Report From the 2022 Mary Tyler Moore Vision Initiative Diabetic Retinal Disease Clinical Endpoints Workshop

The Mary Tyler Moore Vision Initiative Diabetic Retinal Disease (DRD) Clinical Endpoints Workshop was held on October 22, 2022 to accelerate progress toward establishment of useful clinical and research endpoints and development of new therapeutics that have important relevance across the full spectrum of DRD pathology. More than 90 patient representatives, clinicians, scientists, funding and regulatory agencies, diagnostic, therapeutic and biotech industry representatives discussed the needs for new diagnostic and therapeutic approaches to prevent and restore retinal neurovascular unit integrity. Phase I of the MTM Vision Initiative plans, notably updating the DRD staging system and severity scale, establishing a human ocular biorepository and resource, and clinical endpoints and biomarker development and validation, was emphasized.

Setting Priorities for Diabetic Retinopathy Clinical Research and Identifying Evidence Gaps

PURPOSE

Prioritizing comparative effectiveness research may contribute to obtaining answers that clinicians perceive they need and may minimize research that could be considered wasteful. Our objective was to identify evidence gaps and set priorities for new systematic reviews and randomized controlled trials for managing diabetic retinopathy (DR), including diabetic macular edema (DME).

DESIGN

Cross-sectional study.

PARTICIPANTS

Diabetic Retinopathy Clinical Research Network (DRCR.net) investigators.

METHODS

We provided recommendations from the American Academy of Ophthalmology's 2012 Preferred Practice Patterns for Diabetic Retinopathy as 91 answerable clinical research questions about intervention effectiveness to 410 DRCR.net investigators to rate each question's importance from 0 (not important) to 10 (very important) using a 2-round Delphi survey and to suggest additional questions. We considered questions as high priority if at least 75% of respondents to both rounds assigned an importance rating of 5 or more in round 2. We also extracted outcome measures relevant to DR and asked respondents to identify those that must be measured in all studies. We mapped Cochrane reviews published up to March 2016 to high-priority clinical research questions.

MAIN OUTCOME MEASURE

Ranking of importance of each clinical question.

RESULTS

Thirty-two individuals completed rounds 1 and 2 and suggested 15 questions. Among the final list of 106 clinical research questions, 22 questions met our definition of high priority: 9 of 22 concerned the effectiveness of anti-VEGF therapy, and 13 of 22 focused on how often patients should be followed up (re-examination) and treatment effectiveness in patients with specific characteristics (e.g., DME). Outcomes that 75% or more of respondents marked as "must be measured in all studies" included visual acuity and visual loss, death of participants, and intraocular pressure. Only 1 prioritized question was associated with conclusive evidence from a Cochrane systematic review.

CONCLUSIONS

A limited response rate among DRCR.net members identified 22 comparative effectiveness research questions as high priority for the management of DR, including DME, but few were associated with Cochrane reviews. These results support the need of systematic reviews and randomized controlled trials to address evidence gaps.

Molecular abnormalities of mdm-2 in human sarcomas

MDM-2 is an oncoprotein that seems to function, at least in part, by interacting with the p53 protein and modulating its tumor-suppressing activity. The MDM-2 gene codes for p57, p74, p76, p85, and p90 proteins. Overexpression of only the p90 MDM-2 protein has been reported in sarcomas showing MDM-2 gene amplification. In addition, post-transcriptional mechanisms have been demonstrated to play a role in the expression of MDM-2 proteins. We investigated MDM-2 gene amplification, mRNA and protein levels in various cases of sarcomas. We found MDM-2 gene amplification in 12 (26%) of 46 cases of sarcoma: 11 of 13 cases of liposarcoma and 1 of 6 cases of malignant fibrous histiocytoma. The MDM-2 amplification correlated with the presence of elevated levels of mRNA and protein in the liposarcomas. In sarcomas other than liposarcomas, mRNA was overexpressed in 7 (30%) of 23 cases, without MDM-2 amplification. In 15 (62.5%) of 24 cases of sarcoma and in 1 case of lipoma the MDM-2 protein was overexpressed as shown by Western blot analysis. Interestingly, p57 not p90 was the most commonly overexpressed MDM-2 protein. These data indicate that the molecular abnormalities affecting MDM-2 expression in cases of sarcoma include transcriptional, post-transcriptional, and gene dosage (amplification) mechanisms. Furthermore, our findings suggest that MDM-2 p57 protein may be as important as p90 in the pathogenesis of human sarcomas.

Depression and cardiovascular disease

This manuscript reviews the evidence that depression is associated with increased risk of mortality and explores the evidence that treating depression reduces that risk. The thought that depression and death are linked is ancient, but scientifically it has been difficult to prove. After the World War II, type "A" personality appeared capable of identifying cardiac patients at increased risk of death. By the mid 1970s that evidence appeared to weaken and may have been altered by the changing treatment of cardiovascular disease. At the same time, research began to focus on a diagnosis of depression as a predictor but it was 25 years before the association was firmly established. Originally examined in medically healthy in-dividuals followed for long periods of time, in the early 1990s epidemiological research began examining the influence of depression in patients with overt cardiovascular disease. That focus has been primarily on post-MI depression and the obvious question was if treating depression would reduce the risk. Such studies require a very large sample and initially there was no safety data available with any antidepressant drug. Gradually evidence has accumulated that SSRI antidepressants were safe and effective and there is a suggestion that they reduce not only depression but medical adverse events as well. However, that evidence is not definitive and the reason behind the association between depression and cardiovascular morbidity and mortality remains uncertain.

Randomized trial of peribulbar triamcinolone acetonide with and without focal photocoagulation for mild diabetic macular edema: a pilot study

OBJECTIVE

To provide pilot data on the safety and efficacy of anterior and posterior sub-Tenon injections of triamcinolone either alone or in combination with focal photocoagulation in the treatment of mild diabetic macular edema (DME).

DESIGN

Prospective, phase II, multicenter, randomized clinical trial.

PARTICIPANTS

One hundred nine patients (129 eyes) with mild DME and visual acuity 20/40 or better.

METHODS

The participants were assigned randomly to receive either focal photocoagulation (n = 38), a 20-mg anterior sub-Tenon injection of triamcinolone (n = 23), a 20-mg anterior sub-Tenon injection followed by focal photocoagulation after 4 weeks (n = 25), a 40-mg posterior sub-Tenon injection of triamcinolone (n = 21), or a 40-mg posterior sub-Tenon injection followed by focal photocoagulation after 4 weeks (n = 22). Follow-up visits were performed at 4, 8, 17, and 34 weeks.

MAIN OUTCOME MEASURES

Change in visual acuity and retinal thickness measured with optical coherence tomography (OCT).

RESULTS

At baseline, mean visual acuity in the study eyes was 20/25 and mean OCT central subfield thickness was 328 mum. Changes in retinal thickening and in visual acuity were not significantly different among the 5 groups at 34 weeks (P = 0.46 and P = 0.94, respectively). There was a suggestion of a greater proportion of eyes having a central subfield thickness less than 250 mum at 17 weeks when the peribulbar triamcinolone was combined with focal photocoagulation. Elevated intraocular pressure and ptosis were adverse effects attributable to the injections.

CONCLUSIONS

In cases of DME with good visual acuity, peribulbar triamcinolone, with or without focal photocoagulation, is unlikely to be of substantial benefit. Based on these results, a phase III trial to evaluate the benefit of these treatments for mild DME is not warranted.

Comparison of competitive-nested PCR and real-time PCR in detecting BCR-ABL fusion transcripts in chronic myeloid leukemia patients

Real-time RT-PCR has great advantages for estimating transcript levels in a variety of situations. These include relative rapid assay times (hours), reliability and ease of performing replicate analyses. In contrast, competitive PCR is a very labor-intensive procedure requiring a few days to generate useful data. We compared the same samples from CML patients by both methods. Importantly, we used the Bcr-Abl junction plasmid DNA, which is used as a competitor in the manual competitive PCR assay, to generate a standard curve for the real-time assay. This permitted reporting the real-time data as the number of BCR-ABL transcripts per microg of total RNA, which is the same format used for the competitive PCR assay. In this study, a total of 435 peripheral blood and marrow samples from 285 CML patients were analyzed by RT-PCR; these patients were undergoing therapy by STI-571, interferon, and bone marrow transplantation treatment. Most samples also had assay values for the Philadelphia chromosome (Ph), FISH and Western blotting for the Bcr-Abl oncoprotein. Our findings indicated that the real-time assay was less sensitive than the manual competitive RT-PCR assay (t = 5.118; P < 0.001). Of interest, the transcript levels in cell line mixtures with various ratios of K562/KG-1 (BCR-ABL positive/negative) cells were also significantly higher with the competitive RT-PCR assays than real-time RT-PCR, except for levels of BCR-ABL below 200 transcripts per microg of RNA. In both patient and cell line experiments, dividing the BCR-ABL transcripts by the total ABL transcripts virtually eliminated the difference between real-time BCR-ABL transcript values and quantitative competitive BCR-ABL transcript values, indicating that both BCR-ABL and ABL transcripts were underestimated by the real-time assay. In addition, the increased sensitivity of the nested, competitive RT-PCR was readily apparent in patients with minimal residual disease, which by the real-time were negative in the majority of patients but were positive by nested, competitive RT-PCR in 44.6% (n = 29) of samples analyzed (n = 65). These findings indicate that real-time RT-PCR, when normalized for the total ABL transcripts, can be used to monitor CML patients during therapy, but we suggest that nested, competitive RT-PCR be used to determine BCR-ABL/ABL transcript ratios at low transcript values or especially when real-time analyses are negative.

Quantitative measurement of BCR/abl transcripts using real-time polymerase chain reaction

BACKGROUND

Quantitative real-time polymerase chain reaction (Q-Rt-PCR) is a new tool in the detection and quantification of the BCR/abl fusion transcripts in chronic myelogenous leukemia (CML). This study investigates its specificity, sensitivity and potential clinical usefulness.

PATIENTS AND METHODS

Parallel analysis of Q-Rt-PCR and the conventional reverse transcription-mediated PCR (RT-PCR) were performed on 567 samples from 481 patients. Treatment response was monitored by Q-Rt-PCR at 6 and 12 months of 61 patients on STI-571 and 103 patients on interferon.

RESULTS

The concordance rate between Q-Rt-PCR and RT-PCR was 96.3% (546/567), with 341 positives and 205 negatives. The positive equivalents ranged from 2 x 10(-6) to 1.2 microg of K562 cell RNA. Karyotyping in 372 samples revealed excellent correlation with Q-Rt-PCR measurements (P < 0.001). Setting residual BCR/abl < 0.01 as an early goal of molecular response, we observed that STI-571 induced a better response than interferon: 49% (20 of 41 patients) versus 35% (15 of 62 patients) at 6 months (P = 0.025) and 52% (32 of 61 patients) versus 34% (35 of 103 patients) at 12 months (P = 0.01), respectively.

CONCLUSIONS

Q-Rt-PCR provides reliable measurements of BCR/abl fusion transcripts. It is potentially useful in assessing molecular residual disease after therapy.

Cytogenetic findings in lymphoplasmacytic lymphoma/Waldenström macroglobulinemia. Chromosomal abnormalities are associated with the polymorphous subtype and an aggressive clinical course

We correlated bone marrow cytogenetic findings with morphologic and immunophenotypic data in 37 patients with lymphoplasmacytic lymphoma (LPL)/Waldenström macroglobulinemia (WM). Each LPL/WM case was classified as lymphoplasmacytoid (n = 18), lymphoplasmacytic (n = 10), or polymorphous (n = 9) using the Kiel criteria. Of 12 cases with chromosomal abnormalities, a single numeric abnormality was present in 4 and a complex karyotype in 8. The most common numeric abnormalities were and -8 in 3 cases each; the most common structural abnormality was del(6q) in 6 cases. Cytogenetic abnormalities were significantly less common in the lymphoplasmacytic and lymphoplasmacytoid groups (5/28 [18%]) compared with the polymorphous group (7/9 [78%]). Clinical follow-up was available for 28 patients for a median of 36 months. Six (67%) of 9 patients with aneuploid tumors, including 4 with polymorphous subtype, subsequently had clinical progression or developed high-grade lymphoma. In contrast, 4 (21%) of 19 patients with diploid tumors, including 1 of polymorphous type, developed clinical progression or high-grade lymphoma. We conclude that abnormal cytogenetic findings in LPL/WM correlate with the polymorphous subtype and poor prognosis.

Spectral karyotyping study of chromosome abnormalities in human leukemia

Chromosomal analysis plays an important role in the diagnosis, treatment and prognosis of human leukemia. Currently, the GTG-banding technique (G-banding) is the most commonly used diagnostic method in clinical cytogenetics. G-banding analysis of subtle chromosomal rearrangements or complex karyotypes with multiple markers can be inadequate because of poor chromosome morphology and/or an insufficient yield of analyzable metaphases. Fluorescence in situ hybridization (FISH) is a highly sensitive and specific method to detect chromosomal alterations. Conventional FISH is used optimally in instances where only one or a few abnormalities are investigated. Spectral karyotyping (SKY), a novel cytogenetic technique, has been developed to unambiguously display and identify all chromosomes at one time using a spectrum of 24 different colors. This report presents the use of SKY for examination of the entire karyotype in specimens with complex chromosomal abnormalities from three leukemia patients. Conventional cytogenetic analysis (G-banding) showed complex hyperdiploid clones with multiple markers in each case. SKY was able to clarify and identify additional cryptic chromosomal translocations [e.g., t(2;10), t(3;10), t(5;7), t(7;18), t(9;17), t(10;12), t(13;16)] insertions [e.g., ins(17;9), ins(20;Y)], duplications [e.g., i(8)(q10), dup(4)(q31q35)] and marker chromosomes in each case. This study demonstrates that the combination of SKY and G-band techniques results in a more complete characterization of the complex chromosomal aberrations seen in leukemia.

Mature B-cell leukemias with more than 55% prolymphocytes. A heterogeneous group that includes an unusual variant of mantle cell lymphoma

We studied 20 cases of mature B-cell leukemia with more than 55% prolymphocytes in peripheral blood or bone marrow, fulfilling the French-American-British criteria for B-cell prolymphocytic leukemia (PLL). Cases segregated into 3 groups: de novo PLL, 6; PLL occurring in patients with a previous well-established diagnosis of chronic lymphocytic leukemia (PLL-HxCLL), 10; and t(11;14)(q13;q32)-positive neoplasms, 4. All cases expressed monotypic immunoglobulin light chain, and most were positive for CD5. All t(11;14)-positive neoplasms were CD23- and uniquely positive for cyclin D1. Cytogenetic abnormalities were present in 19; in all 19, the karyotype was complex, indicating clonal evolution and genomic instability. The most frequent cytogenetic abnormality in de novo PLL involved chromosome 7 in 4 cases. Trisomy 12 or add(12p) was present in 4 cases of PLL-HxCLL. We conclude that mature B-cell leukemias with more than 55% prolymphocytes are a heterogeneous group that includes t(11;14)-positive neoplasms, which we suggest are best classified as mantle cell lymphoma. We also suggest that prolymphocytic morphologic features are a common end-stage of transformation for several B-cell neoplasms.

11q23 abnormalities in patients with acute myelogenous leukemia and myelodysplastic syndrome as detected by molecular and cytogenetic analyses

11q23 chromosomal abnormalities and rearrangement of the mixed lineage leukemia (MLL) gene are important prognostic factors in acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS). However, the presence of 11q23 abnormalities does not always correlate with that of MLL gene rearrangement. We retrospectively compared the occurrence of 11q23 abnormalities (measured by karyotyping) and MLL gene rearrangement (measured by Southern blotting) in bone marrow from 311 consecutive adult patients with AML or MDS. 11q23 abnormalities were found in 18 patients (5.8%), of whom 7 (39%) did not have the MLL gene rearrangement. MLL gene rearrangement was detected in 35 patients (11.2%). Of these 35 patients, only 11 (31%) had cytogenetic evidence of 11q23 abnormalities. None of the 21 patients with chronic myelomonocytic leukemia had 11q23 abnormalities or MLL gene rearrangement. 11q23 abnormalities were associated with shorter survival than was a diploid karyotype. Both cytogenetic and molecular studies should be performed to detect 11q23 abnormalities in patients with AML or MDS.

Enhanced detection of chromosomal abnormalities with the use of RxFISH multicolor banding technique

Hematological disorders often have complex karyotypes with multiple markers. Proper assignment of chromosome number or aberration or both can be difficult. Specific identification of chromosomal abnormalities aids in the diagnosis and selection of treatment of patients. Fluorescence in situ hybridization (FISH) has been applied to the identification of translocations, markers, and other chromosomal abnormalities in clinical cytogenetics. However, the standard FISH technique is unable to detect the entire genome in a single experiment. This report presents the use of a cross-species comparative genomic hybridization color-banding technique (RxFISH) that permits examination of an entire karyotype at one time. Specimens from two patients, one with acute lymphocytic leukemia (ALL) and the other with multiple myeloma (MM), were studied. Metaphases were prepared by standard culture techniques. Conventional cytogenetic analysis (GTG banding) showed multiple clones in each of the cases. These clones were hyperdiploid metaphases with complex chromosomal abnormalities and multiple markers. The slides were then hybridized with FITC-, Cy-3-, and Cy-5-labeled RxFISH probes; the results were analyzed by a digital imaging system. The RxFISH color banding confirmed the hyperdiploid metaphases and identified multiple chromosomal abnormalities. In the specimen from the patient with ALL, several chromosomes, which had been classified as markers by G-banding, were found to be specific chromosomes. This study suggests that RxFISH can provide more accurate and specific identification of complex chromosomal abnormalities. RxFISH is a useful complement to the clinical cytogenetic laboratory armamentarium.

Political analysis of health reform in the Dominican Republic

This article examines the major political challenges associated with the adoption of health reform proposals, through the experience of one country, the Dominican Republic. The article briefly presents the problems of the health sector in the Dominican Republic, and the health reform efforts that were initiated in 1995. The PolicyMaker method of applied political analysis is described, and the results of its application in the Dominican Republic are presented, including analysis of the policy content of the health reform, and assessment of five key groups of players (public sector, private sector, unions, political parties, and other non-governmental organizations). The PolicyMaker exercise was conducted in collaboration with the national Office of Technical Coordination (OCT) for health reform, and produced a set of 11 political strategies to promote the health reform effort in the Dominican Republic. These strategies were partially implemented by the OCT, but were insufficient to overcome political obstacles to the reform by late 1997. The conclusion presents six factors that affect the pace and political feasibility of health reform proposals, with examples from the case of the Dominican Republic.

Deletions and losses in chromosomes 5 or 7 in adult acute lymphocytic leukemia: incidence, associations and implications

Deletions or losses in chromosomes 5 or 7 are recurrent non-random abnormalities in acute myeloid leukemia (AML), and are associated with prior exposure to carcinogens or leukemogenic agents, and with poor prognosis. Their occurrence and significance in adult acute lymphocytic leukemia (ALL) is not well described. The aim of the study was to evaluate the incidence, associations and implications of chromosome 5 or 7 abnormalities in adult ALL. Patients with newly diagnosed ALL referred to MD Anderson Cancer Center between 1980 and 1996 were analyzed. Characteristics and outcome of patients with or without chromosome 5 or 7 abnormalities were compared by standard statistical methods. Thirty-one of 468 patients (6.6%) had chromosome 5 or 7 abnormalities. Loss of chromosome 5 occurred in six cases, three of them had both chromosome 5 and 7 abnormalities. Deletion or loss of chromosome 7 occurred as a single abnormality in three patients; in 28 patients it was associated with other abnormalities. The most significant cytogenetic association was with the Philadelphia chromosome (Ph) abnormality occurring in nine patients (29%). Compared with patients without the abnormalities, patients with chromosome 5 or 7 abnormalities tended to express CD34 more frequently (74% vs 54% P = 0.07), to be older (age >60 years 29% vs 18% P = 0.14), and to be associated with Ph (29% vs 11% P = 0.004). With therapy, the complete response (CR) rate with chromosome 5 or 7 abnormalities was lower (64% vs 79% P = 0.038) but the survival rate was similar (3-year survival rate 32% vs 36% P = 0.14). When the 22 patients without Ph were considered separately, the CR and survival rates were similar among patients with or without chromosome 5 or 7 abnormalities. Abnormalities in chromosome 5 or 7 are not specific for AML, and may occur in ALL. Unlike in AML, chromosome 5 or 7 abnormalities in ALL were not predictive of worse prognosis, which is accounted for mostly by the association with Ph.

A simple efficient method of sequential G-banding and fluorescence in situ hybridization

Several methods of chromosome identification to be used in combination with G-banding by the trypsin technique with Giemsa staining (G-banding) and fluorescence in situ hybridization (FISH) have been developed in the past few years. Unfortunately, these methods are impractical to use in the clinical laboratory and can provide inconsistent results. We report a simple, efficient, and reliable method of G-banding and FISH for use in clinical cytogenetics. G-banded chromosomes are codenatured with a direct- or indirect-labeled DNA prove (by using either chromosome painting or a chromosome centromeric probe) followed by a hybridization and signal detection. The procedure requires no pretreatment or additional fixation and results in good preservation of chromosome morphology and good intensity of the FISH signal.

Prognostic value of cytogenetics in multiple myeloma

Karyotypic studies of bone marrow were conducted in 79 previously untreated patients with multiple myeloma who received a standard programme of chemotherapy. An abnormal karyotype was observed in 46% of patients, virtually all showing multiple abnormalities consistent with a long period of preclinical clonal evolution. Patients with an abnormal pattern showed various aberrations with hyperdiploidy in 64%, pseudodiploidy in 5% and hypodiploidy in 31%. The number of chromosomes affected ranged from two to 19 (median 10), with at least one trisomy in 83%, one monosomy in 75%, and one translocation in 42% of patients. Lymphoma-like karyotypes were present in 17% of patients with an abnormality but were not associated with atypical clinical features, such as an extramedullary mass, leukaemia, or increased serum lactate dehydrogenase. Monosomy or deletion of chromosome 13 was present in 47% of patients with an abnormal pattern, who lived for a shorter duration (median 10 months) than patients with other abnormalities (median 34 months) or with diploidy (median 35 months). The cause of the short survival of patients with monosomy or deletion of chromosome 13 was not clear, but further studies on the relationship with specific oncogenes are indicated.

Philadelphia chromosome-positive myeloid cells in the peripheral blood of chronic myelogenous leukemia patients: comparison with the frequency detected in cycling cells of the bone marrow

Monitoring the frequency of the Philadelphia (Ph) chromosome in chronic myelogenous leukemia (CML) is important in determining the effectiveness of treatment for patients during therapy. This can be done with high resolution by subjecting short-term bone marrow cultures (48 h) to 24 h of mitotic arrest before harvest and detecting Ph-positive (Ph+) metaphases by fluorescence in situ hybridization (FISH) in a procedure termed hypermetaphase FISH or HMF. Here, we compared procedures for detecting Ph+ interphase cells (interphase FISH or I-FISH) in peripheral blood polymorphonucleocytes (PMNs) with HMF results on the bone marrow of the same 26 CML patients in different stages of remission. The probes for I-FISH in these experiments were relatively large (200-300 kb) and sufficiently resolved in PMNs so that 97.5% of the cells were scorable. The correlation between the frequencies of Ph+ cells from the two different cell sources was excellent (r = 0.983, P < 0.0001); however, there was a consistently higher level of Ph+ cells observed in the cycling marrow cells than in the peripheral blood PMNs. This was discussed in terms of current theories of apoptosis in CML cells. The large number of PMNs analyzable by I-FISH (approximately 500/patient in this study) provided sufficiently narrow 99% confidence intervals to suggest the procedure as an effective and efficient method for monitoring the frequency of Ph+ cells in CML patients undergoing therapy. However, for detection and quantification of minimal residual disease, HMF is preferable to I-FISH because of the much lower frequency of false-positive readings with the former procedure.

Electron microscopic localization of lacZ expression in the proximal convoluted tubular cells of the kidney in transgenic mice carrying chimeric erythropoietin/lacZ gene constructs

Regulated expression of the erythropoietin (EPO) gene in the adult kidney plays a key role in the regulation of erythropoiesis. However, uncertainty exists regarding the type of kidney cells involved in EPO gene expression. We previously showed by light microscopy that the lacZ reporter gene is expressed and inducible by hypoxia/anemia in the proximal convoluted tubular (PCT) cells of the kidneys of transgenic mice carrying the 5'-lacZ construct, in which the lacZ gene was placed downstream of a 7.0-kb mouse EPO gene segment containing 6.5 kb of the 5'-flanking sequence. We, report here the light and transmission electron microscopic examination of lacZ expression in the kidneys of transgenic mice carrying the 5'-lacZ construct and two additional constructs carrying the 6.5-kb 5'-flanking sequence with the body of the gene alone, or along with the 1.2-kb 3'-flanking sequence. The electron microscopic analyses unequivocally demonstrated that lacZ under the regulatory control of the 6.5-kb 5'-flanking sequence with or without the body of the gene and the 1.2-kb 3'-flanking sequence was expressed predominantly in the proximal convoluted tubular cells of the kidney following hypoxia induction.

Diminished cardiac vagal tone in schizophrenia: associations to brain laterality and age of onset

We measured high-frequency (rapid) heart rate variability (HRV) from 24-hour Holter electrocardiograms to index cardiovagal tone in 23 patients with DSM-III-R schizophrenia or schizoaffective disorder. High-frequency HRV, quantitated by measuring the percent of successive normal interbeat intervals greater than 50 msec (PNN50), demonstrated a bimodal distribution: 11 of 23 patients had a PNN50 of > and = 8.0 (mean value = 17.7 +/- 11.0), and 12 had a PNN50 of < and = 4.0 (mean value = 1.8 +/- 1.0); no subject had a PNN50 value between 4.0 and 8.0. All 12 low cardiovagal tone patients (versus only 6/11 of the other patients) had a schizophrenia (not schizoaffective) diagnosis (p = .013). PNN50 was not associated with present age, gender, smoking, IQ scores, or symptomatology, but patients with lower cardiovagal tone did have a significantly later age of onset (20.5 +/- 5.3 vs. 14.8 +/- 2.8 years: p = .005). PNN50 subgroups also differed on dichotic listening measures of brain laterality. The low group failed to show left ear (right hemisphere) advantage for complex tones seen in the other patients and normal adults. They also showed larger right ear (left hemisphere) advantage for dichotic words than the other patients. This evidence of relative right hemisphere disadvantage in patients with low cardiovagal tone is consistent with findings linking autonomic nervous system and right hemisphere function. These findings also support the existence of subgroups of schizophrenia patients differing in autonomic activity, brain laterality, and clinical features.

Expression profile of MDM-2 proteins in chronic lymphocytic leukemia and their clinical relevance

The MDM-2 oncoprotein exists in an autoregulatory feedback loop with the tumor suppressor protein p53. Therefore, intracellular levels of these two proteins may play important roles in cell proliferation and tumorigenesis. Several MDM-2 proteins (Mr 35-100 Kd) have been demonstrated in human cell lines. We report here the expression profile of MDM-2 and p53 proteins in 87 cases of chronic lymphocytic leukemia (CLL) as detected by immunoblot analysis. The MDM-2 proteins (p57, p59, p67, and p90) were found to be overexpressed in different combinations in 56/87 (64%) of cases of CLL when compared with normal volunteers. The MDM-2 protein p57 was predominantly overexpressed 46/87 (53%) in CLL. In 22/87 (25%) cases of CLL p57 was overexpressed alone, and in 24/87 (28%) cases it was co-overexpressed with other MDM-2 proteins p59/p67/p90. Six of the 87 cases of CLL showed overexpression of the tumor suppressor protein p53 by immunoblot analysis, and five of those cases also co-overexpress MDM-2 protein p57. No statistically significant correlation of MDM-2 protein overexpression to clinical disease stage and history of previous chemotherapy of CLL patients has been found. However, considering the oncogenic potential of overexpressed MDM-2 proteins, a possible role of MDM-2 proteins in the promotion of CLL disease remains to be evaluated.

Usefulness of detection of minimal residual disease by 'hypermetaphase' fluorescent in situ hybridization after allogeneic BMT for chronic myelogenous leukemia

Hypermetaphase FISH (HMF), a molecular cytogenetic procedure combining the long term mitotic arrest of bone marrow cultures with detection of a specific chromosomal rearrangement by fluorescence in situ hybridization (FISH), has recently been shown to be effective in determining the frequency of Philadelphia chromosome positive (Ph+) cells in the bone marrow of chronic myelogenous leukemia (CML) patients undergoing treatment. By combining the probe for the Ph chromosome with one for the detection of the X chromosome, we used HMF to monitor the presence of malignant cells within the emerging host cell population in the marrow of a CML patient that had undergone sex-mismatched allogeneic bone marrow transplantation. In successive studies, we detected 0.5% and 1.75% Ph+ cells, respectively, confirmed by Western blot analysis for p210 protein. These readings occurred concordantly with a repopulation of host-derived diploid female cells. Standard G-band cytogenetic analyses did not detect any Ph+ cells at these time points. Intervention with donor lymphocyte infusion reinduced complete remission. This experience indicates that HMF is useful to identify low levels of repopulation by Ph+ cells in the marrow post-BMT at a stage when intervention is most efficacious.

Assessing the efficiency of leukoreduction of cellular blood components. Use of a simplified formalin-fixation and batch-counting method

To simplify the quality control procedure used to determine the efficiency and consistency of bedside leukoreduction, a counting protocol using prefiltration and postfiltration aliquots fixed in 10% formaldehyde was designed. To assess the reliability of the values obtained by counting the formalin-fixed samples, a parallel study was performed using our standard protocol of counting fresh propidium iodide-stained samples in a Nageotte chamber under a fluorescent microscope. A total of 30 single-donor platelet concentrates and 30 units of packed red blood cells were analyzed in parallel using the standard and formalin-fixation methods. Furthermore, the aliquots fixed in formaldehyde were split and counted at 1, 3, and 30 days. The results showed no significant quantitative difference between the two methods. Of note is that the counts in formaldehyde-fixed samples at 1, 3, and 30 days were consistent among themselves. The formaldehyde fixation of samples obtained for quality control of leukoreduction allows blood collection and storage at 4 degrees C and batch counting when and where convenient.

Comparison of bcr-abl protein expression and Philadelphia chromosome analyses in chronic myelogenous leukemia patients

The Philadelphia chromosome (Ph) is found in most chronic myelogenous leukemia (CML) patients. The bcr-abl oncoprotein (P210 or P185), the product of the fused bcr-abl gene produced by the Ph, is known to be the major factor in initiation and maintenance of the leukemic state in these types of leukemias. The authors have devised a Western blot test to detect and quantitate the bcr-abl oncoprotein in blood and bone marrow cells. The authors analyzed 1,155 peripheral blood samples from CML patients, for which there were same day Ph data, to determine if there was a correlation between bcr-abl protein levels and the percentage of Ph. A ratio of bcr-abl protein (P210 or P185) to normal abl protein (P145), the latter is ubiquitously expressed in all blood cells, has been established as a criterion for quantitating bcr-abl levels. The bcr-abl/abl protein ratio from 399 patient who were 100% Ph-positive had a mean of 2.47 (standard error [SE] of +/- 0.05); no false negatives were detected. A decreasing ratio was found in patients with decreasing percentages of Ph. The relationship between the ratio of bcr-abl/abl proteins to the percentage of Ph-positive cells was nearly linear in 392 patients with Ph percentages between 5% to 95% (r = 0.97, P < .001). For patients in remission with no detectable Ph, the bcr-abl/abl ratio had a mean of 0.01 (SE = 0 +/- 0.00). The level of bcr-abl expression in samples from peripheral blood and bone marrow also were compared. The results indicated that the amount of bcr-abl protein within peripheral blood is usually similar to that in marrow. In conclusion, quantitation of the bcr-abl oncoprotein in peripheral blood cells or marrow cells as measured by a Western blot assay provides reliable data for both diagnosis and monitoring patients with pH-chromosome positive leukemia.

Differential expression of lacZ in the liver and kidney of transgenic mice carrying chimeric lacZ-erythropoietin gene constructs with or without its 1.2 kb 3'-flanking sequence

Erythropoietin (EPO) plays a key role in erythropoiesis and is expressed predominantly in the fetal liver and in the adult kidney. The EPO gene is up-regulated at the transcriptional level under hypoxic/anemic conditions. We studied the role of the 5'- and 3'-flanking sequences of the mouse EPO gene in its tissue-specific and hypoxia-induced expression by developing transgenic mouse lines carrying chimeric EPO-lacZ gene constructs. Transgenic mice carrying a 6.5 kb segment of the 5'-sequence and most of the EPO gene in which lacZ was substituted for exon 1 (5'-lacZ-EPO) demonstrated induction of lacZ expression following hypoxia/ anemia induction in both the liver and kidney of adult mice. However, transgenic mice carrying the above construct along with the 1.2 kb 3'-flanking sequence (5'-lacZ-EPO-3') showed a high level of lacZ expression following hypoxia/anemia induction in adult kidney but not in adult liver. With the aim of further understanding the role of the 3'-flanking sequence in tissue-specific expression of the EPO gene, we studied the interactions of protein factors with this 1.2 kb 3' region and demonstrated that multiple sets of protein factors interact tissue specifically with a 10 bp sequence, TCAAAGATGG, located downstream of the previously characterized 3' hypoxia-responsive enhancer element.

Abnormal expression of MDM-2 in breast carcinomas

MDM-2 is a cellular oncoprotein that binds to the p53 protein and abrogates its growth-suppressing function. At least seven MDM-2 mRNAs and five proteins (p90, p85, p76, p74, and p57) have been reported in tissue culture. MDM-2 gene amplification occurs in human sarcomas and high-grade gliomas. MDM-2 overexpression without gene amplification has been reported in leukemias and lymphomas. Here we report MDM-2 mRNA overexpression in 24 (73%) out of 33 cases of human breast carcinoma as compared with normal breast tissue. The MDM-2 overexpression was seen in the absence of MDM-2 gene amplification. MDM-2 protein expression was studied by western blot analysis in 21 of these cases of carcinoma. We found complete concordance between MDM-2 mRNA overexpression and MDM-2 protein levels. MDM-2 proteins were overexpressed in 15 of 21 breast carcinoma tissue samples but not in normal breast tissue controls. Ten of these fifteen cases overexpressed MDM-2 p57 protein, two cases overexpressed both p57 and p90, and three cases overexpressed only p90. MDM-2 overexpression was confirmed by immunohistochemistry. p53 overexpression was also studied by immunohistochemistry, 69% of breast carcinomas that overexpressed the MDM-2 mRNA had detectable nuclear p53 protein. These findings demonstrate that MDM-2 oncoprotein expression is altered in primary human breast carcinomas at both mRNA and protein levels. In addition, our results suggest that MDM-2 p57 protein represents the main MDM-2 protein altered in breast carcinomas.

p16INK4A and p15INK4B gene deletions in primary leukemias

The 9p21 locus has been deleted at a high frequency in a wide variety of tumors. Recently, two genes, p16INK4A and p15INK4B (also called MTS1 and MTS2), have been localized in close proximity at the 9p21 locus, encoding cyclin-dependent kinases 4/6 inhibitors of relative molecular mass 16 kD and 15 kD, respectively and also found to be deleted at a high frequency in tumor cell lines. We analyzed p16INK4A and p15INK4B genes in 178 cases of primary leukemias including 81 cases of chronic lymphocytic leukemia (CLL), seven of hairy cell leukemia (HCL), seven of chronic myelogenous leukemia (CML), 43 of acute myelogenous leukemia (AML), 27 of acute lymphoblastic leukemia (ALL), and 13 of myelodysplastic syndrome (MDS) by Southern blot analyses. The ALL cases showed a relatively high frequency of homozygous deletions (22%, 6 of 27) at the p16INK4A gene locus. Interestingly, of the six cases with p16INK4A homozygous deletions, only three showed homozygous deletions at the p15INK4B gene. In 81 CLL patients, we detected one homozygous and five heterozygous deletions at both the p16INK4A and p15INK4B genes and two heterozygous deletions at the p16INK4A gene alone. Deletion of these two genes in AML cases is relatively low (9%). We did not detect deletions in any of the MDS, HCL, and CML cases examined. Sequence analyses of p16INK4A gene of six CLL cases with heterozygous deletion at this locus showed a 27-bp deletion at the splice acceptor site of intron 1 in one case and changes in the coding sequence in three other cases. The data presented in this report showed that (1) p16INK4A and p15INK4B genes are preferentially deleted homozygously in ALL and heterozygously in CLL cases with frequent mutation in the second allele, and (2) p16INK4A gene appears to be more frequently deleted than p15INK4B gene.

Euglobulin lysis times: an update

There are several clot lysis tests available to assess the presence of increased fibrinolysis in a clinical situation. These include whole blood, plasma, and "eugloblin" lysis tests. The euglobulin lysis test (ELT) is actually a modified plasma clot lysis time, which detects increased plasminogen activation and subsequent fibrinolysis. It does not detect the activity of antiplasmins. The purpose of this study was to determine ELT for a group of 25 ambulatory normals. There were 10 males and 15 females, ranging in age from 25 to 56 years. Citrate anticoagulated samples were obtained immediately after application of a tourniquet and 10 minutes after application of a sphygmomanometer inflated to midway between systolic and diastolic pressure. The citrated plasma was precipitated with cold acetic acid. The precipitate contained fibrinogen, plasminogen, and plasminogen activators, with fibrinolytic inhibitors theoretically removed. The precipitate was redissolved and the euglobulin solution was clotted with thrombin. The clotted sample was then incubated at 37 degrees C and was observed at 10 minute intervals for clot lysis.

RESULTS

The reference range of onset of fibrinolysis was from 1.25 to 12 hours, with a mean of 3.78 hours +/- 2.45 hours (1 S.D.). Venostasis (use of the sphygmomanometer) resulted in an ELT that was shorter than the non-venostasis specimens in 11 of 25 specimens. This is thought to be secondary to in vivo activation of plasminogen.

CONCLUSION

The average euglobulin lysis time in 25 ambulatory normals is approximately 3.5 hours. The ELTs vary over a broad range (1.25 to 12.0 hours) in normal ambulatory volunteers.(ABSTRACT TRUNCATED AT 250 WORDS)

Depressed affect, hopelessness, and the risk of ischemic heart disease in a cohort of U.S. adults

Major depression has been associated with mortality from ischemic heart disease (IHD). In addition, a symptom of depression--hopelessness--has been suggested as a determinant of health status. We studied the relation of both depressed affect and hopelessness to IHD incidence using data from a cohort of 2,832 U.S. adults age 45-77 years who participated in the National Health Examination Follow-up Study (mean follow-up = 12.4 years) and had no history of IHD or serious illness at baseline. We used the depression subscale of the General Well-Being Schedule to define depressed affect and a single item from the scale to define hopelessness. At baseline, 11.1% of the cohort had depressed affect; 10.8% reported moderate hopelessness, and 2.9% reported severe hopelessness. Depressed affect and hopelessness were more common among women, blacks, and persons who were less educated, unmarried, smokers, or physically inactive. There were 189 cases of fatal IHD during the follow-up period. After we adjusted for demographic and risk factors, depressed affect was related to fatal IHD [relative risk = 1.5; 95% confidence interval (CI) = 1.0-2.3]; the relative risks of fatal IHD for moderate and severe levels of hopelessness were 1.6 (95% CI = 1.0-2.5) and 2.1 (95% CI = 1.1-3.9), respectively. Depressed affect and hopelessness were also associated with an increased risk of nonfatal IHD. These data indicate that depressed affect and hopelessness may play a causal role in the occurrence of both fatal and nonfatal IHD.

Determination of bupropion and its major basic metabolites in plasma by liquid chromatography with dual-wavelength ultraviolet detection

A method for the determination of bupropion and its three major basic metabolites in plasma is described. Following an extraction from alkaline plasma into 1.5% v/v isoamyl alcohol in n-heptane, a portion of the acid-backwashed extract was injected onto a column packed with trimethylsilyl reverse-phase material and eluted with a phosphate buffer-acetonitrile (80:20) mobile phase containing an ion-pairing reagent and triethylamine. The compounds were detected with a dual-wavelength UV detector (214 and 254 nm) to optimize sensitivity and facilitate simultaneous detection. The method provides an absolute recovery of approximately 85% for bupropion and approximately 98% for the metabolites. Day-to-day reproducibility did not exceed 4.0% for all compounds. The detection limits were approximately 5 ng/mL for bupropion and 100 ng/mL for the major metabolites. The limit of 100 ng/mL for metabolite quantitation is imposed by the internal standard concentration selected for steady-state studies. In single-dose pharmacokinetic studies, 10% of the steady-state concentration of internal standard was used; this permitted a 10-ng/mL lower limit of detection. Steady-state plasma levels of bupropion and the metabolites from eight different patients are presented.

Phosphorylation of brain synaptic and coated vesicle proteins by endogenous Ca2+/calmodulin- and cAMP-dependent protein kinases

Phosphorylation of brain synaptic and coated vesicle proteins was stimulated by Ca2+ and calmodulin. As determined by 5-15% sodium dodecylsulfate (SDS) polyacrylamide gel electrophoresis (PAGE), molecular weights (Mr) of the major phosphorylated proteins were 55,000 and 53,000 in synaptic vesicles and 175,000 and 55,000 in coated vesicles. In synaptic vesicles, phosphorylation was inhibited by affinity-purified antibodies raised against a 30,000 Mr protein doublet endogenous to synaptic and coated vesicles. When this doublet, along with clathrin, was extracted from coated vesicles, phosphorylation did not take place, implying that the protein doublet may be closely associated with Ca2+/calmodulin-dependent protein kinase. Affinity-purified antibodies, raised against clathrin used as a control antibody, failed to inhibit Ca2+/calmodulin-dependent phosphorylation in either synaptic or coated vesicles. Immunoelectron cytochemistry revealed that this protein doublet was present in axon terminal synaptic and coated vesicles. Synaptic vesicles also displayed cAMP-dependent kinase activity; coated vesicles did not. The molecular weights of phosphorylated synaptic vesicle proteins in the presence of Mg2+ and cAMP were: 175,000, 100,000, 80,000, 57,000, 55,000, 53,000, 40,000, and 30,000. Based on the different phosphorylation patterns observed in synaptic and coated vesicles, we propose that brain vesicle protein kinase activities may be involved in the regulation of exocytosis and in retrieval of synaptic membrane in presynaptic axon terminals.

Use of a medical-grade silicone adhesive as a denture liner in the treatment of idiopathic oral mucosal irritation

The results of the survey confirmed the clinical observation that soft liners were the best course of treatment in specifically selected patients. Most patients were satisfied with the appearance of the denture, and the length of time the patient could wear the soft-lined prosthesis increased considerably. The silicone liner also reduced irritation and increased the ability to chew food, with the patient's ability to taste food remaining essentially unaffected. The maintenance of cleanliness of the silicone, which had been a problem in the past, seemed to be markedly reduced. Above all, the enthusiastic patient acceptance of the product indicates that adhesive type A may be an excellent alternative to hard acrylic resin denture liners when a change of material is necessary.

Studies on the toxicity and binding kinetics of abrin in normal and Epstein Barr virus-transformed lymphocyte culture-I: experimental results - 3

The effects of treatment with varying doses of abrin, a D-galactose binding lectin, on DNA and protein synthesis of normal and Epstein Barr virus-transformed lymphocytes have been investigated. Using data on EBV-transformed lymphocyte cell density as a function of time and dose of abrin, one can demonstrate that the mean number of sites bound/EBV-lymphocyte needed to exert a biological influence upon the cell DNA synthesis lies between 59,264 and 370,000 sites/cell. Using a simple packing model, one can demonstrate that a theoretical estimate places the number of binding sites between 57,600 and 360,000 sites/cells.

Studies on toxicity and binding kinetics of abrin in normal and Epstein Barr virus-transformed lymphocyte culture-I: experimental results - 2

The effects of treatment with varying doses of abrin, a D-galactose binding lectin, on DNA and protein synthesis of normal and Epstein Barr virus-transformed lymphocytes have been investigated. Studies of activation and stimulation indices, as well as two new indices; the metabolic self and cross-coupling indices, lead to the prediction that there are three morphologically distinct subpopulations of EBV-transformed lymphocytes with different abrin binding site numbers. This conclusion is supported by SEM morphological differences.

Studies on the toxicity and binding kinetics of abrin in normal and Epstein Barr virus-transformed lymphocyte culture-I: experimental results - 1

The effects of treatment with varying doses of abrin, a D-galactose binding lectin, on DNA and protein synthesis of normal and Epstein Barr virus-transformed lymphocytes have been investigated. Activation, stimulation and relative toxicity factor indices are studied as well as possible relationships between the DNA and protein synthesis rates, as measured by simultaneous 3H-TdR and 14C-leucine uptake.

Human growth hormone response to levodopa. Relation to menopause, depression, and plasma dopa concentration

After ingestion of 500 mg of levodopa, postmenopausal women had significantly diminished human growth hormone (HGH) responses (mean, 4.6 ng/ml), as compared with those of age-matched men (mean, 9.1 ng/ml; P smaller than .05). The differences between the groups were not related to plasma dopa concentrations. The HGH responses to levodopa of age-matched unipolar and bipolar depressed men, and of unipolar depressed postmenopausal women, did not differ significantly from their respective normal control groups. Depressive illness of these types does not appear to affect the HGH response to levodopa, once the effect of the menopause is taken into account.