Beyond the 510(k): The regulation of novel moderate-risk medical devices, intellectual property considerations, and innovation incentives in the FDA's De Novo pathway

Moderate-risk medical devices constitute 99% of those that have been regulated by the U.S. Food and Drug Administration (FDA) since it gained authority to regulate medical technology nearly five decades ago. This article presents an analysis of the interaction between the 510(k) process -the historically dominant path to market for most medical devices- and the De Novo pathway, a more recent alternative that targets more novel devices, including those involving new technologies, diagnostics, hardware, and software. The De Novo pathway holds significant potential for innovators seeking to define new categories of medical devices, as it represents a less burdensome approach than would have otherwise been needed historically. Moreover, it supports the FDA in its effort to modernize the long-established 510(k) pathway by promoting the availability of up-to-date device "predicates" upon which subsequent device applications can be based, reflecting positive spillovers that are likely to encourage manufacturers to adopt current state-of-the-art technologies and modern standards of safety and effectiveness. We analyze the of characteristics all the De Novo classification requests to date, including the submission type, trends, FDA review times, and device types. After characterizing how the De Novo process has been used over time, we discuss its unique challenges and opportunities with respect to medical device software and AI-enabled devices, including considerations for intellectual property, innovation, and competition economics.

Patient preferences in chronic immune-mediated inflammatory diseases potentially treated with biological drugs: discrete choice analysis using real-world data analysis

OBJECTIVES

Immune-mediated inflammatory diseases (IMIDs) represent a high burden due to their chronicity, high prevalence, and associated comorbidities. Chronic patients' preferences must be considered in IMIDs treatment and follow-up. The objective of this study was to further understand patient's preferences in private settings.

METHODS

A literature review was performed to choose the most relevant criteria for patients. A D-efficient discrete choice experiment was designed to elicit preferences of adult patients with IMIDs and potential biological treatment prescription. Participants were collected from private practices (rheumatology, dermatology, and gastroenterology) from February to May 2022. Patients chose between option pairs, characterized by six health-care attributes, as well as monthly out-of-pocket drug price. Responses were analyzed through a conditional logit model.

RESULTS

Eighty-seven patients answered the questionnaire. The most frequent pathologies were Rheumatoid Arthritis (31%) and Psoriatic Arthritis (26%). The most relevant criteria were choosing the preferred physician (OR 2.25 [SD0.26]); reducing time until visit with specialist (OR 1.79 [SD0.20]), access through primary care (OR 1.60 [SD0.08]), and an increase in monthly out-of-pocket price from 100€ to 300€ (OR 0.55 [SD0.06]) and to 600€ (OR 0.08 [SD0.02]).

CONCLUSIONS

Chronic IMIDs patients showed a preference toward a faster, personalized service, even with a trade-off in terms of out-of-pocket price.

Fluoxetine increased adult neurogenesis is mediated by 5-HT3 receptor

Adult neurogenesis is an aspect of structural plasticity that remains active during adulthood in some brain regions. One of them is the subgranular zone (SGZ) of the dentate gyrus of the hippocampus. Adult neurogenesis is reduced by different factors and in disorders of the CNS, including major depression. Antidepressant treatments, such as chronic fluoxetine administration, recover the normal level of adult neurogenesis. Fluoxetine treatment increases the free concentration of the neurotransmitter serotonin and this monoamine is implicated in the regulation of the neurogenic process; however, the target of the action of this neurotransmitter has not been fully elucidated. In this study, we have tried to determine the relevance of the serotonin receptor 3 (5-HT3) in the hippocampal neurogenesis of adult rats. We have used fluorescent immunohistochemistry to study the expression of the 5-HT3 receptor in different neurogenesis stages in the SGZ, identifying its expression in stem cells, amplifying neural progenitors and immature neurons. Moreover, we have studied the impact of a 5-HT3 antagonist (ondansetron) in the fluoxetine-induced adult neurogenesis. We observed that fluoxetine alone increases the number of both proliferating cells (ki67 positive) and immature neurons (DCX positive) in the SGZ. By contrast, co-treatment with ondansetron blocked the increase in proliferation and neurogenesis. This study demonstrates that the activation of 5-HT3 receptors is necessary for the increase of adult neurogenesis induced by fluoxetine.

Study of Recycling Potential of FFP2 Face Masks and Characterization of the Plastic Mix-Material Obtained. A Way of Reducing Waste in Times of Covid-19

The purpose of this study is to investigate how to recycle FFP2 face masks used during Covid-19 pandemic without using previous sorting process and to characterize the properties of the material obtained. The way of splitting and processing the mixture of materials was studied as well as the final properties such as chemical, thermal and mechanical characteristics. The resulting recycled material is a blend of polymers with such mechanical and thermal properties that could be used as an alternative to recycled PP (polypropylene). Avoidance of previous sorting process gives the face mask recycling a new and simplified way of preventing this material to be disposed in environment and an opportunity of second life for the polymers they are made of. With this work we lay the basis to reduce the plastic pollution related with the recommended use of face masks during Covid-19 pandemic.

GRAPHIC ABSTRACT

Outcomes of single versus double hormone receptor-positive breast cancer. A GEICAM/9906 sub-study

BACKGROUND

Retrospective data suggest better outcomes for patients with double hormonal receptor (oestrogen [ER] and progesterone receptor [PgR])-positive (dHR+) early breast cancer, compared with single hormonal receptor-positive, sHR+, (ER+/PgR- or ER-/PgR+) disease. Here, we evaluate the classification according to intrinsic subtypes and clinical outcomes of sHR+ versus dHR+ in HER2-negative breast cancer patients enrolled in GEICAM/9906 study (NCT00129922).

METHODS

Archival tumours were retrieved retrospectively for the analysis of ER, PgR and HER2 status and classified into intrinsic subtypes using the PAM50 gene expression assay. Disease-free survival (DFS) and overall survival (OS) were explored using a Cox proportional hazard analysis.

RESULTS

Data on intrinsic subtypes were available in 571 (50%) patients with ER+ and/or PR+, and HER2-negative primary tumours. The incidence of luminal A and luminal B subtypes were 52%/36% in dHR+ tumours (ER+/PgR+), and 15%/58% in ER+/PgR-tumours. ER-/PgR+ tumours were mainly luminal A (52%). Compared with ER+/PgR+ patients, DFS was similar in ER-/PgR+ (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.57-2.34, p = 0.70) but worse in ER+/PgR- patients (HR 1.60, 95% CI 1.12-2.28, p < 0.01). Similar results were observed for OS (HR 1.50, p = 0.30 and HR 1.86, p < 0.01, respectively).

CONCLUSIONS

The ER+/PgR- group is characterised by higher proliferation and worse outcomes. In spite of the ER-/PgR+ subgroup resembles ER+/PgR+ disease in terms of molecular subtypes and outcomes, the small number of patients in this subgroup prevents from drawing any conclusions.

TRIAL REGISTRATION

EudraCT: 2005-003108-12 (retrospectively registered 28/06/2005). CLINICALTRIALS.

GOV IDENTIFIER

NCT00129922 (retrospectively registered 10/08/2005).

Impacto de maloclusiones sobre la calidad de vida y necesidad de tratamiento ortodóntico en escolares de dos escuelas privadas Azogues - Ecuador, 2015

Objetivos: Evaluar el impacto de las condiciones orales atribuidas a maloclusiones sobre la calidad de vida a través del CS Child-OIDP y Necesidad De Tratamiento Ortodóntico a través del INTO en escolares de 11 a 12 años de dos escuelas privadas en Azogues-Ecuador, año 2015. Material y métodos: Esta investigacion evaluó a170 escolares para determinar el impacto de las maloclusiones sobre la calidad de vida, mediante la versión pe- ruana del Child-OIDP, utilizando únicamente. las condiciones atribuidas a maloclusiones, (CS Child-OIDP Po- sición de los dientes, espacios, tamaño y forma y deformidades cracenofaciales), sobre los desempeños diarios, y la Necesidad de Tratamiento De Ortodoncia mediante el Indice de Necesidad de Tratamiento de Ortodoncia (INTO) . Resultados: Las condiciones más prevalentes fueron: posición de los dientes (63,5%), y dientes sepa- rados (40,5%); los desempeños más afectados fueron comer (65,3%) y sonreír (51,8%); respecto de la necesidad de tratamiento ortodóntico según el componente estético, el 91,18% de los escolares no tuvieron necesidad de tratamiento y según el componente de salud dental, el 10%; al asociar las dos variables, se encontró diferencia es- tadísticamente significativa en el desempeño sonreír p=0,02; según el Componente de Salud Dental. Conclusio- nes: La condición más prevalente fue posición de los dientes, los desempeños diarios más afectados fueron comer y sonreír, al asociar Necesidad de Tratamiento y desempeños afectados en los dos componentes revelaron a los desempeños comer y sonreír como los más afectados, existiendo significancia estadística en el desempeño sonreír.

Bacterial Production of a Pederin Analogue by a Free-Living Marine Alphaproteobacterium

The polyketide pederin family are cytotoxic compounds isolated from insects, lichen, and marine sponges. During the past decade, different uncultivable bacteria symbionts have been proposed as the real producers of these compounds, such as those found in insects, lichen, and marine sponges, and their trans-AT polyketide synthase gene clusters have been identified. Herein we report the isolation and biological activities of a new analogue of the pederin family, compound 1, from the culture of a marine heterotrophic alphaproteobacterium, Labrenzia sp. PHM005. This is the first report of the production of a pederin-type compound by a free-living marine bacteria that could be cultured in the laboratory.

[Comparison of the cost-utility of direct oral anticoagulants for the prevention of stroke in patients with atrial fibrillation in Spain]

INTRODUCTION

Apixaban, dabigatran and rivaroxaban are three new direct oral anticoagulants (DOACs) used in the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF) in Spain.

AIM

To assess the relative cost-utility of the three DOACs compared with vitamin K antagonists.

PATIENTS AND METHODS

A Markov model with 3-month cycles was used to simulate NVAF patients starting with treatment and followed up for their lifetime from the perspective of the National Health System. The model included 36 health states including treatment combinations, disability and events history and considered a hypothetical cohort of 10,000 NVAF patients. Relative efficacy was calculated from a formal indirect treatment comparison using data from the pivotal trials of each DOAC.

RESULTS

Dabigatran was associated with the highest number of quality-adjusted life years (QALY) (8.40 QALY), followed by apixaban (8.33 QALY), rivaroxaban (8.15 QALY) and acenocoumarol (8.03 QALY). Patients taking acenocoumarol had the lowest total costs (€22,230), followed by dabigatran (€24,564), apixaban (€24,655) and rivaroxaban (€25,900). Incremental cost-utility ratios compared to vitamin K antagonists, were €6,397, €8,039 and €29,957/QALY for dabigatran, apixaban and rivaroxaban, respectively. If compared together, dabigatran dominated apixaban and rivaroxaban. Sensitivity analyses confirmed the robustness of the baseline case.

CONCLUSIONS

All three direct anticoagulants are cost-effective against acenocoumarol. Dabigatran is economically dominant over rivaroxaban and apixaban in the Spanish setting, as it is more effective and cheaper.

[Training degree assessment of staff producing parenteral nutrition in Pharmacy Services]

OBJECTIVE

To assess the level of expertise of Pharmacy personnel in the manufacturing of total parenteral nutrition.

MATERIAL AND METHODS

An on-line survey including 17 questions concerning key aspects of TPN manufacturing was designed. Survey monkey software was used to create the survey and to analize its results.

RESULTS

135 answers were received. 95% of the participant Pharmacy services had written standard manufacturing procedures. 67% answered that phosphate salts should be the first electrolite to be additioned into the total parenteral nutrition and 34% affirmed that validation of the aseptic manufacturing technique was not performed. As far as personnel training was concerned, 19% of respondents had not received any specific training, although 99% considered it would be necessary to receive it.

CONCLUSIONS

The polled personell has an acceptable level of expertise but adequate training courses are still necessary and should be promoted from Pharmacy services.

Validation of semi-quantitative methods for DAT SPECT: influence of anatomical variability and partial volume effect

The aim of this work was to evaluate the influence of anatomical variability between subjects and of the partial volume effect (PVE) on the standardized Specific Uptake Ratio (SUR) in [(123)I]FP-bib SPECT studies. To this end, magnetic resonance (MR) images of 23 subjects with differences in the striatal volume of up to 44% were segmented and used to generate a database of 138 Monte Carlo simulated SPECT studies. Data included normal uptakes and pathological cases. Studies were reconstructed by filtered back projection (FBP) and the ordered-subset expectation-maximization algorithm. Quantification was carried out by applying a reference method based on regions of interest (ROIs) derived from the MR images and ROIs derived from the Automated Anatomical Labelling map. Our results showed that, regardless of anatomical variability, the relationship between calculated and true SUR values for caudate and putamen could be described by a multiple linear model which took into account the spill-over phenomenon caused by PVE (R² ≥ 0.963 for caudate and ≥0.980 for putamen) and also by a simple linear model (R(2) ≥ 0.952 for caudate and ≥0.973 for putamen). Calculated values were standardized by inverting both linear systems. Differences between standardized and true values showed that, although the multiple linear model was the best approach in terms of variability (X² ≥ 11.79 for caudate and ≤7.36 for putamen), standardization based on a simple linear model was also suitable (X² ≥ 12.44 for caudate and ≤12.57 for putamen).

Why the (dis)agreement? Family context and child-parent perspectives on health-related quality of life and psychological problems in paediatric asthma

BACKGROUND

Children's health-related quality of life (HrQoL) and psychological problems are important outcomes to consider in clinical decision making in paediatric asthma. However, children's and parents' reports often differ. The present study aimed to examine the levels of agreement/disagreement between children's and parents' reports of HrQoL and psychological problems and to identify socio-demographic, clinical and family variables associated with the extent and direction of (dis)agreement.

METHODS

The sample comprised 279 dyads of Portuguese children with asthma who were between 8 and 18 years of age (M = 12.13; SD = 2.56) and one of their parents. The participants completed self- and proxy-reported questionnaires on paediatric generic HrQoL (KIDSCREEN-10), chronic-generic HrQoL (DISABKIDS-37) and psychological problems (Strengths and Difficulties Questionnaire). Children's and parents' perceptions of family relationships were measured with the Family Environment Scale and the caregiving burden was assessed using the Revised Burden Measure.

RESULTS

The child-parent agreement on reported HrQoL and psychological problems was poor to moderate (intraclass correlation coefficients between 0.32 and 0.47). The rates of child-parent discrepancies ranged between 52.7% (psychological problems) and 68.8% (generic HrQoL), with 50.5% and 31.5% of the parents reporting worse generic and chronic-generic HrQoL, respectively, and 33.3% reporting more psychological problems than their children. The extent and direction of disagreement were better explained by family factors than by socio-demographic and clinical variables: a greater caregiving burden was associated with increased discrepancies in both directions and children's and parents' perceptions of less positive family relationships were associated with discrepancies in different directions.

CONCLUSIONS

Routine assessment of paediatric HrQoL and psychological problems in healthcare and research contexts should include self- and parent-reported data as complementary sources of information, and also consider the family context. The additional cost of conducting a more in-depth assessment of paediatric adaptation outcomes can be offset through more efficient allocation of health resources.

Cost minimisation analysis of fingolimod vs natalizumab as a second line of treatment for relapsing-remitting multiple sclerosis

INTRODUCTION

At present, there is a lack of economic assessments of second-line treatments for relapsing-recurring multiple sclerosis. The aim of this study was to compare the efficiency between fingolimod and natalizumab in Spain.

METHODS

A cost minimisation analysis model was developed for a 2-year horizon. The same relapse rate was applied to both treatment arms and the cost of resources was calculated using Spain's stipulated rates for 2012 in euros. The analysis was conducted from the perspective of Spain's national health system and an annual discount rate of 3% was applied to future costs. A sensitivity analysis was performed to validate the robustness of the model.

RESULTS

Indirect comparison of fingolimod with natalizumab revealed no significant differences (hazard ratio between 0.82 and 1.07). The total direct cost, considering a 2-year analytical horizon, a 7.5% discount stipulated by Royal Decree, and a mean annual relapse rate of 0.22, was € 40914.72 for fingolimod and € 45890.53 for natalizumab. Of the total direct costs that were analysed, the maximum cost savings derived from prescribing fingolimod prescription was € 4363.63, corresponding to lower administration and treatment maintenance costs. Based on the sensitivity analysis performed, fingolimod use was associated with average savings of 11% (range 3.1%-18.7%).

CONCLUSIONS

Fingolimod is more efficient than natalizumab as a second-line treatment option for relapsing-remitting multiple sclerosis and it generates savings for the Spanish national health system.

Objectively measured physical activity and C-reactive protein: National Health and Nutrition Examination Survey 2003-2004

The association between physical activity (PA) and C-reactive protein (CRP) is inconsistent, with nearly all studies using self-report measures of PA. The purpose of this study was to examine the association between objectively measured PA and CRP in US adults and children. Adults (N=2912) and children (N=1643) with valid accelerometer data and CRP data were included in the analyses. Logistic regression analysis was used to assess the odds of meeting PA guidelines across CRP quartiles for children and among adults with low, average, and high CRP levels. For adults, after adjustments for age, gender, race, body mass index, smoking, diabetes, and high-density lipoprotein cholesterol (HDL-C), compared with those with low CRP levels, odds ratios were 0.59 (CI=0.45-0.77) and 0.46 (CI=0.28-0.76) for participants with average and high CRP levels, respectively. For children, after adjustments for age, gender, race, weight status, and HDL-C, compared with those in CRP quartile 1, odds ratios were 0.96 (CI=0.5-1.84), 1.23 (CI=0.71-2.12), and 0.79 (CI=0.33-1.88) for participants in quartiles 2, 3, and 4, respectively. Objectively measured PA is inversely associated with CRP in adults, with PA not related to CRP in children.

Similarities amid the difference: caregiving burden and adaptation outcomes in dyads of parents and their children with and without cerebral palsy

This study had two main objectives: first, to examine the direct and indirect effects, via social support, of caregiving burden on the adaptation outcomes of children/adolescents with cerebral palsy and their parents; and second, to assess the invariance of such models in clinical vs. healthy subsamples. Participants were 210 dyads of children/adolescents and one of their parents (total N=420), divided in 93 dyads of children/adolescents with cerebral palsy and 117 dyads of children/adolescents with no medical diagnosis. Data on caregiving burden, social support and adaptation outcomes were obtained through self-report questionnaires. Caregiving burden was linked to parents and their children's psychological maladjustment and quality of life both directly (except for children's quality of life) and indirectly through social support. Findings were invariant across clinical and healthy subsamples. Caregiving burden may influence adaptation outcomes of children/adolescents with CP and their parents both directly and via their social support perceptions. These patterns are similar to those observed in typically developing children/adolescents.

Abstract P1-07-18: Association between Bone Turnover Markers in patients with breast cancer and bone metastases on treatment with bisphosphonates (ZOMAR study)

Background: The presence of bone metastases (BMe) alters the balance of bone remodeling and consequently, levels of bone turnover markers (BTM). Increased levels of these biomarkers are related to the risk of skeletal-related events (SREs), disease progression and death. Treatment with bisphosphonates reduces the probability of SREs through osteoclastic activity inhibition. The aim of this study was to determine the relation between BTM, bone metastasis development and SREs, disease progression and death in patients with breast cancer (BC) and BMe.

Patients and methods: Observational, prospective and multicenter study. Patients with BC and BMe; no previous bone treatment in the last 6 months prior to study entry. Urinary aminoterminal telopeptide of collagen I (NTX, Osteomark NTx Urine, Wampole Laboratories, USA); urinary alpha-alpha-isomer of carboxyterminal telopeptide of collagen I (αα-CTX, ALPHA Crosslaps EIA, ids, UK) and serum bone alkaline phosphatase (BALP, OSTASE BAP, ids, UK) were determined at baseline (V0) and every 3 mo along 18 months (V6). Patients were treated with zoledronic acid (ZA) at inclusion and every 3–4 weeks.

Results: 234 patients with BC and BMe were analyzed. BTM results were available for 219 patients at basal visit (V0) and every 3 mo of treatment along 18 months (V6). Population basal characteristics (234 patients): mean age: 59.8 years; ER+: 80.3%; PR+: 64.9%; HER 2+: 18.3%. Patients with pathologic baseline levels were: 49.8% NTX, 39.6% αα-CTX and 83.4% BALP. A significant decrease was observed in BTM at V2 vs V0 after 6 months: 13.7%, 8.4% and 58.4% presented pathologic values of NTX, αα-CTX and BALP respectively. Normalized levels remained steady throughout 18 mo follow-up, finding significant decrease for each BMT for each time point except at V6 for αα-CTX. Regarding association between BTM and SREs, progression and exitus, a significant association was observed between pathologic levels of BTM throughout follow-up: with SRE at V3, V4 for NTX; with disease progression at V3, V4, V5, V6 for NTX, at V2 for αα–CTX and at each follow up visit for BALP; and with death at V1,4,5 for NTX, at V5 for αα–CTX and at V1,2,3,4,5 for BALP.

Conclusions: Addition of ZA to standard systemic therapy reduced BTM levels during the first 3 months of treatment and normalized levels remained steady throughout 18 months follow up except at Month 18 for αα-CTX. Pathological levels of BTM were significantly associated with SRE, disease progression and death.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-07-18.

OT3-01-15: Phase III Trial Evaluating the Addition of Bevacizumab to Endocrine Therapy as First-Line Treatment for Advanced Breast Cancer: The LEA Study

Background

Retrospective clinical data suggest that high vascular endothelial growth factor (VEGF) levels in breast tumors are associated with a decreased response to endocrine therapy. We designed the randomized phase III LEA study of first-line bevacizumab in combination with endocrine therapy, to address the hypothesis that anti-VEGF treatment can prevent resistance to endocrine therapy in patients with advanced breast cancer sensitive to such treatment.

Methods: Postmenopausal patients with evaluable locally recurrent or metastatic breast cancer, HER2−negative- and estrogen receptor (ER)-and/or progesterone receptor (PgR)-positive disease, and eligible to receive hormonal treatment are candidates for this study. Patients are randomized to receive letrozole 2.5mg daily or fulvestrant, 250mg every 4 weeks (Arm A) or the same hormonal therapy plus bevacizumab 15mg/kg every 3 weeks (Arm B). The primary objective is to compare progression-free survival (PFS) between the treatment arms. Secondary endpoints are overall survival, time to treatment failure, overall response rate, response duration, clinical benefit rate and safety. In total, 344 patients (172 in each treatment arm) will be needed to detect a hazard ratio of 0.69 (corresponding to a median PFS of 9 months in Arm A and 13 months in Arm B) with a power of 80% and a two-tailed log-rank test at 0.05. With an expected drop-out rate of 10%, 378 patients will be included. Efficacy analysis will be triggered after 270 events.

Results: Recruitment began in November 2007. To date, 348 patients have been included in the study in Spain (n=244) and Germany (n=104). We anticipate completing recruitment by September 2011. Baseline characteristics of the first 334 randomized patients are shown in the table.

P5-14-22: Prospective Observational Study To Describe the Clinicopathological and Biological Characteristics and the Management of Metastatic Breast Cancer Patients Who Experienced Complete or Partial Remission or Disease Stabilization during at Least 3 Years

Background

Trastuzumab has shown an improvement in survival outcomes among patients with HER2+ metastatic breast cancer (MBC). Identification of pathological, clinical factors and tumor genetic profile that may predict long-term remission has become a key-issue. We aimed to describe the clinicopathological and biological characteristics of MBC patients who experienced complete response (CR), partial response (PR), or stable disease (SD) during at least 3 years and their management in routine clinical practice.

Methods: Multicenter, observational, cross-sectional study. Data were collected from women with HER2+ MBC treated with a trastuzumab-based regimen who maintained a partial or complete remission or disease stabilization beyond 3 years. The interim results from the first 65 patients evaluated are presented.

Results: Median age: 59 (52-70) years. Metastatic disease was diagnosed after a median of 23.5 (1.6−48.8) months since primary tumor diagnosis. The predominant tumor type was ductal carcinoma (89.2%) and 47% showed histological grade III. Mean tumor size: 3.6±2.2cm (anatomical pathology), 5.1±2.8cm (imaging studies). Hormonal status: Progesterone receptor positive 46% and estrogen receptor positive 43%. Most common metastatic sites: lung (23%), liver (17%) and bone (14%). Overexpression of HER2 was assessed by IHC in 97% of patients, of whom 94% were HER2+ (3+) and 17% had FISH+ HER2 status. Tumor was positive for p53 and Ki67 in 23% and 41.5%, respectively. Surgery was performed on 83% of patients, of which 73% underwent radical mastectomy; 96% had their axillary nodes removed. Surgery of metastases was performed on 7.8%. First line chemotherapy was received by 91% with the most frequent schemes being paclitaxel (24%), vinorelbine (15%) and paclitaxel/carboplatine (14%). First line hormonal therapy and radiotherapy was used in 45% and 12%, respectively. All patients received first line trastuzumab, administered on a weekly schedule in 51%. Trastuzumab was used in combination in most of patients (89.2%) with a median number of cycles of 18 (7.0−41.5) and during a median of 53.3±25 months. 66% of patients achieved a CR, 21% PR and 13% had SD. Median time since trastuzumab was initiated to CR, PR or SD was 5 (4-7) months. Median duration of CR, PR or SD was 56 (44.5−78.0) months. Trastuzumab was maintained beyond CR, PR or SD in 99% during a median of 46.5 (35-67) months. 75% of patients continue on treatment with trastuzumab. Only 2 patients discontinued trastuzumab due to toxicity. At the time of the analysis, 19% had progressed, 57% were alive and free of disease and among patients on treatment (93%), 54% were on trastuzumab. Cardiac toxicity was the most common toxicity (36%) among those suffering at least one (22%).

Conclusions: The preliminary findings support that trastuzumab provides a substantial long-term survival benefit with a manageable safety profile in HER2+ MBC patients. This study adds to the evidence that there may be benefit in continuing trastuzumab after achieving remission or disease stabilization. Final results will be presented in the forthcoming congress.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-14-22.

Comparative study of approximate entropy and sample entropy robustness to spikes

OBJECTIVE

There is an ongoing research effort devoted to characterize the signal regularity metrics approximate entropy (ApEn) and sample entropy (SampEn) in order to better interpret their results in the context of biomedical signal analysis. Along with this line, this paper addresses the influence of abnormal spikes (impulses) on ApEn and SampEn measurements.

METHODS

A set of test signals consisting of generic synthetic signals, simulated biomedical signals, and real RR records was created. These test signals were corrupted by randomly generated spikes. ApEn and SampEn were computed for all the signals under different spike probabilities and for 100 realizations.

RESULTS

The effect of the presence of spikes on ApEn and SampEn is different for test signals with narrowband line spectra and test signals that are better modeled as broadband random processes. In the first case, the presence of extrinsic spikes in the signal results in an ApEn and SampEn increase. In the second case, it results in an entropy decrease. For real RR records, the presence of spikes, often due to QRS detection errors, also results in an entropy decrease.

CONCLUSIONS

Our findings demonstrate that both ApEn and SampEn are very sensitive to the presence of spikes. Abnormal spikes should be removed, if possible, from signals before computing ApEn or SampEn. Otherwise, the results can lead to misunderstandings or misclassification of the signal regularity.

Antitumor actinopyranones produced by Streptomyces albus POR-04-15-053 isolated from a marine sediment

Four new antitumor pyranones, PM050511 (1), PM050463 (2), PM060054 (3), and PM060431 (4), were isolated from the cell extract of the marine-derived Streptomyces albus POR-04-15-053. Their structures were elucidated by a combination of spectroscopic methods, mainly 1D and 2D NMR and HRESIMS. They consist of an α-methoxy-γ-pyrone ring containing a highly substituted tetraene side chain glycosylated at C-10 in the case of 1 and 4. Compounds 1 and 4 displayed strong cytotoxicity against three human tumor cell lines with GI₅₀ values in the submicromolar range, whereas 2 showed subnanomolar activity as an inhibitor of EGFR-MAPK-AP1-mediated mitogenic signaling, causing inhibition of EGF-mediated AP1 trans-activation and EGF-mediated ERK activation and slight inhibition of EGF-mediated JNK activation. Taken together, these results suggest that members of the pyranone family of compounds could be developed as potential antitumor agents.

Sperm competition, sperm numbers and sperm quality in muroid rodents

Sperm competition favors increases in relative testes mass and production efficiency, and changes in sperm phenotype that result in faster swimming speeds. However, little is known about its effects on traits that contribute to determine the quality of a whole ejaculate (i.e., proportion of motile, viable, morphologically normal and acrosome intact sperm) and that are key determinants of fertilization success. Two competing hypotheses lead to alternative predictions: (a) sperm quantity and quality traits co-evolve under sperm competition because they play complementary roles in determining ejaculate's competitive ability, or (b) energetic constraints force trade-offs between traits depending on their relevance in providing a competitive advantage. We examined relationships between sperm competition levels, sperm quantity, and traits that determine ejaculate quality, in a comparative study of 18 rodent species using phylogenetically controlled analyses. Total sperm numbers were positively correlated to proportions of normal sperm, acrosome integrity and motile sperm; the latter three were also significantly related among themselves, suggesting no trade-offs between traits. In addition, testes mass corrected for body mass (i.e., relative testes mass), showed a strong association with sperm numbers, and positive significant associations with all sperm traits that determine ejaculate quality with the exception of live sperm. An "overall sperm quality" parameter obtained by principal component analysis (which explained 85% of the variance) was more strongly associated with relative testes mass than any individual quality trait. Overall sperm quality was as strongly associated with relative testes mass as sperm numbers. Thus, sperm quality traits improve under sperm competition in an integrated manner suggesting that a combination of all traits is what makes ejaculates more competitive. In evolutionary terms this implies that a complex network of genetic and developmental pathways underlying processes of sperm formation, maturation, transport in the female reproductive tract, and preparation for fertilization must all evolve in concert.

Brachylaima aspersae n. sp. (Digenea: Brachylaimidae) infecting farmed snails in NW Spain: morphology, life cycle, pathology, and implications for heliciculture

The life cycle of Brachylaima aspersae n. sp. (Trematoda: Brachylaimidae) in heliciculture farms is elucidated in light of field and experimental studies. Embryonated asymmetrical eggs (33.3 μm × 20.2 μm) are passed in the faeces of the definitive host, the domestic mouse (Mus musculus), and are ingested by its unique first intermediate host, the helicid snail Helix aspersa aspersa. After hatching, the miracidium develops into a highly branched sporocyst in the connective tissues of the digestive gland. Microcaudate cercariae emerging from this gastropod migrate up the ureter of the second intermediate host, the snails H. a. aspersa and H. a. maxima, and develop into non-encysted metacercariae in the kidney. Following predation of infected snails, the metacercariae develop into adults preferentially in the proximal portion of the duodenum of the definitive host. The strict oioxenic character for the first intermediate host, as well as the cercarial chaetotaxy (3 C(I)V+1 C(I)D, 10 C(II), 5 C(III)V, 14 C(III)L, 2 C(III)D, 16 H, 6 S(I), 6 S(II), 6 S(III), 2 A(I)L+1 A(I)V, 1 A(II)L, 3 ML, 1 P(I)L and 3 P(III)L), the distinct pars prostatica, the variable appearance of testes (rounded to irregular, with smooth or slightly to moderately lobulated margins), the size of eggs, the position of acetabulum (located somewhat posterior to the anterior third of body), and the microhabitat of the adult in the final host allow differentiation of B. aspersae from other well-known species in the genus. Massive infections with sporocysts or metacercariae of this brachylaimid may induce extensive pathological changes in the organs affected. Our results confirm that control of rodents in heliciculture farms is essential to minimize the potential health risks and morbimortality associated with this newly described species.

Economic evaluation of the levonorgestrel-releasing intrauterine system for the treatment of dysfunctional uterine bleeding in Spain

OBJECTIVE

To compare the cost and effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) versus combined oral contraception (COC) and progestogens (PROG) in first-line treatment of dysfunctional uterine bleeding (DUB) in Spain.

STUDY DESIGN

A cost-effectiveness and cost-utility analysis of LNG-IUS, COC and PROG was carried out using a Markov model based on clinical data from the literature and expert opinion. The population studied were women with a previous diagnosis of idiopathic heavy menstrual bleeding. The analysis was performed from the National Health System perspective, discounting both costs and future effects at 3%. In addition, a sensitivity analysis (univariate and probabilistic) was conducted.

RESULTS

The results show that the greater efficacy of LNG-IUS translates into a gain of 1.92 and 3.89 symptom-free months (SFM) after six months of treatment versus COC and PROG, respectively (which represents an increase of 33% and 60% of symptom-free time). Regarding costs, LNG-IUS produces savings of € 174.2-309.95 and € 230.54-577.61 versus COC and PROG, respectively, after 6 months-5 years. Apart from cost savings and gains in SFM, quality-adjusted life months (QALM) are also favourable to LNG-IUS in all scenarios, with a range of gains between 1 and 2 QALM compared to COC and PROG.

CONCLUSIONS

The results indicate that first-line use of the LNG-IUS is the dominant therapeutic option (less costly and more effective) in comparison with first-line use of COC or PROG for the treatment of DUB in Spain. LNG-IUS as first line is also the option that provides greatest health-related quality of life to patients.