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Moyo TK, Kishtagari A, Villaume M, McMahon B, Mohan SR, Stopczynski T, Chen SC, Fan R, Huo Y, Moon H, Tang Y, Bejan CA, Childress M, Anderson I, Rawling K, Simons RM, Moncrief A, Caza R, Dugger L, Collins A, Dudley CV, Ferrell PB, Byrne M, Strickland SA, Ayers GD, Landman BA, Mason EF, Mesa RA, Palmer JM, Michaelis LC, Savona MR. PI3K Inhibition Restores and Amplifies Response to Ruxolitinib in patients with Myelofibrosis. Clin Cancer Res 2023:725707. [PMID: 37036505 DOI: 10.1158/1078-0432.ccr-22-3192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/20/2023] [Accepted: 04/06/2023] [Indexed: 04/11/2023]
Abstract
PURPOSE Treatment options are limited beyond JAK inhibitors for patients with primary myelofibrosis (PMF), or secondary MF. Preclinical studies have revealed that PI3Kδ inhibition cooperates with ruxolitinib, a JAK1/2 inhibitor, to reduce proliferation and induce apoptosis of JAK2V617F mutant cell lines. PATIENTS AND METHODS In a phase I dose-escalation and expansion study, we evaluated the safety and efficacy of a selective PI3Kδ inhibitor umbralisib in combination with ruxolitinib in MF patients who had a suboptimal response or lost response to ruxolitinib. Enrolled subjects were required to be on a stable dose of ruxolitinib for ≥8 weeks and continue that maximally tolerated dose at study enrollment. The recommended dose of umbralisib in combination with ruxolitinib was determined using a modified 3+3 dose escalation design. Safety, pharmacokinetics, and efficacy outcomes were evaluated, and spleen size was measured with a novel automated digital atlas. RESULTS Thirty-seven MF patients with prior exposure to ruxolitinib were enrolled. 2 patients treated with 800mg umbralisib experienced reversible Grade 3 asymptomatic pancreatic enzyme elevation, but no dose-limiting toxicities were seen at lower umbralisib doses. Two patients (5%) achieved complete response (CR), and 12 patients (32%) met the IWG-MRT response criteria of clinical improvement (CI). With a median follow-up of 50.3 months for censored patients, overall survival was greater than 70% after 3 years of follow-up. CONCLUSIONS Adding umbralisib to ruxolitinib in patients was well-tolerated and may re-sensitize MF patients to ruxolitinib without unacceptable rates of adverse events seen with earlier generation PI3Kδ inhibitors.
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Affiliation(s)
- Tamara K Moyo
- Levine Cancer Institute, Charlotte, NC, United States
| | | | - Matthew Villaume
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | | | | | - Tess Stopczynski
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Sheau-Chiann Chen
- Vanderbilt University Medical Center, Nashville, Davidson, United States
| | - Run Fan
- Vanderbilt University Medical Center, Nashville, United States
| | | | | | | | - Cosmin A Bejan
- Vanderbilt University Medical Center, Nashville, TN, United States
| | | | - Ingrid Anderson
- Cumberland Pharmaceuticals (United States), Nashville, TN, United States
| | - Kyle Rawling
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | | | | | - Rebekah Caza
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Laura Dugger
- Vanderbilt University Medical Center, United States
| | | | | | - P Brent Ferrell
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Michael Byrne
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | | | - Gregory D Ayers
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | | | - Emily F Mason
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ruben A Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
| | | | | | - Michael R Savona
- Vanderbilt University School of Medicine, Nashville, TN, United States
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Zahid S, Khan N, Branham K, Othman M, Karoukis AJ, Sharma N, Moncrief A, Mahmood MN, Sieving PA, Swaroop A, Heckenlively JR, Jayasundera T. Phenotypic conservation in patients with X-linked retinitis pigmentosa caused by RPGR mutations. JAMA Ophthalmol 2013; 131:1016-25. [PMID: 23681342 DOI: 10.1001/jamaophthalmol.2013.120] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE For patients with X-linked retinitis pigmentosa and clinicians alike, phenotypic variability can be challenging because it complicates counseling regarding patients' likely visual prognosis. OBJECTIVE To evaluate the clinical findings from patients with X-linked retinitis pigmentosa with 13 distinct RPGR mutations and assess for phenotypic concordance or variability. DESIGN Retrospective medical record review of data collected from 1985 to 2011. SETTING Kellogg Eye Center, University of Michigan. PATIENTS A total of 42 patients with X-linked retinitis pigmentosa with mutations in RPGR. Age at first visit ranged from 4 to 53 years, with follow-up ranging from 1 to 11 visits (median follow-up time, 5.5 years; range, 1.4-32.7 years, for 23 patients with >1 visit). MAIN OUTCOMES AND MEASURES Clinical data assessed for concordance included visual acuity (VA), Goldmann visual fields (GVFs), and full-field electroretinography (ERG). Electroretinography phenotype (cone-rod vs rod-cone dysfunction) was defined by the extent of photopic vs scotopic abnormality. Qualitative GVF phenotype was determined by the GVF pattern, where central or peripheral loss suggested cone or rod dysfunction, respectively. Goldmann visual fields were also quantified and compared among patients. RESULTS Each mutation was detected in 2 or more related or unrelated patients. Five mutations in 11 patients displayed strong concordance of VA, while 4 mutations in 16 patients revealed moderate concordance of VA. A definitive cone-rod or rod-cone ERG pattern consistent among patients was found in 6 of 13 mutations (46.2%); the remaining mutations were characterized by patients demonstrating both phenotypes or who had limited data or nonrecordable ERG values. Concordant GVF phenotypes (7 rod-cone pattern vs 4 cone-rod pattern) were seen in 11 of 13 mutations (84.6%). All 6 mutations displaying a constant ERG pattern within the mutation group revealed a GVF phenotype consistent with the ERG findings. CONCLUSIONS AND RELEVANCE While VA and ERG phenotypes are concordant in only some patients carrying identical mutations, assessment of GVF phenotypes revealed stronger phenotypic conservation. Phenotypic concordance is important for establishing proper counseling of patients diagnosed as having X-linked retinitis pigmentosa, as well as for establishing accurate patient selection and efficacy monitoring in therapeutic trials.
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Affiliation(s)
- Sarwar Zahid
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI 48105, USA
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Mirvis DM, Berson AS, Goldberger AL, Green LS, Heger JJ, Hinohara T, Insel J, Krucoff MW, Moncrief A, Selvester RH. Instrumentation and practice standards for electrocardiographic monitoring in special care units. A report for health professionals by a Task Force of the Council on Clinical Cardiology, American Heart Association. Circulation 1989; 79:464-71. [PMID: 2644056 DOI: 10.1161/01.cir.79.2.464] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The proposed recommendations for continuous electrocardiographic monitoring systems represent goals for future development. Description of a technique in the report does not constitute an endorsement of its clinical use. Lead systems for ECG monitoring must adequately sense the cardiac electrical field and the leads should be standardized. Future monitors should be capable of simultaneously displaying and analyzing multiple leads. Recommendations for electrode placement and position of patient are made. Important parameters in each category of standards for instrumentation published in 1983 in the American National Standard for Cardiac Monitors, Heart Rate Meters, and Alarms are listed. Selected procedures proposed by the Association for the Advancement of Medical Instrumentation to inform users of minimally acceptable accuracy of computerized systems in a standardized manner are presented. Emphasis is placed on the importance of nursing and medical staff capabilities. Personnel qualifications and training as well as systems to assure and maintain quality of immediate ECG diagnosis are highlighted.
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