Vincristine dosing, drug exposure and therapeutic drug monitoring in neonate and infant cancer patients

Background

The anticancer drug vincristine is associated with potentially dose-limiting side-effects, including neurotoxicity and myelosuppression. However, there currently exists a lack of published clinical pharmacology data relating to its use in neonate and infant patients. We report a study investigating vincristine dosing and drug exposure, alongside the feasibility and impact of a therapeutic drug monitoring treatment approach, in this challenging patient population.

Patients and methods

Vincristine pharmacokinetic data from a total of 57 childhood cancer patients, including 26 neonates and infants, were used to characterise a population pharmacokinetic model. Vincristine was administered at doses of 0.02–0.05 mg/kg or 0.75–1.5 mg/m² in neonates and infants aged <1 year or ≤12 kg and doses of 1.5 mg/m² in older children.

Results

A two-compartment model provided the best fit for the population analysis. There was no significant difference in vincristine clearance normalised for body surface area between neonates/infants and older children. Lower doses administered to neonates and infants resulted in significantly lower drug exposures (area under the curve [AUC]), compared with older children (p = 0.047). Vincristine doses of <0.05 mg/kg in neonates and infants resulted in significantly lower AUC values than observed in those receiving doses of ≥0.05 mg/kg (p ≤ 0.0001). Therapeutic drug monitoring was shown to be feasible, effective and well tolerated in neonates and infants experiencing suboptimal drug exposures.

Conclusion

Doses of <0.05 mg/kg should not be used in neonate and infant patients because of a high risk of patients experiencing potentially suboptimal drug exposures. Therapeutic drug monitoring approaches in neonates and infants are supported by the data generated, with a proposed target therapeutic window of 50–100 μg/l∗h.

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Vincristine dosing and drug exposure was investigated in neonates and infants.

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Vincristine concentrations were quantified in 210 plasma samples from 57 children.

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Lower drug exposures were observed in infants and neonates compared with older children.

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Therapeutic drug monitoring can be used to avoid suboptimal vincristine drug exposures.

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Vincristine dosing guidance is provided for treatment of neonate and infant patients.

Fast Ion Transport in the Three-Dimensional Reversed-Field Pinch

We report on the first comprehensive experimental and numerical study of fast ion transport in the helical reversed-field pinch (RFP). Classical orbit effects dominate the macroscopic confinement properties. The strongest effect arises from growth in the dominant fast ion guiding-center island, but substantial influence from remnant subdominant tearing modes also plays a critical role. At the formation of the helical RFP, neutron flux measurements indicate a drastic loss of fast ions at sufficient subdominant mode amplitudes. Simulations corroborate these measurements and suggest that subdominant tearing modes strongly limit fast ion behavior. Previous work details a sharp thermal transport barrier and suggests the helical RFP as an Ohmically heated fusion reactor candidate; the enhanced transport of fast ions reported here identifies a key challenge for this scheme, but a workable scenario is conceivable with low subdominant tearing mode amplitudes.

Correlation polarimetry for broadband magnetic fluctuation measurements

Correlation techniques have been successfully utilized for plasma diagnostics like electron cyclotron emission to reduce measurement noise. We present the first application of such a technique to Faraday-effect polarimetry measurements on the Madison Symmetric Torus (MST). The MST far infrared (FIR) interferometer-polarimeter diagnostic utilizes 11 vertical chords with a chord separation of 7-8 cm and a heterodyne detection system for fluctuation measurements up to several hundred kHz. The planar-diode mixers viewing each chord represent independent noise sources; modifying the optical setup so that two different mixers view the same chord allows cross correlation between the two independent signals to reduce the noise floor in fluctuation measurements. In this manner, the noise floor in both interferometry and polarimetry measurements in reversed-field pinch discharges has been reduced by a factor of 20-30. The correlation polarimeter provides a sensitive measurement of broadband magnetic fluctuations.

Thomson scattering systems on C-2W field-reversed configuration plasma experiment

TAE Technologies' newly constructed C-2W experiment aims to improve the ion and electron temperatures in a sustained field-reversed configuration plasma. A suite of Thomson scattering systems has been designed and constructed for electron temperature and density profile measurements. The systems are designed for electron densities of 1 × 10¹² cm^-3 to 2 × 10¹⁴ cm^-3 and temperature ranges from 10 eV to 2 keV. The central system will provide profile measurements of T_e and n_e at 16 radial locations from r = -9 cm to r = 64 cm with a temporal resolution of 20 kHz for 4 pulses or 1 kHz for 30 pulses. The jet system will provide profile measurements of T_e and n_e at 5 radial locations in the open field region from r = -5 cm to r = 15 cm with a temporal resolution of 100 Hz. The central system and its components have been characterized, calibrated, installed, and commissioned. A maximum-likelihood algorithm has been applied for data processing and analysis.

Characterization and calibration of the Thomson scattering diagnostic suite for the C-2W field-reversed configuration experiment

The new C-2W Thomson scattering (TS) diagnostic consists of two individual subsystems for monitoring electron temperature (T_e) and density (n_e): one system in the central region is currently operational, and the second system is being commissioned to monitor the open field line region. Validating the performance of the TS's custom designed system components and unique calibration of the detection system and diagnostic as a whole is crucial to obtaining high precision T_e and n_e profiles of C-2W's plasma. The major components include a diode-pumped Nd:YAG laser which produces 35 pulses at up to 20 kHz, uniquely designed collection lenses with a fast numerical aperture, and uniquely designed polychromators with filters sets to optimize a T_e ranging from 10 eV to 2 keV. This paper describes the design principles and techniques used to characterize the main components of the TS diagnostic on C-2W, as well as the results of Rayleigh scattering calibrations performed for the whole system response.

An upgraded interferometer-polarimeter system for broadband fluctuation measurements

Measuring high-frequency fluctuations (above tearing mode frequencies) is important for diagnosing instabilities and transport phenomena. The Madison Symmetric Torus interferometer-polarimeter system has been upgraded to utilize improved planar-diode mixer technology. The new mixers reduce phase noise and allow more sensitive measurements of fluctuations at high frequency. Typical polarimeter rms phase noise values of 0.05°-0.07° are obtained with 400 kHz bandwidth. The low phase noise enables the resolution of fluctuations up to 250 kHz for polarimetry and 600 kHz for interferometry. The importance of probe beam alignment for polarimetry is also verified; previously reported tolerances of ≤0.1 mm displacement for equilibrium and tearing mode measurements minimize contamination due to spatial misalignment to within acceptable levels for chords near the magnetic axis.

Electron kinetic effects on interferometry, polarimetry and Thomson scattering measurements in burning plasmas (invited)

At anticipated high electron temperatures in ITER, the effects of electron thermal motion on Thomson scattering (TS), toroidal interferometer/polarimeter (TIP), and poloidal polarimeter (PoPola) diagnostics will be significant and must be accurately treated. The precision of the previous lowest order linear in τ = Te/mec(2) model may be insufficient; we present a more precise model with τ(2)-order corrections to satisfy the high accuracy required for ITER TIP and PoPola diagnostics. The linear model is extended from Maxwellian to a more general class of anisotropic electron distributions that allows us to take into account distortions caused by equilibrium current, ECRH, and RF current drive effects. The classical problem of the degree of polarization of incoherent Thomson scattered radiation is solved analytically exactly without any approximations for the full range of incident polarizations, scattering angles, and electron thermal motion from non-relativistic to ultra-relativistic. The results are discussed in the context of the possible use of the polarization properties of Thomson scattered light as a method of Te measurement relevant to ITER operational scenarios.

Improvements to the calibration of the MST Thomson scattering diagnostic

Calibration of the Madison Symmetric Torus Thomson scattering system has been refined to improve temperature fluctuation measurements. Multiple avalanche photodiodes have been directly calibrated for use as reference detectors during calibration, improving accuracy and ease of use. From the absolute calibration we calculate corrections to the gain for variation in detector operating temperature. We also measure the spatial uniformity of detector responsivity for several photodiodes, and present a method of accounting for non-uniformity in the calibration process. Finally, the gain and noise enhancement are measured at multiple wavelengths to improve temperature and uncertainty measurements.

Pulse-burst laser systems for fast Thomson scattering (invited)

Two standard commercial flashlamp-pumped Nd:YAG (YAG denotes yttrium aluminum garnet) lasers have been upgraded to "pulse-burst" capability. Each laser produces a burst of up to 15 2 J Q-switched pulses (1064 nm) at repetition rates of 1-12.5 kHz. Variable pulse-width drive (0.15-0.39 ms) of the flashlamps is accomplished by insulated gate bipolar transistor (IGBT) switching of electrolytic capacitor banks. Direct control of the laser Pockels cell drive enables optimal pulse energy extraction, and up to four 2 J laser pulses during one flashlamp pulse. These lasers are used in the Thomson scattering plasma diagnostic system on the MST reversed-field pinch to record the dynamic evolution of the electron temperature profile and temperature fluctuations. To further these investigations, a custom pulse-burst laser system with a maximum pulse repetition rate of 250 kHz is now being commissioned.

Enhancing high-order above-threshold dissociation of H2+ beams with few-cycle laser pulses

High-order (three-photon or more) above-threshold dissociation (ATD) of H(2)(+) has generally not been observed using 800 nm light. We demonstrate a strong enhancement of its probability using intense 7 fs laser pulses interacting with beams of H(2)(+), HD(+), and D(2)(+) ions. The mechanism invokes a dynamic control of the dissociation pathway. These measurements are supported by theory that additionally reveals, for the first time, an unexpectedly large contribution to ATD from highly excited electronic states.

Determining the absolute efficiency of a delay line microchannel-plate detector using molecular dissociation

We present a method to measure the absolute detection efficiency of a delay-line microchannel-plate detector using the breakup of diatomic molecular ions. This method provides the absolute total detection efficiency, as well as the individual efficiency for each signal of the detector. The method is based on the fact that molecular breakup always yields two hits on the detector, but due to finite detection efficiency some of these events are recorded as single particles while others are detected in pairs. We demonstrate the method by evaluating the detection efficiency for both timing and position signals of a delay-line detector using laser-induced dissociation of molecular ions. In addition, the detection efficiency as a function of position has been determined by dividing the detector into sectors.

Yeast polypeptide fusion surface display levels predict thermal stability and soluble secretion efficiency

Efficiency of yeast cell surface display can serve as a proxy screening variable for enhanced thermal stability and soluble secretion efficiency of mutant proteins. Several single-chain T cell receptor (scTCR) single-site mutants that enable yeast surface display, along with their double and triple mutant combinations, were analyzed for soluble secretion from the yeast Saccharomyces cerevisiae. While secretion of the wild-type scTCR was not detected, each of the single, double, and triple mutants were produced in yeast supernatants, with increased expression resulting from the double and triple mutants. Soluble secretion levels were strongly correlated with the quantity of active scTCR displayed as a fusion to Aga2p on the surface of yeast. Thermal stability of the scTCR mutants correlated directly with the secreted and surface levels of scTCR, with evidence suggesting that intracellular proteolysis by the endoplasmic reticulum quality control apparatus dictates display efficiency. Thus, yeast display is a directed evolution scaffold that can be used for the identification of mutant eucaryotic proteins with significantly enhanced stability and secretion properties.