Phase II study of the histone deacetylase inhibitor belinostat in thymic malignancies

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Background: Thymic malignancies are rare tumors. Chemotherapy is used for advanced disease. There is no established role of second-line therapy in patients with refractory or recurrent disease. Belinostat is an HDAC inhibitor with activity in cutaneous and peripheral T cell lymphoma and is being investigated in several solid tumors. One prolonged minor response (31 m) was seen in a phase I study of this agent in a patient with thymoma. Methods: Patients with recurrent thymoma or thymic carcinoma, progressing after platinum-based chemotherapy were eligible. They were also required to have measurable disease, PS 0–2 and normal organ functions. Belinostat was given iv at 1.0 g/m2 on days 1–5 of a 21-day cycle until disease progression or intolerable side effects. Correlative markers of activity in blood and tumor were performed. Results: From December 07 to December 08, 22 patients have been accrued from 2 institutions; 12 patients were males, median age 52 (23–72), 14 thymomas and 8 thymic carcinomas, mean number of prior regimens 3.5 (1–10), 16 prior tumor resection and 3 myasthenia gravis. A median of 4 cycles have been given (1–15+). Treatment was well tolerated, with nausea being the most common side effect and well controlled with prophylactic antiemetics. 21 patients are evaluable for response: 2 had a partial response (9+, 9+ m), 13 stable disease (3–11+ m) and 6 progression. No responses were seen in 8 evaluable patients with thymic carcinomas. Acetylated lysine and tubulin were analyzed in lymphocytes and monocytes by multiparameter flow cytometry. An increase of protein acetylation (2–10 fold) over baseline was observed at 1 hour post-infusion on day 3 of the first cycle in all patients analyzed. Other correlative markers are being investigated. Conclusions: The thymoma cohort has been expanded to the second stage of the study. Belinostat has activity in patients with recurrent or refractory thymoma.

No significant financial relationships to disclose.

Effects of glycerol co-solvent on the rate and form of polymer gel dose response

A factor currently limiting the clinical utility of x-ray CT polymer gel dosimetry is the overall low dose sensitivity (and hence low dose resolution) of the system. Hence, active research remains in the investigation of polymer gel formulations with increased CT dose response. An ideal polymer gel dosimeter will exhibit a sensitive CT response which is linear over a suitable dose range, making clinical implementation reasonably straightforward. This study reports on the variations in rate and form of the CT dose response of irradiated polymer gels manufactured with glycerol, which is a co-solvent that permits dissolution of additional bisacrylamide above its water solubility limit (3% by weight). This study focuses on situations where the concentration of bisacrylamide is kept at or below its water solubility limit so that the influence of the co-solvent on the dose response can be explored separately from the effects of increased cross-linker concentration. CT imaging and Raman spectroscopy are used to construct dose-response curves for irradiated gels varying in (i) initial total monomer (%T) and (ii) initial co-solvent concentration. Results indicate that: (i) for a fixed glycerol concentration, gel response increases linearly with %T. Furthermore, the functional form of the dose response remains constant, in agreement with a previous model of polymer formation. (ii) Polymer gels with constant %T and increasing co-solvent concentrations also show enhanced CT response. In addition, the functional form of the response is altered in these gels as co-solvent concentration is increased. Raman data indicate that the fraction of bis-acrylamide incorporated into polymerization, as opposed to cyclization, increases as co-solvent concentration increases. The changes in functional form indicate varying polymer yields (per unit dose), akin to relative fractional monomer/cross-linker (i.e. %C) changes in earlier studies. These results are put into context of the model of polymer formation. The implications of these results on the clinical utility of polymer gels with co-solvent are highlighted.

Efficacy and safety of abatacept or infliximab vs placebo in ATTEST: a phase III, multi-centre, randomised, double-blind, placebo-controlled study in patients with rheumatoid arthritis and an inadequate response to methotrexate

OBJECTIVES

This double-blind trial evaluated the efficacy and safety of abatacept or infliximab vs placebo. The primary objective of this study was to evaluate the mean change from baseline in Disease Activity Score (based on erythrocyte sedimentation rates; DAS28 (ESR)) for the abatacept vs placebo groups at day 197.

METHODS

Patients with rheumatoid arthritis (RA) and an inadequate response to methotrexate (MTX) were randomised 3:3:2 to abatacept ( approximately 10 mg/kg every 4 weeks, n = 156), infliximab (3 mg/kg every 8 weeks, n = 165), or placebo (every 4 weeks, n = 110) and background MTX. Safety and efficacy were assessed throughout the study.

RESULTS

Similar patient demographics and clinical characteristics were present at baseline between groups, with mean scores of approximately 1.7 for HAQ-DI and 6.8 for DAS28 (ESR). At 6 months, mean changes in DAS28 (ESR) were significantly greater for abatacept vs placebo (-2.53 vs -1.48, p<0.001) and infliximab vs placebo (-2.25 vs -1.48, p<0.001). For abatacept vs infliximab treatment at day 365, reductions in the DAS28 (ESR) were -2.88 vs -2.25. At day 365, the following response rates were observed for abatacept and infliximab, respectively: American College of Rheumatology (ACR) 20, 72.4 and 55.8%; ACR 50, 45.5 and 36.4%; ACR 70, 26.3 and 20.6%; low disease activity score (LDAS), 35.3 and 22.4%; DAS28-defined remission, 18.7 and 12.2%; good European League Against Rheumatism (EULAR) responses, 32.0 and 18.5%; and Health Assessment Questionnaire Disability Index (HAQ-DI), 57.7 and 52.7%. Mean changes in physical component summary (PCS) were 9.5 and 7.6, and mental component summary (MCS) were 6.0 and 4.0, for abatacept and infliximab, respectively. Over 1 year, adverse events (AEs) (89.1 vs 93.3%), serious AEs (SAEs) (9.6 vs 18.2%), serious infections (1.9 vs 8.5%) and discontinuations due to AEs (3.2 vs 7.3%) and SAEs (2.6 vs 3.6%) were lower with abatacept than infliximab.

CONCLUSIONS

In this study, abatacept and infliximab (3 mg/kg every 8 weeks) demonstrated similar efficacy. Overall, abatacept had a relatively more acceptable safety and tolerability profile, with fewer SAEs, serious infections, acute infusional events and discontinuations due to AEs than the infliximab group.

TRIAL REGISTRATION NUMBER

NCT00095147.

Estimates of heat stress relief needs for Holstein dairy cows

Estimates of environmental heat stress are required for heat stress relief measures in cattle. Heat stress is commonly assessed by the temperature-humidity index (THI), the sum of dry and wet bulb temperatures. The THI does not include an interaction between temperature and humidity, although evaporative heat loss increases with rising air temperature. Coat, air velocity, and radiation effects also are not accounted for in the THI. The Holstein dairy cow is the primary target of heat stress relief, followed by feedlot cattle. Heat stress may be estimated for a variety of conditions by thermal balance models. The models consist of animal-specific data (BW, metabolic heat production, tissue and coat insulation, skin water loss, coat depth, and minimal and maximal tidal volumes) and of general heat exchange equations. A thermal balance simulation model was modified to adapt it for Holstein cows by using Holstein data for the animal characteristics in the model, and was validated by comparing its outputs to experimental data. Model outputs include radiant, convective, skin evaporative, respiratory heat loss and rate of change of body temperature. Effects of milk production (35 and 45 kg/d), hair coat depth (3 and 6 mm), air temperature (20 to 45 degrees C), air velocity (0.2 to 2.0 m/s), air humidity (0.8 to 3.9 kPa), and exposed body surface (100, 75, and 50%) on thermal balance outputs were examined. Environmental conditions at which respiratory heat loss attained approximately 50% of its maximal value were defined as thresholds for intermediate heat stress. Air velocity increased and humidity significantly decreased threshold temperatures, particularly at higher coat depth. The effect of air velocity was amplified at high humidity. Increasing milk production from 35 to 45 kg/d decreased threshold temperature by 5 degrees C. In the lying cow, the lower air velocity in the proximity of body surface and the smaller exposed surface markedly decrease threshold temperature. The large variation in thresholds due to environmental and animal factors justifies the use of thermal balance-based indices for estimating heat stress. Such an approach may make possible estimates of threshold temperatures at which heat stress relief is required for widely different cattle types and environmental situations.

Extending the Potential of Evaporative Cooling for Heat-Stress Relief

Factors were analyzed that limit the range of environmental conditions in which stress from heat may be relieved by evaporative cooling in shaded animals. Evaporative cooling reduces air temperature (Ta), but increases humidity. Equations were developed to predict Ta reduction as a function of ambient temperature and humidity and of humidity in cooled air. Predictions indicated that a reduction of Ta becomes marginal at humidities beyond 45%. A reduction of Ta lessens with rising ambient Ta. The impact of increasing humidity on respiratory heat loss (Hre) was estimated from existing data published on Holstein cattle. Respiratory heat loss is reduced by increased humidity up to 45%, but is not affected by higher humidity. Skin evaporative and sensible heat losses are determined not only by the humidity and temperature gradient, but also by air velocity close to the body surface. At higher Ta, the reduction in sensible heat loss is compensated for by an increased demand for Hre. High Hre may become a stressor when panting interferes with resting and rumination. Effects of temperature, humidity, air velocity, and body surface exposure to free air on Hre were estimated by a thermal balance model for lactating Holstein cows yielding 35 kg/d. The predictions of the simulations were supported by respiratory rate observations. The Hre was assumed to act as a stressor when exceeding 50% of the maximal capacity. When the full body surface was exposed to a 1.5 m/s air velocity, humidity (15 to 75%) had no significant predicted effect on Hre. For an air velocity of 0.3 m/s, Hre at 50% of the maximum rate was predicted at 34, 32.5, and 31.5 degrees C for relative humidities of 55, 65, and 75%, respectively. Similar results were predicted for an animal with two-thirds of its body surface exposed to 1.5 m/s air velocity. If air velocity was reduced for such animals to 0.3 m/s, the rise in Hre was expected to occur at approximately 25 degrees C and 50% relative humidity. Maximal rates of Hre were estimated at 27 to 30 degrees C when ambient humidity was 55% relative humidity and higher. High humidity may stress animals in evaporative cooling systems. Humidity stress may be prevented by a higher air velocity on the body surface of the animal, particularly in sheltered areas in which the exposed body surface is reduced, such as mangers and stalls. This may extend the use of evaporative cooling to less dry environments.

Lung-surfactant-meconium interaction: in vitro study in bulk and at the air-solution interface

Lung surfactants (LSs) form a monolayer at the lung's alveoli air-solution interface and play a crucial role in making normal breathing possible by reducing the surface tension. LS are affected by various agents that hamper their normal functioning. Tobacco smoke [Bringezu, F.; Pinkerton, K. E.; Zasadzinski, J. A. Langmuir 2003, 19, 2900-2907] and meconium, the first excrement of the newborn, are examples for such LS poison. In neonates, intrauterine aspiration of meconium is a known cause for morbidity and mortality. We studied in vitro the interactions between modified porcine LSs (Curosurf), used as LS replacement, and meconium, as well as between their artificial analogues, phospholipids mixture, and taurocholic acid (TA), respectively. The interactions were examined both in the bulk solution and at the air-water interface, representing the pre- and postnatal situations. It was found that the artificial analogues represent the natural system reliably and exhibit similar effects. TA, a principle component of bile, is an amphiphilic sterol compound in which the hydrophilic and hydrophobic moieties are presented at different faces of the sterol plane. Here we found that TA affects the structure of both monolayers at the interface and surfactant aggregates in solution. A likely poisoning mechanism is by stereoselective penetration of TA into the lamellar or monolayer structures, thus disrupting the contiguous structure of the intact monolayer or the bilayer vesicle structure.

Temperature dependence of the organization and molecular interactions within phospholipid/diacetylene Langmuir films

Surface pressure-area isotherms and Brewster angle microscopy images of mixed binary films of dimyristoylphosphatidylcholine (DMPC) and the diacetylene 10,12-tricosadiynoic acid (TRCDA) were recorded at different temperatures and mole ratios to investigate the molecular interactions and cooperative properties of the films. The experiments revealed that segregation, on the one hand, and significant intermolecular interactions, on the other hand, both contribute to the thermodynamic properties of the phospholipids and the diacetylene assemblies. In particular, the data demonstrate that higher temperatures and greater percentage of DMPC promote repulsion between the liquid-condensed phospholipid monolayer and the TRCDA domains. In contrast, at high TRCDA mole ratios, film contraction occurred (lower molecular areas) due to TRCDA multilayer formation (at high temperature) or intermolecular affinities (at low temperature).

Variations of surfactant monolayer surface density in induced steady wave regime

Fluctuations of an insoluble surfactant concentration along the free liquid surface induced by steady surface waves are considered theoretically. The energy of a waved surface is assumed to consist of surface tension, curvature, and van der Waals energy components. Dependencies of the surface tension and the bending stiffness versus the surfactant concentration are assumed to be linear relative to some reference level. The van der Waals energy is taken in the form of interaction term for a thin film. Minimization of the total energy allows the expression for the deviations of concentration to be obtained. The distribution of a surfactant concentration relative to some reference level has been found to be periodic, with a period that is half of the wave period, and the amplitude of oscillations is a function of a wave number that is very similar to the Landau expansion of the free-energy near the critical point in phase transitions.

Frequency of returning to work one and six months following percutaneous coronary intervention for acute myocardial infarction

We conducted an analysis of the frequency and variables associated with early (after 1 month) and late (after 6 months) return to work after percutaneous coronary intervention for acute myocardial infarction in patients who had been randomized in the Stent Primary Angioplasty in Myocardial Infarction trial. Of 450 patients who were employed before the acute myocardial infarction, 230 (51%) returned to work within 1 month with no increases in in-hospital and 1- or 6-month event rates compared with those who did not return to work. Multivariate analysis showed that predictors of early return to work were employment in the United States, no history of smoking, and single-vessel coronary disease. At 6 months, 353 of 435 patients (78%) had returned to work, and multivariate analysis showed that predictors of late return to work were employment in the United States and absence of angina.

Tissue and External Insulation Estimates and Their Effects on Prediction of Energy Requirements and of Heat Stress

Published data were used to develop improved equations to predict tissue insulation (TI) and external insulation (EI) and their effects on maintenance requirements of Holstein cattle. These are used to calculate lower critical temperature (LCT), energy cost of exposure to temperatures below LCT, and excess heat accumulating in the body at temperatures above LCT. The National Research Council classifies TI by age groups and body condition score; and in the EI equation air velocity effects are linear and coat insulation values are derived from beef animals in cold climates. These lead to low LCT values, which are not compatible with known effects of environment on the performance of Holsteins in warm climates. Equations were developed to present TI as a function of body weight, improving prediction of TI for animals of similar age but differing in body weight. An equation was developed to predict rate of decrease of TI at ambient temperatures above LCT. Nonlinear equations were developed that account for wind effects as boundary layer insulation effects dependent on body weight and air velocity. Published data were used to develop adjustments for hair coat effects on EI in Holstein cows. While by NRC equations, wind has negligible effects on heat loss, the recalculated effects of air velocity on heat loss were consistent with published effects of forced ventilation on the responses of the Holstein cow. The derived LCT was higher by 10 to 20 degrees C than that calculated by NRC (2001) and accounted for known Holstein performance in temperate and warm climates. These equations pointed to tentative significant effects of cold (-10 degrees C) on energy requirements (7 Mcal/d) further increased by 1 m/s wind (15 Mcal/d), even in high-producing cows. Needs for increased heat dissipation and estimating heat stress development at ambient temperatures above the LCT are predicted. These equations can be used to revise NRC equations for heat exchange.

Effects of body surface area estimates on predicted energy requirements and heat stress

The 0.09 x W(0.67) equation (where W = weight in kilograms) used to estimate body surface area (SA) in cattle energy requirements models was developed using measurements of sheep that weighed between 24 and 38 kg. The SA estimates it produced were compared with those of the equation 0.14 x W(0.57), based on Holstein cattle weighing 41 to 617 kg. The estimate of SA produced by the first equation was 23% greater for a 650-kg cow than that obtained by the second equation. The impact of SA estimates on thermal comfort range and development of cold and heat stress effects was calculated, using a thermal balance model, for a 600-kg cow producing 35 kg/d. Predicted metabolic heat production increment at -10 degrees C ambient temperature with 0.5 m/s wind velocity was 0.44 Mcal/d and 1.21 Mcal/d by the first and second equation, respectively. Predicted lower critical temperature (LCT) was -8.7 degrees C by the first equation and -0.6 degrees C by the second equation, an 8 degrees C difference. The LCT difference between SA estimates increased from 4.6 to 9.4 degrees C, with milk production rising from 10 to 45 kg/d. By the first equation, skin nonevaporative heat loss started to decrease at 15 degrees C and became close to nil at and ambient temperature of 35 degrees C, whereas by the second equation, respective values were 10 degrees C and 39 degrees C, a 5 degrees C shift in the estimated temperature at which thermal stress would start developing. The larger SA and skin water loss predicted by the first equation reduced by 50% the respiratory heat loss involved in maintenance of thermal balance at higher temperatures for a 600-kg cow. The second equation seems preferable for Holstein SA estimation since it is based on Holstein cattle data. It provides more adequate estimates of energy requirement in the cold and of heat stress relief needs for Holstein cattle.

Systemic lupus erythematosus-associated pulmonary hypertension: good outcome following sildenafil therapy

A 46-year-old woman with systemic lupus erythematosus (SLE) and concomitant severe pulmonary hypertension (PH) is described. Other secondary causes of PH including thromboembolism, phospholipid syndrome, valvular disease and interstitial pulmonary involvement were ruled out. Owing to her lack of clinical response to conventional therapy, sildenafil was begun at increasing doses up to 400 mg daily. Both clinical and hemodynamic improvement ensued. This appears to be the first clinical report of the use of sildenafil in SLE followed by resolution of severe PH.

Favorable histologic findings and tensile strength at 14 years in knitted polyester aortofemoral and femoropopliteal grafts in the same patient

Patent right and left limbs of an aortobifemoral knitted polyester graft and a patent left femoropopliteal graft, both implanted for 14 years, were removed 40 hr postmortem from a 63-year-old man. Healing studies were performed, using routine and immunocytochemistry staining scanning electron microscopy (SEM), and transmission electron microscopy (TEM) on multiple samples taken from sites sufficiently far from the anastomoses to avoid pannus healing. Evaluation by weight-elongation comparison with a fresh graft demonstrated that structural stability and strength were well preserved. Anastomoses were patent with no remarkable intimal hyperplasia. There was no thrombus on the flow surface of either graft. Histologic studies of these grafts revealed uniform through-wall tissue ingrowth and extensive patches of endothelial cells scattered over the flow surface, confirmed by factor VIII, SEM, and TEM. These findings document that long-term stable tensile strength and healing with flow surface endothelialization can be attained with knitted polyester grafts in the human.

Schizophrenia subgroups differing in dichotic listening laterality also differ in neurometabolism and symptomatology

Schizophrenia patients vary in right ear advantage (REA) on dichotic listening tests for assessing left hemispheric dominance for language processing. The authors examined if patients with low REA differed from other patients in symptoms and in resting brain metabolism. SPECT was conducted during visual fixation for 9 healthy control subjects and 16 schizophrenia patients: 8 with normal and 8 with diminished REA. REA-diminished patients had greater positive symptoms and lower mental status scores (all P<0.05) and had right middle temporal gyrus hypermetabolism. Both schizophrenia groups had decreased right frontal and increased medial temporal lobe metabolism vs. control subjects. REA-diminished patients had right temporal lobe hypermetabolism under a resting condition (eyes open, visual fixation). Results suggest reduced right ear (left hemisphere) advantage for dichotic word perception in schizophrenia is related to a predisposition to overactivate right temporal lobe regions and to positive symptoms. In contrast, the prefrontal-medial temporal imbalance present in both patient groups may typify the schizophrenia syndrome.