Investigation into clinicopathological and pathological findings, prognosis, and aetiology of lorikeet paralysis syndrome in rainbow lorikeets (Trichoglossus haematodus)

Objective

To report the temporal and spatial distribution of rainbow lorikeets presenting with lorikeet paralysis syndrome (LPS) and their clinicopathologic and pathologic findings, exposure to toxins, and response to treatment.

Methods

Records of lorikeets admitted in 2017 and 2018 to facilities in south‐east Queensland (QLD) were reviewed and LPS and non‐LPS cases were mapped and their distribution compared. Plasma biochemistries and complete blood counts were done on 20 representative lorikeets from south‐east QLD and Grafton, New South Wales (NSW). Tissues from 28 lorikeets were examined histologically. Samples were tested for pesticides (n = 19), toxic elements (n = 23), botulism (n = 15) and alcohol (n = 5).

Results

LPS occurred in warmer months. Affected lorikeets were found across south‐east QLD. Hotspots were identified in Brisbane and the Sunshine Coast. Lorikeets had a heterophilic leucocytosis, elevated muscle enzymes, uric acid and sodium and chloride. Specific lesions were not found. Exposure to cadmium was common in LPS and non‐LPS lorikeets. Treated lorikeets had a 60–93% See Table 2 depending on severity of signs.

Clinical significance

The primary differential diagnosis for lorikeets presenting with lower motor neuron signs during spring, summer and autumn in northern NSW and south‐east Queensland should be LPS. With supportive care, prognosis is fair to good.

Linezolid- and Vancomycin-resistant Enterococcus faecium in Solid Organ Transplant Recipients: Infection Control and Antimicrobial Stewardship Using Whole Genome Sequencing

BACKGROUND

Vancomycin-resistant enterococci are an important cause of healthcare-associated infections and are inherently resistant to many commonly used antibiotics. Linezolid is the only drug currently approved by the US Food and Drug Administration to treat vancomycin-resistant enterococci; however, resistance to this antibiotic appears to be increasing. Although outbreaks of linezolid- and vancomycin-resistant Enterococcus faecium (LR-VRE) in solid organ transplant recipients remain uncommon, they represent a major challenge for infection control and hospital epidemiology.

METHODS

We describe a cluster of 4 LR-VRE infections among a group of liver and multivisceral transplant recipients in a single intensive care unit. Failure of treatment with linezolid in 2 cases led to a review of standard clinical laboratory methods for susceptibility determination. Testing by alternative methods including whole genome sequencing (WGS) and a comprehensive outbreak investigation including sampling of staff members and surfaces was performed.

RESULTS

Review of laboratory testing methods revealed a limitation in the VITEK 2 system with regard to reporting resistance to linezolid. Linezolid resistance in all cases was confirmed by E-test method. The use of WGS identified a resistant subpopulation with the G2376C mutation in the 23S ribosomal RNA. Sampling of staff members' dominant hands as well as sampling of surfaces in the unit identified no contaminated sources for transmission.

CONCLUSIONS

This cluster of LR-VRE in transplant recipients highlights the possible shortcomings of standard microbiology laboratory methods and underscores the importance of WGS to identify resistance mechanisms that can inform patient care, as well as infection control and antibiotic stewardship measures.

C-51 Long Term Neuropsychological Follow-Up of Radiation Induced Cognitive Decline (RICD) in Cerebellar Medulloblastoma

Objective

We expanded upon an early case study suggesting long-term, sequential neurocognitive evaluation and academic interventions following pediatric cerebellar medulloblastoma. This five-year-old patient (now forty) has indeed undergone lifespan assessment and clearly benefitted from appropriate interventions to date.

Method

This left-handed, white, male is status post (s/p) gross total resection and whole brain radiation. In adulthood, he developed radiation necrosis with hemorrhage and refractory seizures (s/p right temporal lobectomy). More recently, radiation induced bilateral parietal meningiomas were identified (s/p gamma knife).

Results

We analyzed cognitive, medical/oncological, imaging and interventional data at developmentally meaningful time points and found consistent declines in intellectual skills and cognitive function spanning attention/concentration, processing speed, visual perceptual/organization and visually based learning/memory; however, we noted stabilization and even improvement in important areas. Areas of age-appropriate functioning were noted in expressive vocabulary, verbal abstract reasoning, delayed verbal memory, and problem-solving, among others.

Conclusions

Although some studies have addressed long-term outcomes in pediatric medulloblastoma, we provide a unique perspective to the literature by documenting serial neurocognitive findings in addition to interventions across the lifespan. Our findings suggest that appropriate academic interventions/neurocognitive rehabilitation strategies are in fact meaningful at the individual level and propose that a focus on strengths can improve outcomes. We propose that this previously recommended model of assessment/intervention truly become the available standard of care in all pediatric oncologic populations.

T-Cell Exhaustion Signatures Vary with Tumor Type and Are Severe in Glioblastoma

Purpose: T-cell dysfunction is a hallmark of glioblastoma (GBM). Although anergy and tolerance have been well characterized, T-cell exhaustion remains relatively unexplored. Exhaustion, characterized in part by the upregulation of multiple immune checkpoints, is a known contributor to failures amid immune checkpoint blockade, a strategy that has lacked success thus far in GBM. This study is among the first to examine, and credential as bona fide, exhaustion among T cells infiltrating human and murine GBM.Experimental Design: Tumor-infiltrating and peripheral blood lymphocytes (TILs and PBLs) were isolated from patients with GBM. Levels of exhaustion-associated inhibitory receptors and poststimulation levels of the cytokines IFNγ, TNFα, and IL2 were assessed by flow cytometry. T-cell receptor Vβ chain expansion was also assessed in TILs and PBLs. Similar analysis was extended to TILs isolated from intracranial and subcutaneous immunocompetent murine models of glioma, breast, lung, and melanoma cancers.Results: Our data reveal that GBM elicits a particularly severe T-cell exhaustion signature among infiltrating T cells characterized by: (1) prominent upregulation of multiple immune checkpoints; (2) stereotyped T-cell transcriptional programs matching classical virus-induced exhaustion; and (3) notable T-cell hyporesponsiveness in tumor-specific T cells. Exhaustion signatures differ predictably with tumor identity, but remain stable across manipulated tumor locations.Conclusions: Distinct cancers possess similarly distinct mechanisms for exhausting T cells. The poor TIL function and severe exhaustion observed in GBM highlight the need to better understand this tumor-imposed mode of T-cell dysfunction in order to formulate effective immunotherapeutic strategies targeting GBM. Clin Cancer Res; 24(17); 4175-86. ©2018 AACRSee related commentary by Jackson and Lim, p. 4059.

Abstract 1533: Transcriptional inhibition of brachyury in chordoma is associated with adoption of quiescent phenotype

BACKGROUND: Brachyury is a mesoderm specification transcription factor involved in notochord development and overexpressed in a variety of cancers, including chordoma. High levels of brachyury protein expression in cancers is associated with a poor prognosis in part due to its role in mediating epithelial-mesenchymal transition (EMT). TG02 is a multikinase inhibitor that targets transcriptional regulation of cyclin-dependent kinases (CDKs). Because chordoma is characterized by a relative paucity of genomic mutations and largely driven by the super-enhancer activity of brachyury expression, we investigated the downstream effect of a transcriptional inhibitor, TG02, in chordomas.

METHODS: Established chordoma cell lines, UCH-1 and UM-Chor1, were exposed to increasing concentrations of TG02 to determine effect on brachyury protein expression. qPCR was used to analyze brachyury mRNA expression as well as the mesenchymal proteins, vimentin and fibronectin, typically associated with brachyury expression in tumor cells. Cell migration was

evaluated using wound healing assay. CellTiterGlo Luminescence Assay was used to quantify cell viability.

RESULTS: TG02 down-regulated protein expression of brachyury in a dose-dependent manner. Attenuation of brachyury expression was seen within 4 hours and persisted for 5 days upon single exposure to a clinically relevant concentration of TG02. Brachyury downregulation did not affect cell count or viability, and was associated with a quiescent phenotype, including impaired migration. Expression of vimentin and fibronectin, both associated with EMT, was also suppressed within 4 hours of TG02 treatment and persisted for 24 hours.

CONCLUSIONS: Inhibition of brachyury expression and its downstream signaling is associated with quiescent behavior of chordoma cells. Pharmacologically induced transcriptional targeting of brachyury using TG02, a potent CDK9 inhibitor, represents a potential therapeutic strategy.

Citation Format: Ashlee N. Seldomridge, Jinkyu Jung, Heather M. Sonnemann, Amber Giles, Kristan Meetze, Mark R. Gilbert, Claudia M. Palena, Deric M. Park. Transcriptional inhibition of brachyury in chordoma is associated with adoption of quiescent phenotype [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1533. doi:10.1158/1538-7445.AM2017-1533

Computer aided prognosis for cell death categorization and prediction in vivo using quantitative ultrasound and machine learning techniques

PURPOSE

At present, a one-size-fits-all approach is typically used for cancer therapy in patients. This is mainly because there is no current imaging-based clinical standard for the early assessment and monitoring of cancer treatment response. Here, the authors have developed, for the first time, a complete computer-aided-prognosis (CAP) system based on multiparametric quantitative ultrasound (QUS) spectroscopy methods in association with texture descriptors and advanced machine learning techniques. This system was used to noninvasively categorize and predict cell death levels in fibrosarcoma mouse tumors treated using ultrasound-stimulated microbubbles as novel endothelial-cell radiosensitizers.

METHODS

Sarcoma xenograft tumor-bearing mice were treated using ultrasound-stimulated microbubbles, alone or in combination with x-ray radiation therapy, as a new antivascular treatment. Therapy effects were assessed at 2-3, 24, and 72 h after treatment using a high-frequency ultrasound. Two-dimensional spectral parametric maps were generated using the power spectra of the raw radiofrequency echo signal. Subsequently, the distances between "pretreatment" and "post-treatment" scans were computed as an indication of treatment efficacy, using a kernel-based metric on textural features extracted from 2D parametric maps. A supervised learning paradigm was used to either categorize cell death levels as low, medium, or high using a classifier, or to "continuously" predict the levels of cell death using a regressor.

RESULTS

The developed CAP system performed at a high level for the classification of cell death levels. The area under curve of the receiver operating characteristic was 0.87 for the classification of cell death levels to both low/medium and medium/high levels. Moreover, the prediction of cell death levels using the proposed CAP system achieved a good correlation (r = 0.68,  p < 0.001) with histological cell death levels as the ground truth. A statistical test of significance between individual treatment groups with the corresponding control group demonstrated that the predicted levels indicated the same significant changes in cell death as those indicated by the ground-truth levels.

CONCLUSIONS

The technology developed in this study addresses a gap in the current standard of care by introducing a quality control step that generates potentially actionable metrics needed to enhance treatment decision-making. The study establishes a noninvasive framework for quantifying levels of cancer treatment response developed preclinically in tumors using QUS imaging in conjunction with machine learning techniques. The framework can potentially facilitate the detection of refractory responses in patients to a certain cancer treatment early on in the course of therapy to enable switching to more efficacious treatments.

Use of core biopsy in diagnosing cervical lymphadenopathy: a viable alternative to surgical excisional biopsy of lymph nodes?

OBJECTIVES Lymphoma often presents with a neck mass and while fine-needle aspiration cytology may be suggestive, tissue biopsy is required for reliable diagnosis and classification of a lymphoma that is sufficient to deliver the correct treatment for the patient. Traditionally, excisional biopsy of a lymph node has been the standard method of tissue sampling, providing ample tissue for assessment. However, this requires theatre time, and preceding fine-needle aspiration cytology, which may incur a delay. With careful use of tissue, coupled with advances in immunohistochemical and molecular investigative techniques, core biopsy provides a possible alternative to traditional fine-needle aspiration and excisional biopsy. In this study, we aimed to determine the efficacy of diagnosing neck masses. METHOD A retrospective analysis was performed of patients being investigated for a neck mass who were undergoing ultrasound-guided core biopsies of cervical lymph nodes over a 17-month period. The final histology report was scrutinised to assess whether adequate tissue was obtained to allow for full tissue diagnosis. RESULTS Over the 17-month period analysed, 70 patients with cervical lymphadenopathy underwent core biopsy. Of these, 63 (90%) were diagnostic for either lymphoma or other pathology and did not require further tissue sampling. Overall, 19 patients were diagnosed with lymphoma, of which only 1 required further biopsy due to inconclusive initial core biopsy. CONCLUSIONS Current guidelines for investigating lymphomas require that excisional biopsy be performed to obtain ample tissue to allow full nodal architecture assessment and ancillary investigation to reach an accurate histological classification. Within our head and neck multidisciplinary team, however, it is considered that results from core biopsies can be obtained in a more timely fashion and with histological accuracy equal to those of open biopsy. The results obtained demonstrate that core biopsy is an effective tool for investigation. We believe this should be the first-line investigation of choice, as it reduces the need for patients to undergo surgery, is more cost effective and offers a faster diagnosis.

Physiological, Tumor, and Metastatic Niches: Opportunities and Challenges for Targeting the Tumor Microenvironment

The primary tumor niche and the related but distinct premetastatic/metastatic niche comprise a number of essential players, including immune cells, stromal cells, and extracellular matrix. The cross-talk between these components is key to tumor progression. Many of these cell types and signaling pathways in the tumor microenvironment also are found in physiological and stem cell niches, such as the bone marrow, colonic crypt, and skin bulge. Here they play tightly regulated roles in wound healing and tissue homeostasis. Understanding the similarities and differences between these distinct niches may better inform our ability to therapeutically target the tumor microenvironment. In this review we discuss a number of tumor and metastatic niche components as they relate to stem cell niches and highlight potential therapeutic strategies in pediatric cancers.

Abstract 4126: CSF-1R inhibition blocks rhabdomyoscarcoma metastasis by polarizing macrophage differentiation

Colony Stimulating Factor 1 (CSF-1) is overexpressed by many tumors and predicts poor clinical outcome. CSF-1 expression results in the recruitment of CSF-1R (Fms)-expressing cells, which have been shown to suppress tumor immunity, thereby promoting cancer progression. PLX3397 is a novel, orally active small molecule inhibitor that selectively targets CSF-1R, KIT, and oncogenic FIT3. CSF-1R and KIT regulate the tumor, tumor microenvironment, and the pre-metastatic niche. However, it is unknown if targeting the myeloid CSF-1R expressing component of the tumor microenvironment regulates metastasis of pediatric tumors, such as rhabdomyosarcoma. Using the M3-9-M murine syngeneic orthotopic rhabdomyosarcoma model, we evaluated the effects of PLX3397 on primary tumor growth and metastatic progression. This highly metastatic rhabdomyosarcoma model has high infiltration of CSF-1R-expressing bone marrow-derived cells, which includes inflammatory monocytes, M2 macrophages, and myeloid-derived suppressor cells. Therefore, we hypothesized PLX3397 would have a direct effect on CSF-1R expressing M2 macrophages and inflammatory monocytes, resulting in decreased metastasis. Using both in vitro and in vivo models, we found that PLX3397 treatment decreased tumor-infiltrating M2 macrophages and skewed the differentiation of inflammatory monocytes toward M1 macrophages and development of immunocompetent mature dendritic cells. This resulted in impairment of spontaneous M3-9-M metastasis to secondary sites. In addition, we have found that the polarization of inflammatory monocytes reversed the T cell suppressive capability of tumor-derived myeloid cells. In conclusion, CSF-1R blockage with PLX3397 inhibited metastatic progression by decreasing the infiltration of M2 macrophages in the primary tumor and pre-metastatic niche. The polarization of inflammatory monocytes to dendritic cells restored the immune recognition and decreased metastasis. This data supports our rationale for testing PLX3397 in patients with high M2 infiltration and suggests value in this agent as an adjuvant setting for metastasis prevention in high-risk patients.

Note: This abstract was not presented at the meeting.

Citation Format: Justin Evans, Amber Giles, Caitlin Reid, Rosandra Kaplan. CSF-1R inhibition blocks rhabdomyoscarcoma metastasis by polarizing macrophage differentiation. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4126. doi:10.1158/1538-7445.AM2015-4126

Las lesiones oculares en el tifo exantemático

Aun cuando son, relativamente, incompletas nuestras observaciones sobre este tema debido a la escasez de material patológico y a la condición en que el mismo llegó para su estudio, juzgamos conveniente una descripción para animar a otros observadores nuestros a fin de completar el cuadro anatómico. Otra razón más que no simpele a publicar estos apuntes es el de comparar nunestros resultados con los de varios investigadores y notar sus analogías.

Abstract 2074: Metastasis prevention using fibroblast activation protein-targeting prodrugs at the pre-metastatic niche

Metastasis is the major cause of cancer death, and therapies that effectively target this process are required in order to improve patient survival. Previous work by Kaplan et al demonstrated that activated resident stromal cells and recruited bone marrow derived cells (BMDCs) form an altered microenvironment at distant sites in response to the primary tumor, termed the pre-metastatic niche, that promotes metastatic progression. Current on-going studies in the laboratory focus on in-depth investigations of the role, composition and mechanism of action by which each cell population including the bone marrow-derived hematopoietic cells and the activated stromal cells within the pre-metastatic niche contribute to metastatic progression. Fibroblast activation protein (FAP) is a serine protease that is overexpressed by tumor associated stromal cells, including cancer-associated fibroblasts (CAFs) and is implicated in the suppression of tumor immunity. Using a mouse model that expresses FAP promoter-driven mCherry and luciferase, we demonstrate that FAP gene expression is up-regulated in both tumor-bearing mice in pre-metastatic tissue at pre-metastatic time-points and in non-tumor-bearing mice injected with tumor-conditioned media, suggesting that metastatic tumors secrete factors that increases the number of FAP-expressing cells at the pre-metastatic niche. The studies described herein investigate the hypothesis that FAP-expressing cells at the pre-metastatic niche promote metastasis, and FAP-targeted cytotoxic drug delivery will aid in targeting tumor colonization and inhibiting metastatic progression.

Citation Format: Meera Murgai, Amber Giles, Miki Kasai, Yorleny Vicioso, Crystal Mackall, Rosandra Kaplan. Metastasis prevention using fibroblast activation protein-targeting prodrugs at the pre-metastatic niche. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2074. doi:10.1158/1538-7445.AM2014-2074

Prevalence and management of chronic kidney disease in primary care patients in the UK

BACKGROUND

This study aimed to estimate the prevalence of chronic kidney disease (CKD) in the UK in 2010 and to assess prevalence, comorbidities and comedications associated with the disease over time, following inclusion of CKD in the Quality and Outcomes Framework (QOF).

METHODS

This was a retrospective, longitudinal study assessing individuals with prevalent or incident CKD (identified using estimated glomerular filtration rate readings and/or Read codes) in the General Practice Research Database (GPRD) in 2010. Individuals were assessed at two time points: in 2010 and at the date of their first classification of CKD in the GPRD.

RESULTS

The prevalence of stage 3-5 CKD in 2010 was 5.9%. In patients with stage 3-5 CKD at first classification, their disease remained stable, progressed or improved by 2010 in approximately 50%, 10-15% and 25-30% of patients, respectively. Diagnoses of cardiovascular-related comorbidities (hypertension, hypercholesterolaemia, diabetes and cardiovascular disease), and treatment with antihypertensives and lipid-modifying therapy (LMT), increased with worsening disease severity. When patients were stratified by diagnosis date, the proportion of patients with stage 3-5 CKD and cardiovascular-related comorbidities decreased with time, and the relative use of LMT and antihypertensives among patients with hypercholesterolaemia and hypertension increased with time.

CONCLUSIONS

Chronic kidney disease is generally stable or progressive, although more patients improve disease stage than previously assumed. Data suggest that the introduction of CKD into the QOF has increased awareness of CKD among physicians in the UK, allowing for earlier intervention and better control of CKD progression.

Hepatic SIRT1 attenuates hepatic steatosis and controls energy balance in mice by inducing fibroblast growth factor 21

BACKGROUND & AIMS

The hepatocyte-derived hormone fibroblast growth factor 21 (FGF21) is a hormone-like regulator of metabolism. The nicotinamide adenine dinucleotide-dependent deacetylase SIRT1 regulates fatty acid metabolism through multiple nutrient sensors. Hepatic overexpression of SIRT1 reduces steatosis and glucose intolerance in obese mice. We investigated mechanisms by which SIRT1 controls hepatic steatosis in mice.

METHODS

Liver-specific SIRT1 knockout (SIRT1 LKO) mice and their wild-type littermates (controls) were divided into groups that were placed on a normal chow diet, fasted for 24 hours, or fasted for 24 hours and then fed for 6 hours. Liver tissues were collected and analyzed by histologic examination, gene expression profiling, and real-time polymerase chain reaction assays. Human HepG2 cells were incubated with pharmacologic activators of SIRT1 (resveratrol or SRT1720) and mitochondrion oxidation consumption rate and immunoblot analyses were performed. FGF21 was overexpressed in SIRT1 LKO mice using an adenoviral vector. Energy expenditure was assessed by indirect calorimetry.

RESULTS

Prolonged fasting induced lipid deposition in livers of control mice, but severe hepatic steatosis in SIRT1 LKO mice. Gene expression analysis showed that fasting up-regulated FGF21 in livers of control mice but not in SIRT1 LKO mice. Decreased hepatic and circulating levels of FGF21 in fasted SIRT1 LKO mice were associated with reduced hepatic expression of genes involved in fatty acid oxidation and ketogenesis, and increased expression of genes that control lipogenesis, compared with fasted control mice. Resveratrol or SRT1720 each increased the transcriptional activity of the FGF21 promoter (-2070/+117) and levels of FGF21 messenger RNA and protein in HepG2 cells. Surprisingly, SIRT1 LKO mice developed late-onset obesity with impaired whole-body energy expenditure. Hepatic overexpression of FGF21 in SIRT1 LKO mice increased the expression of genes that regulate fatty acid oxidation, decreased fasting-induced steatosis, reduced obesity, increased energy expenditure, and promoted browning of white adipose tissue.

CONCLUSIONS

SIRT1-mediated activation of FGF21 prevents liver steatosis caused by fasting. This hepatocyte-derived endocrine signaling appears to regulate expression of genes that control a brown fat-like program in white adipose tissue, energy expenditure, and adiposity. Strategies to activate SIRT1 or FGF21 could be used to treat fatty liver disease and obesity.

Impact of lipid-lowering therapy on the prevalence of dyslipidaemia in patients at high-risk of cardiovascular events in UK primary care - a retrospective database study

AIMS

To estimate the prevalence of dyslipidaemias in high-risk patients new to lipid-modifying therapy (LMT), and establish the extent to which these lipid abnormalities are addressed by treatment in UK clinical practice.

METHODS

The PRIMULA study was a retrospective analysis, conducted using the UK General Practice Research Database. Two periods were studied as follows: a pretreatment period, defined as the 12 months before initiation of LMT (the index date), and a follow-up period of at least 12 months. Patients included in the study (n = 25,011) had dyslipidaemia with at least one abnormal lipid measurement [total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) or triglycerides (TG)] in the pretreatment period. All patients were at high risk of cardiovascular events, which was defined as having a history of cardiovascular disease, a 10-year Framingham risk score higher than 20%, diabetes or hypertension, as defined by the Joint British Societies 2 guidelines.

RESULTS

At the index date, 98% of patients were initiated on statin monotherapy. After 12 months of treatment, 15.2% (sub-group range: 11.0-22.9%) of all high-risk patients had no lipid abnormalities. The proportions of patients with high TC or LDL-C levels decreased from 98.8% to 68.9%, and from 99.2% to 68.7%, respectively, over 12 months. The prevalence of high TG levels decreased from 45.0% to 26.9%, whereas that of low HDL-C levels increased, from 16.6% to 18.0%. Risk factors for cardiovascular events were not consistently associated with the likelihood of attaining optimal lipid levels.

CONCLUSIONS

Despite widespread use of statins, many individuals at high risk of cardiovascular events have persistently abnormal lipid levels, with over two-thirds of patients not achieving target levels of LDL-C or TC. Management of dyslipidaemia is therefore suboptimal in this important high-risk group in UK standard practice.

A UK retrospective observational study of clinical outcomes and healthcare resource utilisation of infliximab treatment in Crohn's disease

BACKGROUND

Crohn's disease (CD) places a substantial burden on healthcare systems, with the majority of costs arising from hospitalisation and surgery.

AIM

To evaluate the 'real-world' clinical effectiveness, impact on healthcare utilisation and cost of infliximab for the treatment of CD in UK practice.

METHODS

A non-interventional, retrospective analysis of medical records from patients with CD treated with infliximab at 18 hospital centres across the UK. The primary objective was to compare cumulative clinical outcomes and healthcare resource utilisation for the 0- to 24-month post-infliximab period with the 12 months preceding infliximab treatment. Predefined outcomes included the number of elective surgical procedures, hospitalisations and healthcare provider consultations. Costs associated with healthcare utilisation were collected from the perspective of the UK National Health Service (NHS).

RESULTS

The study involved 380 patients. Infliximab significantly reduced the mean number of elective (from 0.18 to 0.11; P = 0.0035) and non-elective (from 0.46 to 0.29; P < 0.0001) hospitalisations, and the number of consultations with gastroenterologists, gastrointestinal surgeons and radiologists (from 4.0 to 3.5, from 0.7 to 0.5 and from 0.5 to 0.2, respectively; all P < 0.001); all decreases were associated with significant cost reductions. The mean number of elective surgical procedures (including correction of severe anal fistulae and abscess drainage) was significantly reduced.

CONCLUSIONS

The observed reductions in numbers of hospitalisations, surgical procedures and consultations with healthcare professionals are key indicators of the clinical effectiveness of infliximab for the treatment of CD. These benefits result in overall decreases in healthcare resource utilisation, which translate into cost savings for the NHS.

Wnt signalling in pituitary development and tumorigenesis

Wnt signalling is activated in both pituitary organogenesis and its mature function. Wnt ligands and Wnt signalling pathways are critical for the regulation of the formation of the pituitary. In the mature pituitary, Wnt signalling pathways control cell activity and may stimulate cell proliferation in both physiological and pathological processes. This review compares Wnt signalling pathways active in the developing and mature pituitary and explores how this gives us further insight into the development of pituitary adenomas.

Abstract 4585: Breaking metastatic dormancy during surgical resection of a primary tumor and implications for treatment strategies

At the time of a cancer diagnosis, most patients have localized tumors. Despite elaborate staging schemas for each cancer type in an attempt to stratify patients, the vast majority of patients that die will do so from metastatic disease. We hypothesized that surgery augments the already ongoing activation and mobilization of bone marrow-derived progenitor cells that are critical to colonizing tumor cells at distant sites. These bone marrow-derived cells, by inducing a local inflamed tumor microenvironment, provide survival signals to these seeding tumor cells. Our data show increased metastatic burden in the lung after surgical resection of the primary tumor using two murine cancer models, B16 melanoma and E0771 breast carcinoma. In these models, we also show a surge in hematopoietic and endothelial progenitor cells in the hours and days immediately following resection of the primary tumor, which is not similarly observed in control mice, where surgery was performed in the absence of the primary tumor. We also confirmed that a factor specific to the plasma of the tumor-bearing mice is responsible for this mobilization by using in vitro migration assays, whereby plasma from tumor-bearing mice and surgically resected mice induced an increased migration of lineage negative bone marrow cells compared to the plasma of wild type mice. We confirmed increased levels of MCP-1 and MCSF, both known to mobilize progenitor cells, in the plasma of mice with surgical resection. Additionally, targeting these bone marrow derived hematopoietic and endothelial progenitor cells with Pazopanib prevents the surge in bone marrow-derived cells into the circulation, abolishes the enhanced metastatic spread in mice undergoing surgical resection of the primary tumor, and provides a significant prolongation of survival. Finally, we correlated these data to a cohort of breast cancer patients where circulating levels of progenitor cells were analyzed at time points before and after surgery, which confirmed the mobilization of progenitor cells with surgery. Together, these results provide evidence for the increased risk of metastatic spread after surgical resection of the primary tumor and suggest that blocking progenitor cell mobilization by adjuvant treatment during or immediately following surgery, the incidence of metastatic recurrence may be reduced.

Citation Format: Selena R. Granitto, Amber Giles, Simon Lavotshkin, Daniel Rutigliano, David Lyden, Rosandra N. Kaplan. Breaking metastatic dormancy during surgical resection of a primary tumor and implications for treatment strategies. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4585. doi:10.1158/1538-7445.AM2013-4585

Abstract LB-284: Bone marrow-derived progenitor cells develop into myeloid-derived suppressor cells at metastatic sites

The ability of tumor cells to metastasize to distant tissues is the most lethal aspect of cancer. Prior to detectable metastasis tumors elicit distant changes within the bone marrow and future sites of metastasis, including formation of the pre-metastatic niche. We have found that prior to detectable spontaneous metastasis, a primary tumor causes enhanced production and mobilization of progenitor cells from the bone marrow into the blood. We find in cancer patients that increased circulating progenitors are associated with metastatic disease progression. By utilizing bone marrow transplant models and a novel ex vivo lung culture, we demonstrate that bone marrow-derived progenitor cells accumulate at the primary tumor as well as metastatic lesions. As our cancer models approach detectable spontaneous metastases, we observe a loss of progenitor cells in pre-metastatic sites and an increase in myeloid-derived suppressor cells (MDSCs). We further traced adoptively transferred bone marrow-derived progenitors in tumor-bearing mice and demonstrate that these cells contribute to the MDSC population. Together, these data suggest that circulating progenitor cells provide a prognostic tool to predict metastatic dissemination. Furthermore, these cells likely contribute to metastatic progression by developing into MDSCs within the primary tumor and at metastatic sites.

Citation Format: Amber Giles, Yorleny Vicioso, Christianne Persenaire, Miki Kasai, Steven Highfill, Arnulfo Mendoza, Rosandra Kaplan. Bone marrow-derived progenitor cells develop into myeloid-derived suppressor cells at metastatic sites. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr LB-284. doi:10.1158/1538-7445.AM2013-LB-284

Ultrasound-activated microbubble cancer therapy: ceramide production leading to enhanced radiation effect in vitro

Blood vessels within tumours represent a key component for cancer cell survival. Disruption of these vessels can be achieved by inducing vascular endothelial-cell apoptosis. Moreover, endothelial cell apoptosis has been proven to be enhanced by ceramide-increasing drugs. Herein, we introduce a novel therapeutic approach which uses ultrasound-stimulated microbubbles used in combination with radiation to cause a rapid accumulation of ceramide in endothelial cells in-vitro. We also test this modality directly with other cell types as a general method of killing cancer cells. Human umbilical vein endothelial cells (HUVEC), acute myeloid leukemia cells (AML), murine fibrosarcoma cells (KHT-C), prostate cancer cells (PC3), breast cancer cells (MDA-MB-231) and astrocytes were used to evaluate this mechanism of inducing cell death. Survival was measured by clonogenic assays, and ceramide content was detected using immunohistochemistry. Exposure of cell types to ultrasound-stimulated bubbles alone resulted in increases in ceramide for all cell types and survivals of 12 ± 2%, 65 ± 5%, 83 ± 2%, 58 ± 4%, 58 ± 3%, 18 ± 7% for HUVEC, AML, PC3, MDA, KHT-C and astrocyte cells, respectively. Results from selected cell types involving radiation treatments indicated additive treatment enhancements and increases in intracellular ceramide content one hour after exposure to ultrasound-activated microbubbles and radiation. Endothelial cell survival decreased from 8 ± 1% after 2 Gy of radiation treatment alone and from 12 ± 2% after ultrasound and microbubbles alone, to 1 ± 1% with combined treatment. In Asmase +/+ astrocytes, survival decreased from 56 ± 2% after 2 Gy radiation alone and from 17 ± 7% after ultrasound and microbubbles alone, to 5 ± 2% when combined. Using ASMase deficient astrocytes (Asmase -/-) and Sphingosine-1-phosphate (S1P), we also demonstrate that ultrasound-activated microbubbles stimulate ASMase activity and ceramide production. These findings suggest that ultrasound-stimulated microbubbles could be used as a new biomechanical method to enhance the effects of radiation.

Microbubble and ultrasound radioenhancement of bladder cancer

BACKGROUND

Tumour vasculature is an important component of tumour growth and survival. Recent evidence indicates tumour vasculature also has an important role in tumour radiation response. In this study, we investigated ultrasound and microbubbles to enhance the effects of radiation.

METHODS

Human bladder cancer HT-1376 xenografts in severe combined immuno-deficient mice were used. Treatments consisted of no, low and high concentrations of microbubbles and radiation doses of 0, 2 and 8 Gy in short-term and longitudinal studies. Acute response was assessed 24 h after treatment and longitudinal studies monitored tumour response weekly up to 28 days using power Doppler ultrasound imaging for a total of 9 conditions (n=90 animals).

RESULTS

Quantitative analysis of ultrasound data revealed reduced blood flow with ultrasound-microbubble treatments alone and further when combined with radiation. Tumours treated with microbubbles and radiation revealed enhanced cell death, vascular normalisation and areas of fibrosis. Longitudinal data demonstrated a reduced normalised vascular index and increased tumour cell death in both low and high microbubble concentrations with radiation.

CONCLUSION

Our study demonstrated that ultrasound-mediated microbubble exposure can enhance radiation effects in tumours, and can lead to enhanced tumour cell death.

ShcA and c-Abl provide a new signaling axis regulating beta-selection (63.8)

Progression of immature CD4-CD8- thymocytes through β selection checkpoint is determined by signals from the pre-T cell receptor (pre-TCR) along with signals from Notch. Knockout of the adapter protein ShcA, or transgenic expression of a phosphorylation-defective mutant of ShcA (ShcFFF) leads to a severe block at β selection. Our studies to mechanistically understand the ShcA function showed that ShcA acts upstream of ERK, and the transcription factors Egr-1 and Egr-3 during β selection; however, phospho-ShcA also appeared to be linked to other signaling pathways. We performed a yeast three-hybrid screen, using as bait ShcA that was phosphorylated by Lck. This screen identified binding of c-Abl (via its SH2 domain) to phosphorylated ShcA. During pre TCR dependent signaling, phosphorylation of ShcA was required for optimal c-Abl phosphorylation. Using mice deficient either in c-Abl and/or its homologue Arg, we show that ShcA and c-Abl regulate DN thymocyte proliferation, and the proper localization of DN thymocytes near the thymic cortex. Ectopic expression of a constitutive active c-Abl allowed thymocytes to resume proliferation, differentiation, and CXCR4 dependent migration to SDF-1α. Collectively, these data reveal a previously unappreciated ShcA::c-Abl signaling axis that appears to critically influence thymic β selection.

Hepatic overexpression of SIRT1 in mice attenuates endoplasmic reticulum stress and insulin resistance in the liver

Endoplasmic reticulum (ER) stress has been implicated in the pathophysiology of human type 2 diabetes (T2DM). Although SIRT1 has a therapeutic effect on metabolic deterioration in T2DM, the precise mechanisms by which SIRT1 improves insulin resistance remain unclear. Here, we demonstrate that adenovirus-mediated overexpression of SIRT1 in the liver of diet-induced insulin-resistant low-density lipoprotein receptor-deficient mice and of genetically obese ob/ob mice attenuates hepatic steatosis and ameliorates systemic insulin resistance. These beneficial effects were associated with decreased mammalian target of rapamycin complex 1 (mTORC1) activity, inhibited the unfolded protein response (UPR), and enhanced insulin receptor signaling in the liver, leading to decreased hepatic gluconeogenesis and improved glucose tolerance. The tunicamycin-induced splicing of X-box binding protein-1 and expression of GRP78 and CHOP were reduced by resveratrol in cultured cells in a SIRT1-dependent manner. Conversely, SIRT1-deficient mouse embryonic fibroblasts challenged with tunicamycin exhibited markedly increased mTORC1 activity and impaired ER homeostasi and insulin signaling. These effects were abolished by mTORC1 inhibition by rapamycin in human HepG2 cells. These studies indicate that SIRT1 serves as a negative regulator of UPR signaling in T2DM and that SIRT1 attenuates hepatic steatosis, ameliorates insulin resistance, and restores glucose homeostasis, largely through the inhibition of mTORC1 and ER stress.

Clinical in situ study investigating abrasive effects of two commercially available toothpastes

The aim of this study was to determine if the abrasive effect on dentine of two commercially available toothpastes, known to vary in their in vitro abrasive levels, can be differentiated in an in situ model after 10 days, assessed by contact profilometry. This was a single centre, single blind, randomized, split mouth, two treatment, in situ study, in 34 healthy subjects, evaluating the abrasive effects of two marketed desensitizing toothpastes, (Colgate Sensitive Multi Protection toothpaste - C; Sensodyne Total Protection - S). Subjects wore bi-lateral, lower buccal appliances, each fitted with four dentine sections which were power brushed three times a day with the treatment regimen. Each subject received two toothpaste treatments for 10 days during the treatment period. Samples were measured at baseline and day 10 by contact and non-contact profilometry and day 5 by contact profilometry. Thirty-four subjects were included in the efficacy analysis. Results from contact profilometry showed statistically significant (P < 0.0001) dentine loss compared to baseline at day 5 and 10 for both pastes. At each time point, C showed statistically significantly greater dentine loss than S, P < 0.0001. After 10 days treatment, the difference in dentine loss between the pastes was 1.4 microm. The non-contact profilometry data showed similar trends. After 10 days of treatment, C showed statistically significantly greater dentine loss than S, with treatment difference of 0.9 microm, P = 0.0057. The methodology used has successfully differentiated between the abrasivity of the two pastes in respect of dentine surface loss over time in an in situ environment.

Prospective Study to Evaluate the Influence of FAST on Trauma Patient Management

BACKGROUND

Previous studies have concentrated on the accuracy of Focused Assessment with Sonography in Trauma (FAST), but evaluation of whether FAST changes subsequent management has not been fully assessed.

METHODS

This prospective study compared 419 trauma admissions in two groups, FAST and no-FAST, for demographics, time of resuscitation, and action after resuscitation. The 194 patients undergoing FAST had their management plan specified before, and confirmed after, FAST was performed to assess for change in management. To ensure scan consistency and to minimize bias, criteria were established to define an adequate FAST.

RESULTS

FAST was performed in 194 patients (46%), assessing for free fluid. Management was changed in 59 cases (32.8%) after FAST. Laparotomy was prevented in 1 patient, computed tomography was prevented in 23 patients, and diagnostic peritoneal lavage was prevented in 15 patients. Computed tomography rates were reduced from 47% to 34% and diagnostic peritoneal lavage rates were reduced from 9% to 1%.

CONCLUSIONS

FAST plays a key role in trauma, changing subsequent management in an appreciable number of patients.

Efficacy of auxiliary partial orthotopic liver transplantation for cure of hemophilia in a canine hemophilia A model

Metabolic liver disease can be cured by orthotopic liver transplantation. Some successful cases of whole or partial liver transplantation have been reported. Because liver function in these recipients is normal save for the production of the responsive metabolic factor, auxiliary partial orthotopic liver transplantation (APOLT) may produce a benefit. However, no experimental model of APOLT for metabolic liver diseases has been reported. We established a canine APOLT model to evaluate the clinical feasibility and efficacy of APOLT to cure hemophilia. The donor normal beagle dog was used to establish an APOLT model. A left lobe partial liver graft taken from the donor was orthotopically transplanted to the recipient after resection of the native left lobe preserving the native right lobe. Recipients showed no atrophy and comparable blood flow in both the graft and the native liver at the time of exploration after APOLT. Thus, APOLT was performed from a normal donor to a recipient with hemophilia A. In this recipient, blood factor VIII activity markedly increased after APOLT and was maintained for 7 weeks. No episode of bleeding was seen during the observation. In conclusion, a canine APOLT model was successfully established as evidenced by sustained production of factor VIII in a hemophilia recipient. These findings suggest the clinical feasibility and efficacy of APOLT for metabolic liver diseases.