shortened waiting time, reduced severity of symptoms, and better exit status (high recovery and step-down rates).

Ixazomib maintenance therapy in newly diagnosed multiple myeloma: An integrated analysis of four phase I/II studies

OBJECTIVES

To evaluate the safety and efficacy of maintenance therapy with the oral proteasome inhibitor ixazomib in patients with newly diagnosed multiple myeloma (NDMM) not undergoing transplantation.

METHODS

Data were pooled from four NDMM phase I/II studies; patients received induction therapy with once- or twice-weekly ixazomib plus lenalidomide-dexamethasone (IRd), melphalan-prednisone (IMP), or cyclophosphamide-dexamethasone (ICd), followed by single-agent ixazomib maintenance, given at the last tolerated dose during induction, until disease progression, death, or unacceptable toxicity.

RESULTS

A total of 121 patients achieved stable disease or better after induction (weekly IRd, n = 25; twice-weekly IRd, n = 18; weekly or twice-weekly IMP, n = 35; weekly ICd, n = 43) and received ≥ 1 dose of ixazomib maintenance. Grade ≥ 3 drug-related adverse events occurred in 24% of patients during maintenance; each event was reported in ≤2% of patients. Rates of complete response were 22% after induction and 35% after maintenance. A total of 28 patients (23%) improved their response during maintenance.

CONCLUSIONS

Ixazomib maintenance following ixazomib-based induction is associated with deepening of responses and a positive safety profile with no cumulative toxicity in patients with NDMM not undergoing transplantation, suggesting that ixazomib is feasible for long-term administration. Phase III investigation of ixazomib maintenance is ongoing.

A phase I/II dose-escalation study investigating all-oral ixazomib-melphalan-prednisone induction followed by single-agent ixazomib maintenance in transplant-ineligible newly diagnosed multiple myeloma

This phase I/II dose-escalation study investigated the all-oral ixazomib-melphalan-prednisone regimen, followed by single-agent ixazomib maintenance, in elderly, transplant-ineligible patients with newly diagnosed multiple myeloma. Primary phase I objectives were to determine the safety and recommended phase II dose of ixazomib-melphalan-prednisone. The primary phase II objective was to determine the complete plus very good partial response rate. In phase I, patients were enrolled to 4 arms investigating weekly or twice-weekly ixazomib (13 28-day cycles or nine 42-day cycles) plus melphalan-prednisone. In phase II, an expansion cohort was enrolled at the recommended phase II ixazomib dose. Of the 61 patients enrolled, 26 received the recommended phase II dose (ixazomib 4.0 mg [days 1, 8, 15] plus melphalan-prednisone 60 mg/m² [days 1-4], 28-day cycles). Of the 61 enrolled patients, 36 (13 of 26 in the recommended phase II dose cohort) received single-agent ixazomib maintenance (days 1, 8, 15; 28-day cycles). In phase I, 10/38 patients reported dose-limiting toxicities in cycle 1, including grade 3 and/or 4 neutropenia (n=6) and thrombocytopenia (n=4). Complete plus very good partial response rate was 48% (48% at recommended phase II dose), including 28% (22%) complete response or better; responses deepened during maintenance in 34% (33%) of evaluable patients. After median follow up of 43.6 months, median progression-free survival was 22.1 months. Adverse events were mainly hematologic events, gastrointestinal events, and peripheral neuropathy. This study demonstrates the feasibility, tolerability, and activity of ixazomib-melphalan-prednisone induction and single-agent ixazomib maintenance in transplant-ineligible newly diagnosed multiple myeloma patients. clinicaltrials.gov identifier 01335685.

Identification of novel genes and transcription factors involved in spleen, thymus and immunological development and function

We constructed and analyzed six serial analysis of gene expression (SAGE) libraries to identify genes with previously uncharacterized roles in spleen or thymus development. A total of 625 070 tags were sequenced from the three spleen (embryonic day (E)15.5, E16.5 and adult) and three thymus (E15.5, E18.5 and adult) libraries. These tags corresponded to 83 182 tag types, which mapped unambiguously to 36 133 different genes. Genes over-represented in these libraries, compared to 115 mouse SAGE libraries (www.mouseatlas.org), included genes of known and unknown immunological or developmental relevance. The expression profiles of 11 genes with unknown roles in spleen and thymus development were validated using reverse transcription-qPCR. We further characterized the expression of one of these candidates, RIKEN cDNA 9230105E10 that encodes a murine homolog of Trim5alpha, in numerous adult tissues and immune cell types. In addition, we demonstrate that transcript levels are upregulated in response to TLR stimulation of plasmacytoid dendritic cells and macrophages. This work provides the first evidence of regulated and cell type-specific expression of this gene. In addition, these observations suggest that the SAGE libraries provide an important resource for further investigations into the molecular mechanisms regulating spleen and thymus organogenesis, as well as the development of immunological competence.

A novel approach of intravenous electrocardiograph technique in correct position the long-term central venous catheter

Intravenous electrocardiograph (IVECG) can correctly positioning the catheter tip by enlarging p wave as it is moved toward right atrium, and it is a safe, reliable and accurate technique. To evaluate the efficacy of wire-conducted IVECG signal and IVECG signal from the port with sodium bicarbonate (NaHCO3) flushed catheter and to compare those with conventional anatomy landmark method was the propose of this study. This prospective study was carried out in 216 patients who suffered from malignant diseases. The correct position of the catheter tip among these groups was confirmed as follows. In group 1 (n = 80), the anatomy landmark method and portable chest radiograph recognized the correct position. In group 2 (n = 72), IVECG signal was conducted from guide wire to identify the tip position. In group 3 (n = 64), IVECG signal was conducted from the port with NaHCO3 (0.8 mEq/mL) flushed catheter to ascertain the tip position. The patient characteristics did not differ significantly among the groups. The duration of operation was significantly (P < 0.001) longer in group 1 than in group 2 and group 3 (45.4 +/- 9.3 minutes vs 35.7 +/- 8.0 minutes and 35.2 +/- 9.7 minutes, respectively). Catheter tip placement times were shorter in group 2 and group 3 than in group 1 (5.3 +/- 2.9 minutes and 6.4 +/- 3.0 minutes vs 16.7 +/- 5.7 minutes, respectively); there was a statistically significant difference between the group 1 and group 2 and group 3 (p < 0.001). Nonetheless, the duration of operation and catheter tip placement time was similar in group 2 and group 3. Early and late complications within the subsequent 3 months showed no significant difference among groups. We concluded that IVECG signal conducted from guide wire obtained a similar efficiency to that signal from the port with NaHCO3 flushed catheter on positioning the catheter tip of the venous Port-A-Cath system. It is recommended to use these methods to facilitate implanting long-term central venous devices.

One-stage microneurovascular free abductor hallucis muscle transplantation for reanimation of facial paralysis

We introduce a new method using abductor hallucis muscle free transplantation for reanimation of the cheek with long-standing facial palsy in six young patients. The muscle is used to reanimate facial palsy because it has many unique advantages: (1) appropriate size and shape of the muscle and adequate bulk, (2) closely parallel alignment and unvaried anatomy of the main vessels and nerve distribution to the muscle, (3) a long neurovascular pedicle, (4) easy surgical isolation of the muscle and its neurovascular pedicle, and (5) no functional deficit after muscle removal. The nerve and muscle grafts can be performed by microneurovascular anastomosis in one surgical procedure. The follow-up period was over 1 year. A satisfactory result was obtained in five of six patients.

Microvascular free flap based on the medial femoral main cutaneous artery

This article introduces a free flap based on the medial femoral main cutaneous artery. Flap transfer was carried out in two cases with complete postoperative success. An anatomical description of the midportion of the medial femoral region, based on magnification and binocular dissection microscope studies is provided, and the operative procedure is described.