Cross cultural adaptation, reliability and validity of the Greek version of Identification of Functional Ankle Instability (IdFAI) questionnaire

BACKGROUND

The objectives of our study were to develop the Greek version of the Identification of Functional Ankle Instability (IdFAI) questionnaire and to evaluate its psychometric properties.

METHODS

The IdFAI was translated and adapted into Greek according to the guidelines for cross-cultural adaptation of self report measures. It was tested for test-retest reliability, validity, internal consistency and floor-ceiling effects in 141 participants (54 males, 87 females; 23.5 ± 7.2 years). All participants were asked to fill the Greek IdFAI (IdFAI-GR), the Cumberland Ankle Instability Tool (CAIT), and the Lower Extremity Functional Scale (LEFS), in order to determine construct validity. To determine the test-retest reliability, fifty randomly selected individuals re-filled IdFAI seven days after the first session.

RESULTS

The IdFAI-GR had high internal consistency (Cronbach alpha = 0.94) and excellent test-retest reliability (ICC_2,1 = 0.97; SEM = 0.7). The IdFAI-GR had strong correlation with the CAIT (r = 0.7; p < 0.001) and moderate correlation with the LEFS (r = 0.5; p < 0.001). No ceiling or floor effects were observed.

CONCLUSION

The Greek IdFAI questionnaire has proven to be a valid and reliable instrument to identify functional ankle instability. It can therefore, be used for both clinical and research purposes in Greek-speaking individuals.

Phase II trial of single-agent panobinostat consolidation improves responses after sub-optimal transplant outcomes in multiple myeloma

Panobinostat is a pan-deacetylase inhibitor that modulates the expression of oncogenic and immune-mediating genes involved in tumour cell growth and survival. We evaluated panobinostat-induced post-transplant responses and identified correlative biomarkers in patients with multiple myeloma who had failed to achieve a complete response after autologous transplantation. Patients received panobinostat 45 mg administered three-times weekly (TIW) on alternate weeks of 28-day cycles commencing 8-12 weeks post-transplant. Twelve of 25 patients (48%) improved their depth of response after a median (range) of 4·3 (1·9-9·7) months of panobinostat. In responders, T-lymphocyte histone acetylation increased after both three cycles (P < 0·05) and six cycles (P < 0·01) of panobinostat when compared to baseline, with no differences in non-responders. The reduction in the proportion of CD127+ CD8+ T cells and CD4:CD8 ratio was significantly greater, after three and six cycles of panobinostat compared to pre-transplant, in non-responders when compared to responders. Whole marrow RNA-seq revealed widespread transcriptional changes only in responders with baseline differences in genes involved in ribosome biogenesis, oxidative phosphorylation and metabolic pathways. This study confirmed the efficacy of panobinostat as a single agent in multiple myeloma and established acetylation of lymphocyte histones, modulation of immune subsets and transcriptional changes as pharmacodynamic biomarkers of clinical benefit.

Human myeloma cell- and plasma-derived extracellular vesicles contribute to functional regulation of stromal cells

Circulating small extracellular vesicles (sEV) represent promising non-invasive biomarkers that may aid in the diagnosis and risk-stratification of multiple myeloma (MM), an incurable blood cancer. Here, we comprehensively isolated and characterized sEV from human MM cell lines (HMCL) and patient-derived plasma (psEV) by specific EV-marker enrichment and morphology. Importantly, we demonstrate that HMCL-sEV are readily internalised by stromal cells to functionally modulate proliferation. psEV were isolated using various commercial approaches and pre-analytical conditions (collection tube types, storage conditions) assessed for sEV yield and marker enrichment. Functionally, MM-psEV was shown to regulate stromal cell proliferation and migration. In turn, pre-educated stromal cells favour HMCL adhesion. psEV isolated from patients with both pre-malignant plasma cell disorders (monoclonal gammopathy of undetermined significance [MGUS]; smouldering MM [SMM]) and MM have a similar ability to promote cell migration and adhesion, suggesting a role for both malignant and pre-malignant sEV in disease progression. Proteomic profiling of MM-psEV (305 proteins) revealed enrichment of oncogenic factors implicated in cell migration and adhesion, in comparison to non-disease psEV. This study describes a protocol to generate morphologically-intact and biologically functional sEV capable of mediating the regulation of stromal cells, and a model for the characterization of tumour-stromal cross-talk by sEV in MM.

TOP2A expression predicts responsiveness to carfilzomib in myeloma and informs novel combinatorial strategies for enhanced proteasome inhibitor cell killing

Microarray was utilized to determine if a genetic signature associated with resistance to carfilzomib (CFZ) could be identified. Twelve human myeloma (MM) cell lines (HMCLs) were treated with CFZ and a cell-viability profile was assessed categorizing HMCLs as sensitive or resistant to CFZ. The gene expression profiles (GEP) of untreated resistant versus sensitive HMCLs revealed 29 differentially expressed genes. TOP2A, an enzyme involved in cell cycle and proliferation, was overexpressed in carfilzomib-resistant HMCLs. TOP2A protein expression levels, evaluated utilizing trephine biopsy specimens acquired prior to treatment with proteasome inhibitors, were higher in patients failing to achieve a response when compared to responding patients. Logistic-regression analysis confirmed that TOP2A protein expression was a highly significant predictor of response to PIs (AUC 0.738). Further, the combination of CFZ with TOP2A inhibitors, demonstrated synergistic cytotoxic effects in vitro, providing a rationale for combining topoisomerase inhibitors with CFZ to overcome resistance in MM.

Abstract 454: The role of autophagy in multiple myeloma disease progression

Multiple Myeloma (MM) is an incurable hematologic neoplasm characterized by accumulation of malignant plasma cells in the bone marrow (BM). MM cells establish close ties with the BM, however at late stages they utilize as yet unknown mechanisms to acquire independence from the microenvironment and survive in extramedullary/nutrient deprived sites. Autophagy, a process responsible for degradation of proteins and organelles under stress conditions, has been suggested as a mechanism whereby tumor cells can withstand metabolic stress.

Using two newly acquired human myeloma cell lines (HMCL), TK1 and TK2, from the medullary and extramedullary sites of a MM patient respectively, we investigated the ability of autophagy to confer stress/glutamine deprivation tolerance.

Results

HMCLs require exogenous L-Glutamine (Gln) for sustained proliferation in vitro. However, when TK1 and TK2 were grown under Gln deprivation conditions (8mM, 4mM, 2mM, 0mM) we observed striking differences in their growth response. The TK2 (peripheral blood) cell line continued proliferating until day 14 (p=0.0046), whereas proliferation of the TK1 cell line significantly decreased in the absence of Gln (p=0.0028 between 8mM and 0mM). Furthermore, the proliferative advantage of TK2 was abrogated at 2mM and 0mM of Gln by the use of an autophagy inhibitor (chloroquine [CQ] (p=0.000235 and p=0.000069 respectively), implicating this process in Gln deprivation tolerance of TK2.

Additionally, Gln concentration was inversely correlated with TK1 survival, but not TK2, as measured by annexin-V/PI staining. Cell death in TK1 increased at 24h, from 36.022% at Gln 8mM to 56.2% at Gln 0mM, irrespective of autophagy inhibition. In TK2 cells, Gln deprivation did not cause a significant increase in cell death, whereas inhibition of autophagy increased cell death by two-fold. Accordingly, apoptosis (as measured by PARP cleavage) was induced by the addition of CQ only in TK2 under Gln deprivation. Resistance of TK2 cells to metabolic stress also correlated with up-regulation of the autophagic pathway upon CQ exposure, as demonstrated by a higher LC3BII/I turnover and the presence of autophagic vacuoles in TK2 (but not TK1) cells.

In addition to upregulation of autophagy, Gln deprivation also induced the expression of glutamine synthetase in TK2 but not TK1 cells. Chemical inhibition of this enzyme by methionine-sulfoximine (5mM) under Gln deprivation conditions was able to induce significant cell death in TK2 and not TK1 (32.57% and 2.53% increase respectively). These data demonstrate that Gln synthesis is an additional mechanism whereby TK2 cells tolerate Gln starvation.

In conclusion we have shown that MM survival outside the BM can be attributed to the ability of cells to overcome “glutamine addiction” due to up-regulation of autophagy and ability to synthesise Gln. Thus, autophagy inhibition is an attractive alternative approach to target late-stage, Gln independent, metastatic cells.

Citation Format: Ioanna Savvidou, Sahan Chandrasekara, Tiffany Khong, Andrew Spencer. The role of autophagy in multiple myeloma 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 454.

Proliferation and bone marrow engraftment of AML blasts is dependent on β-catenin signalling

B-catenin is the central effector molecule of the canonical Wnt signalling pathway, which controls self-renewal of haematopoietic stem cells. Deregulation of this pathway occurs in various malignancies including myeloid leukaemias. The present study examined the functional outcome of stable β-catenin down-regulation through lentivirus-mediated expression of short hairpin RNA (shRNA). Reduction of the β-catenin levels in acute myeloid leukaemia (AML) cell lines and patient samples decelerated their in vitro proliferation ability without affecting cell viability. Transplantation of leukaemic cells with control or reduced levels of β-catenin in non-obese diabetic severe combined immunodeficient animals indicated that, while the immediate homing of the cells was unaffected, the bone marrow engraftment was directly dependent on β-catenin levels. Subsequent examination of bone sections revealed that β-catenin was implicated in the localization of AML to the endosteum. Examination of adhesion molecule expression before and after transplantation, revealed down-regulation of CD44 expression, accompanied by reduced in vitro adhesion. Gene expression analysis disclosed the presence of an autocrine compensatory mechanism, which responds to the reduced β-catenin levels by altering the expression of positive and negative pathway regulators. In conclusion, our study showed that β-catenin comprises an integral part of AML cell proliferation, cell cycle progression, and adhesion, and influences disease establishment in vivo.

Bioluminometric assay for relative quantification of mutant allele burden: application to the oncogenic somatic point mutation JAK2 V617F

Unlike the inherited mutations, which are present in all cells, somatic (acquired) mutations occur only in certain cells of the body and, quite often, are oncogenic. Quantification of mutant allele burden (percentage of the mutant allele) is critical for diagnosis, monitoring of therapy, and detection of minimal residual disease. With point mutations, the challenge is to quantify the mutant allele while discriminating from a large excess of the normal allele that differs in a single base-pair. To this end, we report the first bioluminometric assay for quantification of the allele burden and its application to JAK2 V617F somatic point mutation, which is a recently (2005) discovered molecular marker for myeloproliferative neoplasms. The method is performed in microtiter wells and involves a single PCR, for amplification of both alleles, followed by primer extension reactions with allele-specific primers. The products are captured in microtiter wells and detected by oligo(dT)-conjugated photoprotein aequorin. The photoprotein is measured within seconds by simply adding Ca(2+). We have demonstrated that the percent (%) luminescence signal due to the mutant allele is linearly related to the allele burden. As low as 0.85% of mutant allele can be detected and the linearity extends to 100%. The assay is complete within 50 min after the amplification step.

Intravascular B-cell lymphoma with leukemic presentation: case report and literature review

Intravascular lymphoma is an extremely rare, disseminated, and aggressive extranodal CD20+ non-Hodgkin's lymphoma characterized by the presence of lymphoma cells only in the lumina of small vessels. We report a 72-year-old woman with a diagnosis of intravascular lymphoma presented with splenomegaly and leukemic appearance in the peripheral blood smear. Her clinical course was rapidly deteriorated before the initiation of specific chemotherapy and finally died due to multiorgan insufficiency. Bone marrow biopsy revealed a characteristic infiltration of CD5, CD10 B-cell lymphoma. To our knowledge, this is the first reported case of a CD5, CD10 intravascular B-cell lymphoma with leukemic presentation in peripheral blood with multiple cytogenetic aberrations.

False allegations of child physical abuse: a case of Münchausen by proxy-like syndrome?

The diagnosis of factitious disorder by proxy is still under investigation. Few studies have researched the psychological status and potential underlying psychopathology of the perpetrator, as well as the impact on the child's development and the pathological reactions of rearing a child within the context of a distorted reality. In this article, we present the case of a 12-year-old boy where this diagnosis was suspected. Both he and his parents brought forth false allegations of repeated physical abuse induced by his schoolteacher. The parents presented with shared psychosis and the child presented with conduct disorder, factitious disorder, and emotional problems. We suggest that this case represents a Münchausen by proxy-like syndrome involving both the legal and medical systems. Hypotheses regarding the pathogenesis of symptoms in the child are noted, underscoring the differences between Münchausen by proxy syndrome appearing in infancy with that appearing in older children.

Narratives about their children by mothers hospitalized on a psychiatric unit

The diagnosis of "mental illness" is accompanied by negative implications regarding a person's competence. Self- and other-descriptions about the "patient" are embedded within broader cultural and societal discourses, influencing his/her relationships. The parental role seems to be one of the most sensitive, especially for women. Mothers hospitalized in psychiatric units often have to separate themselves from their children either temporarily, during hospitalization, or permanently, after a loss of custody. However, many studies have shown that mothering remains important for them. We interviewed 20 women, inpatients on a psychiatric unit and mothers of 3.5-18-year-old children, recording their narratives about their children and exploring their thoughts and understanding of the concepts of motherhood and mental illness. We also explored the way in which the mother-child dyad interacted with the family and its social context. Most mothers had a consistent and coherent narrative about their children and they had certain expectations of them. The mother-child bond was strong, even when the children had been removed from their mothers' custody. However, mothers were facing great difficulties with their partner and with the broader family context. Also, the social discourses regarding mental illness, (e.g., violence and incapability for mothering), were extremely oppressive for these women. They felt that they were the victims of societal attitudes even before they became pregnant. These findings suggest the importance of listening to the voices of these women; acknowledging their competence in the therapeutic context; involving them with their families, and in legal and social contexts; and in planning supportive programs for them.

Treatment of alcohol withdrawal with gabapentin

Gabapentin is an anticonvulsant agent, also effective in the treatment of mood disorders and anxiety disorders. Three cases of alcohol withdrawal treated with gabapentin are presented. All patients received gabapentin 400 mg tid for 3 days, 400 mg bid for 1 day, and finally 400 mg for 1 day. Withdrawal symptoms subsided and no adverse effects were observed. The possible effectiveness of gabapentin in the treatment of alcohol withdrawal warrants further investigation by systematic and well-designed studies.