Efficacy of the nanoparticle-drug conjugate CRLX101 in combination with bevacizumab in metastatic renal cell carcinoma: results of an investigator-initiated phase I-IIa clinical trial.

BACKGROUND: Anti-angiogenic therapies are effective in metastatic renal cell carcinoma (mRCC), but resistance is inevitable. A dual-inhibition strategy focused on hypoxia-inducible factor (HIF) is hypothesized to be active in this refractory setting. CRLX101 is an investigational camptothecin-containing nanoparticle-drug conjugate (NDC), which durably inhibits HIF1α and HIF2α in preclinical models and in gastric cancer patients. Synergy was observed in the preclinical setting when combining this NDC and anti-angiogenic agents, including bevacizumab. PATIENTS AND METHODS: Patients with refractory mRCC were treated every 2 weeks with bevacizumab (10 mg/kg) and escalating doses of CRLX101 (12, 15 mg/m(2)) in a 3 + 3 phase I design. An expansion cohort of 10 patients was treated at the recommended phase II dose (RP2D). Patients were treated until progressive disease or prohibitive toxicity. Adverse events (AEs) were assessed using CTCAE v4.0 and clinical outcome using RECIST v1.1. RESULTS: Twenty-two patients were response-evaluable in an investigator-initiated trial at two academic medical centers. RCC histologies included clear cell (n = 12), papillary (n = 5), chromophobe (n = 2), and unclassified (n = 3). Patients received a median of two prior therapies, with at least one prior vascular endothelial tyrosine kinase inhibitor therapy (VEGF-TKI). No dose-limiting toxicities were observed. Grade ≥3 AEs related to CRLX101 included non-infectious cystitis (5 events), fatigue (3 events), anemia (2 events), diarrhea (2 events), dizziness (2 events), and 7 other individual events. Five of 22 patients (23%) achieved partial responses, including 3 of 12 patients with clear cell histology and 2 of 10 patients (20%) with non-clear cell histology. Twelve of 22 patients (55%) achieved progression-free survival (PFS) of >4 months. CONCLUSIONS: CRLX101 combined with bevacizumab is safe in mRCC. This combination fulfilled the protocol's predefined threshold for further examination with responses and prolonged PFS in a heavily pretreated population. A randomized phase II clinical trial in mRCC of this combination is ongoing.

Chimerism, graft survival, and withdrawal of immunosuppressive drugs in HLA matched and mismatched patients after living donor kidney and hematopoietic cell transplantation.

Thirty-eight HLA matched and mismatched patients given combined living donor kidney and enriched CD34(+) hematopoietic cell transplants were enrolled in tolerance protocols using posttransplant conditioning with total lymphoid irradiation and anti-thymocyte globulin. Persistent chimerism for at least 6 months was associated with successful complete withdrawal of immunosuppressive drugs in 16 of 22 matched patients without rejection episodes or kidney disease recurrence with up to 5 years follow up thereafter. One patient is in the midst of withdrawal and five are on maintenance drugs. Persistent mixed chimerism was achieved in some haplotype matched patients for at least 12 months by increasing the dose of T cells and CD34(+) cells infused as compared to matched recipients in a dose escalation study. Success of drug withdrawal in chimeric mismatched patients remains to be determined. None of the 38 patients had kidney graft loss or graft versus host disease with up to 14 years of observation. In conclusion, complete immunosuppressive drug withdrawal could be achieved thus far with the tolerance induction regimen in HLA matched patients with uniform long-term graft survival in all patients.

Inhibition of αvß6 promotes acute renal allograft rejection in nonhuman primates.

The integrin αvß6 activates latent transforming growth factor-ß (TGF-ß) within the kidney and may be a target for the prevention of chronic allograft fibrosis after kidney transplantation. However, TGF-ß also has known immunosuppressive properties that are exploited by calcineurin inhibitors (CNIs); thus, the net benefit of αvß6 inhibition remains undetermined. To assess the acute impact of interference with αvß6 on acute rejection, we tested a humanized αvß6-specific monoclonal antibody (STX-100) in a randomized, double-blinded, placebo-controlled nonhuman primate renal transplantation study to evaluate whether αvß6 blockade alters the risk of acute rejection during CNI-based immunosuppression. Rhesus monkeys underwent renal allotransplantation under standard CNI-based maintenance immunosuppression; 10 biopsy-confirmed rejection-free animals were randomized to receive weekly STX-100 or placebo. Animals treated with STX-100 experienced significantly decreased rejection-free survival compared to placebo animals (p = 0.049). Immunohistochemical analysis confirmed αvß6 ligand presence, and αvß6 staining intensity was lower in STX-100-treated animals (p = 0.055), indicating an apparent blockade effect of STX-100. LAP, LTBP-1 and TGF-ß were all decreased in animals that rejected on STX-100 compared to those that rejected on standard immunosuppression alone, suggesting a relevant effect of αvß6 blockade on local TGF-ß. These data caution against the use of αvß6 blockade to achieve TGF-ß inhibition in kidney transplantation.

Bayesian analysis of longitudinal Johne's disease diagnostic data without a gold standard test.

A Bayesian methodology was developed based on a latent change-point model to evaluate the performance of milk ELISA and fecal culture tests for longitudinal Johne's disease diagnostic data. The situation of no perfect reference test was considered; that is, no "gold standard." A change-point process with a Weibull survival hazard function was used to model the progression of the hidden disease status. The model adjusted for the fixed effects of covariate variables and random effects of subject on the diagnostic testing procedure. Markov chain Monte Carlo methods were used to compute the posterior estimates of the model parameters that provide the basis for inference concerning the accuracy of the diagnostic procedure. Based on the Bayesian approach, the posterior probability distribution of the change-point onset time can be obtained and used as a criterion for infection diagnosis. An application is presented to an analysis of ELISA and fecal culture test outcomes in the diagnostic testing of paratuberculosis (Johne's disease) for a Danish longitudinal study from January 2000 to March 2003. The posterior probability criterion based on the Bayesian model with 4 repeated observations has an area under the receiver operating characteristic curve (AUC) of 0.984, and is superior to the raw ELISA (AUC=0.911) and fecal culture (sensitivity=0.358, specificity=0.980) tests for Johne's disease diagnosis.

Scaling laws for melting ice avalanches.

This Letter describes an investigation of interfacial melting in ice-bearing granular flows. It is proposed that energy associated with granular collisions causes melting at an ice particle's surface, which can thus occur at temperatures well below freezing. A laboratory experiment has been designed that allows quantification of this process and its effect on the dynamics of a granular shear flow of ice spheres. This experiment employs a rotating drum, half filled with ice particles, situated in a temperature controlled laboratory. Capillary forces between the wetted melted particle surfaces lead to the clumping of particles and enhanced flow speeds, in turn leading to further melting. Dimensional analysis defines a parameter space for further experimentation.

Incidence of progressive multifocal leukoencephalopathy in patients without HIV.

OBJECTIVE: To estimate the incidence rate (IR) of progressive multifocal leukoencephalopathy (PML) in patients without HIV. METHODS: Within a large US health insurer database between January 2000 and June 2008, we conducted a retrospective observational study. We identified people with autoimmune diseases, chronic lymphocytic leukemia (CLL), non-Hodgkin lymphoma (NHL), or history of bone marrow or solid organ transplantation, and a general population cohort. We developed a PML case-finding algorithm and validated PML diagnoses in medical charts. RESULTS: There were 138,469 patients with autoimmune diseases, 25,706 with NHL or CLL, and 8,778 with transplants. Among 699 people who met screening criteria for potential PML, 89 had a claim diagnosis of PML (International Classification of Diseases-9 046.3). Medical records were sought for 24 patients without HIV, and 6 had confirmed PML upon review of medical records. The PML IR was 2.4 (95% confidence interval [CI] 0.06-13.18) in the systemic lupus erythematosus cohort and 10.8 (95% CI 0.27-60.39) in the autoimmune vasculitis cohort per 100,000 person-years. In the NHL and CLL cohorts, the IR was 8.3 (95% CI 1.71-24.24) and 11.1 (0.28-61.74) per 100,000 person-years. The IR among patients with bone marrow transplantation was 35.4 per 100,000 person-years (95% CI 0.90-197.29). There were no cases of PML among patients with rheumatoid arthritis (95% CI 0.0-2.24), multiple sclerosis (95% CI 0.0-5.24), Sjögren disease (95% CI 0.0-21.84), or solid organ transplantation (95% CI 0.0-26.81). CONCLUSIONS: In this large population-based investigation of PML with thorough case finding and a known source population, the IR of medical record-confirmed PML was rare in non-HIV patient cohorts.

Characteristics and antecedents of progressive multifocal leukoencephalopathy in an insured population.

Based on health insurance claims from a large U.S. health insurer, the authors identified 44 progressive multifocal leukoencephalopathy (PML) cases from 2002 through 2004 and described their characteristics, including antecedent diagnoses and treatments as well as survival. Immunosuppressive conditions such as HIV/AIDS, rather than potentially immunosuppressive treatments, were the main antecedents of PML. A lower mortality was observed among PML patients whose antecedent diagnosis was HIV/AIDS, the majority of whom received highly active antiretroviral therapy.

Estimating receiver operating characteristic curves with covariates when there is no perfect reference test for diagnosis of Johne's disease.

Paratuberculosis (Johne's disease) is a significant animal health problem. Evaluation of diagnostic tests for Johne's disease has been difficult due to lack of a gold standard test. In recent years, there has been interest in receiver operating characteristic (ROC) curve estimation without any gold standard test. Typically, either Bayesian or maximum likelihood methods are proposed. Although these methods overcome the lack of a gold standard test in ROC curve estimation, little work has been done to incorporate covariates in the analysis. In this paper, we propose a method for estimation of ROC curves based on statistical models to adjust for covariate effects when the true disease states of test animals are unknown. The covariates may be correlated with the disease process or with the diagnostic testing procedure, or both. We propose a 2-part Bayesian model: first, a logistic regression model for disease prevalence is used to fit the covariates; second, a linear model is used to fit the covariates to the distribution of test scores. We used Markov chain Monte Carlo methods to compute the posterior estimates of the sensitivities and specificities that provide the groundwork for inference concerning the diagnostic procedure's accuracy. We applied the methodology to milk ELISA scores from several dairy-cow herds for the diagnostic testing of paratuberculosis. We found that both milk yield and its interaction with age had significant effects on the disease process whereas only milk yield was significant on the testing procedure.

Correct and incorrect use of child restraints: results from an urban survey in New Zealand.

This study describes the incorrect use of child restraints among car drivers with young children and examines factors that may influence their misuse. A cross-sectional survey was undertaken in supermarket car parks with car drivers travelling with children under the age of 8 years. The main measure was errors in child restraint use. Short interviews were conducted with 1113 drivers with a close inspection of the child restraints used in the vehicles. Only 4% of children were unrestrained but 64% of drivers made at least one error in restraint use. Most respondents thought using a restraint was easy, but 65% of these drivers made at least one error. Child restraints are used, but many are incorrectly fitted and/or have the child incorrectly placed in them. Correct use is a moderately complex task. Restraint systems need to be designed to minimize the opportunity for error and maximize safety.

Selenium supplementation, baseline plasma selenium status and incidence of prostate cancer: an analysis of the complete treatment period of the Nutritional Prevention of Cancer Trial.

OBJECTIVE: To present the results (to January 1996, the end of blinded treatment) of the Nutritional Prevention of Cancer (NPC) Trial, a randomized trial of selenium (200 micro g daily) designed to test the hypothesis that selenium supplementation (SS) could reduce the risk of recurrent nonmelanoma skin cancer among 1312 residents of the Eastern USA. MATERIALS AND METHODS: Original secondary analyses of the NPC to 1993 showed striking inverse associations between SS and prostate cancer incidence. A subsequent report revealed that this effect was accentuated among men with the lowest baseline plasma selenium concentrations. The effects of treatment overall and within subgroups of baseline prostate-specific antigen (PSA) and plasma selenium concentrations were examined using incidence rate ratios and Cox proportional hazards models. RESULTS: SS continued to significantly reduce the overall incidence (relative risk and 95% confidence interval) of prostate cancer (0.51, 0.29-0.87). The protective effect of SS appeared to be confined to those with a baseline PSA level of

Discovering subpopulation structure with latent class mixed models.

The linear mixed model is a well-known method for incorporating heterogeneity (for example, subject-to-subject variation) into a statistical analysis for continuous responses. However heterogeneity cannot always be fully captured by the usual assumptions of normally distributed random effects. Latent class mixed models offer a way of incorporating additional heterogeneity which can be used to uncover distinct subpopulations, to incorporate correlated non-normally distributed outcomes and to classify individuals. The methodology is motivated with examples in health care studies and a detailed illustration is drawn from the Nutritional Prevention of Cancer trials. Latent class models are used with longitudinal data on prostate specific antigen (PSA) as well as incidence of prostate cancer. The models are extended to accommodate prostate cancer as a survival endpoint; this is compared to treating it as a binary endpoint. Four subpopulations are identified which differ both with regard to their PSA trajectories and their incidence rates of prostate cancer.

An analysis of cancer prevention by selenium.

The nutritional functions of selenium (Se) are recognized as being due to a number of Se-containing proteins. It is not clear, however, whether any of these function in the anti-tumorigenic effects of Se most of which have been demonstrated for Se exposures greater than those required for selenoprotein expression. Indeed, other anti-tumorigenic mechanisms have been demonstrated for certain Se-metabolites. The Nutritional Prevention of Cancer Trial found supplemental Se (200 microg/day, as Se-enriched yeast) to be associated with significant reductions in cancer risks in subjects with pre-treatment plasma Se concentrations below ca. 120 ng/ml (1.5 nmoles/ml), which level would appear to require food-Se intakes of ca. 1.5 microg/kg body weight/day. However, the putative anti-carcinogenic Se-metabolite(s) should be more relevant than total plasma Se as a supplementation target for cancer prevention. These may be components of the non-protein-bound fraction of Se in plasma, which constitutes 2-4% of total plasma Se.

A latent class mixed model for analysing biomarker trajectories with irregularly scheduled observations.

This paper considers a latent class model to uncover subpopulation structure for both biomarker trajectories and the probability of disease outcome in highly unbalanced longitudinal data. A specific pattern of trajectories can be viewed as a latent class in a finite mixture where membership in latent classes is modelled with a polychotomous logistic regression. The biomarker trajectories within a latent class are described by a linear mixed model with possibly time-dependent covariates and the probabilities of disease outcome are estimated via a class specific model. Thus the method characterizes biomarker trajectory patterns to unveil the relationship between trajectories and outcomes of disease. The coefficients for the model are estimated via a generalized EM (GEM) algorithm, a natural tool to use when latent classes and random coefficients are present. Standard errors of the coefficients are calculated using a parametric bootstrap. The model fitting procedure is illustrated with data from the Nutritional Prevention of Cancer trials; we use prostate specific antigen (PSA) as the biomarker for prostate cancer and the goal is to examine trajectories of PSA serial readings in individual subjects in connection with incidence of prostate cancer.

Statistical models for longitudinal biomarkers of disease onset.

We consider the analysis of serial biomarkers to screen and monitor individuals in a given population for onset of a specific disease of interest. The biomarker readings are subject to error. We survey some of the existing literature and concentrate on two recently proposed models. The first is a fully Bayesian hierarchical structure for a mixed effects segmented regression model. Posterior estimates of the changepoint (onset time) distribution are obtained by Gibbs sampling. The second is a hidden changepoint model in which the onset time distribution is estimated by maximum likelihood using the EM algorithm. Both methods lead to a dynamic index that represents a strength of evidence that onset has occurred by the current time in an individual subject. The methods are applied to some large data sets concerning prostate specific antigen (PSA) as a serial marker for prostate cancer. Rules based on the indices are compared to standard diagnostic criteria through the use of ROC curves adapted for longitudinal data.

Synovial joint disease in wild cetaceans.

During necropsy of cetaceans stranded or accidentally net-captured along the western coast of the Gulf of Mexico from 1991 to 1996, we found 13 of 59 (22%) animals had abnormalities of the atlanto-occipital and/or humeroscapular joints, the synovial joints. A few cases demonstrated mild roughening of the articular cartilage, while the majority exhibited complete erosion with thickened synovium and bony proliferation. The lesions resulted in ankylosis of both joints in one animal. In humans and terrestrial mammals, synovial joint diseases are known to be debilitating. Cetaceans depend on neck and flipper movement for locomotion, feeding, avoiding danger, and reaching the water's surface for breathing. Therefore, synovial joint disease may be significant mortality factor in these marine animals.

Effects of short-term strenuous endurance exercise upon corpus luteum function.

PURPOSE: The present study tested whether short-term, abruptly initiated training can cause corpus luteum dysfunction when exercise is limited to either the follicular or luteal phase of the cycle. METHODS: Reproductive hormone excretion and menstrual characteristics were studied in sedentary women who exercised only during the follicular (N = 5) or the luteal (N = 4) phase. Six women served as controls, three of whom exercised at a low volume and three who remained sedentary. Weekly progressive increments in exercise volume continued until either ovulation (follicular group) or menses (luteal group) occurred. Physical activity and nutrient intake were closely monitored with the intent to maintain body weight. RESULTS: No luteal phase disturbances occurred in any of the control subjects, whereas 40% of follicular and 50% of luteal exercisers experienced luteal defects. The proportion of menstrual cycles disrupted was not different between luteal and follicular exercisers (50% vs 30%, respectively) but was significantly greater than the proportion of cycles disrupted in control subjects (P < 0.05). CONCLUSIONS: These results suggest that exposure to abrupt onset of training can alter luteal function, regardless of the menstrual cycle phase in which exercise occurs. This study also demonstrates that a relatively low volume of exercise suffices to induce mild disturbances in luteal function.

Angiomatosis, a newly recognized disease in Atlantic bottlenose dolphins (Tursiops truncatus) from the Gulf of Mexico.

A new disease, angiomatosis, was recognized in 25 of 54 (46.3%) Atlantic bottlenose dolphins (Tursiops truncatus) necropsied after being stranded along the Texas Gulf coast during 1991-1996. Angiomatosis was first recognized by the authors in 1992 and has increased in incidence and severity, affecting 100% of juveniles and adults. This disease is characterized by proliferation of small, thick-walled blood vessels diffusely throughout the lungs, without inflammation, exudation, or alveolar hemorrhage. The vascular proliferation also occurs in lung-associated and other visceral lymph nodes. Hemangiomas frequently occur in affected lymph nodes and occasionally in the lungs. The vascular proliferation reduces airspace and may occlude small airways. Angiomatosis appears to be a broad-field defect of vascular endothelium. Although this process appears to be an increasingly important factor in the morbidity of T. truncatus, its etiology has not been determined.

Morphology of the complex laryngeal gland in the Atlantic bottlenose dolphin, Tursiops truncatus.

A complex lymphoepithelial gland is a constant feature in the larynx of Atlantic bottlenose dolphins, Tursiops truncatus, based on study of 56 animals. Larynges were removed from fresh, non-decomposed beach-stranded animals for gross examination and histological sampling. A large lymphoepithelial gland occurs in the rostro-ventral mucosa of the larynx, overlying the cricoid cartilage. It presents as a well-defined, elevated, and heavily trabeculated area. Histological examination reveals a pseudostratified columnar epithelium which branches into the underlying submucosa. The epithelial-lined folds and crypts thus formed are surrounded by aggregations of lymphocytes, which infiltrate this epithelium. Mucous glands are often associated with these lymphoid aggregations. The histological appearance of the laryngeal gland is remarkably similar to the palatine, or dorsal oropharyngeal tonsils, of T. truncatus. It may be analogous to the nasopharyngeal adenoid of terrestrial animals. Age-related involution of the laryngeal gland is not as obvious with increasing animal age (or length) as it is in other mucosa-associated lymphoid tissue. The distribution of this gland among cetaceans is not yet known. We have observed it in individuals of every species we have studied, including Lagenodelphis hosei, Stenella coeruleoalba, Stenella attenuata, Globicephala macrorhynchus, Steno bredanensis, Physeter catodon, Pseudorca crassidens, Mesoplodon europaeus, and Kogia breviceps.

The mediating effect of participation efficacy on evaluation use.

Participatory evaluation is commonly understood as stakeholder involvement in evaluation decision-making and is generally accepted as a means of increasing the use of evaluation information. There are, however, few empirical studies that attempt to explain the causal processes of participatory evaluation and how it is expected to work to increase the use of evaluation information. The purpose of this study was to gain a better understanding of participatory evaluation by testing a series of causal relations in a proposed model of participatory evaluation. An intervening mechanism design (Chen, 1990) in conjunction with structural equation modeling was used to test the plausibility of the model. The sample included 315 elementary and secondary teachers who participated in the 1995/1996 British Columbia School Accreditation Program. Results indicated the model was a plausible representation of the data and was thereby a tenable explanation of how participatory evaluation can be expected to work to increase the use of evaluation information.

Myocardial contraction band necrosis in stranded cetaceans.

The term contraction band necrosis describes focal hypercontraction and lysis of small groups of myocardial cells. Contraction band necrosis of the myocardium was identified in 100% of 52 whales and dolphins (cetaceans) stranded along the western coast of the Gulf of Mexico between April 1991 and November 1996. The myocardial lesions in the cetaceans were identical, both grossly and histologically, to those previously described in man and other animals. Such lesions may contribute to the high mortality rate in stranded cetaceans.