Effect of dose adjustment on the safety and efficacy of afatinib for EGFR mutation-positive lung adenocarcinoma: post hoc analyses of the randomized LUX-Lung 3 and 6 trials.

BACKGROUND: Afatinib 40 mg/day is approved for first-line treatment of EGFR mutation-positive non-small-cell lung cancer (NSCLC). In the case of drug-related grade ≥3 or selected prolonged grade 2 adverse events (AEs), the dose can be reduced by 10 mg decrements to a minimum of 20 mg. Here, we evaluate the influence of afatinib dose reduction on AEs, pharmacokinetics and progression-free survival (PFS) in the phase III LUX-Lung 3 and 6 (LL3/6) trials. PATIENTS AND METHODS: Treatment-naïve patients with advanced EGFR mutation-positive NSCLC in LL3 (global) and LL6 (China, Thailand, South Korea) were randomized to afatinib or chemotherapy. All afatinib-treated patients (LL3, n = 229; LL6, n = 239) were included in the post hoc analyses. Incidence and severity of common AEs before and after afatinib dose reduction were assessed. Afatinib plasma concentrations were compared in patients who reduced to 30 mg versus those remaining at 40 mg. PFS was compared between patients who dose reduced within the first 6 months of treatment and those who did not. RESULTS: Dose reductions occurred in 53.3% (122/229) and 28.0% (67/239) of patients in LL3 and LL6, respectively; most (86.1% and 82.1%) within the first 6 months of treatment. Dose reduction led to decreases in the incidence of drug-related AEs, and was more likely in patients with higher afatinib plasma concentrations. On day 43, patients who dose reduced to 30 mg (n = 59) had geometric mean afatinib plasma concentrations of 23.3 ng/ml, versus 22.8 ng/ml in patients who remained on 40 mg (n = 284). The median PFS was similar in patients who dose reduced during the first 6 months versus those who did not {LL3: 11.3 versus 11.0 months [hazard ratio (HR) 1.25]; LL6: 12.3 versus 11.0 months (HR 1.00)}. CONCLUSIONS: Tolerability-guided dose adjustment is an effective measure to reduce afatinib-related AEs without affecting therapeutic efficacy. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov identifiers: NCT00949650 and NCT0112393.

Classroom ventilation and indoor air quality-results from the FRESH intervention study.

Inadequate ventilation of classrooms may lead to increased concentrations of pollutants generated indoors in schools. The FRESH study, on the effects of increased classroom ventilation on indoor air quality, was performed in 18 naturally ventilated classrooms of 17 primary schools in the Netherlands during the heating seasons of 2010-2012. In 12 classrooms, ventilation was increased to targeted CO2 concentrations of 800 or 1200 ppm, using a temporary CO2 controlled mechanical ventilation system. Six classrooms were included as controls. In each classroom, data on endotoxin, ß(1,3)-glucans, and particles with diameters of <10 µm (PM10 ) and <2.5 µm (PM2.5 ) and nitrogen dioxide (NO2 ) were collected during three consecutive weeks. Associations between the intervention and these measured indoor air pollution levels were assessed using mixed models, with random classroom effects. The intervention lowered endotoxin and ß(1,3)-glucan levels and PM10 concentrations significantly. PM10 for instance was reduced by 25 µg/m³ (95% confidence interval 13-38 µg/m³) from 54 µg/m³ at maximum ventilation rate. No significant differences were found between the two ventilation settings. Concentrations of PM2.5 and NO2 were not affected by the intervention. Our results provide evidence that increasing classroom ventilation is effective in decreasing the concentrations of some indoor-generated pollutants.

A phase Ib, open-label study to assess the safety of continuous oral treatment with afatinib in combination with two chemotherapy regimens: cisplatin plus paclitaxel and cisplatin plus 5-fluorouracil, in patients with advanced solid tumors.

BACKGROUND: In this phase Ib, dose-escalation study, the oral irreversible ErbB family blocker afatinib (BIBW 2992) was combined with cisplatin (Cadila Healthcare Ltd, Ahmedabad, India) 50 or 75 mg/m(2)/paclitaxel (Bristol-Myers Squibb Pharmaceuticals Ltd, New York, USA) (Taxol)175 mg/m(2) (regimen A) or cisplatin 75-100 mg/m(2)/5-fluorouracil 750-1000 mg/m(2) (regimen B) in patients with advanced solid tumors. PATIENTS AND METHODS: The primary objective was to assess dose-limiting toxicities (DLTs) during cycle 1 for each regimen, from which the maximum tolerated dose (MTD) was determined. Patients received once daily oral afatinib 20, 30, 40 or 50 mg in 21-day cycles (3 + 3 design). RESULTS: The MTD for afatinib in regimens A (n = 26) and B (n = 21) was determined as 20 mg and 30 mg following DLTs in five and four patients in cycle 1, respectively. Most frequent adverse events (AEs, any grade) were diarrhea and nausea. Disease control was observed in 54% and 29% of patients in regimens A and B, respectively. Plasma sampling suggested no relevant pharmacokinetic interaction between afatinib and the chemotherapeutic agents. CONCLUSIONS: The MTD of afatinib was 20 mg with cisplatin-paclitaxel and 30 mg with cisplatin-5-fluorouracil. Pre-emptive management of side-effects is important to maintain adequate safety and tolerability. Both combinations showed antitumor activity across tumor types and lines of prior treatment.

Assembly of DNA curtains using hydrogen silsesquioxane as a barrier to lipid diffusion.

We have established a single-molecule imaging experimental platform called "DNA curtains" in which DNA molecules tethered to a lipid bilayer are organized into patterns at nanofabricated metallic barriers on the surface of a microfluidic sample chamber. This technology has wide applications for real-time single-molecule imaging of protein-nucleic acid interactions. Here, we demonstrate that DNA curtains can also be made from hydrogen silsesquioxane (HSQ). HSQ offers important advantages over metallic barriers because it can be lithographically patterned directly onto fused silica slides without any requirement for further processing steps, thereby offering the potential for rapid prototype development and/or scale up for manufacturing.

Quantum dot nanoarrays: self-assembly with single-particle control and resolution.

The develpoment of a highly selective immobilization strategy for the self-assembly of quantum dots (QDs) from solution on lithographically defined, biochemically functionalized metal nanopatterns is presented. Nanosale control is achieved for the formation of predominantly single-particle structures consisting of a QD coupled to a metal nanoparticle, and assembled into an ordered nanoarray.

A phase I, open-label dose-escalation study of continuous treatment with BIBF 1120 in combination with paclitaxel and carboplatin as first-line treatment in patients with advanced non-small-cell lung cancer.

BACKGROUND: BIBF 1120 is an oral potent inhibitor of vascular endothelial growth factor receptor, fibroblast growth factor receptor and platelet-derived growth factor receptor, the three key receptor families involved in angiogenesis. This phase I, open-label dose-escalation study investigated BIBF 1120 combined with paclitaxel (Taxol) and carboplatin in first-line patients with advanced (IIIB/IV) non-small-cell lung cancer. PATIENTS AND METHODS: Patients received BIBF 1120 (starting dose 50 mg b.i.d.) on days 2-21 and paclitaxel (200 mg/m2) and carboplatin [area under curve (AUC)=6 mg/ml/min] on day 1 of each 21-day cycle. Primary end points were safety and BIBF 1120 maximum tolerated dose (MTD) in this combination. Pharmacokinetics (PK) profiles were evaluated. RESULTS: Twenty-six patients were treated (BIBF 1120 50-250 mg b.i.d.). BIBF 1120 MTD was 200 mg b.i.d. in combination with paclitaxel and carboplatin. Six dose-limiting toxicity events occurred during treatment cycle 1 (liver enzyme elevations, thrombocytopenia, abdominal pain, and rash). Best responses included 7 confirmed partial responses (26.9%); 10 patients had stable disease. BIBF 1120 200 mg b.i.d. had no clinically relevant influence on the PK of paclitaxel 200 mg/m2 and carboplatin AUC 6 mg/ml/min and vice versa. CONCLUSIONS: BIBF 1120 MTD was 200 mg b.i.d when given with paclitaxel and carboplatin; this combination demonstrated an acceptable safety profile. No relevant changes in PK parameters of the backbone chemotherapeutic agents or BIBF 1120 were observed.

High-resolution imaging of the immunological synapse and T-cell receptor microclustering through microfabricated substrates.

T-cell activation via antigen presentation is associated with the formation of a macromolecular membrane assembly termed the immunological synapse (IS). The genesis of the IS and the onset of juxtacrine signalling is characterized by the formation of cell membrane microclusters and the organization of such into segregated microdomains. A central zone rich in T-cell receptor (TCR)-major histocompatibility complex microclusters termed the central supramolecular activation cluster (cSMAC) forms the bullseye of this structure, while the cellular interface surrounding the cSMAC is characterized by regions enriched in adhesion and co-stimulatory molecules. In vitro, the study of dynamic TCR microcluster coalescence and IS genesis in T-cell populations is hampered by cell migration within the culture system and resolution constraints resulting from lateral cell-cell contact. Here, we detail a novel system describing the fabrication of micropit arrays designed to sequester single T-cell-antigen presenting cell (APC) conjugates and promote IS formation in the horizontal imaging plane for high-resolution studies of microcluster dynamics. We subsequently use this system to describe the formation of the cSMAC in T-cell populations and to investigate the morphology of the interfacial APC membrane.

Comparative pharmacology of chemically distinct NADPH oxidase inhibitors.

BACKGROUND AND PURPOSE: Oxidative stress [i.e. increased levels of reactive oxygen species (ROS)] has been suggested as a pathomechanism of different diseases, although the disease-relevant sources of ROS remain to be identified. One of these sources may be NADPH oxidases. However, due to increasing concerns about the specificity of the compounds commonly used as NADPH oxidase inhibitors, data obtained with these compounds may have to be re-interpreted. EXPERIMENTAL APPROACH: We compared the pharmacological profiles of the commonly used NADPH oxidase inhibitors, diphenylene iodonium (DPI), apocynin and 4-(2-amino-ethyl)-benzolsulphonyl-fluoride (AEBSF), as well as the novel triazolo pyrimidine VAS3947. We used several assays for detecting cellular and tissue ROS, as none of them is specific and artefact free. KEY RESULTS: DPI abolished NADPH oxidase-mediated ROS formation, but also inhibited other flavo-enzymes such as NO synthase (NOS) and xanthine oxidase (XOD). Apocynin interfered with ROS detection and varied considerably in efficacy and potency, as did AEBSF. Conversely, the novel NADPH oxidase inhibitor, VAS3947, consistently inhibited NADPH oxidase activity in low micromolar concentrations, and interfered neither with ROS detection nor with XOD or eNOS activities. VAS3947 attenuated ROS formation in aortas of spontaneously hypertensive rats (SHRs), where NOS or XOD inhibitors were without effect. CONCLUSIONS AND IMPLICATIONS: Our data suggest that triazolo pyrimidines such as VAS3947 are specific NADPH oxidase inhibitors, while DPI and apocynin can no longer be recommended. Based on the effects of VAS3947, NADPH oxidases appear to be a major source of ROS in aortas of SHRs.

Fabrication of Nanoscale Bioarrays for the Study of Cytoskeletal Protein Binding Interactions Using Nanoimprint Lithography.

We describe a high throughput patterning process used to create arrays of molecular-scale features for the study of cytoskeletal protein binding interactions. The process uses a shadow-evaporated metal mask to facilitate lift-off of features defined by nanoimprint lithography. This simple and robust approach alleviates difficulties in pattern transfer of ultra-small features and results in arrays of highly ordered sub-10 nm features which are then functionalized with extracellular matrix proteins. Application of these arrays is demonstrated in cell spreading assays.

Plasma fluorination of diamond-like carbon surfaces: mechanism and application to nanoimprint lithography.

Diamond-like carbon (DLC) films, used as molds for nanoimprint lithography, were treated with a fluorocarbon-based plasma in order to enhance their anti-adhesion properties. While ellipsometry and atomic force microscope measurements showed negligible changes in thickness and surface roughness after plasma processing, contact angle measurement found fluorine plasma-treated DLC surfaces to be highly hydrophobic, with surface energy values reduced from approximately 45 mJ m(-2) for untreated films to approximately 20-30 mJ m(-2) after fluorination. X-ray photoelectron spectroscopy revealed a thin (from approximately 0.5 to approximately 3 nm) fluorocarbon layer on the DLC surface. Proposed mechanisms for the formation of this layer include two competing processes: etching of DLC and deposition of fluorocarbon material, with one or the other mechanism dominant, depending on the plasma conditions. Fluorocarbon plasma-treated DLC molds for nanoimprint lithography were used to pattern sub-20 nm size features with a high degree of repeatability, demonstrating an extended lifetime of the anti-adhesion coating.

Gold-Tipped Elastomeric Pillars for Cellular Mechanotransduction.

We describe a technique for the fabrication of arrays of elastomeric pillars whose top surfaces are treated with selective chemical functionalization to promote cellular adhesion in cellular force transduction experiments. The technique involves the creation of a rigid mold consisting of arrays of circular holes into which a thin layer of Au is deposited while the top surface of the mold and the sidewalls of the holes are protected by a sacrificial layer of Cr. When an elastomer is formed in the mold, the Au adheres to the tops of the molded pillars. This can then be selectively functionalized with a protein that induces cell adhesion, while the rest of the surface is treated with a repellent substance. An additional benefit is that the tops of the pillars can be fluorescently labeled for improved accuracy in force transduction measurements.

Fabrication of Nanoscale "Curtain Rods" for DNA Curtains Using Nanoimprint Lithography.

We have developed a new lithographically-based patterning process which significantly increases the throughput of experiments which probe how repair proteins scan DNA molecules for errors. In this process, nanoscale barriers are formed to interrupt the flow of a lipid bilayer in which DNA is tethered to proteins in the bilayer. The barriers trap the DNA, which is then stretched out by hydrodynamic flow, resulting in the formation of "DNA curtains." Nanoimprint lithography is used to facilitate massively parallel data collection for protein diffusion experiments on DNA.

Plasma fluorination of carbon-based materials for imprint and molding lithographic applications.

Diamondlike carbon nanoimprint templates are modified by exposure to a fluorocarbon-based plasma, yielding an ultrathin layer of a fluorocarbon material on the surface which has a very low surface energy with excellent antiwear properties. We demonstrate the use of these plasma fluorinated templates to pattern features with dimensions approximately 20 nm and below. Furthermore, we show that this process is extendable to other carbon-based materials. Plasma fluorination can be applied directly to nanoimprint resists as well as to molds used to form elastomer stamps for microcontact printing and other applications requiring easy mold release.

Fabrication of elastomer Pillar Arrays with Modulated Stiffness for Cellular Force Measurements.

The mechanical properties of a cell's environment can alter behavior such as migration and spreading, and control the differentiation path of stem cells. Here we describe a technique for fabricating substrates whose rigidity can be controlled locally without altering the contact area for cell spreading. The substrates consist of elastomeric pillar arrays in which the top surface is uniform but the pillar height is changed across a sharp step. Preliminary results demonstrate the effects on cell migration and morphology at the step boundary.

Lateral scaling in carbon-nanotube field-effect transistors.

We have fabricated carbon-nanotube (CN) field-effect transistors with multiple, individually addressable gate segments. The devices exhibit markedly different transistor characteristics when switched using gate segments controlling the device interior versus those near the source and drain. We ascribe this difference to a change from Schottky-barrier modulation at the contacts to bulk switching. We also find that the current through the bulk portion is independent of gate length for any gate voltage, offering direct evidence for ballistic transport in semiconducting carbon nanotubes over at least a few hundred nanometers, even for relatively small carrier velocities.

Field-modulated carrier transport in carbon nanotube transistors.

We have investigated the electrical transport properties of carbon nanotube field-effect transistors as a function of channel length, gate dielectric film thickness, and dielectric material. Our experiments show that the bulk properties of the semiconducting carbon nanotubes do not limit the current flow through the metal/nanotube/metal system. Instead, our results can be understood in the framework of gate and source-drain field induced modulation of the nanotube band structure at the source contact. The existence of one-dimensional Schottky barriers at the metal/nanotube interface determines the device performance and results in an unexpected scaling behavior.

What is the paradigm: hospital or home health care for pressure ulcers?

A home health care (HHC) referral should link the patient in a cost-effective fashion to the physician, home care, and instructions regarding ulcer management. Twenty-one patients (mean age, 74.6 years) had stage III pressure ulcers (<100 cm2) and an involved family member at home. Risk and contributing factors included cardiac disease (n = 9), hypertension (n = 14), end-stage renal disease (n = 7), smoking (n = 11), diabetes (n = 8), chronic brain syndrome (n = 14), cerebrovascular accident (n = 5), and above-the-knee amputation (n = 2). Treatment regimens included standard wound care, pressure relief and, where appropriate, culture-specific antibiotics, as well as a rehabilitation program. Home care progressively decreased the frequency of the nurse HHC and physician office visits. Resolution of the pressure ulcer varied from 6 to 32 weeks. Only two patients had progression of their wound and required hospital readmission. The billable fees included: 1) an office visit, $30.00 (medicare reimbursement, $14.00); 2) the HHC nurse visit, $159.00 (medicare reimbursement, $105.00); 3) supplies, $75.00 to $150.00/week (variable reimbursement); 4) hospitalization, $400.00 to $900.00/day; and 5) a chronic-care bed, $400.00 to $750.00/day. HHC, given a responsible support team and an involved family member, was more socially and financially acceptable than an inpatient facility. Intermittent physician visits with HHC proved safe and reliable, with 90 per cent successfully healing their wounds.

Sequential biannual prevalence studies of pressure ulcers at Allegheny-Hahnemann University Hospital.

To assess the prevalence, documentation and care of pressure ulcers, and the effect of teaching and prevention strategies in a 750-bed university hospital, one-day studies were conducted in 1993, 1995, and 1997. Data gathered was used to evaluate areas in need of improvement and find cost-effective ways to reduce the prevalence of pressure ulcers. The overall prevalence of ulcers decreased from 18 percent in 1993 to 10 percent in 1995 and 1997. The prevalence of nosocomial ulcers decreased from 14 percent in 1993 to 8 percent in 1995 and 6 percent in 1997. The number of nutritional consults increased from 54 percent in 1993 to 67 percent in 1997, and more than half of all patients tested had serum albumin levels < 3.5 mg/dL. Skin assessments upon admission were completed in the majority of patients. While ulcer documentation was less than adequate for the majority of patients in 1993 and 1997, care measures, e.g., placement of patients on specialty beds or mattresses and use of dressings that provide a moist environment, improved considerably. The results of this study indicate that system-wide educational efforts aimed at all levels of patient care providers, and multi-specialty prevention and care efforts can reduce the prevalence of pressure ulcers.

Pressure ulcers: collaboration in wound care. Is there a reasonable approach?

Pressure ulcers represent a significant impact on utilization of healthcare beds, cost for the insurer, and adverse emotional impact for the family. With this in mind, one must address in an effective fashion a method of objective assessment using the current methodology to deal with risk factors in mobility, disease states, and nutrition, as well as give significant attention to prevention protocols. One should adhere to a schedule of turning the patient, sleep surfaces, and appropriate skin care while recognizing the impact of each. Finally, treatment modalities should be undertaken, not only with cost-effective issues in mind, but with ease and convenience for the healthcare provider and the least discomfort for the patient as well. One can focus on debridement by way of enzymatic, autolytic, or surgical methods, recognizing surgery as the least effective for our goals in the management of this patient. Assessment and, finally, reassessment using the available scales will allow us to provide effective healthcare in a therapeutic fashion.

Moist wound healing.

The optimum wound environment to enhance wound healing is a balance of nutrition, hypoxia, and removal of debris in an occlusive moist environment. With increasing knowledge of the healing process and the variety of dressings available, the end result of any wound management will be an expedited wound healing with maximum patient comfort.