Safety and Efficacy of Apixaban vs Enoxaparin for Preventing Postoperative Venous Thromboembolism in Women Undergoing Surgery for Gynecologic Malignant Neoplasm: A Randomized Clinical Trial.

Importance: Current guidelines recommend a 28-day course of enoxaparin for thromboprophylaxis after surgery for gynecologic cancer. The high cost of this medication and the low adherence rates observed in prior studies provide an opportunity to benefit patients by demonstrating the safety of a more cost-effective, easier to use thromboprophylactic. Objective: To investigate the safety and efficacy of an oral treatment alternative for thromboprophylaxis in postoperative patients with gynecologic cancer. Design, Setting, and Participants: This was a patient-based, multicenter, open-label, blinded, end point, randomized clinical trial conducted May 2015 to March 2019 in outpatient and inpatient gynecologic oncology settings. Women undergoing surgery for suspected or confirmed gynecologic cancer were approached for recruitment. The trial compared rates of major bleeding and clinically relevant nonmajor bleeding events during a 90-day follow-up period in patients taking apixaban or enoxaparin for postoperative thromboprophylaxis using a modified intent-to-treat analysis. Data analysis was performed from October to December 2019. Interventions: Women were randomized to 28 days of apixaban (2.5 mg orally twice daily) or enoxaparin (40 mg subcutaneously daily). Main Outcomes and Measures: The primary outcome was major bleeding and clinically relevant nonmajor bleeding events. Secondary outcomes included incidence of venous thromboembolic events, adverse events, medication adherence, participant quality of life, and medication satisfaction. Results: Of 500 women recruited for the study, 400 were enrolled and randomized (median age, 58.0 years; range, 18.0-89.0 years); 204 received apixaban and 196 received enoxaparin. Treatment groups did not differ in terms of race/ethnicity, cancer stage, or surgery modality (open vs robotic). There were no statistically significant differences between the apixaban and enoxaparin groups in terms of rates of major bleeding events (1 patient [0.5%] vs 1 patient [0.5%]; odds ratio [OR], 1.04; 95% CI, 0.07-16.76; P > .99), clinically relevant nonmajor bleeding events (12 patients [5.4%] vs 19 patients [9.7%]; OR, 1.88; 95% CI, 0.87-4.1; P = .11), venous thromboembolic events (2 patients [1.0%] vs 3 patients [1.5%]; OR, 1.57; 95% CI, 0.26-9.50; P = .68), adverse events, medication adherence, or quality of life between the groups. Participant satisfaction was significantly greater in the apixaban group with regard to ease of taking the medication (186 patients [98.9%] vs 110 patients [58.8%]; OR, 0.06; 95% CI, 0.01-0.25; P < .001) and pain associated with taking the medication (4 patients [2.1%] vs 92 patients [49.2%]; OR, 9.20; 95% CI, 2.67-31.82; P < .001). Conclusions and Relevance: These findings suggest that oral apixaban is a potentially safe, less painful, and easier-to-take alternative to subcutaneous enoxaparin for thromboprophylaxis after surgery for gynecologic cancer. The efficacy of apixaban to prevent venous thromboembolic events is hypothesized as being equivalent. Trial Registration: ClinicalTrials.gov Identifier: NCT02366871.

Ovarian Tumor Cell Expression of Claudin-4 Reduces Apoptotic Response to Paclitaxel.

A significant factor contributing to poor survival rates for patients with ovarian cancer is the insensitivity of tumors to standard-of-care chemotherapy. In this study, we investigated the effect of claudin-4 expression on ovarian tumor cell apoptotic response to cisplatin and paclitaxel. We manipulated claudin-4 gene expression by silencing expression [short hairpin RNA (shRNA)] in cells with endogenously expressed claudin-4 or overexpressing claudin-4 in cells that natively do not express claudin-4. In addition, we inhibited claudin-4 activity with a claudin mimic peptide (CMP). We monitored apoptotic response by caspase-3 and Annexin V binding. We examined proliferation rate by counting the cell number over time as well as measuring the number of mitotic cells. Proximity ligation assays, immunoprecipitation (IP), and immunofluorescence were performed to examine interactions of claudin-4. Western blot analysis of tubulin in cell fractions was used to determine the changes in tubulin polymerization with changes in claudin-4 expression. Results show that claudin-4 expression reduced epithelial ovarian cancer (EOC) cell apoptotic response to paclitaxel. EOCs without claudin-4 proliferated more slowly with enhanced mitotic arrest compared with the cells expressing claudin-4. Furthermore, our results indicate that claudin-4 interacts with tubulin, having a profound effect on the structure and polymerization of the microtubule network. In conclusion, we demonstrate that claudin-4 reduces the ovarian tumor cell response to microtubule-targeting paclitaxel and disrupting claudin-4 with CMP can restore apoptotic response. IMPLICATIONS: These results suggest that claudin-4 expression may provide a biomarker for paclitaxel response and can be a target for new therapeutic strategies to improve response.

Spatial and temporal influence of onsite wastewater treatment systems, centralized effluent discharge, and tides on aquatic hazards of nutrients, indicator bacteria, and pharmaceuticals in a coastal bayou.

In the rapidly urbanizing watersheds and estuaries flowing to the Gulf of Mexico in Texas, USA, instream flows are increasingly influenced by point source and nonpoint source discharges. Spatial and temporal tidal influences on water quality, especially for contaminants of emerging concern (CECs), is poorly understood in estuaries and coastal systems. We selected Dickinson Bayou, an urban estuary in Galveston County, Texas, for study because it has historically impaired water quality, receives point source discharge from one major wastewater treatment plant (WWTP), while also being influenced by high densities of onsite sewage facilities upstream in the watershed. We explored the occurrence and potential hazards of aquatic contaminants, including nutrients, indicator bacteria for pathogens, and CECs, in relation to this point source discharge, across seasons and at high and low tides. Aquatic contaminants and associated hazards varied significantly in relation to the WWTP discharge, and were influenced by onsite systems. In fact, spatiotemporal water quality varied by class of contaminants (e.g., nutrients, indicator bacteria, CECs), which indicates that traditional surface water monitoring activities should account for such environmental complexity. This study provides a diagnostic approach for future studies of emerging water quality challenges across gradients of rapidly urbanizing coastal bays and estuaries.

Ontogenetic dietary shifts and bioaccumulation of diphenhydramine in Mugil cephalus from an urban estuary.

Though bioaccumulation of pharmaceuticals has received attention in inland waters, studies of pharmaceutical bioaccumulation in estuarine and marine systems are limited. Further, an understanding of pharmaceutical bioaccumulation across size classes of organisms displaying ontogenetic feeding shifts is lacking. We selected the striped mullet, Mugil cephalus, a euryhaline and eurythermal species that experiences dietary shifts with age, to identify whether a model base, diphenhydramine, accumulated in a tidally influenced urban bayou. We further determined whether diphenhydramine accumulation differed among size classes of striped mullet over a two year study period. Stable isotope analysis identified that ontogenetic feeding shifts of M. cephalus occurred from juveniles to adults. However, bioaccumulation of diphenhydramine did not significantly increase across age classes of M. cephalus but corresponded to surface water levels of the pharmaceutical, which suggests inhalational uptake to diphenhydramine was more important for bioaccumulation than dietary exposure in this urban estuary.

Bevacizumab induced hypertension in gynecologic cancer: Does it resolve after completion of therapy?

Hypertension (HTN) induced by bevacizumab is a side effect that is often thought to resolve after treatment. However, there are currently no reports on rates of resolution. We assess the incidence and timing of the resolution of bevacizumab induced HTN. We evaluated all patients treated with bevacizumab for gynecologic malignancies at a single institution from 2012 through 2014. HTN was retrospectively diagnosed and staged by CTCAE v4.0 criteria. Resolution of HTN was defined as ≥ 2 values return to baseline blood pressure and/or discontinuation/decrease of blood pressure medications. We identified 104 patients; 35 were excluded due to receiving bevacizumab at time of analysis. Grade 2 or higher induced HTN was identified in 34/69 (49.3%) patients, of which 26/69 (37.7%) had grade 2 HTN and 8/69 (11.6%) had grade 3/4 HTN. Onset of HTN occurred at a median of 67 (14-791) days. Resolution of HTN occurred in 28/34 (82.4%) patients with a median time to resolution of 87 (3-236) days. BMI, history of HTN, blood pressure medications, prior bevacizumab treatment, number of bevacizumab cycles, CA-125 and albumin at initiation of treatment were not independent risk factors associated with developing HTN in multivariate analysis. Median PFS for those with HTN was 12.5 (1.9-45.8) months vs 11.0 (2.1-44.7) for those without (p = 0.17). Hypertension induced by bevacizumab resolved in 82% of patients in a median of 87 days. There were no identifiable risk factors associated with induced HTN and HTN was not a biomarker for improved prognosis in our cohort.

Predicted and observed therapeutic dose exceedances of ionizable pharmaceuticals in fish plasma from urban coastal systems.

Instream flows of the rapidly urbanizing watersheds and estuaries of the Gulf of Mexico in Texas (USA) are increasingly dominated by reclaimed waters. Though ionizable pharmaceuticals have received increasing attention in freshwaters, many research questions remain unanswered, particularly in tidally influenced urban coastal systems, which experience significant spatiotemporal variability in pH that influences bioavailability and bioaccumulation. The authors coupled fish plasma modeling of therapeutic hazard values with field monitoring of water chemistry variability and pharmaceutical occurrence to examine whether therapeutic hazards to fish existed within these urban coastal ecosystems and whether therapeutic hazards differed within and among coastal locations and seasons. Spatial and temporal fluctuations in pH within study sites altered the probability of encountering pharmaceutical hazards to fish. Significant water quality differences were consistently observed among traditional parameters and pharmaceuticals collected from surface and bottom waters, which are rarely sampled during routine surface water quality assessments. The authors then compared modeling predictions of fish plasma concentrations of pharmaceuticals to measured plasma levels from various field-collected fish species. Diphenhydramine and diltiazem were observed in plasma of multiple species, and diltiazem exceeded human therapeutic doses in largemouth bass, catfish, and mullet inhabiting these urban estuaries. Though the present study only examined a small number of target analytes, which represent a microcosm of the exposome of these fish, coastal systems are anticipated to be more strongly influenced by continued urbanization, altered instream flows, and population growth in the future. Unfortunately, aquatic toxicology information for diltiazem and many other pharmaceuticals is not available for marine and estuarine organisms, but such field observations suggest that potential adverse outcomes should be examined.

Resection and Advancement Flap Closure of a Combined Vascular Malformation of the Mons Pubis.

BACKGROUND: Vascular malformations are congenital abnormalities that do not spontaneously regress and may require surgical resection for treatment. CASE: A healthy 23-year-old woman presented with a painless, slowly enlarging mass of the mons pubis. Ultrasonography and magnetic resonance imaging demonstrated a cystic mass with minimal Doppler flow. The final pathology showed a combined lymphatic-venous vascular malformation. A meshed advancement flap was used to close the skin after surgical resection. These flaps create a lattice of small cutaneous defects that heal rapidly by secondary intention and optimize wound healing. CONCLUSION: Lower genital tract vascular malformations are rare but often become symptomatic in adolescents or young women. Larger lesions may warrant surgical resection. Flap closures may aid in proper wound healing.

Bioaccumulation of human pharmaceuticals in fish across habitats of a tidally influenced urban bayou.

Though pharmaceuticals and other contaminants of emerging concern are increasingly observed in inland water bodies, the occurrence and bioaccumulation of pharmaceuticals in estuaries and coastal ecosystems are poorly understood. In the present study, bioaccumulation of select pharmaceuticals and other contaminants of emerging concern was examined in fish from Buffalo Bayou, a tidally influenced urban ecosystem that receives effluent from a major (∼200 million gallons per day) municipal wastewater treatment plant in Houston, Texas, USA. Using isotope dilution liquid chromatography-tandem mass spectrometry, various target analytes were observed in effluent, surface water, and multiple fish species. The trophic position of each species was determined using stable isotope analysis. Fish tissue levels of diphenhydramine, which represented the only pharmaceutical detected in all fish species, did not significantly differ between freshwater and marine fish predominantly inhabiting benthic habitats; however, saltwater fish with pelagic habitat preferences significantly accumulated diphenhydramine to the highest levels observed in the present study. Consistent with previous observations from an effluent-dependent freshwater river, diphenhydramine did not display trophic magnification, which suggests site-specific, pH-influenced inhalational uptake to a greater extent than dietary exposure in this tidally influenced urban ecosystem. The findings highlight the importance of understanding differential bioaccumulation and risks of ionizable contaminants of emerging concern in habitats of urbanizing coastal systems.

Global Assessment of Bisphenol A in the Environment: Review and Analysis of Its Occurrence and Bioaccumulation.

Because bisphenol A (BPA) is a high production volume chemical, we examined over 500 peer-reviewed studies to understand its global distribution in effluent discharges, surface waters, sewage sludge, biosolids, sediments, soils, air, wildlife, and humans. Bisphenol A was largely reported from urban ecosystems in Asia, Europe, and North America; unfortunately, information was lacking from large geographic areas, megacities, and developing countries. When sufficient data were available, probabilistic hazard assessments were performed to understand global environmental quality concerns. Exceedances of Canadian Predicted No Effect Concentrations for aquatic life were >50% for effluents in Asia, Europe, and North America but as high as 80% for surface water reports from Asia. Similarly, maximum concentrations of BPA in sediments from Asia were higher than Europe. Concentrations of BPA in wildlife, mostly for fish, ranged from 0.2 to 13 000 ng/g. We observed 60% and 40% exceedences of median levels by the US Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey in Europe and Asia, respectively. These findings highlight the utility of coordinating global sensing of environmental contaminants efforts through integration of environmental monitoring and specimen banking to identify regions for implementation of more robust environmental assessment and management programs.

Glc7/protein phosphatase 1 regulatory subunits can oppose the Ipl1/aurora protein kinase by redistributing Glc7.

Faithful chromosome segregation depends on the opposing activities of the budding yeast Glc7/PP1 protein phosphatase and Ipl1/Aurora protein kinase. We explored the relationship between Glc7 and Ipl1 and found that the phosphorylation of the Ipl1 substrate, Dam1, was altered by decreased Glc7 activity, whereas Ipl1 levels, localization, and kinase activity were not. These data strongly suggest that Glc7 ensures accurate chromosome segregation by dephosphorylating Ipl1 targets rather than regulating the Ipl1 kinase. To identify potential Glc7 and Ipl1 substrates, we isolated ipl1-321 dosage suppressors. Seven genes (SDS22, BUD14, GIP3, GIP4, SOL1, SOL2, and PEX31) encode newly identified ipl1 dosage suppressors, and all 10 suppressors encode proteins that physically interact with Glc7. The overexpression of the Gip3 and Gip4 suppressors altered Glc7 localization, indicating they are previously unidentified Glc7 regulatory subunits. In addition, the overexpression of Gip3 and Gip4 from the galactose promoter restored Dam1 phosphorylation in ipl1-321 mutant cells and caused wild-type cells to arrest in metaphase with unsegregated chromosomes, suggesting that Gip3 and Gip4 overexpression impairs Glc7's mitotic functions. We therefore propose that the overexpression of Glc7 regulatory subunits can titrate Glc7 away from relevant Ipl1 targets and thereby suppress ipl1-321 cells by restoring the balance of phosphatase/kinase activity.