Real-world evidence analysis of palbociclib prescribing patterns for patients with advanced/metastatic breast cancer treated in community oncology practice in the USA one year post approval.

BACKGROUND: Rapidly evolving understanding of cancer biology has presented novel opportunities to translate that understanding into clinically relevant therapy. Palbociclib, a novel, first-in-class cyclin-dependent kinase (CDK) 4/6 inhibitor was approved in the USA in February 2015 for the treatment of advanced/metastatic breast cancer. We examined real-world evidence in the first year post approval to understand the clinical and demographic characteristics of patients treated with palbociclib in community oncology practices and the dosing, treatment, and complete blood count (CBC) monitoring patterns. METHODS: This was a retrospective observational study of structured data from a US electronic medical record (EMR) database. Female patients receiving palbociclib after 31 January 2015 were followed through 31 March 2016. Our methodological rules were constructed to aggregate drugs received according to the order in which they are given, i.e., identify the line of therapy as first, second, or third line, etc., using treatment order and course description fields from the EMR. RESULTS: There were 763 patients initiating palbociclib who met the selection criteria. Of those, 612 (80.2%) received palbociclib concomitantly with letrozole. Mean follow up was 6.4 months and mean age at palbociclib initiation was 64 years. Of patients with a known starting dose (n = 417), 79.9% started on palbociclib 125 mg. Dose reductions were observed in 20.1% of patients. Percentages of patients according to line of therapy at initiation of palbociclib were first-line, 39.5%; second-line, 15.7%; third-line, 13.1%; and fourth-line therapy or later, 31.7%. On average, two CBC tests were conducted during the first cycle of palbociclib treatment. Overall, 74.6% of patients had a neutropenic event during follow up including 47.3% and 8.0% of patients with a grade 3 or 4 occurrence, respectively. CONCLUSIONS: Real-world palbociclib use one year post US approval demonstrates a more heterogeneous patient population than that studied in the clinical trials with more than half of the patients receiving palbociclib plus letrozole in later lines of therapy. CBC testing rates suggested good provider compliance with monitoring guidelines in the USA prescribing information. The occurrence of grade 3 and 4 neutropenia (based on laboratory results) was consistent with the rates of grade 3 and 4 neutropenia in two phase-III studies (PALOMA-2, 56% and 10%; PALOMA-3, 55% and 11%, respectively). Understanding palbociclib utilization in real-world patients and how drug dosing and monitoring are performed aids in the understanding of safe and effective use of the drug.

Thrombotic microangiopathies of pregnancy: Differential diagnosis.

Thrombotic microangiopathy (TMA) disorders are characterized by microangiopathic hemolytic anemia, thrombocytopenia and end-organ injury. In pregnancy and postpartum, TMA is most commonly encountered with HELLP (hemolysis, elevated liver enzymes, low platelet count syndrome) or preeclampsia with severe features, but rarely TMA is due to thrombotic thrombocytopenic purpura (TTP) or atypical hemolytic uremic syndrome (aHUS). Due to overlapping clinical and laboratory features, TTP and aHUS are often mistaken for preeclampsia or HELLP. Unfortunately, delays in appropriate diagnosis and treatment may be life-threatening. Our objective is to alert obstetrician-gynecologists, certified nurse midwives, family medicine providers, and subspecialty consultants, to the range of TMA disorders that may occur in and around pregnancy. To do this, we have provided a review of individual disorders that comprise the differential diagnosis of pregnancy TMA, and we have proposed a systematic approach to make an accurate diagnosis with readily available clinical and laboratory data. In complex or critical cases, we recommend a multidisciplinary team approach (e.g., Critical Care, Hematology, Maternal Fetal Medicine, Nephrology) to expedite diagnosis and treatment, which may be life-saving.

Methionine-80-sulfoxide cytochrome c: preparation, purification and electron-transfer capabilities.

In order to explore the electron-transferring properties of methionine-80-sulfoxide cytochrome c, the pure, chromatographically homogeneous methionine-80-sulfoxide cytochrome c was previously published procedure (Ivanetich, K.M., Bradshaw, J.J. and Kaminsky, L.S. (1976) Biochemistry 15, 1144-1153) was found to produce a mixture of products. In the pure derivative, visible spectroscopy indicates that the 695 nm band indicative of the Met-80-Fe coordination is missing, amino acid analysis indicates that only one methionine is modified to the sulfoxide, and the E0' is found to be 240 mV vs. N.H.E. For succinate cytochrome c reductase activity, the Km for modified cytochrome was about one-ninth that of the native protein, while the maximum turnover number of the reductase with the modified protein was only about 54% of that with native protein. In contrast, the activity with cytochrome oxidase measured polarographically using ascorbate and TMPD under two different buffer/pH conditions, gave Km values that were very similar for both the native and modified cytochromes c, but the maximum turnover numbers of the oxidase with the modified protein were less than 40% of native in either buffer. It is concluded that the Met-80-sulfoxide cytochrome c in the reduced form is able to maintain substantially its heme crevice structure and thus maintain Km values similar to those of native protein. However, the low maximum turnover numbers for oxidase activity with the modified protein in the reduced state indicate that electron transfer itself has been significantly decreased, probably because the parity of acid/base and electrostatic interactions of Met-80 sulfur with the Fe in the two redox states has been disrupted.

The role of histidine-42 in the oxidation-reduction mechanism of Chromatium vinosum high potential iron-sulfur protein.

The second order rate constants for the oxidation of high potential iron-sulfur protein (Hipip) of Chromatium vinosum by ferricyanide were determined as a function of ionic strength and pH. From the ionic strength results, calculations were done to correct the rate constant at each pH for the electrostatic interactions between Hipip and ferricyanide. The electrostatic corrections are necessary since the charge of the protein changes as a function of pH and can mask the ionization of mechanistically important amino acid residues. An apparent pKa congruent to 7 was obtained from electrostatically corrected rate-pH profile, indicating the possible participation of histidine. Perturbation difference spectroscopic studies of Hipip as a function of pH also gave apparent pKa values of 6.9 and 6.7 for the reduced and oxidized protein, respectively. That it was indeed His 42 (the only His in the polypeptide) that was responsible for the kinetic and spectroscopic pKa values was demonstrated by modification of His 42 of Hipip by the histidine selective reagent diethylpyrocarbonate. No modification of Tyr 19 could be detected. It is concluded that either deprotonation or modification of His 42 results in the destabilization of the reduced cluster and thus a faster rate of oxidation. This work provides the first experimental evidence of the 'squeeze effect' mechanism (Carter, C.W., Jr., Kraut, J., Freer, S.T. and Alden, R.A. (1974) J. Biol. Chem. 249, 6339--6346) in which the polypeptide directly modulates the stability of the iron-sulfur cluster.

Cyanide reactivity of cytochrome c derivatives.

The kinetic rates and equilibrium association constants for cyanide binding have been measured for a series of cytochrome c derivatives as a probe of heme accessibility. The series included horse and yeast cytochromes iodinated at Tyr 67 and 74, horse cytochrome formylated at Trp 59 in both a low and high redox potential form, the Met 80 sulfoxide derivative of horse cytochrome and the N-acylisourea heme propionate derivative of tuna cytochrome. Native cytochromes c are well known to bind cyanide slowly in a reaction simply first order both in cytochrome and cyanide up to at least 100 mM in cyanide. The derivative demonstrate markedly different kinetics which indicate the following conclusions. (1) In spite of chemical modification at different loci, all the derivatives have highly similar reactivity, suggesting common ligation structures and mechanisms for reaction. (2) Compared to native cytochromes, reaction rates are 10-20 fold greater. This is in accord with a more accessible heme crevice, but not a completely opened crevice. For the completely opened case, rate increases are expected to be between three and five orders of magnitude. (3) Reaction rates are either independent of cyanide concentration (zero order) or show only slight variation. A mechanism which accounts for the data over four orders of magnitude in concentration postulates a protein conformation step, opening of the heme crevice, as the rate determining step. This conformation change has a limiting rate of 6 . 10(-2) s-1.

Partitioning of electrostatic and conformational contributions in the redox reactions of modified cytochromes c.

The reduction of acetylated, fully succinylated and dicarboxymethyl horse cytochromes c by the radicals CH3CH(OH), CO2.-, O2.-, and e-aq' and the oxidation of the reduced cytochrome c derivatives by Fe(CN)3-6 were studied using the pulse radiolysis technique. Many of the reactions were also examined as a function of ionic strength. By obtaining rate constants for the reactions of differently charged small molecules redox agents with the differently charged cytochrome c derivatives at both zero ionic strength and infinite ionic strength, electrostatic and conformational contributions to the electron transfer mechanism were effectively partioned from each other in some cases. In regard to cytochrome c electron transfer mechanism, the results, especially those for which conformational influences predominate, are supportive of the electron being transferred in the heme edge region.

A phase I trial of intravenously-administered recombinant tumor necrosis factor-alpha in cancer patients.

We report a phase I clinical investigation of 30-minute and four-hour intravenous (IV) infusions of recombinant tumor necrosis factor (rTNF)-alpha. Thirty-nine patients with disseminated cancer received escalating doses of rTNF-alpha for five consecutive days every 2 weeks for a total duration of 8 weeks. Dose escalations followed a modified Fibonacci scale with a minimum of four patients entered at each dose level: 5, 10, 25, 50, 75, 100, 150, 200, and 250 micrograms/m2/d. Toxicities consisted mainly of constitutional symptoms including fever, chills, headache, and fatigue, increasing in severity with dose escalation. No significant differences in dose-limiting toxicities were seen between the two rates of IV infusion. The maximum tolerated dose (MTD) was 200 micrograms/m2 with dose limiting toxicity being constitutional symptoms and hypotension. Hematologic changes included median decrease in both granulocyte and platelet counts of 38% and 41%, respectively (range, 16% to 85%), although clinically significant granulocytopenia and thrombocytopenia were not observed. Hematological parameters returned to baseline within 72 hours after rTNF-alpha was stopped. rTNF-alpha induced changes in lipid metabolism were manifested by median fasting triglyceride elevations above baseline (median, 103 micrograms/dL) of 157% (range, 16% to 389%) after five days of therapy with doses greater than 75 micrograms/m2, associated with a median increase in very-low-density lipoprotein (VLDL) of 80%. Serum rTNF peak levels exceeding 10 ng/mL were observed 30 minutes following rTNF-alpha infusions at MTD dose. Twelve of 34 patients had no change in their evaluable disease for a median duration of 18 weeks (range, 8 to 30 weeks), and 22 patients showed progressive disease. This study forms the framework for phase II trials of IV administered rTNF-alpha.

Cytokine regulation of trophoblast steroidogenesis.

Activated monocytes and lymphocytes secrete cytokines that act as autocrine and paracrine mediators to promote and regulate local immune processes. These cell types are abundant at the maternal-fetal interface, and cytokines may play a role in pregnancy maintenance or failure. The purpose of this study was to determine the effects of selected monocyte- and lymphocyte-derived cytokines on trophoblast progesterone and estradiol production. JEG-3 choriocarcinoma cells were cultured in supplemented medium alone or in various concentrations of selected recombinant monocyte or lymphocyte cytokines. The cytokines were evaluated both individually and in combination. After 48 h of incubation, the culture supernatant was aspirated and stored at -20 C. Samples were then analyzed for steroid concentration by specific RIAs. Specific interleukin-1 (IL-1)-and tumor necrosis factor (TNF)-neutralizing antibodies were evaluated for their ability to abrogate the cytokine's observed stimulatory effect. To evaluate the physiological relevance of the progesterone-stimulating effect observed with monocyte-derived cytokines, JEG-3 cells were incubated with activated monocyte supernatant or directly cocultured with activated monocytes, and supernatants from these cultures were analyzed for progesterone levels. The monocyte cytokines [IL-1 alpha (5 U/mL), IL-1 beta (5 U/mL), and TNF alpha (1000 U/mL) significantly stimulated trophoblast progesterone production (nanograms per mL): JEG-3 control, 4.1 +/- 0.5; IL-1 alpha, 7.8 +/- 0.9; IL-1 beta, 8.8 +/- 0.5; and TNF alpha 7.2 +/- 0.8 (P < 0.05). Neither the monocyte nor the lymphocyte cytokines altered trophoblast estradiol production. Activated monocyte supernatant and direct JEG-3-monocyte cocultures also significantly stimulated trophoblast progesterone production in vitro. The stimulatory effect of the monocyte-derived cytokines was specific, as demonstrated by neutralization assay. The increased trophoblast progesterone production was not due to enhanced cellular proliferation, but to enhance cellular steroidogenesis, as measured by quantitative DNA analysis. The lymphocyte cytokines (IL-2, interferon-gamma, and granulocyte-macrophage colony-stimulating factor had no effect on trophoblast progesterone production. We conclude that monocyte IL-1 alpha, IL-1 beta, and TNF alpha may regulate trophoblast progesterone production through paracrine effects. Monocyte-trophoblast interactions may be significant in normal pregnancy as well as pregnancy disorders.

A competitive solid-phase radioimmunoassay for translational factors employing monoclonal antibodies.

Monoclonal antibodies produced by the hybridoma techniques were purified by chromatography on DEAE Affi-Gel blue, and covalently coupled to Affi-Gel 10 to purify their antigens. The purified components were used to develop a sensitive competitive radioimmune assay for the quantitative determination of translational factors, as described here with a monoclonal antibody directed against yeast elongation factor 3. Antigen was adsorbed to polyvinyl chloride plastic surfaces and a limiting concentration of monoclonal antibody necessary to bind to the adsorbed antigen was determined. Varying concentrations of purified antigen and of samples containing unknown amounts of antigen were then mixed with the limiting concentration of monoclonal antibody, prior to or at the same time as the reaction of the antibody with the surface-adsorbed antigen. The amount of monoclonal antibody that bound to the surface-adsorbed antigen was determined with a second antibody, radioactive goat anti-mouse antibody. The addition of the free antigen preparations to the monoclonal antibody served to compete for the antibody with the antigen adsorbed to the plastic surfaces. The concentration of antigen in the unknown samples was estimated from the titration curves obtained with varying concentrations of pure antigen. This technique did not require isotopic labeling, modification or derivatization of the monoclonal antibody or its antigen.

Progesterone and estradiol suppress human mononuclear cell cytotoxicity.

Fetal trophoblast is generally resistant to lysis by cytotoxic cells. We hypothesized that progesterone and estrogens secreted by the trophoblast act at the choriodecidual interface where they are present in high concentrations to provide a local, paracrine immunosuppressive effect on cellular cytotoxicity. Using peripheral blood mononuclear cells as effector cells in a cytotoxicity assay, we evaluated the effects of progesterone, estrone, estradiol and estriol, either alone or in combination, on cellular cytotoxicity. Both progesterone and estradiol suppressed cytotoxicity in a dose-dependent manner. Estrone, estriol, pregnenolone and cholesterol had no effect. A synergistic suppression of cytotoxicity was observed when estrone, estradiol, estriol and progesterone were combined. We speculate that trophoblast production of progesterone and estradiol may be an important local immunosuppressive mechanism contributing to fetal survival.

Immunomodulation of cellular cytotoxicity to herpes simplex virus infection in pregnancy by inhibition of eicosanoid metabolism.

In an effort to evaluate the relationships among pregnancy, cellular cytotoxicity and herpes simplex virus (HSV) infection, we conducted a series of experiments investigating: (1) the maternal cellular cytotoxic response to HSV infection as compared with non-pregnant hosts, (2) the influence of both cyclooxygenase and lipoxygenase products on cytotoxicity by selective inhibition of their metabolic pathways, and (3) the potential pregnancy-related differences in immune response to selective inhibition of eicosanoid metabolism. Indomethacin was used for cyclooxygenase blockade and nordihydroguaiaretic acid was used to evaluate lipoxygenase inhibition. In the non-infected animals no differences in cytotoxicity were observed between pregnant (1.5% +/- 0.7%) and non-pregnant (4.6% +/- 2.0%) groups. HSV infection increased cytotoxicity equally in both groups (pregnant: 10.6% +/- 2.0% vs. non-pregnant: 14.2% +/- 3.4%). Indomethacin did not significantly alter cytotoxicity in either the pregnant or the non-pregnant groups compared with controls (12.8% +/- 1.8% vs. 10.6% +/- 2.0% and 14.3% +/- 3.9% vs. 14.2% +/- 3.4%, respectively). In contrast, NDGA elicited a significant reduction in the cytotoxic response in both pregnant and non-pregnant hosts (6.2% +/- 1.1% vs. 10.6% +/- 2.0% and 5.7% +/- 1.1% vs. 14.2% +/- 3.4%, respectively). From our study we conclude that: (1) cytotoxicity is maintained at low levels in the absence of HSV infection, (2) HSV infection induces a significant augmentation in host cellular cytotoxicity, (3) pregnant and non-pregnant cytotoxic responses to HSV infection appear comparable, (4) indomethacin does not augment in vitro cytotoxicity to HSV infection and (5) NDGA suppresses cytotoxicity, providing evidence that lipoxygenase metabolites are essential to cytotoxic cell function.

Cervical hydrosonography in pregnancy to assess cervical length by transabdominal ultrasound.

BACKGROUND: Some women's cervices cannot be evaluated because they are obscured by obesity or vertex-presenting fetuses. Measuring cervical length in these cases is difficult or impossible. TECHNIQUE: We hypothesized that the problem of obscured cervices on transabdominal ultrasound could be resolved by introducing sterile water into the vagina, creating a hydroacoustic window between the vaginal lumen and the cervix. Women with unmeasurable cervices on transabdominal ultrasound had repeat studies after introduction of 60 mL of sterile water into their vaginas, and cervical length measurements taken were compared with those made on transvaginal scans. EXPERIENCE: Six pregnant women were studied (four singleton, one twin, and one triplet pregnancy). In all cases, previously unidentifiable cervices were seen adequately. No complications were noted. Statistical analysis (kappa 0.66) suggested good correlation between transabdominal cervical hydrosonography and transvaginal measurements of cervical length. CONCLUSION: Introducing water into the vagina at transabdominal ultrasound can make an obscured cervix visible and measurable.

Molecular interpretation of kinetic-ionic strength effects.

A recent and important approach to investigating electron transfer mechanisms of redox proteins has been through kinetic-ionic strength studies. There is, however, significant controversy as to whether such studies (1) yield information regarding the charge (or location) of the electron transfer site or (2) more simply reflect the influence of net or overall protein charge on the electrostatic interactions. A critical analysis using different theoretical approaches is made of our recent work and of the bulk of the published non-physiological small molecule-protein and protein-protein kinetic ionic strength studies; it is concluded that (1) the approximated Bronsted-Debye-Huckel equation can not be used at all for protein redox reactions, (2) irrespective of the theoretical approaches discussed, such studies do not provide information regarding the charge of the electron transfer site, (3) it is the net charge of the reactants that control the electrostatic interactions, (4) both the equation derived by Wherland and Gray and the full Bronsted-Debye-Huckel equation provide reasonably good approximations of net protein charge, (5) pH changes quantitatively modulate net protein charge, and (6) thus, protein redox rates need to be electrostatically corrected if relevant interpretations of kinetic-ionic strength experiments are to be made.

Complications of organic solvents in synthetic drug application.

Aziridinylbenzoquinone (AZQ), Acridinyl Anisidide (m-AMSA), Tenipsode Thenvlidene-Lignan-(VM-26), and PCNU are relatively new synthetic drugs believed to have a wide spectrum of antitumor activity. Preparation of these drugs for administration requires reconstitution with an organic solvent which decomposes the thermoplastic components of I.V. infusion devices and chemo-dispensing pins. The products of this decomposition may lead to cellular damage and complicate the infusion of these agents.

Using entropies of reaction to predict changes in protein stability: tyrosine-67-phenylalanine variants of rat cytochrome c and yeast Iso-1 cytochromes c.

Using the voltammetric method of square-wave voltammetry, a direct electrochemical examination was made of the wild type and Tyr67Phe mutant of both rat cytochrome c and yeast iso-1-cytochrome c. In addition to determining the equilibrium reduction potential (E0') for each cytochrome, the entropy of reaction, deltaS0'(Rxn)(deltaS0'(Rxn) = S0'(Red) - S0'(Ox)), for the reduction process was determined via the non-isothermal method. Having determined deltaS0'(Rxn) and E0', deltaH0' was calculated. For rat cytochrome c, it was found that deltaS0'(Rxn) = -43 J mol(-1) K(-1) for the wild type and -53 J mol(-1) K(-1) for the Tyr67Phe variant, with the deltaH0' for both the wild type and variant nearly identical, indicating that the changes in reduction potential and probably stability are due to changes in deltaS0'(Rxn). In contrast the measured deltaS0'(Rxn) for yeast iso-1-cytochrome c demonstrated significant changes in both entropic and enthalpic contributions in going from wild type to mutant cytochrome c. The entropy of reaction provides information regarding the relative degree of solvation, and very likely the degree of compactness, of the oxidized state versus the reduced state of the redox protein. A thermodynamic scheme and stability derivation are presented that show how the entropies of reaction of wild type versus variant cytochromes contribute to and predict changes in stability in going from oxidized to reduced protein. For yeast iso-1-cytochrome c, the thermodynamically predicted change in stability was very close to the experimentally observed value, based on previous differential scanning calorimetric stability measurements. While such data is not available for rat cytochrome c, consideration of the enormously increased local stability of the rat oxidized cytochrome c variant predicts that the reduced rat variant will be even more stable than the already stabilized oxidized variant.

Characterization of the recombinant Clostridium pasteurianum ferredoxin and comparison of its properties with those of the native protein.

Ferredoxins (Fds) constitute an important class of nonheme iron-sulfur proteins. One of the most studied Fds is the [8Fe-8S] Fd from Clostridium pasteurianum. The gene for this Fd has previously been cloned and sequenced. We report the expression of this Fd in Escherichia coli, and the characterization and comparison of this recombinant protein to the native Fd. We have found that the purified recombinant protein has the same enzymatic, redox, magnetic and electronic properties as the native Fd isolated from C. pasteurianum, which indicates that the two [4Fe-4S] clusters present in the Fd were correctly formed in E. coli.

Pulmonary edema after photocoagulation of the endometrium with the Nd:YAG laser. A case report.

A woman developed pulmonary edema as a result of fluid overload during Nd:YAG ablation of endometrial tissue. As a result of a miscalculation of fluid administration and collection, she was overhydrated with irrigation fluid. The clinical picture of pulmonary edema was noted in the immediate postoperative period and responded to positive pressure ventilation and diuretic therapy. The mechanism of pulmonary edema is postulated to have been the result of the absorption of irrigating fluid through open venous channels resulting from the laser ablation.

Angiographic embolization in the management of late postpartum hemorrhage. A case report.

Bilateral selective embolization of the internal iliac arteries was utilized to control late recurrent post-partum hemorrhage. Angiographic embolization appears to be safe and effective, and giving consideration to its use in patients in similar situations is recommended.

Perceptions of ganja and cocaine in urban Jamaica.

This article, based on ethnographic research, discusses the dynamic relationship between ganja (marijuana) and cocaine in five areas within Montego Bay, an urban-tourist center in Jamaica, West Indies. The focus is on the contrasting and conflicting social perceptions related to the current role of each substance in the society, as well as the interrelationship between these two substances. Of particular interest in the analysis of use and distribution patterns of each substance is the seemingly conflicting moral versus economic dilemma surrounding the drug trade; perceptions related to the effects of these two substances on the body and mind; and perceptions related to the role these substances play in local crime and physical violence. Community-level social perceptions will be compared to official discourse and actions regarding demand reduction, prevention, and enforcement of "drug" laws.

Contributors to disruption and dissolution of older-child adoptions.

According to recent evidence, adoptive placements that do not work out are increasingly common. This article reviews research on rates of, and contributors to, adoption and "foster-adoption" disruptions and dissolutions. Implications for practice are included.