Efficacy and safety of midostaurin in patients with advanced systemic mastocytosis: 10-year median follow-up of a phase II trial.

Patients with advanced systemic mastocytosis (SM) (e.g. aggressive SM (ASM), SM with an associated hematologic neoplasm (SM-AHN) and mast cell leukemia (MCL)) have limited treatment options and exhibit reduced survival. Midostaurin is an oral multikinase inhibitor that inhibits D816V-mutated KIT, a primary driver of SM pathogenesis. We conducted a phase II trial of midostaurin 100 mg twice daily, administered as 28-day cycles, in 26 patients (ASM, n=3; SM-AHN, n= 17; MCL, n=6) with at least one sign of organ damage. During the first 12 cycles, the overall response rate was 69% (major/partial response: 50/19%) with clinical benefit in all advanced SM variants. With ongoing therapy, 2 patients achieved a complete remission of their SM. Midostaurin produced a ⩾50% reduction in bone marrow mast cell burden and serum tryptase level in 68% and 46% of patients, respectively. Median overall survival for the entire cohort was 40 months, and 18.5 months for MCL patients. Low-grade gastrointestinal side effects were common and manageable with antiemetics. The most frequent grade 3/4 nonhematologic and hematologic toxicities were asymptomatic hyperlipasemia (15%) and anemia (12%). With median follow-up of 10 years, no unexpected toxicities emerged. These data establish the durable activity and tolerability of midostaurin in advanced SM.

Safety, efficacy and biological predictors of response to sequential azacitidine and lenalidomide for elderly patients with acute myeloid leukemia.

Acute myeloid leukemia (AML) is a disease of the elderly. Poor outcomes with standard therapies necessitate novel approaches. Outpatient regimens sufficiently potent and well tolerated to induce remissions and enable continuation therapy may be beneficial. In this phase-1 study, we determined the maximum tolerated dose (MTD) and the efficacy for sequential azacitidine and lenalidomide as remission induction and continuation therapy in elderly, previously untreated patients. We investigated the impact on global DNA methylation and bone marrow cytokines, and sought biological predictors of response. Eighteen patients were enrolled. The MTD was not reached. Median follow-up was 8.2 months (10.3 months for survivors). Common adverse events included fatigue, injection site reactions, constipation, nausea, pruritus and febrile neutropenia. Ten patients responded (56%), and the rate of complete remissions (CRs) or CRs with incomplete recovery of blood counts for evaluable patients was 44% (7/16). The median response duration was 6.2 months. DNA demethylation and changes in bone marrow cytokines were observed; responders had a unique cytokine profile and a trend towards lower methylation levels. Sequential azacitidine and lenalidomide was well tolerated with encouraging clinical and biological activity in previously untreated elderly AML patients. This trial is registered at ClinicalTrials.gov (NCT00890929).

Synthesis and X-ray crystal structure determination of first examples of donor-functionalized terphenyl lanthanide complexes.

The molecular structures of novel donor-functionalized terphenyl derivatives of trivalent ytterbium, yttrium, and samarium of composition [DanipYb(mu2-Cl)2(mu3-Cl)Li(THF)]2 (1) and [DanipLn(mu2-Cl)2(mu2-Cl)Li(THF)2]2 (Ln = Y, 2; Ln = Sm, 3) are reported [Danip = 2,6-di(o-anisol)phenyl]. The complexes are obtained from the reaction of equimolar amounts of DanipLi and LnCl3 (Ln = Yb, Y, Sm) in tetrahydrofuran at room temperature in 60% yield. 1-2 toluene crystallizes in the monoclinic space group Ponebar. Crystal data for 1-2 toluene at 203 K: a = 9.7281(9) A; b = 12.7989(12) A; c = 13.4870(12) A; alpha = 91.553(2) degrees; beta = 103.957(2) degrees; gamma = 109.916(2) degrees; V = 1521.2(2) A(3); Z' = 1; D(calcd) = 1.615 g cm(-3); R1 = 3.43%. 2-toluene crystallizes in the monoclinic space group Ponebar. Crystal data for 2-toluene at 203 K: a = 10.4152(10) A; b = 12.5783(12) A; c = 14.4640(14) A; alpha = 69.963(2) degrees; beta = 80.900(2) degrees; gamma = 66.603(2) degrees; V = 1633.3(3) A(3); Z' = 1; D(calcd) = 1.386 g cm(-3); R1 = 4.07%. 3-toluene crystallizes in the monoclinic space group Ponebar. Crystal data for 3-toluene at 203 K: a = 10.3457(8) A; b = 12.5658(10) A; c = 14.4365(11) A; alpha = 70.2250(10) degrees; beta = 81.2820(10) degrees; gamma = 66.8330(10) degrees; V = 1623.3(2) A(3); Z' = 1; D(calcd) = 1.521 g cm(-3); R1 = 3.40%. Complexes 1-3 represent first examples of donor-functionalized terphenyl complexes of the elements ytterbium, yttrium, and samarium, respectively. The molecular structures of 1-3 feature a "constraint geometry" type arrangement of the Danip ligand at the lanthanide atom. The complexes reported are dimeric and composed of lithium chloride bridged DanipLnCl(2) moieties (Ln = Yb, Y, Sm), stabilized through additional coordination of two methoxy functions to the lanthanide atom.

Terphenyl ligand systems in lanthanide chemistry: use of the 2,6-di(1-naphthyl)phenyl ligand for the synthesis of kinetically stabilized complexes of trivalent ytterbium, thulium, and yttrium.

The molecular structures of terphenyl derivatives of trivalent ytterbium, thulium, and yttrium of general composition DnpLnCl(2)(THF)(2) [Dnp = 2,6-di(1-naphthyl)phenyl] are reported. The complexes (Ln = Yb: 1; Ln = Tm: 2; Ln = Y: 3) are synthesized by reaction of 1 equiv of DnpLi with 1 equiv of LnCl(3) (Ln = Yb, Tm, or Y) in tetrahydrofuran at room temperature in 50% yield. Attempts to prepare a Dnp scandium compound gave heterobimetallic [(THF)(3)Sc(2)OCl(5)Li(THF)](2) (4) in low yield. 1 crystallizes in the monoclinic space group C2/c. Crystal data for 1 at 203 K: a = 14.333(3) A, b = 16.353(3) A, c = 12.427(2) A, beta = 91.021(4) degrees, Z = 4, D(calcd) = 1.637 g cm(-3), R(1) = 4.44%. 2 crystallizes in the monoclinic space group C2/c. Crystal data for 2 at 203 K: a = 14.333(1) A, b = 16.374(2) A, c = 12.404(1) A, beta = 90.934(2) degrees, Z = 4, D(calcd) = 1.628 g cm(-3), R(1) = 3.00%. 3 crystallizes in the monoclinic space group C2/c. Crystal data for 3 at 203 K: a = 14.348(3) A, b = 16.476(3) A, c = 12.356(2) A, beta = 90.987(4) degrees, Z = 4, D(calcd) = 1.441 g cm(-3), R(1) = 5.62%. 4 crystallizes in the monoclinic space group P2(1)/n. Crystal data for 4 at 203 K: a = 11.0975(9) A, b = 11.0976(9) A, c = 21.3305(18) A, beta = 94.718(2) degrees, Z = 2, D(calcd) = 1.051 g cm(-3), R(1) = 3.45%. Complexes 1-3 represent examples of novel chiral (racemic) organometallic complexes of the lanthanide elements ytterbium and thulium and the group 3 element yttrium, respectively. The molecular structures of monomeric 1-3 exhibit distorted trigonal-bipyramidal coordination environments at the metal center, with the two oxygen atoms of the tetrahydrofuran ligands occupying the axial positions of a trigonal-bipyramidal coordination polyeder. The molecular structure of the scandium compound 4 shows a complex polynuclear heterobimetallic arrangement.

Aerobic and strength training in patients with chronic obstructive pulmonary disease.

The purpose of this study was to evaluate whether strength training is a useful addition to aerobic training in patients with chronic obstructive pulmonary disease (COPD). Forty-five patients with moderate to severe COPD were randomized to 12 wk of aerobic training alone (AERO) or combined with strength training (AERO + ST). The AERO regimen consisted of three weekly 30-min exercise sessions on a calibrated ergocycle, and the ST regimen included three series of eight to 10 repetitions of four weight lifting exercises. Measurements of peripheral muscle strength, thigh muscle cross-sectional area (MCSA) by computed tomographic scanning, maximal exercise capacity, 6-min walking distance (6MWD), and quality of life with the chronic respiratory questionnaire were obtained at baseline and after training. Thirty-six patients completed the program and constituted the study group. The strength of the quadriceps femoris increased significantly in both groups (p < 0.05), but the improvement was greater in the AERO + ST group (20 +/- 12% versus 8 +/- 10% [mean +/- SD] in the AERO group, p < 0.005). The thigh MCSA and strength of the pectoralis major muscle increased in the AERO + ST group by 8 +/- 13% and 15 +/- 9%, respectively (p < 0.001), but not in the AERO group (3 +/- 6% and 2 +/- 10%, respectively, p > 0.05). These changes were significantly different in the two study groups (p < 0.01). The increase in strength of the latissimus dorsi muscle after training was modest and of similar magnitude for both groups. The changes in peak exercise work rate, 6MWD, and quality of life were comparable in the two groups. In conclusion, the addition of strength training to aerobic training in patients with COPD is associated with significantly greater increases in muscle strength and mass, but does not provide additional improvement in exercise capacity or quality of life.

The relationship of antiphospholipid antibodies to thromboembolic events in pediatric patients with systemic lupus erythematosus: a cross-sectional study.

The purpose of this study was to evaluate pediatric patients with systemic lupus erythematosus (SLE) to determine 1) the incidence of thrombosis, 2) the incidence of antiphospholipid antibodies, and 3) whether there is an association between the presence of antiphospholipid antibodies and thrombosis. We performed a cross-sectional cohort study in 59 consecutive SLE patients who had been managed at rheumatology clinics in two pediatric hospitals. A history, questionnaire, and chart review were completed by the study nurse blinded to laboratory results. Only the thrombotic events that could be substantiated by review of radiographic tests were accepted. The presence of antiphospholipid antibodies was determined by prospective analysis for a lupus anticoagulant and anticardiolipin antibodies on two separate occasions at least 3 mo apart. Patients were considered to be positive if one or more tests were positive on both occasions. Thirteen thrombotic events occurred in 10 of the 59 patients (17%). Fourteen patients (24%) were classified as positive for lupus anticoagulant, and 19 patients (27%) were classified as positive for anticardiolipin antibodies. A significant relationship between the presence of a lupus anticoagulant and a thrombotic event was shown: odds ratio 28.7 (95% confidence interval 4.03-138.2, p < 0.001). A nonsignificant trend was seen for the presence of an anticardiolipin antibody and a thrombotic event: odds ratio 2.12 (95% confidence interval 0.71-22.8, p=0.08). We conclude that in pediatric patients with SLE: 1) a significant proportion of patients have thrombotic events, 2) a significant proportion of patients have antiphospholipid antibodies, and 3) there is a significant relationship between the presence of a lupus anticoagulant and thrombotic events.

Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease.

The applicability of high-intensity training and the possibility of inducing physiologic adaptation to training are still uncertain in patients with severe chronic obstructive pulmonary disease (COPD). The purposes of this study were to evaluate the proportion of patients with moderate to severe COPD in whom high-intensity exercise training (30-min exercise session at 80% of baseline maximal power output [Wmax]) is feasible, and the response to training in these patients. We also sought to evaluate the possible influence of disease severity on the training intensity achieved and on the development of physiologic adaptation following endurance training. Forty-two patients with COPD (age = 66 +/- 7 yr, FEV1 = 38 +/- 13% predicted, [mean +/- SD]) were evaluated at baseline and after a 12-wk endurance training program. Each evaluation included a stepwise exercise test on an ergocycle up to the individual maximal capacity during which minute ventilation (VE), oxygen consumption (VO2), carbon dioxide production (VCO2), and arterial lactic acid concentrations were measured. The training consisted of 25 to 30-min exercise sessions on a calibrated ergocycle three times a week, with a target training intensity at 80% of Wmax. The training intensity was adjusted with the objective of reaching the target intensity, but also to ensure that the cycling exercise could be maintained for the specified duration. The training intensity sustained for the duration of each exercise session averaged 24.5 +/- 12.6, 51.7 +/- 17.4, 63.8 +/- 22.4, and 60.4 +/- 22.7% of Wmax at Weeks 2, 4, 10, and 12, respectively. High-intensity training was achieved in zero, three, five, and five patients at Weeks 2, 4, 10, and 12, respectively. A significant increase in VO2max and Wmax occurred with training (p < 0.0002). This improvement in exercise capacity was accompanied by a 6% and 17% reduction in VE and in arterial lactic acid concentration for a given work rate, respectively (p < 0.0001), suggesting that physiologic adaptation to training occurred. The intensity of training achieved, in % Wmax, was not influenced by the initial VO2max, age, or FEV1. The effects of training were compared in patients with an FEV1 > or = 40% or < 40% predicted. Percent changes in VO2max, Wmax, and VE, were significant and of similar magnitude for both groups, whereas the decrease in arterial lactic acid for a given work rate reached statistical significance only in those patients with an FEV1 > or = 40% predicted. We conclude that although most patients were unable to achieve high-intensity training as defined in this study, significant improvement in their exercise capacity was obtained and physiologic adaptation to endurance training occurred. The training intensity expressed as a percent of the individual maximum exercise capacity, and the relative effectiveness of training, were not influenced by the severity of airflow obstruction.

Skeletal muscle adaptation to endurance training in patients with chronic obstructive pulmonary disease.

The purpose of this study was to evaluate the physiologic responses to endurance training in patients with moderate to severe airflow obstruction by specifically looking at changes in skeletal muscle enzymatic activities. Eleven patients (age = 65 +/- 7 yr, mean +/- SD, FEV1 = 36 +/- 11% of predicted value, range = 24 to 54%) were evaluated before and after an endurance training program. Each evaluation included a percutaneous biopsy of the vastus lateralis and a stepwise exercise test on an ergocycle up to his/her maximal capacity. VE, VO2, VcO2, and serial arterial lactic acid concentration were measured during the exercise test. The activity of two oxidative enzymes, citrate synthase (CS) and 3-hydroxyacyl-CoA dehydrogenase (HADH), and of three glycolytic enzymes, lactate dehydrogenase, hexokinase, and phosphofructokinase was determined. The training consisted of 30-min exercise sessions on a calibrated ergocycle, 3 times a week for 12 wk. The aerobic capacity was severely reduced at baseline (VO2max = 54 +/- 12% of predicted) and increased by 14% after training (p < 0.05). For an identical exercise workload, there was a significant reduction in VE (34.5 +/- 10.0 versus 31.9 +/- 9.0 L/min, p < 0.05) and in arterial lactic acid concentration (3.4 +/- 1.3 versus 2.8 +/- 0.9 mmol/L, p < 0.01) after training. The lactate threshold also increased after training (p < 0.01) while the activity of the three glycolytic enzymes was similar at the two evaluations. In contrast, the activity of CS and HADH increased significantly after training (22.3 +/- 3.5 versus 25.8 +/- 3.8 mumol/min/g muscle for CS, p < 0.05, and 5.5 +/- 2.9 versus 7.7 +/- 2.5 mumol/min/g for HADH, p < 0.01). A significant inverse relationship was found between the percent changes in the activity of CS and HADH, and the percent changes in arterial lactic acid during exercise (p = 0.01). We conclude that endurance training can reduce exercise-induced lactic acidosis and improve skeletal muscle oxidative capacity in patients with moderate to severe chronic obstructive pulmonary disease (COPD).

Characterization of an acquired IgG inhibitor of coagulation factor XIII in a patient with systemic lupus erythematosus.

An acquired IgG inhibitor to factor XIII was identified in a 30-year-old Vietnamese woman with systemic lupus erythematosus. The IgG fraction was isolated from plasma by chromatography on an agarose gel column and by protein G adsorption. The anti-factor XIII activity, identified within the IgG fraction, inhibited factor XIII from both normal plasma (a2b2) and platelets (a2). A normal level of the b subunit was measured by immunoelectrophoresis of the patient's plasma, but the a subunit was not detected. These results suggested the presence of an IgG immunoglobulin which recognized the a subunit and interfered with its activity.

Vertical Flux of Biogenic Carbon in the Ocean: Is There Food Web Control?

Models of biogenic carbon (BC) flux assume that short herbivorous food chains lead to high export, whereas complex microbial or omnivorous food webs lead to recycling and low export, and that export of BC from the euphotic zone equals new production (NP). In the Gulf of St. Lawrence, particulate organic carbon fluxes were similar during the spring phytoplankton bloom, when herbivory dominated, and during nonbloom conditions, when microbial and omnivorous food webs dominated. In contrast, NP was 1.2 to 161 times greater during the bloom than after it. Thus, neither food web structure nor NP can predict the magnitude or patterns of BC export, particularly on time scales over which the ocean is in nonequilibrium conditions.

A novel congenital haemostatic defect: combined factor VII and factor XI deficiency.

Isolated deficiencies of factors VII and XI are both rare. Not surprisingly, therefore, combined factor VII and XI deficiency has not been reported previously. We report here a kindred with a combined heterozygous deficiency for both factors VII and XI. The proposita is a 28-year-old woman who had both a prolonged prothrombin time (PT) and a prolonged activated partial prothrombin time (APTT) associated with a mild bleeding tendency. Coagulation studies were performed on the six available members of this kindred. The PT and APTT were normal or mildly abnormal in five of these individuals. Factor VII coagulant activity (VII:C) varied from 0.33 to 0.77 units/ml in affected subjects. In contrast, the concentration of factor VII-related antigen for the six individuals ranged from 0.68 to 2.10 units/ml. Comparable factor VII:C levels were obtained when each subject's plasma was tested with either a rabbit or a human thromboplastin reagent. Factor XI coagulant activity was less than 0.5 units/ml in three of the six subjects and normal (approximately 1.0 units/ml) in the other three. The concentrations of thrombin-antithrombin-III and prothrombin fragment 1.2 were within normal limits for all individuals. In addition to being associated with heterozygous factor XI deficiency, the abnormal factor VII molecule in the plasma of affected individuals in this kindred appears to represent a newly described mutation. This is suggested by the pattern of reactivity with thromboplastin from different species, the normal tissue factor binding and the bleeding tendency in heterozygous individuals in this kindred.