Updated results from the phase 3 HELIOS study of ibrutinib, bendamustine, and rituximab in relapsed chronic lymphocytic leukemia/small lymphocytic lymphoma.

We report follow-up results from the randomized, placebo-controlled, phase 3 HELIOS trial of ibrutinib+bendamustine and rituximab (BR) for previously treated chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) without deletion 17p. Overall, 578 patients were randomized 1:1 to either ibrutinib (420 mg daily) or placebo, in combination with 6 cycles of BR, followed by ibrutinib or placebo alone. Median follow-up was 34.8 months (range: 0.1-45.8). Investigator-assessed median progression-free survival (PFS) was not reached for ibrutinib+BR, versus 14.3 months for placebo+BR (hazard ratio [HR] [95% CI], 0.206 [0.159-0.265]; P < 0.0001); 36-month PFS rates were 68.0% versus 13.9%, respectively. The results are consistent with the primary analysis findings (HR = 0.203, as assessed by independent review committee, with 17-month median follow-up). Median overall survival was not reached in either arm; HR (95% CI) for ibrutinib+BR versus placebo: 0.652 (0.454-0.935; P = 0.019). Minimal residual disease (MRD)-negative response rates were 26.3% for ibrutinib+BR and 6.2% for placebo+BR (P < 0.0001). Incidence of treatment-emergent adverse events (including grades 3-4) were generally consistent with the initial HELIOS report. These long-term data support improved survival outcomes and deepening responses with ibrutinib+BR compared with BR in relapsed CLL/SLL.

EGR2 mutations define a new clinically aggressive subgroup of chronic lymphocytic leukemia.

Recurrent mutations within EGR2 were recently reported in advanced-stage chronic lymphocytic leukemia (CLL) patients and associated with a worse outcome. To study their prognostic impact, 2403 CLL patients were examined for mutations in the EGR2 hotspot region including a screening (n=1283) and two validation cohorts (UK CLL4 trial patients, n=366; CLL Research Consortium (CRC) patients, n=490). Targeted deep-sequencing of 27 known/postulated CLL driver genes was also performed in 38 EGR2-mutated patients to assess concurrent mutations. EGR2 mutations were detected in 91/2403 (3.8%) investigated cases, and associated with younger age at diagnosis, advanced clinical stage, high CD38 expression and unmutated IGHV genes. EGR2-mutated patients frequently carried ATM lesions (42%), TP53 aberrations (18%) and NOTCH1/FBXW7 mutations (16%). EGR2 mutations independently predicted shorter time-to-first-treatment (TTFT) and overall survival (OS) in the screening cohort; they were confirmed associated with reduced TTFT and OS in the CRC cohort and independently predicted short OS from randomization in the UK CLL4 cohort. A particularly dismal outcome was observed among EGR2-mutated patients who also carried TP53 aberrations. In summary, EGR2 mutations were independently associated with an unfavorable prognosis, comparable to CLL patients carrying TP53 aberrations, suggesting that EGR2-mutated patients represent a new patient subgroup with very poor outcome.

Development and evaluation of a secondary reference panel for BCR-ABL1 quantification on the International Scale.

Molecular monitoring of chronic myeloid leukemia patients using robust BCR-ABL1 tests standardized to the International Scale (IS) is key to proper disease management, especially when treatment cessation is considered. Most laboratories currently use a time-consuming sample exchange process with reference laboratories for IS calibration. A World Health Organization (WHO) BCR-ABL1 reference panel was developed (MR(1)-MR(4)), but access to the material is limited. In this study, we describe the development of the first cell-based secondary reference panel that is traceable to and faithfully replicates the WHO panel, with an additional MR(4.5) level. The secondary panel was calibrated to IS using digital PCR with ABL1, BCR and GUSB as reference genes and evaluated by 44 laboratories worldwide. Interestingly, we found that >40% of BCR-ABL1 assays showed signs of inadequate optimization such as poor linearity and suboptimal PCR efficiency. Nonetheless, when optimized sample inputs were used, >60% demonstrated satisfactory IS accuracy, precision and/or MR(4.5) sensitivity, and 58% obtained IS conversion factors from the secondary reference concordant with their current values. Correlation analysis indicated no significant alterations in %BCR-ABL1 results caused by different assay configurations. More assays achieved good precision and/or sensitivity than IS accuracy, indicating the need for better IS calibration mechanisms.

Distinct patterns of novel gene mutations in poor-prognostic stereotyped subsets of chronic lymphocytic leukemia: the case of SF3B1 and subset #2.

Recent studies have revealed recurrent mutations of the NOTCH1, SF3B1 and BIRC3 genes in chronic lymphocytic leukemia (CLL), especially among aggressive, chemorefractory cases. Nevertheless, it is currently unknown whether their presence may differ in subsets of patients carrying stereotyped B-cell receptors and also exhibiting distinct prognoses. Here, we analyzed the mutation status of NOTCH1, SF3B1 and BIRC3 in three subsets with particularly poor prognosis, that is, subset #1, #2 and #8, aiming to explore links between genetic aberrations and immune signaling. A remarkably higher frequency of SF3B1 mutations was revealed in subset #2 (44%) versus subset #1 and #8 (4.6% and 0%, respectively; P<0.001). In contrast, the frequency of NOTCH1 mutations in subset #2 was only 8%, lower than the frequency observed in either subset #1 or #8 (19% and 14%, respectively; P=0.04 for subset #1 versus #2). No associations were found for BIRC3 mutations that overall were rare. The apparent non-random association of certain mutations with stereotyped CLL subsets alludes to subset-biased acquisition of genomic aberrations, perhaps consistent with particular antigen/antibody interactions. These novel findings assist in unraveling specific mechanisms underlying clinical aggressiveness in poor-prognostic stereotyped subsets, with far-reaching implications for understanding their clonal evolution and implementing biologically oriented therapy.

[Neurological soft signs in schizophrenia: correlations with age, sex, educational status and psychopathology].

Though the pathobiology of schizophrenia can be examined in multiple levels, the organic notion of brain disease suggests that neurological features will be present. One straightforward, inexpensive method of investigating brain dysfunction in schizophrenia is thought the bedside assessment of neurological abnormalities with a standard neurological examination. Neurological abnormalities are traditionally classified as "hard signs" (impairments in basic motor, sensory, and reflex behaviors, which do not appear to be affected in schizophrenia) and "soft signs", which refer to more complex phenomena such as abnormalities in motor control, integrative sensory function, sensorimotor integration, and cerebral laterality. Additionally, neurological soft signs (NSS) are minor motor and sensory abnormalities that are considered to be normal in the course of early development but abnormal when elicited in later life or persist beyond childhood. Soft signs also, have no definitive localizing significance but are indicative of subtle brain dysfunction. Most authors believe that they are a reflection not only of deficient integration between the sensory and motor systems, but also of dysfunctional neuronal circuits linking subcortical brain structures such as the basal ganglia, the brain stem, and the limbic system. Throughout the last four decades, studies have consistently shown that NSS are more frequently present in patients with schizophrenia than in normal subjects and non-psychotic psychiatric patients. However, the functional relevance of NSS remains unclear and their specificity has often been challenged, even though there is indication for a relative specificity with regard to diagnosis, or symptomatology. Many studies have considered soft signs as categorical variables thus hampering the evaluation of fluctuation with symptomatology and/or treatment, whereas other studies included insufficient number of assessed signs, or lacked a comprehensive assessment of extrapyramidal symptomatology. Factors such as sex, age or family history of schizophrenia, are said to influence the performance of neurological examination, whereas relative few studies have provided longitudinal follow-up data on neurological soft signs in a sufficient number of patients, in order to address a possible deterioration of neurological functions. Finally, one additional difficulty when analyzing the NSS literature lies in the diversity of symptoms that are evaluated in the studies and/or non-standardized procedures or scoring. We will review some basic issues concerning recurrent difficulties in the measurement and definition of soft signs, as well as controversies on the significance of these signs with respect to clinical subtyping of schizophrenia, and social and demographic variables.

Industrial yogurt manufacture: monitoring of fermentation process and improvement of final product quality.

Lactic acid fermentation during the production of skim milk and whole fat set-style yogurt was continuously monitored by measuring pH. The modified Gompertz model was successfully applied to describe the pH decline and viscosity development during the fermentation process. The viscosity and incubation time data were also fitted to linear models against ln(pH). The investigation of the yogurt quality improvement practices included 2 different heat treatments (80 degrees C for 30 min and 95 degrees C for 10 min), 3 milk protein fortifying agents (skim milk powder, whey powder, and milk protein concentrate) added at 2.0%, and 4 hydrocolloids (kappa-carrageenan, xanthan, guar gum, and pectin) added at 0.01% to whole fat and skim yogurts. Heat treatment significantly affected viscosity and acetaldehyde development without influencing incubation time and acidity. The addition of whey powder shortened the incubation time but had a detrimental effect on consistency, firmness, and overall acceptance of yogurts. On the other hand, addition of skim milk powder improved the textural quality and decreased the vulnerability of yogurts to syneresis. Anionic stabilizers (kappa-carrageenan and pectin) had a poor effect on the texture and palatability of yogurts. However, neutral gums (xanthan and guar gum) improved texture and prevented the wheying-off defect. Skim milk yogurts exhibited longer incubation times and higher viscosities, whereas they were rated higher during sensory evaluation than whole fat yogurts.

Beneficial effect of long-acting injectable risperidone on the neurocognitive deficit of a schizophrenic patient: A case report.

We report the case of a 37-year-old female patient suffering from schizophrenia, disorganized type. Adherence to treatment was always a major problem. During the last 2 years the patient was disorganized and was refusing treatment. Since the patient was already receiving a very high (double) dose per os, it was decided to administer two 50 ml ampoules of long-acting, injectable risperidone plus 5 mg of haloperidol per os daily. After 80 days of treatment, all positive, negative and even neurocognitive symptoms improved markedly. Extrapyramidal side effects did not appear at any stage of treatment. The most impressive neurocognitive improvement concerned the clock drawing test, which was in parallel with her improvement in both the positive and negative symptoms of the PANSS.

pH-specific aqueous synthetic chemistry in the binary cadmium(II)-citrate system. Gaining insight into cadmium(II)-citrate speciation with relevance to cadmium toxicity.

The involvement of Cd(II) in toxic manifestations and pathological aberrations in lower and higher organisms entails interactions with low and high molecular mass biological targets. To understand the relevant chemistry in aqueous media, we have launched pH-dependent synthetic efforts targeting Cd(II) with the physiological ligand citric acid. Reactions of Cd(II) with citric acid upon the addition of NaOH at pH 2.5 and pyridine at pH 3 and the addition of ammonia at pH approximately 7 led to the new complexes [Cd3(C6H5O7)2(H2O)5] x H2O (1) and (NH4)[Cd(C6H5O7)(H2O)] x H2O (2), respectively. Complexes 1 and 2 were characterized by elemental analysis, spectroscopy (FT-IR and NMR), and X-ray crystallography. Complex 1 crystallizes in the monoclinic space group P2(1)/n, with a = 18.035(6) A, b = 10.279(4) A, c = 12.565(4) A, beta = 109.02(1) degrees, V = 2202(2) A3, and Z = 4. Complex 2 crystallizes in the monoclinic space group P2(1), with a = 9.686(4) A, b = 8.484(4) A, c = 7.035(3) A, beta = 110.28(1) degrees, V = 542.3(4) A3, and Z = 2. Complex 1 is a trinuclear assembly with the citrate ligand securing a stable metallacyclic ring around one Cd(II), with the terminal carboxylates spanning into the coordination sphere of two nearby Cd(II) ions. Complex 2 contains mononuclear units of Cd(II) bound by citrate in an overall coordination number of 8. In both 1 and 2, the participating citrates exhibit three different modes of coordination, thus projecting a distinct yet variable aqueous structural chemistry of Cd(II) with physiological substrates. The pH-dependent chemistry and its apparent structural diversity validate past solution speciation studies, projecting the existence of mononuclear species such as the one in the anion of 2. The spectroscopic and structural properties of 2 emphasize the significance of the information emerging from synthetic studies that otherwise would not have been revealed through conventional solution studies, while concurrently shedding light onto the linkage of the requisite chemistry with the potential biological toxicity of Cd(II).

Mononuclear titanium(IV)-citrate complexes from aqueous solutions: pH-specific synthesis and structural and spectroscopic studies in relevance to aqueous titanium(IV)-citrate speciation.

Titanium is a metal frequently employed in a plethora of materials supporting medical applications. In an effort to comprehend the involvement of titanium in requisite biological interactions with physiological ligands, synthetic efforts were launched targeting aqueous soluble species of Ti(IV). To this end, aqueous reactions of TiCl(4) with citric acid afforded expediently, under pH-specific conditions, the colorless crystalline materials Na(6)[Ti(C(6)H(4.5)O(7))(2)(C(6)H(5)O(7))].16H(2)O (1) and Na(3)(NH(4))(3)[Ti(C(6)H(4.5)O(7))(2)(C(6)H(5)O(7))].9H(2)O (2). Complexes 1 and 2 were characterized by elemental analysis, FT-IR, (13)C-MAS solid state and solution NMR, cyclic voltammetry, and X-ray crystallography. 1 crystallizes in the triclinic space group P, with a = 15.511(9) A, b = 15.58(1) A, c = 9.848(5) A, alpha = 85.35(2) degrees, beta = 76.53(2) degrees, gamma = 61.97(2) degrees, V = 2042(2) A(3), and Z = 2. 2 crystallizes in the triclinic space group P, with a = 12.437(5) A, b = 12.440(5) A, c = 12.041(5) A, alpha = 83.08(2) degrees, beta = 81.43(2) degrees, gamma = 67.45(2) degrees, V = 1697(2) A(3), and Z = 2. The X-ray structures of 1 and 2 reveal the presence of a mononuclear complex, with Ti(IV) coordinated to three citrate ligands in a distorted octahedral geometry around Ti(IV). The citrates employ their central alkoxide and carboxylate groups to bind Ti(V), while the terminal carboxylates stay away from the Ti(IV)O(6) core. Worth noting in 1 and 2 is the similar mode of coordination but variable degree of protonation of the bound citrates, with the locus of (de)protonation being the noncoordinating terminal carboxylates. As a result, this work suggests the presence of a number of different Ti(IV)-citrate species of the same nuclearity and coordination geometry as a function of pH. This is consistent with the so far existing pool of mononuclear Ti(IV)-citrate species and provides a logical account of the aqueous speciation in the requisite binary system. Such information is vital in trying to delineate the interactions of soluble and bioavailable Ti(IV) forms promoting biological interactions in humans. To this end, chemical properties, structural attributes, and speciation links to potential ensuing biological effects are dwelled on.

Primary treatment of multiple myeloma with thalidomide, vincristine, liposomal doxorubicin and dexamethasone (T-VAD doxil): a phase II multicenter study.

BACKGROUND: High-dose chemotherapy with autologous stem cell transplantation after initial cytoreductive chemotherapy with the combination vincristine, doxorubicin and dexamethasone (VAD) is considered an effective therapy for many patients with newly diagnosed, symptomatic multiple myeloma. Response to initial cytoreductive chemotherapy is important for the long-term outcome of such patients. Thalidomide has recently shown significant antimyeloma activity. We studied the efficacy and toxicity of the combination of a liposomal doxorubicin-containing VAD regimen with thalidomide, administered on an outpatient basis, as initial cytoreductive treatment in previously untreated patients with symptomatic myeloma. PATIENTS AND METHODS: Thirty-nine myeloma patients were treated with vincristine 2 mg intravenously (i.v.), liposomal doxorubicin 40 mg/m(2) i.v. administered as single dose on day 1, and dexamethasone 40 mg per os daily for 4 days. Dexamethasone was also given on days 15-18 of the first cycle of treatment. The regimen was administered every 4 weeks for four courses. Thalidomide was given daily at a dose of 200 mg at bedtime. Response to treatment was evaluated after four cycles of treatment. After completion of four cycles, the patients were allowed to proceed to high-dose chemotherapy or to receive two additional cycles of the same treatment. RESULTS: On an intention-to-treat basis, 29 of the 39 patients (74%) responded to treatment. Four patients (10%) achieved complete and 25 (64%) partial response. Three patients (8%) showed minor response and seven (18%) were rated as non-responders. Major grade 3 or 4 toxicities consisted of neutropenia (15%), thrombocytopenia (15%), deep vein thrombosis (10%), constipation (10%), skin rash (5%) and peripheral neuropathy (5%). Two patients (5%) experienced early death due to infection. CONCLUSIONS: The combination of vincristine, liposomal doxorubicin, and dexamethasone (VAD doxil) with thalidomide is an effective and relatively well-tolerated initial cytoreductive treatment. Prospective randomized studies are required in order to assess the effect of this regimen on the long-term outcome of patients with multiple myeloma.

Craniofacial manifestations of Smith-Lemli-Opitz syndrome: case report.

The Smith-Lemli-Opitz syndrome is characterized by striking craniofacial features, microcephaly, mental deficiency, growth retardation, 2-3 syndactyly of the feet, and genital malformations. We present a patient and discuss dentofacial aspects of the syndrome.

The effect of recombinant alpha-interferon on natural killer cell activity and clinical course in patients with myelodysplastic syndrome.

Thirteen patients with myelodysplastic syndrome (MDS) were included in this study and consented to treatment with recombinant alpha-interferon (a-IFN). These patients were subclassified: six as RAEB, one as RAEB-T and six as CMML. T-cell subsets and natural killer cells were identified in the peripheral blood with the use of monoclonal antibodies and natural killer cell activity (NKa) was assayed before, during and after a-INF treatment. The treatment schedule consisted of 2.0 MU/m2 sc t.i.w. continuously for the three months. Prior to treatment, NKa was found decreased in 11 of 13 patients as compared to that of normal individuals. Following a-IFN administration, a rise of NKa was observed in eight of the eleven patients. In those who responded, a-IFN was continued for 1 to 21 months. Alpha-IFN treatment was myelosuppressive for most of the patients, but transient increase of the number of neutrophils and platelets was observed in 3 and of the reticulocytes in one patient. Disease progression was recorded in 9/13 patients (69%) at a median time of 17.3 months. The median overall survival was 30.5 months (range 7.5 to 65+ months). No evidence of a relationship was found between the rise in Nka and the limited clinical improvement observed. Two NKa responders under continuous a-IFN treatment are in stable clinical condition for 36+ and 65+ months. The study provides only limited evidence that a-IFN may improve the clinical course of patients with MDS.