Fellowships and defence engagement: from clinical niches to strategic impact

Medical fellowships have traditionally developed the individual rather than furthering military or national strategic objectives. This paper describes a medical fellowship with the British Antarctic Survey to illustrate the benefits to the individual, to the military and to wider international defence engagement efforts.By rebranding such fellowships as Defence Healthcare Engagement and by treating international organisations on a par with partner nations, the humble fellowship can facilitate enduring, mutually beneficial healthcare engagement at low cost and with minimal additional resources.

Abstract OT2-07-04: A phase 1b study of poziotinib in combination with T-DM1 in women with advanced or metastatic HER2-positive breast cancer

Background:Poziotinib represents a new class of irreversible quinazoline inhibitors of ErbB receptor tyrosine kinases that inhibit the proliferation of tumor cells in culture and in vivo by inhibiting HER-1 (EGFR), HER-2, HER-4. ErbB signaling plays important roles in the progression of HER2+ breast cancer. Poziotinib has promising clinical activity in breast cancer, and other solid tumors including lung, gastric, and colorectal cancers.

Study SPI-POZ-101, is being conducted to evaluate the safety and efficacy of the combination of daily poziotinib and T-DM1, HER2 antibody-drug-conjugate every three weeks in patients with HER2+ advanced or metastatic breast cancer.

Trial Objectives and Design: The primary objectives of the study are to determine the maximum tolerated dose (MTD) or maximum administered dose (MAD) of daily poziotinib plus T-DM1 (every 3 weeks) in women with advanced or metastatic HER2 positive breast cancer; and to evaluate the Objective Response Rate (ORR) in these patients.

The secondary objectives include disease control rate (DCR), progression-free-survival (PFS), safety and pharmacokinetics at the MTD/MAD dose level of poziotinib plus T-DM1.

In Part 1, the dose of poziotinib plus standard dose of T-DM1 (3.6 mg/kg IV) on Day 1 of each cycle will be determined using a “3+3” design with up to 3 escalating dose levels, 8, 10 and 12 mg with no DLT or to de-escalate to 6 mg with DLT observed in Cycle 1. Patients in current dose cohort, if not discontinued, will continue treatment until discontinuation of therapy.

In Part 2 of the study, approximately 10 patients will be treated at the MTD/MAD to confirm dose for safety of the combination and to evaluate preliminary efficacy.

Eligibility Criteria: The study will enroll female patients between 18 and 90 years with confirmed HER2 overexpression or gene-amplified tumor via immunohistochemistry [IHC] with IHC 3+ or IHC 2+ with confirmatory fluorescence in situ hybridization [FISH]+ or [ISH]+ and must have had at least 2 lines of anti-HER2 directed therapies either in the metastatic or early-stage disease setting. Patients must have adequate hematologic, hepatic, cardiac and renal functions and have at least one measurable lesion per RECIST 1.1 criteria. Exclusion criteria includes unstable CNS metastases or seizure disorder; anticancer chemotherapy, TKIs, biologics, immunotherapy, radiotherapy, or investigational treatment within 15 days; ≥ Grade 2 adverse events; known hypersensitivity to receptor tyrosine kinase inhibitors or any of the components of poziotinib tablets or T-DM1 IV solution.

Statistical Methods: Part 1 of the study will enroll 3 to 6 patients at each dose using 3+3 design. Part 2 will enroll 10 patients at the MTD/MAD. The efficacy analysis will be conducted using the Evaluable Population based on RECIST 1.1. The Clopper-Pearson 95% confidence interval will be estimated using exact method based on binomial distribution.

Target Accrual:Part 1: 6-18 patients Part 2: 10 patients

ClinicalTrials.gov Identifier: NCT03429101

Contact Information: Spectrum Pharmaceuticals. SPI-POZ-101@sppirx.com

Poziotinib is currently under clinical investigation and has not been approved for use in breast cancer.

Citation Format: Bhat G, Potter D, Bharadwaj J, Khan N, Shabazz L, Tache J, Yang Z. A phase 1b study of poziotinib in combination with T-DM1 in women with advanced or metastatic HER2-positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-07-04.

Abstract P1-12-06: Endothelial dysfunction in breast cancer survivors on aromatase inhibitors (AIs) over time

Endothelial dysfunction in breast cancer survivors on aromatase inhibitors (AIs) over time

Background: AIs reduce breast cancer-related mortality however they may increase cardiovascular (CV) risk. Our previously published cross-sectional study suggested women on AIs were more likely to have endothelial dysfunction when measured by EndoPAT ratio as compared to healthy postmenopausal women. Reductions in EndoPAT ratio (<1.67) and small artery elasticity (SAE) and increases in highly sensitive C-reactive protein (CRP) are associated with worsening endothelial dysfunction and increased cardiovascular events. We present data from a longitudinal pilot study looking at endothelial dysfunction over time in women on AIs.

Methods: Fourteen women with locally advanced breast cancer prescribed an AI underwent vascular testing at baseline (pre-AI) and at 6 months. Subjects with tobacco use, hypertension or hyperlipidemia were excluded. Consented subjects underwent biomarker analysis and radial artery pulse wave analysis using the HDI/Pulse Wave CR-2000 CV Profiling System and pulse contour analysis using the Endo-PAT2000 system. Biomarkers were obtained using a fasting blood draw to evaluate the following lipids and inflammatory markers: serum ultrasensitive estradiol, serum glucose, total cholesterol (TC), low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), and triglycerides (TG), CRP, plasminogen-activator 1 (PA1), and tissue-type plasminogen activator (tPA). Changes between baseline and follow-up using Wilcoxon signed-rank tests were analyzed.

Results: Mean baseline age was 59 years and median body mass index was 26.5 kg/m2. Median systolic blood pressure and total cholesterol were 120/70 mm/Hg and 228 mg/dL, respectively. Baseline ultrasensitive estradiol levels were 7 pg/mL and hsCRP was 2.45 mg/dL. Prior to AI therapy, endoPAT ratio was 2.18 (1.19, 2.43). After six months, EndoPAT ratio declined to a median 1.12 (0.85, 1.86) (p=0.045). There were no statistically significant changes in serum glucose, TC, LDL, HDL, hsCRP, PA1 and tPA. HsCRP remained elevatedat median 2.98 mg/L. At six months, estradiol levels decreased to a median of 2 pg/mL (p=0.052), however, there appeared to be no linear association between changes in EndoPAT and estradiol (p=0.91).

Conclusion: Breast cancer survivors on AIs have endothelial dysfunction, a predictor of adverse CV disease. These changes develop while on AIs. Underlying pathophysiology requires further evaluation.

Cardiovascular markersMeasuresBaselineFollow-Up at 6 MonthsChangeP-valueBMI (kg/m2)26.5 (24.4, 31.6)27.1 (23.9, 32.9)0.5 (0.0, 1.3)0.056SBP (mmHg)120 (115, 124)123 (114, 127)-0.8 (-7.4, 3.6)0.91DBP (mmHg)70 (61, 73)69 (62, 71)0.0 (-3.0, 2.6)0.88Total Cholesterol (mg/dL)228 (202, 244)213 (210, 229)-1 (-18, 27)0.70HDL (mg/dL)64 (58, 69)73 (61, 77)2 (-3, 14)0.44LDL (mg/dL)143 (121, 159)129 (120, 142)6 (-11, 14)0.65Estradiol (pg/mL)7 (4, 15)2 (2, 3)-8 (-12, -3)0.05hsCRP (mg/dL)2.45 (1.14, 6.07)2.98 (0.90, 4.81)-8 (-12, -3)0.85EndoPAT Ratio2.18 (1.19, 2.43)1.12 (0.85, 1.86)-0.16 (-1.45, -0.02)0.0451.Summaries shown are median (1st quartile, 3rd quartile).

Citation Format: Blaes AH, Petersen A, Beckwith H, Potter D, Florea N, Yee D, Vogel R, Duprez D. Endothelial dysfunction in breast cancer survivors on aromatase inhibitors (AIs) over time [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-12-06.

Abstract PD1-09: Phase 2 safety and efficacy results of TAK-228 in combination with exemestane or fulvestrant in postmenopausal women with ER-positive/HER2-negative metastatic breast cancer previously treated with everolimus

Background: TAK-228 is an investigational, oral and highly selective ATP-competitive inhibitor of TORC1/2. Targeting the PI3K/AKT/mTOR pathway with the dual TORC1/2 inhibitor TAK-228 may restore sensitivity to endocrine therapies in patients (pts) with breast cancer who have progressed on the combination of an endocrine agent plus a TORC1 inhibitor. Here we report data from the phase 2 portion of a phase 1b/2 study of TAK-228 plus exemestane (E) or fulvestrant (F).

Methods: Postmenopausal women with ER+ and HER2-, inoperable or metastatic breast cancer (MBC) following everolimus (EVE) plus E or F after progression, received oral TAK-228 (4 mg QD) plus E (25 mg QD) or F (500 mg monthly) for 28-day cycles until progressive disease (PD) or unacceptable toxicity (NCT02049957). Pts were enrolled into parallel cohorts based on prior response to EVE plus E or F and were given the same prior therapy (E or F) at their established dose: EVE-sensitive, defined as disease progression after complete response (CR), partial response (PR), or ≥6 mos stable disease (SD); or EVE-resistant, defined as disease progression without a CR or PR, or after <6 mos SD. Primary endpoint was clinical benefit rate at 16 wks (CR, PR, or SD at 16 wks; CBR-16). Secondary endpoints included CBR at 24 wks (CBR-24), overall response rate (ORR), progression-free survival (PFS), overall survival (OS) and safety.

Results: From Oct 2015 to Dec 2017, 94 pts were enrolled. Median age was 58 y (range 32–83). At baseline, most pts (67%) had stage IV disease and others were stage IA–IIIC (24%), other (3%) or unknown (5%); 94% of EVE-sensitive (93% E vs 100% F) and 88% of EVE-resistant pts (91% E vs 75% F) had received ≥4 prior lines of therapy. Pts received a median of 3 cycles (1–15) of TAK-228. At data cutoff (24 Apr 2018), 98% of pts had discontinued treatment, mainly due to PD (76%) or adverse events (AEs; 14%). CBR-16 was 41% (n=21) in EVE-sensitive and 26% (n=11) in EVE-resistant pts (table). CBR-24 was 24% in EVE-sensitive (19% E vs 50% F) and 23% in EVE-resistant (23% E vs 25% F) pts. Eleven of 21 pts who achieved CBR-16 also achieved CBR-24 (6 SD, 5 PR) in the EVE-sensitive cohort and 8 of 11 pts in the EVE-resistant cohort (6 SD, 2 PR). The ORR was 12% in EVE-sensitive pts and 9% in EVE-resistant pts (table). Median PFS (95% CI) was 4.1 mos (2.2–5.5) and 3.4 mos (1.9–5.4), and median OS (95% CI) was 15.9 mos (14.1–19.5) and 14.0 mos (13.0–16.0) in the EVE-sensitive and -resistant cohorts, respectively. Drug-related any grade and grade ≥3 AEs were seen in 90% and 29% of pts, respectively. Most common drug-related any grade AEs were nausea (50%), fatigue (38%), hyperglycemia and diarrhea (each 29%); 22% of pts reported a serious AE. No deaths were reported. Treatment is ongoing in two pts.

Conclusion: TAK-228 plus E or F showed modest clinical benefit in pts with previously treated, EVE-sensitive or -resistant MBC, with an acceptable safety profile.

 EVE-sensitive (N=51)EVE-resistant (N=43) TAK-228+TAK-228+Best response, n (%)E (n=43)F (n=8)E (n=35)F (n=8)ORR=CR+PR4 (9)2 (25)3 (9)1 (13)CR001 (3)0PR4 (9)2 (25)2 (6)1 (13)CBR-1617 (40)4 (50)9 (26)2 (25)

Citation Format: Diamond JR, Potter D, Salkeni M, Silverman P, Haddad T, Forget F, Awada A, Canon J-L, Danso M, Lortholary A, Bourgeois H, Tan-Chiu E, Patel C, Neuwirth R, Leonard EJ, Lim B. Phase 2 safety and efficacy results of TAK-228 in combination with exemestane or fulvestrant in postmenopausal women with ER-positive/HER2-negative metastatic breast cancer previously treated with everolimus [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD1-09.

Gamma-Normal-Gamma Mixture Model for Detecting Differentially Methylated Loci in Three Breast Cancer Cell Lines

With state-of-the-art microarray technologies now available for whole genome CpG island (CGI) methylation profiling, there is a need to develop statistical models that are specifically geared toward the analysis of such data. In this article, we propose a Gamma-Normal-Gamma (GNG) mixture model for describing three groups of CGI loci: hypomethylated, undifferentiated, and hypermethylated, from a single methylation microarray. This model was applied to study the methylation signatures of three breast cancer cell lines: MCF7, T47D, and MDAMB361. Biologically interesting and interpretable results are obtained, which highlights the heterogeneity nature of the three cell lines. This underlies the premise for the need of analyzing each of the microarray slides individually as opposed to pooling them together for a single analysis. Our comparisons with the fitted densities from the Normal-Uniform (NU) mixture model in the literature proposed for gene expression analysis show an improved goodness of fit of the GNG model over the NU model. Although the GNG model was proposed in the context of single-slide methylation analysis, it can be readily adapted to analyze multi-slide methylation data as well as other types of microarray data.

Abstract S5-07: Aromatase inhibitors and endothelial function: Is there an association with early cardiovascular disease?

Background: As more women are cured from their breast cancer, survivors with early stage breast cancer are at greater risk of dying from cardiovascular disease than their breast cancer. Aromatase inhibitors (AI) have been shown to reduce breast cancer-related mortality in women with estrogen receptor (ER)-positive disease which makes up 75% of all breast cancer cases. The use of AIs has been associated with higher rates of hypertension, hypercholesterolemia, angina pectoris and ischemic cardiovascular disease. In the aging population taking AIs, little is known about the direct impact of AIs on endothelial function, a predictor of cardiovascular disease. Endothelial dysfunction identified by reactive hyperemia using Endo-PAT has been associated with an increased risk of cardiac adverse events, independent of Framingham risk score.

Methods: At the University of Minnesota in 2014-2015, 25 healthy postmenopausal women and 36 postmenopausal women with locally advanced breast cancer and prescribed an aromatase inhibitor were identified. Subjects with a history of hypertension or hyperlipidemia were excluded. Consented subjects underwent biomarker analysis and pulse wave analysis using the HDI/Pulse Wave CR-2000 Cardiovascular Profiling System and pulse contour analysis using the Endo-PAT2000 system. Biomarkers and functional test markers were compared between cases and controls using T-tests and Wilcoxon Rank-Sum tests.

Results: Mean age (61.7 vs 58.8 years), body mass index (27.4 vs 26.2 kg/m2), race (93% vs 92% Caucasian), and tobacco use (100% nonsmokers) were similar between cases and controls, respectively. Mean systolic blood pressure (BP) was elevated in cases (128.3 mmHg vs 114.5 mmHg, p=0.0006). There were no differences in lipid profiles. Median ultrasensitive estradiol levels were reduced in cases (2 vs 15 pg/mL, p<0.0001). Median high sensitive C-reactive protein was significantly elevated in cases (4146 vs 1406 ng/L, p=0.05). There were no differences seen in markers of hemostasis or endothelial damage, including circulating endothelial cells, vascular cell adhesion molecule, P-selectin. Median large artery elasticity (12.5 vs 15.1 ml/mmHg, p=0.02), small artery elasticity (5.2 vs 6.7 ml/mmHg, p=0.04), and endoPAT ratio (0.8 vs 2.6, p<0.0001) were significantly reduced in breast cancer survivors on AIs as compared to controls. There was no correlation between use of chemotherapy, radiation therapy, type of AI, or duration of AI use and endothelial function among the cases. When adjusting for differences in BP, endoPAT ratio continued to remain significantly decreased in breast cancer survivors (0.8 vs 2.6, p<0.0001).

Conclusion: Postmenopausal women with breast cancer on AIs have reductions in endothelial function, a predictor of adverse cardiovascular disease (acute coronary syndrome, chest pain, myocardial infarction, cardiac death). With the growing trend that longer duration of endocrine therapy is needed, further work is needed to confirm these findings.

Citation Format: Blaes AH, Beckwith H, Hebbel R, Solovey A, Potter D, Yee D, Vogel R, Luepker R, Duprez D. Aromatase inhibitors and endothelial function: Is there an association with early cardiovascular disease? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S5-07.

A review of recent analyses of the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS)

Introduction

The objective of this analysis is to identify, assess the quality and summarize the findings of peer-reviewed articles that used data from the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS) published since November 2011 and data from provincial oversamples of the CIS as well as to illustrate evolving uses of these datasets.

Methods

Articles were identified from the Public Health Agency of Canada’s data request records tracking access to CIS data and publications produced from that data. At least two raters independently reviewed and appraised the quality of each article.

Results

A total of 32 articles were included. Common strengths of articles included clearly stated research aims, appropriate control variables and analyses, sufficient sample sizes, appropriate conclusions and relevance to practice or policy. Common problem areas of articles included unclear definitions for variables and inclusion criteria of cases. Articles frequently measured the associations between maltreatment, child, caregiver, household and agency/referral characteristics and investigative outcomes such as opening cases for ongoing services and placement.

Conclusion

Articles using CIS data were rated positively on most quality indicators. Researchers have recently focussed on inadequately studied categories of maltreatment (exposure to intimate partner violence [IPV]), neglect and emotional maltreatment) and examined factors specific to First Nations children. Data from the CIS oversamples have been underutilized. The use of multivariate analysis techniques has increased.

Spray-dried plasma and fresh frozen plasma modulate permeability and inflammation in vitro in vascular endothelial cells

BACKGROUND

After major traumatic injury, patients often require multiple transfusions of fresh frozen plasma (FFP) to correct coagulopathy and to reduce bleeding. A spray-dried plasma (SDP) product has several logistical benefits over FFP use in trauma patients with coagulopathy. These benefits include ease of transport, stability at room temperature, and rapid reconstitution for infusion. Our past work suggests that FFP promotes endothelial stability by inhibiting endothelial permeability.

STUDY DESIGN AND METHODS

The main goal of this project is to determine if solvent-detergent-treated SDP is equivalent to FFP in inhibiting vascular endothelial cell (EC) permeability and inflammation in vitro. Furthermore, this study aimed to determine if solvent-detergent treatment and spray drying of plasma alters the protective effects of FFP on EC function. The five groups tested in our studies are the following: 1) fresh frozen-thawed plasma (FFP); 2) solvent-detergent-treated FFP; 3) solvent-detergent-treated SDP; 4) lactated Ringer's solution; and 5) Hextend.

RESULTS

This study demonstrates that in vitro SDP and FFP equivalently inhibit vascular EC permeability, EC adherens junction breakdown, and endothelial white blood cell binding, an effect that is independent of changes in Vascular Cell Adhesion Molecule 1, Intracellular Adhesion Molecule 1, or E-selectin expression on ECs. Solvent-detergent treatment of FFP does not alter the protective effects of FFP on endothelial cell function in vitro.

CONCLUSION

These data suggest the equivalence of FFP and SDP on modulation of endothelial function and inflammation in vitro.

The sensitivity of pre-hospital and in-hospital tools for the identification of major trauma patients presenting to a major trauma centre

The identification of major trauma patients before arrival in hospital allows the activation of an appropriate trauma response. The Wessex triage tool (WTT) uses a combination of anatomical injury assessment and physiological criteria to identify patients with major trauma suitable for triage direct to a major trauma centre (MTC), and has been adopted by the South-West Peninsula Trauma Network (PTN). A retrospective database review, using the Trauma Audit Research Network (TARN) database, was undertaken to identify a population of patients presenting to Derriford Hospital with an injury severity score (ISS) > 15. The WTT was then applied to this population to identify the sensitivity of the tool. The sensitivity of the WTT at identifying patients with an ISS>15 was 53%. One of the reasons for this finding was that elderly patients who are defined as having major trauma due to the nature of their injuries, but who did not have a mechanism to suggest they had sustained major trauma (such as a fall from standing height), were not identified by these triage tools. The implications of this are discussed.

The sensitivity of pre-hospital and in-hospital tools for the identification of major trauma patients presenting to a major trauma centre

The identification of major trauma patients before arrival in hospital allows the activation of an appropriate trauma response. The Wessex triage tool (WTT) uses a combination of anatomical injury assessment and physiological criteria to identify patients with major trauma suitable for triage direct to a major trauma centre (MTC), and has been adopted by the South-West Peninsula Trauma Network (PTN). A retrospective database review, using the Trauma Audit Research Network (TARN) database, was undertaken to identify a population of patients presenting to Derriford Hospital with an injury severity score (ISS) >15. The WTT was then applied to this population to identify the sensitivity of the tool. The sensitivity of the WTT at identifying patients with an ISS> 15 was 53%. One of the reasons for this finding was that elderly patients who are defined as having major trauma due to the nature of their injuries, but who did not have a mechanism to suggest they had sustained major trauma (such as a fall from standing height), were not identified by these triage tools. The implications of this are discussed.

P4-02-11: Insulin-Like Growth Factor I Promotes Estrogen Receptor Positive Breast Cancer Cell Proliferation, in Part, through CYP1A1 Signaling

Activation of the transmembrane tyrosine kinase insulin-like growth factor 1 receptor (IGF-1R) contributes to breast cancer progression. Nonetheless, the mechanisms by which the IGF-1R contributes to breast cancer progression need to be better characterized to further develop therapeutic strategies that target this pathway. It is known that cytochrome P450 monooxygenases synthesize metabolites from endogenous and exogenous sources that promote breast cancer proliferation. Here we propose that activity of the IGF-1R modulates the activity of CYP1A1 to promote breast cancer cell proliferation. We have found that IGF-IR activation by treatment with IGF1 (5nM ) for 4hrs induces cytochrome P450 1A1 (CYP1A1) mRNA levels in estrogen receptor (ER) positive line T47D-CO, but not ER negative line MDA-MB-231. Treatment with IGF1 promotes the proliferation of ER positive lines T47D-CO and MCF7. Interestingly, we found that treatment with IGF1 only partially compensates the growth-inhibition induced by CYP1A1 knock down by siRNA, suggesting that IGF1 requires CYP1A1 for full promotion of cell growth. These preliminary data suggest that IGF-1 signaling functions, in part, through CYP1A1 to promote ER positive breast cancer cell proliferation. The mechanism of IGF-1 signaling through CYP1A1 is novel and may represent an effector mechanism for IGF-1. Further understanding the role of CYP1A1 downstream of the IGF-1R may allow novel approaches for inhibition of breast cancer cell proliferation downstream of the IGF-1R.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-02-11.

A multicentre randomised controlled trial and economic evaluation of ion-exchange water softeners for the treatment of eczema in children: the Softened Water Eczema Trial (SWET)

OBJECTIVES

To determine whether installation of an ion-exchange water softener in the home could improve atopic eczema in children and, if so, to establish its likely cost and cost-effectiveness.

DESIGN

An observer-blind, parallel-group randomised controlled trial of 12 weeks duration followed by a 4-week observational period. Eczema was assessed by research nurses blinded to intervention at baseline, 4 weeks, 12 weeks and 16 weeks. The primary outcome was analysed as intent-to-treat, using the randomised allocation rather than actual treatment received. A secondary per-protocol analysis excluded participants who failed to receive their allocated treatment and who were deemed to be protocol violators.

SETTING

Secondary and primary care referral centres in England (UK) serving a variety of ethnic and social groups and including children living in both urban and periurban homes.

PARTICIPANTS

Three hundred and thirty-six children (aged 6 months to 16 years) with moderate/severe atopic eczema, living in homes in England supplied by hard water (≥ 200 mg/l calcium carbonate).

INTERVENTIONS

Participants were randomised to either installation of an ion-exchange water softener plus usual eczema care (group A) for 12 weeks or usual eczema care alone (group B) for 12 weeks. This was followed by a 4-week observational period, during which water softeners were switched off/removed from group A homes and installed in group B homes. Standard procedure was to soften all water in the home, but to provide mains (hard) water at a faucet-style tap in the kitchen for drinking and cooking. Participants were therefore exposed to softened water for bathing and washing of clothes, but continued to drink mains (hard) water. Usual care was defined as any treatment that the child was currently using in order to control his or her eczema. New treatment regimens used during the trial period were documented.

MAIN OUTCOME MEASURES

Primary outcome was the difference between group A and group B in mean change in disease severity at 12 weeks compared with baseline, as measured using the Six Area, Six Sign Atopic Dermatitis (SASSAD) score. This is an objective severity scale completed by blinded observers (research nurses) unaware of the allocated intervention. Secondary outcomes included use of topical medications, night-time movement, patient-reported eczema severity and a number of quality of life measures. A planned subgroup analysis was conducted, based on participants with at least one mutation in the gene encoding filaggrin (a protein in the skin thought to be important for normal skin barrier function).

RESULTS

Target recruitment was achieved (n = 336). The analysed population included 323 children who had complete data. The mean change in primary outcome (SASSAD) at 12 weeks was -5.0 [standard deviation (SD) 8.8] for the water softener group (group A) and -5.7 (SD 9.8) for the usual care group (group B) [mean difference 0.66, 95% confidence interval (CI) -1.37 to 2.69, p = 0.53]. The per-protocol analysis supported the main analysis, and there was no evidence that the treatment effect varied between children with and without mutations in the filaggrin gene. No between-group differences were found in the three secondary outcomes that were assessed blindly (use of topical medications; night-time movement; proportion showing reasonable, good or excellent improvement). Small, but statistically significant, differences in favour of the water softener were found in three of the secondary outcomes that were assessed by participants [Patient-Oriented Eczema Measure (POEM); well-controlled weeks (WCWs); Dermatitis Family Index (DFI)]. The results of the economic evaluation, and the uncertainty surrounding them, suggest that ion-exchange water softeners are unlikely to be a cost-effective intervention for children with atopic eczema from an NHS perspective.

CONCLUSIONS

Water softeners provided no additional benefit to usual care in this study population. Small, but statistically significant, differences were found in some secondary outcomes as reported by parents, but it is likely that such improvements were the result of response bias. Whether or not the wider benefits of installing a water softener in the home are sufficient to justify the purchase of a softener is something for individual householders to consider on a case-by-case basis. This trial demonstrated overwhelming demand for non-pharmacological interventions for the treatment of eczema, and this is something that should be considered when prioritising future research in the field.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71423189.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 15, No. 8. See the HTA programme website for further project information. Results of this trial are also published at www.plosmedicine.org.

Nevirapine-associated hepatotoxicity was not predicted by CD4 count ≥250 cells/μL among women in Zambia, Thailand and Kenya

OBJECTIVE

The aim of the study was to determine risk factors for developing severe hepatotoxicity (grade 3 or 4 hepatotoxicity) and rash-associated hepatotoxicity (rash with ≥ grade 2 hepatotoxicity) among women initiating nevirapine-based antiretroviral therapy (ART).

METHODS

The Non-Nucleoside Reverse Transcriptase Inhibitor Response Study was a prospective cohort study carried out in Zambia, Thailand and Kenya. Between May 2005 and January 2007, we enrolled antiretroviral-naïve HIV-infected women initiating nevirapine-based ART. At enrollment and at weeks 2, 4, 8, 16 and 24, participants had serum alanine transferase (ALT) and aspartate transaminase (AST) measured and were evaluated clinically for hepatitis and rash.

RESULTS

Nevirapine-based ART was initiated in 820 women and baseline ALT or AST results were abnormal (≥ grade 1) in 113 (14%) women. After initiating nevirapine-based ART, severe hepatotoxicity occurred in 41 (5%) women and rash-associated hepatotoxicity occurred in 27 (3%) women. In a multivariate logistic regression model, severe hepatotoxicity and rash-associated hepatotoxicity were both associated with baseline abnormal (≥ grade 1) ALT or AST results, but not with a baseline CD4 cell count ≥250 cells/μL. Three participants (0.4%) died with symptoms suggestive of fatal hepatotoxicity; all three women had baseline CD4 count <100 cells/μL and were receiving anti-tuberculosis therapy.

CONCLUSION

Among women taking nevirapine-based ART, severe hepatotoxicity and rash-associated hepatotoxicity were predicted by abnormal baseline ALT or AST results, but not by a CD4 count ≥250 cells/μL. In resource-limited settings where transaminase testing is available, testing should focus on early time-points and on women with abnormal baseline ALT or AST results.

Preclinical validation of a microarray method for full molecular karyotyping of blastomeres in a 24-h protocol

BACKGROUND

Preimplantation genetic screening (PGS) has been used in an attempt to determine embryonic aneuploidy. Techniques that use new molecular methods to determine the karyotype of an embryo are expanding the scope of PGS.

METHODS

We introduce a new method for PGS, termed 'parental support', which leverages microarray measurements from parental DNA to 'clean' single-cell microarray measurements on embryonic cells and explicitly computes confidence in each copy number call. The method distinguishes mitotic and meiotic copy errors and determines parental source of aneuploidy.

RESULTS

Validation with 459 single cells of known karyotype indicated that per-cell false-positive and false-negative rates are roughly equivalent to the 'gold standard' metaphase karyotype. The majority of the cells were run in parallel with a clinical commercial PGS service. Computed confidences were conservative and roughly concordant with accuracy. To examine ploidy in human embryos, the method was then applied to 26 disaggregated, cryopreserved, cleavage-stage embryos for a total of 134 single blastomeres. Only 23.1% of the embryos were euploid, though 46.2% of embryos were mosaic euploid. Mosaicism affected 57.7% of the embryos. Counts of mitotic and meiotic errors were roughly equivalent. Maternal meiotic trisomy predominated over paternal trisomy, and maternal meiotic trisomies were negatively predictive of mosaic euploid embryos.

CONCLUSIONS

We have performed a major preclinical validation of a new method for PGS and found that the technology performs approximately as well as a metaphase karyotype. We also directly measured the mechanism of aneuploidy in cleavage-stage human embryos and found high rates and distinct patterns of mitotic and meiotic aneuploidy.

Identification of candidate epigenetic biomarkers for ovarian cancer detection

Ovarian cancer ranks the most lethal among gynecologic neoplasms in women. To develop potential biomarkers for diagnosis, we have identified five novel genes (CYP39A1, GTF2A1, FOXD4L4, EBP, and HAAO) that are hypermethylated in ovarian tumors, compared with the non-malignant normal ovarian surface epithelia, using the quantitative methylation-specific polymerase chain reactions. Interestingly enough, multivariate Cox regression analysis has identified hypermethylation of CYP39A1 correlated with an increase rate of relapsing (P=0.032, hazard ratio >1). Concordant hypermethylation in at least three loci was observed in 50 out of 55 (91%) of ovarian tumors examined. The test sensitivity and specificity were assessed to be 96 and 67% for CYP39A1; 95 and 88% for GTF2A1; 93 and 67% for FOXD4L4; 81 and 67% for EBP; 89 and 82% for HAAO, respectively. Our data have identified, for the first time, GTF2A1 alone, or GTF2A1 plus HAAO are excellent candidate biomarkers for detecting this disease. Moreover, the known functions of these gene products further implicate dysregulated transcriptional control, cholesterol metabolism, or synthesis of quinolinic acids, may play important roles in attributing to ovarian neoplasm. Molecular therapies, by reversing the aberrant epigenomes using inhibitory agents or by abrogating the upstream signaling pathways that convey the epigenomic perturbations, may be developed into promising treatment regimens.

An integrative ChIP-chip and gene expression profiling to model SMAD regulatory modules

Background

The TGF-β/SMAD pathway is part of a broader signaling network in which crosstalk between pathways occurs. While the molecular mechanisms of TGF-β/SMAD signaling pathway have been studied in detail, the global networks downstream of SMAD remain largely unknown. The regulatory effect of SMAD complex likely depends on transcriptional modules, in which the SMAD binding elements and partner transcription factor binding sites (SMAD modules) are present in specific context.

Results

To address this question and develop a computational model for SMAD modules, we simultaneously performed chromatin immunoprecipitation followed by microarray analysis (ChIP-chip) and mRNA expression profiling to identify TGF-β/SMAD regulated and synchronously coexpressed gene sets in ovarian surface epithelium. Intersecting the ChIP-chip and gene expression data yielded 150 direct targets, of which 141 were grouped into 3 co-expressed gene sets (sustained up-regulated, transient up-regulated and down-regulated), based on their temporal changes in expression after TGF-β activation. We developed a data-mining method driven by the Random Forest algorithm to model SMAD transcriptional modules in the target sequences. The predicted SMAD modules contain SMAD binding element and up to 2 of 7 other transcription factor binding sites (E2F, P53, LEF1, ELK1, COUPTF, PAX4 and DR1).

Conclusion

Together, the computational results further the understanding of the interactions between SMAD and other transcription factors at specific target promoters, and provide the basis for more targeted experimental verification of the co-regulatory modules.

Phase II study of biweekly cetuximab (C) and irinotecan (I) as a second-line regimen for metastatic colorectal cancer (mCRC)

e15088

Background: I + C is a standard second line mCRC regimen. Our study investigated the efficacy and safety of a biweekly I + C combination in patients (pts) with mCRC. Methods: mCRC pts who failed 1st line fluoropyrimidine/oxaliplatin regimens and had not received I or C, were eligible for this open label phase II trial with response rate (RR) as the primary end-point and planned sample size of 31 patients to achieve a 25% RR with 80% power. C 500 mg/m2 IV was administered on d1 followed by I 180 mg/m2 IV over 60 minutes biweekly. Results: Pt. characteristics (n=32): Male (n=17), female (n=15), Median age 59.9; ECOG PS ≤1 (31 pt), PS=2 (1). Median number of cycles 3 (range 1–21), 17pts received ≤ 3 cycles. Chemotherapy doses were reduced/delayed in 20 pts. Initial I dose was reduced to 150mg/m2 in 12 pts due to previous radiation (6 pts), age ≥ 70 years (5 pts), or PS 2 (1 pt). Grade 3 or 4 adverse events: acneiform rash (n=6), diarrhea (n=5), and neutropenia (n=4); possible grade 5 (respiratory failure). One PR was seen, 12 pts had stable and 13 pts PD; 6 pts were not evaluable for response. Median OS 11.1 mos (95% CI 6.0–15.1) and TTP 2.4 mos (95% CI 1.4-NA). Among the 23 pts tested, 9 pts had KRAS, and 2 pts BRAF mutations. There was a trend towards higher OS and TTP among pts with wild type (wt) KRAS (OS 11.9 vs 9.96mo, p=0.66; TTP 5.97 vs 3.11mo, p=0.288) and BRAF (OS 12 vs 4.6mo, p=0.17; TTP 4.56 vs 1.86mo, p=0.239). Conclusions: The lower RR than previously reported was likely caused by the small sample size and possibly those factors leading to initial I dose reductions. In addition 90% of patients had prior therapy with FOLFOX/bevacizumab. The OS and TTP are consistent with those reported previously (Martin et al Brit J Cancer 2008, Pfeiffer P et al Ann Oncol 2008), supporting biweekly I + C as a convenient second-line regimen in mCRC.

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Genital tract infections among HIV-infected pregnant women in Malawi, Tanzania and Zambia

SUMMARY

The aim of this study was to compare the prevalence and factors associated with genital tract infections among HIV-infected pregnant women from African sites. Participants were recruited from Blantyre and Lilongwe, Malawi; Dar es Salaam, Tanzania; and Lusaka, Zambia. Genital tract infections were assessed at baseline. Of 2627 eligible women enrolled, 2292 were HIV-infected. Of these, 47.8% had bacterial vaginosis (BV), 22.4% had vaginal candidiasis, 18.8% had trichomoniasis, 8.5% had genital warts, 2.6% had chlamydia infection, 2.2% had genital ulcers and 1.7% had gonorrhoea. The main factors associated with genital tract infections included genital warts (adjusted odds ratio [AOR] 1.8, 95% CI 1.2-2.7), genital ulcers (AOR 2.4, 95% CI 1.2-5.1) and abnormal vaginal discharge (AOR 2.5, 95% CI 1.9-3.3) for trichomoniasis. BV was the most common genital tract infection followed by candidiasis and trichomoniasis. Differences in burdens and risk factors call for enhanced interventions for identification of genital tract infections among HIV-infected women.

Breast cancer-associated fibroblasts confer AKT1-mediated epigenetic silencing of Cystatin M in epithelial cells

The interplay between histone modifications and promoter hypermethylation provides a causative explanation for epigenetic gene silencing in cancer. Less is known about the upstream initiators that direct this process. Here, we report that the Cystatin M (CST6) tumor suppressor gene is concurrently down-regulated with other loci in breast epithelial cells cocultured with cancer-associated fibroblasts (CAF). Promoter hypermethylation of CST6 is associated with aberrant AKT1 activation in epithelial cells, as well as the disabled INNP4B regulator resulting from the suppression by CAFs. Repressive chromatin, marked by trimethyl-H3K27 and dimethyl-H3K9, and de novo DNA methylation is established at the promoter. The findings suggest that microenvironmental stimuli are triggers in this epigenetic cascade, leading to the long-term silencing of CST6 in breast tumors. Our present findings implicate a causal mechanism defining how tumor stromal fibroblasts support neoplastic progression by manipulating the epigenome of mammary epithelial cells. The result also highlights the importance of direct cell-cell contact between epithelial cells and the surrounding fibroblasts that confer this epigenetic perturbation. Because this two-way interaction is anticipated, the described coculture system can be used to determine the effect of epithelial factors on fibroblasts in future studies.

Methylation analysis by microarray

Differential methylation hybridization (DMH) is a high-throughput DNA methylation screening tool that utilizes methylation-sensitive restriction enzymes to profile methylated fragments by hybridizing them to a CpG island microarray. This array contains probes spanning all the 27,800 islands annotated in the UCSC Genome Browser. Herein we describe a DMH protocol with clearly identified quality control points. In this manner, samples that are unlikely to provide good read-outs for differential methylation profiles between the test and the control samples will be identified and repeated with appropriate modifications. The step-by-step laboratory DMH protocol is described. In addition, we provide descriptions regarding DMH data analysis, including image quantification, background correction, and statistical procedures for both exploratory analysis and more formal inferences. Issues regarding quality control are addressed as well.

Differential methylation hybridization: profiling DNA methylation with a high-density CpG island microarray

Differential methylation hybridization (DMH) is a high-throughput DNA methylation screening tool that utilizes methylation-sensitive restriction enzymes to profile methylated fragments by hybridizing them to a CpG island microarray. This array contains probes spanning all the 27,800 islands annotated in the UCSC Genome Browser. Herein we describe a revised DMH protocol with clearly identified quality control points. In this manner, samples that are unlikely to provide good readouts for differential methylation profiles between the test and the control samples will be identified and repeated with appropriate modifications. In addition to the step-by-step laboratory DMH protocol, we also provide a detailed description regarding DMH data analysis. The suggested microarray platform contains 244,000 probes and it can be a daunting barrier for researchers with no prior experience in analyzing DNA methylation data. We have created a data analysis pipeline available in a user friendly, publicly available interface, the Broad Institute's GenePattern software, which can be accessed at http://bisr.osumc.edu :8080/gp. This permits scientists to use our existing data analysis modules on their own data. As we continue to update our analysis algorithm and approaches to integrate high-throughput methylation data with other large-scale data types, we will make these new computation protocols available through the GenePattern platform.