Randomized phase II study of modified FOLFOX-6 in combination with ramucirumab or icrucumab as second-line therapy in patients with metastatic colorectal cancer after disease progression on first-line irinotecan-based therapy.

BACKGROUND: Icrucumab and ramucirumab are recombinant human IgG1 monoclonal antibodies that bind VEGF receptors 1 and 2 (VEGFR-1 and -2), respectively. This randomized phase II study evaluated the antitumor activity and safety of icrucumab and ramucirumab each in combination with mFOLFOX-6 in patients with metastatic colorectal cancer after disease progression on first-line therapy with a fluoropyrimidine and irinotecan. PATIENTS AND METHODS: Eligible patients were randomly assigned to receive mFOLFOX-6 alone (mFOLFOX-6) or in combination with ramucirumab 8 mg/kg IV (RAM+mFOLFOX-6) or icrucumab 15 mg/kg IV (ICR+mFOLFOX-6) every 2 weeks. Randomization was stratified by prior bevacizumab therapy. The primary end point was progression-free survival (PFS). Secondary end points included overall survival (OS), tumor response, safety, and PK. RESULTS: In total, 158 patients were randomized, but only 153 received treatment (49 on mFOLFOX-6, 52 on RAM+mFOLFOX-6, and 52 on ICR+mFOLFOX-6). Median PFS was 18.4 weeks on mFOLFOX-6, 21.4 weeks on RAM+mFOLFOX-6, and 15.9 weeks on ICR+mFOLFOX-6 (RAM+mFOLFOX-6 versus mFOLFOX-6, stratified hazard ratio [HR] 1.116 [95% CI 0.713-1.745], P = 0.623; ICR+mFOLFOX-6 versus mFOLFOX-6, stratified HR 1.603 [95% CI 1.011-2.543], P = 0.044). Median survival was 53.6 weeks on mFOLFOX-6, 41.7 weeks on RAM+mFOLFOX-6, and 42.0 weeks on ICR+mFOLFOX-6. The most frequent adverse events reported on the ramucirumab arm (RAM+mFOLFOX-6) were fatigue, nausea, and peripheral sensory neuropathy; those on the icrucumab arm (ICR+mFOLFOX-6) were fatigue, diarrhea, and peripheral sensory neuropathy. Grade ≥3 serious adverse events occurred at comparable frequency across arms. CONCLUSIONS: In this study population, combining ramucirumab or icrucumab with mFOLFOX-6 did not achieve the predetermined improvement in PFS. CLINICALTRIALSGOV: NCT01111604.

Efficacy of Coronary Computed Tomography Angiography for the De Novo Detection of Chronic Total Occlusion Prior to Coronary Angiography: A Preliminary and Retrospective Study.

Coronary computed tomography angiography (CCTA) offers high-resolution anatomic characterization of the coronary vasculature but may be suboptimal for lesions dependent on real-time visualization of flow including chronic total occlusion (CTO). In CTOs, heavy calcification and distal vessel opacification from collateralization may confound luminal assessment. Several studies have examined the role of CCTA in characterizing known CTOs to guide percutaneous coronary intervention (PCI). However, the efficacy of CCTA in the de novo diagnosis of CTOs prior to coronary angiography (CAG) has not been demonstrated. A total of 233 consecutive patients who presented for CAG within a 3-month period of having CCTA were retrospectively reviewed. Those patients with prior diagnosis of CTO or prior bypass of the occluded vessels were excluded. Sensitivity and specificity analysis of CCTA in identifying CTOs using CAG as the gold standard was performed. The prevalence of CTO was 21.11% in the population that met criteria for analysis ( n = 199). The sensitivity of CCTA in predicting CTO was 57.1%, while the specificity was 96.8%. The positive predictive value and negative predictive value of CCTA in detection of CTO were 82.8 and 89.4%, respectively. Our study shows that CCTA has excellent specificity but poor sensitivity in the detection of CTO thus limiting its clinical use in de novo diagnosis. Further studies to determine the effect of de novo CTO diagnosis on clinically important procedural factors, such as radiation exposure, contrast use, and need for repeat procedures, are warranted and may implicate a role for CCTA in this setting.

A phase 1 study of anti-TGFß receptor type-II monoclonal antibody LY3022859 in patients with advanced solid tumors.

PURPOSE: LY3022859 is an anti-TGFßRII IgG1 monoclonal antibody that inhibits receptor-mediated signaling activation. The primary objective of this phase I study was to determine a phase II dose in patients with advanced solid tumors. Secondary objectives were to assess safety and pharmacokinetics (PK). METHODS: LY3022859 was infused intravenously (IV) at 1.25 mg/kg over 1 h every 2 weeks (Q2W) (cohort 1A) and at flat doses of 12.5 mg (cohort 1B) and 25 mg (cohort 2) over 3 h Q2W. RESULTS: Fourteen patients were enrolled in cohorts 1A (n = 2), 1B (n = 5), and 2 (n = 7). DLTs were experienced by both patients in cohort 1A (infusion-related reaction) and 2 patients in cohort 2 (cytokine release syndrome and infusion-related reaction). No MTD was determined. At the 25 mg dose level (cohort 2), after fifth infusion, LY3022859 had a short t1/2 (4.37-7.80 h) and rapid clearance (CLss, 0.412 L/h). Exposure increased twofold (from 28.5 to 60.2 µg·h/mL) with increase in dose from 12.5 to 25 mg. No accumulation was observed after repeat administration. CONCLUSIONS: The MTD for LY3022859 was not determined. Dose escalation beyond 25 mg was considered unsafe due to worsening symptoms (uncontrolled cytokine release) despite prophylaxis (corticosteroids and antihistamines). TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01646203.

Posterior subluxation and dislocation of the shoulder in obstetric brachial plexus palsy.

We describe the results of surgical treatment in a prospective study of 183 consecutive cases of subluxation (101) and dislocation (82) of the shoulder secondary to obstetric brachial plexus palsy between 1995 and 2000. Neurological recovery was rated 'good' or 'useful' in all children, whose lesions fell into groups 1, 2 or 3 of the Narakas classification. The mean age at operation was 47 months (3 to 204). The mean follow-up was 40 months (24 to 124). The mean gain in function was 3.6 levels (9.4 to 13) using the Mallet score and 2 (2.1 to 4.1) on the Gilbert score. The mean active global range of shoulder movement was increased by 73 degrees ; the mean range of active lateral rotation by 58 degrees and that of supination of the forearm by 51 degrees . Active medial rotation was decreased by a mean of 10 degrees . There were 20 failures. The functional outcome is related to the severity of the neurological lesion, the duration of the dislocation and onset of deformity.

Thrombocytopenia in MDS: epidemiology, mechanisms, clinical consequences and novel therapeutic strategies.

Thrombocytopenia is commonly seen in myelodysplastic syndrome (MDS) patients, and bleeding complications are a major cause of morbidity and mortality. Thrombocytopenia is an independent factor for decreased survival and has been incorporated in newer prognostic scoring systems. The mechanisms of thrombocytopenia are multifactorial and involve a differentiation block of megakaryocytic progenitor cells, leading to dysplastic, hypolobated and microscopic appearing megakaryocytes or increased apoptosis of megakaryocytes and their precursors. Dysregulated thrombopoietin (TPO) signaling and increased platelet destruction through immune or nonimmune mechanisms are frequently observed in MDS. The clinical management of patients with low platelet counts remains challenging and approved chemotherapeutic agents such as lenalidomide and azacytidine can also lead to a transient worsening of thrombocytopenia. Platelet transfusion is the only supportive treatment option currently available for clinically significant thrombocytopenia. The TPO receptor agonists romiplostim and eltrombopag have shown clinical activity in clinical trials in MDS. In addition to thrombopoietic effects, eltrombopag can inhibit leukemic cell proliferation via TPO receptor-independent effects. Other approaches such as treatment with cytokines, immunomodulating drugs and signal transduction inhibitors have shown limited activity in selected groups of MDS patients. Combination trials of approved agents with TPO agonists are ongoing and hold promise for this important clinical problem.

Efficacy and safety of extended dosing schedules of CC-486 (oral azacitidine) in patients with lower-risk myelodysplastic syndromes.

CC-486, the oral formulation of azacitidine (AZA), is an epigenetic modifier and DNA methyltransferase inhibitor in clinical development for treatment of hematologic malignancies. CC-486 administered for 7 days per 28-day treatment cycle was evaluated in a phase 1 dose-finding study. AZA has a short plasma half-life and DNA incorporation is S-phase-restricted; extending CC-486 exposure may increase the number of AZA-affected diseased target cells and maximize therapeutic effects. Patients with lower-risk myelodysplastic syndromes (MDS) received 300 mg CC-486 once daily for 14 days (n=28) or 21 days (n=27) of repeated 28-day cycles. Median patient age was 72 years (range 31-87) and 75% of patients had International Prognostic Scoring System Intermediate-1 risk MDS. Median number of CC-486 treatment cycles was 7 (range 2-24) for the 14-day dosing schedule and 6 (1-24) for the 21-day schedule. Overall response (complete or partial remission, red blood cell (RBC) or platelet transfusion independence (TI), or hematologic improvement) (International Working Group 2006) was attained by 36% of patients receiving 14-day dosing and 41% receiving 21-day dosing. RBC TI rates were similar with both dosing schedules (31% and 38%, respectively). CC-486 was generally well-tolerated. Extended dosing schedules of oral CC-486 may provide effective long-term treatment for patients with lower-risk MDS.

Frequencies of mitochondrial DNA haplotypes in laboratory cage populations of the mosquito, Aedes albopictus.

A laboratory cage experiment was undertaken to study changes over time in the frequencies of two mitochondrial DNA (mtDNA) haplotypes in the mosquito, Aedes albopictus, under two conditions: bidirectionally compatible matings and unidirectionally incompatible matings. Frequencies were monitored for 10 generations in three replicate cages for each of the two conditions above. In cages with bidirectionally compatible strains, changes in haplotype frequencies were nondirectional and neither haplotype increased in frequency. Statistical analysis of relative proportions of the two haplotypes in each generation indicated that the magnitude of the observed fluctuations could be expected under an assumption of random genetic drift alone. In cages with unidirectionally incompatible matings, mtDNA of females that lay inviable eggs upon mating with males of another strain, decreased significantly in the F1 generation and was completely replaced in the F2 generation.

Coevolution between a cockroach and its bacterial endosymbiont: a biogeographical perspective.

Cryptocercus are subsocial, xylophagous cockroaches that live in temperate forests. Like other cockroaches, Cryptocercus harbour endosymbiotic bacteria in their fat bodies. Two species of Cryptocercus occur in the palaearctic, one each in eastern Russia and south-central China. In the USA, there are five species: one in the north-west and four in the south-east. Little is known about the relationship between the Eurasian and North American Cryptocercus or the causes of the disjunct distribution. Here, a molecular phylogeny for six out of the seven Cryptocercus species and their endosymbionts is inferred in an attempt to understand the evolution and biogeography of the genus. Our analysis showed that the North American Cryptocercus are monophyletic, suggesting that a single colonization event was followed by vicariance. There was complete concordance between the host and endosymbiont phylogenetic trees. Divergence estimates based on endosymbiont DNA sequences suggested that the palaearctic and nearctic Cryptocercus diverged 70-115 million years (Myr) ago and the eastern- and western-USA species diverged 53-88 Myr ago. These divergence estimates were correlated with biogeographical events, and a hypothesis is presented to explain the current distribution of Cryptocercus. Our findings suggest that Cryptocercus has had a long evolutionary history, dating back to the Jurassic.

Molecular cloning and characterization of a greenbug (Schizaphis graminum) cDNA encoding acetylcholinesterase possibly evolved from a duplicate gene lineage.

An acetylcholinesterase (AChE, EC 3.1.1.7) cDNA was cloned and characterized from a greenbug (Schizaphis graminum (Rondani)) cDNA library. The complete cDNA (3283 bp) contains a 2028-bp open reading frame encoding 676 amino acid residues. The putative AChE preproenzyme has a 17 amino acid signal peptide, a 78 amino acid activation peptide and a mature enzyme of 581 amino acid residues. The first nine amino acid residues (YTSDDPLII) that were determined by sequencing the N-terminus of a 72-kDa AChE purified from the greenbug matched the nine residues deduced from the cDNA. The key amino acid residues, including the three residues Ser206 (200 in Torpedo), Glu332 (327) and His446 (440) forming a catalytic triad, three pairs of cysteine putatively forming intrachain disulfide bonds, and 10 out of the 14 aromatic residues lining the active site gorge of the Torpedo AChE, are conserved. However, Ser336 (Phe331) in the greenbug substituted an aromatic amino acid residue that is conserved in all other known AChEs. Northern blot analysis of mRNA revealed a 3.7-kb transcript, and Southern blot analysis suggested a single copy of this gene in the greenbug. The deduced amino acid sequence is most similar to AChE1 of the nematodes Caenorhabditis briggsae and C. elegans with 43% identity. Phylogenetic analysis showed that the greenbug AChE formed a cluster with those of nematodes, a squid and ticks, and grouped out of the insect cluster. This result suggests that the cloned gene evolved from a different duplicate gene lineage of insect AChEs.

Polymerase chain reaction-based method for the detection of canine heartworm (Filarioidea: Onchocercidae) in mosquitoes (Diptera: Culicidae) and vertebrate hosts.

A polymerase chain reaction (PCR)-based test was developed to aid in identification of Dirofilaria sp. and for use in surveys for infected vectors of Dirofilaria immitis (Leidy). A set of PCR primers was designed based on the DNA sequence of a D. immitis surface antigen gene. The predicted product was a 378 base-pair DNA fragment. The target fragment was amplified from free D. immitis larvae (both L3 and microfilariae), individual infected mosquitoes, pools of 30 mosquitoes (including a single infected mosquito), infected mosquitoes stored desiccated at room temperature for 7 mo, and whole blood from a dog infected with D. immitis. These primers did not amplify a homologous fragment from a mermithid or from 4 other species of filarioid nematodes (including 1 other Dirofilaria species). Third-stage larvae from field-collected mosquitoes also were tested. Field-collected L3, identified tentatively as D. immitis, were confirmed by PCR. There was no amplification using the PCR test for L3 identified tentatively as Dirofilaria sp. (possibly D. tenuis Chandler). These data provide a strong indication of the specificity of these primers. The potential utility of this technique for detecting the presence of D. immitis in field populations of mosquitoes is discussed.

Random amplified polymorphic DNA of mosquito species and populations (Diptera: Culicidae): techniques, statistical analysis, and applications.

A polymerase chain reaction (PCR)-based method is described for the identification and differentiation of mosquito species and populations. The method, described first by Williams et al. (1990), employs single 10 base-long primers of arbitrary DNA sequence and results in the amplification of random segments of DNA known as random amplified polymorphic DNA (RAPD). We wished to determine if RAPD of mosquito DNA could be used for the differentiation of species and populations, identification of unknown specimens, and the reconstruction of phylogeny. RAPD of mosquito DNA results in the amplification of a series of DNA fragments of varying length. Most amplified fragments are unique to an individual; however, our data indicated that in each of the five species of Aedes examined, some fragments are species-specific and are present in all individuals of that species. This enabled us to derive a diagnostic profile for each of the five species. A nearest-neighbor analysis of all the amplified DNA fragments discriminated among species on a multivariate basis. Several individuals of Aedes albopictus (Skuse), included in the analysis as "unknowns," were correctly identified as belonging to Ae. albopictus. UPGMA clustering of presence-absence data enabled the separation of different Aedes species as well as different populations of Ae. albopictus. The entomological applications of RAPD include the construction of diagnostic profiles for species identification and differentiation among conspecific populations.

Characterization of acetylcholinesterase purified from the lesser grain borer, Rhyzopertha dominica (Coleoptera: Bostrichidae).

Acetylcholinesterase (AChE, EC 3.1.1.7) purified from the lesser grain borer (Rhyzopertha dominica) was significantly inhibited by higher concentrations of the substrates acetylthiocholine (ATC), acetyl-(beta-methyl) thiocholine (A beta MTC) and propionylthiocholine (PTC). 2. The efficiency of AChE for hydrolyzing different substrates was ATC > A beta MTC > PTC > S-butyrylthiocholine. The enzyme activity was completely inhibited by 10(-5) M eserine or BW284C51, but was only partially inhibited by ethopropazine at the same concentration. These results confirmed that the purified enzyme was an typical insect AChE. 3. Non-denaturing and SDS polyacrylamide gel electrophoresis (PAGE) showed only one major molecular form in the purified AChE with a molecular weight of about 107,000 prior to reduction and about 56,000 after reduction, suggesting the homodimer of AChE linked with disulfide bonds.

A liquid chromatographic method for the simultaneous determination of promethazine and three of its metabolites in plasma using electrochemical and UV detectors.

A new assay method has been developed for the quantitation of promethazine (PMZ) with a sensitivity and reproducibility as good as any previously reported method. This method is also capable of quantitatively determining three metabolites of PMZ (monodemethylated, sulphoxidated, and monodemethylated sulphoxidated PMZ), which has not been previously described. The method uses high-performance liquid chromatography with amperometric and UV detection simultaneously and requires only one extraction step from serum with chloroform. The method uses trifluoperazine as the internal standard. The limit of detection level for PMZ is 1.0 ng/ml when a 0.2-mL specimen of plasma is assayed. A validation study is also conducted for evaluating the recovery, precision, linearity of response, sensitivity, and selectivity of the method.

Effect of material property representation on stresses in endoprostheses.

The present study sought to examine if, and to what extent, the representation of the elastic properties of material(s) in a model of an endoprosthesis per se or a construct that includes an endoprosthesis affects the stresses in the model, when the finite element analysis method is used to obtain these stresses. For this purpose, two models were examined. One was of an elastomeric metacarpophalangeal joint implant, with the material being assumed to have isotropic elastic properties in one case while it was represented as hyperelastic in the other. The model used in the second study case was that of a construct comprising the tibial component of a total knee replacement, the associated tibial insert, the resected bones, and the acrylic bone cement layer. In one analysis of this model, all the materials were taken to have isotropic elastic properties, while in the other analysis, the cortical bone was represented as transversely isotropic, with all other materials being considered to have isotropic elastic properties. The result show that, in both study cases considered, there is a strong effect of the representation of the elastic properties of material(s) on the stresses in the models.

Effect of the archwire slot profile on the performance of bonded orthodontic brackets.

The finite element analysis method and a two-dimensional idealization were used to conduct a parametric study of the effect of the archwire slot (or insert) profile on the stresses in, deformation of, and efficiency of a model of a bonded edge-wise "combination-materials" type of orthodontic bracket. The results are consistent with a priori expectations and are qualitatively the same as those obtained by previous workers who used the two-dimensional photoelasticity stress analysis method. The results thus highlight a possible approach to improving the clinical performance of these brackets.

Inverted cyclops lesion after anterior cruciate ligament reconstruction.

We report the case of an inverted cyclops lesion limiting extension of the knee joint after a four-strand hamstring anterior cruciate ligament (ACL) reconstruction. One case has been reported previously following a bone-tendon-bone reconstruction of the ACL but a similar case has not been reported.

Management of severe Dupuytren's contracture of the proximal interphalangeal joint with use of a central slip facilitation device.

Thirty-eight fingers in 27 patients with Dupuytren's contracture of the proximal interphalangeal joint (PIPJ) in excess of 70° were treated using a staged technique. The first stage involved applying a mini external fixator across the PIPJ for continuous extension over 6 weeks with intensive hand therapy to maintain mobility of the joint and help correct the deformity. Twice weekly during hand therapy sessions the tension of the elastic band across the mini ex-fix was increased, allowing that full active flexion of the PIPJ against the elastic band could still be achieved. The second stage, 4 weeks after the external fixator was applied, involved an open palm technique of fasciectomy for the contracted cords restricting metacarpophalangeal joint movement and dermofasciectomy with full-thickness skin grafting over the proximal phalanx for bands restricting PIPJ movement. The external fixator was used to maintain active extension force until the graft healed. It was generally removed in the outpatient clinic under ring block 2 weeks after the second stage procedure. The patients were followed for a mean of 20.6 (6-48) months. The mean preoperative PIPJ deformity improved from 75° to 37° postoperatively. Overall, 69% of results were rated as good to excellent. Only one patient reported any on-going functional problems. There were eight cases of pin site infections and one case each of loose pins, osteoarthritics at the PIPJ, reflex sympathetic dystrophy, and disease recurrence needing PIPJ fusion. We conclude that our simple staged procedure is a valid alternative in the management of severe Dupuytren's PIPJ contracture.

Inhibition of p38alpha MAPK disrupts the pathological loop of proinflammatory factor production in the myelodysplastic syndrome bone marrow microenvironment.

Myelodysplastic syndromes (MDS) are common causes of ineffective hematopoiesis and cytopenias in the elderly. Various myelosuppressive and proinflammatory cytokines have been implicated in the high rates of apoptosis and hematopoietic suppression seen in MDS. We have previously shown that p38 MAPK is overactivated in MDS hematopoietic progenitors, which led to current clinical studies of the selective p38alpha inhibitor, SCIO-469, in this disease. We now demonstrate that the myelosuppressive cytokines TNFalpha and IL-1beta are secreted by bone marrow (BM) cells in a p38 MAPK-dependent manner. Their secretion is stimulated by paracrine interactions between BM stromal and mononuclear cells and cytokine induction correlates with CD34+ stem cell apoptosis in an inflammation-simulated in vitro bone marrow microenvironment. Treatment with SCIO-469 inhibits TNF secretion in primary MDS bone marrow cells and protects cytogenetically normal progenitors from apoptosis ex vivo. Furthermore, p38 inhibition diminishes the expression of TNFalpha or IL-1beta-induced proinflammatory chemokines in BM stromal cells. These data indicate that p38 inhibition has anti-inflammatory effects on the bone marrow microenvironment that complements its cytoprotective effect on progenitor survival. These findings support clinical investigation of p38alpha as a potential therapeutic target in MDS and other related diseases characterised by inflammatory bone marrow failure.

Population structure and colony composition of two Zootermopsis nevadensis subspecies.

Understanding the origin and maintenance of eusociality in termites has proved problematic, in part, due to a lack of knowledge concerning the variability and evolutionary changes in termite breeding structure. One way to address this is to compare the population genetics of a broad range of termite species. However, few studies have investigated the population genetics of basal termite taxa. We used 12 polymorphic microsatellite loci to characterize and compare the colony genetic structure of 18 colonies of two basal termite subspecies, Zootermopsis nevadensis nevadensis and Zootermopsis nevadensis nuttingi. The average relatedness (r) among individuals within a colony was high (0.59) and similar to values reported for other termite species. Average relatedness between colony founders was lower (0.21) suggesting the alates outbreed. Genotypes of workers and soldiers in 4 out of the 18 colonies were consistent with reproduction by a single pair of primary reproductives and the remaining colonies were inferred to have been derived from more than two reproductives. Eleven colonies with three or more reproductives were consistent with replacement reproductives (neotenics) and the remaining three colonies included genetic contribution from three or more primary reproductives. Comparisons between the subspecies revealed significant differences in breeding structure, specifically in the number and types of reproductives (that is, primaries or neotenics). Furthermore, we observed a larger proportion of colonies with greater than three primary reproductives compared to more derived termite lineages. Thus, our results suggest that breeding structure can vary significantly among termite taxa.

Accelerated bone healing and excessive callus formation in patients with femoral fracture and head injury.

The effect of head injury on systemic physiology, including bone healing is still a topic of vivid discussion. Whether the observed changes genuinely represent accelerated fracture healing or are a form of local heterotopic ossification remains unclear. We aimed to investigate whether in patients with long bone fractures the presence of head injury is associated with accelerated bone healing and excessive callus formation. In total 67 patients were studied 17 with head injury and 50 without head injury (25 treated with reamed and the other 25 with the unreamed nailing technique). Both groups were comparable in terms of age, sex, ISS. All underwent stabilisation of their femoral fracture with intramedullary nailing. The quantification of fracture healing response was estimated by taking the radiological ratio of the largest diameter of callus formed into two planes and the adjacent normal diameter of femoral canal. The minimum follow up of the patients was 12 months. In patients with head injury, the mean time to fracture union was significantly shorter than either the reamed or unreamed group (10.5 weeks compared with 20.5 and 26.9 weeks, p<0.001). The difference between the mean callus to diaphyseal ratio was statistically significant for both the AP and Lateral projections (AP: mean difference 0.462, 95% CI 0.312 to 0.602, p<0.0001, LAT: mean difference 0.289, 95% CI 0.142 to 0.436, p<0.001) with the head injured patients having more florid callus compared to the control group.