The price of tumor control: an analysis of rare side effects of anti-CTLA-4 therapy in metastatic melanoma from the ipilimumab network

Background: Ipilimumab, a cytotoxic T-lymphocyte antigen-4 (CTLA-4) blocking antibody, has been approved for the treatment of metastatic melanoma and induces adverse events (AE) in up to 64% of patients. Treatment algorithms for the management of common ipilimumab-induced AEs have lead to a reduction of morbidity, e.g. due to bowel perforations. However, the spectrum of less common AEs is expanding as ipilimumab is increasingly applied. Stringent recognition and management of AEs will reduce drug-induced morbidity and costs, and thus, positively impact the cost-benefit ratio of the drug. To facilitate timely identification and adequate management data on rare AEs were analyzed at 19 skin cancer centers. Methods and Findings: Patient files (n = 752) were screened for rare ipilimumab-associated AEs. A total of 120 AEs, some of which were life-threatening or even fatal, were reported and summarized by organ system describing the most instructive cases in detail. Previously unreported AEs like drug rash with eosinophilia and systemic symptoms (DRESS), granulomatous inflammation of the central nervous system, and aseptic meningitis, were documented. Obstacles included patientś delay in reporting symptoms and the differentiation of steroid-induced from ipilimumab-induced AEs under steroid treatment. Importantly, response rate was high in this patient population with tumor regression in 30.9% and a tumor control rate of 61.8% in stage IV melanoma patients despite the fact that some patients received only two of four recommended ipilimumab infusions. This suggests that ipilimumab-induced antitumor responses can have an early onset and that severe autoimmune reactions may reflect overtreatment. Conclusion: The wide spectrum of ipilimumab-induced AEs demands doctor and patient awareness to reduce morbidity and treatment costs and true ipilimumab success is dictated by both objective tumor responses and controlling severe side effects

Synergistic Inhibition of Endothelial Cell Proliferation, Tube Formation, and Sprouting by Cyclosporin A and Itraconazole

Pathological angiogenesis contributes to a number of diseases including cancer and macular degeneration. Although angiogenesis inhibitors are available in the clinic, their efficacy against most cancers is modest due in part to the existence of alternative and compensatory signaling pathways. Given that angiogenesis is dependent on multiple growth factors and a broad signaling network in vivo, we sought to explore the potential of multidrug cocktails for angiogenesis inhibition. We have screened 741 clinical drug combinations for the synergistic inhibition of endothelial cell proliferation. We focused specifically on existing clinical drugs since the re-purposing of clinical drugs allows for a more rapid and cost effective transition to clinical studies when compared to new drug entities. Our screen identified cyclosporin A (CsA), an immunosuppressant, and itraconazole, an antifungal drug, as a synergistic pair of inhibitors of endothelial cell proliferation. In combination, the IC50 dose of each drug is reduced by 3 to 9 fold. We also tested the ability of the combination to inhibit endothelial cell tube formation and sprouting, which are dependent on two essential processes in angiogenesis, endothelial cell migration and differentiation. We found that CsA and itraconazole synergistically inhibit tube network size and sprout formation. Lastly, we tested the combination on human foreskin fibroblast viability as well as Jurkat T cell and HeLa cell proliferation, and found that endothelial cells are selectively targeted. Thus, it is possible to combine existing clinical drugs to synergistically inhibit in vitro models of angiogenesis. This strategy may be useful in pursuing the next generation of antiangiogenesis therapy

Role of the trauma nurse coordinator in Hong Kong

Background: Trauma is one of the leading causes of death for all ages in Hong Kong. In 2003, the Hospital Authority designated five hospitals as trauma centres. Five Trauma Nurse Coordinators (TNCs) were employed to facilitate multidisciplinary care and to coordinate all aspects of quality improvement for injured patients. The present paper investigates the characteristics and roles of TNCs in Hong Kong. Methods: A questionnaire was developed and sent to all TNCs in HK to ascertain information about demographic characteristics, education, job training, roles and the TNCs’ position within the organizational structure. Results: The TNCs were 30–40 years of age (four females); are experienced registered graduate nurses; hold post-registration certificates or diplomas in emergency/critical care; and have 11–18 years nursing experience. All TNCs have pursued masters degrees, with two completed. Four of the TNCs had received formal training on computerized data management, abbreviated injury scale coding and trauma nurse coordination. TNCs averaged 2.5 years experience in their post. TNCs manage the trauma registry, are involved in clinical patient management, quality assurance activities, professional and public education and research. Conclusion: TNCs play an important role in trauma management in Hong Kong

Ipilimumab-induced endocrinopathies: when to start corticosteroids (or not)

With the expanding use of ipilimumab, oncologists are not only faced with most common side effects, such as diarrhea and rush, but also with unusual adverse events, such as certain endocrinopathies. These include hypophysitis (0\u201317 %), thyroid disease or abnormalities in thyroid function tests (0\u20132 %), and occasionally primary adrenal insuf\ufb01cienc