Effect of Roflumilast Cream vs Vehicle Cream on Chronic Plaque Psoriasis: The DERMIS-1 and DERMIS-2 Randomized Clinical Trials

IMPORTANCE

Once-daily roflumilast cream, 0.3%, a potent phosphodiesterase 4 inhibitor, demonstrated efficacy and was well tolerated in a phase 2b trial of patients with psoriasis.

OBJECTIVE

To evaluate the efficacy of roflumilast cream, 0.3%, applied once daily for 8 weeks in 2 trials of patients with plaque psoriasis.

DESIGN, SETTING, AND PARTICIPANTS

Two phase 3, randomized, double-blind, controlled, multicenter trials (DERMIS-1 [trial 1; n = 439] and DERMIS-2 [trial 2; n = 442]) were conducted at 40 centers (trial 1) and 39 centers (trial 2) in the US and Canada between December 9, 2019, and November 16, 2020, and between December 9, 2019, and November 23, 2020, respectively. Patients aged 2 years or older with plaque psoriasis involving 2% to 20% of body surface area were enrolled. The dates of final follow-up were November 20, 2020, and November 23, 2020, for trial 1 and trial 2, respectively.

INTERVENTIONS

Patients were randomized 2:1 to receive roflumilast cream, 0.3% (trial 1: n = 286; trial 2: n = 290), or vehicle cream (trial 1: n = 153; trial 2: n = 152) once daily for 8 weeks.

MAIN OUTCOMES AND MEASURES

The primary efficacy end point was Investigator Global Assessment (IGA) success (clear or almost clear status plus ≥2-grade improvement from baseline [score range, 0-4]) at week 8, analyzed using a Cochran-Mantel-Haenszel test stratified by site, baseline IGA score, and intertriginous involvement. There were 9 secondary outcomes, including intertriginous IGA success, 75% reduction in Psoriasis Area and Severity Index (PASI) score, and Worst Itch Numeric Rating Scale score of 4 or higher at baseline achieving 4-point reduction (WI-NRS success) at week 8 (scale: 0 [no itch] to 10 [worst imaginable itch]; minimum clinically important difference, 4 points).

RESULTS

Among 881 participants (mean age, 47.5 years; 320 [36.3%] female), mean IGA scores in trial 1 were 2.9 [SD, 0.52] for roflumilast and 2.9 [SD, 0.45] for vehicle and in trial 2 were 2.9 [SD, 0.48] for roflumilast and 2.9 [SD, 0.47]) for vehicle. Statistically significantly greater percentages of roflumilast-treated patients than vehicle-treated patients had IGA success at week 8 (trial 1: 42.4% vs 6.1%; difference, 39.6% [95% CI, 32.3%-46.9%]; trial 2: 37.5% vs 6.9%; difference, 28.9% [95% CI, 20.8%-36.9%]; P < .001 for both). Of 9 secondary end points, statistically significant differences favoring roflumilast vs vehicle were observed for 8 in trial 1 and 9 in trial 2, including intertriginous IGA success (71.2% vs 13.8%; difference, 66.5% [95% CI, 47.1%-85.8%] and 68.1% vs 18.5%; difference, 51.6% [95% CI, 29.3%-73.8%]; P < .001 for both), 75% reduction in PASI score (41.6% vs 7.6%; difference, 36.1% [95% CI, 28.5%-43.8%] and 39.0% vs 5.3%; difference, 32.4% [95% CI, 24.9%-39.8%]; P < .001 for both), WI-NRS success (67.5% vs 26.8%; difference, 42.6% [95% CI, 31.3%-53.8%] and 69.4% vs 35.6%; difference, 30.2% [95% CI, 18.2%-42.2%]; P < .001 for both). The incidence of treatment-emergent adverse events was 25.2% with roflumilast vs 23.5% with vehicle in trial 1 and 25.9% with roflumilast vs 18.4% with vehicle in trial 2. The incidence of serious adverse events was 0.7% with roflumilast vs 0.7% with vehicle in trial 1 and 0% with roflumilast vs 0.7% with vehicle in trial 2.

CONCLUSIONS AND RELEVANCE

Among patients with chronic plaque psoriasis, treatment with roflumilast cream, 0.3%, compared with vehicle cream resulted in better clinical status at 8 weeks. Further research is needed to assess efficacy compared with other active treatments and to assess longer-term efficacy and safety.

TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: NCT04211363, NCT04211389.

Silicosis: enlarged cervical lymph nodes, pericardial effusion and lung abnormalities

Silicosis is an occupational lung parenchymal disease caused by inhaling silica. It requires differentiation from a malignant tumour and granulomatous disease. We describe the case of a woman with silicosis who exhibited enlargement of bilateral cervical lymph nodes, pericardial effusion and lung abnormalities. She was diagnosed with silicosis based on histological examination of a resected cervical lymph node, lung tissue biopsy and history of silica exposure. She underwent glucocorticoid therapy during hospitalization. The lung abnormalities, enlarged cervical lymph nodes and pericardial effusion were ameliorated by glucocorticoid therapy, but she relapsed shortly thereafter. In conclusion, silicosis with cervical lymph node enlargement and pericardial effusion is rare and should be differentiated from a malignant tumour and granulomatous disease. Some patients may respond well to steroids in the short term.

Long-term safety and efficacy of bempedoic acid in patients at high risk of atherosclerotic cardiovascular disease: results from the CLEAR Harmony open-label extension study

Background

Bempedoic acid (BA) is an oral first-in-class, ATP-citrate lyase inhibitor that lowers low-density lipoprotein cholesterol (LDL-C) levels in adults with hypercholesterolemia. In the phase 3 CLEAR Harmony study (NCT02666664, n=2230), BA 180 mg for 52 weeks significantly lowered LDL-C at week 12 compared with placebo and was maintained for 52 weeks in hypercholesterolemic patients with atherosclerotic cardiovascular disease (ASCVD) and/or heterozygous familial hypercholesterolemia (HeFH) on stable, maximally tolerated statins.

Purpose

To report long-term safety, tolerability, and efficacy of BA from the CLEAR Harmony open-label extension (OLE) study (NCT03067441).

Methods

After completing the 52-week placebo-controlled CLEAR Harmony study, patients immediately entered the OLE and received BA for 78 weeks, followed by a 4-week washout period; the potential cumulative exposure to BA was 2.5 years. The primary endpoint was long-term safety of BA in the OLE.

Results

A total of 1462 patients enrolled in the OLE (BA n=970; placebo n=492 from CLEAR Harmony). At OLE baseline, mean (SD) age was 66.9 (8.7) years, 73.9% were male, 96.3% had ASCVD, 3.7% had HeFH with or without ASCVD, and all were receiving statins (93.5% moderate or high intensity). At baseline of CLEAR Harmony, patients had mean (SD) LDL-C of 102.9 (29.9) mg/dL (BA) and 99.0 (24.2) mg/dL (placebo). The majority of OLE patients (86.2%, n=1260) completed 78 weeks of BA treatment. At week 12 and 78 of OLE treatment, respectively, mean LDL-C lowering from CLEAR Harmony baseline was –14.9% and –14.4%. A total of 1143 patients (78.2%) reported a treatment-emergent adverse event (TEAE), and 299 (20.5%) reported a serious TEAE. TEAEs of special interest, determined by the therapeutic area or prior observations in preclinical or early clinical studies, occurred at similar rates as CLEAR Harmony (creatine kinase elevations, 1.8%; gout, 2.6%; hepatic enzyme elevations, 2.0%; hypoglycemia, 1.2%; muscular disorders, 8.5%; neurocognitive disorders, 0.9%; new onset/worsening diabetes mellitus, 5.5%; renal disorders, 2.8%) with biochemical changes that were stable over the course of the study and approached baseline levels after treatment discontinuation. Overall, 114 patients (7.8%) reported a TEAE leading to discontinuation of BA (most common: myalgia [0.6%], muscle spasm [0.5%]).

Conclusion

Durable lipid lowering was observed through 78 weeks of BA treatment and patient adherence to BA therapy was high (86.2%). Overall safety during the OLE was similar to results reported in the 52-week-long CLEAR Harmony study and the overall BA phase 3 clinical program, with no new safety findings.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Esperion Therapeutics, Inc., funded the research for this study and provided writing support for this abstract. Medical writing assistance was provided by Agnella Izzo Matic, PhD, CMPP, and Kelly M Cameron, PhD, CMPP, of JB Ashtin.

Effect of bempedoic acid on uric acid and gout in 3621 patients with hypercholesterolemia: pooled analyses from phase 3 trials

Background

Bempedoic acid (BA), an oral ATP-citrate lyase inhibitor, significantly lowers low-density lipoprotein cholesterol levels in patients with hypercholesterolemia. In clinical trials of BA, small mean increases in uric acid have been reported. BA weakly inhibits organic anion transporter 2 (OAT2) in vitro, which may account for small elevations in serum uric acid.

Purpose

To assess uric acid levels and incidence of gout with BA treatment.

Methods

Data were pooled from 4 randomized (2:1), double-blind studies of BA (180 mg daily) vs placebo for 12 weeks to 52 weeks in patients with hypercholesterolemia on stable background lipid-lowering therapy. Safety assessments included adverse events of special interest (elevation in uric acid levels, gout) and laboratory assessments.

Results

A total of 2424 patients treated with BA and 1197 patients on placebo were included in this analysis. Mean (SD) baseline uric acid levels were 6.0 (1.4) mg/dL for both groups. History of gout was reported by 5.2% (127/2424) and 5.8% (69/1197) in the BA and placebo groups, respectively. At week 12, mean (SD) serum uric acid levels (% change from baseline) increased from baseline with BA treatment by 0.82 (0.97) mg/dL (14.8%) vs –0.02 (0.82) mg/dL (0.67%) for placebo. Elevations in serum uric acid levels typically occurred within the first 4 weeks of treatment, remained stable during treatment, and returned to baseline after treatment discontinuation. Gout was reported in 1.4% (BA) and 0.4% (placebo) of patients, and hyperuricemia was reported in 1.7% (BA) and 0.6% (placebo) of patients. Other potential clinical consequences of elevated uric acid levels (eg, events associated with nephrolithiasis), were similar between groups (0.7% vs 0.8%). In both groups, patients who reported gout during the studies were more likely to have a medical history of gout or elevated baseline uric acid levels (Table). Few patients discontinued treatment due to gout (n=1, &lt;0.1% [BA]) or uric acid increases (n=2, &lt;0.1% [BA]).

Conclusion

Mean increases in uric acid levels were small, remained stable while patients continued to receive treatment, were infrequently associated with AEs, and were reversible on discontinuation of BA

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Esperion Therapeutics funded the research for this study and provided writing support for this abstract. Medical writing assistance was provided by Agnella Izzo Matic, PhD, CMPP, and Kelly M Cameron, PhD, CMPP, of JB Ashtin.

Emergency management of 2019 novel coronavirus: implications for the dermatology department

Since cases first emerged in December 2019, COVID‐19 (a type of coronavirus) has rapidly become pandemic. This fast‐tracked paper (published quickly) from China on COVID‐19 is written by dermatologists at the epicentre of the outbreak in Wuhan.

Dermatology clinic staff may be at risk because protective equipment is not routinely available, and skin lesions might possibly transmit the virus indirectly. These authors suggest preventive measures based on experience in this and previous coronavirus outbreaks.

Online consultation for non‐urgent patients reduces the numbers of patients attending clinics. Nurse‐led triage, to identify patients with possible COVID‐19, at the entrances of hospital and skin clinics directs patients with a cough or fever to a specific COVID‐19 area and a dermatologist is consulted if the fever might be related to skin disease.

Clinic staff wear N95 masks and observe hand hygiene during consultations. Patients are admitted to a ward only if routine blood tests and chest CT scans exclude COVID‐19. Triage will not detect patients who are showing no symptoms but who are developing the disease, so the hospital should provide an on‐call expert team to discuss inpatients suspected or diagnosed with COVID‐19 and refer them to radiology, respiratory or intensive care colleagues as required.

Confirmed cases are managed following local policies. Skin disorders in COVID‐19 inpatients can usually be managed remotely using photographs, email and teleconferencing. If necessary a multidisciplinary team (a team of medical staff from different specialties) can meet in the clean area of the isolation ward. If the dermatologist must see the patient, all records should be provided in advance to minimise exposure time.

With these precautions, as of 20th February 2020 no infected patients were detected in the Wuhan Dermatology Department.

This is a summary of the study: Emergency management for preventing and controlling nosocomial infection of 2019 novel coronavirus: implications for the dermatology department

Linked Article: Tao et al. Br J Dermatol 2020; 182:1477–1478

Emergency management for preventing and controlling nosocomial infection of the 2019 novel coronavirus: implications for the dermatology department

Plain language summary available online

Assessment of denosumab treatment effects and imaging response in patients with giant cell tumor of bone

Background

Denosumab has been shown to reduce tumor size and progression, reform mineralized bone, and increase intralesional bone density in patients with giant cell tumor of bone (GCTB); however, radiologic assessment of tumors in bone is challenging. The study objective was to assess tumor response to denosumab using three different imaging parameters in a prespecified analysis in patients with GCTB from two phase 2 studies.

Methods

The studies enrolled adults and adolescents (skeletally mature and at least 12 years of age) with radiographically measurable GCTB that were given denosumab 120 mg every 4 weeks, with additional doses on days 8 and 15 of cycle 1. The proportion of patients with an objective tumor response was assessed using either Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST), European Organisation for Research and Treatment of Cancer response criteria (positron emission tomography [PET] scan criteria), or inverse Choi density/size (ICDS) criteria. Target lesions were measured by computed tomography or magnetic resonance imaging (both studies), PET (study 2 only), or plain film radiograph (study 2 only).

Results

Most patients (71.6%) had an objective tumor response by at least one response criteria. Per RECIST, 25.1% of patients had a response; per PET scan criteria, 96.2% had a response; per ICDS, 76.1% had a response. 68.5% had an objective tumor response ≥ 24 weeks. Using any criteria, crude incidence of response ranged from 56% (vertebrae/skull) to 91% (lung/soft tissue), and 98.2% had tumor control ≥ 24 weeks. Reduced PET avidity appeared to be an early sign of response to denosumab treatment.

Conclusion

Modified PET scan criteria and ICDS criteria indicate that most patients show responses and higher benefit rates than modified RECIST, and therefore may be useful for early assessment of response to denosumab.

Trial registration

ClinicalTrials.gov Clinical Trials Registry NCT00396279 (retrospectively registered November 6, 2006) and NCT00680992 (retrospectively registered May 20, 2008).

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1478-3) contains supplementary material, which is available to authorized users.

Effect of ventilation velocity on hexavalent chromium and isocyanate exposures in aircraft paint spraying

Exposure control system performance was evaluated during aircraft paint spraying at a military facility. Computational fluid dynamics (CFD) modeling, tracer gas testing, and exposure monitoring examined contaminant exposure vs. crossflow ventilation velocity. CFD modeling using the RNG k-ϵ turbulence model showed exposures to simulated methyl isobutyl ketone of 294 and 83.6 ppm, as a spatial average of five worker locations, for velocities of 0.508 and 0.381 m/s (100 and 75 fpm), respectively. In tracer gas experiments, observed supply/exhaust velocities of 0.706/0.503 m/s (136/99 fpm) were termed full-flow, and reduced velocities were termed 3/4-flow and half-flow. Half-flow showed higher tracer gas concentrations than 3/4-flow, which had the lowest time-averaged concentration, with difference in log means significant at the 95% confidence level. Half-flow compared to full-flow and 3/4-flow compared to full-flow showed no statistically significant difference. CFD modeling using these ventilation conditions agreed closely with the tracer results for the full-flow and 3/4-flow comparison, yet not for the 3/4-flow and half-flow comparison. Full-flow conditions at the painting facility produced a velocity of 0.528 m/s (104 fpm) midway between supply and exhaust locations, with the supply rate of 94.4 m³/s (200,000 cfm) exceeding the exhaust rate of 68.7 m³/s (146,000 cfm). Ventilation modifications to correct this imbalance created a midhangar velocity of 0.406 m/s (80.0 fpm). Personal exposure monitoring for two worker groups-sprayers and sprayer helpers ("hosemen")-compared process duration means for the two velocities. Hexavalent chromium (Cr[VI]) exposures were 500 vs. 360 µg/m³ for sprayers and 120 vs. 170 µg/m³ for hosemen, for 0.528 m/s (104 fpm) and 0.406 m/s (80.0 fpm), respectively. Hexamethylene diisocyanate (HDI) monomer means were 32.2 vs. 13.3 µg/m³ for sprayers and 3.99 vs. 8.42 µg/m³ for hosemen. Crossflow velocities affected exposures inconsistently, and local work zone velocities were much lower. Aircraft painting contaminant control is accomplished better with the unidirectional crossflow ventilation presented here than with other observed configurations. Exposure limit exceedances for this ideal condition reinforce continued use of personal protective equipment.

"A Baby Was an Added Burden": Predictors and Consequences of Unintended Pregnancies for Female Sex Workers in Mombasa, Kenya: A Mixed-Methods Study

INTRODUCTION

Female sex workers (FSW) have high rates of unintended pregnancy, sexually transmitted infections including HIV, and other adverse sexual and reproductive health outcomes. Few services for FSWs include contraception. This mixed-methods study aimed to determine the rate, predictors and consequences of unintended pregnancy among FSWs in Mombasa, Kenya.

METHODS

A prospective cohort study of non-pregnant FSWs was conducted. Quantitative data were collected quarterly, including a structured questionnaire and testing for pregnancy and HIV. Predictors of unintended pregnancy were investigated using multivariate logistic regression. Qualitative data were gathered through focus group discussions and in-depth interviews with FSWs who became pregnant during the study, and interviews with five key informants. These data were transcribed, translated and analysed thematically.

RESULTS

Four hundred women were enrolled, with 92% remaining in the cohort after one year. Fifty-seven percent reported using a modern contraceptive method (including condoms when used consistently). Over one-third (36%) of women were using condoms inconsistently without another method. Twenty-four percent had an unintended pregnancy during the study. Younger age, having an emotional partner and using traditional or no contraception, or condoms only, were independent predictors of unintended pregnancy. Women attributed pregnancy to forgetting to use contraception and being pressured not to by clients and emotional partners, as well as "bad luck". They described numerous negative consequences of unintended pregnancy.

CONCLUSION

Modern contraceptive uptake is surprisingly low in this at-risk population, which in turn has a high rate of unintended pregnancy. The latter may result in financial hardship, social stigma, risk of abandonment, or dangerous abortion practices. FSWs face considerable barriers to the adoption of dual method contraceptive use, including low levels of control in their emotional and commercial relationships. Reproductive health services need to be incorporated into programs for sexually transmitted infections and HIV, which address the socially-determined barriers to contraceptive use.

Surgical downstaging in an open-label phase II trial of denosumab in patients with giant cell tumor of bone

Background

Surgical resection with curative intent for giant cell tumor of bone (GCTB) may be associated with severe morbidity. This interim analysis evaluated reduction in surgical invasiveness after denosumab treatment in patients with resectable GCTB.

Methods

Patients with primary or recurrent GCTB, for whom the initially planned surgery was associated with functional compromise or morbidity, received denosumab 120 mg subcutaneously every 4 weeks (additional doses on days 8 and 15 of the first cycle). Planned and actual GCTB-related surgical procedures before and after denosumab treatment were reported. Patients were followed for surgical outcome, adverse events, and recurrence following resection.

Results

Overall, 222 patients were evaluable for surgical downstaging (54 % were women; median age 34 years). Lesions (67 % primary and 33 % recurrent) were located in the axial (15 %) and appendicular skeleton (85 %). At the data cutoff date, most patients had not yet undergone surgery (n = 106; 48 %) or had a less morbid procedure (n = 84; 38 %) than originally planned. Median (interquartile range) time on denosumab was 19.5 (12.4–28.6) months for the 106 patients who had not undergone surgery and were continuing on monthly denosumab. Native joint preservation was 96 % (n = 24/25) for patients with planned joint/prosthesis replacement and 86 % (n = 30/35) for patients with planned joint resection/fusion. Of the 116 patients who had surgery (median postsurgical follow-up 13.0 [8.5–17.9] months), local recurrence occurred in 17 (15 %) patients.

Conclusion

For patients with resectable GCTB, neoadjuvant denosumab therapy resulted in beneficial surgical downstaging, including either no surgery or a less morbid surgical procedure.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-015-4634-9) contains supplementary material, which is available to authorized users.

The role of denosumab in the prevention of hypercalcaemia of malignancy in cancer patients with metastatic bone disease

BACKGROUND

We compared the activity of denosumab with zoledronic acid for delaying or preventing hypercalcaemia of malignancy (HCM) in patients with advanced cancer and bone metastases or with multiple myeloma.

METHODS

Patient-level data were combined from two identically designed, randomised, double-blind, active-controlled, phase III trials of advanced cancer patients with breast cancer and other solid tumours (excluding breast or prostate cancer) or multiple myeloma. End-points included time to first on-study HCM, time to first and subsequent on-study HCM, proportion of patients experiencing HCM and proportion of patients experiencing recurrent HCM.

RESULTS

Denosumab significantly delayed the time to first on-study HCM, representing a 37% reduction in the hazard ratio (HR) compared with zoledronic acid (HR, 0.63; 95% confidence interval (CI): 0.41-0.98; P = 0.042) and reduced the risk of developing recurrent HCM (time to first and subsequent on-study HCM) by 52% (rate ratio, 0.48; 95% CI: 0.29-0.81; P = 0.006). The median time on study was 12.9 months. Fewer patients receiving denosumab compared with zoledronic acid experienced an HCM event (1.7% versus 2.7%; P = 0.028). Of the 84 patients experiencing an HCM event, 40% of those receiving zoledronic acid experienced >1 event of HCM compared with 31% of those receiving denosumab.

CONCLUSION

Denosumab treatment was more efficacious than treatment with zoledronic acid in delaying or preventing HCM in advanced cancer patients with breast cancer, other solid tumours or multiple myeloma.

Anti-factor Xa and activated partial thromboplastin time measurements for heparin monitoring in mechanical circulatory support

OBJECTIVES

This study investigated the relationship between anti-factor Xa (anti-FXa) and activated partial thromboplastin time (aPTT) for monitoring intravenous unfractionated heparin (IV-UFH) in patients with continuous-flow left ventricular assist devices (CF-LVADs).

BACKGROUND

CF-LVADs have become mainstream therapy for patients with advanced heart failure. Thromboembolic events, device thrombosis, and bleeding continue to be a challenge with this technology. Adequate anticoagulation is required to prevent these adverse events.

METHODS

A prospective study of consecutive patients implanted with a CF-LVAD was conducted. Paired samples were considered concordant if aPTT values fell into expected ranges for subtherapeutic, therapeutic, and supratherapeutic anti-FXa levels. Heparin dosing was on the basis of anti-Xa levels.

RESULTS

A total of 340 paired values from 38 patients were evaluated. Anti-FXa and aPTT were discordant in 253 samples (74.4%), with a high degree of variability in aPTT for any given anti-FXa level (r(2) = 0.57). Results were discordant in 104 samples (63.8%) from patients undergoing bridging therapy with warfarin and in 149 samples (84.2%) from patients with device obstruction and/or hemolysis (p < 0.001). The most common pattern of discordance was a supratherapeutic aPTT value despite a therapeutic anti-FXa level (49.1% for bridging vs. 75.8% for device obstruction and/or hemolysis; p < 0.001).

CONCLUSIONS

Levels of aPTT were disproportionately prolonged relative to the corresponding anti-FXa levels in CF-LVAD patients, particularly those with device obstruction. Hemolysis and warfarin administration may falsely elevate aPTT, resulting in overestimation of heparin concentration and under-anticoagulation. Use of aPTT and anti-FXa to guide heparin therapy may lead to different estimates of heparin concentration in the same patient.

Effects of denosumab on pain and analgesic use in giant cell tumor of bone: interim results from a phase II study

BACKGROUND

Giant cell tumor of bone (GCTB) is an aggressive primary osteolytic tumor. GCTB often involves the epiphysis, usually causing substantial pain and functional disability. Denosumab, a fully human monoclonal antibody against receptor activator of nuclear factor κΒ ligand (RANKL), is an effective treatment option for patients with advanced GCTB. This analysis of data from an ongoing, open-label study describes denosumab's effects on pain and analgesic use in patients with GCTB.

MATERIAL AND METHODS

Patients with unresectable disease (e.g. sacral or spinal GCTB, or multiple lesions including pulmonary metastases) were enrolled into Cohort 1 (N = 170), and patients with resectable disease whose planned surgery was associated with severe morbidity (e.g. joint resection, limb amputation, or hemipelvectomy) were enrolled into Cohort 2 (N = 101). Patients received denosumab (120 mg) subcutaneously every four weeks, with additional doses on study days 8 and 15. Patients assessed worst pain severity with the Brief Pain Inventory - Short Form (BPI-SF) at baseline, at each visit for the first six months, and every three months thereafter.

RESULTS

Clinically relevant pain improvement was reported by 29% of patients in Cohort 1 and 35% in Cohort 2 during week 1 and by ≥ 50% of patients in each cohort at each study visit from months 2-30. Median time to clinically relevant improvement was 30 (95% CI 16, 57) days in Cohort 1 and 15 (95% CI 15, 29) days in Cohort 2. Results in patients with moderate/severe pain at baseline were similar. Fewer than 30% of patients in Cohort 1 and 10% in Cohort 2 experienced clinically relevant pain worsening at any visit through 27 months. Most patients had no/low analgesic use during the study.

CONCLUSION

Most patients treated with denosumab experienced clinically relevant decreases in pain within two months.

Abstract P4-12-20: Clinical outcomes of patients with recurrent HER2-positive breast cancer after exposure to adjuvant trastuzumab

Background:

Trastuzumab has become the cornerstone of adjuvant therapy for patients with HER2-positive breast cancer, as it has significantly impacted on overall survival for these patients. Unfortunately, not all patients are cured, and recurrences occur in up to 13% of patients. In the post-trastuzumab era, long-term outcomes for HER2-positive breast cancer patients who develop recurrent disease after exposure to adjuvant trastuzumab is unknown.

Methods:

We retrospectively identified patients with stage I-III HER2-positive breast cancer treated at The Ohio State University Medical Center from 1995-2011. Patients were divided into two groups: those exposed to adjuvant trastuzumab, and those who never received adjuvant trastuzumab. Medical records were reviewed to obtain demographic data, disease status at diagnosis, adjuvant and metastatic therapeutic regimens, date and location of recurrent disease, date of last follow-up and vital status. Time-dependent analyses were carried out using Kaplan-Meier estimates.

Results:

Six hundred and sixty-two patients were initially identified and included in the analysis. Of the 374 patients who did not receive adjuvant trastuzumab, 96 patients had recurrence (26%). There were 288 patients who received adjuvant trastuzumab, with 33 patients developing relapse (11%). In the patients who received adjuvant trastuzumab and subsequently recurred, there was a higher incidence of CNS recurrence (n = 8; 24%) than those who did not receive adjuvant trastuzumab (n = 10; 10%). Those that received adjuvant trastuzumab also had fewer bone metastases (n = 3; 9%) than the patients who did not receive adjuvant trastuzumab (n = 29; 30%). There was no difference in overall survival in patients with metastatic progression after exposure to adjuvant trastuzumab compared to patients with metastatic HER2-positive breast cancer without prior adjuvant trastuzumab (p = 0.41). Of the 33 patients who relapsed after adjuvant trastuzumab, the majority received HER2-targeted therapy in the form of trastuzumab or lapatinib (n = 22; 67%). Eleven patients received trastuzumab-based therapy and 9 received lapatinib-based therapy. Two patients received the combination of trastuzumab and lapatinib. The remainder received cytotoxic therapy alone (n = 3; 9%), endocrine therapy (n = 1; 3%) or local therapy (surgery or radiation) (n = 4; 12%). Three patients received no therapy.

Conclusion:

There was no difference in overall survival for HER2-positive breast cancer patients who recur after adjuvant trastuzumab compared to metastatic patients without exposure to adjuvant trastuzumab. CNS disease as the first site of recurrence occured more frequently in patients who had received adjuvant trastuzumab than in those who were not previously exposed to trastuzumab. Continued HER2-targeted therapy after relapse on adjuvant trastuzumab was the regimen of choice in the first-line metastatic setting.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-20.

Reactive oxygen species from human astrocytes induced functional impairment and oxidative damage

Reactive oxygen species (ROS) have been shown to be a contributor to aging and disease. ROS also serve as a trigger switch for signaling cascades leading to corresponding cellular and molecular events. In the central nervous system (CNS), microglial cells are likely the main source of ROS production. However, activated astrocytes also appear to be capable of generating ROS. In this study we investigated ROS production in human astrocytes stimulated with interleukin (IL)-1β and interferon (IFN)-γ and its potential harmful effects. Although IFN-γ alone had no effect, it potentiated IL-1β-induced ROS production in a time-dependent manner. One of the sources of ROS in IL-1β-activated astrocytes was from increased superoxide production in mitochondria accompanied by enhanced manganese superoxide dismutase and inhibited catalase expression. NADPH oxidase (NOX) may also contribute to ROS production as astrocytes express NOX isoforms. Glutamate uptake, which represents one of the most important methods of astrocytes to prevent excitotoxicity, was down-regulated in IL-1β-activated astrocytes, and was further suppressed in the presence of IFN-γ; IFN-γ itself exerted minimal effect. Elevated levels of 8-isoprostane in IL-1β ± IFN-γ-activated human astrocytes indicate downstream lipid peroxidation. Pretreatment with diphenyleneiodonium abolished the IL-1β ± IFN-γ-induced ROS production, restored glutamate uptake function and reduced 8-isoprostane to near control levels suggesting that ROS contributes to the dysfunction of activated astrocytes. These results support the notion that dampening activated human astrocytes to maintain the redox homeostasis is vital to preserve their neuroprotective potential in the CNS.

Evaluating results from the multiple myeloma subset of patients treated with denosumab or zoledronic acid (ZA) in a randomized phase III study

8589

Background: Denosumab (dmab) is a fully human monoclonal antibody against RANKL and is superior to ZA in preventing skeletal-related events (SREs) as shown in 3 identically designed phase 3 trials (N=5723). Overall survival (OS) was balanced between treatment groups in the overall study populations of these trials. In the trial of patients (pts) with solid tumors (excluding breast and prostate) and multiple myeloma (MM), OS was longer for dmab pts with lung cancer, shorter for pts with MM, and balanced for pts with other solid tumors. This analysis further characterizes the results from the MM subset of this trial. Methods: Pts with solid tumors or MM were randomized (1:1) to receive 120 mg of SC dmab or 4 mg of IV ZA Q4W. Daily calcium and vit D supplements were strongly recommended. The primary endpoint was the time to first on-study SRE; results from the primary endpoint and lung cancer subset were previously reported. Results: Of 1776 randomized pts, 10% had MM (93 ZA, 87 dmab). OS favored ZA (hazard ratio: 2.26; 10 subject difference in deaths). 1-year OS was 83% dmab, 97% ZA. Imbalances in baseline prognostic characteristics were observed. More pts in the dmab arm had low baseline renal function (CrCl < 40 mL/min) (ZA 2 [2%], dmab 9 [10%]) and more ZA pts underwent stem cell transplant (ZA 23 [25%], dmab 15 [17%]). Additionally, more ZA pts had stage I tumors at diagnosis (ZA 13 [14%], dmab 9 [10%]) and better performance status (ECOG = 0; ZA 30 [32%], dmab 21 [24%]). Study discontinuations due to consent withdrawal or lost to follow-up were also higher in the ZA group (ZA 17 [18%], dmab 11 [13%]) and occurred earlier in the ZA arm (ZA 59%, dmab 45% within 9 months of randomization). Conclusions: In this SRE study of dmab vs ZA, pts were stratified by baseline characteristics known to affect SRE outcomes, but not by prognostic factors or concurrent anticancer therapy that may impact survival in MM. OS results in the MM cohort are difficult to interpret due to small sample size and imbalances in baseline disease characteristics, stem cell transplant therapy, and consent withdrawal or loss of follow-up that favored ZA. A phase 3 trial is currently underway, which controls for these factors in pts with MM. Clinical trial information: NCT00330759.

Clinical benefit in patients with metastatic bone disease: results of a phase 3 study of denosumab versus zoledronic acid

BACKGROUND

Patients with metastatic bone disease are living longer in the metastatic stage due to improvements in cancer therapy, making strategies to prevent the aggravation of bone disease and its complications, such as skeletal-related events (SREs) and pain, increasingly important.

PATIENTS AND RESULTS

In this phase 3 trial in patients with advanced cancer (excluding breast and prostate cancer) or multiple myeloma, denosumab reduced the risk of radiation to bone by 22% relative to zoledronic acid (P = 0.026), prevented worsening of pain and pain interference (2-point increase in Brief Pain Inventory score; P < 0.05 versus zoledronic acid), and reduced the frequency of a shift from no/weak opioid analgesic use to strong opioids (P < 0.05 versus zoledronic acid at months 3-5). Denosumab delayed the time to moderate-to-severe pain compared with zoledronic acid in patients with mild or no pain at the baseline (P = 0.04), supporting early treatment. Health-related quality-of-life scores were similar in both groups. The number needed to treat to avoid one SRE for denosumab was 3 patient-years versus placebo and 10 patient-years versus zoledronic acid.

CONCLUSION

The use of denosumab was associated with better prevention of the complications of metastatic bone disease secondary to solid tumors or multiple myeloma versus zoledronic acid.

Effect of denosumab on prolonging bone-metastasis-free survival (BMFS) in men with nonmetastatic castrate-resistant prostate cancer (CRPC) presenting with aggressive PSA kinetics

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Background: Denosumab, an anti-RANK-ligand monoclonal antibody, has been shown to prolong BMFS by a median 4.2 months and with a 15% risk reduction vs. placebo in men with non-metastatic CRPC and baseline PSA value ≥ 8.0 ng/mL and/or PSA doubling time (DT) ≤ 10.0 months. To determine the efficacy of denosumab in men at greatest risk for bone metastases, we evaluated BMFS in a subset of men with PSADT < 6 months, a cutoff based on a previous report (Smith MR, et al: J Clin Oncol. 23:2918-2925, 2005).

Methods: 1432 men with non-metastatic CRPC (baseline [median] PSA: 12.3 ng/mL, PSADT: 5.1 months, ADT duration: 47.1 months) were randomized 1:1 to receive monthly subcutaneous denosumab 120 mg or placebo. The first patient enrolled February 2006; primary analysis cut-off was July 2010, when > 660 men had developed bone metastasis or died. The primary endpoint was BMFS (time to first bone metastasis or death from any cause). BMFS results are presented for men with baseline PSADT < 6 months.

Results: Median BMFS in the placebo group of men with PSADT < 6 months was 6.5 months shorter than for the placebo group in the full population (18.7 months vs. 25.2 months), indicating that these men are at particularly high risk. In this group of men with PSADT < 6 months, denosumab prolonged BMFS by a median of 7.2 months and with a 23% reduction in risk compared with placebo (Table).

Conclusions: Patients with shortened PSADT are at higher risk of developing bone metastasis and denosumab is markedly effective at prolonging BMFS in this subset of patients.

[Table: see text]

Darbepoetin alfa impact on health status in diabetes patients with kidney disease: a randomized trial

BACKGROUND AND OBJECTIVES

Quality of life (QOL) is markedly impaired in patients with anemia, diabetes mellitus, and chronic kidney disease. Limited data exist regarding the effect of anemia treatment on patient perceptions. The objectives were to determine the longitudinal impact of anemia treatment on quality of life in patients with diabetes and chronic kidney disease and to determine the predictors of baseline and change in QOL.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a large, double blind study, patients with type 2 diabetes mellitus, nondialysis chronic kidney disease (estimated GFR, 20 to 60 ml/min per 1.73 m(2)), and anemia (hemoglobin 10.4 g/dl) were randomized to darbepoetin alfa or placebo. QOL was measured with Functional Assessment of Cancer Therapy-Fatigue, Short Form-36, and EuroQol scores over 97 weeks.

RESULTS

Patients randomized to darbepoetin alfa reported significant improvements compared with placebo patients in Functional Assessment of Cancer Therapy-Fatigue, and EuroQol scores visual analog scores, persisting through 97 weeks. No consistent differences in Short Form-36 were noted. Consistent predictors of worse change scores include lower activity level, older age, pulmonary disease, and duration of diabetes. Interim stroke had a substantial negative impact on fatigue and physical function.

CONCLUSION

Darbepoetin alfa confers a consistent, but small, improvement in fatigue and overall quality of life but not in other domains. These modest QOL benefits must be considered in the context of neutral overall effect and increased risk of stroke in a small proportion of patients. Patient's QOL and potential treatment risk should be considered in any treatment decision.

Azimuthal charged-particle correlations and possible local strong parity violation

Parity-odd domains, corresponding to nontrivial topological solutions of the QCD vacuum, might be created during relativistic heavy-ion collisions. These domains are predicted to lead to charge separation of quarks along the system's orbital momentum axis. We investigate a three-particle azimuthal correlator which is a P even observable, but directly sensitive to the charge separation effect. We report measurements of charged hadrons near center-of-mass rapidity with this observable in Au + Au and Cu + Cu collisions at square root of s(NN) = 200 GeV using the STAR detector. A signal consistent with several expectations from the theory is detected. We discuss possible contributions from other effects that are not related to parity violation.

Growth of long range forward-backward multiplicity correlations with centrality in Au + Au collisions at square root of sNN = 200 GeV

Forward-backward multiplicity correlation strengths have been measured with the STAR detector for Au + Au and p + p collisions at square root of s(NN) = 200 GeV. Strong short- and long-range correlations (LRC) are seen in central Au + Au collisions. The magnitude of these correlations decrease with decreasing centrality until only short-range correlations are observed in peripheral Au + Au collisions. Both the dual parton model (DPM) and the color glass condensate (CGC) predict the existence of the long-range correlations. In the DPM, the fluctuation in the number of elementary (parton) inelastic collisions produces the LRC. In the CGC, longitudinal color flux tubes generate the LRC. The data are in qualitative agreement with the predictions of the DPM and indicate the presence of multiple parton interactions.

K/pi Fluctuations at relativistic energies

We report K/pi fluctuations from Au + Au collisions at sqrt[s(NN)]= 19.6, 62.4, 130, and 200 GeV using the STAR detector at the Relativistic Heavy Ion Collider. K/pi fluctuations in central collisions show little dependence on incident energy and are on the same order as those from NA49 at the Super Proton Synchrotron in central Pb + Pb collisions at sqrt[s(NN)]=12.3 and 17.3 GeV. We report results for the collision centrality dependence of K/pi fluctuations and results for charge-separated fluctuations. We observe that the K/pi fluctuations scale with the charged particle multiplicity density.

Observation of two-source interference in the photoproduction reaction AuAu --> AuAurho0

In ultraperipheral relativistic heavy-ion collisions, a photon from the electromagnetic field of one nucleus can fluctuate to a quark-antiquark pair and scatter from the other nucleus, emerging as a rho{0}. The rho{0} production occurs in two well-separated (median impact parameters of 20 and 40 F for the cases considered here) nuclei, so the system forms a two-source interferometer. At low transverse momenta, the two amplitudes interfere destructively, suppressing rho{0} production. Since the rho{0} decays before the production amplitudes from the two sources can overlap, the two-pion system can only be described with an entangled nonlocal wave function, and is thus an example of the Einstein-Podolsky-Rosen paradox. We observe this suppression in 200 GeV per nucleon-pair gold-gold collisions. The interference is 87%+/-5%(stat.)+/-8%(syst.) of the expected level. This translates into a limit on decoherence due to wave function collapse or other factors of 23% at the 90% confidence level.

Indications of conical emission of charged hadrons at the BNL relativistic heavy ion collider

Three-particle azimuthal correlation measurements with a high transverse momentum trigger particle are reported for pp, d+Au, and Au+Au collisions at sqrt[s_{NN}]=200 GeV by the STAR experiment. Dijet structures are observed in pp, d+Au and peripheral Au+Au collisions. An additional structure is observed in central Au+Au data, signaling conical emission of correlated charged hadrons. The conical emission angle is found to be theta=1.37+/-0.02(stat)-0.07+0.06(syst), independent of p_{ perpendicular}.

System-size independence of directed flow measured at the BNL relativistic heavy-ion collider

We measure directed flow (v_{1}) for charged particles in Au+Au and Cu+Cu collisions at sqrt[s_{NN}]=200 and 62.4 GeV, as a function of pseudorapidity (eta), transverse momentum (p_{t}), and collision centrality, based on data from the STAR experiment. We find that the directed flow depends on the incident energy but, contrary to all available model implementations, not on the size of the colliding system at a given centrality. We extend the validity of the limiting fragmentation concept to v_{1} in different collision systems, and investigate possible explanations for the observed sign change in v_{1}(p_{t}).

Forward neutral-pion transverse single-spin asymmetries in p + p collisions at sqrt[s] = 200 GeV

We report precision measurements of the Feynman x (xF) dependence, and first measurements of the transverse momentum (pT) dependence, of transverse single-spin asymmetries for the production of pi0 mesons from polarized proton collisions at sqrt[s] = 200 GeV. The xF dependence of the results is in fair agreement with perturbative QCD model calculations that identify orbital motion of quarks and gluons within the proton as the origin of the spin effects. Results for the pT dependence at fixed xF are not consistent with these same perturbative QCD-based calculations.

Longitudinal double-spin asymmetry for inclusive jet production in p[over -->] + p[over -->] collisions at sqrt[s]=200 GeV

We report a new STAR measurement of the longitudinal double-spin asymmetry A(LL) for inclusive jet production at midrapidity in polarized p + p collisions at a center-of-mass energy of sqrt[s]=200 GeV. The data, which cover jet transverse momenta 5<p(T)<30 GeV/c, are substantially more precise than previous measurements. They provide significant new constraints on the gluon spin contribution to the nucleon spin through the comparison to predictions derived from one global fit to polarized deep-inelastic scattering measurements.

Measurement of transverse single-spin asymmetries for Dijet production in proton-proton collisions at sqrt[s]=200 GeV

We report the first measurement of the opening angle distribution between pairs of jets produced in high-energy collisions of transversely polarized protons. The measurement probes (Sivers) correlations between the transverse spin orientation of a proton and the transverse momentum directions of its partons. With both beams polarized, the wide pseudorapidity (-1< or = eta < or = +2) coverage for jets permits separation of Sivers functions for the valence and sea regions. The resulting asymmetries are all consistent with zero and considerably smaller than Sivers effects observed in semi-inclusive deep inelastic scattering. We discuss theoretical attempts to reconcile the new results with the sizable transverse spin effects seen in semi-inclusive deep inelastic scattering and forward hadron production in pp collisions.

Partonic Flow and phi-Meson production in Au+Au collisions at sqrt radical sNN = 200 GeV

We present first measurements of the phi-meson elliptic flow (v2(pT)) and high-statistics pT distributions for different centralities from radical sNN=200 GeV Au+Au collisions at RHIC. In minimum bias collisions the v2 of the phi meson is consistent with the trend observed for mesons. The ratio of the yields of the Omega to those of the phi as a function of transverse momentum is consistent with a model based on the recombination of thermal s quarks up to pT approximately 4 GeV/c, but disagrees at higher momenta. The nuclear modification factor (R CP) of phi follows the trend observed in the K S 0 mesons rather than in Lambda baryons, supporting baryon-meson scaling. These data are consistent with phi mesons in central Au+Au collisions being created via coalescence of thermalized s quarks and the formation of a hot and dense matter with partonic collectivity at RHIC.

Transverse momentum and centrality dependence of high-pT nonphotonic electron suppression in Au+Au collisions at sqrt[s NN]=200 GeV

The STAR collaboration at the BNL Relativistic Heavy-Ion Collider (RHIC) reports measurements of the inclusive yield of nonphotonic electrons, which arise dominantly from semileptonic decays of heavy flavor mesons, over a broad range of transverse momenta (1.2<p(T)<10 GeV/c) in p+p, d+Au, and Au+Au collisions at sqrt[s_{NN}]=200 GeV. The nonphotonic electron yield exhibits an unexpectedly large suppression in central Au+Au collisions at high p(T), suggesting substantial heavy-quark energy loss at RHIC. The centrality and p(T) dependences of the suppression provide constraints on theoretical models of suppression.

An evaluation of conditions that may affect the performance of houseboat exhaust stacks in prevention of carbon monoxide poisonings from generators

National Institute for Occupational Safety and Health (NIOSH) researchers evaluated two exhaust stack designs for reducing carbon monoxide (CO) exposures from gasoline-powered generator exhaust on houseboats. Tests were conducted (a) after dark, (b) in high-temperature and high-humidity environments, (c) during temperature inversions, (d) under various generator loads, and (e) at different houseboat trim angles. Two different designs of houseboat exhaust stacks were evaluated and compared with the side-exhaust configuration, which is standard on many houseboats. The two designs were flagpole and vertical stack. Both exhaust stacks performed dramatically better than the standard water level, side-exhaust configuration. The highest mean CO concentrations on the upper and lower decks of the houseboat with the vertical exhaust stack were 27 ppm and 17 ppm. The highest mean CO concentrations on the upper and lower decks of the houseboat with the modified flagpole stack were 5 ppm and 2 ppm. These findings are much lower than the 67 ppm and 341 ppm for the highest mean CO concentrations found on the upper and lower decks of houseboats having the usual side-exhausted configuration. The NIOSH evaluation also indicated that high-temperature and high-humidity levels, temperature inversions, generator loading, and houseboat trim angles had little effect on the exhaust stack performance. It also demonstrated the importance of proper design and installation of exhaust stacks to ensure that all exhaust gases are released through the stack. Based on the results of this work, NIOSH investigators continue to recommend that houseboat manufacturers, rental companies, and owners retrofit their gasoline-powered generators with exhaust stacks to reduce the hazard of CO poisoning and death to individuals on or near the houseboat.