Recurrent or metastatic salivary gland tumor (MSGT) patients treated with selinexor, a first in class selective exportin-1 (XPO1) inhibitor

6586

Background: MSGT are rare with limited systemic treatments. This single institution, prospective study in recurrent or metastatic (RM) MSGT involved 2 phases: genomic profiling followed by treatment with either genomically-matched or unmatched therapy. Here we present the results of the unmatched arm for patients (pts) treated with S an oral selective inhibitor of XPO1 that leads to activation of tumor suppressor proteins and retention of oncoprotein mRNAs in the cell nucleus, inducing cancer cell apoptosis. Methods: Patients (pts) with RM-MSGT had archived paraffin embedded tumor samples profiled with targeted next generation sequencing, immunohistochemistry for androgen receptor (AR) and fluorescent in-situ hybridization for HER-2 and ALK. If no actionable mutations were identified or if no matched agents were available, pts with progressive disease could receive S (60mg given twice weekly Q28 days). The study had a simon-2 stage design; 1 partial response in the first 18 pts treated with S, would trigger an additional 7pts to receive S in stage 2. Results: Between July 2014 and April 2019 85 pts were enrolled on study: 73 had sequencing which identified 41 with no actionable mutations and 32 with actionable mutations. 18 pts (10F/8M, median age 61 years [40-79]) were treated with S and included adenoid cystic (n = 8), salivary duct (n = 4), acinic cell (n = 2) and other subtypes (n = 4). Of these 18, 4 pts had actionable aberrations: AR amplification (n = 2), mutations in SMARCB1 (n = 1) and CDKN2A (n = 1). 13pts were treatment naïve, 3pts and 2pts received 1 and 2 or more lines of treatment respectively prior to enrollment: androgen deprivation therapy (n = 2), chemotherapy (n = 3), early phase clinical trials (n = 3). The median number of cycles of S received were 3 (range: 1-19). The best response by RECIST was SD in 13pts (72%) (SD > 6 months (range: 6-18 months) in 5pts (28%); tumor reduction measured in 7pts (39%)), no PRs, PD in 3pts (17%), and 2pts (11%) were not evaluable for response due to insufficient duration of treatment coming off early due to toxicity. The median PFS (95% CI) was 7.6 (3.5-NA) months and the median OS (95% CI) was 15.4 (7.3-NA) months. The most common drug-related toxicities were grade 1-2 fatigue 14pts (78%), nausea 13pts (72%) and dysguesia 10pts (56%). 5 (28%) pts had a dose reduction and 6 (33%) in total had a dose interruption due to toxicity. Conclusions: Single agent antitumor activity was limited and the side effect profile was tolerable. No specific genomic aberration was associated with response to S. Clinical trial information: NCT02069730 .

Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trial

BACKGROUND

Alcohol-related hospital admissions have doubled in the last ten years to > 1.2 m per year in England. High-need, high-cost (HNHC) alcohol-related frequent attenders (ARFA) are a relatively small subgroup of patients, having multiple admissions or attendances from alcohol during a short time period. This trial aims to test the effectiveness of an assertive outreach treatment (AOT) approach in improving clinical outcomes for ARFA, and reducing resource use in the acute setting.

METHODS

One hundred and sixty ARFA patients will be recruited and following baseline assessment, randomly assigned to AOT plus care as usual (CAU) or CAU alone in equal numbers. Baseline assessment includes alcohol consumption and related problems, physical and mental health comorbidity and health and social care service use in the previous 6 months using standard validated tools, plus a measure of resource use. Follow-up assessments at 6 and 12 months after randomization includes the same tools as baseline plus standard measure of patient satisfaction. Outcomes for CAU + AOT and CAU at 6 and 12 months will be compared, controlling for pre-specified baseline measures. Primary outcome will be percentage of days abstinent at 12 months. Secondary outcomes include emergency department (ED) attendance, number and length of hospital admissions, alcohol consumption, alcohol-related problems, other health service use, mental and physical comorbidity 6 and 12 months post intervention. Health economic analysis will estimate the economic impact of AOT from health, social care and societal perspectives and explore cost-effectiveness in terms of quality adjusted life years and alcohol consumption at 12-month follow-up.

DISCUSSION

AOT models piloted with alcohol dependent patients have demonstrated significant reductions in alcohol consumption and use of unplanned National Health Service (NHS) care, with increased engagement with alcohol treatment services, compared with patients receiving CAU. While AOT interventions are costlier per case than current standard care in the UK, the rationale for targeting HNHC ARFAs is because of their disproportionate contribution to overall alcohol burden on the NHS. No previous studies have evaluated the clinical and cost-effectiveness of AOT for HNHC ARFAs: this randomized controlled trial (RCT) targeting ARFAs across five South London NHS Trusts is the first.

TRIAL REGISTRATION

International standard randomized controlled trial number (ISRCTN) registry: ISRCTN67000214, retrospectively registered 26/11/2016.

Autonomous adaptation to climate-driven change in marine biodiversity in a global marine hotspot

While governments and natural resource managers grapple with how to respond to climatic changes, many marine-dependent individuals, organisations and user-groups in fast-changing regions of the world are already adjusting their behaviour to accommodate these. However, we have little information on the nature of these autonomous adaptations that are being initiated by resource user-groups. The east coast of Tasmania, Australia, is one of the world's fastest warming marine regions with extensive climate-driven changes in biodiversity already observed. We present and compare examples of autonomous adaptations from marine users of the region to provide insights into factors that may have constrained or facilitated the available range of autonomous adaptation options and discuss potential interactions with governmental planned adaptations. We aim to support effective adaptation by identifying the suite of changes that marine users are making largely without government or management intervention, i.e. autonomous adaptations, to better understand these and their potential interactions with formal adaptation strategies.

Comparison of Clinical Outcomes Following Patients' First and Second Concussions

Purpose

The objective of this study was to examine differences in self-reported symptoms, neurocognitive performance, and vestibular-ocular insufficiencies between patients’ first and second concussions. A secondary purpose was to explore the role of risk factors on recovery.

Methods

We conducted a retrospective medical chart review of 73 (32-M/41-F) patients aged 15.69 (SD=1.67) years from a concussion specialty clinic with two separate concussions (84.9% of 1st and 79.5% of 2nd sport-related) that occurred between August 2010 and April 2018. Clinical outcomes included the PCSS, ImPACT, and the Vestibular/Ocular Motor Screening (VOMS). A series of paired samples t-tests were used to compare clinical outcomes along with chi-square analyses for risk factor associations.

Results

Verbal memory scores were higher following the second (M=80.67, SD=15.3) (M=76.32, SD=15.65) (t[73]=–2.18, p=.03) concussion. Visual motor processing speed was faster following the second concussion (M=35.04, SD= 7.90) (M=31.35, SD=7.63) (t[73]=–5.72, p<.001). There were no other significant differences observed. Recovery time was similar for the first (61.07, SD=58.41.5) and second (67.91 SD=70.10) respectively, t(70)=–.91, p=.37. There was no relationship between any risk factors, and recovery time for either injury with the exception a significant association between gender and recovery time (>21 days) with the 1st injury for females (χ2, N=73)=10.58, p=.001.

Conclusion

Findings suggest that a second concussion does not result in more pronounced symptoms, worse neurocognitive performance, or increased deficits on vestibular/ocular performance and/or longer recovery time. The only significant risk factor to a recovery over 21 days included gender.

PCNT point mutations and familial intracranial aneurysms

OBJECTIVE

To identify novel genes involved in the etiology of intracranial aneurysms (IAs) or subarachnoid hemorrhages (SAHs) using whole-exome sequencing.

METHODS

We performed whole-exome sequencing in 13 individuals from 3 families with an autosomal dominant IA/SAH inheritance pattern to look for candidate genes for disease. In addition, we sequenced PCNT exon 38 in a further 161 idiopathic patients with IA/SAH to find additional carriers of potential pathogenic variants.

RESULTS

We identified 2 different variants in exon 38 from the PCNT gene shared between affected members from 2 different families with either IA or SAH (p.R2728C and p.V2811L). One hundred sixty-four samples with either SAH or IA were Sanger sequenced for the PCNT exon 38. Five additional missense mutations were identified. We also found a second p.V2811L carrier in a family with a history of neurovascular diseases.

CONCLUSION

The PCNT gene encodes a protein that is involved in the process of microtubule nucleation and organization in interphase and mitosis. Biallelic loss-of-function mutations in PCNT cause a form of primordial dwarfism (microcephalic osteodysplastic primordial dwarfism type II), and ≈50% of these patients will develop neurovascular abnormalities, including IAs and SAHs. In addition, a complete Pcnt knockout mouse model (Pcnt ^-/-) published previously showed general vascular abnormalities, including intracranial hemorrhage. The variants in our families lie in the highly conserved PCNT protein-protein interaction domain, making PCNT a highly plausible candidate gene in cerebrovascular disease.

Comment on "Tracking the global footprint of fisheries"

Kroodsma et al (Reports, 23 February 2018, p. 904) mapped the global footprint of fisheries. Their estimates of footprint and resulting contrasts between the scale of fishing and agriculture are an artifact of the spatial scale of analysis. Reanalyses of their global (all vessels) and regional (trawling) data at higher resolution reduced footprint estimates by factors of >10 and >5, respectively.

Ecology can inform genetics: Disassortative mating contributes to MHC polymorphism in Leach's storm-petrels (Oceanodroma leucorhoa)

Studies of MHC-based mate choice in wild populations often test hypotheses on species exhibiting female choice and male-male competition, which reflects the general prevalence of females as the choosy sex in natural systems. Here, we examined mutual mate-choice patterns in a small burrow-nesting seabird, the Leach's storm-petrel (Oceanodroma leucorhoa), using the major histocompatibility complex (MHC). The life history and ecology of this species are extreme: both partners work together to fledge a single chick during the breeding season, a task that requires regularly travelling hundreds of kilometres to and from foraging grounds over a 6- to 8-week provisioning period. Using a 5-year data set unprecedented for this species (n = 1078 adults and 925 chicks), we found a positive relationship between variation in the likelihood of female reproductive success and heterozygosity at Ocle-DAB2, a MHC class IIB locus. Contrary to previous reports rejecting disassortative mating as a mechanism for maintaining genetic polymorphism in this species, here we show that males make significant disassortative mate-choice decisions. Variability in female reproductive success suggests that the most common homozygous females (Ocle-DAB2*01/Ocle-DAB2*01) may be physiologically disadvantaged and, therefore, less preferred as lifelong partners for choosy males. The results from this study support the role of mate choice in maintaining high levels of MHC variability in a wild seabird species and highlight the need to incorporate a broader ecological framework and sufficient sample sizes into studies of MHC-based mating patterns in wild populations in general.

Biodiversity redistribution under climate change: Impacts on ecosystems and human well-being

Distributions of Earth's species are changing at accelerating rates, increasingly driven by human-mediated climate change. Such changes are already altering the composition of ecological communities, but beyond conservation of natural systems, how and why does this matter? We review evidence that climate-driven species redistribution at regional to global scales affects ecosystem functioning, human well-being, and the dynamics of climate change itself. Production of natural resources required for food security, patterns of disease transmission, and processes of carbon sequestration are all altered by changes in species distribution. Consideration of these effects of biodiversity redistribution is critical yet lacking in most mitigation and adaptation strategies, including the United Nation's Sustainable Development Goals.

Morphological and genetic factors shape the microbiome of a seabird species (Oceanodroma leucorhoa) more than environmental and social factors

BACKGROUND

The microbiome provides multiple benefits to animal hosts that can profoundly impact health and behavior. Microbiomes are well-characterized in humans and other animals in controlled settings, yet assessments of wild bird microbial communities remain vastly understudied. This is particularly true for pelagic seabirds with unique life histories that differ from terrestrial bird species. This study was designed to examine how morphological, genetic, environmental, and social factors affect the microbiome of a burrow-nesting seabird species, Leach's storm petrel (Oceanodroma leucorhoa). These seabirds are highly olfactory and may rely on microbiome-mediated odor cues during mate selection. Composition and structure of bacterial communities associated with the uropygial gland and brood patch were assessed using 16S rRNA amplicon-based Illumina Mi-Seq analysis and compared to burrow-associated bacterial communities. This is the first study to examine microbial diversity associated with multiple body sites on a seabird species.

RESULTS

Results indicate that sex and skin site contribute most to bacterial community variation in Leach's storm petrels and that major histocompatibility complex (MHC) genotype may impact the composition of bacterial assemblages in males. In contrast to terrestrial birds and other animals, environmental and social interactions do not significantly influence storm petrel-associated bacterial assemblages. Thus, individual morphological and genetic influences outweighed environmental and social factors on microbiome composition.

CONCLUSIONS

Contrary to observations of terrestrial birds, microbiomes of Leach's storm petrels vary most by the sex of the bird and by the body site sampled, rather than environmental surroundings or social behavior.

Flight-Test of a Tactile Situational Awareness System in a Land-based Deck Landing Task

The National Research Council of Canada and Defence Research and Development Canada flight-tested the U.S. Naval Aerospace Medical Research Laboratory's Tactile Situational Awareness System (TSAS) in a dynamic task. The TSAS vest uses small pneumatic actuators or ‘tactors’ to transmit information to the pilot. Eleven pilots used the TSAS to cue horizontal axis performance in a land-based deck landing task flown in the NRC Bell 205 helicopter. Pilots tracked a vertically moving target with and without the TSAS in good and degraded visual conditions. The TSAS effectively cued longitudinal fore/aft drifts and reduced RMS error. It had less effect on lateral positioning error, possibly due to the presence of strong visual cues. Pilot situational awareness during degraded visual environment conditions in high sea states was significantly improved by the TSAS, as measured by the China Lake situational awareness rating scale. No change in workload, as measured by Modified Cooper Harper Workload Scale, was attributable to the TSAS use. The improvements in situational awareness and the reduction in longitudinal error suggest that the TSAS would be beneficial for helicopter ship deck landing.

Evaluating control activity as a measure of workload in flight test

This paper describes an investigation of a workload measurement technique based on pilot control movements. The Dynamic Interface Modeling and Simulation System Product Metric (DIMSS PM) assumes that pilot control activity can be used to evaluate pilot workload. Three qualified test pilots flew the fly-bywire NRC Bell 205 helicopter in a short test program that compared the DIMSS PM with subjective workload ratings and handling qualities ratings. The pilots performed a variation of an ADS-33E bob-up with varying levels of simulated turbulence and modified cyclic control characteristics. Good agreement was found for most in-flight test conditions between DIMSS Workload Metric scores and subjective workload ratings from the Bedford Workload Scale and Cooper-Harper handling qualities ratings. While, the DIMSS Workload Metric did not accurately reflect workload increases due to variations in the cyclic stick characteristics, the metric shows promise as an objective measurement tool of pilot workload in well-defined tests.

Is economic valuation of ecosystem services useful to decision-makers? Lessons learned from Australian coastal and marine management

Economic valuation of ecosystem services is widely advocated as being useful to support ecosystem management decision-making. However, the extent to which it is actually used or considered useful in decision-making is poorly documented. This literature blindspot is explored with an application to coastal and marine ecosystems management in Australia. Based on a nation-wide survey of eighty-eight decision-makers representing a diversity of management organizations, the perceived usefulness and level of use of economic valuation of ecosystem services, in support of coastal and marine management, are examined. A large majority of decision-makers are found to be familiar with economic valuation and consider it useful - even necessary - in decision-making, although this varies across groups of decision-makers. However, most decision-makers never or rarely use economic valuation. The perceived level of importance and trust in estimated dollar values differ across ecosystem services, and are especially high for values that relate to commercial activities. A number of factors are also found to influence respondent's use of economic valuation. Such findings concur with conclusions from other studies on the usefulness and use of ESV in environmental management decision-making. They also demonstrate the strength of the survey-based approach developed in this application to examine this issue in a variety of contexts.

Modelling marine community responses to climate-driven species redistribution to guide monitoring and adaptive ecosystem-based management

As a consequence of global climate-driven changes, marine ecosystems are experiencing polewards redistributions of species - or range shifts - across taxa and throughout latitudes worldwide. Research on these range shifts largely focuses on understanding and predicting changes in the distribution of individual species. The ecological effects of marine range shifts on ecosystem structure and functioning, as well as human coastal communities, can be large, yet remain difficult to anticipate and manage. Here, we use qualitative modelling of system feedback to understand the cumulative impacts of multiple species shifts in south-eastern Australia, a global hotspot for ocean warming. We identify range-shifting species that can induce trophic cascades and affect ecosystem dynamics and productivity, and evaluate the potential effectiveness of alternative management interventions to mitigate these impacts. Our results suggest that the negative ecological impacts of multiple simultaneous range shifts generally add up. Thus, implementing whole-of-ecosystem management strategies and regular monitoring of range-shifting species of ecological concern are necessary to effectively intervene against undesirable consequences of marine range shifts at the regional scale. Our study illustrates how modelling system feedback with only limited qualitative information about ecosystem structure and range-shifting species can predict ecological consequences of multiple co-occurring range shifts, guide ecosystem-based adaptation to climate change and help prioritise future research and monitoring.

Information preferences for the evaluation of coastal development impacts on ecosystem services: A multi-criteria assessment in the Australian context

Ecosystem based management requires the integration of various types of assessment indicators. Understanding stakeholders' information preferences is important, in selecting those indicators that best support management and policy. Both the preferences of decision-makers and the general public may matter, in democratic participatory management institutions. This paper presents a multi-criteria analysis aimed at quantifying the relative importance to these groups of economic, ecological and socio-economic indicators usually considered when managing ecosystem services in a coastal development context. The Analytic Hierarchy Process (AHP) is applied within two nationwide surveys in Australia, and preferences of both the general public and decision-makers for these indicators are elicited and compared. Results show that, on average across both groups, the priority in assessing a generic coastal development project is for the ecological assessment of its impacts on marine biodiversity. Ecological assessment indicators are globally preferred to both economic and socio-economic indicators regardless of the nature of the impacts studied. These results are observed for a significantly larger proportion of decision-maker than general public respondents, questioning the extent to which the general public's preferences are well reflected in decision-making processes.

Pulmonary Veno-Occlusive Disease

Pulmonary hypertension is a well-known though poorly characterized disease in veterinary medicine. In humans, pulmonary veno-occlusive disease (PVOD) is a rare cause of severe pulmonary hypertension with a mean survival time of 2 years without lung transplantation. Eleven adult dogs (5 males, 6 females; median age 10.5 years, representing various breeds) were examined following the development of severe respiratory signs. Lungs of affected animals were evaluated morphologically and with immunohistochemistry for alpha smooth muscle actin, desmin, CD31, CD3, CD20, and CD204. All dogs had pulmonary lesions consistent with PVOD, consisting of occlusive remodeling of small- to medium-sized pulmonary veins, foci of pulmonary capillary hemangiomatosis (PCH), and accumulation of hemosiderophages; 6 of 11 dogs had substantial pulmonary arterial medial and intimal thickening. Ultrastructural examination and immunohistochemistry showed that smooth muscle cells contributed to the venous occlusion. Increased expression of CD31 was evident in regions of PCH indicating increased numbers of endothelial cells in these foci. Spindle cells strongly expressing alpha smooth muscle actin and desmin co-localized with foci of PCH; similar cells were present but less intensely labeled elsewhere in non-PCH alveoli. B cells and macrophages, detected by immunohistochemistry, were not co-localized with the venous lesions of canine PVOD; small numbers of CD3-positive T cells were occasionally in and around the wall of remodeled veins. These findings indicate a condition in dogs with clinically severe respiratory disease and pathologic features resembling human PVOD, including foci of pulmonary venous remodeling and PCH.

A Survey of GPs Awareness and Use of Risk Assessment Tools and Cardiovascular Disease Prevention Guidelines

Cardiovascular disease (CVD) is the leading cause of death worldwide. This study aimed to benchmark awareness and use of CVD risk assessment (RA) tools and prevention guidelines in Irish general practice. 493 (18%) Irish general practitioners (GPs) were invited to participate in a cross-sectional study in 2011. 213 (43%) GPs responded with most being male (n = 128, 58.2%) and aged ≥ 45 years (n = 124, 56.8%). While 197 (92.5%) GPs were aware of at least one RA tool, only 69 (32.4%) GPs reported frequent use. 187 (87.8%) GPs were aware of one or more CVD prevention guidelines with 115 (54.0%) GPs reporting frequent use of at least one guideline. No age or gender difference observed. Barriers to implementation of CVD prevention guidelines were lack of remuneration, too many CVD guidelines and time constraints. Most Irish GPs were aware of RA tools and CVD prevention guidelines with half reporting frequent use of guidelines.

Trends in percutaneous coronary intervention and angiography in Ireland, 2004-2011: Implications for Ireland and Europe

BACKGROUND/OBJECTIVES

To study temporal trends in crude and age standardised rates of cardiac catheterisation and percutaneous coronary intervention (PCI) in Ireland, 2004-2011.

METHODS

Two data sources were used: a) a survey of publicly and privately funded hospitals with cardiac catheter laboratories to obtain the annual number of procedures performed and b) anonymised data from the Hospital In-Patient Enquiry (HIPE) for angiography and PCI in acute publicly funded hospitals; age standardised rates were calculated to study trends over time.

RESULTS

From 2004 to 2011 the crude rate of angiography and PCI increased by 47.8% and 35.9% respectively, with rates of 6689 and 1825 per million population in 2011. Following age standardisation, however, PCI activity showed a non-significant decrease over time. The PCI to angiography ratio decreased from 30% to 27% and PCI was performed predominantly for stable coronary heart disease (54%) in 2011.

CONCLUSION

Angiography and PCI rates have increased in Ireland but PCI crude and age adjusted rates show divergent trends. While Ireland differs from USA and UK, with a higher proportion of PCI being performed for stable CHD in recent years, little systematic surveillance of cardiological interventions within Europe is available to benchmark improvements in Ireland.

Primary care in nursing homes revisited: survey of the experiences of primary care physicians

The Irish Health Information and Quality Authority (HIQA) published National Quality Standards for Residential Care Settings for Older People in 2009. We reported on experiences of general practitioners (GPs) in Dublin caring for nursing home patients (NHPs) in 2006. We revisit these experiences following publication of HIQA's standards. 400 GPs received an anonymous postal survey. Of 204 respondents, 145 (71%) felt NHPs required more contact time and 124 (61%) reported more complex consultations compared to other patients. Only 131 (64%) felt adequately trained in gerontology. 143 (70%) reported access to specialist advice, but only 6 (3%) reported a change in this following HIOA standards. 65 (32%) had witnessed substandard care in a NH, of which 16 (25%) made no report, similar figures to 2006. There remains similar levels of concern regarding patient complexity, substandard care, access to specialist support and training in the care of NHPs. Many GPs expressed uncertainty regarding their role in implementing HIQA standards.