Comprehensive multiplexed autoantibody profiling of patients with advanced urothelial cancer

BACKGROUND

Comprehensive profiling of autoantibodies (AAbs) in metastatic urothelial cancer (mUC) has not been performed to date. This may aid in diagnosis of UC, uncover novel therapeutic targets in this disease as well as identify associations between AAbs and response and toxicity to systemic therapies.

METHODS

We used serum from patients with mUC collected prior to and after systemic therapy (immune checkpoint inhibitor (ICI) or platinum-based chemotherapy (PBC)) at Dana-Farber Cancer Institute. 38 age-matched and sex-matched healthy controls (HCs) from healthy blood donors were also evaluated. The SeroTag immuno-oncology discovery array (Oncimmune) was used, with quantification of the AAb reactivity toward 1132 antigens. Bound AAbs were detected using an anti-immunoglobulin G-specific detection antibody conjugated to the fluorescent reporter dye phycoerythrin. The AAb reactivity was reported as the median fluorescence intensity for each color and sample using a Luminex FlexMAP3D analyzer. Clinical outcomes of interest included radiographic response and development of immune-related adverse events (irAEs). Significance analysis of microarray was used to compare mUC versus HC and radiographic response. Associations with irAE were evaluated using a logistic regression model. P<0.05 was considered statistically significant.

RESULTS

66 patients were included with a median age of 68 years; 54 patients (82%) received ICI and 12 patients (18%) received PBC. Compared with HCs, AAbs against the cancer/testis antigens (CTAG1B, CTAG2, MAGEB18), HSPA1A, TP53, KRAS, and FGFR3 were significantly elevated in patients with mUC. AAbs against BRCA2, TP53, and CTNBB1 were associated with response, and those against BICD2 and UACA were associated with resistance to ICI therapy. AAbs against MITF, CDH3, and KDM4A were associated with development of irAEs in patient who received an ICI. A higher variance in pre-to-post treatment fold change in AAb levels was seen in patients treated with ICI versus PBC and was associated with response to ICI.

CONCLUSIONS

This is the first report of comprehensive AAb profiling of patients with mUC and identified key AAbs that were elevated in patients with mUC versus HCs as well as AAbs associated with therapeutic response to ICI. These findings are hypothesis generating and further mechanistic studies evaluating humoral immunity in UC are required.

ATM deficiency confers specific therapeutic vulnerabilities in bladder cancer

Ataxia-telangiectasia mutated (ATM) plays a central role in the cellular response to DNA damage and ATM alterations are common in several tumor types including bladder cancer. However, the specific impact of ATM alterations on therapy response in bladder cancer is uncertain. Here, we combine preclinical modeling and clinical analyses to comprehensively define the impact of ATM alterations on bladder cancer. We show that ATM loss is sufficient to increase sensitivity to DNA-damaging agents including cisplatin and radiation. Furthermore, ATM loss drives sensitivity to DNA repair-targeted agents including poly(ADP-ribose) polymerase (PARP) and Ataxia telangiectasia and Rad3 related (ATR) inhibitors. ATM loss alters the immune microenvironment and improves anti-PD1 response in preclinical bladder models but is not associated with improved anti-PD1/PD-L1 response in clinical cohorts. Last, we show that ATM expression by immunohistochemistry is strongly correlated with response to chemoradiotherapy. Together, these data define a potential role for ATM as a predictive biomarker in bladder cancer.

Association of peripheral blood neutrophil-lymphocyte ratio (NLR) and red cell distribution width (RDW) with immune checkpoint inhibitors (ICIs) for metastatic urothelial carcinoma (mUC)

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Background: Determining a benefit from ICIs radiographically may take months and may be confounded by pseudoprogression. The NLR & RDW are readily accessible inflammatory markers from routine peripheral blood analysis and have been associated with outcomes in malignancies. We evaluated the association of early changes in NLR and RDW within 4 weeks after initiating ICI with any regression of tumor (ART) and overall survival (OS) in mUC. Methods: This study included de-identified data from Dana-Farber Cancer Institute in pts with mUC who were treated with ICIs from 2015 to 2020. Age, gender, setting (untreated vs. post-platinum), sites of metastasis (mets), performance status (PS), platelet count, RDW, and NLR at baseline and 3-4 weeks after initiating the ICI were collected. The primary objective was to assess the association of early increase in NLR by ≥1.0 from baseline or RDW at 3-4 weeks (as a continuous variable) post-ICI therapy with ART and OS. ART was assessed via subsequent imaging at any time point while on ICI. A multivariable logistic regression model and Cox proportional-hazards model were employed to identify the association of NLR changes with ART and OS, respectively, using backward selection. Results: A total of 330 pts were evaluable. The median age was 70 years, 72.1% (n = 298) were male and 69.4% (n= 227) received post-platinum ICI (remaining were platinum naïve). 46.5% (n = 146) experienced ART and the median OS was 13 months (11.14-16.14). An increase in NLR ≥ 1 in 3-4 weeks was associated with a lower rate of ART (OR: 0.41, 95% CI 0.24-0.70; p: 0.001) and worse OS (hazard ratio [HR]: 1.84, 95% CI 1.37-2.46; p < 0.0001) on multivariable analysis (Table). Higher RDW values at 3-4 weeks were associated with worse OS (HR: 1.08, 95% CI 1.03-1.14; p: 0.0004) but were not associated with ART. Conclusions: In pts with mUC initiating ICI, an early increase in NLR ≥ 1 and higher RDW in 3-4 weeks were associated with poor outcomes. Early changes in these readily available variables may enable early modification or intensification of therapy to improve outcomes. External validation of these findings is warranted. [Table: see text]

A109 LINKING PRIMARY AND SPECIALTY CARE FOR THE MANAGEMENT OF DIGESTIVE HEALTH CONDITIONS: AN EVALUATION OF GUT LINK IMPLEMENTATION

Background

Severe restrictions on in-person encounters and endoscopic procedures for digestive care have occurred as a result of the COVID-19 pandemic. This has exacerbated pre-existing barriers in access to gastroenterology (GI) care across Nova Scotia (NS) for patients and primary healthcare providers (PHCPs). In response, a provincial PHCP-GI consultative service (GUT LINK) was implemented at a single tertiary care center with the goal of supporting PHCPs in the management of non-urgent GI referral conditions.

Aims

To implement and evaluate the acceptability, feasibility, appropriateness, and early effectiveness of the GUT LINK PHCP-GI consultation service.

Methods

This is an ongoing prospective observational cohort study. All referrals received through the EMR-based referral and triage management system between May and November 2020 that were deemed to be amenable to management within primary care with specialist support were returned to the PHCP with the suggestion to arrange a GUT LINK telephone consultation. GUT LINK appointments were scheduled through an administrative support telephone line with the PHCP and a GI specialist. A post-consultation e-questionnaire was distributed to PHCPs who consented to participate. Feasibility (number of and indication for referrals, PHCP participation rates), acceptability and appropriateness (satisfaction, future use, likelihood to recommend) metrics and outcomes (case resolution, re-referrals, proportion requiring endoscopic investigations) were recorded. Patient charts were reviewed to determine whether the patient ultimately required GI speciality care. Analyses were descriptive and expressed as frequencies, means (+/-SD), medians (+/-SE), and proportions (%).

Results

A total of 45 GUT LINK consultations were completed between May and November 2020. Of these, 20% required GI specialist care and 80% have remained within primary care, with a median follow-up of 101 (+/-9.1) days. The indications for GUT LINK consultation included lower GI symptoms (64%), abnormal imaging or investigations (17%), and upper GI symptoms (19%).

To date, 21 PHCP agreed to be contacted for the post-consultation survey and 10 have been completed. All PHCPs reported that GUT LINK consultation was easy to access, while 90% found the advice helpful and 80% reported that that it resolved the issue. Following the GUT LINK appointment, 80% felt they would not need to refer their patient to GI.

Conclusions

The implementation of GUT LINK was acceptable, feasible, and improved access to specialist support for management of undifferentiated GI symptoms. Future research will focus on comprehensive stakeholder engagement in order to design, implement, and evaluate GUT LINK PHCP care pathways.

Funding Agencies

CAG

"Ask me what I need": A call for shifting responsibility upwards and creating inclusive learning environments in clinical placement

BACKGROUND

Ontario's human-rights legislation and institutions' support for students with disabilities have influenced these students' increased enrolment in the postsecondary environment. Yet more attention is paid to in-classroom than to out-of-classroom experiences. Students with disabilities enrolled in nursing are least likely to be accommodated. This has significant implications for access and equity upon graduation, as clinical placements are a bridge between school and employment.

OBJECTIVES

To explore clinical instructors' and students who identify with disabilities' perspectives on nursing clinical placements.

METHOD

A descriptive case-report was used: interactive take-home diaries were completed and semi-structured interviews were conducted with clinical instructors (n-14) and nursing students with disabilities (n-14) in Ontario. An iterative inductive analysis was undertaken.

RESULTS

Three overarching themes were identified: (a) an immovable clinical environment in relation to technology and time, (b) a perceived conflict between nursing and disability identity, and (c) a need to shift responsibility upwards while listening to lived experience. The clinical environment is a highly contested space; different identity groups have distinct roles and differing degrees of power within it.

CONCLUSION

Our research calls for a shift in the nursing landscape to be led by education and medical institutions that can build supportive networks, develop clear policies and listen to nursing students with disabilities.

Researching “Good Death” in a Hong Kong Palliative Care Program: A Clinical Data-Mining Study

This study operationalizes and assesses the percentage of “good deaths” achieved among Chinese cancer patients in a palliative care program, the profile of these patients, the relationship between patients with a good death and psychosocial factors, and the differences in background factors, and physical and psychosocial conditions between patients who experienced a good death and those who did not. Clinical data mining was the research method used. Records of deceased cancer patients between 2003 and 2005 in a palliative care unit were the sole data source. Good death was operationally defined as the patient's record indicating no pain (physical) or anxiety (psychological), and having open and honest communication with family (social) in the final assessment by the Support Team Assessment Schedule (STAS) just before death. Using these criteria, about one-fifth of patients (21.5%; 137 out of 638) experienced a good death. Those with a good death were significantly older and were in palliative care longer. Their records also indicated lower levels of constipation, insomnia, oral discomfort, and family anxiety at their first and at their final STAS assessments. Good death was positively associated with recorded indicators of fullness in life, caregivers' acceptance and support, and negatively with reported feelings of upset about changes in the course of their illness. The results heighten awareness among social workers and other healthcare professionals about the value of good death in patients in palliative care. This empirically-based awareness can foster professionals' ability to set intervention objectives to help patients in palliative care achieve this universally accepted goal.

The PRIME North America randomized double-blind clinical trial of olanzapine versus placebo in patients at risk of being prodromally symptomatic for psychosis. II. Baseline characteristics of the "prodromal" sample

The first double-blind placebo-controlled clinical trial of an atypical neuroleptic medication is being conducted in symptomatic treatment-seeking patients meeting new diagnostic criteria for a putative prodromal syndrome. This identifies them as being at high risk for developing psychosis in the near future. The study aims include prevention of psychosis onset and disability, as well as palliation of ongoing symptomatology. The purpose of this report is to describe the study's "prodromally symptomatic" sample at baseline, i.e., at intake immediately prior to randomization and prior to receiving study medication. Sixty treatment-seeking patients meeting prodromal inclusion criteria were recruited across four sites: New Haven, CT (n=39), Toronto, Ontario (n=9), Calgary, Alberta (n=6), and Chapel Hill, NC (n=6). The sample was young (median age 16), largely male (65%), and came from families with high titers of serious mental illness (44%). Most patients (93%) met criteria for the Attenuated Positive Symptom (APS) prodromal syndrome and presented with significant but nonpsychotic suspiciousness, perceptual aberrations, unusual thought content, and conceptual disorganization. They presented with minimal to mild affective symptoms and substance use/abuse, but they were quite functionally compromised (mean Global Assessment of Functioning (GAF) score=42). The prodromal sample was compared with other clinical-trial samples of adolescent depression, adolescent mania, and first episode schizophrenia. Prodromal patients proved not to be depressed or manic. They were less severely ill than untreated first episode schizophrenia but more severely ill than treated first episode schizophrenia. While not psychotically disabled, these patients nevertheless present with a clinical syndrome. Subsequent reports will detail the effects of drug versus placebo on prodromal symptoms, neuropsychological profile, and the rate of conversion to psychosis.

Screening for psychosocial risk in an urban prenatal clinic population: a retrospective practice-based research study

Recognition of the need for early identification of risk factors led a "practice-based research" (Epstein, 1995) team of social workers in the prenatal clinic at Mount Sinai to develop a standardized, comprehensive screening, monitoring and evaluation instrument for all patients in their service. To explore the effects of psychosocial risk factors empirically, available information collected from 435 women screened with the original instrument between 1992-93 was converted into a quantitative data-base. The intention was to conduct a retrospective study of the prenatal patient population, including demographic characteristics, problems presented, social work interventions, and treatment outcomes. Among the findings anxiety and ambivalence related to pregnancy were significant risk factors. This model of social work service delivery is consistent with the focus of prenatal care as clinical preventative medicine.

Comparing social work's role in renal dialysis in Israel and the United States: the practice-based research potential of available clinical information

This paper demonstrates the use of clinical data-mining in a study of social work interventions with dialysis patients in two countries, the US and Israel. We aimed to examine the role of social workers in improving kidney patient outcomes and to determine the potential of readily available patient information for studying this process. The findings showed considerable differences between the patient samples in both countries, as far as the socio-demographic background was considered. In spite of this, there were numerous similarities in the type of psycho-social problems and reactions, as well as the social workers' interventions. Differences which arose in various patient states and outcomes were examined in light of variations in the health care systems and socio-cultural contexts of renal dialysis in both sites.

Social work practice with pre- and post-liver transplant patients: a retrospective self study

This paper describes a retrospective, practice-based research study of social work interventions with liver transplant candidates and recipients. This study is based on a retrospective chart review conducted to examine psychosocial risk factors, interventions and medical outcomes. Psychosocial interventions provided to patients and families before and after transplant will be described as well as their relationship to medical outcomes. Research Findings and practice implications will be discussed.

Introduction: promoting and maintaining a reflective professional staff in a hospital-based social work department

Promoting and sustaining a staff of reflective social work practitioners requires a supportive departmental structure and culture. Providing such support is a particular yet necessary challenge to social work administrators in the current health care environment. This article discusses an array of administrative strategies employed in one hospital social work department to promote reflective social work practice. More specifically, it describes the role of practice-based research in enhancing worker reflectiveness.

Using available clinical information in practice-based research: mining for silver while dreaming of gold

Social workers in health and mental health settings routinely collect and record enormous quantities of clinical information about clients, psycho-social interventions and client responses to these interventions. Despite its abundance and non-intrusiveness, social work researchers generally have ignored available clinical information, claiming that it is unreliable and subject to too many threats to validity to warrant serious consideration as a data source. Instead, many researchers have advocated "gold standard" experimental studies, employing standardized instruments and prospective data-collection. As a result, the research potential of retrospective studies based on available clinical information has been relatively unexplored and untested. This paper asserts that available clinical information can be converted into valuable retrospective, data-bases for practice-based research studies. Exemplars of such studies in health and mental health settings are provided as are guidelines for their conduct.

Dialysis patient characteristics and outcomes: the complexity of social work practice with the end stage renal disease population

This article describes a demonstration project designed to explore psychosocial risk and resiliency factors, social work interventions and health-related outcomes with dialysis patients. The study is unique in including an interdisciplinary research team to guide the process, using available data contained within the medical record and focusing on interventions and outcomes over time rather than at one or two points in patients' treatment histories. It demonstrates the complexity of practice with dialysis patients and the crucial role for social workers in enhancing patient outcomes. Secondary benefits of this methodology and implications for social work practice and research are discussed.

Creating experimental analogs with available clinical information: credible alternatives to "gold-standard" experiments?

Comparison of the implementation and findings of a "gold standard" evaluation of social work intervention and its experimental analog based on available clinical information illustrates the strengths and weaknesses of each. From a practice-research integration perspective, however, "clinical data-mining" may be a credible alternative to randomized controlled experiments.

Specifying intensive case management: a multiple perspective approach

"Intensive case management" (ICM) programs for people with serious mental illness are found widely throughout the United States. However, there is no standard definition or conceptualization of ICM. Despite these differences, ICM aspires to a set of common principles and core functions derived from the concept of continuity of care. This study attempted to identify the elements of ICM program theory by integrating information from the ICM literature with survey and focus-group data reflecting the perspectives of three distinct ICM respondent groups (researchers/administrators, program managers, and case managers). The findings suggest a strong consensus about the structural dimensions of ICM, but a moderate consensus about their operationalization. More generally, the results support viewing ICM as more "client oriented," in contrast with conventional case management programs that are more "system driven."

Evaluating the Mount Sinai Leadership Enhancement Program: a developmental perspective

The principal evaluators of the Mount Sinai Leadership Exchange program used a developmental approach to evaluating the program, applying qualitative and quantitative data within the program as the program developed. Over the course of its development, evaluation, and refinement, the leadership enhancement program emerged as a vehicle for true international exchange of ideas, skills, resources, and collegiality.

[Alternating rifampicin and ceftriaxone for Neisseria meningitidis eradication in contacts]

Following the occurrence of a case of meningococcal disease in a kibbutz, extensive preventive measures were instituted, consisting of alternate courses of rifampicin (10 mg/kg for 2 consecutive days) and ceftriaxone (single IM injection of 125 mg). Throughout the observation period Neisseria meningitidis was absent from oropharyngeal secretions of all those treated, but was found in those of an untreated control group. The alternate use of rifampicin and ceftriaxone should be considered for the long-term prevention of the occurrence of oropharyngeal carriers of Neisseria meningitidis.

Confronting the challenge of computerization for social workers in health care settings

Computerization and information technology will profoundly affect the work of health care social workers in the coming years. This paper reviews recent trends in information technology in health care systems and their implications for social workers. It describes recent innovations in information systems designed specifically for social workers. It concludes with a review of recent studies of utilization of computer and information systems by social workers and from these derives some of the conditions that must be created if social workers are to effectively make use of this technology.

Epidemiology of rubella and congenital rubella infection in Israel, a country with a selective immunization program

A rubella immunization program directed at girls aged 12 years started in Israel in 1973, and its extension in 1980 to women of childbearing age had produced by 1983 several changes in the epidemiologic pattern of rubella infection in women of childbearing age and in the risk of congenital rubella: a 55%-77% decline in the incidence of the disease in the 15-44-year age group; a progressive reduction in the rate of seronegativity among women from greater than 20% to less than 10%; a risk of infection during pregnancy and a percentage of abortions associated with rubella infection in the 1983 outbreak that were one-twelfth and one-tenth, respectively, the values associated with the 1978 and 1979 epidemics; and an evident decrease in the frequency of cases of congenital rubella, as detected by either passive or active surveillance. It is predicted that of the women who will be pregnant in 1985, 98.2% and 94.3% of those in the 18-23 year and 24-44 year age groups, respectively, will be immune by the end of 1984.

Adult onset Still's disease: a cause of pyrexia of unknown origin

A case of adult onset Still's disease is reported. A middle aged woman presented with prolonged high fever, rash, polyarthritis, leukocytosis and abnormal liver function tests. The clinical features and multisystem nature of this condition are emphasised.

Relationship between culture density and catabolite repression of an inducible aliphatic amidase in a thermophilic bacillus

A direct correlation between the absorbance of a thermophilic bacillus and specific amidase activity was observed, which was found to depend on the cell density of the culture rather than on the time of contact of the culture with the inducer. Dilution of high density cultures caused the specific amidase activity to decrease. Environmental factors such as pH, concentration of inducer or degree of aeration, and level of NH+4 and glutamate had no effect on amidase synthesis. The decrease in amidase activity upon dilution could not be ascribed to destruction by oxygen or by inactivation or decay. Several lines of evidence suggest that catabolite repression is responsible for the phenomenon described. Succinate-grown cultures gave a stronger dilution effect thatn glutamate-grown cells. The mutant strain E-21, relatively resistant to catabolite repression, did not show the characteristic dilution effect nor the direct correlation between absorbance and specific amidase activity.

Regulatory control and function of alanine dehydrogenase from a thermophilic bacillus

L-alanine dehydrogenase, (L-alanine:NAD+ oxidoreductase (deaminating), EC 1.4.1.1) synthesis in a thermophilic bacillus was found to be subjected to regulatory control. Addition of L- and D-alanine and L-serine to cultures growing in the presence of either succinate or pyruvate, induced an accelerated synthesis of the alanine dehydrogenase enzyme. Synthesis of the enzyme was dependent on the presence of inducer during growth and was arrested by addition of glucose. Catabolite repression by glucose was abolished by limiting the ammonium concentration during growth. The apparent Km values of the substrates involved in alanine dehydrogenase activity are as follows (M): NH4+, 4-10(-2); pyruvate, 5-10(-4); NADH, 6-10(-5); L-alanine, 3.1-10(-3) and NAD, 2-10(-4). Alanine dehydrogenase activity was measurable at temperatures below the minimal growth temperature (at 25 degrees C) and the highest activity was found at 65 degrees C; heat denaturation occurred at 80 degrees C.

Normal-pressure hydrocephalus due to tentorial meningioma

Normal-pressure hydrocephalus and the associated triad of dementia, apraxic gait and urinary incontinence may be casued by various, sometimes unsuspected, lesions, usually those that block the flow of cerebrospinal fluid (CSF) around the tentorium. A 58-year-old woman with insidious onset of behaviour and gait problems had occult, normal-pressure hydrocephalus and a tentorial meningioma, resection of which produced complete recovery. This case demonstrates that a distinction must be made between the syndrome of normal-pressure hydrocephalus resulting from disturbance in CSF dynamics and the pathophysiologic features of the underlying lesion.

Purification and properties of glutamate dehydrogenase from a thermophilic bacillus

A 250- to 300-fold purification of a nicotinamide adenine denucleotide phosphate (NADP)-dependent glutamate dehydrogenase (GDH, E.C. 1.4.1.4) with a yield of 60% from a thermophilic bacillus is described. More than one NADP-specific GDH was detected by polyacrylamide gel electrophoresis. The enzyme is of high molecular weight (approximately 2 X 10-6), similar to that of the beef and frog liver GDH. The pI of the thermophilic GDH is at pH 5.24. The enzyme is highly thermostable at the pH range of 5.8 to 9.0. The purified GDH, unlike the crude enzyme, was very labile at subzero temperatures. An unidentified factor(s) from the crude cell-free extract prevented the inactivation of the purified GDH at -70 C. Various reactants of the GDH system and D-glutamate also protected, to some extent, the enzyme from inactivation at -70 C. From the Michaelis constants for glutamate (1.1 X 10-2M), NADP (3 X 10-4M), ammonia (2.1 X 10-2M), alpha-ketoglutarate (1.3 X 10-3M), and reduced NADP (5.3 X 10-5M), it is suggested that the enzyme catalyzes in vivo the formation of glutamate from ammonia and alpha-ketoglutarate. The amination of alpha-ketoglutarate and deamination of glutamate by the thermophilic GDH are optimal at the pH values of 7.2 and 8.4, respectively.

Production and purification of the thermophilic bacteriophage TP-84

A new procedure for production and purification of the thermophilic bacteriophage TP-84 in high yields is described. Cultures of Bacillus stearothermophilus strain 10, enriched with nutrients to obtain heavy growth and to prevent sporulation and maintained at a pH of 6.5, were infected with the phage in a 100-liter fermentor. Addition of magnesium chloride (0.01 M) and a temperature of 58-C were essential for maximal phage production. Phage (5 times 1011 infective particles/ml) was precipitated with polyethylene glycol (molecular weight 6,000) in the presence of sodium chloride and was further purified by cesium chloride density centrifugation.

Intracellular protein breakdown in a thermophile

Protein breakdown of 5 to 7% per hr was found in nitrogen-starved cells of an unclassified prototrophic thermophilic bacillus; a similar protein-breakdown rate (6.5% per hr) was found in resting cells of Escherichia coli. In the thermophile, the rate of protein breakdown was markedly influenced by the temperature; it was maximal between 45 and 55 C, and it decreased considerably at 35 and 75 C, temperatures which are only slightly below or above the minimal and maximal growth temperatures. Growing cultures of the thermophile showed little, if any, protein breakdown, a finding similar to that of others with E. coli.

Prototrophic thermophilic bacillus: isolation, properties, and kinetics of growth

A thermophilic bacillus (minimal growth temperature 41 C, optimal 55 to 58 C, and maximal 65 C) was isolated from a manure pile. It is very similar to Bacillus stearothermophilus, but it differs in its inability to hydrolyze starch. The thermophilic isolate is a prototroph which grows in a minimal medium consisting of glucose, ammonium salt, phosphate buffer, and inorganic salts. At all temperatures studied (low to high), the same minimal nutritional requirements prevailed. The Arrhenius constant for growth was found to be 15,000 and 13,500 cal/mole in the minimal and rich media, respectively.