Neratinib and Ado-Trastuzumab-Emtansine for Pre-treated and Untreated HER2-positive Breast Cancer Brain Metastases: Translational Breast Cancer Research Consortium Trial 022.

PURPOSE: Treatment options for HER2-positive breast cancer brain metastases (BCBM) remain limited. We previously reported central nervous system (CNS) activity for neratinib and neratinib-capecitabine. Preclinical data suggest that neratinib may overcome resistance to ado-trastuzumab-emtansine (T-DM1) when given in combination. In TBCRC 022's cohort 4, we examined the efficacy of neratinib plus T-DM1 in patients with HER2-positive BCBM. PATIENTS AND METHODS: In this multicenter, phase II study, patients with measurable HER2-positive BCBM received neratinib 160 mg daily plus T-DM1 3.6 mg/kg intravenously every 21 days in three parallel-enrolling cohorts (cohort 4A-previously untreated BCBM, cohorts 4B and 4C- BCBM progressing after local CNS-directed therapy without [4B] and with [4C] prior exposure to T-DM1). Cycle 1 diarrheal prophylaxis was required. The primary endpoint was the Response Assessment in Neuro-Oncology-Brain Metastases (RANO-BM) by cohort. Overall survival (OS) and toxicity were also assessed. RESULTS: Between 2018-2021, 6, 17, and 21 patients enrolled to cohorts 4A, 4B, and 4C. Enrollment was stopped prematurely for slow accrual. The CNS objective response rate in cohorts 4A, 4B, and 4C was 33.3% (95% confidence interval [CI]: 4.3-77.7%), 35.3% (95% CI: 14.2-61.7%), and 28.6% (95% CI: 11.3-52.2%), respectively; 38.1-50% experienced stable disease for ≥6 months or response. Diarrhea was the most common grade 3 toxicity (22.7%). Median OS was 30.2 months (cohort 4A; 95% CI: 21.9, not reached [NR]), 23.3 months (cohort 4B; 95% CI: 17.6, NR), and 20.9 months (cohort 4C; 95% CI: 14.9, NR). CONCLUSION: We observed Intracranial activity for neratinib plus T-DM1, including those with prior T-DM1 exposure, suggesting synergistic effects with neratinib. Our data provide additional evidence for neratinib-based combinations in patients with HER2-positive BCBM, even those who are heavily pre-treated.

Species-specific thermal classification schemes can improve climate related marine resource decisions.

Global climate change increasingly contributes to large changes in ecosystem structure. Timely management of rapidly changing marine ecosystems must be matched with methods to rapidly quantify and assess climate driven impacts to ecological communities. Here we create a species-specific, classification system for fish thermal affinities, using three quantifiable datasets and expert opinion. Multiple sources of information limit potential data bias and avoid misclassification. Using a temperate kelp forest fish community in California, USA as a test case for this new methodology, we found the majority of species had high classification agreement across all four data sources (n = 78) but also a number of low agreement species (2 sources disagree from the others, n = 47). For species with low agreement, use of just one dataset to classify species, as is commonly done, would lead to high risk of misclassification. Differences in species classification between individual datasets and our composite classification were apparent. Applying different thermal classifications, lead to different conclusions when quantifying 'warm' and 'cool' species density responses to a marine heatwave. Managers can use this classification approach as a tool to generate accurate, timely and simple information for resource management.

Marine protected areas do not prevent marine heatwave-induced fish community structure changes in a temperate transition zone.

Acute climate events like marine heatwaves have the potential to temporarily or permanently alter community structure with effects on biodiversity and ecosystem services. We aimed to quantify the magnitude and consistency of climate driven community shifts inside and outside Marine Protected Areas before and after a marine heatwave using a kelp forest fish community dataset in southern California, USA. Abundance, biomass, diversity and recruitment of warm-water affinity species during the marine heatwave were significantly greater compared with prior years yet cool-water affinity species did not show commensurate declines. Fish communities inside MPAs were not buffered from these community shifts. This result is likely because the particular species most responsible for the community response to environmental drivers, were not fisheries targets. Resource managers working to preserve biodiversity in a changing climate will need to consider additional management tools and strategies in combination with protected areas to mitigate the effect of warming on marine communities.

Phase I dose-escalation trial of tucatinib in combination with trastuzumab in patients with HER2-positive breast cancer brain metastases.

BACKGROUND: Brain metastases are frequent in HER2-positive breast cancer. ONT-380 (tucatinib) is a potent selective inhibitor of HER2 with intracranial activity in preclinical models. PATIENTS AND METHODS: This was a phase I study of tucatinib with trastuzumab, without chemotherapy, in patients with progressive, measurable HER2-positive brain metastases. The study tested two schedules of tucatinib: cohort A was twice daily and cohort B was once daily. The primary objective was determination of the maximum tolerated dose (MTD). Secondary end points included objective response (intracranial and extracranial) using modified RECIST and clinical benefit rate (CBR). RESULTS: Overall, 41 patients were enrolled (cohort A, n = 22; cohort B, n = 19). Patients had a median of two prior treatments for metastatic breast cancer and 83% had progressed after prior brain radiation. The MTD of tucatinib for cohort A was 300 mg twice daily and for cohort B was 750 mg once daily. The most common dose-limiting toxicities included thrombocytopenia and aspartate transaminase/alanine aminotransferase elevation. Grade 3/4 aspartate transaminase/alanine aminotransferase elevation occurred in nine of 41 patients (22%). Intracranial responses were observed in two of 17 (12%) patients in cohort A and one of 17 (6%) patients in cohort B treated at the MTD. In cohort A, CBR at 16 weeks was 35% (n = 6). In cohort B, CBR at 16 weeks was 53% (n = 9). Of 15 patients overall who experienced clinical benefit, 12 (80%) had received prior neratinib and/or lapatinib. Median progression-free survival for cohorts A and B was 3.4 and 4.1 months, respectively. CONCLUSION: The combination of tucatinib and trastuzumab is tolerable and demonstrated preliminary evidence of efficacy in patients with HER2-positive brain metastases. CLINICAL TRIAL REGISTRATION: NCT01921335.

MBRRACE-UK: saving lives, improving mothers' care - implications for anaesthetists.

In December 2014, the latest UK Confidential Enquiry into Maternal Deaths report was published, covering the surveillance period from 2009 to 2012. This is the first report since a significant change in the organisational structure of the body responsible for surveillance and dissemination of reports. The Confidential Enquiry Reports are regarded as a gold standard worldwide and have contributed to quality improvement of maternity care both in the UK and elsewhere. This article aims to give obstetric anaesthetists an overview of the current report and highlight the pertinent implications for anaesthetic practice.

A compact high-performance low-field NMR apparatus for measurements on fluids at very high pressures and temperatures.

We discuss an innovative new high-performance apparatus for performing low-field Nuclear Magnetic Resonance (NMR) relaxation times and diffusion measurements on fluids at very high pressures and high temperatures. The apparatus sensor design and electronics specifications allow for dual deployment either in a fluid sampling well logging tool or in a laboratory. The sensor and electronics were designed to function in both environments. This paper discusses the use of the apparatus in a laboratory environment. The operating temperature and pressure limits, and the signal-to-noise ratio (SNR) of the new system exceed by a very wide margin what is currently possible. This major breakthrough was made possible by a revolutionary new sensor design that breaks many of the rules of conventional high pressure NMR sensor design. A metallic sample holder capable of operating at high pressures and temperatures is provided to contain the fluid under study. The sample holder has been successfully tested for operation up to 36 Kpsi. A solenoid coil wound on a slotted titanium frame sits inside the metallic sample holder and serves as an antenna to transmit RF pulses and receive NMR signals. The metal sample holder is sandwiched between a pair of gradient coils which provide a linear field gradient for pulsed field gradient diffusion measurements. The assembly sits in the bore of a low-gradient permanent magnet. The system can operate over a wide frequency range without the need for tuning the antenna to the Larmor frequency. The SNR measured on a water sample at room temperature is more than 15 times greater than that of the commercial low-field system in our laboratory. Thus, the new system provides for data acquisition more than 200 times faster than was previously possible. Laboratory NMR measurements of relaxations times and diffusion coefficients performed at pressures up to 25 Kpsi and at temperatures up to 175 °C with crude oils enlivened with dissolved hydrocarbon gases (referred to as "live oils") are shown. This is the first time low-field NMR measurements have been performed at such high temperatures and pressures on live crude oil samples. We discuss the details of the apparatus design, tuning, calibration, and operation. NMR data acquired at multiple temperatures and pressures on a live oil sample are discussed.

Receiving enzyme replacement therapy for a lysosomal storage disorder: a preliminary exploration of the experiences of young patients and their families.

Medical intervention for lysosomal storage disorders becomes part of life, shaping the reality of the condition for affected individuals and families. Enzyme replacement therapy (ERT) is available to treat some lysosomal storage disorders. ERT is costly and time consuming, requiring frequent hospital visits to receive intravenous infusions. This qualitative study sought to explore the impact of receiving ERT for a lysosomal storage disorder on the health related quality of life (HRQoL) of young patients and their families. Fifteen semi-structured interviews were conducted with young people and parents and siblings of young people accessing ERT for Pompe disease, Gaucher disease or mucopolysaccharidosis types I or II living in Victoria, Australia. Interviews were transcribed then analyzed thematically. The biopsychosocial model assisted in interpreting themes. Findings revealed positive attitudes towards ERT, with noticed improvements in physical and psychosocial well-being. Participants prioritised intervention over other activities and provided suggestions for improving current service delivery. Communication with family members and professionals was deemed important, especially in respect to information provision. Participants described challenges associated with living with a lysosomal storage disorder and receiving ERT and coping strategies, such as positive thinking and ways to manage uncertainty. These findings provide valuable insights into the impact of living with a chronic genetic condition and receiving intensive treatment on HRQoL.

Inhibition of HIV-1 protease: the rigidity perspective.

MOTIVATION: HIV-1 protease is a key drug target due to its role in the life cycle of the HIV-1 virus. Rigidity analysis using the software First is a computationally inexpensive method for inferring functional information from protein crystal structures. We evaluate the rigidity of 206 high-resolution (2 Å or better) X-ray crystal structures of HIV-1 protease and compare the effects of different inhibitors binding to the enzyme. RESULTS: Inhibitor binding has little effect on the overall rigidity of the protein homodimer, including the rigidity of the active site. The principal effect of inhibitor binding on rigidity is to constrain the flexibility of the ß-hairpin flaps, which move to allow access to the active site of the enzyme. We show that commercially available antiviral drugs which target HIV-1 protease can be divided into two classes, those which significantly affect flap rigidity and those which do not. The non-peptidic inhibitor tipranavir is distinctive in its consistently strong effect on flap rigidity. CONTACT: jack.heal@warwick.ac.uk; r.roemer@warwick.ac.uk SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

Rapid simulation of protein motion: merging flexibility, rigidity and normal mode analyses.

Protein function frequently involves conformational changes with large amplitude on timescales which are difficult and computationally expensive to access using molecular dynamics. In this paper, we report on the combination of three computationally inexpensive simulation methods--normal mode analysis using the elastic network model, rigidity analysis using the pebble game algorithm, and geometric simulation of protein motion--to explore conformational change along normal mode eigenvectors. Using a combination of ElNemo and First/Froda software, large-amplitude motions in proteins with hundreds or thousands of residues can be rapidly explored within minutes using desktop computing resources. We apply the method to a representative set of six proteins covering a range of sizes and structural characteristics and show that the method identifies specific types of motion in each case and determines their amplitude limits.

CHEMICAL CONSEQUENCES OF THE C/O RATIO ON HOT JUPITERS: EXAMPLES FROM WASP-12b, COROT-2b, XO-1b, AND HD 189733b.

Motivated by recent spectroscopic evidence for carbon-rich atmospheres on some transiting exo-planets, we investigate the influence of the C/O ratio on the chemistry, composition, and spectra of extrasolar giant planets both from a thermochemical-equilibrium perspective and from consideration of disequilibrium processes like photochemistry and transport-induced quenching. We find that although CO is predicted to be a major atmospheric constituent on hot Jupiters for all C/O ratios, other oxygen-bearing molecules like H2O and CO2 are much more abundant when C/O < 1, whereas CH4, HCN, and C2H2 gain significantly in abundance when C/O > 1. Other notable species like N2 and NH3 that do not contain carbon or oxygen are relatively unaffected by the C/O ratio. Disequilibrium processes tend to enhance the abundance of CH4, NH3, HCN, and C2H2 over a wide range of C/O ratios. We compare the results of our models with secondary-eclipse photometric data from the Spitzer Space Telescope and conclude that (1) disequilibrium models with C/O ~ 1 are consistent with spectra of WASP-12b, XO-1b, and CoRoT-2b, confirming the possible carbon-rich nature of these planets, (2) spectra from HD 189733b are consistent with C/O ≲ 1, but as the assumed metallicity is increased above solar, the required C/O ratio must increase toward 1 to prevent too much H2O absorption, (3) species like HCN can have a significant influence on spectral behavior in the 3.6 and 8.0 µm Spitzer channels, potentially providing even more opacity than CH4 when C/O > 1, and (4) the very high CO2 abundance inferred for HD 189733b from near-infrared observations cannot be explained through equilibrium or disequilibrium chemistry in a hydrogen-dominated atmosphere. We discuss possible formation mechanisms for carbon-rich hot Jupiters, including scenarios in which the accretion of CO-rich, H2O-poor gas dominates the atmospheric envelope, and scenarios in which the planets accrete carbon-rich solids while migrating through disk regions inward of the snow line. The C/O ratio and bulk atmospheric metallicity provide important clues regarding the formation and evolution of the giant planets.

Menopausal hot flushes and night sweats: where are we now?

OBJECTIVE: An overview of the current knowledge on the etiology and treatment of vasomotor symptoms in postmenopausal women. MATERIALS AND METHODS: Acknowledged experts in the field contributed a brief assessment of their areas of interest which were combined and edited into the final manuscript. RESULTS: Women around the world experience vasomotor symptoms as they enter and complete the menopause transition. Vasomotor symptoms, specifically hot flushes, are caused by a narrowing of the thermoneutral zone in the brain. This effect, although related to estrogen withdrawal, is most likely related to changes in central nervous system neurotransmitters. Peripheral vascular reactivity is also altered in symptomatic women. Estrogen replacement therapy is the most effective treatment for hot flushes. Of the other interventions investigated, selective serotonin and selective norepinephrine reuptake inhibitors and gabapentin show efficacy greater than placebo. Objective monitoring of hot flushes indicates a robust improvement with hormone replacement therapy but little to no change with placebo. These data suggest that the subjective assessment of responses to therapy for vasomotor symptom results in inaccurate data. Hot flushes have recently been associated with increased cardiovascular risks and a lower incidence of breast cancer, but these data require confirmation. CONCLUSIONS: Vasomotor symptoms are experienced by women of all ethnic groups. They are caused by changes in the central nervous system associated with estrogen withdrawal and are best treated with estrogen replacement therapy. Objective monitoring of hot flushes indicates that placebo has little to no effect on their improvement. Subjective assessments of hot flushes in clinical trials may be inaccurate based on objective measurement of the frequency of hot flushes. Based on preliminary reports, women experiencing hot flushes have an increased risk of cardiovascular disease and a reduced incidence of breast cancer.

Measurement and calculation of the emission anisotropy of an X1 252Cf neutron source.

The authors have measured the emission anisotropy from a (252)Cf spontaneous fission neutron source in an X1 encapsulation. The measurements were made in a large low-scatter laboratory using a long counter, and data were taken at angles varying in 10 degrees steps from 0 degrees to 180 degrees relative to the cylindrical axis of the source. Corrections were made for room scatter, loss of neutrons due to air scatter and detector dead time. Calculations corresponding to these measurements were subsequently carried out using the two Monte Carlo codes MCNP and MCBEND, and the results are compared with the measurements and with each other.

Immunobiology of gestational trophoblastic diseases.

Gestational trophoblastic diseases (GTDs) comprise a group of interrelated diseases characterized by development after gestation, widespread metastases, and high curability with chemotherapy. The good prognosis of GTDs is considered partly a result of the host immune response to paternal antigens expressed on trophoblastic cells. In this study, we review current understanding of the immunobiology of GTDs. First of all, we describe the microenvironment between trophoblastic cells and subpopulation of immune cells. Second, immunogenetics, immune microenvironment around abnormal trophoblast, and mechanism of GTDs escaping from maternal immune system surveillance were also discussed. Third, we propose the possible immunotherapy for persistent GTDs, particularly the vaccine designed on human chorionic gonadotrophin, which is generally accepted as a tumor marker for GTDs diagnosis. Due to the low incidence of GTDs and high response to chemotherapy, there have been few literatures about immunobiologic characteristics of GTDs compared with the other gynecologic malignancies, such as ovarian cancer, but the immunologic behavior of GTDs should be explored for further understanding of the etiology of these diseases and to help designing immunotherapeutic strategies for persistent GTDs.

Brain pH has a significant impact on human postmortem hippocampal gene expression profiles.

Studies of neurobiological disorders in the brain, including schizophrenia, rely on the use of postmortem brain tissues, in which an understanding of the effects of various pre- and postmortem variables on gene expression is critical. In several different brain regions, pH has been shown to have a large effect on postmortem brain gene expression patterns. One region that has not yet been evaluated in such studies is the hippocampus, a region often implicated in schizophrenia research. In the present study, we show that postmortem brain pH is similar across different brain regions. Brain pH accounted for greater variation in hippocampal gene expression profiles than any other parameter evaluated, including gender and schizophrenia. The predictive value of brain pH in an independent sample set was also greater than the disease, demonstrating that pH represents one of the most important control parameters in human postmortem gene expression studies in schizophrenia.

Venous thromboembolism syndrome in gynecological cancer.

Venous thromboembolism (VTE) could be presented as an initial clinical feature in some cancer patients or a complication followed by various cancer treatments, which all indicates a poor outcome. This review focuses on elucidating the relationship of VTE and the main gynecological cancers including ovarian, endometrial, and cervical cancers. First, the general VTE information about gynecological cancer are introduced; second, the risk factors of VTE developing in gynecological cancer were discussed; third, we do a retrospective analysis on a novel treatment targeting coagulation cascade; and last, we analyze VTE as a remarkable complication followed by recombinant human erythropoietin and anti-vascular endothelial growth factor treatment in gynecological cancer patients. In summary, the interaction between the coagulation system and cancer progression is a novel promising area to be explored in the study of VTE in patients with gynecological cancer.

Neopterin as an indicator of immune activation and prognosis in patients with gynecological malignancies.

Malignant tumors may contribute to host response that involves both the adaptive and innate immune systems. Among other biochemical indicators of systemic immune and inflammatory activity, activation of macrophages by interferon-gamma induces a marked increase in the production of neopterin. Neopterin production by activated macrophages is also associated with tryptophan degradation. In addition to tumors of other primary locations, increased urinary and serum neopterin concentrations have been reported in patients with gynecological cancers, including epithelial ovarian carcinoma, cervical carcinoma, endometrial carcinoma, uterine sarcomas, and vulvar carcinoma, but not in women with benign neoplasms or precancerous disorders. Increased neopterin concentrations have been associated with poor prognosis. Elevated levels of neopterin have also been observed in the tumor microenvironment. Systemic (urinary or serum) or local (ascitic fluid) neopterin concentrations increased after therapeutic administration of cytokines. Elevated neopterin concentrations have been associated with anemia of chronic disease and increased urinary zinc loss in patients with gynecological malignancy. Elevated neopterin has also been connected with depressed function of peripheral blood lymphocytes and a decrease in CD4+ T-cell numbers.

Characterization of allelic variants at chromosome 15q14 in schizophrenia.

Evidence of genetic linkage for schizophrenia at chromosome 15q14 has been reported in nine independent studies, but the molecular variants responsible for transmission of genetic risk are unknown. National Institute of Mental Health Schizophrenia Genetics Initiative families were genotyped for single nucleotide polymorphisms (SNPs) and dinucleotide repeat markers in the 15q14 linkage region and analyzed based on the presence of particular alleles of the dinucleotide repeat marker D15S165 in the 15q14 region. Two alleles showed both familial transmission disequilibrium and population-wide association with schizophrenia. The two groups identified by these two D15S165 alleles differ in age of onset, number of hospitalizations and intensity of nicotine abuse, as well as in predominant ethnicity. Variations in the frequency of SNPs in CHRNA7, the alpha-7-nicotinic acetylcholine receptor subunit gene at 15q14, were found in each group. Further sequencing in these two groups may yield more definitive identification of the molecular pathology.

Differential modulation of gene expression in the NMDA postsynaptic density of schizophrenic and control smokers.

Nicotine is known to induce the release of multiple neurotransmitters, including glutamate and dopamine, through activation of nicotinic receptors. Gene expression in the N-methyl-d-aspartate postsynaptic density (NMDA-PSD), as well as other functional groups, was compared in postmortem hippocampus of schizophrenic and nonmentally ill smokers and nonsmokers utilizing a microarray and quantitative RT-PCR approach. The expression of 277 genes was significantly changed between all smokers and nonsmokers. Specific gene groups, most notably genes expressed in the NMDA-PSD, were prevalent among these transcripts. Analysis of the interaction between smoking and schizophrenia identified several genes in the NMDA-PSD that were differentially affected by smoking in patients. The present findings suggest that smoking may differentially modulate glutamatergic function in schizophrenic patients and control subjects. The biological mechanisms underlying chronic tobacco use are likely to differ substantially between these two groups.

Retrospective review: re-treatment of patients with ovarian cancer with carboplatin after platinum resistance.

The objective of the analysis was to determine the effectiveness of re-treating patients with ovarian cancer, primary peritoneal cancer, and fallopian tube cancer with carboplatin after being deemed platinum resistant. From a database period January 1, 1996, to December 12, 2002, 34 patients were identified who received nonplatinum agents before resuming treatment with carboplatin. The median age was 65 years, and a median of two nonplatinum chemotherapy (range 1-5) prior to re-treatment with carboplatin was received. The median platinum-free interval from the time platinum was last received to re-treatment with carboplatin was 15.2 months (95% confidence interval [CI] 12.6-17.9; range 6.2-47.0). A median number of four cycles of carboplatin (range 1-11) was received. Two patients (5.9%) achieved partial response, while 21 patients (61.7%) achieved stable disease. The median time to progression for these 23 patients after re-treatment with carboplatin was 5.7 months (95% CI 5.2-6.3; range 1.8-15.3). Twenty-seven patients have died, and all patients have progressed. Seven patients are still receiving salvage therapy. The median overall survival from the time deemed to be platinum resistant is 23.2 months (95% CI 20.1-26.4). Patients who have been deemed platinum resistant may still benefit from platinum re-treatment after an interval of treatment with nonplatinum agents.