Drug Monographs: Ixazomib and Necitumumab.

The complexity of cancer chemotherapy requires pharmacists be familiar with the complicated regimens and highly toxic agents used. This column reviews various issues related to preparation, dispensing, and administration of antineoplastic therapy, and the agents, both commercially available and investigational, used to treat malignant diseases. Questions or suggestions for topics should be addressed to Dominic A. Solimando, Jr, President, Oncology Pharmacy Services, Inc., 4201 Wilson Blvd #110-545, Arlington, VA 22203, e-mail: OncRxSvc@comcast.net; or J. Aubrey Waddell, Professor, University of Tennessee College of Pharmacy; Oncology Pharmacist, Pharmacy Department, Blount Memorial Hospital, 907 E. Lamar Alexander Parkway, Maryville, TN 37804, e-mail: waddfour@charter.net.

Male contraception: another Holy Grail.

The idea that men should participate in family planning by playing an active role in contraception has become more acceptable in recent years. Up to the present the condom and vasectomy have been the main methods of male contraception. There have been and continue to be efforts to develop an acceptable hormonal contraceptive involving testosterone (T) suppression. However the off target affects, delivery of the analogs and the need for T replacement have proven difficult obstacles to this technology. Research into the development of non-hormonal contraception for men is progressing in several laboratories and this will be the subject of the present review. A number of promising targets for the male pill are being investigated. These involve disruption of spermatogenesis by compromising the integrity of the germinal epithelium, interfering with sperm production at the level of meiosis, attacking specific sperm proteins to disrupt fertilizing ability, or interfering with the assembly of seminal fluid components required by ejaculated sperm for acquisition of motility. Blocking contractility of the vas deferens smooth muscle vasculature to prevent ejaculation is a unique approach that prevents sperm from reaching the egg. We shall note the lack of interest by big pharma with most of the support for male contraception provided by the NIH.

The Equivalence of Remote Electronic and Paper Patient Reported Outcome (PRO) Collection.

Individual patient level Patient Reported Outcomes (PROs) are increasingly important in clinical practice. Web-based collection enables clinicians to remotely collect scores at regular intervals, away from the clinic setting. In this randomized crossover study, 47 patients, having undergone hip surgery, were allocated to two groups. Group 1 completed the web-based scores followed by the paper equivalents one week later; Group 2 completed the scores the other way around. The Intraclass Correlation Coefficient (ICC) for the Oxford Hip Score was 0.99, 0.98 to 0.99 (ICC, 95% CI) and the ICCs for the other scores were between 0.95 and 0.97. We conclude that remote ePRO collection using this web-based system reveals excellent equivalence to paper PRO collection of the Oxford Hip, McCarthy, UCLA and howRu scores.

Endogenous and Therapeutic Estrogens: Maestro Conductors of the Microenvironment of ER+ Breast Cancers.

Estrogen receptor alpha (ERα) marks heterogeneous breast cancers which display a repertoire of somatic genomic mutations and an immune environment that differs from other breast cancer subtypes. These cancers also exhibit distinct biological behaviors; despite an overall better prognosis than HER2+ or triple negative breast cancers, disseminated dormant cells can lead to disease recurrence decades after the initial diagnosis and treatment. Estrogen is the best studied driver of these cancers, and antagonism or reduction of estrogen activity is the cornerstone of therapeutic approaches. In addition to reducing proliferation of ERα+ cancer cells, these treatments also alter signals to multiple other target cells in the environment, including immune cell subpopulations, cancer-associated fibroblasts, and endothelial cells via several distinct estrogen receptors. In this review, we update progress in our understanding of the stromal cells populating the microenvironments of primary and metastatic ER+ tumors, the effects of estrogen on tumor and stromal cells to modulate immune activity and the extracellular matrix, and net outcomes in experimental and clinical studies. We highlight new approaches that will illuminate the unique biology of these cancers, provide the foundation for developing new treatment and prevention strategies, and reduce mortality of this disease.

Femoroacetabular impingement and classification of the cam deformity: the reference interval in normal hips.

BACKGROUND AND PURPOSE: Most patients with femoroacetabular impingement (FAI) have a cam deformity, which may be quantified by measuring the alpha angle and anterior offset ratio (AOR). Knowledge of what constitutes a "normal" alpha angle and AOR is limited. We defined the reference intervals of these measurements from normal hips in the general population. PATIENTS AND METHODS: 157 individuals from the general population were reviewed clinically and radiographically. 74 individuals with clinical evidence of hip disease or radiographic evidence of osteoarthritis (OA) were excluded, leaving a study group of 83 individuals (mean age 46 (22-69) years, 44 females) with normal hips. The alpha angles and AORs were measured from cross-table lateral radiographs taken in 15 degrees internal rotation. A validation study consisting of a cadaver study and a measurement reliability study was also performed. RESULTS: The mean alpha angle was 48 degrees in men and 47 degrees in women. The mean AOR was 0.19, the same in men and women. Thus, sexes were combined to derive 95% confidence intervals for the population mean alpha angle (46-49 degrees ) and AOR (0.18-0.20). The 95% reference interval for the alpha angle was 32-62 degrees degrees, and for the AOR it was 0.14-0.24. The validation study confirmed that these measurements were resistant to a reasonable degree of variation in positioning and that the repeatability and reproducibility of the measurements was good. INTERPRETATION: These reference intervals indicate that clinically and radiographically normal hips may have alpha angles and AORs that have previously been considered "abnormal". The thresholds provided by this study will aid classification of individuals involved in longitudinal studies of FAI and OA, and may be of use to the practicing clinician in evaluating the young adult with hip pain.

Chromatin context dominates estrogen regulation of pS2 gene expression.

Chromatin structure and transcription factor activity collaborate to set the transcription level of a gene. Our understanding of the relative contributions of each of these factors at a specific gene is limited. We studied the effects of an altered chromatin environment on the activity of the estrogen-responsive pS2 promoter. We created stable cell lines with the pS2 promoter situated in an alternative chromatin site in addition to it being in its native site. Both promoters were estrogen-responsive for estrogen receptor alpha (ERalpha) recruitment, but transcription was inducible only at the native site. At the recombinant site, transcription was high and constitutive. Higher histone H3 and H4 acetylation (acH3 and acH4), as well as trimethylated lysine 4 on histone H3 levels, was observed at the recombinant site compared to the native site in vehicle treated cells. Inhibition of histone deacetylases (HDACs) resulted in increased acH4, but only modest increases in acH3, ERalpha binding and basal transcription at the native pS2 site. Inhibiting HDACs had no effect on transcription from the recombinant site. These data suggest that highly active chromatin is not only permissive for transcription, but can override the requirement for the transcription factor at an inducible promoter.

High histone acetylation and decreased polycomb repressive complex 2 member levels regulate gene specific transcriptional changes during early embryonic stem cell differentiation induced by retinoic acid.

Histone modifications play a crucial role during embryonic stem (ES) cell differentiation. During differentiation, binding of polycomb repressive complex 2 (PRC2), which mediates trimethylation of lysine 27 on histone H3 (K27me3), is lost on developmental genes that are transcriptionally induced. We observed a global decrease in K27me3 in as little as 3 days after differentiation of mouse ES cells induced by retinoic acid (RA) treatment. The global levels of the histone K27 methyltransferase EZH2 also decreased with RA treatment. A loss of EZH2 binding and K27me3 was observed locally on PRC2 target genes induced after 3 days of RA, including Nestin. In contrast, direct RA-responsive genes that are rapidly induced, such as Hoxa1, showed a loss of EZH2 binding and K27me3 after only a few hours of RA treatment. Following differentiation induced by leukemia inhibitor factor (LIF) withdrawal without RA, Hoxa1 was not transcriptionally activated. Small interfering RNA-mediated knockdown of EZH2 resulted in loss of K27me3 during LIF withdrawal, but the Hoxa1 gene remained transcriptionally silent after loss of this repressive mark. Induction of histone hyperacetylation overrode the repressive K27me3 modification and resulted in Hoxa1 gene expression. Together, these data show that there are multiple temporal phases of derepression of PRC2 target genes during ES cell differentiation and that other epigenetic marks (specifically, increased acetylation of histones H3 and H4), in addition to derepression, are important for gene-specific transcriptional activation. This report demonstrates the temporal interplay of various epigenetic changes in regulating gene expression during early ES cell differentiation.

Skimboarding: a new danger in the surf?

Skimboarding is an increasingly popular activity on the beach. Over a six week period we saw 10 patients with fractures or dislocations, half of whom required operative intervention. The majority (80%) were of the lower limb, some of which were severe.

Comparison of nutrient intakes from two selected diet plans considered healthful versus the cutoff points for green lights as defined by the UK's multiple traffic light scheme.

This study compared nutrient intakes from 7-day menus for the US MyPlate and DASH Eating Plan versus the cutoff points for green lights defined by the UK's multiple traffic light (MTL) scheme. For both diets, the foods achieved green lights for saturated fat and salt, and for beverages for total fat, saturated fat and salt. The other nutrients achieved amber lights but were within the range of the two diets. By contrast, the MTL threshold for salt in beverages was outside the range of the diets. The values for salt in beverages in the MyPlate and Dash diet plans were 0.06±0.07 and 0.19±0.01 (s.d.) g/100 ml, which are both considerably lower compared with the cutoff of 0.3 g/100 ml for an MTL green light. Adjusting the green MTL threshold values to the median values for a healthful diet could help make MTL labelling a more valid way of helping consumers choose a healthful diet.

Transcription factor accessibility and histone acetylation of the progesterone receptor gene differs between parental MCF-7 cells and a subline that has lost progesterone receptor expression.

The human progesterone receptor (PgR) gene has a complex promoter that produces alternate mRNAs encoding the PgRA (94 kDa) and PgRB (120 kDa) protein isoforms. Expression of PgR is induced by estradiol (E(2)) in the breast, reproductive tract and many cell lines despite the lack of a classical estrogen responsive element (ERE) in the promoter regions. We employed chromatin immunoprecipitation (ChIP) to analyze the sites of estrogen receptor alpha (ERalpha) and Sp1 occupancy of the PgR promoters in vivo. We also assessed the functional relevance of histone acetylation levels on the accessibility of transcription factors to the promoter and subsequent hormone-induced transcription. We utilized MCF-7 human breast cancer cells that express PgR in response to E(2) and the MCF-7 derived C4 cell strain that has lost PgR expression as a model system. We found that promoter-wide levels of histone acetylation were not decreased in C4 cells, but that access was partially blocked for Sp1 and completely blocked for ERalpha. The basal level of histone acetylation at six localized regions of the promoter did show some differences between cell lines, but it did not correlate with transcription factor binding. Furthermore, we found only a modest and highly localized change in histone acetylation levels in response to E(2) at only one of three sites of ERalpha binding in MCF-7 cells. This was at the B1 site at the distal 5' end of the promoter. This site also showed a significant decrease in basal histone acetylation in C4 compared to MCF-7 cells. We speculate that the histone acetylation level at this site may be a marker for chromatin structure that affects the access of transcription factors to the whole promoter.

Osteoporotic fractures: an unusual presentation of haemochromatosis.

The association of haemochromatosis and osteoporosis is well established, but it is unclear whether this is due to iron overload, hypogonadism, liver disease, or diabetes mellitus. We describe a young eugonadal male patient with osteoporotic fractures as a presenting feature of haemochromatosis, suggesting that factors other than hypogonadism contribute to osteoporosis.

Effect of oral contraceptives on plasma androgenic steroids and their precursors.

Plasma dehydroepiandrosterone (DHEA), its sulfate ester (DHEAS), and androstenedione (A2), delta5-pregnenolone (delta5-P), and 17 alpha-hydroxypregnenolone were measured in women using estrogen-containing oral contraceptives and in female controls of similar age. All three androgenic steroids and their two C21 precursors were reduced in the oral contraceptive users compared with the controls. It is concluded that oral contraceptives cause a decrease in plasma DHEA, DHEAS, and A2, one possible mechanism for which is the inhibition of delta5-P synthesis from cholesterol.

PIP: An attempt to confirm the effect of oral contraceptives (OCs) on the plasma dehydroepiandrosterone sulfate (DHEAS) and to explore the biochemical site of their action is presented. 89 women taking estrogen-containing OCs for 6 months or longer and 47 controls were studied. Both groups were of similar age, and with regular menstrual cycles. OCs used were Ovral (ethinyl estradiol, 50 mcg, norgestrel, .05 mg), Demulen 50 (ethinyl estradiol, 50 mcg; ethynodiol diacetate, 1 mg), and Ortho-Novum 1/50 (mestranol, 50 mcg; norethindrone, 1 mg). A single sample of plasma was made from the heparinized blood taken between 7-8 a.m. between Days 15-21 of a contraceptive treatment cycle in the experimental group and between Days 15-21 of a menstrual cycle in the control group. The results of the plasma DHEAS, DHEA, and androstenedione assays showed that all 3 OC preparations caused reductions in the androgenic steroids when compared with the controls. Results of statistical comparisons between the different OCs did not indicate if ethinyl estradiol or mestranol exerted a greater effect. Concentrations of delta-5-P and 17-delta-5-P were found to be lower in the experimental cases than in the controls. It is concluded that OCs cause a decrease in plasma DHEA, DHEAS, and androstenedione, with 1 possible mechanism being the inhibition of delta-5-P synthesis from cholesterol.

Protein absorption and energy digestibility at high altitude.

To test the hypothesis that malabsorption of dietary protein is partly responsible for the weight loss observed during prolonged altitude exposure, six healthy male subjects [31.8 +/- 4.5 (SD) yr] received 15N-labeled soya protein by mouth and [15N]glycine intravenously at 122 and 5,000 m. From the subsequent 4-day total urine and fecal pools, the different fractions of the administered 15N were determined by mass spectrometry. Weight and skinfold thickness were measured at the beginning and end of the altitude exposure. In addition, the overall digestible energy of the diet at altitude was assessed by a 3-day diet control and adiabatic bomb calorimetric assessment of the energy content of the corresponding fecal pool. The average decrease of the subjects' weight during altitude exposure was 3%. Loss of fat mass at altitude estimated from the skinfold measurements was 9%. Protein absorption, calculated as 100--[fecal excretion of 15N after ingestion of 15N soya protein (% of dose given)--fecal excretion of 15N after injection of 15N glycine (% of dose given)], was not significantly impaired at altitude compared with sea level (96 vs. 97%, respectively), and overall digestible energy at altitude, calculated as 100--percent undigested gross energy in the feces, amounted to 96%. It is concluded that, at least up to an altitude of 5,000 m, malabsorption does not play a role in altitude-related weight loss.

Increased severity of malaria infection in rats fed supplementary amino acids.

Infection with Plasmodium berghei malaria is severely inhibited in rats fed on a low protein diet. A range of amino acid supplements was added to a 4.2% casein diet to determine whether the relationship between level of infection and protein content could be attributed to the dietary amounts of the essential amino acids. Significant increases in levels of infection were achieved by supplementation with specific combinations of amino acids. Threonine was most effective in increasing the degree of parasitaemia but its effect was further enhanced when it was combined with dietary excess of certain other amino acids, notably valine, isoleucine and methionine.

Resistance to superinfection with Plasmodium berghei in rats fed a protein-free diet.

The development of resistance to reinfection with Plasmodium berghei was studied in rats in which the primary infection had been almost totally suppressed by feeding a protein-free diet (peak parasitaemia 0.5%; patent for only the first four days after inoculation) On Days 5, 9, 15, 23 and 28 after primary inoculation groups of animals were challenged with the same strain of parasite. At the same time the diet was changed to that of a 17% casein formula. The development of resistance as judged by the level of parasitaemia following challenge reached a significant level nine days after the primary inoculation and almost complete protection by Day 23 of the study. The protective activity was immunological since it could be transferred to other animals by a single intravenous injection of a suspension of spleen cells from infected donors. The study illustrates that infected animals experiencing severe protein malnutrition are still capable of mounting a substantial immune response to malaria.

Extending intramedullary rods in congenital pseudarthrosis of the tibia.

Five patients with Boyd type II congenital pseudarthrosis of the tibia underwent excision of the pseudarthrosis and double onlay bone grafting. Stability was maintained by extending intramedullary rods. Clinical union was achieved in all cases at a mean of 8.6 months (range six to 11). The rods extended by 15.7% (range 2% to 31.4%) as growth occurred. One rod was removed because of infection and a vascularised free fibular graft was subsequently performed. The extending rods provided stability while union occurred and did not require revision as the legs grew. The rods can be removed easily and have not jeopardized further surgical options.

Curved Kuntscher nail arthrodesis after failure of knee replacement.

We report the use of long curved Kuntscher nails to maintain stability during arthrodesis of nine infected and five uninfected failures of total knee replacement. The curvature of the nail helps positioning and avoids the need for cortical perforation. A single-stage operation was possible in most cases. Union rates are comparable with those of other series and even patients with delayed union have satisfactory function.

Do warming blankets increase bacterial counts in the operating field in a laminar-flow theatre?

Patient warming systems are used routinely to prevent hypothermia under anaesthesia. Airflow from warming blankets may potentially influence bacterial counts either by pumping 'dirty air' from floor level to the operating area or by blowing the patients' skin cells into the operating field from airflow under the blanket. Using slit-air sampling we analysed the air quality within a laminar-flow theatre at a simulated operating site. We assessed the effect of 'high shedding of skin' under the blanket using volunteer patients with psoriasis. We also simulated general theatre activity outside the laminar-flow area in order to determine whether the bacterial counts in the operating field were affected. No colonies were grown in any of the groups tested and our results suggest that the patient warming system does not influence bacterial counts at the operating site in an ultraclean air-ventilated theatre, even with patients who have high shedding of skin cells.

Anterior knee pain in rheumatoid patients after total knee replacement. Possible selection criteria for patellar resurfacing.

Postoperative anterior knee pain was evaluated in a consecutive series of 138 knees in 108 patients with rheumatoid arthritis treated by total knee replacement with Mark I Insall-Burstein prostheses. No knee had primary patellar resurfacing, and in the 119 knees followed up for a mean of 63.9 months, none had secondary resurfacing. Anterior knee pain was absent in 87 knees (73%), mild in 16 (13.5%) and moderate or severe in 16 (13.5%). The height of the patella above the prosthetic joint line was the only variable which was directly related to the incidence of anterior knee pain. The sensitivity and specificity of patellar height measurements for identifying patients with or without pain were derived. From these data, a selective policy of resurfacing the patella in those at risk was adopted. Choosing a patellar height of 15 mm or less, patellar resurfacing could be avoided in 80% of patients likely to have no pain, and the patella could be resurfaced in 65% of those likely to have anterior knee pain.

Genetic influences in the aetiology of femoroacetabular impingement: a sibling study.

Femoroacetabular impingement causes pain in the hip in young adults and may predispose to the development of osteoarthritis. Genetic factors are important in the aetiology of osteoarthritis of the hip and may have a role in that of femoroacetabular impingement. We compared 96 siblings of 64 patients treated for primary impingement with a spouse control group of 77 individuals. All the subjects were screened clinically and radiologically using a standardised protocol for the presence of cam and pincer deformities and osteoarthritis. The siblings of those patients with a cam deformity had a relative risk of 2.8 of having the same deformity (66 of 160 siblings hips versus 23 of 154 control hips, p < 0.00001). The siblings of those patients with a pincer deformity had a relative risk of 2.0 of having the same deformity (43 of 116 sibling hips versus 29 of 154 control hips, p = 0.001). Bilateral deformity occurred more often in the siblings (42 of 96 siblings versus 13 of 77 control subjects, relative risk 2.6, p = 0.0002). The prevalence of clinical features in those hips with abnormal morphology was also greater in the sibling group compared with the control group (41 of 109 sibling hips versus 7 of 46 control hips, relative risk 2.5, p = 0.007). In 11 sibling hips there was grade-2 osteoarthritis according to Kellgren and Lawrence versus none in the control group (p = 0.002). Genetic influences are important in the aetiology of primary femoroacetabular impingement. This risk appears to be manifested through not only abnormal joint morphology, but also through other factors which may modulate progression of the disease.