The use of erythropoiesis-stimulating agents with ruxolitinib in patients with myelofibrosis in COMFORT-II: an open-label, phase 3 study assessing efficacy and safety of ruxolitinib versus best available therapy in the treatment of myelofibrosis

BACKGROUND: Anemia is considered a negative prognostic risk factor for survival in patients with myelofibrosis. Most patients with myelofibrosis are anemic, and 35-54 % present with anemia at diagnosis. Ruxolitinib, a potent inhibitor of Janus kinase (JAK) 1 and JAK2, was associated with an overall survival benefit and improvements in splenomegaly and patient-reported outcomes in patients with myelofibrosis in the two phase 3 COMFORT studies. Consistent with the ruxolitinib mechanism of action, anemia was a frequently reported adverse event. In clinical practice, anemia is sometimes managed with erythropoiesis-stimulating agents (ESAs). This post hoc analysis evaluated the safety and efficacy of concomitant ruxolitinib and ESA administration in patients enrolled in COMFORT-II, an open-label, phase 3 study comparing the efficacy and safety of ruxolitinib with best available therapy for treatment of myelofibrosis. Patients were randomized (2:1) to receive ruxolitinib 15 or 20 mg twice daily or best available therapy. Spleen volume was assessed by magnetic resonance imaging or computed tomography scan.

RESULTS: Thirteen of 146 ruxolitinib-treated patients had concomitant ESA administration (+ESA). The median exposure to ruxolitinib was 114 weeks in the +ESA group and 111 weeks in the overall ruxolitinib arm; the median ruxolitinib dose intensity was 33 mg/day for each group. Six weeks before the first ESA administration, 10 of the 13 patients had grade 3/4 hemoglobin abnormalities. These had improved to grade 2 in 7 of the 13 patients by 6 weeks after the first ESA administration. The rate of packed red blood cell transfusions per month within 12 weeks before and after first ESA administration remained the same in 1 patient, decreased in 2 patients, and increased in 3 patients; 7 patients remained transfusion independent. Reductions in splenomegaly were observed in 69 % of evaluable patients (9/13) following first ESA administration.

CONCLUSIONS: Concomitant use of an ESA with ruxolitinib was well tolerated and did not affect the efficacy of ruxolitinib. Further investigations evaluating the effects of ESAs to alleviate anemia in ruxolitinib-treated patients are warranted (ClinicalTrials.gov identifier, NCT00934544; July 6, 2009).

Ca2+- and volume-sensitive chloride currents are differentially regulated by agonists and store-operated Ca2+ entry.

Using patch-clamp and calcium imaging techniques, we characterized the effects of ATP and histamine on human keratinocytes. In the HaCaT cell line, both receptor agonists induced a transient elevation of [Ca2+]i in a Ca2+-free medium followed by a secondary [Ca2+]i rise upon Ca2+ readmission due to store-operated calcium entry (SOCE). In voltage-clamped cells, agonists activated two kinetically distinct currents, which showed differing voltage dependences and were identified as Ca2+-activated (ICl(Ca)) and volume-regulated (ICl, swell) chloride currents. NPPB and DIDS more efficiently inhibited ICl(Ca) and ICl, swell, respectively. Cell swelling caused by hypotonic solution invariably activated ICl, swell while regulatory volume decrease occurred in intact cells, as was found in flow cytometry experiments. The PLC inhibitor U-73122 blocked both agonist- and cell swelling–induced ICl, swell, while its inactive analogue U-73343 had no effect. ICl(Ca) could be activated by cytoplasmic calcium increase due to thapsigargin (TG)-induced SOCE as well as by buffering [Ca2+]i in the pipette solution at 500 nM. In contrast, ICl, swell could be directly activated by 1-oleoyl-2-acetyl-sn-glycerol (OAG), a cell-permeable DAG analogue, but neither by InsP3 infusion nor by the cytoplasmic calcium increase. PKC also had no role in its regulation. Agonists, OAG, and cell swelling induced ICl, swell in a nonadditive manner, suggesting their convergence on a common pathway. ICl, swell and ICl(Ca) showed only a limited overlap (i.e., simultaneous activation), although various maneuvers were able to induce these currents sequentially in the same cell. TG-induced SOCE strongly potentiated ICl(Ca), but abolished ICl, swell, thereby providing a clue for this paradox. Thus, we have established for the first time using a keratinocyte model that ICl, swell can be physiologically activated under isotonic conditions by receptors coupled to the phosphoinositide pathway. These results also suggest a novel function for SOCE, which can operate as a "selection" switch between closely localized channels.

The Complete Works of John Milton: Volume III: The Shorter Poems (816pp.)

Volume III of the new eleven-volume edition of Milton's Complete Works provides a definitive scholarly edition of all of Milton's shorter poems in English, Latin, Italian, and Greek, as well as his Mask, taken from both published and manuscript sources. It includes his 1645 Poems complete with all prefatory materials, thus illuminating the ways in which author, publisher, and print shop shaped this volume. It then presents all the new poems added in the 1673 edition (with the new Table of Contents), as well as the poems omitted from both editions. A careful collation of textual variants among these sources as well as the 1637 anonymous publication of Milton's Mask is provided. The Bridgewater manuscript of Milton's Mask (probably close to the acting version) and his working copy from the Trinity Manuscript, with its many alterations and additions, are transcribed in their entirety, so that the various versions may be compared and studied. 

A special feature of this edition is a new translation of Milton's many Latin and Greek poems that is both accurate and attentive to their literary qualities. This is augmented by a detailed and comprehensive commentary that highlights classical, vernacular, and neo-Latin parallels. A poetic translation of Milton's six Italian sonnets and Canzone is also supplied. In addition, the Appendices contain all the versions of Milton's shorter poems in all the contemporary manuscript and printed sources, so they may be examined in relation to their specific contexts. The transcription of all the versions of Milton's poems in the Trinity Manuscript allows in several cases, notably 'Lycidas' and 'At a Solemn Music,' for examination of the evolution of these poems as Milton weighed choiced of diction and sound qualities, enabling further understanding of his poetic practices. 

Barbara Lewalski is responsible for text, textual apparatus, and commentary pertaining to the vernacular poems in all sections of this edition including the appendices, and manuscript transcriptions (with the exception of A Maske), as well as the Occasions, Vernacular Poems,and Textual Introductions. Estelle Haan is responsible for text, textual apparatus, and commentary for the Poemata in all sections of this edition,and for the Poemata Introduction. She has also provided all translations from Latin, Italian, and Greek in the Testimonia, Poemata, and associated commentary, and transcriptions of the BL Damon, the Bodleian AdJoannem Rousium, and A Maske from the Trinity and Bridgewater manuscripts. Andrew McNeillie has provided poetic translations for Milton’s Italian sonnets, and Jason Rosenblatt has provided some Hebrew text and commentary pertaining to Milton’s Psalm translations.John Cunningham has transcribed Henry Lawes’ music for Milton’s masque, with commentary (Appendix E). Biblical references are taken from the King James (Authorized) Version.