Tucatinib, Trastuzumab, and Capecitabine for HER2-Positive Metastatic Breast Cancer.

BACKGROUND: Patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer who have disease progression after therapy with multiple HER2-targeted agents have limited treatment options. Tucatinib is an investigational, oral, highly selective inhibitor of the HER2 tyrosine kinase. METHODS: We randomly assigned patients with HER2-positive metastatic breast cancer previously treated with trastuzumab, pertuzumab, and trastuzumab emtansine, who had or did not have brain metastases, to receive either tucatinib or placebo, in combination with trastuzumab and capecitabine. The primary end point was progression-free survival among the first 480 patients who underwent randomization. Secondary end points, assessed in the total population (612 patients), included overall survival, progression-free survival among patients with brain metastases, confirmed objective response rate, and safety. RESULTS: Progression-free survival at 1 year was 33.1% in the tucatinib-combination group and 12.3% in the placebo-combination group (hazard ratio for disease progression or death, 0.54; 95% confidence interval [CI], 0.42 to 0.71; P<0.001), and the median duration of progression-free survival was 7.8 months and 5.6 months, respectively. Overall survival at 2 years was 44.9% in the tucatinib-combination group and 26.6% in the placebo-combination group (hazard ratio for death, 0.66; 95% CI, 0.50 to 0.88; P = 0.005), and the median overall survival was 21.9 months and 17.4 months, respectively. Among the patients with brain metastases, progression-free survival at 1 year was 24.9% in the tucatinib-combination group and 0% in the placebo-combination group (hazard ratio, 0.48; 95% CI, 0.34 to 0.69; P<0.001), and the median progression-free survival was 7.6 months and 5.4 months, respectively. Common adverse events in the tucatinib group included diarrhea, palmar-plantar erythrodysesthesia syndrome, nausea, fatigue, and vomiting. Diarrhea and elevated aminotransferase levels of grade 3 or higher were more common in the tucatinib-combination group than in the placebo-combination group. CONCLUSIONS: In heavily pretreated patients with HER2-positive metastatic breast cancer, including those with brain metastases, adding tucatinib to trastuzumab and capecitabine resulted in better progression-free survival and overall survival outcomes than adding placebo; the risks of diarrhea and elevated aminotransferase levels were higher with tucatinib. (Funded by Seattle Genetics; HER2CLIMB ClinicalTrials.gov number, NCT02614794.).

Determining the neurocognitive profile of children with tuberous sclerosis complex within the Western Cape region of South Africa.

BACKGROUND: Tuberous sclerosis complex (TSC) is a multisystem genetic disorder associated with a wide spectrum of cognitive impairments that can often result in impaired academic, social and adaptive functioning. However, studies investigating TSC have found it difficult to determine whether TSC is associated with a distinct cognitive phenotype and more specifically which aspects of functioning are impaired. Furthermore, children with TSC living in low-income and middle-income countries, like South Africa, experience additional burdens due to low socio-economic status, high mortality rates and poor access to health care and education. Hence, the clinical population of South Africa may vary considerably from those populations from high-income countries discussed in the literature. METHODS: A comprehensive neuropsychological battery composed of internationally recognised measures examining attention, working memory, language comprehension, learning and memory, areas of executive function and general intellectual functioning was administered to 17 children clinically diagnosed with TSC. RESULTS: The exploration of descriptive data indicated generalised cognitive difficulties in most cognitive domains, aside from memory. With only two participants performing in the average to above-average ranges, the rest of the sample showed poor verbal comprehension, perceptual reasoning, working memory, processing speed, disinhibition, and problems with spatial planning, problem solving, frustration tolerance, set shifting and maintaining a set of rules. Furthermore, correlational findings indicated several associations between socio-demographic and cognitive variables. CONCLUSIONS: Importantly, this is the first study to comprehensively examine multiple domains of neurocognitive functioning in a low-resource setting sample of children with TSC. Current study findings showed that children with TSC have generalised impairments across several cognitive domains, rather than domain-specific impairments. Therefore, although examining individual aspects of cognition, such as those found in previous literature, is important, this approach is limiting. With a comprehensive assessment, including understanding the associations between domains, appropriate and directed support can be provided to ensure all aspects of development are addressed and considered.

Pathology of grey seals Halichoerus grypus in southwest England including pups in early rehabilitation.

Few investigations have examined the pathology of grey seals Halichoerus grypus in southwest England, where it is the most abundant marine mammal. Here, primary pathological findings are presented from 107 post-mortem examinations of grey seals in southwest England between 2013 and 2020. Over three-quarters were pups in their first year of life; the origins of the carcasses reflected the known breeding season and breeding sites of grey seals in the region. Trauma was the most common primary pathological finding (n = 49), followed by infectious disease (n = 36). Traumatic findings included fisheries-related trauma (n = 15), other acute physical traumas (n = 15) and other chronic traumas (n = 19). Infectious disease findings included respiratory infections (n = 21) and gastrointestinal infections (n = 9). There was no difference in the primary pathological findings for seals found dead or that died or were euthanased on the day they were found compared to those dying in early rehabilitation, suggesting that it is appropriate to include findings from seals in early rehabilitation in studies of wild grey seal pathology. Seals that had not been frozen before post-mortem examination were nearly twice as likely to have a primary pathological finding of infectious disease or trauma than those that had been frozen, highlighting the need, wherever possible, to avoid freezing seals prior to post-mortem examination.

Cardiovascular malformations caused by NOTCH1 mutations do not keep left: data on 428 probands with left-sided CHD and their families.

PURPOSE: We aimed to determine the prevalence and phenotypic spectrum of NOTCH1 mutations in left-sided congenital heart disease (LS-CHD). LS-CHD includes aortic valve stenosis, a bicuspid aortic valve, coarctation of the aorta, and hypoplastic left heart syndrome. METHODS: NOTCH1 was screened for mutations in 428 nonsyndromic probands with LS-CHD, and family histories were obtained for all. When a mutation was detected, relatives were also tested. RESULTS: In 148/428 patients (35%), LS-CHD was familial. Fourteen mutations (3%; 5 RNA splicing mutations, 8 truncating mutations, 1 whole-gene deletion) were detected, 11 in familial disease (11/148 (7%)) and 3 in sporadic disease (3/280 (1%)). Forty-nine additional mutation carriers were identified among the 14 families, of whom 12 (25%) were asymptomatic. Most of these mutation carriers had LS-CHD, but 9 (18%) had right-sided congenital heart disease (RS-CHD) or conotruncal heart disease (CTD). Thoracic aortic aneurysms (TAAs) occurred in 6 mutation carriers (probands included 6/63 (10%)). CONCLUSION: Pathogenic mutations in NOTCH1 were identified in 7% of familial LS-CHD and in 1% of sporadic LS-CHD. The penetrance is high; a cardiovascular malformation was found in 75% of NOTCH1 mutation carriers. The phenotypic spectrum includes LS-CHD, RS-CHD, CTD, and TAA. Testing NOTCH1 for an early diagnosis in LS-CHD/RS-CHD/CTD/TAA is warranted.Genet Med 18 9, 914-923.

Influence of personalized extended interval dosing on the natalizumab wearing-off effect - a sub-study of the NEXT-MS trial.

BACKGROUND AND OBJECTIVES: Wearing-off symptoms during natalizumab treatment in multiple sclerosis are characterized by an increase of MS-related symptoms prior to natalizumab administration. The influence of extended interval dosing (EID) on wearing-off symptoms are important to consider, as this might cause hesitancy in initiating or continuing EID. METHODS: Participants of the NEXT-MS trial, in which treatment intervals are adjusted based on drug concentrations, were divided into two groups: an extended group containing participants with at least one week of additional interval extension, and a group with a fixed interval during the trial (range 4-7 weeks). Changes in the occurrence, frequency, onset, and severity of wearing-off symptoms were evaluated. RESULTS: 255 participants were included (extended group n = 171, fixed group n = 84). The odds on occurrence of wearing-off symptoms in the extended group did not increase after extending the treatment interval. Additional analyses for frequency, onset, and severity of wearing-off symptoms showed no changes over time. Mean decrease in natalizumab drug concentration did not influence the frequency of wearing-off symptoms. DISCUSSION: Wearing-off symptoms were not reinforced by further extending the natalizumab interval. Wearing-off symptoms might increase in a minority of patients after EID, although our data support the view that wearing-off symptoms appear to be unrelated to the decrease in natalizumab trough drug concentrations.

Discontinuation of first-line disease-modifying therapy in relapse onset multiple sclerosis.

BACKGROUND: It is not known if and when first-line disease modifying therapy (DMT) can safely be discontinued in relapse onset multiple sclerosis (MS) patients. OBJECTIVES: To investigate the characteristics of patients who discontinued first-line DMT, and the occurrence of clinical and radiological inflammatory disease activity after discontinuation. METHODS: We collected clinical and MRI parameters from patients with relapse onset MS in the MS Center Amsterdam and Rijnstate Hospital Arnhem who discontinued first-line DMT with no intention of restarting or switching treatment. RESULTS: In total, 130 patients were included in the analyses. After discontinuation, 78 patients (60%) experienced disease activity. Sixty-three patients (48.5%) showed MRI activity after DMT discontinuation, 40 patients (30.8%) experienced relapse(s), and 29 patients (22.3%) restarted DMT. Higher age at DMT discontinuation was associated with a lower risk of MRI activity (45 -55 vs. <45 years: OR 0.301, p = 0.007, >55 vs. <45 years, OR: 0.296, p = 0.044), and with a lower risk of relapse(s) after discontinuation (45-55 vs. <45 years: OR=0.495, p = 0.106, >55 vs. <45 years: OR=0.081, p = 0.020). CONCLUSION: Higher age at first-line DMT discontinuation is associated with lower risk and severity of radiological disease activity in MS, and a lower risk of relapse(s) after discontinuation.

Natalizumab discontinuation in a Dutch real-world cohort.

OBJECTIVE: To determine characteristics of multiple sclerosis patients that discontinued natalizumab treatment in a real-world cohort. METHODS: Data was collected from an ongoing observational cohort study of all natalizumab treated patients at the Amsterdam UMC. RESULTS: Of 253 patients who ever received natalizumab treatment, 147 have discontinued treatment. The most frequent reason for treatment discontinuation was JC-virus (JCV) positivity. CONCLUSIONS: JCV positivity seems the most frequent reason for natalizumab discontinuation. The heterogeneity in treatment switches reflects the advances made in treatment options, and underlines the need for adequate patient counselling.

Response to brentuximab vedotin versus physician's choice by CD30 expression and large cell transformation status in patients with mycosis fungoides: An ALCANZA sub-analysis.

INTRODUCTION: Mycosis fungoides (MF), the most common type of cutaneous T-cell lymphoma, can lead to disfiguring lesions, debilitating pruritus and frequent skin infections. This study assessed response to brentuximab vedotin in patients with MF in the phase III ALCANZA study. METHODS: Baseline CD30 levels and large-cell transformation (LCT) status were centrally reviewed in patients with previously-treated CD30-positive MF using ≥2 skin biopsies obtained at screening; eligible patients required ≥1 biopsy with ≥10% CD30 expression. Patients were categorised as CD30min < 10% (≥1 biopsy with <10% CD30 expression), or CD30min ≥ 10% (all biopsies with ≥10% CD30 expression) and baseline LCT present or absent. Efficacy analyses were the proportion of patients with objective response lasting ≥4 months (ORR4) and progression-free survival (PFS). RESULTS: Clinical activity with brentuximab vedotin was observed across all CD30 expression levels in patients with ≥1 biopsy showing ≥10% CD30 expression. Superior ORR4 was observed with brentuximab vedotin versus physician's choice in patients: with CD30min < 10% (40.9% versus 9.5%), with CD30min ≥ 10% (57.1% versus 10.3%), with LCT (64.7% versus 17.6%) and without LCT (38.7% versus 6.5%). Brentuximab vedotin improved median PFS versus physician's choice in patients: with CD30min < 10% (16.7 versus 2.3 months), with CD30min ≥ 10% (15.5 versus 3.9 months), with LCT (15.5 versus 2.8 months) and without LCT (16.1 versus 3.5 months). Safety profiles were generally comparable across subgroups. CONCLUSION: These exploratory analyses demonstrated that brentuximab vedotin improved rates of ORR4 and PFS versus physician's choice in patients with CD30-positive MF and ≥1 biopsy showing ≥10% CD30 expression, regardless of LCT status. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT01578499.

Antibody recognition of the type 14 pneumococcal capsule. Evidence for a conformational epitope in a neutral polysaccharide.

Oligosaccharides consisting of one or more tetrasaccharide repeating units were derived from the capsular polysaccharide of type 14 pneumococcus (Pn14) by endo-beta-galactosidase digestion. The relative affinity of anticapsular antibody binding to derivative oligosaccharides of different chain lengths was measured in a Pn 14 ELISA inhibition assay. The concentration of inhibiting antigen required to achieve 50% inhibition of IgG binding increased progressively from 5.6 x 10(-4) M to 7.0 x 10(-11) M as the inhibiting saccharide chain length increased from 1 tetrasaccharide repeating unit to 2,500 repeating units. These data indicate that antibodies directed against the Pn14 polysaccharide recognize a conformational epitope fully expressed only in high molecular weight forms of the antigen. Similar results were found for inhibition of Fab fragment binding, suggesting that recognition of the conformational epitope is largely dependent on the intrinsic affinity of the Fab combining region. Unlike previously reported polysaccharides for which conformational epitopes have been described, the Pn14 polysaccharide does not contain negatively charged residues, indicating that expression of conformational determinants is not limited to acidic polysaccharides. Antibody recognition of conformational epitopes may be a common mechanism by which the host immune response discriminates between bacterial polysaccharides and host oligosaccharides of similar structure.

Genetic factors in non-syndromic congenital heart malformations.

The genetic defect in most patients with non-syndromic congenital heart malformations (CHM) is unknown, although more than 40 different genes have already been implicated. Only a minority of CHM seems to be due to monogenetic mutations, and the majority occurs sporadically. The multifactorial inheritance hypothesis of common diseases suggesting that the cumulative effect of multiple genetic and environmental risk factors leads to disease, might also apply for CHM. We review here the monogenic disease genes with high-penetrance mutations, susceptibility genes with reduced-penetrance mutations, and somatic mutations implicated in non-syndromic CHM.

Frozen storage of lesser mealworm larvae (Alphitobius diaperinus) changes chemical properties and functionalities of the derived ingredients.

The effect of frozen storage on the chemical properties and ingredient functionalities of Lesser mealworms was investigated at -20 °C for 2 months. Major changes occurred in the first week of frozen storage. Proteins, among which heavy chain myosin, underwent denaturation and aggregation, as shown by a decrease in solubility, SDS-PAGE pattern, and Confocal Laser Scanning Microscopy. The ice melting point in larvae was -32.5 °C as determined by DSC: 25% of water is not frozen at -20 °C, possibly due to anti-freezing proteins preventing ice formation. The presence of unfrozen water favoured various enzymatic activities as shown by a pH decrease, indicating protein hydrolysis. The molecular changes during frozen storage increased the browning reactions due to phenoloxidase activity. Foaming ability, foam stability and gel network stability increased upon frozen storage due to protein denaturation. Results provide important information regarding the opportunity of frozen storage of insect larvae for both research and industrial purposes.

First Case of Idiopathic Eosinophilic Meningoencephalitis in a Sheep.

A 1.5-year-old ewe was presented with neurological signs that had been observed from about 2 days prior to death. There had been no clinical response to anti-inflammatory and antibiotic treatment. Histopathological examination of the brain revealed a severe and widespread eosinophilic meningoencephalomyelitis of unknown aetiology. Defining histological features included diffuse angiocentric eosinophilic infiltrates in the neuroparenchyma and meninges, neuronal necrosis, astrocytosis, neuropil vacuolation and occasional glial scars. Differential diagnostics for eosinophilic meningoencephalitis were taken into account and investigated by means of special stains, immunohistochemistry, bacteriology and polymerase chain reaction. No pathological changes or ancillary tests were supportive or revealed a specific aetiology for the condition and therefore it was considered idiopathic. Idiopathic meningoencephalitis is a rare disease, mainly described in man and rarely in dogs, with no apparent aetiological cause or potential breed predisposition. To our knowledge this is the first case of idiopathic eosinophilic meningoencephalitis in a sheep and provides a histopathological guideline for prospective comparative pathology studies.

Further delineation of Pitt-Hopkins syndrome: phenotypic and genotypic description of 16 novel patients.

BACKGROUND: Haploinsufficiency of the gene encoding for transcription factor 4 (TCF4) was recently identified as the underlying cause of Pitt-Hopkins syndrome (PTHS), an underdiagnosed mental-retardation syndrome characterised by a distinct facial gestalt, breathing anomalies and severe mental retardation. METHODS: TCF4 mutational analysis was performed in 117 patients with PTHS-like features. RESULTS: In total, 16 novel mutations were identified. All of these proven patients were severely mentally retarded and showed a distinct facial gestalt. In addition, 56% had breathing anomalies, 56% had microcephaly, 38% had seizures and 44% had MRI anomalies. CONCLUSION: This study provides further evidence of the mutational and clinical spectrum of PTHS and confirms its important role in the differential diagnosis of severe mental retardation.

Cornelia de lange syndrome: a recognizable fetal phenotype.

We describe a fetus with Cornelia de Lange syndrome diagnosed after termination of pregnancy at 21 weeks. Prenatally, growth retardation, diaphragmatic hernia, cystic hygroma and a right hand with only three rays were diagnosed by ultrasound in the second trimester of pregnancy. Postnatal magnetic resonance imaging confirmed the prenatal findings, and the presence of the typical dysmorphic features led to the diagnosis of Cornelia de Lange syndrome. The diagnosis was confirmed by the finding of a truncating mutation in the NIPBL gene. This case illustrates that the diagnosis Cornelia the Lange syndrome can be suspected prenatally in the second trimester, and can be diagnosed in fetuses after induction or newborns at birth as the typical phenotype is present early.

Novel Pulmonary Vasculitis with Splendore-Hoeppli Reaction in Grey Seals (Halichoerus grypus) Associated with Otostrongylus circumlitus Infection.

Lungworm infection in seals is an important cause of morbidity and mortality, inducing bronchopneumonia and affecting population dynamics in some areas of the world. We present a series of cases of lungworm infection in grey seals (Halichoerus grypus) associated with novel, significant and unusual pulmonary vascular changes. Grey seals (n = 180) that were stranded, in rehabilitation or in long-term captivity in the UK were subjected to post-mortem examination between 2012 and 2018. Lung tissue was collected from 47 individuals for histopathological examination. Polymerase chain reaction (PCR) on formalin-fixed and paraffin wax-embedded (FFPE) material was attempted for parasite identification on selected sections using lungworm-specific primers, and nematode morphology within sections was evaluated histologically. Fourteen of 47 (30%) of these grey seals showed evidence of segmental granulomatous and eosinophilic vasculitis with an intramural Splendore-Hoeppli reaction in medium to large pulmonary arteries. Intravascular nematodes suggestive of Otostrongylus circumlitus were seen in two cases. PCR on FFPE material was unable to detect a signal on selected tissue sections. Of the 14 affected seals, nine had concurrent bronchopneumonia and four had intra-alveolar/bronchiolar Parafilaroides spp. Thirteen of 14 animals with vasculitis lesions were weaned pups with only one adult affected. Previous pathological descriptions of lungworm infection in grey seals have dealt mainly with the bronchopneumonia. This case series has identified previously unrecorded vascular changes characterized by an intramural Splendore-Hoeppli reaction. Such change would impact on vascular integrity, increasing the likelihood of vascular rupture with pulmonary haemorrhage and increased risk of intravascular coagulation. A host-parasite relationship with the persistence of antigenic material following close contact with, or migration through, the blood vessel wall is suspected.

Postural orthostatic tachycardia syndrome (POTS): a common but unfamiliar syndrome.

Postural orthostatic tachycardia syndrome (POTS) is a condition in which a change from a supine to an upright position causes an abnormally large increase in heart rate which may be accompanied by a variety of physical complaints. We report two cases illustrating the heterogeneity of this syndrome. We give an update on the etiology of POTS, which is still poorly understood, and its overlap with other syndromes such as chronic fatigue syndrome. Clinicians should be aware of POTS, a fairly common clinical entity, that can result in significant impairments to a patient's quality of life. Lifestyle measures (under which adequate fluid and salt intake, exercise) are a first line of treatment; if insufficient, pharmacotherapy can be considered to improve quality of life.

Measurement techniques to determine tibial rotation after total knee arthroplasty are less accurate than we think.

BACKGROUND: The present study assessed the inter- and intra-observer reliability of tibial and femoral rotation measures after total knee arthroplasty (TKA), and evaluated the correlation between these measurement techniques and their clinical relevance. METHODS: Femoral rotation and tibial rotation were determined on 42 2D CT-scans made three-months after TKA. Reliability of the radiological measurements (including Berger's method, the anatomical tibial axis and the tibial tuberosity trochlear-groove) was assessed with 15 randomly selected patients measured twice by three observers. Functional outcomes were scored one-year postoperatively with the KSS, VAS pain, VAS satisfaction, KOOS, and Kujala. RESULTS: The inter- and intra-observer reliability of the rotational measurements ranged from good to excellent (ICC 0.67-0.98). Tibial rotation measured with the Berger technique was most reliable (ICC inter = 0.91; ICC intra = 0.96). No strong correlations were found between the different rotational measures or the clinical outcomes and rotational outliers. CONCLUSIONS: Tibial rotation is most reliable measured with the technique described by Berger. There were no strong correlations found between the different tibial rotation measures or between the clinical outcomes and the rotational outliers. Further research is needed to gain more insight into optimal positioning and measuring rotation in TKA for clinical practice.

CD44 as a receptor for colonization of the pharynx by group A Streptococcus.

The pharynx is the primary reservoir for strains of group A STREPTOCOCCUS: (GAS) associated both with pharyngitis (streptococcal sore throat) and with invasive or "flesh-eating" soft tissue infections. We now report that CD44, a hyaluronic acid-binding protein that mediates human cell-cell- and cell-extracellular matrix-binding interactions, functions as a receptor for GAS colonization of the pharynx in vivo. We found that attachment of GAS to murine epithelial keratinocytes was mediated by binding of the GAS hyaluronic acid capsular polysaccharide to CD44. In studies of transgenic mice with a selective defect in epithelial expression of CD44, GAS adherence to CD44-deficient keratinocytes in vitro was reduced compared with adherence to keratinocytes expressing normal levels of CD44. After intranasal inoculation, GAS colonized the oropharynx of wild-type mice but failed to colonize transgenic mice deficient in CD44 expression. GAS colonization of wild-type mice could be blocked by coadministration of mAb to CD44 or by pretreatment of the animals with exogenous hyaluronic acid. These results provide evidence that CD44 serves as a receptor for GAS colonization of the pharynx and support the potential efficacy of disrupting the interaction between the GAS hyaluronic acid capsule and CD44 as a novel approach to preventing pharyngeal infection.

Hyaluronic acid capsule and the role of streptococcal entry into keratinocytes in invasive skin infection.

It has been suggested that entry of pathogenic bacteria, including streptococci, into epithelial cells may represent an early stage of invasive infections. We found that poorly encapsulated wild-type strains and unencapsulated mutants of group A Streptococcus entered cultured human keratinocytes with high efficiency, while strains that produced large amounts of hyaluronic acid capsule did not, regardless of M-protein type or clinical source of the isolate. However, encapsulated streptococci produced extensive local necrosis and systemic infection in a mouse model of skin infection, while an isogenic acapsular strain did not. The results implicate the hyaluronic acid capsule as a virulence factor in soft tissue infection. Entry of poorly encapsulated group A Streptococcus into human epithelial cells does not appear to represent an initial step in invasive disease; rather, the capacity of encapsulated strains to avoid uptake by epithelial cells is associated with enhanced virulence in skin and soft tissue infection.