Assessment of renal outcome following therapy in monoclonal immunoglobulin deposition disease: Emphasizing the need for a consensus approach

Monoclonal immunoglobulin deposition disease (MIDD), often associated with plasma cell dyscrasias, predominantly affects the kidneys. In this disease, hematologic response (HR) to treatment can be reliably assessed by International Myeloma Working Group (IMWG) consensus criteria, while uniform criteria for assessing renal response are lacking. We report a retrospective analysis of renal outcomes among 34 patients with MIDD. With most patients treated with bortezomib and autologous stem cell transplantation, 26 of 28 (94%) achieved very good partial HR or better. We demonstrate that both IMWG (based on estimated glomerular filtration rate, eGFR) and amyloid (based on proteinuria) criteria are needed to capture renal response: among 28 evaluable patients, 6 (21%) had isolated proteinuria, while 13 (46%) had isolated decreased eGFR. Using both criteria, which were concordant in patients with both decreased eGFR and proteinuria, 22 of 28 patients (79%) achieved a renal response, including 2 of 7 discontinuing dialyses. All 6 patients (100%) with isolated proteinuria and 7 of 13 (54%) with isolated decreased eGFR achieved renal response, suggesting that isolated proteinuria is an early manifestation of MIDD associated with reversible renal damage. Baseline eGFR predicted renal response (p = .02 by quartile) and survival (p = .02), while HR (CR vs. non-CR) did not, probably because of high HR rate. With a median follow-up of 110 months, the median overall survival was 136 months (95% CI: 79-NR) and median renal survival had not been reached. Prospective studies using uniform renal response criteria are needed to optimize the management of MIDD.

Morphological study of the anatomical variations of anterior belly of digastric muscle in Brazilian cadavers

BACKGROUND

Cases of variations in anterior belly of the digastric muscle must be carefully identified to avoid misinterpretations and assist in the correct surgical or aesthetic procedure and help in the teaching of anatomy. The aim of this study was to describe the anatomical variations of anterior belly of digastric muscle in Brazilian cadavers.

MATERIALS AND METHODS

Thirty-one human heads were selected, from adult cadavers (18-80 years, 29 males and 2 females). The morphology of the anterior belly of the digastric muscle was observed, identifying the possible anatomical variations that were characterised and classified according to the amount of muscle bellies, fibre direction and place of origin and insertion. The morphometric measurements were performed using a digital calliper. To analyse the data obtained, photographic documentation, anatomical description and individual morphometric description of each muscle belly were performed. The incidence of anatomical variation was obtained in percentage (%).

RESULTS

The anatomical variation of the anterior belly of the digastric muscle was present in 6 cadavers (19.31%; 1 female and 5 male). All anatomical variations presented an accessory belly to the anterior belly. However, these accessory bellies were configured differently in the location, direction of muscle fibres and in their dimensions (length and width).

CONCLUSIONS

The gross anatomy of the anterior belly of the digastric muscle and their variations is important to assist in surgical procedures, pathological or diagnostic function. In addition, asymmetrical variations in the submental region must be carefully identified to avoid misinterpretations.

Carfilzomib and dexamethasone induction with lenalidomide, clarithromycin and dexamethasone consolidation and lenalidomide maintenance for newly diagnosed multiple myeloma

Combination treatment regimens including a proteasome inhibitor (PI), an immunomodulatory agent (IMiD) and a corticosteroid are standards of care for initial treatment of multiple myeloma (MM). We aimed to evaluate if a sequential treatment program using PI induction followed by IMiD based consolidation and maintenance could achieve similar outcomes with reduced toxicities. This phase 2 study was designed to assess the safety and efficacy of the Car-BiRd regimen: carfilzomib and dexamethasone (Kd) induction until maximum response, followed by lenalidomide, clarithromycin and dexamethasone (BiRd) consolidation until next maximum response, then lenalidomide maintenance in patients with newly diagnosed MM. Seventy-two patients, including both transplant eligible and ineligible patients, were enrolled and evaluated for response. The overall response rate to the Car-BiRd regimen was 94% with 83% of patients achieving a ≥ VGPR and 35% achieving a CR/sCR. The rate of CR/sCR increased from 7% with Kd induction to 21% with BiRd consolidation and 35% with lenalidomide maintenance. These results did not meet the study's target endpoint of a CR rate of 55%. The median PFS using this deferred transplant approach was 37.3 months (95% CI 27.9, 52.7) and median OS was not reached with a median follow-up of 60 months. Toxicities were primarily low grade and manageable. Hematologic toxicities were lower than those expected with a combination PI/IMiD protocol. The sequential Car-BiRd regimen is an effective and safe approach for the upfront treatment of MM including patients unfit for transplant.

Once weekly selinexor, carfilzomib and dexamethasone in carfilzomib non-refractory multiple myeloma patients

Background

Proteasome inhibitors (PIs), including carfilzomib, potentiate the activity of selinexor, a novel, first-in-class, oral selective inhibitor of nuclear export (SINE) compound, in preclinical models of multiple myeloma (MM).

Methods

The safety, efficacy, maximum-tolerated dose (MTD) and recommended phase 2 dose (RP2D) of selinexor (80 or 100 mg) + carfilzomib (56 or 70 mg/m²) + dexamethasone (40 mg) (XKd) once weekly (QW) was evaluated in patients with relapsed refractory MM (RRMM) not refractory to carfilzomib.

Results

Thirty-two patients, median prior therapies 4 (range, 1–8), were enrolled. MM was triple-class refractory in 38% of patients and 53% of patients had high-risk cytogenetics del(17p), t(4;14), t(14;16) and/or gain 1q. Common treatment-related adverse events (all/Grade 3) were thrombocytopenia 72%/47% (G3 and G4), nausea 72%/6%, anaemia 53%/19% and fatigue 53%/9%, all expected and manageable with supportive care and dose modifications. MTD and RP2D were identified as selinexor 80 mg, carfilzomib 56 mg/m², and dexamethasone 40 mg, all QW. The overall response rate was 78% including 14 (44%) ≥ very good partial responses. Median progression-free survival was 15 months.

Conclusions

Weekly XKd is highly effective and well-tolerated. These data support further investigation of XKd in patients with MM.

Foramen tympanicum prevalence in the population of Southeast Brazil: a morphological study in computed tomography scans

BACKGROUND

The foramen tympanicum is located on the anteroinferior region of the external acoustic meatus and posteromedial to the temporomandibular joint in children between the 1st and the 5th year of life. It is considered an anatomical variation when it persists in adults. The aim of this study was to verify the prevalence as well as to characterise the foramen tympanicum in computed tomography (CT) scans of the population from southeastern part of Brazil.

MATERIALS AND METHODS

A total of 78 CT scans of dry human skulls (20 female and 58 male) were used, which were selected randomly regarding the ages, ranged from 15 to 100 years. The foramen tympanicum was identified in the images of the axial plane and confirmed in the images of the coronal and sagittal planes. The largest diameter (in mm) was obtained. The descriptive statistics (in %), Fisher's test and χ2 test were performed to compare the prevalence of foramen tympanicum between sexes and sides. The probability value ≤ 0.05 was defined as a level of significance. Descriptive statistics were performed to verify the mean diameter of the foramen on the right and left sides of the skulls.

RESULTS

The prevalence of foramen tympanicum was higher in females (p = 0.0070), bilaterally, as the absolute values of females were lower in relation to males. Fisher's exact test showed that the prevalence of foramen tympanicum was significantly higher in females (45%) than in males (15.52%). On the right side, the mean axial diameter was 2.23 mm (range 0.93-3.75 mm). On the left side, the mean axial diameter was 2.22 mm (range 0.9-3.61 mm).

CONCLUSIONS

The knowledge of anatomical variations is extremely valuable for an accurate diagnosis, treatment plan and prognosis and a thorough preoperative assessment.

Selinexor containing regimens in patients with multiple myeloma (MM) previously treated with anti-CD38 monoclonal antibodies (αCD38 mAbs)

e20020

Background: Exportin 1 (XPO1) mediates the nuclear export and functional inactivation of tumor suppressor proteins, is required for MM growth, is associated with poor prognosis in MM and mediates resistance to standard MM therapies. Selinexor (SEL) is a first-in-class, oral selective inhibitor of nuclear export (SINE) compound approved in combination with dexamethasone (dex) ± bortezomib for patients (pts) with previously treated MM. Once MM becomes refractory to αCD38 mAb, pts have limited effective treatment options and poor prognosis. Overall response rate (ORR) to the first regimen after refractoriness to an αCD38 mAb is 31%, median progression-free survival (mPFS) is 3.4 months (m), and median overall survival (mOS) is 8.6 m. The doublet SEL-dex (Xd) has shown ORR ̃26% in triple-class (IMID, PI, αCD38 mAb) refractory MM; SEL-based triplets could be more effective in this population. Methods: STOMP (Selinexor and Backbone Treatments of Multiple Myeloma Patients) is a multi-arm, open-label, Phase 1b/2 study evaluating SEL in various triplet combinations. Here, we retrospectively analyzed the efficacy and safety of SEL-containing triplets in pts previously treated with αCD38 mAbs. Pts received SEL-dex (Xd) plus pomalidomide (XPd, n = 19), bortezomib (XVd, n = 4), lenalidomide (XRd, n = 4), daratumumab (XDd, n = 2) or carfilzomib (XKd, n = 18). ORR, mOS, mPFS and adverse events (AEs) were analyzed. Results: Among the 47 pts, median age 64 yrs, female 53%, median time from diagnosis 5.1 yrs, median number of prior regimens 5 (range, 2–11). Prior daratumumab (96%), isatuximab (4%); 96% had MM refractory to aCD38 mAb, 81% had triple-class refractory MM, 74% and 47% were quad- and penta-exposed, 43% and 15% had quad- and penta-refractory MM. αCD38 mAb was included in the immediate prior regimen of 57% of pts and median duration from end of most recent aCD38 mAb therapy to first dose of study treatment was 6.9 weeks (range, 2.6-114.9). ORR was 51% among the 45 evaluable pts, 59% in the XPd arm (n = 17; 2 pts were not efficacy evaluable) and 67% in the XKd arm. ORR was 47% (9/19) among pts with quad-refractory MM and evaluable efficacy. Among all evaluable pts mPFS was 8.8 m (95% CI: 4.9, NE) and mOS was 20.4 m (95% CI: 9.6, NE). Among the 25 pts with αCD38 mAb in their immediate prior regimen, efficacy was similar to that regimen: ORR 52% vs. 45%, mPFS 8.8 vs. 9.3 m. The most common treatment emergent AEs were nausea (72%), anemia (64%), thrombocytopenia (60%), fatigue (57%), which were managed with standard supportive care and dose modifications. Conclusions: SEL-containing triplets in pts with MM previously treated with αCD38 mAbs, most of whom had triple-class refractory MM, exhibit tolerability and comparable effectiveness to their most recent αCD38 mAb-containing regimens. Compared to historical control, mOS was much higher among these patients. Further investigation is warranted. Clinical trial information: NCT02343042.

Treatment response among patients with multiple myeloma initiating daratumumab across different lines of therapy: A real-world chart review study

e18737

Background: Daratumumab (DARA), a CD38 monoclonal antibody, has been approved for the treatment of multiple myeloma (MM) among previously-treated patients since 2015, and among newly-diagnosed patients since 2018. This study aimed to describe real-world treatment response among patients initiating DARA across different lines of therapy since 2018. Methods: A retrospective chart review of adult patients with MM initiating DARA (monotherapy or as part of a combination regimen) between 1/2018 and 5/2020 was conducted at two clinical sites in the US (Levine Cancer Institute & Weill Cornell Medical College). De-identified patient-level data were abstracted in an electronic case report form. Treatment patterns, overall response rate (ORR) and proportion of patients with very good partial response (VGPR) or better were reported using descriptive statistics and stratified by line of therapy (first line [1L], second line [2L] or third line or later [3L+]). Results: A total of 202 patient charts were extracted. Patients were, on average, 65.3 years old at MM diagnosis and 68.1 years old at DARA initiation; 109 (54.0%) were male; 104 (51.5%) were White and 65 (32.2%) were Black or African American; 64 (31.7%) received a stem cell transplant (SCT) prior to the line of DARA initiation. Twenty-one (10.4%), 53 (26.2%) and 128 (63.4%) patients initiated DARA in 1L, 2L and 3L+, respectively. Median follow-up time was 6.2 months for 1L patients and 13.8 months for 2L+ patients. The most common 1L regimen was DARA with bortezomib, lenalidomide ± dexamethasone (DVRd; n=10, 47.6%) followed by DARA with lenalidomide ± dexamethasone (DRd; n=8, 38.1%). The most common 2L regimen was DRd (n=15, 28.3%) followed by DARA with pomalidomide ± dexamethasone (DPd, n=13, 24.5%) and DARA with bortezomib ± dexamethasone (DVd, n=13, 24.5%). The most common regimen in 3L+ was DPd (n=62, 48.4%). Among patients initiating DARA in 1L, 2L or 3L+ the ORR was 100.0%, 81.6% and 76.0%, and the proportion of patients achieving VGPR or better was 73.3%, 65.8% and 51.0%, respectively (Table 1). Median time to treatment response ranged between 2.6 and 2.8 months post-initiation. Conclusions: In this study, patients initiated on DARA had high ORR and rates of VGPR or better, including an ORR of 100% among 1L DARA users. These findings suggest that DARA-based regimens are an effective treatment option across all lines of therapy, with highest response rate in 1L. [Table: see text]

Oral selinexor, pomalidomide, and dexamethasone (XPd) at recommended phase 2 dose in relapsed refractory multiple myeloma (MM)

8018

Background: Exportin 1 (XPO1) mediates the nuclear export and functional inactivation of tumor suppressor proteins (TSPs), is associated with poor prognosis in MM, and contributes to proteasome inhibitor (PI) and immunomodulatory drug (IMiD) resistance. Selinexor (SEL) is a novel, oral, first-in-class selective inhibitor of nuclear export (SINE) compound that blocks XPO1, forcing the nuclear retention and activation of TSPs. SEL is approved with low-dose dexamethasone (dex) ± bortezomib (BOR) for patients (pts) with previously treated MM. In the Phase 3 BOSTON study, once weekly (QW) SEL, QW BOR, and dex (XVd) significantly increased progression-free survival (PFS) and overall response rate (ORR) with marked reduction of peripheral neuropathy as compared to standard twice weekly BOR/dex (Vd), despite XVd utilizing 40% less BOR and 25% less dex than Vd. Pomalidomide (POM) plus dex (Pd) has an ORR of 31% and median PFS (mPFS) of 4 months in MM pts refractory to BOR and lenalidomide (LEN). We hypothesized that the addition of once weekly SEL to Pd (XPd) would be an active, all-oral combination with an acceptable safety profile in pts with LEN refractory and BOR treated MM. Methods: In the SPd arm of the multi-arm Phase 1b/2 STOMP study, SEL was evaluated at 60, 80, or 100 mg QW or 60 or 80 mg twice weekly in combination with Pd. Study objectives were to determine the maximum tolerated dose and recommended Phase 2 dose (RP2D), and assess the safety and activity of the SPd regimen including in pts receiving the RP2D. Results: As of 4 Jan 2021, 65 pts (33 male) were enrolled with median age of 64 years (range 37-85 years) and median of 3 (range 1-10) prior lines of therapy. Previously treated/refractory rates were LEN 100%/85%, BOR 92%/49%, carfilzomib 43%/37%, POM 31%/29%, and daratumumab (dara) 26%/26%. RP2D was SEL 60 mg QW, POM 4 mg (days 1-21), dex 40 mg QW. Common hematologic, treatment-related adverse events (TRAEs) included (all grades, grades ≥3) neutropenia (63%, 55%), anemia (58%, 32%), and thrombocytopenia (54%, 31%). Non-hematologic TRAEs included nausea (62%, 2%), fatigue (55%, 11%), and decreased appetite (45%, 2%). Among POM naïve or nonrefractory MM pts (N = 44), ORR was 57% (1 sCR, 1 CR, 8 VGPR, 15 PR); mPFS was 12.2 months. In pts treated with RP2D (N = 20), ORR was 65% (1 sCR, 5 VGPR, 7 PR); mPFS was not reached with a median follow-up time of 3.9 months. In POM-refractory pts and those with prior dara, ORR was 44% (7/16) and 60% (9/15), respectively. Conclusions: SEL, once weekly, can be safely combined with Pd in pts with heavily pretreated MM. No new safety signals were identified. The all-oral combination of XPd is highly active with an ORR of 65% at RP2D (compared to expected ORR ≤30% for Pd) and produces durable responses with a mPFS of 12.2 months overall. These data support a planned Phase 3 study with an all-oral combination of XPd vs Pd in pts who have been previously treated with LEN, a PI, and an anti-CD38 mAb. Clinical trial information: NCT02343042.

Once weekly selinexor, carfilzomib, and dexamethasone (XKd) in carfilzomib nonrefractory multiple myeloma (MM) patients

8038

Background: Exportin 1 (XPO1) mediates the nuclear export and functional inactivation of tumor suppressor proteins (TSPs), is associated with poor prognosis in MM, and contributes to proteasome inhibitor (PI) and immunomodulatory drug (IMiD) resistance. Selinexor (SEL) is a novel, oral, first-in-class selective inhibitor of nuclear export (SINE) compound that blocks XPO1, forcing the nuclear retention and activation of TSPs. SEL in combination with low dose dexamethasone (dex) ± bortezomib (BOR) is FDA approved for previously treated MM. The synergy of SEL with the PI BOR has been confirmed in the phase 3 BOSTON study in MM patients (pts) with 1-3 prior therapies; once weekly (QW) SEL, QW BOR, and dex (XVd) significantly increased progression-free survival (PFS), time to next therapy, and overall response rate (ORR) as compared to standard twice weekly BOR/dex (Vd), despite XVd using 40% less BOR and 25% less dex than standard Vd. We hypothesized that the addition of QW SEL to the PI carfilzomib (CAR)-dex (XKd) would be an active and tolerable regimen in pts with heavily pretreated MM. Methods: In the XKd arm of the multi-arm Phase 1b/2 STOMP study, SEL at 80 or 100 mg QW was evaluated in combination with CAR at 56 or 70 mg/m2 QW plus dex at 40 mg QW in pts with heavily pretreated MM not refractory to CAR. Study objectives were to determine the maximum tolerated dose and recommended phase 2 dose (RP2D) and assess the safety and activity of the XKd regimen. Results: As of 4Jan2021, 27 pts were enrolled: 18 (67%) were male, median age 71 years (range 50-76), and median of 4 (range 1-8) prior lines of therapy. All 27 pts were previously treated with BOR, 26 (96%) lenalidomide (LEN), 19 (70%) pomalidomide (POM), 18 (67%) daratumumab (dara). The majority (67%) of pts were triple-class pretreated (PI, IMiD, and anti-CD38 mAb), and 44% had triple-class refractory MM. Nine pts (33%) had MM quad-refractory to BOR, LEN, POM, and dara. Common hematologic treatment-related adverse events (TRAEs) (total, grade ≥3) included thrombocytopenia (74%, 56%), anemia (59%, 19%), and neutropenia (30%, 7%). Non-hematologic TRAEs included nausea (67%, 4%), fatigue (52%, 7%), and anorexia (52%, 4%). RP2D was identified as SEL 80 mg QW, CAR 56 mg/m2 QW, and dex 40 mg QW. As of 3Feb2021, ORR was 78% (21/27) with 5 pts reaching CR (19%), 8 VGPR (30%), and 8 PR (30%). Median PFS was 23.7 months. Among 18 pts pretreated with dara, ORR was 67% and median PFS 23.7 months. In 9 pts whose MM was refractory to BOR, LEN, POM, and dara, ORR was 67% with 4 VGPR (44%). Conclusions: In pts with heavily pretreated MM, weekly XKd is highly active with an ORR of 78% and deep responses (≥VGPR 48%) with an overall PFS of 23 months. All AEs including grade 3/4 thrombocytopenia can be managed with appropriate supportive care and dose modifications. These data support further investigation of XKd in pts with previously treated MM including those previously treated with dara.

High-dose lenalidomide and melphalan as conditioning for autologous stem cell transplantation in relapsed or refractory multiple myeloma

8021

Background: Autologous stem cell transplantation (ASCT) remains a standard of care of eligible patients with multiple myeloma, despite the many novel therapies introduced over the past decade. High dose melphalan (HDM) is the only approved regimen to date. Lenalidomide (LEN) is an oral immunomodulatory drug which has become the backbone of myeloma therapy from induction through salvage and maintenance. Early studies noted a dose response relationship, and found myelosuppression to be the dose limiting toxicity. We previously reported on our phase 1 study of high dose lenalidomide (HDLEN) with HDM in conditioning for ASCT, where no DLT was noted up to 350mg PO daily of LEN. Here we report the phase 2 data of patients undergoing ASCT with combination conditioning regimen. Methods: 50 patients with relapsed/refractory multiple myeloma (RRMM) underwent ASCT using HDLEN+HDM conditioning. HDLEN was dosed at 350mg PO daily from day -5 to day -1 and HDM was dosed 100mg/m2 on days -2 and -1. TPatients were heavily pre-treated: 32% had prior HDM-ASCT, 96% had received prior lenalidomide, and 42% prior pomalidomide; 40% prior anti-CD38 mAB. Of note, 68% entered the study with progressive disease at time of enrollment. Results: Overall response rate was 96%, with 80% being ≥VGPR. Median progression free survival (PFS) was noted at 14.3 months, while overall survival (OS) was 68.2 months. PFS was similar when patients were stratified by prior ASCT, depth of response at enrollment, or presence of high risk FISH. Toxicities were mostly hematologic (100% neutropenia and thrombocytopenia, 90% anemia), GI (88% diarrhea, 72% nausea, 42% vomiting) and metabolic (30-96% derangement in electrolytes), and similar to historical controls receiving HDM alone. Second malignancies were noted in 2 patients. Conclusions: HDLEN/HDM is a well tolerated and effective conditioning regimen for ASCT in patients with RRMM. This regimen merits further investigation as ASCT is likely to remain an integral part of the treatment of RRMM patients, yet few advancements have been made to this modality. HDLEN may be particularly useful in patients with high risk disease and those progressing after multiple lines of therapy. HDLEN added little toxicity to HDM and SPMs were not more frequent than expected per SEER database for patients in this age range. Clinical trial information: NCT01054196. [Table: see text]

Plasma Cell Myeloma Presenting With Amyloid-Laden Crystal-Negative Histiocytosis

OBJECTIVES

Crystal-storing histiocytosis (CSH) is rare in plasma cell dyscrasias, with only 3 cases reported in the setting of amyloid. No cases of crystal-negative histiocytosis coincident with multiple myeloma and amyloidosis have been reported previously.

METHODS

A 58-year-old woman presented with pain due to destructive bone lesions and was found to have plasma cell myeloma (PCM) and marrow amyloid deposition associated with crystal-negative histiocytosis. Differential diagnoses included Langerhans cell histiocytosis, Erdheim-Chester disease, and Rosai Dorfman disease. BRAF mutations were negative, and there was no evidence of paraprotein crystals, arguing against typical CSH.

RESULTS

The patient was treated with bortezomib, cyclophosphamide, and dexamethasone, and she subsequently underwent autologous stem cell transplant and ixazomib maintenance. She achieved complete remission with improvement of her symptoms and preserved remission after following up at 60 months.

CONCLUSIONS

We describe a case of crystal-negative histiocytosis associated with PCM. CSH is a rare disorder associated with paraprotein-producing conditions in which immunoglobulins aggregate as intracellular crystals in the lysosomes of organ-specific phagocytic macrophages. Light chain tropism in PCM can also lead to the development of amyloid deposition in organs and, in rare cases, is associated with light chain aggregation as intracellular crystals in macrophages.

Human identification by the analysis of palatal rugae printed in complete dentures

The study of palatal rugae is shown to be scientifically valid to human identification due to the unique number and style of the palatal ridges. Dentures provide an array of data and specifics that allow for the individualization of their wearers. This article describes the identification of edentulous, skeletonized remains through the analysis of the palatal rugae printed on the complete upper denture and subsequent comparison with the palatal rugae of an old complete denture of an unknown missing person. The analyses focus on the form, classification, location, and size of the palatal rugae which, in conjunction with the information obtained from the anthropological examination, resulted in a positive identification of the cadaver. This method has a significant impact on the identification process, particularly when other identification methodologies and techniques cannot be implemented. This case report highlights the importance of palatal rugae in human identification in cases of edentulous cadavers.

Once weekly selinexor, carfilzomib, and dexamethasone (SKd) in patients with relapsed/refractory multiple myeloma (MM)

8530

Background: Selinexor is a novel, first-in-class selective inhibitor of nuclear export (SINE), which blocks exportin 1 (XPO1), forcing the nuclear retention and activation of tumor suppressor proteins. Selinexor in combination with low dose dexamethasone (Sel-dex) was approved by the FDA, based on data from the STORM study wherein Sel-dex induced an overall response rate (ORR) of 26.2% in patients (pts) with refractory MM. We hypothesize that once weekly (QW) SKd may be an active well tolerated regimen and evaluated this combination in a dose escalation/expansion study. Methods: STOMP is a phase 1b/2 study evaluating various doses and enrolled pts with carfilzomib naive relapsed MM. Oral selinexor was dosed QW at 80 or 100 mg. Carfilzomib was dosed QW (on days 1, 8 and 15 of 28-day cycle) at 56 mg/m2 or 70 mg/m2. Dexamethasone was dosed at 40 mg QW. The primary objectives of the study are to assess the maximum tolerated dose (MTD), recommended phase 2 dose (RP2D), as well as explore the efficacy and safety of SKd. Results: As of January 2020, 18 pts were enrolled. Median age was 71 years (range: 50-76). Median number of prior regimens was 4 (range: 1-8). All pts (n = 18) were previously treated with bortezomib and lenalidomide, and 50% and 56% pts were refractory to bortezomib and lenalidomide respectively. Nine (50%) pts received prior pomalidomide treatment and 8 (44%) pts were refractory. Eleven (61%) pts received prior daratumumab treatment and 9 (50%) were refractory. The MTD was selinexor 80 mg QW, carfilzomib 56 mg/m2 QW and dexamethasone 40 mg QW. The ORR and CBR were 72% and 79% respectively with 4 complete responses, 7 very good partial responses, 2 partial responses, and 1 minimal response. Stable disease was observed in 3 pts. With a median follow-up period of 4.7 (1.8-16.3) months, median progression-free survival has not been reached. Common treatment-related adverse events (total, Grade ≥3) were thrombocytopenia (83.3%, 66.7%), nausea (66.7%, 0%), anemia (55.6%, 11.1%), fatigue (50%, 11.1%), anorexia (44%, 5.6%), weight loss (44%, 0%), and neutropenia (33.3%, 11.1%). Conclusions: Once weekly SKd demonstrated an encouraging ORR of 72% in pts with a median of 4 lines of prior therapy. The majority of responses are deep and predominantly CR and VGPR. The combination is well tolerated with no new safety signal, no Grade ≥3 nausea, vomiting, diarrhea, weight loss or anorexia. The side effects are a function of the dose and schedule and can be managed with dose modification and supportive care. Enrolment is ongoing and supports a phase 3 study of SKd. Clinical trial information: NCT02343042 .

Selinexor, daratumumab, and dexamethasone in patients with relapsed/refractory multiple myeloma (MM)

8510

Background: Selinexor is a first-in-class oral Selective Inhibitor of Nuclear Export (SINE) compound that binds and inactivates exportin 1 (XPO1). Selinexor in combination with low dose dexamethasone (Sel-dex) was approved by the FDA, based on data from the STORM study, wherein Sel-dex induced an overall response rate (ORR) of 26.2% in patients (pts) with relapsed/refractory MM (RRMM). Single agent daratumumab has demonstrated an ORR of 29% in MM reftactory to proteasome inhibitors (PIs)/immunomodulatory drug (IMiDs). We evaluated the safety, tolerability and preliminary efficacy of the combination of Sel-dex and daratumumab (SDd) in pts with MM refractory to PIs/IMiDs. Methods: This is a multicenter, open-label, phase 1b/2 dose escalation and expansion study. Pts were eligible if they had received ≥ 3 prior lines of therapy, including a PI and an IMiD, or whose MM was refractory to a PI and an IMiD. In the expansion phase, pts were required to be anti-CD38 monoclonal antibody-naïve. One dose level was tested at each schedule: selinexor once-weekly (QW at 100 mg) or twice-weekly (BIW at 60 mg) with dexamethasone 40 mg. Daratumumab 16 mg/kg IV was administered per label. Primary objective was to determine the maximum tolerated dose and recommended phase 2 dose (RP2D), and assess safety, tolerability and efficacy of SDd in pts with RRMM. Results: A total of 34 pts were enrolled; 3 in the 60 mg BIW and 31 in the 100 mg QW cohorts. Median age was 69 and median number of prior treatment regimens was 3 (range, 1–10). Out of 34 pts, 62% and 65% were refractory to bortezomib and lenalidomide respectively. Common treatment related adverse events (all grades, grades 3/4) included: thrombocytopenia (71%, 47%), fatigue (62%, 18%), nausea (71%, 9%), anemia (62%, 32%) and neutropenia (50%, 26%). Two dose limiting toxicities (DLTs) were reported in the 60 mg BIW cohort: Grade 3 thrombocytopenia and Grade 2 fatigue requiring dose reduction in selinexor to 100 mg QW. In the 100 mg QW escalation cohort (n = 6), no DLTs occured. 32 patients were evaluable for efficacy. The ORR was 73% (11 VGPR, 11 PR) for 30 daratumumab-naïve pts. Median progression-free survival was 12.5 months in both groups. Conclusions: Based on tolerability and efficacy, the RP2D of SDd is selinexor 100 mg, daratumumab 16 mg/kg and dexamethasone 40 mg, administered QW. In pts with PI and IMiD refractory MM, weekly SDd demonstrated promising activity with an ORR of 73% in daratumumab-naïve pts and a median PFS of 12.5 months. This supports further development of a novel non-PI, non-IMiD backbone in earlier lines of therapy. Clinical trial information: NCT02343042 .

Prospective study to measure the impact of MMprofiler on treatment intention in newly diagnosed multiple myeloma patients (PROMMIS)

8030

Background: Multiple Myeloma (MM) is recognized as a heterogeneous group of patients with varying response and outcome of their disease, associated with various risk factors including genetic aberrations. Risk adapted treatment strategies are beginning to emerge (e.g. mSMART), which include gene expression signatures. SKY92, a 92-gene prognostic signature, classifies MM patients as “high” or “standard” risk. It has been reported to be a robust predictor for Overall and Progression Free Survival (Kuiper 2012, 2015). Here we report the preliminary impact of SKY92 on risk classification and treatment intention decisions in newly diagnosed MM patients enrolled in the PRospective Observational Multiple Myeloma Impact Study (PROMMIS). Methods: Patients with MM had their BM aspirate analyzed using the MMprofiler with SKY92. The physician completed questionnaires with his/her treatment intention, before and after knowing SKY92 results. Results: 39 MM patients were enrolled from 5 US centers. The SKY92 signature classified 15 patients (38%) as high risk. Prior to knowing SKY92 results, physicians regarded 20 (51%) patients as clinically high risk, for whom SKY92 indicated 12 patients to be standard risk. Upon revealing SKY92, 8 patients were then considered standard risk by the physician. For 2 patients with concordant high risk classification results, the confirmation of the risk classification was considered helpful. The impact of treatment intention decisions in clinical high risk patients was 40% (8 out of 20). In the 19 patients (49%) that were regarded clinically standard risk prior to knowing SKY92, SKY92 indicated 7 patients to be high risk. Physicians agreed to this classification. For 4 patients with concordant risk classification, the confirmation was found helpful. The impact of treatment intention decisions in clinical standard risk patients was 37% (7 out of 19). Conclusions: Preliminary results from the PROMMIS trial indicate that SKY92 impacts the physician’s treatment intention for 38% of patients with newly diagnosed MM. Moreover, the physicians found the SKY92 result useful for 54% of the patients. This underlines the relevance and need for assessment of SKY92 in MM patients, and associated risk stratified treatment paradigm. Clinical trial information: NCT02911571.

Phase II study of carfilzomib and dexamethasone therapy for newly diagnosed multiple myeloma

Carfilzomib and dexamethasone (Kd) has significant activity in relapsed and refractory multiple myeloma. Kd has not previously been evaluated in newly diagnosed multiple myeloma (NDMM). We report a single-arm phase 2 study of 72 patients with NDMM to evaluate the efficacy and tolerability of Kd induction. Carfilzomib was administered in two dosing cohorts with dosing of 20/45 mg/m² in the first 25 patients and 20/56 mg/m² in the subsequent 47 patients. Carfilzomib was administered on days 1, 2, 8, 9, 15 and 16 of a 28-day cycle, dexamethasone 20 mg was administered orally on days 1, 2, 8, 9, 15, 16, 22 and 23. Treatment was continued to maximum response, progression of disease, or regimen intolerability. Endpoints included overall response rate (ORR), regimen toxicity and impact of carfilzomib on CD34+ stem cell collection yield. Sixty-five pts achieved at least a partial response (PR) for an ORR of 90%. The maximum response achieved was complete response or better in 5 (7%), very good partial response (VGPR) in 42 (58%), PR in 18 (25%) and stable disease in 7 pts (10%). Toxicities were predominantly low grade with 547 grade 1/2 adverse events and 44 grade ≥3 events. The rate of grade ≥3 cardiovascular adverse events was 11.1% with eight observed events. The activity of Kd described represents the highest rate of overall response and ≥VGPR for any 2-agent combination in NDMM reported to date. Kd demonstrated a safety profile consistent with previously reported carfilzomib studies.

Health related quality of life for multiple myeloma patients according to treatment strategy after autologous stem cell transplant: a cross-sectional study using EORTC, EQ-5D and MY-20 scales

Maintenance (MT) may be prescribed after autologous stem cell transplant (ASCT) but there are often concerns about the impact on quality of life (QoL). QoL was compared between baseline patients (30-100 days post-ASCT and had not commenced MT); MT patients (>100 days post-ASCT and receiving MT), and no MT (>100 days post-ASCT and not receiving MT). Patients completed the EuroQoL five dimension (EQ-5D), the European Organization for Research and Treatment of Cancer QoL Questionnaire Core 30 (EORTC QLQ-C30), and the QoL Questionnaire Myeloma 20 module (QLQ-MY20). Differences between groups were explored with ordinary least squares regressions. Across US and Canada, 303 patients participated. Regression analyses found few differences between MT and no MT. Only diarrhea (EORTC-QLQ C30) and future perspectives (MY-20) domains differentiated; patients on MT scored worse for diarrhea (+9.43; p = .0358) and future perspectives (-11.39; p = .0196). Collectively, the results suggest that MT is not associated with a notable QoL detriment.

Additional value of fetal magnetic resonance imaging in the prenatal diagnosis of central nervous system anomalies: a systematic review of the literature

OBJECTIVES

To analyze literature on the additional value of fetal magnetic resonance imaging (MRI) in assessing central nervous system (CNS) anomalies suspected by ultrasound.

METHODS

A search was performed of PubMed, EMBASE, Cochrane library and the reference lists of identified articles. Inclusion criteria were CNS anomalies suspected/diagnosed by ultrasound, MRI performed after ultrasound, and postmortem examination by autopsy or postnatal assessment. MOOSE guidelines were followed. Outcomes assessed were positive/negative agreement between ultrasound and MRI, additional information provided by MRI, and discordance between ultrasound and MRI. Pooled sensitivity and specificity of MRI were calculated using the DerSimonian-Laird method. Postnatal/postmortem examinations were used as the reference standard.

RESULTS

We identified thirteen articles which included 710 fetuses undergoing both ultrasound and MRI. MRI confirmed ultrasound-positive findings in 65.4% of fetuses and provided additional information in 22.1%. MRI disclosed CNS anomalies in 18.4% of fetuses. In 2.0% of cases, ultrasound was more accurate than MRI. In 30% of fetuses, MRI was so different from ultrasound that the clinical management changed. Agreement was observed mainly for ventriculomegaly (51.3%). Disagreement was noted mainly for midline anomalies (48.6%). Pooled sensitivity of MRI was 97% (95% CI, 95-98%) and pooled specificity was 70% (95% CI, 58-81%).

CONCLUSIONS

MRI supplements the information provided by ultrasound. It should be considered in selected fetuses with CNS anomalies suspected on ultrasound.

Thalidomide, clarithromycin, lenalidomide and dexamethasone therapy in newly diagnosed, symptomatic multiple myeloma

We studied T-BiRD (thalidomide [Thalomid(®)], clarithromycin [Biaxin(®)], lenalidomide [Revlimid(®)] and dexamethasone) in symptomatic, newly diagnosed multiple myeloma. In 28-day cycles, patients received dexamethasone 40 mg/day on days 1, 8, 15, 22, clarithromycin 500 mg twice daily on days 1-28; lenalidomide 25 mg/day on days 1-21; and thalidomide 100 mg/day (50 mg/day on days 1-7 of cycle 1 only) on days 1-28. Twenty-six patients received a median of 6 cycles (range 0-41). Overall response rate (ORR) was 80% for the group and 100% in 11 patients who underwent autologous stem cell transplantation as part of first-line therapy. The 4-year overall survival rate was 74.9%, and the median progression-free survival was 35.6 months. Eight patients discontinued due to regimen toxicity. Grade 3 non hematologic toxicity affected 12 patients (46.2%). T-BiRD is a highly active regimen with potential toxicity limitations. ClinicalTrials.gov identifier: NCT00538733.

Impact of cord entanglement on perinatal outcome of monoamniotic twins: a systematic review of the literature

OBJECTIVE

To review the current literature concerning perinatal outcome of monoamniotic pregnancies with cord entanglement.

METHODS

A search in PubMed, EMBASE and MEDLINE for articles published between January 2000 and December 2011 was performed, using the following keywords: monoamniotic/monochorionic pregnancy(ies); twins; cord entanglement; fetal ultrasound/surveillance. Inclusion criteria for the study were: monoamniotic twins with documented cord entanglement at delivery, and perinatal outcome reported as proportional rates. Exclusion criteria were: higher-order multiple pregnancy; selective feticide; presence of twin reversed arterial perfusion sequence; conjoined twins; fewer than four cases in the series; and non-English language publication. Survival rates were stratified for method of prenatal management, sonographic diagnosis of cord entanglement and delivery mode. A meta-analysis was also performed using data from articles that stratified outcome according to the presence or absence of cord entanglement at birth. Comparison between neonates with cord entanglement and controls was deemed significant if the 95% CI of the pooled odds ratios did not encompass 1. MOOSE (Meta-analysis Of Observational Studies in Epidemiology) guidelines were followed.

RESULTS

Nine articles met the inclusion criteria for this review, including a total of 114 monoamniotic twin sets (228 fetuses) with cord entanglement. The overall survival rate was 202/228 (88.6%). Perinatal mortality occurred in 26 (11.4%) fetuses; of these, 17 (65%) died in utero and nine (35%) died at birth. Five neonatal deaths occurred as a result of prematurity, two were related to structural abnormalities and two were caused by cord entanglement. Sonographic visualization of cord entanglement did not improve outcome. Four articles were included in the meta-analysis, with no significant difference in mortality between controls (n = 66 fetuses) and twins with cord entanglement (n = 82 fetuses), and higher morbidity in controls.

CONCLUSIONS

Cord entanglement does not contribute to prenatal morbidity and mortality in monoamniotic twin pregnancies.

Clarithromycin, pomalidomide, and dexamethasone (ClaPD) in relapsed or refractory multiple myeloma

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Background: Clarithromycin has been shown to enhance anti-myeloma activity of lenalidomide+dexamethasone in the upfront treatment of multiple myeloma (MM). Pomalidomide is an immunomodulatory agent effective in relapsed/refractory MM (RRMM). We hypothesized that clarithromycin may similarly enhance pomalidomide + dexamethasone in RRMM. We now report updated results from a phase 2 trial of ClaPD in RRMM. Methods: 73 patients with RRMM were enrolled in a single-institution phase 2 study of ClaPD. All subjects had ≥ 3 prior lines of therapy, one of which must have included lenalidomide. ClaPD is clarithromycin 500mg twice daily; dexamethasone 40mg weekly; and pomalidomide 4mg for days 1-21 of a 28-day cycle. All patients had VTE prophylaxis with aspirin. Monthly disease response evaluation included immunoelectrophoresis and free light chain analysis; bone marrow biopsy with skeletal imaging was used to confirm MM responses. Treatment continued as tolerated until disease progression. Results: The 66 patients who completed ≥ 1 cycle of ClaPD are reported. Median number of cycles was 6 (range 1-17). Responses were progressive disease: 10%, stable disease: 21%, minimal response: 12%, partial response: 33%, very good partial response: 18%, stringent complete remission: 5%, for an overall response rate (ORR) of 56% and ≥VGPR rate of 23%. Median time to PR was 1.25 cycles (range 1-8). Median PFS was 5 months. Response and PFS were not different in patients refractory to lenalidomide (85%), bortezomib (82%), or double-refractory patients (76%). After a median follow up of 12 months,28 pts (42%) remain on study without progression and 56pts (85%) are alive. Two pts withdrew due to toxicity (1 Grade 3 fatigue, 1 Grade 4 muscular weakness). One patient withdrew consent. Conclusions: ClaPD is highly effective for heavily pre-treated RRMM, particularly in lenalidomide-refractory disesase and compares favorably to previously published Phase 2 data of Pom/Dex (ORR 56% vs 40% - Lacy et. al JCO 2009) without excess toxicity. Response to ClaPD is rapid, well tolerated, and sustained over 7 months in most subjects. These data support the clinical efficacy of pomalidomide based regimens in RRMM.

Pharyngeal airway space and frontal and sphenoid sinus changes after maxillomandibular advancement with counterclockwise rotation for Class II anterior open bite malocclusions

OBJECTIVES

The purpose of this study was to cephalometrically evaluate the pharyngeal airway space and frontal and sphenoid sinus changes after maxillomandibular advancement counterclockwise rotation for class II anterior open bite malocclusion.

METHODS

The study included 49 patients (98 lateral teleradiographs; 36 females and 13 males) who were analysed in the pre-operative (1 week before surgery) and post-operative (6 months after surgery) periods. In each lateral teleradiography, the dimensions of the inferior and superior pharyngeal airway space, TB-PhW1 [the point between the posterior aspect of the tongue to the dorsal pharyngeal wall (oropharynx) (TB) and the point on the dorsal pharyngeal wall closest to TB (PhW1)] and UP-PhW2 [and the point between the posterior aspect of the soft palate to the dorsal pharyngeal wall (nasopharynx) (UP) (PhW2)] measurements were evaluated, as well as the dimensions of the frontal and sphenoid sinuses. The differences between the two operative times were evaluated by Student's t-test.

RESULTS

All measurements showed excellent reproducibility for the intraclass correlation coefficient (ICC > 0.9; p < 0.0001). There was an increase in the measurements TB-PhW1 and UP-PhW2 and a decrease in the dimensions of the frontal and sphenoid sinuses after orthognathic surgery.

CONCLUSIONS

The morphology of the superior and inferior pharyngeal airway space and frontal and sphenoid sinuses changes after 6 months of maxillomandibular advancement counterclockwise rotation for class II anterior open bite malocclusion.

Neonatal outcomes of twins according to birth order, presentation and mode of delivery: a systematic review and meta-analysis

BACKGROUND

The optimal mode of delivery for twins is undetermined.

OBJECTIVE

To review literature regarding the neonatal outcomes following twin delivery.

DATA SOURCES

Searches were conducted in PubMed, Medline, Embase, Cochrane library and reference lists.

SELECTION CRITERIA

Studies selection criteria were: both twins alive at labour, outcomes stratified for birth order, presentation, planned and actual delivery mode. Eighteen articles were included in the meta-analysis (39, 571 twin sets).

DATA COLLECTION AND ANALYSIS

The Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Interstudy heterogeneity (I(2) ) was tested. A fixed model was generated whenever I(2)<25%. Pooled odds ratios (OR) with 95% CI were computed. Intergroup comparison was significant if 95% CI did not encompass 1. The first and second twins were indicated as Twin A (TA) and Twin B (TB), respectively.

MAIN RESULTS

Neonatal morbidity was lower in TA than TB (3.0 versus 4.6%; OR 0.53; 95% CI 0.39-0.70). TA experienced neonatal death less often than TB (0.3 versus 0.6%; OR 0.55; 95% CI 0.38-0.81). No differences were noted between vertex and non-vertex and attempted vaginal delivery versus planned caesarean section in either TA or TB. In TA, neonatal morbidity was lower after vaginal delivery (1.1%) than caesarean section (2.2%; OR 0.47; 95% CI 0.27-0.82). Neonatal death was not associated with actual delivery mode. In TB, morbidity following combined delivery (19.8%) was higher than after vaginal delivery (9.5%; OR 0.55; 95% CI 0.41-0.74) or caesarean section (9.8%; OR 0.47; 95% CI 0.43-0.53). When outcomes were stratified for both presentation and delivery mode, mortality rate was lower after vaginal delivery than caesarean section for both vertex and nonvertex TB. AUTHOR'S CONCLUSION: An attempt at vaginal delivery should be considered in twin pregnancies with vertex/vertex presentation.

Cavum veli interpositi cyst: prenatal diagnosis and postnatal outcome

OBJECTIVE

The cavum veli interpositi (CVI) is a space within the double-layered tela choroidea of the third ventricle. Occasionally, this space is fluid-filled and sonographically visible as an interhemispheric anechoic cyst. Because of its rarity, the incidence of CVI cyst is undetermined and the outcome of affected individuals has been found to be variable. The aim of this study was to report our experience of the sonographic findings and outcome of fetuses affected by CVI cysts.

METHODS

In five fetuses with a CVI cyst, we performed targeted prenatal ultrasound scans of intracranial structures and a detailed anatomical survey to rule out associated malformations. Follow-up consisted of neurological examination and neurosonography.

RESULTS

The CVI cyst appeared as a well-defined anechoic lesion without adjacent mass effect. In all fetuses the cyst was single and in two cases it enlarged slightly during pregnancy. The cyst was isolated in three fetuses and associated with borderline ventriculomegaly in two. A single umbilical artery was the only associated extracranial anomaly and this was detected in only one fetus. Neurosonography confirmed the presence of CVI cysts in all cases after delivery. During postnatal follow-up (range 10-48 months), the cyst regressed in one case within 1 month after delivery while the size of the others remained stable. No infant developed psychomotor disorders.

CONCLUSIONS

Prenatal sonographic diagnosis of CVI cysts is feasible. Its finding in isolation is consistent with favorable postnatal outcome.

Twin-twin transfusion syndrome

Twin-twin transfusion syndrome (TTTS) is a condition unique to monochorionic pregnancies, although very few case reports described the syndrome in dichorionic placentas. The aetiology of TTTS relies in the presence of at least 1 arterio-venous placental anastomosis, through which unequal blood exchange from one twin (donor) to the co-twin (recipient) occurs. The diagnosis of TTTS relies on the sonographic detection of oligohydramnios in the donor's sac and polyhydramnios in the recipient's sac in the second trimester, although signs of TTTS are present since the first trimester. Treatment options for TTTS include serial amnioreduction, septostomy, selective feticide of the apparently sick twin, and selective photocoagulation of placental vessels (SLPCV). Because of the growing evidence that SLPCV is the most efficacious therapy compared to amnioreduction with/without septostomy, the authors reviewed in details the effects of SLPCV on fetal growth and circulation. The authors further explore literature with regard to the prognostic factors. Finally, because Quintero staging system is actually under debate, they discuss the most recent findings on this topic and propose a new staging system to assess severity of TTTS at presentation (Rossi staging system). New topics for future research, which would probably further clarify the natural history of TTTS, are also proposed.

The ultrasound assessment of adipose tissue deposition in fetuses of "well controlled" insulin-dependent diabetic pregnancies

OBJECTIVE

To assess differences in adipose deposition in fetuses from normal pregnancies and women with diabetes.

RESEARCH DESIGN AND METHODS

The study group consisted of 15 well controlled insulin-dependent women with diabetes and 16 controls with a normal glucose. Ultrasound measurements were taken of subcuticular tissue thickness at the abdominal and suprascapular level at 31 and 37 weeks gestation. Triceps and subscapular skinfold thickness were also measured at birth.

RESULTS

Gestational age at delivery and birthweights were not significantly different. At 31 weeks, fasting glucose levels were 5.0 +/- 1 mmol/l for diabetic vs. 3.3 +/- 0.3 mmol/l for controls (P < 0.01), post-prandial 5.6 +/- 0.4 vs. 5.1 +/- 0.3 mmol/l (P < 0.01). At 37 weeks, they were 4.6 +/- 0.2 mmol/l vs. 3.8 +/- 1.1 mmol/l (P < 0.01) and 6.0 +/- 0.6 mmol/l vs. 5.3 +/- 0.3 mmol/l (P < 0.01). Abdominal and suprascapular subcuticular thickness were 4.4 +/- 0.1 mm vs. 3.7 +/- 0.1 mm (P < 0.05) and 4.3 +/- 0.2 mm vs. 3.5 +/- 0.2 mm (P < 0.05) at 31; 5.6 +/- 0.2 mm vs. 4.8 +/- 0.1 mm (P < 0.05) and 5.4 +/- 0.2 mm vs. 4.4 +/- 0.1 mm (P < 0.05) at 37 weeks. At birth, triceps and suprascapular skinfolds were 4.7 +/- 0.1 mm vs. 4.1 +/- 0.1 mm (P < 0.05) and 4.7 +/- 0.2 mm vs. 3.8 +/- 0.1 mm (P < 0.01).

CONCLUSION

Adipose tissue disposition is increased in fetuses of women with well-controlled diabetes. This may be a reflection of higher maternal glucose levels in these women and may explain why even well-controlled diabetic pregnancies are at risk of macrosomia.

The value of ultrasonographic examination of the uterine cervix in predicting post-term pregnancy

OBJECT

To assess whether transvaginal ultrasound is helpful in predicting the post-term onset of labor (> or = 1 weeks).

SETTING

Antenatal clinic of a University hospital and referral center. SUBJECT AND MEHODS: One hundred and twenty singleton uncomplicated pregnancies in primiparous women were enrolled at 37 weeks of gestation. Ultrasound examination of the cervical length by a transvaginal probe was performed at recruitment and at weekly intervals until 40 completed weeks. Subjects were divided into Group A (those with spontaneous onset of labor < or = 1 completed weeks) and Group B (those not in labor by that date).

RESULTS

Eighty women delivered < or = 41 completed weeks, forty were not in labor by that date. The cervix was significantly shorter at 39 and 40 weeks in group A, but no particular cervical length was predictive of post-term delivery.

DISCUSSION

There is a significant difference in cervical length in women delivering at term compared with those due to have a post-term delivery. This difference is significant from 39 weeks of gestation onwards. We speculate that targeted transvaginal ultrasound may be useful in predicting the post-term onset of labor and possibly in assisting its active management.

Effect of insecticides and fungicides on the interaction between members of the mite families Phytoseiidae and Stigmaeidae on citrus

The study was carried out to evaluate the effect of some insecticides and fungicides on the interaction between predacious mites of the families Phytoseiidae and Stigmaeidae on citrus. Euseius citrifolius Denmark and Muma, Euseius concordis (Chant) (Phytoseiidae), and Agistemus aff. bakeri (Stigmaeidae) were the most abundant species of predacious mites. No significant reduction of the population of stigmaeids was detected following the pesticide treatment. On the contrary, the population of those mites increased after the application of methidathion, petroleum oil, deltamethrin, cupric oxychloride and cuprous oxide, as compared to the population of those mites in the control plots. The chemicals promoting increased stigmaeid populations are some of those that promoted reduction of phytoseiid populations. A significant negative correlation was found between the numbers of phytoseiids and stigmaeids on citrus leaves immediately before treatments, and 33, 50, 83 and 105 days after treatment. A clear negative linear correlation between the number of predacious mites from both families was detected for benomyl, cupric oxychloride, cuprous oxide, thiophanate methyl, and control. Phytoseiid-stigmaeid interaction on citrus orchard is discussed.

[Echographic measurement of subcutaneous adipose tissue as fetal growth index]

OBJECTIVE

To evaluate, by 3rd trimester ultrasound examination, fetal adipose tissue to predict fetal growth and birthweight.

PATIENTS AND METHODS

Thirteen pregnant women (group 1) with uncomplicated pregnancy and 9 diabetic women (group 2) have been enrolled. We have examined adipose tissue at the cross sectional level of arm, thigh and abdomen and at the longitudinal sectional level of shoulder. During 3rd trimester measurements were taken at the beginning (28-32 gestational weeks), at the middle (34-38 gestational weeks) and at term (39-41 gestational weeks). At birth we recorded the skinfolds of arm, thigh and shoulder and the neonatal weight. Subsequently, by regression analyses ultrasound parameters of physiological pregnancies were correlated to skinfolds measurements at birth, while abdomen thickness was compared to birthweight. In addition, ultrasound markers of the physiological pregnancies were compared to those of diabetic pregnancies by the t-test.

RESULTS

Fetal limbs examination had not a prognostic value at any gestational week. Shoulder ultrasound measurements appeared well correlated to the shoulder skinfold after birth since the 34th week. Diabetic mothers' fetuses presented much more adipose tissue than control cases, particularly of arm and thigh at 28-32 weeks, of shoulder at 34-38 weeks and in all the markers at term pregnancy.

CONCLUSION

Ultrasound examination of fetal adipose tissue seems to have a predictive value for fetal growth both in physiological and diabetic pregnancy.

FCE 23884, substrate-dependent interaction with the dopaminergic system. II. Preclinical biochemical studies

The effects of FCE 23884 [4-(9,10-didehydro-6-methylergolin-8 beta-yl) methyl-piperazine-2,6-dione] were examined using a variety of biochemical methods. In vitro assays showed that FCE 23884 bound to D-2, alpha-2 and 5-hydroxytryptamine1A sites with Ki values of 6.5, 4.0 and 4.0 nM, respectively. The affinity for D-1 and S-2 receptors was moderate (submicromolar range) and slight or negligible for alpha-1, cholinergic and sigma receptors. In normal rats, FCE 23884 accelerated markedly dopamine (DA) turnover in the neostriatum and nucleus accumbens as indicated by the increased ratios of dihydroxphenyl acetic acid/DA and homovanillic acid/DA. The compound enhanced DA synthesis and utilization rate. After gamma-butyrolactone treatment, a model to study DA autoreceptors function, FCE 23884 almost antagonized completely the gamma-butyrolactone reversal induced by apomorphine on l-dihydroxyphenylalanine accumulation in the two brain areas. In addition, FCE 23884 induced a rapid 20-fold increase of serum prolactin confirming its DA antagonistic profile in normal rats. In contrast with these antidopaminergic properties, FCE 23884 consistently stimulated basal adenylate cyclase activity in vitro (ED50 = 0.6 microM) and elicited a rapid increase of cyclic AMP formation in the neostriatum of normal (35%) and reserpinized (82%) rats in vivo. Furthermore in this last condition both the DA turnover and synthesis rate in the neostriatum and nucleus accumbens decreased after treatment with FCE 23884. These neurochemical data support the behavioral studies indicating that FCE 23884 possesses mixed DA antagonist and agonist properties depending on the experimental conditions, the distinguishing factor being presence or absence of DA.(ABSTRACT TRUNCATED AT 250 WORDS)

FCE 23884, substrate-dependent interaction with the dopaminergic system. I. Preclinical behavioral studies

FCE 23884, a newly synthetized ergoline derivative, shows dopamine (DA) agonist or antagonist properties depending on the functional state of the biological substrate. The compound behaves as a full DA antagonist in normal animals, but shows full agonist properties in denervated models in the same dose range. In normal animals, FCE 23884 impairs Sidmans avoidance in rats, reduces spontaneous locomotion in mice and monkeys and antagonizes apomorphine-induced climbing behavior in mice, yawning in rats, emesis in dogs and amphetamine-induced toxicity in grouped mice. After experimental procedures resulting in severe DA depletion, FCE 23884 behaves as a powerful DA-agonist mainly at D-1 receptors. FCE 23884 induces contralateral turning behavior in 6-hydroxydopamine-lesioned rats and reverses 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced akinesia in monkeys and reserpine-induced hypokinesia in mice. These results indicate that the antagonist or agonist activity of FCE 23884 is substrate-dependent and mostly related to the presence or absence of DA. This leads to the apparently paradoxical suggestion that the compound could be useful both in psychotic states and extrapyramidal diseases, i.e., in clinical conditions characterized by either excessive or impaired DAergic neurotransmission.

Synthesis and anticonvulsant and sedative-hypnotic activity of 4-(alkylimino)-2,3-dihydro-4H-1-benzopyrans and -benzothiopyrans

A series of 4-(alkylimino)-5-hydroxy-7-alkyl-2,3-dihydro-4H-1-benzopyrans and -thiopyrans were synthesized and evaluated for anticonvulsant activity. Preliminary screening of these compounds revealed that 2,2-dimethyl-4-[(2-hydroxyalkyl)imino]-5-hydroxy-7-pentyl-2,3- dihydro-4H-1-benzopyrans 19 and 29, the 7-butyl analogue 34, and the corresponding 7-pentyl-4H-1-benzothiopyrans 38 and 39 had the most promising anticonvulsant activity. Synthesis of both enantiomers of 29 and 39 indicated that the R isomers 30 and 40 were the most active and showed very good protection against MES, pentylenetetrazole, and mercaptopropionic acid induced seizures after oral administration in mice. In the Irwin test these compounds showed a generalized depressant activity but at dosages higher than those showing anticonvulsant activity, whereas acute toxicity after oral administration was low (LD50 higher than 400 mg/kg).

Injections of 6-hydroxydopamine in the substantia nigra of the rat brain: morphological and biochemical effects

Rats with unilateral injections of 6-hydroxydopamine (6-OHDA) into the substantia nigra pars compacta were classified as active and inactive according to the intensity of their spontaneous and/or apomorphine-induced turning behavior (TB), and sacrificed at different survival times for morphological and biochemical analysis. In active rats, at any survival time, dopaminergic fluorescence in the nigrostriatal system as well as dopamine (DA) and 3,4-dihydroxyphenylacetic acid (DOPAC) content of the nucleus caudatus-putamen drastically decreased on the brain side ipsilateral to the injection. Dopaminergic fluorescence as well as DA and DOPAC content of the mesolimbic system ipsilateral to the injection also decreased. In inactive rats, at any survival time, 6-OHDA-induced lesions only partially involved both nigrostriatal and mesolimbic systems. Our results are indicative of a good correlation between the intensity of TB and the extent of 6-OHDA-induced lesions, as assessed by morphological and biochemical analysis.

The importance of adverse reaction reporting by physicians. Suprofen and the flank pain syndrome

The role of spontaneous reporting in detecting the suprofen-associated flank pain syndrome was examined, including the specific effect of the "Dear Doctor" letter in accelerating the information-gathering process once the initial signal was generated. We believe this to be a noteworthy example of the ability of spontaneous reporting to produce a timely and unequivocal signal of drug-related risk. It also serves to demonstrate the need for vigilant postmarketing surveillance for all newly marketed drugs in the United States, even though considerable premarketing and postmarketing drug experience may exist from use in countries outside of the United States.

Receptor adaptive responsiveness in disease models: 6-OHDA lesioned and spontaneously hypertensive rats

We have examined the adaptive modifications of brain monoamine receptors in response to pathophysiological processes in animal disease models: 6-OHDA lesioned and spontaneously hypertensive rats (SHR). The two models share a similar increase in D-1 receptor densities, while noradrenergic receptors are affected in different way: alpha-1 and beta are supersensitive in 6-OHDA lesioned rats and only alpha-2 are increased in SHR. S-1 receptors too are up-regulated in SHR. We must notice that though receptor hypersensitivity in the 6-OHDA model is linked to massive decreases in neurotransmitter levels, this mechanism seems not to exist in the SHR model.

Ulcerogenicity of piroxicam: an analysis of spontaneously reported data

Previous reports have suggested that piroxicam may be more ulcerogenic than other non-steroidal anti-inflammatory drugs (NSAIDs) in use. Critics have attributed this putative relation to flawed comparisons of spontaneously reported data. In this study cases of upper gastrointestinal bleeding, perforation, and ulcer reported to the Food and Drug Administration's spontaneous reporting system over 12 years were examined. Reporting rates for eight NSAIDs were compared over identical periods of their marketing life cycles. After adjustments were made for the heterogeneity in the underlying reporting rates the difference in rates between piroxicam and the other drugs was considerably reduced but piroxicam retained its top ranking among the drugs; however, large and clinically important differences in the frequency of cases of upper gastrointestinal bleeding, perforation, and ulcer between piroxicam and the rest of the NSAIDs compared probably do not exist.

Opioid receptor binding profile of selected dermorphin-like peptides

The receptor binding profile of a selected group of dermorphin-like peptides was determined and correlated with the results of the guinea pig ileum (GPI) and mouse vas deferens (MVD) bioassays and with the currently used antinociception tests in the rat. For the peptides with the characteristic dermorphin D-Ala2-Phe3-Gly4 sequence, a linear negative correlation was found between the reciprocal of sodium shift and relative affinity for the mu-type opioid receptor. For the same peptides, a positive correlation was evidenced between relative potency on GPI and MVD and relative affinity for mu- and delta-type receptors, respectively.

Tremor at rest episodes in unilaterally 6-OHDA-induced substantia nigra lesioned rats: EEG-EMG and behavior

Twenty male adult Wistar rats were unilaterally lesioned in the substantia nigra (SN) with 6-hydroxydopamine (6-OHDA), and prepared with chronic cortical (ECoG) and neck muscle (EMG) electrodes. Longitudinal study over a period of up to 18 months demonstrated the emergence, in about two-thirds of the rats, of spontaneous repetitive episodes of head and neck tremor during awake at rest, of up to 20 seconds duration each, that were associated with spike and wave-like ECoG activities. These episodes of tremor at rest disappeared during sleep and REM sleep episodes, and also following the i.p. administration of L-DOPA. It is assumed that these tremor at rest episodes are analogous to those reported to occur in primates after experimentally induced dysfunction of the nigro-striatal, extrapyramidal system.

Antinociceptive and other opioid effects of a new series of dermorphin analogues after subcutaneous administration in the rat

A series of hepta-, hexa-, penta- and tetrapeptide analogues of dermorphin have been evaluated in the rat for antinociceptive activity after subcutaneous (SC) administration at the screening dose of 4 mg/kg. Effective doses (ED50) were calculated for the most active compounds. Presence of spontaneous movements, defecation, micturition and corneal reflex were also recorded. Syntheses and analytical data of new derivatives are briefly reported.

Structure-activity relationships of dermorphin synthetic analogues

A number of dermorphin analogues have been reviewed for antinociceptive activity after systemic administration. Analgesic peptides as potent as or more potent than dermorphin are found among the hepta- and tetrapeptide analogues, probably because of enhanced stability towards carboxyldipeptidases imparted by the Pro6 and D-Ala2 residues lying on the right and left side, respectively, of the point of cleavage. Hexapeptide analogues are practically inactive. [D-Arg2]derivatives are very potent, particularly in the tetrapeptide series. In binding studies dermorphin behaves as a pure opioid agonist, with a marked affinity and selectivity for the mu-type opioid receptors. In the heptapeptide analogues a direct correlation seems to exist between mu-selectivity and "sodium shift," and between lipophilicity and MVD/GPI potency ratio.

Discovery of new adverse drug reactions. A review of the Food and Drug Administration's spontaneous reporting system

Recently, several studies of spontaneous reporting systems (SRSs) have reported on the published literature's role in producing first reports of new adverse drug reactions. In order to provide further information on other components of SRS, the Food and Drug Administration's SRS was examined with regard to its effectiveness and efficiency in identifying new adverse drug reactions and the form, consistency, and timeliness of its communication of new adverse drug reactions to the medical community. While there was evidence that the literature was more effective in producing first reports of new adverse drug reactions for the years compared, there was reason to conclude that FDA's SRS was capable of making a contribution to the alerting process. Moreover, direct participation by practitioners in FDA's SRS was found to be the most efficiently obtained FDA source of new adverse drug reaction reports.