Myelopreservation with the CDK4/6 inhibitor trilaciclib in patients with small-cell lung cancer receiving first-line chemotherapy: a phase Ib/randomized phase II trial.

BACKGROUND: Chemotherapy-induced damage of hematopoietic stem and progenitor cells (HSPC) causes multi-lineage myelosuppression. Trilaciclib is an intravenous CDK4/6 inhibitor in development to proactively preserve HSPC and immune system function during chemotherapy (myelopreservation). Preclinically, trilaciclib transiently maintains HSPC in G1 arrest and protects them from chemotherapy damage, leading to faster hematopoietic recovery and enhanced antitumor immunity. PATIENTS AND METHODS: This was a phase Ib (open-label, dose-finding) and phase II (randomized, double-blind placebo-controlled) study of the safety, efficacy and PK of trilaciclib in combination with etoposide/carboplatin (E/P) therapy for treatment-naive extensive-stage small-cell lung cancer patients. Patients received trilaciclib or placebo before E/P on days 1-3 of each cycle. Select end points were prespecified to assess the effect of trilaciclib on myelosuppression and antitumor efficacy. RESULTS: A total of 122 patients were enrolled, with 19 patients in part 1 and 75 patients in part 2 receiving study drug. Improvements were seen with trilaciclib in neutrophil, RBC (red blood cell) and lymphocyte measures. Safety on trilaciclib+E/P was improved with fewer ≥G3 adverse events (AEs) in trilaciclib (50%) versus placebo (83.8%), primarily due to less hematological toxicity. No trilaciclib-related ≥G3 AEs occurred. Antitumor efficacy assessment for trilaciclib versus placebo, respectively, showed: ORR (66.7% versus 56.8%, P = 0.3831); median PFS [6.2 versus 5.0 m; hazard ratio (HR) 0.71; P = 0.1695]; and OS (10.9 versus 10.6 m; HR 0.87; P = 0.6107). CONCLUSION: Trilaciclib demonstrated an improvement in the patient's tolerability of chemotherapy as shown by myelopreservation across multiple hematopoietic lineages resulting in fewer supportive care interventions and dose reductions, improved safety profile, and no detriment to antitumor efficacy. These data demonstrate strong proof-of-concept for trilaciclib's myelopreservation benefits. CLINICAL TRAIL NUMBER: NCT02499770.

Neonatal alcohol exposure augments voluntary ethanol intake in the absence of potentiated anxiety-like behavior induced by chronic intermittent ethanol vapor exposure.

Individuals fetally exposed to alcohol have a disproportionate risk for developing lifetime alcohol dependence, an association that may be confounded by the presence of comorbid conditions, such as anxiety. Anxiety is also observed following fetal alcohol exposure and is known to exacerbate ethanol consumption, highlighting the utility of animal models to assess this relationship. The present study evaluated the impact of third-trimester equivalent ethanol exposure on ethanol consumption and anxiety-like, marble burying behavior in adult, male C57BL/6 mice following exposure to chronic intermittent ethanol vapor, proposed to model dependence. Neonatal mice (P5-6, 2.5-3.0 g) were administered one injection of saline or ethanol (2.5 g/kg, subcutaneously [s.c.]). Pre-vapor marble burying and limited-access two-bottle choice ethanol intake (15% v/v, 2 h) were comparable in adults (8 weeks of age) across neonatal treatment groups. Five consecutive drinking sessions were repeated 72 h after each weekly ethanol vapor exposure procedure for a total of five vapor/drinking cycles. Consistent with prior research, an increase in voluntary ethanol drinking was observed in vapor-exposed, neonatal saline-treated mice throughout the study starting after the second vapor cycle compared to both air-exposed control groups. In neonatal ethanol-treated mice, this increase in ethanol intake and preference following vapor exposure was accelerated, being observed after the first vapor cycle, and observed at an augmented level compared to vapor-exposed, neonatal saline-treated mice and air controls for both neonatal conditions. Conversely, marble burying was enhanced equivalently in vapor-exposed mice from either neonatal treatment group relative to their respective air-exposed controls. These data recapitulate clinical observations of enhanced sensitivity for alcohol dependence following developmental alcohol exposure, which may reflect enhanced motivational drive rather than potentiated negative affect. The present model will facilitate the future exploration of mechanisms that underlie increased risk for alcohol use after early developmental exposure.

RET fusions in a small subset of advanced colorectal cancers at risk of being neglected.

Background: Recognition of rare molecular subgroups is a challenge for precision oncology and may lead to tissue-agnostic approval of targeted agents. Here we aimed to comprehensively characterize the clinical, pathological and molecular landscape of RET rearranged metastatic colorectal cancer (mCRC). Patients and methods: In this case series, we compared clinical, pathological and molecular characteristics of 24 RET rearranged mCRC patients with those of a control group of 291 patients with RET negative tumors. RET rearranged and RET negative mCRCs were retrieved by systematic literature review and by taking advantage of three screening sources: (i) Ignyta's phase 1/1b study on RXDX-105 (NCT01877811), (ii) cohorts screened at two Italian and one South Korean Institutions and (iii) Foundation Medicine Inc. database. Next-generation sequencing data were analyzed for RET rearranged cases. Results: RET fusions were more frequent in older patients (median age of 66 versus 60 years, P = 0.052), with ECOG PS 1-2 (90% versus 50%, P = 0.02), right-sided (55% versus 32%, P = 0.013), previously unresected primary tumors (58% versus 21%, P < 0.001), RAS and BRAF wild-type (100% versus 40%, P < 0.001) and MSI-high (48% versus 7%, P < 0.001). Notably, 11 (26%) out of 43 patients with right-sided, RAS and BRAF wild-type tumors harbored a RET rearrangement. At a median follow-up of 45.8 months, patients with RET fusion-positive tumors showed a significantly worse OS when compared with RET-negative ones (median OS 14.0 versus 38.0 months, HR: 4.59; 95% CI, 3.64-32.66; P < 0.001). In the multivariable model, RET rearrangements were still associated with shorter OS (HR: 2.97; 95% CI, 1.25-7.07; P = 0.014), while primary tumor location, RAS and BRAF mutations and MSI status were not. Conclusions: Though very rare, RET rearrangements define a new subtype of mCRC that shows poor prognosis with conventional treatments and is therefore worth of a specific management.

Triage of patients with acute diverticulitis: are some inpatients candidates for outpatient treatment?

AIM: Current recommendations regarding the triage of patients with acute diverticulitis for inpatient or outpatient treatment are vague. We hypothesized that a significant number of patients treated as an inpatient could be managed as an outpatient. METHOD: A retrospective cohort study was carried out of 639 patients admitted for a first episode of diverticulitis. The diagnosis of acute diverticulitis was confirmed by computed tomography (CT). The endpoints included length of stay, need for surgery, percutaneous drainage and mortality. Patients were considered to have had a minimal hospitalization, defined as survival to discharge without needing a procedure, hospitalization of ≤ 3 days and no readmission for diverticulitis within 30 days after discharge. RESULTS: Of 639 patients, 368 (57.6%) had a minimal hospitalization. Female gender and CT scan findings of free air/fluid were negatively associated with the likelihood of minimal hospitalization. The presence of an abscess < 3 cm and stranding on CT did not predict the need for a higher level of care. Despite the statistical significance of several patient-level predictors, the model did not identify patients likely to need only minimal hospitalization. CONCLUSION: Most patients admitted with acute diverticulitis are discharged after minimal hospitalization. Free air/liquid in a patient admitted for acute diverticulitis indicates a more severe clinical course.

MRI of carcinoid tumors: spectrum of appearances in the gastrointestinal tract and liver.

The purpose of this study was to evaluate the spectrum of appearances of gastrointestinal carcinoid tumors at magnetic resonance imaging (MRI) and to elucidate patterns of appearances of carcinoid liver metastases on precontrast and postgadolinium images. The MR examinations of 29 patients (11 men, 18 women; age range, 33-87 years) with histologically confirmed gastrointestinal carcinoid tumors, representing our complete 9.5 years of experience with this entity, were retrospectively reviewed. Twelve patients had MR examinations prior to resection or biopsy of the primary tumor (preoperative group); 17 patients were imaged postsurgically (postoperative group). All MR studies were performed at 1.5 T and comprised T1-weighted spoiled gradient echo (SGE), T2-weighted fat-suppressed turbo spin echo, HASTE, and serial postgadolinium T1-weighted SGE sequences without and with fat suppression. Morphology, signal intensity, and contrast enhancement of primary tumors and of metastases to the mesentery, peritoneum, and liver were evaluated. Primary tumors were visualized in 8 of 12 patients and best demonstrated on postgadolinium T1-weighted fat-suppressed images. The appearance of primary tumors was a nodular mass originating from the bowel wall (4 of 12 patients) or regional uniform bowel wall thickening (4 of 12 patients) with moderate intense enhancement on postgadolinium images. In 4 of 12 patients the primary tumor was prospectively not seen. Mesenteric metastases, seen in eight patients, presented as nodular masses and were associated with mesenteric stranding in seven patients. A total of 156 liver metastases were evaluated in 16 patients. On precontrast T1- and T2-weighted images, 117 metastases (75%) were hypointense and hyperintense, respectively. A total of 146 metastases (94%) were hypervascular, showing moderate intense enhancement during the hepatic arterial phase, and 9 metastases (6%) were hypovascular. Twenty-three metastases (15%) were visible only on immediate postgadolinium images. MRI is able to demonstrate findings in carcinoid tumors, including the primary tumor, mesenteric metastases, and liver metastases. Liver metastases are commonly hypervascular and may be demonstrable only on immediate postgadolinium images.

An evaluation of three self-report physical activity instruments for older adults.

PURPOSE: To assess the known-groups and construct validity of measures from the CHAMPS Physical Activity Questionnaire, Physical Activity Survey for the Elderly (PASE), and the Yale Physical Activity Survey (YPAS). METHODS: The three questionnaires were administered to a convenience sample of older adults (N = 87) recruited from community centers and retirement homes. Validation measures included the SF-36 measures of physical functioning, general health, mental health, and pain; body mass index; performance-based tests of lower body functioning and endurance; and Mini-Logger activity monitor data from ankle and waist sensors. Validity was estimated by testing hypotheses about associations between physical activity and validation measures. RESULTS: As hypothesized, differences in activity levels on all measures were found between older adults in retirement homes (less active) and community centers (more active) (P-values < 0.0001). Correlations of physical activity measures with performance-based measures ranged from 0.44 to 0.68, conforming to hypotheses; hypotheses regarding associations with the SF-36 measures were also confirmed. Body mass index was not correlated with any of the physical activity measures, contrary to hypotheses. Correlations of physical activity measures with Mini-Logger counts ranged from 0.36 to 0.59 (ankle) and 0.42 to 0.61 (waist) as hypothesized. Correlations among the measures from the three instruments ranged from 0.58 to 0.68. CONCLUSIONS: The PASE, YPAS, and CHAMPS each demonstrated acceptable validity, as all measures met nearly all hypotheses. Higher validity coefficients were found for subgroups (men, 65-74 yr, retirement home), suggesting that these instruments may perform better for certain segments of the older adult population.

Patterns of rehabilitation utilization after hip fracture in acute hospitals and skilled nursing facilities.

BACKGROUND: Hospitalized hip fracture patients may receive physical therapy (PT) in acute and/or postacute settings. Patterns of PT use may vary by patient, clinical, and hospital characteristics. These patterns can be analyzed if the acute and postacute stays are linked. OBJECTIVES: We classified the following patterns of PT use: acute PT only, skilled nursing facility (SNF) PT only, acute and SNF PT, and no PT. For each pattern, we compared (1) characteristics of hip fracture patients, (2) length of stay (LOS), and (3) discharge outcomes. SUBJECTS: The study included 187,990 hospitalized hip fracture patients derived from Medicare administrative data. MEASURES: Dependent variables were PT use patterns, acute hospital and SNF LOS, total episode days of care, and discharge destination. Independent variables were demographic, clinical, and facility characteristics. PT use patterns were also used as independent variables in the LOS and discharge destination models. RESULTS: Patterns of PT use were influenced by demographic and clinical characteristics such as age, race, and surgery type. Similarly, different LOS measures and discharge destinations varied by the PT use patterns. Patients receiving acute PT had longer acute LOSs; however, those patients who were subsequently transferred to SNFs had shorter SNF LOSs and total episode days of care. Patients utilizing PT were more likely to be discharged to home after the acute or SNF stay. CONCLUSIONS: Disparities in PT use exist for subgroups of patients such as the elderly and blacks. Providers should determine the most appropriate setting for initiation of PT to achieve better discharge outcomes with efficient use of resources.

Split sample analysis of serum folate levels after 18 days in frozen storage.

Reliable measurement of folate is becoming increasingly important as links between dietary folate intake, the use of vitamins containing folic acid, and health outcomes such as birth defects and cardiovascular disease are identified. This study was undertaken to formally assess whether the quantity of folate in serum declines after the serum is frozen and stored. Blood samples from 83 pregnant women were tested for serum folate shortly after collection and again after 18 days of storage at -20 degrees C. A shift from higher to lower serum folate categories was observed after 18 days of storage. For the first test, 40.9 % of the samples were > or = 20 microg/L compared with 19.3 % of the test results on second test. For the 75 samples in the quantifiable range (< 40 microg/L), a mean decrease of 5.0 microg/L (+/- 0.5) of serum folate was observed (p < 0.0001). When compared to serum samples stored in a non frost-free freezer at -20 degrees C or -70 degrees C, serum stored in a frost-free freezer at -20 degrees C for even a short period of time may be relatively unstable and sensitive to minor temperature fluctuations associated with the freeze-thaw cycles.

Mobility-related function in older adults: assessment with a 6-minute walk test.

OBJECTIVE: To determine the usefulness of the 6-minute walk test as an integrated measure of mobility in older adults. DESIGN: Observational study. SETTING: Community centers and retirement homes in the Los Angeles area. PATIENTS: Eighty-six older adults without significant disease. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Assessments included the 6-minute walk, chair stands, standing balance, gait speed, body mass index, and self-reported physical functioning and general health perceptions. RESULTS: One-week test-retest reliability of the 6-minute walk was .95. As hypothesized, the 6-minute walk distance was significantly greater for active than for inactive older adults (p < .0001), moderately correlated with chair stands (r = .67), standing balance (r = .52), and gait speed (r = -.73). It had a low correlation with body mass index (r = -.07). The correlation of the 6-minute walk with self-reported physical functioning was .55, and its correlation with general health perceptions was .39. Self-report and performance measures explained 69% of the variance in 6-minute walk scores. CONCLUSIONS: The 6-minute walk test is reliable and is valid in relation to the performance and self-reported indicators of physical functioning tested in this study. It could serve as a useful integrated measure of mobility.

Endomembrane trafficking of ras: the CAAX motif targets proteins to the ER and Golgi.

We show that Nras is transiently localized in the Golgi prior to the plasma membrane (PM). Moreover, green fluorescent protein (GFP)-tagged Nras illuminated motile, peri-Golgi vesicles, and prolonged BFA treatment blocked PM expression. GFP-Hras colocalized with GFP-Nras, but GFP-Kras4B revealed less Golgi and no vesicular fluorescence. Whereas a secondary membrane targeting signal was required for PM expression, the CAAX motif alone was necessary and sufficient to target proteins to the endomembrane where they were methylated, a modification required for efficient membrane association. Thus, prenylated CAAX proteins do not associate directly with the PM but instead associate with the endomembrane and are subsequently transported to the PM, a process that requires a secondary targeting motif.

Mammalian prenylcysteine carboxyl methyltransferase is in the endoplasmic reticulum.

Prenylcysteine carboxyl methyltransferase (pcCMT) is the third of three enzymes that posttranslationally modify C-terminal CAAX motifs and thereby target CAAX proteins to the plasma membrane. Here we report the molecular characterization and subcellular localization of the first mammalian (human myeloid) pcCMT. The deduced amino acid sequence of mammalian pcCMT predicts a multiple membrane-spanning protein with homologies to the yeast pcCMT, STE14, and the mammalian band 3 anion transporter. The human gene complemented a ste14 mutant. pcCMT mRNAs were ubiquitously expressed in human tissues. An anti-pcCMT antiserum detected a 33-kDa protein in myeloid cell membranes. Ectopically expressed recombinant pcCMT had enzymatic activity identical to that observed in neutrophil membranes. Mammalian pcCMT was not expressed at the plasma membrane but rather restricted to the endoplasmic reticulum. Thus, the final enzyme in the sequence that modifies CAAX motifs is located in membranes topologically removed from the CAAX protein target membrane.

Physical therapy to improve functioning of older people in residential care facilities.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the effectiveness of an individualized physical therapy mobility training program on the gait, balance, and functional performance of elderly individuals living in residential care facilities. SUBJECTS: Twenty-seven elderly individuals with impaired balance and difficulty performing at least one functional activity participated in the study. The subjects ranged in age from 71 to 97 years (mean = 87.1, SD = 6.7). METHODS: Balance and gait speed were assessed at baseline and following physical therapy that consisted of exercises to improve specific functional limitations. Outcomes were reassessed 1 month following completion of the physical therapy. RESULTS: Gait and balance outcomes were analyzed using a one-way repeated-measures analysis of variance. Improvement was obtained in balance, which was maintained at 1 month follow-up. Gait speed did not improve to a level of statistical significance. CONCLUSION AND DISCUSSION: After physical therapy, subjects improved in balance and functional performance. An improvement in gait speed may require a longer duration of treatment.

Screening for balance and mobility impairment in elderly individuals living in residential care facilities.

BACKGROUND AND PURPOSE: The rapid growth of the elderly population has resulted in a corresponding rise in the number of elderly individuals who experience disability during their lifetimes. The purpose of this study was to test the usefulness of four established clinical measures of balance, gait, and subjective perceptions of fear of falling as screening methods for referring community-dwelling elderly individuals living in residential care facilities for detailed physical therapy evaluation and possible intervention. SUBJECTS: The subjects were a convenience sample of 53 elderly individuals living in two residential care facilities for the elderly. METHODS: Subjects were tested on each of four clinical measures of balance and mobility. Their performance on these measures was compared with a physical therapist's brief evaluation of disability and appropriateness for more detailed evaluation. The usefulness of these tools as screening methods was determined by calculating sensitivity and specificity levels using the physical therapist's evaluation as a standard. RESULTS: The sensitivity and specificity levels of the four clinical measures in their application as screening tests for referral to physical therapy were as follows: Berg Balance Scale, 84% and 78%; balance subscale of the Tinetti Performance-Oriented Mobility Assessment, 68% and 78%; gait speed, 80% and 89%; and Tinetti Fall Efficacy Scale, 59% and 82%. The combination of two tests, Berg Balance Scale and gait speed, yielded the highest sensitivity of 91% and the highest specificity of 70% when a subject tested positive on at least one test. CONCLUSION AND DISCUSSION: These findings indicate the feasibility of developing screening methods for referring community-dwelling elderly individuals for a detailed physical therapy evaluation based on established clinical assessment measures, with a combination of tests measuring balance and gait demonstrating the most promising results.

Bcl-2 blocks degranulation but not fas-based cell-mediated cytotoxicity.

The ability of bcl-2 in target cells to block cell-mediated cytotoxicity by allospecific CTL was tested. The blocking effect was variable. Because killing by CTL involves two different pathways, degranulation (perforin plus granzymes) and fas, we examined the effect of bcl-2 on these pathways independently. Bcl-2 in target cells blocked apoptotic cell death induced either by cytotoxic granule extracts or by CTL killing under conditions in which the fas pathway is blocked. On the other hand, bcl-2 had no effect on target cell-killing either by Fas-specific mAb or by CTL capable of killing only via the fas pathway. These data suggest bcl-2 may block apoptotic lysis induced by perforin plus granzymes, but not apoptotic lysis induced via the fas pathway. Thus, any analysis of the effect of bcl-2 on apoptotic cell death in target cells killed by CTL must take into account the relative contributions of the degranulation vs fas pathways.

The role of the Fas lytic pathway in a perforin-less CTL hybridoma.

The murine CTL hybridoma PMMI has been shown by the most sensitive techniques to be devoid of perforin. We thus used PMMI activated with PMA and ionomycin, to investigate possible alternate lytic pathways in CTLs in the absence of perforin. We found that PMMI is equipped with membrane TNF-alpha as a potential lytic mechanism, but TNF-alpha is unlikely to be involved in acute (4 h) lytic reactions. On the other hand, PMMI readily lyses target cells expressing the gene for the Fas Ag, but does not lyse target cells expressing fas antisense DNA. The generation of fas-dependent lysis required protein synthesis in PMMI, but target cell protein synthesis was not required for lysis. Lysis of Fas-positive target cells by PMMI was accompanied by DNA fragmentation, and both lysis and DNA fragmentation were blocked by inhibition of protein synthesis in the effector cell. We find the relative extent and kinetics of fas-dependent lysis and DNA fragmentation indistinguishable from that seen in "classical" CTL lytic assays. Both fas- and perforin-dependent lysis were blocked by inhibitors of poly(ADP) ribosylation. We found very little difference in the sequence of events in target cells lysed by the fas pathway compared with the classical (probably perforin) lytic pathway. Given the widespread distribution of fas, particularly in hematopoietic target cells, caution may be required in interpreting the relationship between parameters such as DNA fragmentation and 51Cr-release solely on the basis of the granule exocytosis model.

Elimination of ascorbic acid-induced membrane lipid peroxidation and serotonin receptor loss by Trolox-C, a water soluble analogue of vitamin E.

Ascorbic acid is commonly used as an antioxidant to prevent the decomposition of ligands in neurotransmitter receptor studies, but may alter biological membranes by initiating lipid peroxidation in the presence of physiologic metal ions. The aim of the present study was to characterize the effect of ascorbic acid-induced lipid peroxidation on an applicable membrane receptor and to examine an appropriate antioxidant system. Ascorbic acid generated significant lipid peroxidation (5.5 to 45 fold increase in malonaldehyde levels) in three diverse tissues having different membrane properties: bovine brain, mouse teratoma, and rat kidney. In membranes from bovine cerebral cortex, ascorbate-induced lipid peroxidation was associated with a 26% decrease in [3H]-serotonin receptor binding (Bmax = 159 +/- 11 from control of 216 +/- 10 fmol/mg protein), with no significant change in KD. Trolox-C, a water soluble analogue of vitamin E, completely blocked the ascorbate-induced loss of serotonin receptor binding in brain membranes, and the combination of Trolox-C and ascorbate prevented [3H]-serotonin decomposition in solution. Trolox-C also prevented ascorbate-induced lipid peroxidation in brain, teratoma, and kidney membranes. Lipid peroxidation may be a significant factor in the ascorbate-induced alteration of brain membranes as reflected by reduced binding to serotonin receptors. The combination of Trolox-C (200 microM) and ascorbic acid (1.0 mM) maintains a protective environment for oxygen sensitive neurotransmitters while blocking the deleterious effects of ascorbic acid on lipid membranes.

Ligamentotaxis for comminuted distal radial fractures modified by primary cancellous grafting and functional bracing: long-term results.

Ligamentotaxis with the use of external fixator offers a sound method for treating comminuted distal radial fractures. In an effort to shorten the period of external fixation, primary cancellous bone grafting and functional bracing were used as an adjunct to ligamentotaxis. The external fixator was left in place for 3 weeks, followed by functional bracing for another 3 weeks. This paper presents the results of 54 patients with an average follow-up of 31.5 months. Results showed that 80% of the patients regained full range of motion in their hands, wrists, and forearms. More than 80% of the patients regained strong and pain-free wrist functions. Radiologically, there was no loss of reduction or shortening. Nine percent of patients suffered mild arthritic changes in the radiocarpal joints. Final assessment showed that 90% of patients had excellent or good results. Late complications were minimal, apart from the problems of the distal radio-ulnar joints.