Cyclosporine, Pravastatin Sodium, Etoposide, and Mitoxantrone Hydrochloride in Treating Patients With Relapsed or Refractory Acute Myeloid Leukemia

• Sponsor: Fred Hutchinson Cancer Center (Other)
• Overall Status: Terminated
• CT.gov ID: NCT01342887
• Collaborator: National Cancer Institute (NCI) (NIH)
• Enrollment: 6
• Location: 1
• Arm: 1
• Duration (Months): 11
• Patients Per Site Per Month: 0.5

Study Details

Study Description

Brief Summary

This phase I/II trial studies the side effects and best dose of etoposide and mitoxantrone hydrochloride when given together with cyclosporine and pravastatin sodium and to see how well they work in treating patients with relapsed or refractory acute myeloid leukemia (AML). Cyclosporine may inhibit efflux of cancer drugs out of cancer cells and may thereby improve chemotherapy treatment for AML. Pravastatin sodium may stop the growth of cancer cells by blocking some of the nutrients needed for cell growth. Drugs used in chemotherapy, such as etoposide and mitoxantrone hydrochloride, work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Giving cyclosporine together with pravastatin sodium, etoposide, and mitoxantrone hydrochloride may kill more cancer cells

Condition or Disease	Intervention/Treatment	Phase
Adult Acute Megakaryoblastic Leukemia (M7); Adult Acute Minimally Differentiated Myeloid Leukemia (M0); Adult Acute Monoblastic Leukemia (M5a); Adult Acute Monocytic Leukemia (M5b); Adult Acute Myeloblastic Leukemia With Maturation (M2); Adult Acute Myeloblastic Leukemia Without Maturation (M1); Adult Acute Myeloid Leukemia With 11q23 (MLL) Abnormalities; Adult Acute Myeloid Leukemia With Del(5q); Adult Acute Myeloid Leukemia With Inv(16)(p13;q22); Adult Acute Myeloid Leukemia With t(16;16)(p13;q22); Adult Acute Myeloid Leukemia With t(8;21)(q22;q22); Adult Acute Myelomonocytic Leukemia (M4); Adult Erythroleukemia (M6a); Adult Pure Erythroid Leukemia (M6b); Recurrent Adult Acute Myeloid Leukemia	Drug: cyclosporine; Drug: pravastatin sodium; Drug: mitoxantrone hydrochloride; Drug: etoposide; Procedure: bone marrow aspiration	Phase 1/Phase 2

Detailed Description

PRIMARY OBJECTIVES:

1. Determine the maximum tolerated doses of mitoxantrone (mitoxantrone hydrochloride) and etoposide in combination with pravastatin (pravastatin sodium) and cyclosporine.

SECONDARY OBJECTIVES:

1. Describe the complete remission (CR)/CR with incomplete peripheral blood count recovery (CRi) rate after up to 2 cycles of induction therapy.

2. Describe the disease-free survival of patients that achieve CR/CRi. III. Estimate the frequency and severity of regimen-associated toxicities, along with 28-day mortality after start of study treatment.

OUTLINE: This is a phase I/II, dose-escalation study of etoposide and mitoxantrone hydrochloride in combination with pravastatin sodium and cyclosporine.

Patients receive cyclosporine intravenously (IV) continuously on days 5-9. Patients also receive pravastatin sodium orally (PO) every 6 hours on days 1-10, etoposide IV continuously on days 5-9, and mitoxantrone hydrochloride IV continuously on days 5-9. Treatment repeats for up to 2 courses in the absence of disease progression or unacceptable toxicity. Patients achieving CR/CRi may receive 2 additional courses in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up for 1 month.

Study Design

• Study Type: Interventional
• Actual Enrollment: 6 participants
• Allocation: N/A
• Intervention Model: Single Group Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: Cyclosporine Modulation of Drug Resistance in Combination With Pravastatin, Mitoxantrone, and Etoposide for Adult Patients With Relapsed/Refractory Acute Myeloid Leukemia (AML): A Phase 1/2 Study
• Study Start Date: Apr 1, 2011
• Actual Primary Completion Date: Mar 1, 2012
• Actual Study Completion Date: Mar 1, 2012

Arms and Interventions

Arm

Intervention/Treatment

Experimental: Treatment (immunosuppression, enzyme inhibitor, and chemo) Patients receive cyclosporine IV continuously on days 5-9. Patients also receive pravastatin sodium PO every 6 hours on days 1-10, etoposide IV continuously on days 5-9, and mitoxantrone hydrochloride IV continuously on days 5-9. Treatment repeats for up to 2 courses in the absence of disease progression or unacceptable toxicity. Patients achieving CR/CRi may receive 2 additional courses in the absence of disease progression or unacceptable toxicity.

Drug: cyclosporine; Given IV; Other Names: ciclosporin cyclosporin cyclosporin A CYSP Sandimmune ; Drug: pravastatin sodium; Given PO; Other Names: PRAV Pravachol ; Drug: mitoxantrone hydrochloride; Given IV; Other Names: CL 232315 DHAD DHAQ Novantrone ; Drug: etoposide; Given IV; Other Names: EPEG VP-16 VP-16-213 ; Procedure: bone marrow aspiration; Correlative studies

Outcome Measures

Primary Outcome Measures

1. Maximum Tolerated Doses Mitoxantrone Hydrochloride and Etoposide When Combined With Cyclosporine and Pravastatin Sodium [After completion of first 2 courses, up to 22 weeks]

   Determine the doses of mitoxantrone and etoposide that, when combined with CSA and pravastatin, meet minimum standards for both efficacy and toxicity and have the highest efficacy rate among several mitoxantrone and etoposide doses. Assessed by the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 4.0.

Secondary Outcome Measures

1. CR/CRi [After completion of first 2 courses, up to 22 weeks]

   Describe the disease-free survival of patients that achieve Complete Remission (CR)/CR with inadequate recovery of peripheral blood cell counts (CRi). Categorized according to criteria recommended by an International Working Group.

2. Disease-free Survival of Patients That Achieve CR/CRi [Up to 4.5 years]

   Describe the disease-free survival of patients that achieve CR/CRi.

3. Frequency and Severity of Regimen-associated Toxicities [At 28 days]

   Estimate the frequency and severity of regimen-associated toxicities, along with 28-day mortality after start of study treatment

Eligibility Criteria

Criteria

• Ages Eligible for Study: 18 Years and Older
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Inclusion Criteria:

• Treatment-related mortality (TRM) score =< 9.2 as calculated with simplified model

• Prior morphological diagnosis of AML according to the 2008 World Health Organization (WHO) diagnostic criteria; patients with biphenotypic AML are eligible; patients with acute promyelocytic leukemia with t(15;17)(q22;q12) and variants are ineligible

• Relapsed/persistent disease as defined by International Working Group criteria; outside diagnostic material is acceptable as long as peripheral blood and/or bone marrow slides are reviewed at the study institution; flow cytometric analysis of peripheral blood and/or bone marrow should be performed according to institutional practice guidelines

• Patients with prior autologous or allogeneic hematopoietic cell transplantation (HCT) are eligible if relapse occurs > 180 days post-transplant provided symptoms of graft-versus host disease are well controlled with stable use of immunosuppressive agents

• Eastern Cooperative Oncology Group (ECOG) performance status of 0-3, assessed at time of registration

• Should be off any active therapy for AML with the exception of hydroxyurea or low-dose cytarabine (=< 100 mg/m^2) for at least 14 days prior to study registration unless patient has rapidly progressive disease, and all Grade 2-4 non-hematologic toxicities must have resolved

• Bilirubin =< 2 x Institutional Upper Limit of Normal (IULN) unless elevation is thought to be due to hepatic infiltration by AML, Gilbert's syndrome, or hemolysis (assessed within 7 days prior to registration)

• Serum glutamic oxaloacetic transaminase (SGOT) (aspartate aminotransferase [AST]) and serum glutamic pyruvate transaminase (SGPT) (alanine aminotransferase [ALT]) =< 2 x IULN unless elevation is thought to be due to hepatic infiltration by AML (assessed within 7 days prior to registration)

• Serum creatinine =< 1.5 x IULN (assessed within 7 days prior to registration)

• Left ventricular ejection fraction >= 40%, assessed within 28 days prior to registration, e.g. by multi gated acquisition scan (MUGA) scan or echocardiography, or other appropriate diagnostic modality, and no clinical evidence of congestive heart failure; if the patient had anthracycline-based therapy since the most recent cardiac assessment, cardiac evaluation should be repeated if there is clinical or radiographical suspicion of cardiac dysfunction, or if the previous cardiac assessment was abnormal

• Patients with symptoms/signs of hyperleukocytosis or white blood cell (WBC) > 100,000/uL can be treated with leukapheresis prior to enrollment

• Women of childbearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation

• Ability to understand and the willingness to sign a written informed consent document; the consent can be obtained from a legally authorized representative if the patient is unable to provide informed consent

Exclusion Criteria:

• Diagnosis of another malignancy, unless the patient was diagnosed at least 2 years earlier and has been disease-free for at least 6 months following the completion of curative intent therapy with the following exceptions:

• Patients with treated non-melanoma skin cancer, in situ carcinoma, or cervical intraepithelial neoplasia, regardless of the disease-free duration, are eligible for this study if definitive treatment for the condition has been completed

• Patients with organ-confined prostate cancer with no evidence of recurrent or progressive disease based on prostate-specific antigen (PSA) values are also eligible for this study if hormonal therapy has been initiated or a radical prostatectomy has been performed

• Refractory/relapsing blast crisis of chronic myelogenous leukemia (CML)

• Known hypersensitivity to any study drug

• Human immunodeficiency virus (HIV)-positive patients are excluded if their cluster of differentiation (CD)4 count is below 200 cells/uL or if they have active acquired immune deficiency syndrome (AIDS)-related complications, as these patients are at increased risk of lethal infections when treated with marrow-suppressive therapy

• Pregnancy or lactation; women of childbearing potential must undergo pregnancy test within 7 days prior to registration

• Uncontrolled systemic fungal, bacterial, viral, or other infection (defined as exhibiting progressive signs/symptoms related to the infection and without improvement, despite appropriate antibiotics or other treatment)

• Patients may not be receiving any other investigational agents

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	Fred Hutchinson Cancer Research Center/University of Washington Cancer Consortium	Seattle	Washington	United States	98109

Sponsors and Collaborators

• Fred Hutchinson Cancer Center
• National Cancer Institute (NCI)

Investigators

• Principal Investigator: Roland Walter, Fred Hutchinson Cancer Research Center/University of Washington Cancer Consortium

Study Documents (Full-Text)

None provided.

More Information

Publications

None provided.

• Responsible Party: Roland Walter, Principal Investigator, Fred Hutchinson Cancer Center
• ClinicalTrials.gov Identifier: NCT01342887
• Other Study ID Numbers: 2409.00; NCI-2011-00657
• First Posted: Apr 27, 2011
• Last Update Posted: Jul 2, 2017
• Last Verified: Jun 1, 2017

• Additional relevant MeSH terms: Leukemia; Leukemia, Myeloid; Leukemia, Myeloid, Acute; Leukemia, Monocytic, Acute; Leukemia, Myelomonocytic, Acute; Leukemia, Megakaryoblastic, Acute; Leukemia, Erythroblastic, Acute; Cyclosporine; Etoposide; Mitoxantrone; Etoposide phosphate; Pravastatin; Cyclosporins

Study Results

Participant Flow

Arm/Group Title	Treatment (Immunosuppression, Enzyme Inhibitor, and Chemo)
Arm/Group Description	Patients receive cyclosporine IV continuously on days 5-9. Patients also receive pravastatin sodium PO every 6 hours on days 1-10, etoposide IV continuously on days 5-9, and mitoxantrone hydrochloride IV continuously on days 5-9. Treatment repeats for up to 2 courses in the absence of disease progression or unacceptable toxicity. Patients achieving CR/CRi may receive 2 additional courses in the absence of disease progression or unacceptable toxicity. cyclosporine: Given IV pravastatin sodium: Given PO mitoxantrone hydrochloride: Given IV etoposide: Given IV bone marrow aspiration: Correlative studies
Period Title: Overall Study
STARTED	6
COMPLETED	4
NOT COMPLETED	2

Baseline Characteristics

Arm/Group Title	Treatment (Immunosuppression, Enzyme Inhibitor, and Chemo)
Arm/Group Description	Patients receive cyclosporine IV continuously on days 5-9. Patients also receive pravastatin sodium PO every 6 hours on days 1-10, etoposide IV continuously on days 5-9, and mitoxantrone hydrochloride IV continuously on days 5-9. Treatment repeats for up to 2 courses in the absence of disease progression or unacceptable toxicity. Patients achieving CR/CRi may receive 2 additional courses in the absence of disease progression or unacceptable toxicity. cyclosporine: Given IV pravastatin sodium: Given PO mitoxantrone hydrochloride: Given IV etoposide: Given IV bone marrow aspiration: Correlative studies
Overall Participants	6
Age (years) [Mean (Full Range) ]
Mean (Full Range) [years]	51
Sex: Female, Male (Count of Participants)
Female	4 66.7%
Male	2 33.3%

Outcome Measures

1. Primary Outcome

Title	Maximum Tolerated Doses Mitoxantrone Hydrochloride and Etoposide When Combined With Cyclosporine and Pravastatin Sodium
Description	Determine the doses of mitoxantrone and etoposide that, when combined with CSA and pravastatin, meet minimum standards for both efficacy and toxicity and have the highest efficacy rate among several mitoxantrone and etoposide doses. Assessed by the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 4.0.
Time Frame	After completion of first 2 courses, up to 22 weeks

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Treatment (Immunosuppression, Enzyme Inhibitor, and Chemo)
Arm/Group Description	Patients receive cyclosporine IV continuously on days 5-9. Patients also receive pravastatin sodium PO every 6 hours on days 1-10, etoposide IV continuously on days 5-9, and mitoxantrone hydrochloride IV continuously on days 5-9. Treatment repeats for up to 2 courses in the absence of disease progression or unacceptable toxicity. Patients achieving CR/CRi may receive 2 additional courses in the absence of disease progression or unacceptable toxicity. cyclosporine: Given IV pravastatin sodium: Given PO mitoxantrone hydrochloride: Given IV etoposide: Given IV bone marrow aspiration: Correlative studies
Measure Participants	6
Number [doses tolerated]	0

2. Secondary Outcome

Title	CR/CRi
Description	Describe the disease-free survival of patients that achieve Complete Remission (CR)/CR with inadequate recovery of peripheral blood cell counts (CRi). Categorized according to criteria recommended by an International Working Group.
Time Frame	After completion of first 2 courses, up to 22 weeks

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Treatment (Immunosuppression, Enzyme Inhibitor, and Chemo)
Arm/Group Description	Patients receive cyclosporine IV continuously on days 5-9. Patients also receive pravastatin sodium PO every 6 hours on days 1-10, etoposide IV continuously on days 5-9, and mitoxantrone hydrochloride IV continuously on days 5-9. Treatment repeats for up to 2 courses in the absence of disease progression or unacceptable toxicity. Patients achieving CR/CRi may receive 2 additional courses in the absence of disease progression or unacceptable toxicity. cyclosporine: Given IV pravastatin sodium: Given PO mitoxantrone hydrochloride: Given IV etoposide: Given IV bone marrow aspiration: Correlative studies
Measure Participants	6
CR	0 0%
CRi	0 0%
CR/CRi not achieved	6 100%

3. Secondary Outcome

Title	Disease-free Survival of Patients That Achieve CR/CRi
Description	Describe the disease-free survival of patients that achieve CR/CRi.
Time Frame	Up to 4.5 years

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Treatment (Immunosuppression, Enzyme Inhibitor, and Chemo)
Arm/Group Description	Patients receive cyclosporine IV continuously on days 5-9. Patients also receive pravastatin sodium PO every 6 hours on days 1-10, etoposide IV continuously on days 5-9, and mitoxantrone hydrochloride IV continuously on days 5-9. Treatment repeats for up to 2 courses in the absence of disease progression or unacceptable toxicity. Patients achieving CR/CRi may receive 2 additional courses in the absence of disease progression or unacceptable toxicity. cyclosporine: Given IV pravastatin sodium: Given PO mitoxantrone hydrochloride: Given IV etoposide: Given IV bone marrow aspiration: Correlative studies
Measure Participants	6
0-6month survival of those achieving CR/CRi	0 0%
>6month survival of those achieving CR/CRi	0 0%
Participants who do not achieve CR/CRi	6 100%

4. Secondary Outcome

Title	Frequency and Severity of Regimen-associated Toxicities
Description	Estimate the frequency and severity of regimen-associated toxicities, along with 28-day mortality after start of study treatment
Time Frame	At 28 days

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Treatment (Immunosuppression, Enzyme Inhibitor, and Chemo)
Arm/Group Description	Patients receive cyclosporine IV continuously on days 5-9. Patients also receive pravastatin sodium PO every 6 hours on days 1-10, etoposide IV continuously on days 5-9, and mitoxantrone hydrochloride IV continuously on days 5-9. Treatment repeats for up to 2 courses in the absence of disease progression or unacceptable toxicity. Patients achieving CR/CRi may receive 2 additional courses in the absence of disease progression or unacceptable toxicity. cyclosporine: Given IV pravastatin sodium: Given PO mitoxantrone hydrochloride: Given IV etoposide: Given IV bone marrow aspiration: Correlative studies
Measure Participants	6
Early death (within 28 days)	2 33.3%
Experienced Dose-Limiting Toxicity	1 16.7%
Persistent Disease	3 50%

Adverse Events

Arm/Group Title	Treatment (Immunosuppression, Enzyme Inhibitor, and Chemo)
Arm/Group Description	Patients receive cyclosporine IV continuously on days 5-9. Patients also receive pravastatin sodium PO every 6 hours on days 1-10, etoposide IV continuously on days 5-9, and mitoxantrone hydrochloride IV continuously on days 5-9. Treatment repeats for up to 2 courses in the absence of disease progression or unacceptable toxicity. Patients achieving CR/CRi may receive 2 additional courses in the absence of disease progression or unacceptable toxicity. cyclosporine: Given IV pravastatin sodium: Given PO mitoxantrone hydrochloride: Given IV etoposide: Given IV bone marrow aspiration: Correlative studies
All Cause Mortality
	Treatment (Immunosuppression, Enzyme Inhibitor, and Chemo)
	Affected / at Risk (%)	# Events
Total	/ (NaN)
Serious Adverse Events
	Treatment (Immunosuppression, Enzyme Inhibitor, and Chemo)
	Affected / at Risk (%)	# Events
Total	5/6 (83.3%)
Blood and lymphatic system disorders
Febrile Neutropenia	1/6 (16.7%)	1
Infections and infestations
Sepsis	4/6 (66.7%)	4
Renal and urinary disorders
Acute Kidney Injury	1/6 (16.7%)	1
Other (Not Including Serious) Adverse Events
	Treatment (Immunosuppression, Enzyme Inhibitor, and Chemo)
	Affected / at Risk (%)	# Events
Total	6/6 (100%)
Blood and lymphatic system disorders
Anemia	1/6 (16.7%)	1
Febrile Neutropenia	4/6 (66.7%)	7
Pancytopenia	3/6 (50%)	3
Cardiac disorders
Palpitation	1/6 (16.7%)	1
Tachycardia	6/6 (100%)	6
Ear and labyrinth disorders
Ear pain to palpitation	1/6 (16.7%)	1
Eye disorders
Extraocular muscle paresis, worsening	1/6 (16.7%)	1
Gastrointestinal disorders
Diarrhea	3/6 (50%)	4
Esophageal pain	1/6 (16.7%)	1
Heartburn	1/6 (16.7%)	1
Mucositis oral	6/6 (100%)	6
Nausea	6/6 (100%)	6
Oral Thrush	1/6 (16.7%)	1
Vomiting	2/6 (33.3%)	2
General disorders
Chest pain	2/6 (33.3%)	2
Chills	2/6 (33.3%)	2
Fatigue	5/6 (83.3%)	5
Hypothermia	1/6 (16.7%)	2
Malaise	1/6 (16.7%)	1
Edema, bilateral hand and feet	2/6 (33.3%)	2
Edema, face	1/6 (16.7%)	1
Gait disturbance	1/6 (16.7%)	1
Volume Retention	1/6 (16.7%)	1
Hepatobiliary disorders
Transaminitis	1/6 (16.7%)	1
Immune system disorders
Pulmonary Aspergillosis	1/6 (16.7%)	1
Infections and infestations
Cellulitis	1/6 (16.7%)	1
Coagulase Negative Staphylococcus Bacteremia	1/6 (16.7%)	1
E. Coli Urinary Tract Infection	1/6 (16.7%)	1
Rash, chest	3/6 (50%)	3
Sinus Infection	1/6 (16.7%)	1
Vancomycin-Resistant Enterococci Bacteremia	2/6 (33.3%)	2
Viral upper respiratory infection	1/6 (16.7%)	1
Injury, poisoning and procedural complications
Bruising	1/6 (16.7%)	1
Burning sensation during infusion	3/6 (50%)	3
Febrile nonhemolytic transfusion reaction	1/6 (16.7%)	1
Investigations
Blood bilirubin increased	2/6 (33.3%)	2
Jaundice	1/6 (16.7%)	1
Weight Gain	1/6 (16.7%)	1
Metabolism and nutrition disorders
Hypokalemia	4/6 (66.7%)	4
Hypomagnesemia	1/6 (16.7%)	1
Hyponatremia	2/6 (33.3%)	2
Hypophosphatemia	1/6 (16.7%)	1
Anorexia	6/6 (100%)	7
Metabolic acidosis	2/6 (33.3%)	2
Musculoskeletal and connective tissue disorders
Back Pain	1/6 (16.7%)	1
Leg Pain	3/6 (50%)	3
Weakness	4/6 (66.7%)	4
Nervous system disorders
Acute toxic-metabolic encephalopathy	1/6 (16.7%)	1
Dizziness	2/6 (33.3%)	2
Headache	3/6 (50%)	3
Restlessness	1/6 (16.7%)	1
Tremors	1/6 (16.7%)	1
Psychiatric disorders
Altered Mental Status	4/6 (66.7%)	4
Anxiety	1/6 (16.7%)	1
Insomnia	1/6 (16.7%)	1
Nervousness/agitation	1/6 (16.7%)	1
Withdrawn/Unwilling to communicate	1/6 (16.7%)	1
Renal and urinary disorders
Acute Kidney Injury	3/6 (50%)	4
Anuria	1/6 (16.7%)	1
Burning sensation during urination	1/6 (16.7%)	1
Hematuria	2/6 (33.3%)	2
Rhabdomyolysis	1/6 (16.7%)	1
Reproductive system and breast disorders
Pain on left areola, superficial	1/6 (16.7%)	1
Respiratory, thoracic and mediastinal disorders
Bronchospasms	1/6 (16.7%)	1
Cough	1/6 (16.7%)	1
Epistaxis	3/6 (50%)	3
Hypoxia	1/6 (16.7%)	1
Multifocal pneumonia	2/6 (33.3%)	2
Pleural Effusion	2/6 (33.3%)	2
Rhinovirus	2/6 (33.3%)	2
Dyspnea	2/6 (33.3%)	2
Tachypnea	2/6 (33.3%)	2
Skin and subcutaneous tissue disorders
Blanched buttocks	1/6 (16.7%)	1
Periobital Edema	2/6 (33.3%)	2
Scalp rash	1/6 (16.7%)	1
Leukemia cutis	1/6 (16.7%)	1
Pain, right axillary area	2/6 (33.3%)	2
Vascular disorders
Hypertension	6/6 (100%)	6
Hypotension	2/6 (33.3%)	2

Limitations/Caveats

[Not Specified]

More Information

Certain Agreements

All Principal Investigators ARE employed by the organization sponsoring the study.

There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.