POS0088-PARE CHANGES IN PATIENT-REPORTED OUTCOME SCORES DURING COVID-19 PANDEMIC: DATA FROM THE ArthritisPower REGISTRY

Background

The COVID-19 pandemic causes concern among patients with autoimmune and rheumatic disease (ARD) due to increased risk of infection and heightened isolation from social distancing.1

Objectives

Examine how mean patient-reported outcome (PRO) scores for mental, social and physical health fluctuated after COVID-19 vaccine availability was widespread in US.

Methods

We conducted and reported on2 an initial analysis of January 2020 – April 2021 where US participants (pts) of the ArthritisPower (AP) registry completed PROMIS measures of physical health (Physical Function, Pain Interference, Fatigue, Sleep Disturbance), mental health (Anger, Anxiety, Depression) and social health (Social Isolation, Emotional Support). Follow-up analysis was conducted May – December 2021. Only pts from initial analysis were included in follow-up. Null hypothesis was no change in monthly average scores across 23-month pandemic period. Analysis of means compared monthly assessment mean scores to overall mean score for each measure during study period. Pts with < 2 assessment time points and osteoarthritis with no ARD were excluded from analysis.

Results

Total of 49,940 PRO scores were contributed by 2,266 pts during 23-month period, with 8,393 of the scores contributed from May – December 2021. Mean (standard deviation, SD) number of observations per pt was 5.6 (12.5). Pts were 87.6% female, 86.7% white, mean age of 52.1 (12.7) years. Rheumatoid arthritis (n=1,131, 49.9%) was the most common condition. Most commonly reported measures were Pain Interference, Fatigue, Sleep Disturbance and Physical Function, each with >11,000 total results (Table 1).

Table 1.

Avg assessment scores+ by month, mean (SD)

Pain Interf (n= 11536)Fatigue (n= 11591)Sleep Disturb (n= 11257)Physical Func (n= 11202)Depression (n=1489)Anxiety (n= 1066)Social Iso (n=698)Emot Support (n=578)Anger (n=523)Study Period^63.3 (7.8)62.6 (9.5)58.1 (9.0)37.7 (7.6)60.8 (9.2)62.4 (10.5)61.9 (10.2)40.8 (9.8)61.5 (12.8)May 202161.9 (8.2)*60.9 (9.7)*55.2 (8.8)*38.9 (8.5)59.5 (9.2)61.9 (9.8)60.2 (13.3)38.1 (8.3)59.6 (14.5)June61.6 (6.9)*60.9 (9.6)*54.8 (8.9)*38.3 (7.8)59.2 (7.0)60.6 (9.6)61.8 (12.0)39.3 (10.3)60.2 (10.9)July61.8 (7.4)*60.8 (10.2)*56.0 (8.6)*38.1 (7.9)61.0 (7.8)59.9 (12.1)66.8 (8.5)*39.4 (9.7)62.4 (9.7)Aug61.2 (8.5)*60.7 (10.4)*55.8 (9.6)*38.5 (8.5)57.7 (7.9)*58.2 (10.3)*57.2 (11.1)36.9 (12.2)53.3 (19.4)Sep62.4 (8.5)62.3 (10.0)56.2 (8.3)37.3 (7.6)58.7 (8.0)57.7 (11.3)*68.1 (12.8)36.7 (12.1)58.7 (12.0)Oct63.1 (8.4)63.3 (9.9)57.6 (8.6)37.3 (8.0)59.9 (9.9)62.3 (9.0)64.3 (10.3)37.3 (11.4)64.6 (10.2)Nov62.6 (6.8)63.2 (10.0)55.8 (8.6)*36.9 (7.0)59.1 (8.8)61.3 (6.8)61.4 (10.9)38.6 (11.7)60.3 (12.4)Dec62.9 (8.3)64.0 (9.6)56.5 (8.4)37.4 (8.1)60.7 (8.4)63.8 (5.3)65.1 (7.5)38.5 (13.5)68.6 (5.0)*

+PROMIS measures scored 0-100; mean 50 for general US population; 1SD = 10 points

^Study period: January 2020 – December 2021

. *Statistical significance (p<0.05); analysis of means (ANOM)

Pts’ mental and social health assessment scores improved then worsened during last 8 months of 2021 (Figure 1). Overall mean scores were: Anxiety 62.4 (12.5), Social Isolation 61.9 (10.5), and Anger 61.5 (12.8). From July – August, Social Isolation decreased by 1 SD. Compared to overall assessment mean, Anger declined by > ½ SD (53.3 [19.4]) in August and Anxiety declined by ½ SD (57.7 [11.3]) in September. By December, Anger rose by > ½ SD (68.6 [5.0]) of assessment mean. Pain Interference (mean: 63.3 [7.8]), Fatigue (62.6 [9.5]), and Sleep Disturbance (58.1 [9.0]) scores were significantly lower in May, June, July and August compared to the assessment mean, though none decreased by > ½ SD.

Conclusion

ARD members of AP had mental, social and physical health scores improve during summer of 2021, corresponding with widespread availability of vaccines. However mental and social health scores worsened by December as US faced new variants of the virus.

References

[1]George M, et al. Rheumatol. 2021;48:603-7.

[2]Gavigan K, et al. Arth Rheumatol. 2021;73(suppl 10).

Acknowledgements

This work was partially supported through a Patient-Centered Outcomes Research Institute (PCORI) award (PPRN-1306-04811). All statements in this poster, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of PCORI, its Board of Governors or Methodology Committee.

Disclosure of Interests

Kelly Gavigan: None declared, Esteban Rivera: None declared, Jeffrey R. Curtis Consultant of: Gilead, Novartis, and Samsung, Grant/research support from: AbbVie, Amgen, BMS, Corrona, Eli Lilly and Company, Janssen, Myriad, Pfizer, Regeneron, Roche, and UCB, Shilpa Venkatachalam: None declared, Laura Stradford: None declared, David Curtis: None declared, W. Benjamin Nowell Grant/research support from: William B. Nowell is the Principal Investigator on grants/contracts from AbbVie, Eli Lilly and Company, and PCORI, and an employee of the Global Healthy Living Foundation (GHLF). GHLF receives grants, sponsorships and contracts from pharmaceutical manufacturers and private foundations. A full list of GHLF funders is publicly available here: https://www.ghlf.org/our-partners/.

Gingival Thickness and Outcome of Periodontal Plastic Surgery Procedures: A Meta-regression Analysis

OBJECTIVE

To evaluate the impact of soft tissue thickness (STT) on root coverage achieved with different periodontal plastic surgery procedures.

BACKGROUND

Gingival recession has been managed successfully through various surgical approaches, with great variability in outcomes. Anatomic characteristics of the recipient site and selected technique account in part for this variability. Gingival flap thickness is one of the most critical site-related characteristics.

METHODS

An electronic search was conducted on the major databases (PubMed, Embase, Web of Science). Human prospective studies with at least 6 mo of follow-up and with a numeric baseline measurement for gingival thickness were eligible. Only studies including nonsmoking patients were considered. Variables included surgical approach, participant characteristics, local anatomic factors, and follow-up time. Primary outcome was mean percentage root coverage (%RC) achieved, and complete root coverage was a secondary outcome.

RESULTS

A total of 42 studies were included (35 randomized controlled trials, 5 case series, 1 prospective cohort study, and 1 controlled clinical trial). Across studies, the pooled %RC was 81.9% (95% CI, 79.1% to 84.7%). The %RC was not significantly associated (P = 0.267) with baseline soft tissue thickness; however there was a significant (P = 0.031) inverse relationship between STT and %RC after 12-mo follow-up. Subgroup analysis showed that for no graft, there was a significant (P = 0.025) positive relationship between STT and %RC with the exclusion of the single outlier study based on STT.

CONCLUSIONS

STT plays a limited role in predicting root coverage across all approaches; when flaps are performed with no graft, the effect of STT is most critical. The length of time following surgery appears to influence outcomes, with 12-mo follow-up offering greater insight.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can suggest to clinicians which periodontal plastic surgery technique to employ when treating challenging cases. In particular, it can be helpful when selecting the treatment approach to treat thin phenotype sites. This study could help clinicians provide a more appropriate treatment decision in such cases.

Sonographic Measurement of the Patellar Tendon Should Predict Autograft Bone Patellar Tendon Bone (BPTB) Size: Comparison of Anatomical and Clinical Findings

The use of BPTB autograft is frequently used in ACL reconstruction, however, the risk of potential failure in patients with an anatomically unfavorable patellar tendon may predispose to reconstruction failure. Anatomical study of the extensor apparatus of the knee can provide knowledge about the best option obtain the graft and perform a better preoperative planning. Musculoskeletal ultrasound is a simple, reproducible, affordable technique that could be valid for patellar tendon evaluation. The objective of this study is to evaluate the reproducibility of the patellar tendon measurements by ultrasound and compare them with anatomical measurements, both in cadaver and patients undergoing ACLR. The study consists of two phases; first anatomical study in cadaver. The ultrasound measurement was performed by determining the length, width and thickness of the patellar tendon, both by ultrasound and anatomical dissection. The second phase is a cohort of 42 patients pending surgical ACLR. Previous ultrasound and intraoperative measurements were obtained. Regarding the anatomical study, statistical analysis did not show any differences comparing the measurements in length (p = ns) and thickness (p = ns) of the patellar tendon, although differences were obtained when comparing the results obtained for the width of the tendon after the ultrasound and anatomical measurement (p < 0.001). Same results were obtained in second phase of the study. The reproducibility of ultrasound measurements of the PT is comparable to intraoperatively measurements (without width measurement). These findings can be useful for preoperative planning in the reconstruction of ACL with BPTB Graft and to assess technical modifications prior to surgery.

Assessing long-term return to play after hip arthroscopy in football players evaluating risk factors for good prognosis

PURPOSE

Groin pain is the third most common disease in football players and has often been associated with hip pathology such as femoroacetabular impingement and labral lesions. Hip arthroscopy offers possibilities of function restoration via minimally invasive procedures. The aim of this study is to evaluate professional football player's injuries and their return to play after hip arthroscopy for FAI and labral injuries.

METHODS

Patients that underwent hip arthroscopy between 2009 and 2014 were selected retrospectively. From this population, only professional soccer players competing at national level were included (Tegner 10). Arthroscopic surgery was proposed in patients with persistent pain. All patients were assessed for VAS score preoperatively and at 3, 6, 12 and 24 months post-op. HOS (sport and DLA) and mHHS tests were performed at the same time periods.

RESULTS

All patients were men with a mean age of 26.5 ± 7.1 years old. Preoperative VAS (7.4 ± 1.3), HOS ADL (67.7 ± 5.5), HOS sport (37.6 ± 18.7) and mHHS (72.5 ± 8.8) showed improved scores during long-term follow-up. Time to return to play was 10.8 months (SD ± 4.3), with range between 4 and 20 months. Mean follow-up was 45.4 ± 15.6 months (range from 26 to 72 months). No differences were observed between non-active and active patients at final follow-up with respect to chondral lesions, but significant differences were observed with reference to management of the labrum (p = 0.031), where a higher rate of labrectomies existed among inactive patients and a higher rate of suture among active patients.

CONCLUSIONS

Hip arthroscopy is a safe procedure with very good return to play results, but for optimized return to football one should consider patient age at the time of surgery, the condition of the labrum and low scores on the Harris Hip Score (mHHS) and HOS (sport version) as predictive factors for poor prognosis. Level of evidence IV.

Laboratory Animal Legislation in Latin America

A review of existing legislation covering laboratory animals in Latin America is presented. The region presents a spectrum of economic development, political stability, and cultural diversity. With the exception of a few nations, there is a lack of regulations as well as minimal enforcement of existing laws pertaining to laboratory animals. Brazil, Mexico, and Uruguay stand out as the only nations in this region with specific legislation regulating laboratory animal care and use; the history and current status of regulations in these three nations is reviewed.

Enhancement of the physicochemical properties of [Pt(dien)(nucleobase)]2+ for HIVNCp7 targeting

Physicochemical properties of coordination compounds can be exploited for molecular recognition of biomolecules. The inherent π-π stacking properties of [Pt(chelate)(N-donor)]²⁺ ([PtN₄]) complexes were modulated by systematic variation of the chelate (diethylenetriamine and substituted derivatives) and N-donor (nucleobase or nucleoside) in the formally substitution-inert PtN₄ coordination sphere. Approaches to target the HIV nucleocapsid protein HIVNCp7 are summarized building on (i) assessment of stacking interactions with simple tryptophan or tryptophan derivatives to (ii) the tryptophan-containing C-terminal zinc finger and (iii) to the full two-zinc finger peptide and its interactions with RNA and DNA. The xanthosine nucleoside was identified as having significantly enhanced stacking capability over guanosine. Correlation of the LUMO energies of the modified nucleobases with the DFT π-stacking energies shows that frontier orbital energies of the individual monomers can be used as a first estimate of the π-stacking strength to Trp. Cellular accumulation studies showed no significant correlation with lipophilicity of the compounds, but all compounds had very low cytotoxicity suggesting the potential for antiviral selectivity. The conceptual similarities between nucleobase alkylation and platination validates the design of formally substitution-inert coordination complexes as weak Lewis acid electrophiles for selective peptide targeting.

Abstract OT3-3-01: Eniluracil + 5-fluorouracil + leucovorin (EFL) vs. capecitabine phase 2 trial for metastatic breast cancer

Based on a modified dosing protocol designed to optimize efficacy, an open-label EFL vs. capecitabine (4:3 randomization) Phase 2 trial for metastatic breast cancer is in progress. Eniluracil inactivates dihydropyrimidine dehydrogenase, thereby preventing the formation of α-fluoro-β-alanine, and conferring 100% oral bioavailability and a 5 hr half-life on 5-fluorouracil (5-FU). Study drugs are administered orally for 1st- or 2nd-line treatment for metastatic disease in patients previously treated with an anthracycline and a taxane. Arm 1: eniluracil (40 mg) taken 11–16 hr before 5-FU (30 mg/m2); leucovorin (30 mg) taken with 5-FU and the next day. The regimen is administered once/week for 3 weeks/4 weeks. Arm 2: capecitabine (1000 mg/m2) taken bid for 14 days/21days. Arm 2 patients with disease progression could crossover to take EFL in Arm X. Two sites in the USA and 19 in Russia are enrolling. Currently, 115 patients (21% are 1st-line, 70% had previous 5-FU treatment) are enrolled and 83 have had tumor assessments. EFL was well tolerated with no unexpected toxicities. As of May 2012, there were 11, 7, & 1 partial responses in Arms 1, 2, & X, respectively. The primary endpoint, progression-free survival, will be determined approximately 7.5 months after the trial is enrolled with 140 evaluable patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT3-3-01.

Bilateral corneal edema secondary to amantadine in the pediatric population: a case report

PURPOSE

To report a case of amantadine induced corneal edema in a pediatric patient.

METHODS

A comprehensive ophthalmologic evaluation was performed to a 16-year-old female patient who presented with bilateral, painless loss of vision and corneal edema.

RESULTS

Review of the patient's medical information revealed the use of amantadine to alleviate extrapyramidal side effects secondary to psychiatric medications. Complete resolution of bilateral corneal edema was achieved one month after cessation of amantadine therapy.

CONCLUSION

Amantadine induced corneal edema should be considered in the differential diagnosis of bilateral corneal edema in all age groups. Review of the toxic side effects of systemic medications should be performed in every patient who presents with bilateral corneal edema.

Comparison of MammaPrint, BluePrint, and TargetPrint with clinical parameters in patients with breast cancer: Findings from a prospective United States cohort

47

Background: MammaPrint (MP) is a powerful predictor of disease outcome in early stage breast cancer. In addition, TargetPrint (TP), a microarray-based test that measures the mRNA expression level of ER, PR and HER2 and an 80 gene expression Molecular Subtyping profile BluePrint (BP) were developed. In the present study, MP, BP and TP were measured in a prospective U.S. breast cancer patient cohort.

Methods: MP results were evaluated in fresh tumor samples from 127 breast cancer patients (T1-4N0-2; median age 62 [39-97 yr]) collected by core needle biopsy or from a surgical specimen between July 2008 and January 2011. We compared treatment advice as recommended by NCCN guidelines and classification according to MP. In addition, we compared IHC/FISH ER, PR and HER2 assessments with TP. The MP and BP results were used to subtype the patients into molecular subgroups.

Results: For the group of patients (n=59) for which NCCN recommends the use of a multi-gene signature for determining chemotherapy treatment recommendations, 42 patients were classified as High Risk and 17 as Low Risk by MP. Comparison of TP with IHC/FISH indicated a concordance of 98% for ER, 94% for PR, and 98% for HER2. For a subgroup of 53 patients combined MP and BP results were available; 18 patients were Luminal-type/MP Low Risk, 27 patients were Luminal-type/MP High risk, 1 patient was Her2-type/MP Low Risk, 1 patient was Her2-type/MP High Risk and 6 patients were Basal-type/MP High Risk.

Conclusions: Adding the multi-gene signature MammaPrint, as well as BluePrint and TargetPrint provides additional information for treatment guidance. By combining MammaPrint with the BluePrint molecular subtyping profile, specific groups of patients can be recognized that are at high risk of recurrence and that would possibly benefit from specific treatment. This study shows that TargetPrint provides high quality second opinion for local IHC/FISH assessment.

Kinetic evaluation and performance of pilot-scale fed-batch aerated lagoons treating winery wastewaters

Winery wastewater was treated in two pilot-scale aerated lagoons operating in fed-batch mode. A first lagoon of 27.2m(3) working volume was gradually filled with wastewater with an average COD content of 8700mg/L. Given that with the flow-rate used (790L/day) this first lagoon completed its working volume after 30days of starting, part of the liquid contained in the first lagoon was transferred to another adjacent second lagoon of 10.8m(3) working volume. Therefore, the experiment continued in the second lagoon for another additional 24days using an influent with a COD content of 18,700mg/L at a flow-rate of 170L/day. After the 21st day, a maximum COD removal efficiency of 91% was achieved, and this value was maintained virtually constant until the end of the experiments. A mathematical model based on three differential equations solved simultaneously allowed the kinetic parameters of the system to be obtained.

Phase I trial of escalating doses of weekly everolimus (RAD001) in combination with docetaxel for the treatment of metastatic breast cancer (MBC)

1066

Background: Inhibition of mTOR with everolimus (E) may improve efficacy in combination with docetaxel (D), but both drugs are metabolized by CYP3A4, thus a pharmacokinetic (PK) interaction may also exist. Methods: 15 patients (pts) with MBC were treated with docetaxel and everolimus using the continuous reassessment method (CRM) to determine maximum tolerated dose (MTD). Docetaxel doses were 40–75 mg/m2 IV on day 1 of a 21 day cycle. Everolimus doses were 20–50 mg PO on days 1 and 8 of a 21 day cycle (except cycle 2, where only day 8 was given to allow single agent PK analyses of both drugs). Response was measured every 2 cycles using RECIST. Results: Median age= 58 years and 77% of pts had >2 prior chemotherapies for MBC. Initially 2 of 2 pts treated (D= 75 mg/m2, E= 30 mg) developed DLT (neutropenic fever/infection), prompting a mandatory PK evaluation for all pts enrolled in subsequent cohorts. A second cohort of 3 patients (D=60 mg/m2, E=20mg) had no DLT, but no pts received day 8 of E due to grade 3–4 neutropenia. PK analyses demonstrated a 42% lowered (-42%) D clearance at the 60 mg/m2 in the presence of E (n=1). Subsequent cohorts were accrued at D=40 mg/m2 with escalating doses of E (Table). For the entire group, an 18% decrease (-18%) in D clearance was observed when D was administered concomitantly with E. High interpatient variability of D clearance was observed (range +16% to -135%). No pts had CR/PR, but 6 had SD>4 cycles and 2 had SD=8 cycles. Conclusions: Weekly everolimus appears to cause widely variable and unpredictable changes in docetaxel clearance making this combination unfeasible.

[Table: see text]

No significant financial relationships to disclose.

Luxación recidivante postraumática del tendón extensor carpi ulnaris (ECU) en la muñeca: a propósito de un caso

La luxación o subluxación del tendón del extensor carpi ulnaris es uno de los diagnósticos diferenciales, a tener en cuenta, ante la existencia de dolor en el lado cubital de la muñeca, siendo rara su lesión aislada, por lo que su diagnóstico, puede pasar, con frecuencia, desapercibido.

La lesión ocurre durante una hipersupinación del antebrazo, desviación cubital y flexión palmar de la muñeca. Manifestando el paciente la sintomatología dolorosa tras la reducción del tendón con la pronación, dolor que puede llegar a ser muy incapacitante, con disminución del movimiento de pronosupinación de la muñeca, y disminución de fuerza. Debido a su mecanismo de producción y aparición de los síntomas, el diagnóstico es clínico, pues las pruebas complementarias pueden ser normales. La luxación del tendón, sólo ocurre, ante la ruptura o desinserción de su vaina osteofibrosa propia, o capa profunda del sexto compartimento extensor, a pesar de que el ligamento anular dorsal, o capa superficial del retináculo extensor, permanezca intacto. El tratamiento ha de ser quirúrgico, para reconstruir la vaina o corredera osteofibrosa, obteniéndose resultados satisfactorios.

Dose-seeking study of the combination of GM-CSF with pegfilgrastim plus CHOP-rituximab in patients with aggressive non- Hodgkin lymphoma (NHL)

18501

Background: Therapy for aggressive B cell NHL includes CHOP-rituximab (CHOP-R)q 14 days with G-CSF support. We are now investigating CHOP-R plus pegfilgrastim (Neulasta [N]) and low dose GM-CSF (Leukine). The rationale for low dose GM-CSF is based on its stimulation of ADCC which appears to be the most important mechanism of action of R and upregulation of CD20 on B cells, in addition, to other immunomodulating effects. Some of these are seen at lower levels of GM-CSF and appear to be lost at higher doses. N is given in order to allow delivery of chemotherapy q. 2 weeks. Methods: The goal was to determine the optimal dose of GM-CSF needed to support absolute neutrophil count (ANC) recovery >1,000 by day 14 without inducing marked leucocytosis when combined with N. R is given on day 1, CHOP on day 2 and growth factors start on day 3. We used a single fixed low dose of N 3 mg s.c. on day 3 and an escalating dose of GM-CSF starting at 75 mcg s.c. on day 3. GM-CSF was repeated every Monday, Wednesday and Friday. Results: So far we have delivered 65 evaluable courses to 18 pts (16 evaluable) whose median age was 58 (range 26–87). The plan was to escalate GM-CSF as necessary to support ANC recovery by day 14 without inducing severe leucocytosis. GM-CSF was to be escalated in cohorts of 5 patients at: 75, 125 and 250 mcg. The first cohort of 5 was treated at 75 mcg and all 5 recovered their ANC to >1,000 by day 14 and none exceeded ANC >50,000 before day 14. Therefore the next cohort of 5 received the same dose of 75 and all 5 were able to recover by day 14. Subsequently the next 6 were also treated at the same dose of 75 mcg. During 65 total courses, all but 3 pts recovered ANC to >1,000 before day 14. Chemotherapy doses were not reduced unless severe infection (i.e. septic shock or bilateral pneumonia). Because of prolonged or severe neutropenia, intrapatient dose escalations of GM-CSF were done in 2 pts (to 125 mcg) during the 2nd course and to 250 mcg in 1 pt during the 3rd. Conclusions: GM- CSF 75 mcg on Mondays, Wednesdays and Fridays is adequate and safe to support ANC recovery if combined with 3 mg N. However, in view of encouraging data of McLaughlin et al with 250 mcg of Leukine plus R in indolent NHL, in the next study we will attempt to escalate Leukine to 250 mcg.

[Table: see text]

Goserelin plus anastrozole in the treatment of premenopausal hormone receptor positive, recurrent or metastatic breast cancer

1030

Background: Aromatase inhibitors (AIs) are highly active in postmenopausal women with hormone receptor positive breast cancer. However, the AIs do not suppress ovarian estrogen synthesis and are not effective in premenopausal women. This phase II study was initiated to estimate the activity of anastrozole when given with ovarian suppression by goserelin in premenopausal women with ER and/or PgR positive metastatic breast cancer. Methods: Premenopausal women with measurable recurrent or metastatic, ER and/or PgR positive breast cancer; no prior AI or LH-RH agonist/antagonist; no adjuvant chemotherapy within 6 months; ECOG performance status of 0–2; adequate organ function; and who provided signed, informed consent were eligible. A 2 stage phase II design was utilized. Treatment was with goserelin 3.6 mg SQ q4wk and anastrozole 1 mg/day begun on day 22 of protocol treatment. Treatment was continued to disease progression. Results: 35 patients (pts) were enrolled. Three were excluded from analysis for the following: 1 postmenopausal, 1 consent withdrawal, 1 early oophorectomy. Of the remaining 32 pts, median age was 43 yrs (range 26–51 yrs), 18 (56%) had prior chemotherapy, and 9 (28%) had prior SERM. Pts were Asian/Middle Eastern 22%, Caucasian 62%, Black 13%, Hispanic 3%. Disease sites were lymph node 50%, breast 44%, bone 81%, lung 41%, liver 22%, pleural effusion 6% and soft tissue 6%. Receptor status was ER+/PgR+ 75%, ER+/PgR- 22% and ER-/PgR+ 3%. Response: Treatment resulted in complete response (CR) in 1(3%), partial response (PR) in 11(34%), stable disease 6+ mos (SD) in 11(34%), and clinical benefit (CR+PR+SD) 23 (72%). Median TTP was 8 mos (range 2 - 63+ mos); median OS was 26 mos (range 11 - 63+ mos). Estradiol levels were detectable in 30/31 pts at baseline (median 56 pg/ml, range <10 - 273 pg/ml). Mean estradiol levels (pg/ml) were 75 at baseline, 21 at 1 mos, 19 at 3 mos, and 15 at 6 mos. TOXICITY: One grade 3 weight loss. All other toxicities were grade 1–2. Conclusions: Ovarian suppression with goserelin in combination with anastrozole is well tolerated and highly active in the treatment of premenopausal, hormone receptor-positive metastatic breast cancer. Support provided by AstraZeneca Pharmaceuticals

No significant financial relationships to disclose.

Actions of a novel therapeutic formulation: Zn, Se and Mn plus Lachesis Muta venom (O-LM) on radiation deleterious immune effects

14116

Background: We have previously reported that O-LM inhibits malignant cell proliferation and increases survival in rodent tumor models (Int J Cancer S13:183, 2002). Molecular and immunological basis of O-LM action were reported (J Clin Oncol 24:18S, 2006). As O- LM selectively protects normal tissues from high doses of ionizing radiation (Proc Int Cancer Congress,1495–9, 1998), we here investigated O- LM protective action upon radiation effects on immune cells. Methods: Balb/c mice (n=15 each group) were employed: control (C); 2Gy whole body irradiated (IR); treated with O-LM (Zn, Se, Mn 4μg/ml each; L. Muta 4 ng/ml; 0.1 ml/day, sc) for 15 days and 2Gy irradiated (O-LM+IR). Mice were sacrificed at day 3, 7 or 15 post-irradiation (PI). Proliferation was evaluated in lymphocytes by [3H]- Thymidine incorporation after T- or B selective mitogen stimulation. In cell-free supernatants (SN) from mitogen-stimulated cultures cytokines involved in lymphocyte regulation and/or inflammation were determined by ELISA. Results: Irradiation induced a decrease in T lymphocyte proliferation at 3 and 7 days PI (% of decrease in IR: 47.6±9.0, p<0.05; 42.0±7.2, p<0.02 respectively). Pretreatment with O-LM recovered proliferation to basal values (day 3 PI 93.4±10.2%; day 7 PI 130.9±15.3%, O-LM+IR vs. C; p=NS). No modifications were observed in B cells. At day 3 PI, a marked decrease in IFN? levels was obtained in SN of IR mice that was reverted by O-LM treatment (pg/ml: IR 1653±419; C 10884±2783, p<0.02; O-LM+IR 16924±4284, p<0.05 vs C). Also, at day 7 PI, an important increase in TNFa was observed in IR mice, that were reverted by O-LM (pg/ml: IR: 300.7±62.3 vs O-LM+IR: 28.7±2.3, p<0.02). No differences were found in IL-2 levels. Conclusions: The therapeutic action of O-LM is based on its ability of targeting simultaneously multiple pathways involved in cancer development. Present data demonstrate that O-LM protects animals from irradiation by recovering the immune function, improving T lymphocyte activity and modulating the production of key cytokines as IFN? and TNFa. The reported effect may represent a potential benefit for cancer patients undergoing radiotherapy.

No significant financial relationships to disclose.

High incidence of non-neutropenic infections induced by rituximab plus fludarabine and associated with hypogammaglobulinemia: a frequently unrecognized and easily treatable complication

BACKGROUND

Rituximab is associated with low incidence of hypogammaglobulinemia and little morbidity. Our experience with the combination of rituximab + chemotherapy suggested the opposite.

PATIENTS AND METHODS

We analyzed our experience with rituximab plus chemotherapy in 97 patients to determine: frequency and type of non-neutropenic infection (NNI); frequency and type of hypogammaglobulinemia; response to gammaglobulin therapy; and factors associated with NNI.

RESULTS

We observed 40 episodes of NNI in 19 of 97 (20%) patients. By 3 years, 43% of patients treated with rituximab + chemotherapy were projected to have developed at least one NNI. Of 19 with NNI, 15 had Ig levels studied and all 15 had hypogammaglobulinemia. Most frequently affected Ig were IgG (14 of 15) and IgM (13 of 14). IgA was usually spared (six of 14 cases affected). NNIs observed were 18 bronchitis, 16 sinusitis, four pneumonias, three otitis media, two fevers of unknown origin (FUOs) and three herpes zoster. Hospitalization was required in seven of 19. Ten received gammaglobulin infusions and all responded promptly. Gammaglobulin was given only when NNIs recurred. We examined sex, age, histology, type of rituximab-chemotherapy (fludarabine + rituximab versus other chemotherapy + rituximab) for correlation with NNI.

CONCLUSIONS

Indolent histology, female sex and fludarabine + rituximab significantly correlated with frequency of NNI but multivariate analysis picked fludarabine + rituximab followed by female gender as the only two independent variables predictive of NNI.

Randomized trial of yoga in women with breast cancer undergoing radiation treatment

8505

Background: Yoga, an ancient Indian science, incorporates stress-reduction techniques that include regulated breathing, visual imagery, and meditation, as well as various postures that may be useful for cancer patients. Methods: A yoga program was developed that including loosening and breathing exercises, postures, alternate nostril breathing, a deep relaxation technique, and meditation for patients with breast cancer who were undergoing radiotherapy. Women participated in bi-weekly classes during their 6 weeks of radiation treatment. Sixty-one women with breast cancer were randomly assigned to either the yoga program or to a waitlist control group. Patients completed measures of intrusive thoughts and avoidance behaviors (Impact of Events Scale: IES), depressive symptoms (CES-D), sleep disturbances (Pittsburgh Sleep Quality Index), fatigue (BFI), and quality of life (SF-36) at baseline, 1 week, and 1 and 3 months after the last radiation therapy. We report on the outcomes 1 week after the end of radiotherapy. Results: The average age of the women was 52, 3% stage 0, 28% stage I, 43% stage II, and 26% stage III, 48% had undergone breast-conserving surgery, and 75% had received chemotherapy prior to starting radiotherapy. Analysis of covariance, controlling for baseline, revealed that the yoga group had significantly better SF-36 physical function scores (adjusted means: yoga 81.8 vs. control 68.6, P < 0.01), significantly higher SF-36 general health scores (adjusted means: yoga 78.3 vs. control 67.9, P < 0.03), marginally better SF-36 social functioning scores (adjusted means: yoga 85.3 vs. control 76.0, P > 0.1), significantly lower levels of sleep-related daytime dysfunction (adjusted means: yoga 0.5 vs. control 1.2, P < 0.04), and marginally lower levels of fatigue (adjusted means: yoga 1.9 vs. control 3.1, P < 0.06) than the control group. There were no other group differences on the SF-36 subscales or for the CES-D or IES scores. Conclusions: The results indicated that the yoga program was associated with statistically and clinical significant improvements in aspects of quality of life.

No significant financial relationships to disclose.

Phase I combination study of trabectedin (T) and capecitabine (C) in patients with advanced malignancies

2079

Background: T binds to the minor groove of DNA, synergizes with functional nuclease excision repair and targets inducible transcription. T is active in several tumor types and exhibits preclinical synergy with C. The primary objective of this study is to determine the maximum tolerated dose (MTD) of T in combination with C. Secondary objectives include safety and pharmacokinetic (PK) analyses. Methods: Pts with advanced cancer, performance status 0–1 and adequate organ function are eligible. Pts received T starting at 0.4 mg/m2 over 3 hours on day 1 followed by C on days 2 through 15. The initial dose of C was 2000 mg/m2/day and was reduced to 1600 mg/m2/day due to GI dose-limiting toxicity. Dose escalation of T continued. Cycles are repeated every 3 weeks, with PK sampling included. Standard “3+3” dose escalation design, definitions of dose limiting toxicity (DLT), and dose modification for toxicity are implemented. Results: To date, 30 patients have received 112 cycles (range 1–12, median 4) of treatment at 7 dose levels. Two of 3 pts at dose level 4 (C 2000 mg/m2/d and T 0.9 mg/m2) and 2/6 pts at dose level 3 (C 2000 mg/m2/d and T 0.75 mg/ m2) developed gastrointestinal DLT (emesis, diarrhea, pancreatitis). C was subsequently reduced to 1600 mg/m2/d and a new T dose escalation was initiated at 0.6 mg/m2. Treatment has been well tolerated with C 1600 mg/m2/d and T up to the current dose of 0.9 mg/m2 (dose level 4a), with 1of 6 subjects experiencing grade 1 alkaline phosphatase. The most frequently reported related grade 3–4 adverse events (AEs) are diarrhea (23%), neutropenia (20%), nausea (16.6%), hand-foot syndrome (16.6%) and vomiting (13%). Anti-tumor activity to date includes a confirmed partial response lasting 8 months (m) in a patient with cholangiocarcinoma, and prolonged stable disease in 2 patients with breast cancer (6 and 7m), ovarian cancer (11m) and chondrosarcoma (9m). Conclusions: The combination of C 1600mg/m2/d and T up to 0.9mg/m2 is tolerable and has promising activity in several tumor types. Dose escalation of T continues at 1.1 mg/m2. Biologic and pharmacokinetic analyses will be presented.

[Table: see text]

Phase III study of docetaxel weekly (DW) versus every 3 weeks (D) in patients with metastatic breast cancer: Final results

574

Background: D is a semi-synthetic taxane with significant activity in breast cancer. D is usually administered on an every 3-weeks schedule, however, studies have demonstrated drug efficacy and a different toxicity profile when administered on a weekly basis. In this study we compared the weekly schedule versus every 3-weeks to define the safest schedule with the highest efficacy. Methods: Patients (Pts) were enrolled if they had stage IV breast cancer and had received no more than one prior chemotherapy regimen for metastatic disease. Prior treatment with D was not allowed but adjuvant paclitaxel (P) was allowed if > 12 months since the last dose. Pts were randomized to receive D at a starting dose of 75mg/m2 on day 1 or DW at a dose of 35 mg/m2/week for 3 weeks followed by 1 week of rest every 28 days. Doses could be escalated to 100 mg/m2 and 40mg/m2, respectively at the discretion of the investigator. Premedication with dexamethasone was given with each regimen. Results: From 1/2001 until 9/2004, a total of 125 pts were enrolled, 63 in the DW arm and 62 in the D arm. Thirty-nine and 10 pts had received prior anthracycline (A) and P respectively in the D arm while 32 and 11 pts had A and P in the DW arm. Median ages were 56 and 54 years in the D and DW arm, respectively. 118 pts were eligible for an efficacy analysis with a response rate of 35.6%; (95% CI, 23.6%, 49.1%) for the D arm vs 20.3%; (95% CI, 11.0%, 32.8%) for DW. There was no difference between D and DW in median PFS and OS, 5.7 vs 5.5 months (p = 0.46) and 18.3 vs 18.6 months (p = 0.34), respectively. There was a higher overall toxicity rate (grade 3 and 4) in the D arm vs DW, 88.1% vs 55.9% (p = 0.0001). There were 48 (81%) and 6 (10%) pts with grade ¾ granulocytopenia with 6 (10%) and 2 (3%) episodes of neutropenic fever in D vs DW, respectively. Grade 3/4 fatigue and myalgias were reported more often in D than DW, 15 (25%) and 8 (13.5%), and 16 (27%) and 2 (3%), respectively. Grade 3 epiphora was similar in both arms, 4 (7%) and 5 (8%) for D and DW, respectively. Conclusions: D has a higher response rate compare to DW but with a more pronounced toxicity profile. This needs to be kept in mind when making a treatment recommendation for patients with metastatic breast cancer. No difference in PFS or OS was observed between both arms.

No significant financial relationships to disclose.

Prospective study of incidence and severity of epiphora and canalicular stenosis in patients with metastatic breast cancer receiving docetaxel

659

Background: To determine the incidence and severity of epiphora and canalicular stenosis in patients receiving weekly or every-3-weekly docetaxel. Methods: In this prospective trial, each patient underwent an ophthalmologic examination and probing and irrigation of the lacrimal drainage apparatus at baseline and at every 4–6 weeks after initiation of docetaxel. During each visit, epiphora and canalicular stenosis were graded. Patients with epiphora were treated with Tobradex drops. If epiphora worsened or findings on probing and irrigation suggested further canalicular narrowing, silicone intubation was offered. Results: 28 patients received weekly and 28 patients received every-3-weeks docetaxel. 18(64%) patients who received weekly docetaxel developed epiphora. Epiphora was mild in 7 patients, moderate in 5, and severe in 6. Nine patients had resolution of epiphora with Tobradex. Nine patients had worsened canalicular stenosis; 6 underwent surgery. The median cumulative docetaxel dose was 496.5 mg at onset of epiphora and 889.5 mg at surgery. 11 (39%) patients who received every-3-weeks docetaxel developed epiphora. The median cumulative docetaxel dose at the time of onset of epiphora in this group was 420 mg. Epiphora was mild in 9 patients, moderate in 1, and severe in 1. Nine patients had resolution of epiphora in response to Tobradex. Two patients underwent surgery. Conclusions: Epiphora occurred in 64% of patients in the weekly group and 39% of patients in the every-three-weeks group. Moderate or severe canalicular stenosis was seen in about one-third of patients in the weekly group and none of the patients in the every-3-weeks group.

[Table: see text]

A dose dense low toxicity salvage regimen for histologically aggressive non-Hodgkin’s lymphoma (NHL): Gemcitabine, rituximab, oxaliplatin combination (GROC) plus pegfilgrastim

17513

High dose chemo/autologous stem cell transplant (ASCT) is standard treatment for relapsed aggressive NHL. However many are unable to receive ASCT because they are refractory to salvage therapy, too old or too sick. More effective, less toxic salvage regimens are needed prior to ASCT. Gemcitabine (G) and Oxaliplatin (O) are active agents in NHL and exhibit synergism so their combination is attractive to explore together with Rituximab (R). We hereby report the results of a phase I-II trial designed to explore the GROC regimen administered every 14 days with Pegfilgrastim support. After the first 6 pts were entered, the phase I portion was completed; recommended dose: R = 375 mg/m2 on day 1, G = 1,250 mg/M2 on day 2, O = 100 mg/m2 on day 2 and Neulasta 6 mg day 3. So far we have entered 21 pts of which 19 are currently evaluable. Median age = 58 (range = 27–88); 9 were refractory to 1st line therapy, 5 were on 1st relapse, 3 on 2nd and 2 >2 relapses, 12 had high LDH, 10 high Beta-2-M. Using IWG/PET criteria ORR = 79%, CR = 42%, PR = 37%. There was a correlation between response to preceding chemo regimen and response to GROC ( table ). In 6 the response to GROC was better than to preceding regimen while only in 2 was the response worse. At 1 year the projected OS is 49% and PFS 34%. So far, only 5 of 15 responders have relapsed. An intriguing finding is that in 6 of 15 responders, PFS has been longer with GROC than with preceding regimen and shorter in only 1. Grade 4 hematologic toxicity occurred only once. No neutropenic fevers seen. Most common toxicity was reversible transaminitis in 13 (grade 1–2 in 10, grade 3 in 3), neuropathy in 9 (grade 1–2 in 8, grade 3 in 1), diarrhea in 3 (grade 4 in 1). We could deliver courses at a median interval of 14 days. Conclusions: 1- GROC is an effective dose dense salvage regimen. 2- It appears effective even in pts with poor prognostic features including primary refractory disease. 3-Hematologic toxicity is very low and non-hematologic toxicity acceptable.

[Table: see text]

[Table: see text]

Comparative cytotoxicity of alkyl gallates on mouse tumor cell lines and isolated rat hepatocytes

Alkyl esters of gallic acid inhibited the respiration rate of mouse sarcoma 786A and mouse mammary adenocarcinoma TA3 cell lines and its multiresistant variant TA3-MTX-R more effectively than gallic acid, both in the absence and in the presence of the uncoupler CCCP. The order of inhibition of the respiration rate by gallates in intact cells was n-octyl- approximately iso-amyl- approximately n-amyl- approximately iso-butyl->n-butyl->iso-propyl->n-propyl-gallate>>gallic acid. Sarcoma 786A was significantly more susceptible to all seven esters than the TA3 cell line. Respiration rates of the TA3-MTX-R cell line showed almost the same sensitivity to these esters as the TA3 cell line. However, hepatocytes were significantly less sensitive than all tumor cells tested. These alkyl gallates blocked mitochondrial electron flow, mainly at the NADH-CoQ segment, preventing ATP synthesis, which would lead to cellular death. These esters also inhibited, in the same order of potencies as respiration, the growth of 786A, TA3 and TA3-MTX-R cells in culture. In mice carrying TA3 or TA3-MTX-R tumor cells, an important decrease of the tumor growth rate and an increase of survival were observed when mice were treated with iso-butyl gallate alone or in combination with doxorubicin. These results indicate that alkyl gallates are selectively cytotoxic to tumor cells, which may be due to the mitochondrial dysfunctions of these cells.

The Rb1 fraction of ginseng elicits a balanced Th1 and Th2 immune response

Porcine parvovirus (PPV) vaccines containing different adjuvants were evaluated for inducing Th1 or Th2 type of immunity in mice. Isotypes of antigen specific antibodies and levels of cytokines in serum and in lymphocyte culture supernatants measured by ELISA and the Gyrolab Bioaffy were used to determine the polarisation of the immune response. Enumeration of cytokine secreting cells was carried out by ELISPOT assays. Vaccines containing the ginseng-fraction Rb1 induced serum-detectable amounts of IL-4 and IL-10 as early as 24h after primary injection that was confirmed in sera collected at 24 and 72 h post re-vaccination. Five weeks after booster, immune lymphocytes were still producing large amounts of cytokines including IFN-gamma, IL-2, IL-4, IL-10 and TNF-alpha and the antibody titres were still similar to those titres recorded 1 week post booster. The Rb1 adjuvanted vaccines stimulated similar titres of antigen specific IgG1, IgG(2a) and IgG(2b). Thus, the cytokine and the serological data indicated that the Rb1 fraction of ginseng elicits a balanced Th1 and Th2 immune response.

Neuronal thread protein regulation and interaction with microtubule-associated proteins in SH-Sy5y neuronal cells

In Alzheimer's disease (AD), neuronal thread protein (NTP) accumulates in cortical neurons and colocalizes with phospho- tau-immunoreactive cytoskeletal lesions that correlate with dementia. To generate additional information about the potential role of NTP in AD, we characterized its expression and regulation in human SH-Sy5y neuronal cells. Quantitative real-time reverse transcription-polymerase chain reactin and Western blot analysis demonstrated prominent insulin, moderate insulin-like growth factor, type 1 (IGF-1) and minimal nerve growth factor stimulation of NTP expression. In addition, NTP protein was more stable and it progressively accumulated in cells that were stimulated with insulin for 24 or 48 h. Metabolic labeling and phospho-amino acid analysis demonstrated phosphorylation of NTP on Serine residues, 30-60 min after insulin or IGF-1 stimulation, when glycogen synthase kinase 3beta (GSK-3beta) activity would no longer have been suppressed. Kinase inhibitor and in vitro phosphorylation studies demonstrated a role for GSK-3beta in the positive regulation of NTP expression and phosphorylation. Coimmunoprecipitation studies demonstrated physical interactions between NTP and tau or microtubule-associated protein 1b (MAP-1b), and ubiquitin immunoreactivity in NTP immunoprecipitates. In summary, these studies showed that (i) NTP expression is regulated at the level of transcription by insulin and IGF-1 stimulation; (ii) NTP is phosphorylated by GSK-3beta; (iii) NTP can physically interact with tau and MAP-1b and (iv) NTP-MAP complexes are ubiquitinated. The results suggest a functional role for NTP in relation to the turnover or processing of neuronal cytoskeletal proteins, attributes that may be modulated by insulin/IGF-1-mediated signaling.

Ginseng and aluminium hydroxide act synergistically as vaccine adjuvants

The dry extract prepared from the Panax ginseng C.A. Meyer-root (total ginseng (T-ginseng)) contain ginsenosides (G-des) which were shown to have adjuvant properties as demonstrated by: (a) injecting guinea pigs with a mixture of T-ginseng and inactivated porcine parvovirus (PPV) as a conventional vaccine; (b)injecting PPV-antigen and T-ginseng simultaneously but separately at different sites on the animal and (c)injecting only the T-ginseng 1 or 2 weeks prior to immunisation with the PPV-antigen. Using a haemagglutination inhibition (HI) test in the antibody titration, it was found that the mean HI-titre for the animals injected with PPV-antigen only was 320 +/- 0. By comparison, the mean titre value was 2026 +/- 1206 for the sera from the animals injected with the same vaccine but adjuvanted with 4 mg of T-ginseng, while the antibody titre induced by a vaccine containing Al(OH)(3)-gel was 2986 +/- 1596. Interestingly, the T-ginseng and Al(OH)(3) acted synergistically and further improved the antibody response to the PPV-antigen to 6826 +/- 2413, i.e. more than 20 times the HI titre of the non-adjuvanted PPV-vaccine. Immunisations using PPV-vaccines adjuvanted with single purified G-des demonstrated that the ginseng fractions Rb1 and Rg1 are potent adjuvants inducing higher or similar antibody titres than the vaccine adjuvanted with Al(OH)(3), e.g. Rb1 tested at a concentration of 830 microg per dose induced a significantly (P = 0.009) higher antibody titre than the one adjuvanted with Al(OH)(3). Nevertheless, different than the mixture Al(OH)(3)-T-ginseng; Rb1 and Rg1 act antagonistically and partially inhibit each other. The G-des adjuvanted vaccines induced significantly (P = 0.0011) higher titres of IgG2 antibodies compared with IgG1.

Pharmacologic plaque passivation for the reduction of recurrent cardiac events in acute coronary syndromes

Acute coronary syndrome (ACS) is often associated with the rupture of vulnerable atherosclerotic plaque, coronary thrombus formation, and abrupt limitation of blood flow, leading to adverse outcomes. Passivation of vulnerable plaque represents a therapeutic concept that has the potential to prevent or limit the magnitude of a new rupture in order to reduce the recurrence or severity of events. Plaque passivation can be defined as a process by which the structure or content of the atherosclerotic plaque is changed to reduce the risk of subsequent rupture and thrombosis. This may be achieved by using strategies that address different components of the plaque or the endothelium. The following factors can affect the susceptibility of plaque to rupture: macrophage infiltration; accumulation of inflammatory cells; paracrine secretion of enzymes that may cause degradation of the fibrous cap of coronary plaque; shear stress; circadian rhythm variation in stress hormone release; and infectious agents. The use of pharmacologic agents to reduce plaque vulnerability by passivation has been explored. Clinical studies demonstrate that lipid-modifying agents (e.g., statins), antiplatelet agents (acetylsalicylic acid, thienopyridines, thianopyridines, glycoprotein IIb/IIIa inhibitors), and antithrombotic agents (unfractionated heparin and low-molecular-weight heparin) can reduce the occurrence of acute coronary events in ACS patients. In addition, angiographic studies suggest that statins may also promote regression of atherosclerosis. Angiotensin-converting enzyme inhibitors, niacin, and calcium antagonists may also contribute to plaque passivation. This article reviews atherosclerotic plaque development and vulnerability and discusses some clinical studies highlighting the role of plaque passivation in the management of ACS patients.