Induction of cell death in ovarian cancer cells by doxorubicin and oncolytic vaccinia virus is associated with CREB3L1 activation

We have demonstrated that oncolytic vaccinia virus synergizes with doxorubicin (DOX) in inducing immunogenic cell death in platinum-resistant ovarian cancer cells and increases survival in syngeneic and xenograft tumor models. However, the mechanisms underlying the virus- and doxorubicin-mediated cancer cell death remain unknown. In this study, we investigated the effect of the oncolytic virus and doxorubicin used alone or in combination on activation of the cytoplasmic transcription factor CREB3L1 (cyclic AMP [cAMP] response element-binding protein 3-like 1) in ovarian cancer cell lines and clinical specimens. We demonstrated that doxorubicin-mediated cell death in ovarian cancer cell lines was associated with nuclear translocation of CREB3L1 and that the effect was augmented by infection with oncolytic vaccinia virus or treatment with recombinant interferon (IFN)-β used as a viral surrogate. This combination treatment was also effective in mediating nuclear translocation of CREB3L1 in cancer cells isolated from ovarian tumor biopsies at different stages of disease progression. The measurement of CREB3L1 expression in clinical specimens of ovarian cancer revealed lack of correlation with the stage of disease progression, suggesting that understanding the mechanisms of nuclear accumulation of CREB3L1 after doxorubicin treatment alone or in combination with oncolytic virotherapy may lead to the development of more effective treatment strategies against ovarian cancer.

Recurrent Frameshift Neoantigen Vaccine Elicits Protective Immunity With Reduced Tumor Burden and Improved Overall Survival in a Lynch Syndrome Mouse Model

BACKGROUND & AIMS

DNA mismatch repair deficiency drives microsatellite instability (MSI). Cells with MSI accumulate numerous frameshift mutations. Frameshift mutations affecting cancer-related genes may promote tumorigenesis and, therefore, are shared among independently arising MSI tumors. Consequently, such recurrent frameshift mutations can give rise to shared immunogenic frameshift peptides (FSPs) that represent ideal candidates for a vaccine against MSI cancer. Pathogenic germline variants of mismatch repair genes cause Lynch syndrome (LS), a hereditary cancer syndrome affecting approximately 20-25 million individuals worldwide. Individuals with LS are at high risk of developing MSI cancer. Previously, we demonstrated safety and immunogenicity of an FSP-based vaccine in a phase I/IIa clinical trial in patients with a history of MSI colorectal cancer. However, the cancer-preventive effect of FSP vaccination in the scenario of LS has not yet been demonstrated.

METHODS

A genome-wide database of 488,235 mouse coding mononucleotide repeats was established, from which a set of candidates was selected based on repeat length, gene expression, and mutation frequency. In silico prediction, in vivo immunogenicity testing, and epitope mapping was used to identify candidates for FSP vaccination.

RESULTS

We identified 4 shared FSP neoantigens (Nacad [FSP-1], Maz [FSP-1], Senp6 [FSP-1], Xirp1 [FSP-1]) that induced CD4/CD8 T cell responses in naïve C57BL/6 mice. Using VCMsh2 mice, which have a conditional knockout of Msh2 in the intestinal tract and develop intestinal cancer, we showed vaccination with a combination of only 4 FSPs significantly increased FSP-specific adaptive immunity, reduced intestinal tumor burden, and prolonged overall survival. Combination of FSP vaccination with daily naproxen treatment potentiated immune response, delayed tumor growth, and prolonged survival even more effectively than FSP vaccination alone.

CONCLUSIONS

Our preclinical findings support a clinical strategy of recurrent FSP neoantigen vaccination for LS cancer immunoprevention.

Efficient identification of neoantigen-specific T-cell responses in advanced human ovarian cancer

Background

Efficient identification of neoantigen-specific T-cell responses in epithelial ovarian cancer (EOC) remains a challenge. Existing investigations of spontaneous T-cell response to tumor neoepitope in EOC have taken the approach of comprehensive screening all neoantigen candidates, with a validation rate of 0.5–2%.

Methods

Whole-exome and transcriptome sequencing analysis of treatment-naive EOC patients were performed to identify neoantigen candidates, and the immunogenicity of prioritized neoantigens was evaluated by analyzing spontaneous neoantigen-specfic CD4⁺ and CD8⁺ T-cell responses in the tumor and/or peripheral blood. The biological relevance of neoantigen-specific T-cell lines and clones were analyzed by evaluating the capacity of autologous ovarian tumor recognition. Genetic transfer of T-cell receptor (TCR) from these neoantigen-specific T-cell clones into peripheral blood T-cells was conducted to generate neoepitope-specific T-cells. The molecular signature associated with positive neoantigen T-cell responses was investigated, and the impacts of expression level and lymphocyte source on neoantigen identification were explored.

Results

Using a small subset of prioritized neoantigen candidates, we were able to detect spontaneous CD4⁺ and/or CD8⁺ T-cell responses against neoepitopes from autologous lymphocytes in half of treatment-naïve EOC patients, with a significantly improved validation rate of 19%. Tumors from patients exhibiting neoantigen-specific T-cell responses exhibited a signature of upregulated antigen processing and presentation machinery, which was also associated with favorable patient survival in the TCGA ovarian cohort. T-cells specific against two mutated cancer-associated genes, NUP214 and JAK1, recognized autologous tumors. Gene-engineering with TCR from these neoantigen-specific T-cell clones conferred neoantigen-reactivity to peripheral T-cells.

Conclusions

Our study demonstrated the feasibility of efficiently identifying both CD4⁺ and CD8⁺ neoantigen-specific T-cells in EOC. Autologous lymphocytes genetically engineered with tumor antigen-specific TCR can be used to generate cells for use in the personalized adoptive T-cell transfer immunotherapy.

Electronic supplementary material

The online version of this article (10.1186/s40425-019-0629-6) contains supplementary material, which is available to authorized users.

Protein Kinase N1 control of androgen-responsive serum response factor action provides rationale for novel prostate cancer treatment strategy

Sustained reliance on androgen receptor (AR) after failure of AR-targeting androgen deprivation therapy (ADT) prevents effective treatment of castration-recurrent (CR) prostate cancer (CaP). Interfering with the molecular machinery by which AR drives CaP progression may be an alternative therapeutic strategy but its feasibility remains to be tested. Here, we explore targeting the mechanism by which AR, via RhoA, conveys androgen-responsiveness to serum response factor (SRF), which controls aggressive CaP behavior and is maintained in CR-CaP. Following a siRNA screen and candidate gene approach, RNA-Seq studies confirmed that the RhoA effector Protein Kinase N1 (PKN1) transduces androgen-responsiveness to SRF. Androgen treatment induced SRF-PKN1 interaction, and PKN1 knockdown or overexpression severely impaired or stimulated, respectively, androgen regulation of SRF target genes. PKN1 overexpression occurred during clinical CR-CaP progression, and hastened CaP growth and shortened CR-CaP survival in orthotopic CaP xenografts. PKN1's effects on SRF relied on its kinase domain. The multikinase inhibitor lestaurtinib inhibited PKN1 action and preferentially affected androgen regulation of SRF over direct AR target genes. In a CR-CaP patient-derived xenograft, expression of SRF target genes was maintained while AR target gene expression declined and proliferative gene expression increased. PKN1 inhibition decreased viability of CaP cells before and after ADT. In patient-derived CaP explants, lestaurtinib increased AR target gene expression but did not significantly alter SRF target gene or proliferative gene expression. These results provide proof-of-principle for selective forms of ADT that preferentially target different fractions of AR's transcriptional output to inhibit CaP growth.

Abstract 3745: Inhibition of Protein Kinase N1 prevents control of AR over SRF action in advanced prostate cancer

A major limitation in the management of castration-recurrent prostate cancer (CR-CaP) is the lack of treatments to inhibit androgen receptor (AR) action that is driving CaP growth when androgen-deprivation therapy (ADT) has failed. AR action breaks down in fractions that are regulated differently at the molecular level, control diverse aspects of CaP biology and contribute differentially to CaP progression. Blocking a specific fraction(s) of AR action that mediates CaP progression may serve as alternative treatment strategy, yet evidence for such an approach and drugs that render this approach feasible are not known. Our laboratory has identified a mechanism of AR action in which AR conveys androgen-responsiveness to Serum Response Factor (SRF) target genes via androgen activation of RhoA. Androgen-responsive SRF action mediates cell migration and is associated with aggressive CaP behavior and recurrence. Importantly, control of AR over RhoA-SRF action is maintained in CR-CaP, which renders this signaling a potentially attractive novel therapeutic target. Using an siRNA screen, we identified Protein Kinase N1 (PKN1) as the Rho effector that transduces androgen-responsiveness from RhoA to SRF. In promoter-reporter, qRT-PCR and oligoarray assays, knockdown of PKN1 severely impaired the androgen-regulation of SRF target genes, but affected androgen response of only a few (12 of 452) direct AR target genes. In contrast, transient overexpression of PKN1 preferentially stimulated androgen-responsive SRF target gene expression. Stable overexpression of PKN1 hastened growth and shortened survival in CaP orthotopic xenografts. Site-directed mutagenesis showed that the effect of PKN1 on SRF target genes relied on its kinase activity. Treatment with lestaurtinib, a multikinase inhibitor that is also a potent inhibitor of PKN1, mimicked the effects of PKN1 knockdown on expression of SRF and AR target genes in several CaP cell lines and ex vivo CaP explants. Lestaurtinib also inhibited the proliferation of CaP cells that are either ADT-naïve or -resistant, express only the constitutively active AR variant ARv567es, or are growth-stimulated by the AR-activating ADT drug metabolite 5α-abiraterone. RNA-Seq followed by MSigDB analyses confirmed that lestaurtinib impairs androgen-dependent PKN1 activity and revealed that 100 of the 127 MgSigDB gene sets isolated after PKN1 silencing overlapped with 123 gene sets derived after lestaurtinib treatment. Overlapping gene sets included several related to hormonal carcinogenesis and cancer progression, prostate development, signaling cascades that have been implicated in SRF and RhoA function and/or are relevant to CaP. PKN1 inhibition via lestaurtinib, which is used already to treat human hematologic malignancies and is well tolerated by carcinoma patients, may thus serve as novel alternative treatment strategy to target AR-dependent SRF action in CR-CaP.

Citation Format: Varadha Balaji Venkadarkrishnan, Adam DePriest, Yixue Su, Giridhar Mudduluru, Salma Ben-Salem, Sangeeta Kumari, Qiang Hu, Eduardo Cortes, Scott Dehm, Cristina Magi-Galluzzi, Eric Klein, Nima Sharifi, Song Liu, Hannelore Heemers. Inhibition of Protein Kinase N1 prevents control of AR over SRF action in advanced prostate cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3745.

Abstract 4625: Tumor expression of PIM kinases in renal cell carcinoma and the association with disease progression

Hypoxia-inducible factor (HIF) plays an important role in the tumorigenesis of renal cell carcinoma (RCC). Mutational inactivation of the von Hippel-Lindau (VHL) tumor suppressor gene, which is the most frequent molecular event, has been implicated in HIF overexpression. Recent studies found that PIM kinases increase HIF expression in cancer. The PIM Kinases are a family of highly conserved serine/threonine kinases consisting of three isoforms (PIM1, PIM2, and PIM3). PIM kinases play multiple roles in promoting cell proliferation and survival and preventing apoptosis. The expression and the potential function of PIM kinases in RCC remain unclear. Thus, we examined the expression patterns and the clinical significance of the three individual PIM kinases in RCC. PIM expression was examined by immunohistochemical staining tumor tissue and adjacent non-tumor tissue samples from 218 patients with clear cell RCC (ccRCC), including 60 patients with metastatic ccRCC. The expression of each PIM kinase in primary and metastatic ccRCC tissues comparing with adjacent normal tissues was analyzed with variables including tumor stage, grade and survival. Effect of PIM kinase on cell growth in ACHN and 786-O RCC cell lines was examined by individual PIM knockdown with specific siRNA followed by in vitro proliferation assay. Effect of PIM kinase on RCC cell motility was examined by siRNA followed by in vitro Matrigel-based invasion assay. Expression of PIM1, PIM2 and PIM3 was detected in the majority of ccRCC samples (185, 85%), but localization of isoforms differed. PIM1 expression was higher in the nucleus than in cytoplasm, while the reverse was true for PIM 2 and 3. PIM2 and PIM3 expression was higher in cytoplasm than in the nucleus. Higher expression of PIM1 and PIM2 in tumor tissues was significantly associated with metastasis. Nuclear PIM2 was associated with poorly differentiated ccRCC cells. ccRCC patients with increased nuclear PIM2 expression had significantly poorer survival compared with patients with low nuclear PIM2. siRNA-PIM2, but not siRNA-PIM1 and siRNA-PIM3, significantly reduced proliferation of ACHN and 786-O cells. Further, knockdown of PIM2 by siRNA reduced the ability of cell invasion in 786-O cells. In conclusion, PIM kinases, especially PIM2, are associated with ccRCC progression, indicating that PIM kinases may serve as potential markers for metastatic ccRCC. Targeting PIM kinases may have a therapeutic potential in ccRCC. This work was supported by NIH/NCI grant CA067267, CA085142 (Johnson, CS) and National Cancer Institute (NCI) grant P30 CA016056 involving the use of Roswell Park Cancer Institute's Bioinformatics, Pathology Resource Network, Genomics, and Clinical Data Network Shared Resources.

Citation Format: Wei Luo, Yingyu Ma, Eduardo Cortes, Angela Omilian, Wiam Bshara, Gissou Azabdaftari, Brittany Bunch, Candace Johnson, Donald Trump. Tumor expression of PIM kinases in renal cell carcinoma and the association with disease progression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4625.

Respiratory quotient estimations as additional prognostic tools in early septic shock

Central venous-to-arterial carbon dioxide difference (P_cvaCO₂), and its correction by the arterial-to-venous oxygen content difference (P_cvaCO₂/C_avO₂) have been proposed as additional tools to evaluate tissue hypoxia. Since the relationship between pressure and content of CO₂ (CCO₂) might be affected by several factors, some authors advocate for the use of C_cvaCO₂/C_avO₂. The aim of the present study was to explore the factors that might intervene in the difference between P_cvaCO₂/C_avO₂ and C_cvaCO₂/C_avO₂, and to analyze their association with mortality. Observational study in a 30-bed mixed ICU. Fifty-two septic shock patients within the first 24 h of ICU admission were studied. After restoration of mean arterial pressure, hemodynamic and metabolic parameters were evaluated. A total of 110 sets of measurements were performed. Simultaneous P_cvaCO₂/C_avO₂ and C_cvaCO₂/C_avO₂ values were correlated, but agreement analysis showed a significant proportional bias. The difference between P_cvaCO₂/C_avO₂ and C_cvaCO₂/C_avO₂ was independently associated with pH, S_cvO₂, baseline C_cvaCO₂/C_avO₂ and hemoglobin. A stepwise regression analysis showed that pH was the single best predictor for the magnitude of such difference, with very limited effect of other variables. At inclusion, variables associated with ICU-mortality were lactate, pH, P_cvaCO₂/C_avO₂, and the difference between P_cvaCO₂/C_avO₂ and C_cvaCO₂/C_avO₂. Initial S_cvO₂, P_cvaCO₂, C_cvaCO₂/C_avO₂, and cardiac index were not different in survivors and non-survivors. In a population of early septic shock patients, simultaneous values of P_cvaCO₂/C_avO₂ and C_cvaCO₂/C_avO₂ were not equivalent, and the main determinant of the magnitude of the difference between these two parameters was pH. The P_cvaCO₂/C_avO₂ ratio was associated with ICU mortality, whereas C_cvaCO₂/C_avO₂ was not.

Is the tiger shark Galeocerdo cuvier a coastal species? Expanding its distribution range in the Atlantic Ocean using at-sea observer data

The occurrence of tiger shark Galeocerdo cuvier in the Atlantic Ocean was assessed using at-sea observer data from multiple pelagic longline fisheries. Geographic positions of 2764 G. cuvier recorded between 1992 and 2013 and covering a wide area of the Atlantic Ocean were compared with the currently accepted distribution ranges of the species. Most records fell outside those ranges in both the Southern and Northern Hemispheres, which strongly suggests that the distribution range of G. cuvier in the open ocean is considerably larger than previously described.

A comparison study of two lower urinary tract symptoms screening tools in clinical practice: the B-SAQ and OAB-V8 questionnaires

Lower urinary tract symptoms (LUTS) have a detrimental effect on quality-of-life (QoL). However, sufferers are often reluctant to seek help. Screening for LUTS will identify patients with bothersome symptoms who may benefit from treatment and allow patients to self-assess their symptoms and the need for medical intervention, potentially saving costly medical time and reducing long-term morbidity. The aim of this study was to compare the value of two validated questionnaires: the Bladder Control Self Assessment Questionnaire (B-SAQ) and the Overactive Bladder Awareness Tool (OAB-V8) as screening questionnaires in clinical practice. A total of 223 women were recruited prospectively from three centres. Participants completed both questionnaires in the waiting area prior to assessment by a clinician, who completed a symptom evaluation sheet. Data were analysed using receiver operating characteristic curves. Both the B-SAQ and the OAB-V8 performed well in detecting symptoms of OAB and mixed urinary symptoms. The B-SAQ performed better in detecting symptoms of stress incontinence than the OAB-V8. The opportunity to screen for haematuria should never be missed and this is an important omission from the OAB-V8.

Neurogenic detrusor overactivity in patients with spinal cord injury: evaluation and management

Lower urinary tract dysfunction can have a significant impact on patients with spinal cord injury. Over the years, many treatment options have become available. This article reviews the assessment and management of neurogenic detrusor overactivity, with a particular focus on articles from the recent literature. Recent guidelines on the subject will be discussed. Management options include antimuscarinics and bladder emptying measures, botulinum toxin A, and neuromodulation in refractory cases and surgery for intractable cases. Recent and relevant publications in these areas will be summarized and discussed.

Design and Validation of a New Screening Instrument for Lower Urinary Tract Dysfunction: The Bladder Control Self-Assessment Questionnaire (B-SAQ)

OBJECTIVES

To develop and validate a short patient self-assessment screening questionnaire: bladder control self-assessment questionnaire (B-SAQ) for the evaluation of lower urinary tract symptoms. This first validation study was undertaken amongst women.

PATIENTS AND METHODS

Three hundred twenty-nine women attending general gynaecology and urogynaecology clinics completed both the B-SAQ and Kings Health questionnaire prior to medical consultation, and independent physician assessment of the presence of lower urinary tract symptoms (LUTS) and need for treatment. The psychometric properties of the B-SAQ were subsequently analysed.

RESULTS

The B-SAQ was quick and easy to complete, with 89% of respondents completing all items correctly in less than 5 min. The internal consistency (Cronbach's alpha score 0.90-0.91), criterion validity (Pearson's correlation values of 0.79 and 0.81, p<0.0001 with the incontinence impact domain of the Kings Health questionnaire), and test-retest reliability of the questionnaire were good. The sensitivity and specificity of the questionnaire to identify patients with bothersome LUTS was 98% and 79%, respectively.

CONCLUSIONS

LUTS are commonly underreported. Empowering patients to self-assess their bladder symptoms and the need for treatment will improve treatment-seeking behaviour. The B-SAQ is a psychometrically robust, short screening questionnaire that offers patients the ability to assess their bladder symptoms and the bother they cause, and the potential benefit of seeking medical help.

Insulin-like growth factor-1 gene splice variants as markers of muscle damage in levator ani muscle after the first vaginal delivery

OBJECTIVE

Studies in animals and human muscle have demonstrated differential splicing of the insulin-like growth factor-1 gene in response to mechanical strain and damage. We conducted a study on the expression of insulin-like growth factor-1 splice variants in the levator ani muscle after the first vaginal delivery.

STUDY DESIGN

Ten women were recruited after the first vaginal delivery. Biopsy specimens were taken vaginally of the pubovisceral component of the levator ani muscle. Five nonpregnant women were recruited as control subjects. Samples were processed with real-time quantitative polymerase chain reaction, with specific primers for the insulin-like growth factor-1 splice variants.

RESULTS

Insulin-like growth factor splice variants mechano growth factor and insulin-like growth factor-1Ea were significantly up-regulated (100- and 1000-fold) in the delivery population, compared with control subjects (P=.012 and .04, respectively). Statistical analysis indicated a correlation between the expression of the insulin-like growth factor-1 splice variants and the length of the second stage.

CONCLUSION

These results show that damaged levator ani muscle results from stretch and overload after the first vaginal delivery.

Anorexia nervosa and pelvic floor dysfunction

Pelvic floor dysfunction in women with eating disorders is an underexplored area. We present a case of pelvic floor dysfunction in a nulliparous woman with anorexia nervosa.

Evaluation of the fascial technique for surgical repair of isolated posterior vaginal wall prolapse

OBJECTIVE

To study the anatomic and functional efficacy and assess long-term success of the fascial technique in the repair of rectocele.

METHODS

Forty-two women with symptomatic posterior vaginal wall prolapse of at least stage II underwent a surgical repair using the technique of reconstruction of the rectovaginal septum. These women were evaluated at 6 weeks and 18 months postoperatively for anatomic improvement in the grade of their rectocele and a functional improvement in their vaginal, bowel, and sexual symptoms.

RESULTS

Ninety-five percent (40 of 42) were assessed at 6 weeks and 78.5% (33 of 42) attended follow-up at 18 months. Preoperative symptoms included 1) vaginal protrusion (78%); 2) defecation symptoms (76%), which included fecal incontinence alone in 9.5%, evacuation difficulties in 57%, and both fecal incontinence and evacuation difficulties in 9.5%; and 3) sexual dysfunction (33%). At 6-week follow-up there was resolution of vaginal protrusion in 87.5%, and bowel symptoms in 87%. At 18 months there was anatomic cure in 92%, improvement in defecation in 81%, and improvement of sexual dysfunction in 35%. No major complications were seen.

CONCLUSION

This technique is effective in providing relatively long anatomic cure of the rectocele and resolution of its symptoms.

2D NMR analysis of highly restricted internal rotation in 2-methylthio-3H-4-p-bromophenyl)-7-[(ortho- and para-substituted)-phenylthio]-1, 5-benzodiazepines

The complete assignments of twelve 4-aryl-7-thioaryl-1,5-benzodiazepines 1H and 13C spectra, performed with the use of high resolution variable solvent and temperature 1D and 2D techniques (e.g. HOMOCOSY, NOESY, HMQC and HMBC), lead to the determination of conformational equilibria between two rotamers having the aromatic ring of the thioaryl oriented in a perpendicular or helical orientation toward the benzodiazepine ring. The restricted rotation was evaluated from the population of these conformers.

Inhaled NO and almitrine bismesylate in patients with acute respiratory distress syndrome: effect of noradrenalin

The combination of inhaled nitric oxide with almitrine bismesylate has been proposed for the management of acute respiratory distress syndrome in order to divert pulmonary blood flow away from poorly ventilated toward well-ventilated areas. The aims of this prospective and comparative study were to: 1) confirm the beneficial effects on oxygenation of this association; 2) evaluate the haemodynamic effects of this association; and 3) evaluate the influence of noradrenaline (a nonspecific vasoconstrictor) on the modification of gas exchange related to inhaled NO and/or almitrine bismesylate. Forty-one sedated paralysed and ventilated patients were investigated. Haemodynamic and blood gas measurements were performed in a fixed order: baseline; inhalation of NO for 30 min.; intravenous infusion of almitrine bismesylate; and concomitant administration of inhaled NO and almitrine bismesylate. Inhaled NO and almitrine bismesylate increased arterial oxygen tension (Pa,O2)/inspiratory oxygen fraction (FI,O2) (p<0.001). The association of inhaled NO with almitrine bismesylate resulted in a dramatic improvement in Pa,O2/FI,O2 (p<0.0001 versus almitrine bismesylate, p<0.05 versus inhaled NO). In patients receiving noradrenalin (n = 19), almitrine bismesylate had no effect on oxygenation. The present study confirmed that the combination of inhaled NO with almitrine bismesylate improved oxygenation, and demonstrated that almitrine bismesylate has no effect on oxygenation in patients receiving noradrenalin.

Effectiveness of cloxacillin with and without gentamicin in short-term therapy for right-sided Staphylococcus aureus endocarditis. A randomized, controlled trial

BACKGROUND

It is often difficult to administer extended antibiotic therapy in the hospital for right-sided Staphylococcus aureus endocarditis. Although the effectiveness of single-drug therapy given for 4 to 6 weeks and that of two-drug therapy given for 2 weeks have been shown, no data are available on the effectiveness of short-course single-drug therapy.

OBJECTIVE

To compare the efficacy of cloxacillin alone with that of cloxacillin plus gentamicin for the 2-week treatment of right-sided S. aureus endocarditis in intravenous drug users.

DESIGN

Open, randomized study.

SETTING

An academic tertiary care hospital in Barcelona, Spain.

PATIENTS

90 consecutive intravenous drug users who had isolated tricuspid valve endocarditis caused by methicillin-susceptible S. aureus, had no allergy to study medications, and had no systemic infectious complications that required prolonged therapy. An efficacy subset consisted of 74 of these patients who did not meet an exclusion criterion.

INTERVENTION

Cloxacillin (2 g intravenously every 4 hours for 14 days) alone or combined with gentamicin (1 mg/kg of body weight intravenously every 8 hours for 7 days).

MEASUREMENTS

Clinical or microbiological evidence of active infection after 2 weeks of therapy, relapse of staphylococcal infection, or death.

RESULTS

In an analysis of the efficacy subset, treatment was successful in 34 of the 38 patients who received cloxacillin alone (89% [95% CI, 75% to 97%]) and 31 of the 36 patients who received cloxacillin plus gentamicin (86% [CI, 71% to 95%]). Three patients died: one in the cloxacillin group and two in the combination therapy group. Of the 37 patients who completed 2-week treatment with cloxacillin, 34 (92%) were cured, and 3 (8%) needed prolonged treatment to cure the infection. Of the 34 patients who completed 2-week treatment with cloxacillin plus gentamicin, 32 (94%) were cured and 2 (6%) required treatment for 4 weeks. One patient in the combination group had relapse.

CONCLUSIONS

A penicillinase-resistant penicillin used as single-agent therapy for 2 weeks was effective for most patients with isolated tricuspid endocarditis caused by methicillin-susceptible S. aureus. Adding gentamicin did not appear to provide any therapeutic advantages. Additional studies to confirm the therapeutic equivalence of short-course therapy with penicillinase-resistant penicillin alone and therapy with combined regimens are warranted.

Prophylaxis of visceral leishmaniasis in human immunodeficiency virus-infected patients

OBJECTIVE

To assess the effectiveness of two regimens with allopurinol or pentavalent antimony as secondary prophylaxis for visceral leishmaniasis (VL) in human immunodeficiency virus (HIV)-infected patients.

DESIGN

Retrospective, nonrandomized, open trial.

SETTING

A 1,000-bed academic tertiary institutional hospital in Barcelona.

PATIENTS

Forty-six individuals over 14 years old with HIV infection, who recovered from an episode of VL between January 1988 and February 1995.

INTERVENTIONS

Twenty patients did not receive any prophylaxis, nine received 300 mg/8 h of allopurinol, and 17 received 850 mg once-a-month of pentavalent antimony. Patients were followed-up every 3 months, and the endpoint of study was relapse of VL.

RESULTS

Twenty-one patients had recurrent VL: 13 of 20 in the control group (65%), 5 of 9 in the allopurinol group (56%), and 3 of 17 in the antimonial group (18%). Kaplan-Meier estimates of the probability of remaining relapse-free at 12 months were 9% without prophylaxis (95% CI, 0-22%), 21% with allopurinol (95% CI, 0-51%), and 93% with antimonials (95% CI, 82-100%) (P < 0.001). Multivariate analysis showed that the only significant variables related to relapsing course of VL were assignment to the antimonial group, and the fact that the patient had experienced a previous episode of VL.

CONCLUSIONS

Pentavalent antimony given once a month is effective in the prevention of VL relapses in HIV-infected individuals. It is a low-cost treatment that proved to be well tolerated. Therefore, pentavalent antimony should be considered a suitable agent for secondary prophylaxis against VL.

Palladium-103: a new radioactive source in the treatment of unresectable carcinoma of the pancreas: a phase I-II study

Palladium-103 (Pd-103) is introduced in brachytherapy procedures because of its favorable physical properties, including its low energy, rapid dose fall-off, short half-life, and total cumulative dose delivery at a higher dose rate than iodine-125 (I-125) isotope. Intraoperative brachytherapy using I-125 pellets was reported to provide significant palliation and meaningful prolongation of life in highly selected patients with unresectable carcinoma of the pancreas. After considering some of the advantages of Pd-103 over I-125, we designed a phase I-II clinical trial to assess the feasibility of intraoperative Pd-103 in unresectable carcinoma of the pancreas to study the related morbidity when combined with chemotherapy and external beam radiation, and to evaluate the impact on palliation and local control rates. Between December 1989 and December 1993, 15 patients with biopsy-proven unresectable adenocarcinoma of the pancreas were treated with interstitial Pd-103 implants during laparotomy. In 13 patients the lesion was located in the head of the pancreas, in one patient in the uncinate process, and in one patient in the body of the pancreas. The stage distribution was as follows: T1 = 2; T2 = 6, and T3 = 7. In addition, all patients underwent biliary and gastric bypass. The mean number of Pd-103 pellets was 45; the mean total activity to obtain a matched peripheral dose (MPD) of 11,000 cGy was 68.9 mCi. The mean tumor volume encompassing the MPD was 16.5 cc. All patients received postoperative external beam radiation (4,500 cGy over 4 1/2 weeks) and chemotherapy (5-fluorouracil and mitomycin C). This combined treatment, consisting of intraoperative brachytherapy using Pd-103 and postoperative external beam radiation with chemotherapy, was well tolerated in all patients. These were no treatment-related mortalities, and no serious complications, such as bleeding or fistula formation. Pain relief was obtained within 3-6 weeks in 10 out of 12 patients presenting with pain. Survival ranged from 6 to 24 months (median 10 months). The study suggests that Pd-103 can be considered an alternative to I-125 for interstitial brachytherapy for unresectable carcinoma of the pancreas. Symptom relief appeared to occur faster and complications are significantly less. However, this study did not show any improvement in the median survival rate over I-125 due to the advanced stage cancer in the majority of patients in the study.

Tumor ploidy as a risk factor for disease recurrence and short survival in surgically treated Dukes' B2 colon cancer patients

The risk factors for colon cancer recurrence following a curative intent surgery include the tumor location and size, the presence of adhesions, perforation, bowel obstruction, depth of invasion, histological grade, percentage of S phase content and cell kinetic profile. The DNA content of tumor cells has recently been suggested as an additional prognostic factor. In this study we assessed the tumor ploidy as a prognostic factor for recurrence and survival in colon cancer patients. The DNA content of colon cancers in 20 Dukes' B2 patients followed up at our center, who relapsed either locally or systemically, following surgical treatment was measured by image analysis. The data were pair-matched for age, sex, tumor site and grade, and the period of follow-up with 20 Dukes' B2 patients who had no evidence of disease. Aneuploidy occurred in 16 (80%) patients with recurrence, whereas only in 8 (40%) in the control group. Nonaneuploid DNA content was found in 12 (60%) patients of the control group, but in only 4 (20%) patients with a relapse. Aneuploidy was associated with a significantly higher tumor recurrence rate (p = 0.024) and shorter overall survival (p < 0.002). Our data point to a possible indication of a systemic adjuvant chemotherapy in Dukes' B2 colon cancer patients who have aneuploid tumors on image analysis. This should be further investigated in a prospective controlled randomized study.

Tumor ploidy as a risk factor for disease recurrence and short survival in surgically-treated Dukes' B2 colon cancer patients

The risk factors for colon cancer recurrence following a curative intent surgery include the presence of metastatic disease, the tumor location and size, number of positive lymph nodes, the presence of adhesions, perforation, bowel obstruction, depth of invasion, histological grade, percentage of S-phase content, and cell kinetic profile. The DNA content of colon cancers in 20 Dukes' B2 patients in follow-up evaluation at our center, who relapsed, either locally or systemically following surgical treatment was measured by image analysis. The data were pair-matched for age, sex, tumor site, and grade with 20 Dukes' B2 patients who had no evidence of disease. Aneuploidy occurred in 16 (80%) patients with recurrence, as compared with only in 8 (40%) in the control group. Aneuploidy was associated with significantly higher tumor recurrence rate (P = 0.024) and shorter overall survival (P < 0.002). Our data may point out a possible indication for systemic adjuvant chemotherapy in Dukes' B2 colon cancer patients who have aneuploid tumors on image analysis. This warrants further investigation in a prospective controlled randomized study.

Changing the substrate specificity of penicillin G acylase from Kluyvera citrophila through selective pressure

Escherichia coli (muT, mutD, Leu-) cells transformed with plasmid pYKD59 harbouring the pac gene encoding penicillin acylase (PA) from Kluyvera citrophila ATCC 21285 were exposed to environmental conditions that made expression of this enzyme essential for growth. Under these conditions, spontaneous mutants were isolated that used adipyl-L-leucine as the sole source of L-leucine. DNA sequencing of the mutant pac genes identified a transversion mutation of thymine to guanine at position 1163. This mutation was located in the beta-subunit of the enzyme and resulted in conversion of Phe-360 to valine. The assignment of this mutation to the shift in substrate specificity was further confirmed by site-directed mutagenesis. Secondary-structure prediction of the region surrounding Phe-360 suggests that this mutation should not produce any significant structural change. The purified mutant acylase was able to hydrolyse adipyl-, glutaryl-, valeryl-, caproyl-, heptanoyl- and phenoxyacetyl-L-leucine at pH 5 with greater efficiency than the wild-type enzyme. However, the mutant enzyme was not able to hydrolyse glutaryl-7-aminocephalosporanic acid and had lost 90% and 50% of activity on penicillin G and phenylacetyl-L-leucine respectively. Nevertheless, mutant PA retained its original activity on 6-nitro-3-phenylacetamidobenzoate and p-nitrophenylphenylacetate, suggesting that the binding specificity of PA by the acyl and amine moieties of the substrate are not independent phenomena. The small differences observed between the c.d. spectra of the mutant enzyme recorded at pH 5 and 8 suggest the existence of different conformational states at the two pH values, but these differences were indistinguishable from those observed in the native enzyme and cannot be correlated with the shift in substrate specificity. Our results demonstrate that it is possible to change the specificity of PA by laboratory evolution and use it to identify the amino acids involved in substrate recognition. However, the synchronous participation of the alpha- and beta-subunits in the complex induced-fit-like mechanism of acylases suggests that, to obtain new enzymes for industrial application, the selection pressure should be specifically designed for the compound of interest.

Streptococcus milleri as a cause of antecubital abscess and bacteremia in intravenous drug abusers

S milleri should be added to the list of organisms producing wound infections in parenteral drug addicts. Recovery of "viridans streptococci" from an antecubital aspirate should prompt the clinician to request speciation, examine closely for abscess formation, and anticipate prolonged antibiotic therapy.

Topographical analysis of canine parvovirus virions and recombinant VP2 capsids

The distribution of epitopes defined by monoclonal antibodies (MAbs) on the surface of canine parvovirus (CPV) virions and recombinant VP2-capsids was established using immunoelectron microscopy. A correlation appeared to exist between the linear position, neutralizing activity and immunogold staining. Both viral capsids and recombinant capsids gave similar patterns of immunostaining. The neutralizing MAbs that recognized epitopes not previously identified by Pepscan or immunoblotting gave a clear staining. However, MAbs 3C9 and 3C10, identified by Pepscan and immunoblotting as recognizing linear epitopes, did not show any labelling (3C9) or only scattered labelling (3C10). MAb 3C9 recognizes an N-terminal domain of VP2. MAb 4AG6, which recognizes the same linear epitope as 3C10, did not bind to the capsids, indicating a different orientation. An immunofluorescence assay was performed to supplement the B cell epitope characterization. In contrast to other MAbs that gave nuclear and cytoplasmic staining, MAb 3C9 gave a preferential nuclear staining. Based on these results, it is hypothesized that the N terminus of VP2 is barely, or not at all, exposed on the surface of the native virions, but becomes accessible after some virion steric change (e.g. after attachment to the cell receptor).

[Effects of 1,5 benzodiazepine beta lactam on sleep]

Various substances have been used as sleep inductors, but their use has declined, due to their undesirable side effects, and they have been replaced mainly by benzodiazepines. There currently exists a great variety of benzodiazepines with an increasing, clinical use, although they also present certain disadvantages. The effect on sleep of the intraperitoneal administration (0.9 mg/kg) of 7-(p-cl-phenyl)-8-phenoxy-4,5-benzo-3-aza-2-none, was analysed in chronically implanted wistar rats. Results indicate that this substance decreases wakefulness and increases significantly slow-wave and paradoxical sleep. Latency of the first phase of paradoxical sleep show a tendency to increase. It is concluded that this substance has hypnogenic effects.

Recurrent Salmonella arizona infection after treatment for metastatic carcinoma

Serious Salmonella arizona infection may be acquired through the ingestion of rattlesnake meat used as a folk medicine remedy. We report a patient with metastatic carcinoma and a remote history of rattlesnake meat ingestion who developed recurrent S. arizona bacteremia and reactivation of tuberculosis after receiving corticosteroid and radiation therapy. Physicians should be aware of the potential for rattlesnake-associated S. arizona infection to occur as either the presenting manifestation or as a complication in immunosuppressed patients who may take folk remedies, especially Hispanics who live along the United States-Mexico border.

Short-term polycose substitution for lactose reduces calcium absorption in healthy term babies

A vitamin D-independent paracellular and not saturable mechanism important for intestinal calcium absorption turned out to be less effective in lactose-free diets. Twelve normal term babies with identical repletion levels of 25-hydroxyvitamin D (25D) were fed sequentially with starting formulas that differed only in their carbohydrate sources: lactose (control) and polycose. A 3-day test was performed after a 1-week adjustment to the new diet. Fecal excretion of calcium was significantly higher in the lactose-free formula period compared to the control one: 56.6 (13.9) versus 39.6 (12.8) mg/kg/day (p less than 0.02); subsequently, the net retention was considerably higher and statistically significant (p less than 0.01) for the control period versus the lactose-free formula period: 99.4 (15.3) versus 78.1 (14.3). Plasma 25D values were 21.8 (9.1) and 23.7 (7.1) ng/ml at the beginning of the lactose and polycose periods, respectively, and 1,25-dihydroxyvitamin-D values were 64 (62) and 75 (45) pg/ml, not significant. Results suggest that formulas containing polycose as the sole carbohydrate source may reduce the intestinal absorption of calcium in term newborns, but determining long-term biological significance requires further observation.

Beta-interferon therapy in patients with poor-prognosis Kaposi sarcoma related to the acquired immunodeficiency syndrome (AIDS). A phase II trial with preliminary evidence of antiviral activity and low incidence of opportunistic infections

STUDY OBJECTIVE

To study the efficacy of high doses of beta-ser-interferon (recombinant human 17-serine beta-interferon) in patients with human immunodeficiency virus (HIV) infection and Kaposi sarcoma.

DESIGN

A nonrandomized, controlled trial of two high-dose regimens of beta-ser-interferon administered until tumor progression, toxicity, or an acquired immunodeficiency syndrome (AIDS)-defining opportunistic infection occurred.

SETTING

An AIDS treatment clinic at a tertiary care center.

PATIENTS

A sequential sample of 39 patients with biopsy-proven, AIDS-related Kaposi sarcoma were enrolled during a 2-year period. Thirty-eight patients were evaluable for response. Most patients (35 of 38) had one or more of the following clinical or laboratory predictors for a poor response to interferon therapy: HIV p24 antigenemia, low CD4 cell numbers, elevated beta 2-microglobulin levels, previous opportunistic infections, or previous systemic chemotherapy.

INTERVENTIONS

Beta-ser-interferon was self-administered subcutaneously at home 5 days per week. The first 21 patients used 90 million IU/d, and the remainder used 180 million IU/d.

MEASUREMENTS AND MAIN RESULTS

Six patients (16%) had a major clinical response, and 15 (39%) had stable disease for prolonged periods. Toxicities were minimal; the major toxicity was a skin reaction at the injection site. The HIV p24 antigen level declined more than 50% in 8 of the 19 patients with initial values greater than 50 pg/mL. Antiretroviral activity and antitumor activity were seen only in patients with normal initial beta 2-microglobulin levels. Minimal changes were seen in CD4 and CD8 cell numbers. Only 1 patient had an opportunistic infection while on study, but five other patients developed infections after treatment was discontinued for an incidence of six opportunistic infections in 285 patient-observation months.

CONCLUSIONS

The high doses of interferon did not improve the major response rate in patients with poor-prognosis, AIDS-related Kaposi sarcoma. There was, however, a suggestion of antiviral activity in patients with normal beta 2-microglobulin levels and a decrease in the expected incidence of opportunistic infections.

HIV-1, HIV-2, and HTLV-I infection in high-risk groups in Brazil

We conducted a serologic survey for antibodies to human immunodeficiency virus types 1 and 2 (HIV-1 and HIV-2) and human T-cell lymphotropic virus Type I (HTLV-I) in 704 Brazilians with the acquired immunodeficiency syndrome (AIDS) or at risk for it. The study population included 70 homosexual men (11 of whom were prostitutes), 58 bisexual men (19 of whom were prostitutes), 101 female prostitutes from three socioeconomic groups, 13 wives of men with hemophilia who were seropositive for HIV-1 antibodies, and 47 blood donors with positive Venereal Disease Research Laboratory tests for syphilis, all from Rio de Janeiro; 86 female prostitutes from two rural towns in Minas Gerais; 133 patients with AIDS from São Paulo; and 196 men with bleeding disorders who were seropositive for HIV-1 antibodies on enzyme-linked immunosorbent assay, from São Paulo and Rio de Janeiro. The prevalence of HIV-1 infection was highest in the homosexual male prostitutes (45 percent), the wives of patients with hemophilia (38 percent), the bisexual men (28 percent), the homosexual men who were not prostitutes (19 percent), and the female prostitutes from the lower class (9 percent). Combined HIV-1 and HIV-2 infection was found in 3 percent of the patients with AIDS and in 1 percent of the homosexual men. The prevalence of HTLV-I infection ranged from 1 percent in rural female prostitutes to 13 percent in HIV-1-positive men with bleeding disorders in Rio de Janeiro. Combined HIV-1 and HTLV-I infection occurred in 1 to 11 percent of some male subgroups. We conclude that in Brazil HIV-1 infection is already well established among homosexuals, bisexuals, and lower-class female prostitutes, with bisexual men probably acting as a bridge between the heterosexual and homosexual communities, that HTLV-I infection is prevalent in groups at risk for AIDS, and that HIV-2 infection has already been introduced into the country.

Improved method for quantifying vitamin D in proprietary infants' formulas and in breast milk

In this new method for quantifying vitamin D in infants' formulas and breast milk, after repeated lipid extraction, samples are further purified by passage through Sep-Pak cartridges, followed by liquid chromatography, then quantified by competitive protein-binding assay. Analytical recovery is estimated by use of added 3H-labeled vitamin D. For repeated assays of a reconstituted proprietary powdered milk formula in two runs, the intra-assay vitamin D values were 9.0 (SD 1.4) (n = 6) and 8.9 (SD 1.6) micrograms/L (n = 7) (t = 0.07). Assay of a proprietary liquid formula yielded values of 14.9 (SD 0.9) micrograms/L (n = 6). For each, the results agreed with the vitamin D content shown on the label. Vitamin D concentrations in breast milk from two groups of lactating mothers of different social class and nutritional status were 2.3 (SD 1.4) (n = 7) and 2.0 (SD 1.7) micrograms/L (n = 7). Overall recoveries ranged from 65 to 75%. Only 2 mL of milk is required, which facilitates sample collection, and the assay is less time-consuming than other current methods.

Metastatic trichomatricial carcinoma

Trichomatricial carcinoma has been recently recognized as a rare malignant variant of pilomatricoma with a potential for local recurrence and, rarely, for distant metastases. We describe such a tumor in a 52-year-old man who developed local recurrence and axillary lymph node metastases within six months of local excision, followed by bilateral pulmonary metastases and 2 1/2 years later by death due to disseminated tumor. This, to our knowledge, is the second reported case of metastasizing trichomatricial carcinoma.

Effective multimodality treatment for advanced epidermoid carcinoma of the female genital tract

Fifteen patients with advanced or recurrent squamous-cell carcinoma of the cervix, vulva, vagina, and urethra were treated with simultaneous combination chemotherapy (5-fluorouracil infusion and mitomycin C) and radiotherapy (3,000 rad for a period of three weeks). Three to four weeks after completion of radiotherapy, 13 of 15 patients achieved partial or complete tumor shrinkage. Nine of 15 patients are alive, eight of whom (at a median follow-up time of 24 months) have no evidence of disease. The longest survival time was 45 + months. There was minimal toxicity associated with this therapy. The results of this pilot study suggest that the simultaneous administration of radiation and chemotherapy is an effective method of treatment of advanced female genital tract carcinoma.

A comparison of intermittent vs. continuous and of adriamycin vs. methotrexate 5-drug chemotherapy for advanced breast cancer. A Cancer and Leukemia Group B study

The therapeutic effectiveness of intermittent vs. continuous combination chemotherapy and of the substitution of adriamycin for methotrexate in a 5-drug regimen was evaluated in women with metastatic breast carcinoma. Patients were randomly allocated to receive continuous therapy with cyclophosphamide, methotrexate, 5-fluorouracil, vincristine, prednisone ( CMFVP -C, 86 patients), intermittent CMFVP ( CMFVP -I, 109 patients), or intermittent CAFVP (107 patients). The CR + PR rate with CAFVP (71%) was superior to CMFVP -C (50%, p = 0.003) and to CMFVP -I (50%, p = 0.002). The remission duration with CAFVP (14 months, median) was superior to CMFVP -I (7 months) (p less than 0.01), and tended to be superior to CMFVP -C (9 months) (p = 0.07). There was a survival advantage of CAFVP (19 months, median) over CMFVP -I (13 months) (p = 0.01), but not over CMFVP -C (16 months) (p = 0.24). Among CR + PR patients, the survival with CAFVP (29 months, median) was superior (p = 0.02) to both CMFVP -I (18 months) and CMFVP -C (21 months). The CMFVP -C regimen was associated with the highest incidence of leukopenia and neurologic toxicity, but the lowest incidence of GI toxicity. The results indicate that the CAFVP regimen is well tolerated and is superior to the CMFVP regimens.