A multicenter, randomized phase 2 study to establish combinations of CBP501, cisplatin and nivolumab for ≥3rd-line treatment of patients with advanced pancreatic adenocarcinoma

BACKGROUND

There is no standard of care for ≥ 3rd-line treatment of metastatic pancreatic adenocarcinoma (PDAC). CBP501 is a novel calmodulin-binding peptide that has been shown to enhance the influx of platinum agents into tumor cells and tumor immunogenicity. This study aimed to (1) confirm efficacy of CBP501/cisplatin/nivolumab for metastatic PDAC observed in a previous phase 1 study, (2) identify combinations that yield 35% 3-month progression-free survival rate (3MPFS) and (3) define the contribution of CBP501 to the effects of combination therapy.

METHODS

CBP501 16 or 25 mg/m2 (CBP(16) or CBP(25)) was combined with 60 mg/m2 cisplatin (CDDP) and 240 mg nivolumab (nivo), administered at 3-week intervals. Patients were randomized 1:1:1:1 to (1) CBP(25)/CDDP/nivo, (2) CBP(16)/CDDP/nivo, (3) CBP(25)/CDDP and (4) CDDP/nivo, with randomization stratified by ECOG PS and liver metastases. A Fleming two-stage design was used, yielding a one-sided type I error rate of 2.5% and 80% power when the true 3MPFS is 35%.

RESULTS

Among 36 patients, 3MPFS was 44.4% in arms 1 and 2, 11.1% in arm 3% and 33.3% in arm 4. Two patients achieved a partial response in arm 1 (ORR 22.2%; none in other arms). Median PFS and OS were 2.4, 2.1, 1.5 and 1.5 months and 6.3, 5.3, 3.7 and 4.9 months, respectively. Overall, all treatment combinations were well tolerated. Most treatment-related adverse events were grade 1-2.

CONCLUSIONS

The combination CBP(25)/(16)/CDDP/nivo demonstrated promising signs of efficacy and a manageable safety profile for the treatment of advanced PDAC.

CLINICAL TRIAL REGISTRATION

NCT04953962.

Impact of baricitinib in combination with topical steroids on atopic dermatitis symptoms, quality of life and functioning in adult patients with moderate-to-severe atopic dermatitis from the BREEZE-AD7 Phase 3 randomized trial

Background

Baricitinib is an oral, selective, reversible Janus kinase 1/2 inhibitor approved in the European Union and Japan and under investigation in the United States for treatment of atopic dermatitis (AD).

Objectives

To evaluate the impact of baricitinib plus background topical corticosteroids (TCS) on health‐related quality of life (HRQoL), how AD symptoms impact work productivity and life functioning, and treatment benefit using patient‐reported outcome (PRO) assessments in patients with moderate‐to‐severe AD previously experiencing inadequate response to TCS.

Methods

Adult patients with AD in BREEZE‐AD7, a Phase 3, multicentre, double‐blind trial, were randomised 1 : 1 : 1 to daily oral placebo (control) or baricitinib 4‐ or 2‐mg plus TCS. PROs reported Week 1 through Week 16: Dermatology Life Quality Index (DLQI), Work Productivity and Activity Impairment‐AD (WPAI‐AD); Patient‐Reported Outcomes Measurement Information System (PROMIS) Itch and Sleep measures, and Patient Benefit Index (PBI). Data were analysed using logistic regression (categorical) and mixed model repeated measures (continuous). PBI scores were analysed using analysis of variance.

Results

A total of 329 patients were randomised. Treatment with baricitinib 4‐mg (N = 111) or 2 mg (N = 109) plus TCS led to rapid, statistically significant improvements [vs. TCS plus placebo (N = 109)] in DLQI ≥4‐point improvement starting at Week 2 (4‐mg plus TCS, P ≤ 0.001; 2‐mg plus TCS P ≤ 0.05), change from baseline in WPAI‐AD presenteeism at Week 1 (4‐mg plus TCS, P ≤ 0.01; 2‐mg plus TCS P ≤ 0.05) and PROMIS itch interference at Week 2 (4‐mg plus TCS P ≤ 0.01). Improvements were sustained through Week 16 for baricitinib 4‐mg. Statistically significant improvements were observed at Week 16 for PBI global score (4‐mg plus TCS, P ≤ 0.001; 2‐mg plus TCS P ≤ 0.05).

Conclusions

Baricitinib plus TCS vs. placebo plus TCS showed significant improvements in treatment benefit at Week 16 and rapid significant improvements in HRQoL and impact of AD symptoms on work productivity and functioning through 16 weeks.

Motion-induced interruptions and postural equilibrium in linear lateral accelerations

This study assesses lateral tipping motion-induced interruptions (MIIs) in a simulated motion environment. The objective is to revisit MII occurrence and sway motion relationship by focusing on the frequency and acceleration of the lateral motion stimulus. Results verify that MIIs increase with increasing peak sway acceleration, but the effect of sway frequency is not as clear as that of acceleration. Complex multidirectional motions create more tipping MIIs than unidirectional motion. Research should incorporate acceleration, frequency and motion complexity as factors influencing MII occurrence. To describe a temporary loss of balance without tipping, the term 'probable' MII is introduced. This term fills the gap between the theoretical definition and a human-centred perception of an MII where loss of balance is not a binary phenomenon. The 'probable' MIIs were 16-67% more common than the 'definite' MIIs. The developed mathematical model of MII occurrence versus sway acceleration (amplitude, frequency) approximated the observed MIIs with less than 9% difference.

General methodology for evaluating the adhesion force of drops and bubbles on solid surfaces

The shortcomings of the current formulation for calculating the adhesion force for drops and bubbles with noncircular contact lines are discussed. A general formulation to evaluate the adhesion force due to surface forces is presented. Also, a novel methodology, that is, IBAFA, image based adhesion force analysis, was developed to allow implementation of the general formulation. IBAFA is based on the use of multiple profile images of a drop. The images are analyzed (1) to accurately reconstruct the contact line shape, which is analytically represented by a Fourier cosine series, and (2) to measure contact angles at multiple locations along the contact line and determine the contact angle distribution based on a linear piecewise interpolation routine. The contact line shape reconstruction procedure was validated with both actual experiments and simulated experiments. The procedure for the evaluation of the adhesion force was tested using simulated experiments with synthetic drops of known shapes. A comparison with current methods showed that simplifying assumptions (e.g., elliptical contact line or linear contact angle distribution) used in these methods result in errors up to 76% in the estimated adhesion force. However, the drop adhesion force evaluated using IBAFA results in small errors on the order of 1%.

Specific double-stranded RNA interference in undifferentiated mouse embryonic stem cells

Specific mRNA degradation mediated by double-stranded RNA (dsRNA) interference (RNAi) is a powerful way of suppressing gene expression in plants, nematodes, and fungal, insect, and protozoan systems. However, only a few cases of RNAi have been reported in mammalian systems. Here, we investigated the feasibility of the RNAi strategy in several mammalian cells by using the enhanced green fluorescent protein gene as a target, either by in situ production of dsRNA from transient transfection of a plasmid harboring a 547-bp inverted repeat or by direct transfection of dsRNA made by in vitro transcription. Several mammalian cells including differentiated embryonic stem (ES) cells did not exhibit specific RNAi in transient transfection. This long dsRNA, however, was capable of inducing a sequence-specific RNAi for the episomal and chromosomal target gene in undifferentiated ES cells. dsRNA at 8.3 nM decreased the cognate gene expression up to 70%. However, RNAi activity was not permanent because it was more pronounced in early time points and diminished 5 days after transfection. Thus, undifferentiated ES cells may lack the interferon response, similar to mouse embryos and oocytes. Regardless of their apparent RNAi activity, however, cytoplasmic extracts from mammalian cells produced a small RNA of 21 to 22 nucleotides from the long dsRNA. Our results suggest that mammalian cells may possess RNAi activity but nonspecific activation of the interferon response by longer dsRNA may mask the specific RNAi. The findings offer an opportunity to use dsRNA for inhibition of gene expression in ES cells to study differentiation.

Managing faecal retention and incontinence in neurodisability

The large number of patients with faecal retention and/or incontinence in continuing care wards and rehabilitation units presents a considerable challenge. In order to maintain dignity and minimize the unpleasant odour so commonly associated with these wards and units, effective bowel management should be planned for individual patients. For an effective bowel management regime a team approach should be adopted, involving, where possible, the patient and carer as well as all the health professionals administering the care. Two case studies illustrate the use of assessment and management of bowel problems in patients with severe complex neurodisability. Bowel dysfunction in this patient population, in general, is poorly covered in the literature. The present article, by relating theory to practice, offers information and guidance for nurses working with patients who have bowel-related problems.

The efficacy and resource utilization of remifentanil and fentanyl in fast-track coronary artery bypass graft surgery: a prospective randomized, double-blinded controlled, multi-center trial

We compared (a) the perioperative complications; (b) times to eligibility for, and actual time of the following: extubation, less intense monitoring, intensive care unit (ICU), and hospital discharge; and (c) resource utilization of nursing ratio for patients receiving either a typical fentanyl/isoflurane/propofol regimen or a remifentanil/isoflurane/propofol regimen for fast-track cardiac anesthesia in 304 adults by using a prospective randomized, double-blinded, double-dummy trial. There were no differences in demographic data, or perioperative mortality and morbidity between the two study groups. The mini-mental status examination at postoperative Days 1 to 3 were similar between the two groups. The eligible and actual times for extubation, less intense monitoring, ICU discharge, and hospital discharge were not significantly different. Further analyses revealed no differences in times for extubation and resource utilization after stratification by preoperative risk scores, age, and country. The nurse/patient ratio was similar between the remifentanil/isoflurane/propofol and fentanyl/isoflu-rane/propofol groups during the initial ICU phase and less intense monitoring phase. Increasing preoperative risk scores and older age (>70 yr) were associated with longer times until extubation (eligible), ICU discharge (eligible and actual), and hospital discharge (eligible and actual). Times until extubation (eligible and actual) and less intense monitoring (eligible) were significantly shorter in Canadian patients than United States' patients. However, there was no difference in hospital length of stay in Canadian and United States' patients. We conclude that both anesthesia techniques permit early and similar times until tracheal extubation, less intense monitoring, ICU and hospital discharge, and reduced resource utilization after coronary artery bypass graft surgery.

IMPLICATIONS

An ultra-short opioid technique was compared with a standard fast-track small-dose opioid technique in coronary artery bypass graft patients in a prospective randomized, double-blinded controlled study. The postoperative recovery and resource utilization, including stratification of preoperative risk score, age, and country, were analyzed.

Finance modeling in the delivery of medical care in tertiary-care hospitals in the Department of Veterans Affairs

BACKGROUND

In the mid-1990s, the Department of Veterans Affairs (DVA) implemented the Veterans Equitable Resource Allocation (VERA), a new financial model developed to attempt to better distribute the approximately $18 billion annual budget among roughly 170 Veterans Administration Medical Centers (VAMCs). VERA is based on a Health Maintenance Organization (HMO) model. VERA provides reimbursement to each of the 22 regional Veterans Integrated Service Networks (VISNs), and subsequent VISN distribution to individual VAMCs is based on an individual medical center's enrollment of unique social security numbers (uniques). In HMO vocabulary these are individual "covered lives."

METHODS

Currently available demographic and staffing information regarding the DVA's 23 tertiary hospital systems (Category 7 hospitals) on the KLF database (DVA Austin Data Base) and published information on the DVA website were reviewed. The following was obtained: (1) staffing information-physician and nurse full-time employment equivalent (FTEE) staffing; (2) patient demographics and hospital workload-facility uniques (u), outpatient facility uniques, average daily census (ADC), discharges, and outpatient clinic visits. The following staffing ratios were calculated for both physician and nursing: FTEE/(u/1000), FTEE/(discharges/1000), FTEE/(clinic visits/1000), FTEE/ADC. For all categories the means +/- SD were calculated and correlation coefficients were calculated on pertinent pairings.

RESULTS

Although categorized as similar tertiary care facilities, the 23 "Group 7" VA hospitals are anything but equivalent when reviewed using the VERA financing model with respect to physician staffing, nurse staffing, and facility uniques. Using VERA methodology, average physician FTEE and total nursing FTEE staffing/(u/1000) are 3.67 +/- 0.89 and 15.53 +/- 3.77, respectively. Correlation statistics of staffing versus unique SSNs demonstrated correlation coefficients of 0.46 and 0.59 with respect to physician and nurse staffing, respectively. On the other hand, when physician FTEE and nursing FTEE staffing were compared with VAMC workload parameters (total ADC, discharges, and outpatient visits), correlation coefficients were more consistent, ranging from 0.62 to 0.86.

CONCLUSIONS

In the VERA model, the reward of a larger annual budget for an individual VAMC or the regional VISN is realized when staffing of VAMCs is minimized, overall provided medical services (especially costly tertiary services) are limited, and the number of covered lives is maximized. A VAMC staffing system that equates medical services delivered in a tertiary VAMC setting based on an HMO model like VERA (where the user population is skewed toward the sicker, older patient) shows decreased correlation when compared with VAMC workload model parameters.

Cloning and mapping the mouse Crygs gene and non-lens expression of [gamma]S-crystallin

PURPOSE

[gamma]-Crystallins are major structural proteins of the eye lens. While other crystallins have revealed distinct non-lens functions and patterns of expression, [gamma]-crystallins have generally appeared to be the most lens-specific of the crystallins. Here we examine the mouse [gamma]S-crystallin ([gamma]S) gene and its expression.

METHODS

The cDNA and gene for mouse [gamma]S were cloned and sequenced. The Crygs gene was mapped using genetic crosses. Expression patterns in mouse and cow were examined by northern blot, PCR and western blot using a specific peptide antibody.

RESULTS

The Crygs gene was sequenced and mapped to mouse chromosome 16, at or near the locus for the genetic cataract Opj. Northern blots of tissues from new born mice, showed lens specific expression of [gamma]S. However, in the mature mouse eye there was, in addition, clear non-lens expression of [gamma]S. In the adult bovine eye RT-PCR shows that [gamma]S is expressed in lens, retina and cornea. A peptide antibody directed against [gamma]S detects bands of the expected size in western blots of mouse lens and in 33 day old mouse retina.

CONCLUSIONS

These results suggest that [gamma]-crystallins have a non-crystallin role outside the lens, one which may predate the lens in evolutionary terms. Non-lens expression seems to increase with age in young mice, hinting that [gamma]S may have a role similar to that of a stress protein in tissues of the eye, perhaps related to accumulating insults resulting from light exposure.

PCNA and Ki-67 labelling indices in pre-irradiated and post-irradiated astrocytomas: a comparative immunohistochemical analysis for evaluation of proliferative activity

AIM

To determine the tumour proliferative activity in a series of archival cerebral astrocytomas and compare proliferating cell nuclear antigen (PCNA) and Ki-67 labelling indices in the primary and recurring neoplasms following therapeutic radiation.

METHOD

Twenty eight cases of pre-irradiated and post-irradiated astrocytomas (ranging from WHO grades I to IV) were stained immunohistochemically using the avidin-biotin horseradish peroxidase technique. Two antibodies, PC10 and MIB-1, were used to establish the proliferating labelling indices, PC10 identifies PCNA and MIB-1 recognises the Ki-67 antigen.

RESULTS

Both antibodies showed significantly higher labelling indices in the post-irradiated specimens. However, in general, the Ki-67 indices were lower than those for PCNA. MIB-1 immunoreactivity showed less variation and was more intense than that seen with PC10. The discrepancy between the labelling indices of the pre-irradiated and post-irradiated samples raises questions about the evolution of astrocytomas and the effects of therapeutic intervention.

CONCLUSIONS

The data may represent genetic alterations, the natural tumour course, and/or the effect of radiation. Although both of the antibodies reflected the state of growth of neoplastic cells in astrocytomas, MIB-1 was more reliable. A simple immunohistochemical method using proliferation markers does have an important role in the future care of patients with astrocytoma.

Histopathology and vascular endothelial growth factor in untreated and diode laser-treated retinopathy of prematurity

OBJECTIVES

We had the unique opportunity to compare the eyes of a premature infant with stage 3 retinopathy of prematurity (ROP) in both eyes after the condition was treated by diode laser photocoagulation in one eye only. After the infant's death, we investigated the extent of structural damage incurred with the diode laser and examined the effect of treatment on vascular endothelial growth factor (VEGF) expression.

METHODS

The eyes were fixed and embedded in paraffin. Adjacent 6 microns sections were either stained for histopathologic analysis or used for in situ hybridization. VEGF messenger RNA (mRNA) was detected by using radiolabeled antisense riboprobes.

RESULTS

In the treated eye, histopathologic results demonstrated the clinically evident dose-response effect, with sparing of inner retinal elements with mild laser burns and full-thickness retinal cell disruption with severe burns. Scleral and ciliary nerve effects were absent. VEGF mRNA was localized primarily in the ganglion cell layer but was also found in the inner nuclear layer. In the untreated eye, an increase in VEGF mRNA was detected at the peripheral edge of the vascularized retina anterior to the ridge. In the laser-treated eye, VEGF mRNA expression was dramatically upregulated in the ganglion cell layer in areas adjacent to laser burns.

CONCLUSIONS

VEGF mRNA was found to be elevated in the peripheral, avascular retina of the untreated eye, consistent with the hypothesis that retinal hypoxia stimulates VEGF expression. In the treated eye with recurrent ROP, VEGF mRNA was not detected in the photocoagulated areas of retina but was increased between laser scars. This finding confirms the results of prior animal studies and validates the use of these models.

Loss of heterozygosity on chromosome 5q in ovarian cancer is frequently accompanied by TP53 mutation and identifies a tumour suppressor gene locus at 5q13.1-21

Forty-nine ovarian tumours were examined for loss of heterozygosity (LOH) on chromosome 5 using eight microsatellite markers spanning both arms, including one at the APC locus. LOH on 5q was a frequent event, detectable in 23 of 49 (47%) tumours, whereas 5p LOH was detected in only 1 of 22 tumours (5%). Six tumours showed partial LOH on 5q, enabling the candidate region to be localised to a 22 cM region proximal to APC, flanked by D5S424 and D5S644. An association was found between 5q LOH and TP53 mutation, with 18 of 23 (78%) tumours with LOH on 5q also harbouring a TP53 mutation. LOH on 5q was observed in 6 of 18 (33%) stage I tumours, suggesting that it may be an early event in the molecular pathogenesis of certain ovarian carcinomas.

Financing of integrated delivery systems

This chapter addresses the financing of integrated delivery systems. It discusses the assessment of financing needs and taxable financing options, including standard commercial loans, lines of credit, commercial paper, and taxable bonds. The chapter also addresses tax-exempt financing, including tax-exempt bonds, and eligibility for tax-exempt financing.

A comparison of acetaminophen and rimantadine in the treatment of influenza A infection in children

Rimantadine was compared with acetaminophen in a double-blind randomly assigned therapeutic trial in 63 children presenting with influenzal symptoms. Forty-nine of the children were proven to have influenza A by culture on presentation. Forty-three of the cultures, 88%, were influenza A/H1N1 strains. Both drugs were well tolerated. Rimantadine lowered the amount of virus shed in the first 2 days after initiation of therapy. Clinical resolution of illness was not different between the two therapeutic modalities. In individuals who shed virus for 4 days, strains recovered on the last day were relatively resistant to rimantadine.

Ureterosigmoidostomy and carcinoma of the colon

The etiology for development of colon carcinoma associated with ureterosigmoidostomy seems to be related to the urine. The incidence of colon carcinoma associated with ureterosigmoidostomy is 500 times greater than in the normal population, indicating about a 5% life time risk. The development time of these lesions varies from 6 to 50 years postoperatively but it is significantly less in patients more than 40 years old. The possibility exists that colon carcinoma may develop in primary sigmoid urinary diversion conduits or sigmoid internal conduits to either bladder or bowel. No reported bowel carcinoma has developed in an ileal urinary diversion. Followup examination should include stools for blood every 3 months after 2 years, an excretory urogram yearly after 5 years, sigmoid or colonoscopy every 5 years and barium enema every 5 years. If the patient has hematochezia or the excretory urogram demonstrates ureteral obstruction sigmoid or colonoscopy and a barium enema should be done.