Clinical validation study of dried blood spot for determining everolimus concentration in patients with cancer.

PURPOSE: Everolimus treatment is seriously hampered by its toxicity profile. As a relationship between everolimus exposure and effectiveness and toxicity has been established, early and ongoing concentration measurement can be key to individualize the dose and optimize treatment outcomes. Dried blood spot (DBS) facilitates sampling at a patients' home and thereby eases dose individualization. The aim of this study is to determine the agreement and predictive performance of DBS compared to whole blood (WB) to measure everolimus concentrations in cancer patients. METHODS: Paired DBS and WB samples were collected in 22 cancer patients treated with everolimus and analyzed using UPLC-MS/MS. Bland-Altman and Passing-Bablok analysis were used to determine method agreement. Limits of clinical relevance were set at a difference of ± 25%, as this would lead to a different dosing advice. Using DBS concentration and Passing-Bablok regression analysis, WB concentrations were predicted. RESULTS: Samples of 20 patients were suitable for analysis. Bland-Altman analysis showed a mean ratio of everolimus WB to DBS concentrations of 0.90, with 95% of data points within limits of clinical relevance. Passing-Bablok regression of DBS compared to WB revealed no constant bias (intercept 0.02; 95% CI 0.93-1.35) and a small proportional bias (slope 0.89; 95% CI 0.76-0.99). Predicted concentrations showed low bias and imprecision and 90% of samples had an absolute percentage prediction error of < 20%. CONCLUSIONS: DBS is a valid method to determine everolimus concentrations in cancer patients. This can especially be of value for early recognition of over- or underexposure to enable dose adaptations.

A long-term follow-up study of the clinical and radiographic outcome of distal trochanteric transfer in Legg-Calvé-Perthes' disease following varus derotational osteotomy.

AIMS: To assess the long-term effect of distal trochanteric transfer (DTT) on the clinical and radiographic outcomes of patients with Legg-Calvé-Perthes' disease (LCPD) following a varus derotational osteotomy (VDRO). PATIENTS AND METHODS: For this single centre cross-sectional retrospective study we analysed the data of 22 patients (24 hips) with LCPD who had greater trochanteric overgrowth (GTO), following a VDRO performed in our institution between 1959 and 1983. GTO was defined as an articular trochanteric distance (ATD) of < 5 mm. We compared the radiographic and clinical outcomes of patients who underwent DTT for GTO (ten patients, ten hips) with those who did not (12 patients, 14 hips). Age at presentation was 6.9 years (4 to 10) and 8.0 years (3.2 to 12) respectively. Symptoms associated with the hip and general quality of life were assessed using the Harris hip score (HHS) and the Short Form (SF)-36 questionnaires. RESULTS: At long-term follow-up of the DTT group, the ATD was 21.7 mm (standard deviation (sd) 9.8) and the centro-trochanteric distance (CTD) was 13.8 mm (sd 8.3). In the control group the ATD was -0.6 mm (sd 7.8) and the CTD was 32.5 mm (sd 10.2). These differences were statistically significant (p < 0.001). The mean HHS and SF-36 scores were 68.4 (sd 25.0) and 62.0 (sd 27.7) for the DTT group and 73.2 (sd 24.2) and 73.3 (sd 21.5) for the control group, respectively. There was no statistically significant difference in the HHS (p = 0.63) or SF-36 score (p = 0.25). There were four patients who had undergone hip arthroplasty in the DTT group (40%) and one patient (7.1%) in the control group (p = 0.07). The mean age at the time of arthroplasty was 45.3 years (42.1 to 56.5) and 43.6 years respectively. Six patients in the DTT group suffered from moderate to severe osteoarthritis (Tönnis grade 2 or 3) compared with eight patients in the control group (60% versus 57.1%, p = 0.61). CONCLUSION: Although DTT improved the radiographic results in the long-term follow-up of patients with GTO following VDRO, there was no clinical benefit seen in the HHS, SF-36 or incidence of osteoarthritis compared with patients who had not undergone DTT. Cite this article: Bone Joint J 2017;99-B:987-92.

Knee osteoarthritis, degenerative meniscal lesion and osteonecrosis of the knee: Can a simple gait test direct us to a better clinical diagnosis.

INTRODUCTION: The purpose of the current study was to compare the gait patterns in patients with three differing knee pathologies - knee osteoarthritis (OA), degenerative meniscal lesion (DML) and spontaneous osteonecrosis of the knee (SONK) and a group of healthy controls. HYPOTHESIS: A simple gait test will detect differences between different knee pathologies. MATERIAL AND METHODS: Forty-seven patients with bilateral knee OA, 47 patients with DML, 28 patients with SONK and 27 healthy controls were included in this analysis. Patients underwent a spatiotemporal gait assessment and were asked to complete the Western Ontario and McMaster University (WOMAC) Index and the Short-Form (SF)-36 Health Survey. ANOVA tests, followed by Bonferroni multiple comparison tests and the Chi2 tests were performed for continuous and categorical variables, respectively. RESULTS: Significant differences were found for all gait measures and clinical questionnaires between healthy controls and all knee conditions. Patients with SONK differed from patients with bilateral knee OA and DML in all gait measures and clinical questionnaires, except for WOMAC subscales. There were no significant differences between patients with bilateral knee OA and patients with DML. Symmetry was also examined and revealed asymmetry in some gait parameters in patients with SONK and DML. DISCUSSION: Based on the differences in gait parameters that were found in the current study, adding an objective functional spatiotemporal gait test may assist in the diagnostic process of knee pathologies. TYPE OF STUDY: Case Control study Level III.

Therapeutic drug monitoring of everolimus using the dried blood spot method in combination with liquid chromatography-mass spectrometry.

An assay of everolimus based on finger prick sampling and consecutive application as a blood spot on sampling paper has been developed. We explored several methods [K. Hoogtanders, J. van der Heijden, M. Christiaans, P. Edelbroek, J. van Hooff, L. Stolk, J. Pharm. Biomed. Anal. 44 (2006) 658-664; A. Allanson, M. Cotton, J. Tettey, et al., J. Pharm. Biomed. Anal. 44 (2007) 963-969] and developed a new method, namely the impregnation of sampling paper with a solution of plasma-protein, formic acid and ammonium acetate, in combination with the extraction of the blood spot by filter filtration. This kind of sample preparation provides new possibilities for blood spot sampling especially if analytes are adsorbed to the paper. The dried blood spot was analysed using the HPLC-electrospray-tandem mass spectrometry method, with 32-desmethoxyrapamycin as the internal standard. The working range of our study was 2-30 microg/l. Within this range, intra-and inter-assay variability for precision and accuracy was <15%. Everolimus blood spot samples proved stable for 3 days at 60 degrees C and for 32 days at 4 degrees C. Everolimus concentrations of one stable out-patient were compared after both blood spot sampling and conventional venous sampling on various occasions. Results indicate that this new method is promising for therapeutic drug monitoring in stable renal transplant patients.

Interleukin-17 enhances tumor necrosis factor alpha-induced synthesis of interleukins 1,6, and 8 in skin and synovial fibroblasts: a possible role as a "fine-tuning cytokine" in inflammation processes.

OBJECTIVE: To compare the singular and combined effects of tumor necrosis factor alpha (TNFalpha), interleukin-1beta (IL-1beta), and IL-17 on messenger RNA (mRNA) expression, translation, and secretion of IL-6, IL-8, and IL-1beta in fibroblasts. METHODS: Fibroblasts were stimulated with the relevant cytokine(s), pulse labeled with 35S-methionine, and the newly synthesized proteins were immunoprecipitated and subjected to sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Gene expression was determined by Northern blot analysis. Secreted proteins were detected by enzyme-linked immunosorbent assay (ELISA). RESULTS: IL-17 alone was a weaker stimulator of the transcription, translation, and secretion of other interleukins than was TNFalpha or IL-1beta. IL-17 (10 ng/ml) stimulated the expression of IL-6 mRNA by 1.3-fold, while TNFalpha (1 ng/ml) increased it by 3.7-fold, and IL-1beta (0.1 ng/ml) increased it by >30-fold. Unlike TNFalpha and IL-1beta, IL-17 hardly affected the expression of IL-8 and IL-1beta mRNA. Translation of IL-6 was 6.2 times greater with IL-17, but TNFalpha and IL-1beta stimulated it 28.9- and 174-fold, respectively. ELISA-measured secretion of IL-6 and IL-8 increased by 6.7 and 5.8 times, respectively, with IL-17, compared with 52 and 269 times with TNFalpha stimulation and 1,356 and 1,084 times with IL-1beta stimulation. Yet, when IL-17 was combined with other cytokines, these activities were stimulated much beyond the sum of the individual effects. The combination of IL-17 and TNFalpha induced the expression of IL-6 or IL-1beta mRNA 7 times more than their additive stimulation, and that of IL-8 mRNA 3.8 times more. Likewise, the secretion of IL-6 and IL-8 was 20 times and 5 times higher, respectively, than expected. This synergism started after 4 hours of combined treatment, and decayed after 24-48 hours regardless of cytokine presence. It could be blocked with anti-IL-17 but not with anti-IL-1. CONCLUSION: Our findings suggest that the primary role of IL-17 is to synergize with TNFalpha and to fine-tune the inflammation process. Therefore, IL-17 may be a potential target for therapeutic intervention.

Earthquake related scald injuries--experience from the IDF field hospital in Duzce, Turkey.

On the evening of November 12th, 1999, earthquakes stroke the area of Duzce and Bolu in the northwestern part of Turkey. The local medical system, still not recovered completely from the August earthquake, suffered severe damage. An Israeli field hospital was sent to the area to help cope with the earthquake trauma and replace the damaged medical system until it recovered. During the eight days of its active duty, approximately 40 burn patients were seen. Most of the burns were deep partial scald burns of the lower extremity, caused by hot water spill during the quake. Two massive burns were referred to burn centers and the rest were treated either as outpatients, or admitted and underwent daily dressing changes under sedation. All burns improved, and some healed during the hospital's stay in Duzce. Some of the burns needed further skin grafting. Upon disassembling the hospital the burn patients were referred to the recovered local medical system and one child was transferred to continue burn treatment in Israel. The circumstances of evening earthquake and non-industrialized area expressed a new post-earthquake burn syndrome: multiple scald burns due to hot liquid spills. It seems that most of the patients suffering those burns could be treated successfully as outpatients with close follow up.