Harnessing Electronic Patient-Reported Outcomes (ePRO) in Routine Care to Promote Clinical Trial Enrollment: A Randomized Study

PURPOSE/OBJECTIVE(S)

Only approximately 5% of adult cancer patients participate in clinical trials. While collection of patient-reported outcomes (PRO) is now routine in clinical trials, their role in actively improving care is evolving, particularly in radiation oncology. At our single multi-site institution, weekly electronic patient reported outcomes (ePRO) questionnaires regarding acute toxicity are routinely sent to all patients undergoing breast radiation We hypothesized that using ePROs to prompt recruitment to a clinical trial assessing a supportive intervention would increase enrollment.

MATERIALS/METHODS

An automated weekly query of ePRO survey responses was generated to identify patients with moderate or greater fatigue, the primary eligibility criterion for an ongoing randomized clinical trial testing an integrative medicine intervention. 23 radiation oncologists treating breast cancer were randomized to have their patients potentially eligible by ePRO receive a direct portal message about the trial, or to usual care (physician-based referral). Physician randomization was stratified by patient caseload and assigned in a 1:1 ratio. Secondarily, every other patient in the portal message group was assigned to receive the message either from their radiation oncologist or integrative medicine. Statistical analysis included two-sample, two-sided proportion tests.

RESULTS

From September 5, 2022, to December 19, 2022, among 776 patients completing ePROs during radiation treatment, 252 patients (32%) screened positive for fatigue. Of those who screened positive, 135 were randomized to the ePRO-prompted portal message group and 117 to the usual care group (physician-based referral). Among patients in the portal message group, 52 responded (39%) and 27 enrolled (20%), compared to 1 patient referred (0.8%) and 0 enrolled with physician-based referral alone (p < 0.001). In the portal message group, there were 21 responses (30%) and 12 enrollments (17%) among those messaged by their radiation oncologist, compared to 31 responses (48%) and 15 enrollments (23%) among those messaged by integrative medicine. When evaluating the source of the portal message, there was a significant difference in response rate favoring integrative medicine (p = 0.03), but no difference in enrollments (p = 0.39).

CONCLUSION

Utilization of ePROs to prompt recruitment to a trial testing a symptom intervention resulted in increased enrollment compared to standard physician-based referral, suggesting a promising new role for ePROs. Importantly, messaging from the supportive care service directly did not result in a difference in enrollments and may help reduce oncology physician-level barriers to studies testing supportive interventions. Future directions should investigate this method to reduce disparities in patients enrolling on clinical trials and facilitate access to symptom support services in routine cancer care.

Geothelphusa boreas, a new montane freshwater crab (Crustacea: Potamidae: Geothelphusa) from northeastern Taiwan, and the identity of G. hirsuta Tan amp; Liu, 1998

A new freshwater crab is described from the montane area in northeastern Taiwan based on morphological and molecular evidence. Geothelphusa boreas sp. nov., from the Fushan Botanical Garden situated around New Taipei City and Yilan County, is distinct from similar congeners by the structure of the male first gonopod and the proportions of the male thoracic sternites. In addition, after comparing the holotypes of G. takuan and G. hirsuta Tan Liu, 1998, no substantial difference could be found. Molecular evidence from mitochondrial cytochrome oxidase subunit I also supports the recognition of the new species and the conspecificity of G. hirsuta with G. takuan.

Abstract OT1-08-01: A pilot randomized usual care controlled study of yoga for persistent chemotherapy-induced peripheral neuropathy (CIPN) in breast and gynecological cancer survivors

Background: CIPN is a common, painful, and debilitating side effect of many standard chemotherapy regimens. Patients with CIPN typically experience paresthesia (tingling, numbness), pain, and muscle weakness, and may exhibit significant functional decline and diminished quality of life. Our prior study showed that more than half of breast cancer survivors experience persistent CIPN up to a mean duration of 5.6 years and that this symptom is associated with a doubled fall risk. There is an urgent need to identify nonpharmacological approaches to reduce CIPN symptoms and improve cancer survivors' functional outcomes. Yoga is a mind-body modality that includes stretching, flexibility, and balance training; however, little is known about its effects on symptoms and functional outcomes among cancer survivors with CIPN.

Trial Design: We are conducting a two-arm pilot randomized usual care controlled trial in breast and gynecological cancer survivors at Memorial Sloan Kettering Cancer Center (MSK), New York, NY. Eligible subjects in the intervention arm receive one-hour Hatha Yoga classes taught twice weekly for eight weeks, and practice home-based yoga for a total of 12 weeks. Subjects in the wait list control (WLC) arm continue usual care for 12 weeks, followed by eight weeks of yoga classes and home-based yoga.

Eligibility Criteria: 1) Patients with a primary diagnosis of stage I-III breast, ovarian, uterine, or endometrial cancer; 2) moderate to severe CIPN, defined by four or greater on a 0–10 Numeric Rating Scale (NRS); 3) completion of neurotoxic chemotherapy at least three months prior; 4) no changes in anti-neuropathy medications within three months of enrollment; and 5) an ECOG performance status of 0–2.

Specific Aims: The primary endpoint is safety, feasibility, and NRS changes at eight weeks (end of treatment). The secondary endpoints include the Neuropathic Pain Scale (NPS) and Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx) at eight, 12, and 20 weeks.

Statistical Methods: We will accrue 40 patients to get 36 patients evaluable for the primary endpoint at eight weeks. Using an ANCOVA analysis with a sample size of 36, we will be able to detect an effect size of 00.58 standard deviations (SD) of NRS (moderate effect size) between yoga and WLC assuming a NRS correlation between pre- and post-yoga of 0.5 SD. If we assume a 10% dropout rate based on our recently completed trial, we will need to recruit 20 subjects per arm (total of 40) to fall within the precision noted in the sample size calculation. We recognize that the sample size calculation was based on detecting a moderate effect between yoga and WLC and may miss small but clinically meaningful effects that can be used to design a future trial that is sufficiently powered.

Present accrual and target accrual: 40 participants. We have accrued 25 participants as of June 2018 and anticipate accrual completion by October 2018.

Citation Format: Zhi WI, Leeolou MC, Piulson L, Chen P, Patterson C, Paul T, Patil S, Mao JJ, Bao T. A pilot randomized usual care controlled study of yoga for persistent chemotherapy-induced peripheral neuropathy (CIPN) in breast and gynecological cancer survivors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-08-01.

Abstract P1-11-15: Chemotherapy-induced peripheral neuropathy in breast cancer survivors: Comparison of objective and subjective measures

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a common, potentially debilitating, and dose-limiting side effect experienced by breast cancer survivors. CIPN encompasses symptoms such as pain, numbness, and tingling, which can be measured subjectively by patient-reported outcomes (PRO), or objectively by quantitative sensory testing (QST); however, little is known how QST correlates with symptom profiles measured by PRO.

Methods: We conducted a cross-sectional analysis using baseline data of two ongoing clinical trials of breast cancer survivors who experienced moderate to severe CIPN defined by pain, numbness, or tingling ratings of four or greater on a numeric rating scale (NRS) after chemotherapy completion for at least three months. PRO measures of CIPN symptoms included Neuropathic Pain Scale (NPS) and Functional Assessment of Cancer Therapy-Gynecologic Oncology Group/Neurotoxicity subscale (FACT/GOG-Ntx). QST included tactile threshold (TT) measured by Von Frey's filaments, and vibration threshold (VT) measured by biothesiometer. We ran a Spearman correlation to assess the relationship between the subjective measures (NPS and FACT/GOG-Ntx) and objective measures (TT and VT QST).

Results: We included 52 sets of baseline data on 50 unique patients; two patients were enrolled in both trials at different times. Mean age was 61 years (SD 10) and 66% were white. The mean NRS pain score was 3.9 (SD 2.8), numbness 5.7 (SD 2.2), and tingling 4.3 (SD 2.8) on a 0-10 scale. The mean NPS total score was 39.2 (SD 23.1) on a 0-100 scale, and FACT/GOG-Ntx was 26.2 (SD 6.8) on a 0-44 scale. High scores on NRS and NPS and low scores on FACT/GOG-Ntx signify more severe CIPN symptoms. See Table 1 for a summary of the correlation between two questions on FACT/GOG-Ntx on tingling/numbness in hands and feet, and NPS total score with QST. A moderate correlation was observed between FACT/GOG-Ntx and QST results, suggesting patient-reported hand and foot numbness or tingling is associated with decreased hand and foot tactile and vibration perception. NPS was positively correlated with tactile perception for the hand and foot, but not with vibration perception.

Table 1.Correlation between objective and subjective measures of CIPN Tactile QSTVibration QST HandFeetHandFeetFACT/GOG-Ntx-0.33 (P=0.018)-0.28 (P=0.045)-0.37 (P=0.008)-0.40 (P=0.0034)NPS0.34 (P=0.015)0.32 (P=0.022)0.22 (P=0.12)0.03 (P=0.81)

Conclusions: A mild to moderate correlation was observed between subjective and objective measurements of CIPN. As CIPN presents a diverse range of symptoms, better quantifying the subjective and objective measures of CIPN can help incorporate these tools in observational and intervention trials. Understanding the correlation between PRO and QST can help establish QST as a reliable objective measurement of CIPN symptoms, and enable targeted interventions to alleviate CIPN symptoms.

Citation Format: Bao T, Kwon A, Piulson L, Chen P, Li Q, Patil S, Seidman A, Blinder V, Vahdat L, Zhi WI, Mao JJ. Chemotherapy-induced peripheral neuropathy in breast cancer survivors: Comparison of objective and subjective measures [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-15.

Species Identification of Fragmented or Faded Shed Snake Skins by Light Microscopy

Few convenient/expeditious methods for identifying the species of shed snake skins in specific areas have been developed. The scales on shed snake skins are permeable to light and can be examined by light microscopy (LM), which is of higher availability-especially for wild animal researchers and citizen scientists-than conventional approach which examines the scale microstructures by scanning electron microscopy. We collected and examined a total of 801 shed samples or scale specimens from 53 snake species in Taiwan and adjacent islands, and developed the first guide to identify the fragmented or faded shed skins of most snake species by LM. Morphological characters of scales can be examined by LM include the apical notch, apical pits, apical lobes, keels, scale symmetry, unpigmented spots (mechanoreceptor-like organs), interscale follicles, cross/longitudinal micro-ridge, oberhautchen cells, rows of spines, light/tiny dots, and other microstructures. The microstructures on the scale specimens prepared by the stripped method and the impression method were similar to those on shed skins when examined by LM. We investigated the variations of scale morphology associated with ontogeny, body region, and position on scales, discussed the character evolution of snake scale morphology, and certified that the interscale follicles and the unpigmented spots could also be useful characters for shed skin identification. The methods and results of this study could be applied to identify squamate skins/sloughs and even fecal remnants.

Species Identification of Shed Snake Skins in Taiwan and Adjacent Islands

Tein-Shun Tsai and Jean-Jay Mao (2017) Shed snake skins have many applications for humans and other animals, and can provide much useful information to a field survey. When properly prepared and identified, a shed snake skin can be used as an important voucher; the morphological descriptions of the shed skins may be critical for taxonomic research, as well as studies of snake ecology and conservation. However, few convenient/ expeditious methods or techniques to identify shed snake skins in specific areas have been developed. In this study, we collected and examined a total of 1,260 shed skin samples - including 322 samples from neonates/ juveniles and 938 from subadults/adults - from 53 snake species in Taiwan and adjacent islands, and developed the first guide to identify them. To the naked eye or from scanned images, the sheds of almost all species could be identified if most of the shed was collected. The key features that aided in identification included the patterns on the sheds and scale morphology. Ontogenetic differences and intraspecific variation in the patterns of sheds were evident in some snake species, and the proportion of young snakes with patterned shed skins was larger than that of adults. The retention of markings on the ventral side of the body (especially the ventral head) during sloughing was much lower than that on the dorsal side. We hope that this pioneering work will not only encourage other researchers to develop similar keys for their country, but also promote local schools, organizations, and citizen scientists to conduct snake inventories.

Insulin-like peptides regulate vitellogenesis and oviposition in the green lacewing, Chrysopa septempunctata

Insulin-like peptides (ILPs) act through a conserved insulin signaling pathway and play crucial roles in insect metabolism, growth, reproduction, and aging. Application of bovine insulin is able to increase vitellogenin (Vg) mRNA and protein levels in female insects. Here, we first show that injection of bovine insulin into previtellogenic Chrysopa septempunctata female adults promoted ovarian growth, increased Vg protein abundance, elevated reproductive performance, and enhanced protease activity. These data suggested that ILPs play crucial roles in reproductive regulation of the green lacewing, C. septempunctata.

Abstract P5-13-16: Arthralgia-associated aging perceptions predict adherence to aromatase inhibitors among women with breast cancer

Background:Aromatase inhibitors (AIs) are associated with reduced risk of breast cancer recurrence, yet many women discontinue their treatment prematurely, often due to arthralgia. Empirically, breast cancer survivors who experience AI-associated arthralgia often report that they have aged quickly over a short period of time. Objective: We aimed to determine whether survivors with a heightened sense of aging due to arthralgia were more likely to non-adhere to their AI regimen. Methods: We conducted a prospective cohort study in an urban academic cancer center among post-menopausal women with hormone receptor positive breast cancer who were within the first two years of their aromatase inhibitor therapy. Perceptions of aging due to arthralgia were measured by the previously validated Penn Arthralgia Aging Scale. Non-adherence was defined as interrupting treatment or discontinuing the AI before the prescribed treatment length was over. Trained raters abstracted adherence data from medical charts. We performed Cox proportional hazards regression to evaluate the relationship between perceptions of aging due to arthralgia and time to non-adherence while adjusting for potential confounders. Results: Among 509 participants, most were White (81.2%) and had at least some college education (77.9%). The majority had been prescribed anastrozole (88.0%), followed by letrozole (9.0%), and exemestane (3.0%). During the follow up period, 144 (28.3%) did not adhere to the AIs as originally prescribed. In univariate analysis, women with a heightened sense of aging due to arthralgia were at more than twice the risk of non-adherence compared to women with low levels of aging perceptions (Hazard Ratio [HR], 2.20; 95% CI, 1.50 – 3.21; p &lt; 0.001). After adjusting for arthralgia pain severity, depression, and AI type, aging perceptions remained a statistically significant predictor of adherence (HR, 1.71; 95% CI, 1.10-2.67; p = 0.02). Depression status also uniquely predicted non-adherence risk (HR, 1.63; 95% CI, 1.03 – 2.59; p = 0.04). Arthralgia pain severity, which predicted adherence in univariate analysis, was not a significant predictor in the final model (HR, 1.21; 95% CI, 0.84 – 1.75; p = .30). Conclusions: Breast cancer survivors on AIs who have a heightened sense of aging due to arthralgia are at greater risk of non-adhering to their AI regimen. Interventions are needed to help survivors reduce arthralgia and develop adaptive appraisals of their AI experience to achieve optimal adherence.

Citation Format: Mao JJ, Chambless DL, Chen J, Bao T, Brier MJ. Arthralgia-associated aging perceptions predict adherence to aromatase inhibitors among women with breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-16.

Abstract PD4-02: Health beliefs predict adherence to aromatase inhibitors

Background: Post-menopausal breast cancer survivors are often prescribed aromatase inhibitors (AIs) to decrease the chance of cancer recurrence. Despite their efficacy, many survivors do not fully adhere to their AI regimen. To improve adherence rates, it is important to understand which patient factors are associated with adherence. Current research has mostly focused on demographic, cancer, and symptom variables, most of which cannot be modified. One relevant factor that may be modifiable is health beliefs, which include perceived susceptibility of cancer recurrence, perceived benefits of treatment, and perceived barriers to treatment. Among breast cancer patients, each of these has been found to be associated with adherence behaviors, such as mammography and tamoxifen adherence. In this study, we explored whether health beliefs also play a role in adherence to AIs. Objective: The purpose of this longitudinal study was to determine whether patients with lower perceived susceptibility to cancer recurrence, higher perceived barriers to taking AIs, and lower perceived benefits of AIs were more likely to non-adhere to their AI regimen. Method: Four hundred and thirty-seven breast cancer survivors who were currently on an AI completed a survey that included the Health Beliefs and Medication Adherence in Breast Cancer (HBMABC) scales (a measure adapted from the Champion Health Belief Model Scales (CHBMS) for Mammography Screening), as well as questions about their demographics and symptoms. Exploratory and confirmatory factor analysis of the HBMABC yielded a 3-factor solution: perceived susceptibility, perceived benefits, and perceived barriers. Adherence data, including drug holidays (taking breaks from AI treatment) and premature discontinuation (stopping AI treatment early), were collected from physicians' notes in patients' medical charts dating from the day they completed the survey through the end-date of their prescribed AI treatment. Bivariate analyses were conducted to determine variables that were predictive of non-adherence. Variables found to be associated with non-adherence were entered into multiple logistic regression analyses. Results: Eighty-five patients (20.6%) exhibited some form of non-adherence (premature discontinuation, drug holiday, or both). Joint pain severity and the number of years a patient was on an AI at the time of the survey were both associated with non-adherence. After adjusting for these covariates, perceived barriers to AI treatment was significantly associated with non-adherence (OR 1.76, 95% CI: 1.03 – 3.00, p = 0.04). No relationship was found between perceived susceptibility or perceived benefits, and AI adherence. Conclusions: Breast cancer patients on AIs who perceive greater barriers to AI treatment are more likely to non-adhere to their AI regimen. This finding suggests that clinicians can intervene to help modify patients' negative beliefs and ultimately help improve patients' adherence levels.

Citation Format: Brier MJ, Stricker CT, Chambless DL, Chen J, Ahluwalia K, Mao JJ. Health beliefs predict adherence to aromatase inhibitors. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD4-02.

Mesenchymal dental pulp cells attenuate dentin resorption in homeostasis

Dentin in permanent teeth rarely undergoes resorption in development, homeostasis, or aging, in contrast to bone that undergoes periodic resorption/remodeling. The authors hypothesized that cells in the mesenchymal compartment of dental pulp attenuate osteoclastogenesis. Mononucleated and adherent cells from donor-matched rat dental pulp (dental pulp cells [DPCs]) and alveolar bone (alveolar bone cells [ABCs]) were isolated and separately cocultured with primary rat splenocytes. Primary splenocytes readily aggregated and formed osteoclast-like cells in chemically defined osteoclastogenesis medium with 20 ng/mL of macrophage colony-stimulating factor (M-CSF) and 50 ng/mL of receptor activator of nuclear factor κB ligand (RANKL). Strikingly, DPCs attenuated osteoclastogenesis when cocultured with primary splenocytes, whereas ABCs slightly but significantly promoted osteoclastogenesis. DPCs yielded ~20-fold lower RANKL expression but >2-fold higher osteoprotegerin (OPG) expression than donor-matched ABCs, yielding a RANKL/OPG ratio of 41:1 (ABCs:DPCs). Vitamin D3 significantly promoted RANKL expression in ABCs and OPG in DPCs. In vivo, rat maxillary incisors were atraumatically extracted (without any tooth fractures), followed by retrograde pulpectomy to remove DPCs and immediate replantation into the extraction sockets to allow repopulation of the surgically treated root canal with periodontal and alveolar bone-derived cells. After 8 wk, multiple dentin/root resorption lacunae were present in root dentin with robust RANKL and OPG expression. There were areas of dentin resoprtion alternating with areas of osteodentin formation in root dentin surface in the observed 8 wk. These findings suggest that DPCs of the mesenchymal compartment have an innate ability to attenuate osteoclastogenesis and that this innate ability may be responsible for the absence of dentin resorption in homeostasis. Mesenchymal attenuation of dentin resorption may have implications in internal resorption in the root canal, pulp/dentin regeneration, and root resorption in orthodontic tooth movement.

Description of a new montane freshwater crab (Crustacea: Potamidae: Geothelphusa) from northern Taiwan

A new freshwater crab is described from a montane area in northern Taiwan based on morphological characters and molecular evidence. Geothelphusa cilan sp. nov., from the Cilan Forest, situated on the boundary of Hsinchu and Yilan (= Ilan) counties, is close to G. monticola Shy, Ng & Yu, 1994, and G. takuan Shy, Ng & Yu, 1994, but can be distinguished by its male first gonopod (G1) and the ratio of thoracic sternites. Molecular evidence from mitochondrial cytochrome oxidase subunit I (COI) also supports the identity of the new species.

Physiologic load-bearing characteristics of autografts, allografts, and polymer-based scaffolds in a critical sized segmental defect of long bone: an experimental study

Background

To address the challenge of treating critical sized intercalary defects, we hypothesized that under physiologic cyclic loading, autografts, allografts, and scaffolds loaded with and without human mesenchymal stem cells (hMSCs) would have different biomechanical characteristics.

Methods

Using a rat femoral defect model, 46 rats were assigned to four groups, ie, autograft (n = 12), allograft (n = 10), scaffold (n = 13), and scaffold with hMSCs (n = 11). The scaffold groups used a 5 mm segment of scaffold composed of 80% poly-ε-caprolactone and 20% hydroxyapatite. Rats were sacrificed 4 months postoperatively, and the repairs were assessed radiographically and biomechanically.

Results

Autograft and allograft groups exhibited the most bridging callus, while the scaffold/hMSCs group had more callus than the scaffold repairs. Although signs of radiographic healing did not accurately reflect restoration of mechanical properties, addition of hMSCs on the scaffold enhanced bone formation. The scaffold alone group had significantly lower elastic and viscous stiffness and higher phase angles than other repairs and the contralateral controls. Addition of hMSCs increased the elastic and viscous stiffness of the repair, while decreasing the phase angle.

Conclusion

Further comparative analysis is needed to optimize clinical use of scaffolds and hMSCs for critical sized defect repairs. However, our results suggest that addition of hMSCs to scaffolds enhances mechanical simulation of native host bone.

Sustained inflammation induces degeneration of the temporomandibular joint

The temporomandibular joint (TMJ) undergoes degenerative changes among patients who suffer from arthritis, and yet the pathogenesis of TMJ osteoarthritis and rheumatoid arthritis is poorly understood. We hypothesized that sustained inflammation in the TMJ induces structural abnormalities, and accordingly characterized the disc and synovium in a novel model with double injections of complete Freund's adjuvant (CFA), using behavioral, morphological, cellular, and molecular assessments. Thirty-five days following double CFA injections in seven-week-old female Sprague-Dawley rats, the disc in the CFA-induced inflammation group demonstrated multiple degenerative changes, including marked thickening, opacity, and deformation. The discs in the CFA group further showed significantly greater wet and net weights, and elevated collagen, aggrecan, and total glycosaminoglycan contents. The synovium in the CFA-induced inflammation group showed marked infiltration of mononucleated cells and accumulated sub-synovial adipose tissue. Both the disc and synovium had significantly higher iNOS and IL-1β mRNA expression than controls (saline injections). These findings are consistent with our hypothesis that sustained TMJ inflammation, even within the presently observed 35 days, may be a predisposing factor for structural abnormalities. Insight into TMJ inflammation and degeneration is anticipated to improve our understanding of the pathogenesis of TMJ arthritis and help design clinically relevant strategies for tissue engineering.

Induced migration of dental pulp stem cells for in vivo pulp regeneration

Dental pulp has intrinsic capacity for self-repair. However, it is not clear whether dental pulp cells can be recruited endogenously for regenerating pulp tissues, including mineralizing into dentin. This work is based on a hypothesis that dental pulp stem/progenitor cells can be induced to migrate by chemotactic cytokines and act as endogenous cell sources for regeneration and mineralization. Dental stem cells (DSCs) were isolated from adult human tooth pulp and seeded on the surfaces of 3D collagen gel cylinders that were incubated in chemically defined media with stromal-derived factor-1α (SDF1), basic fibroblast growth factor (bFGF), or bone morphogenetic protein-7 (BMP7). Significantly more cells were recruited into collagen gel by SDF1 or bFGF than without cytokines in 7 days, whereas BMP7 had little effect on cell recruitment. BMP7, however, was highly effective, equally to dexamethasone, in orchestrating mineralization of cultured DSCs. Cell membrane receptors for SDF1, bFGF, and BMP7 were up-regulated in treated DSCs. Upon in vivo delivery, bFGF induced re-cellularization and re-vascularization in endodontically treated human teeth implanted into the dorsum of rats. Thus, endogenous dental pulp cells, including stem/progenitor cells, may be recruited and subsequently differentiated by chemotaxis of selective cytokines in the regeneration of dental pulp.

Anatomically shaped tooth and periodontal regeneration by cell homing

Tooth regeneration by cell delivery encounters translational hurdles. We hypothesized that anatomically correct teeth can regenerate in scaffolds without cell transplantation. Novel, anatomically shaped human molar scaffolds and rat incisor scaffolds were fabricated by 3D bioprinting from a hybrid of poly-epsilon-caprolactone and hydroxyapatite with 200-microm-diameter interconnecting microchannels. In each of 22 rats, an incisor scaffold was implanted orthotopically following mandibular incisor extraction, whereas a human molar scaffold was implanted ectopically into the dorsum. Stromal-derived factor-1 (SDF1) and bone morphogenetic protein-7 (BMP7) were delivered in scaffold microchannels. After 9 weeks, a putative periodontal ligament and new bone regenerated at the interface of rat incisor scaffold with native alveolar bone. SDF1 and BMP7 delivery not only recruited significantly more endogenous cells, but also elaborated greater angiogenesis than growth-factor-free control scaffolds. Regeneration of tooth-like structures and periodontal integration by cell homing provide an alternative to cell delivery, and may accelerate clinical applications.

Onset and risk factors for aromatase inhibitor-related arthralgia in breast cancer survivors

Abstract #1120

Purpose: Arthralgia is a common clinical phenomenon seen in postmenopausal women receiving aromatase inhibitors (AI). This study aims to evaluate the perceived onset, prevalence, and risk factors for AI-related arthralgia.&#x2028; Patients and Methods: We performed a cross-sectional analysis of a cohort of postmenopausal women with stage I-III breast cancer receiving adjuvant AI therapy at an outpatient breast oncology clinic at a large university hospital. Patient-reported symptoms and attribution of AI as a cause of arthralgia were main outcomes. Multivariate logistic regression analyses were performed to assess risk factor(s).&#x2028; Results: 300 patients have been enrolled, with a mean age of 61 +/- 10 years, 84% White, and 38(13%) Black. A total of 173 (58%) reported AI-related arhtralgia during the course of AI treatment and 139 (47%) attributed AI as a cause of their current arthralgia. While 103 (34%) reported having “arthritis” prior to AI initiation, 13% reported onset of symptoms within 1 month of medication initiation, 42% between 1-3 months, 27% between 3-6 months, 12% between 6-12 months, and 20% after 12 months. In a multivariate logistic regression model, time since last menstrual period (LMP) was the only significant predictor of reporting AI-related arthralgia; age, race, employment status, chemotherapy, and weight gain since breast cancer were not associated with the clinical syndrome. Controlling for these covariates, those who had LMP within 5 years had the highest probability of reporting AI-related arthralgia (73%), while those with LMP beyond 10 years had the lowest (35%), p=0.017. Prior arthritis was unrelated to AI-related arthralgia either in univariate or multivariate analyses.&#x2028; Conclusions: AI-related arthralgia is common and appears to be inversely related to the length of time since cessation of menstrual function. These findings suggest that estrogen withdrawal may compound these symptoms and may play a role in the mechanism of this disorder.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1120.

Feasibility trial of electro-acupuncture for aromatase inhibitor related arthralgia in breast cancer survivors

Abstract #3105

Background: Arthralgia affects postmenopausal women receiving aromatase inhibitors (AI) for breast cancer. Given the existing evidence for electro-acupuncture (EA) for treatment of osteoarthritis in the general population, this study aims to establish the feasibility of studying EA for treating AI-related arthralgia.&#x2028; Patients and Methods: Postmenopausal women with stage I-III breast cancer with joint pain related to AIs were enrolled in a pilot single arm trial of acupuncture. Acupuncture was provided twice a week for 2 weeks followed by 6 weekly treatments (total of 10 treatments over 8 weeks). Manualized protocol was based on Chinese medicine diagnosis of “Bi” syndrome with eletro-stimulation of needles around the painful joint(s). Pain severity of the modified Brief Pain Inventory was used as the primary outcome. Joint stiffness and Joint interference were secondary outcomes. Patient Global Impression of Change (PGIC) was used to assess clinical relevance. Fatigue and anxiety were also evaluated. Paired-t tests were used for analysis.&#x2028; Results: Twelve women were enrolled and all provided data for analysis. From baseline to the end of intervention, patients reported improvement in pain severity (5.3 to 1.9), stiffness (6.9 to 2.4), and joint symptom interference (4.7 to 0.8), all P&lt;0.001; 11/12 reported joint symptoms “very much improved” based on PGIC . Subjects also reported significant decrease in fatigue (4.4 to 1.9, p=0.005) and anxiety (7.1 to 4.8, p=0.01). One subject withdrew from interventions due to an adverse event (herpes zoster) thought to be unrelated to acupuncture. Two subjects reported grade 1 self-limiting pain associated with acupuncture. No infection or development or worsening of lymphedema was observed.&#x2028; Conclusion: EA is a potentially safe and effective treatment for AI-related arthralgia; thus, a randomized controlled trial is warranted to establish the short term and long term efficacy and safety of EA in breast cancer survivors.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3105.

Craniofacial tissue engineering by stem cells

Craniofacial tissue engineering promises the regeneration or de novo formation of dental, oral, and craniofacial structures lost to congenital anomalies, trauma, and diseases. Virtually all craniofacial structures are derivatives of mesenchymal cells. Mesenchymal stem cells are the offspring of mesenchymal cells following asymmetrical division, and reside in various craniofacial structures in the adult. Cells with characteristics of adult stem cells have been isolated from the dental pulp, the deciduous tooth, and the periodontium. Several craniofacial structures--such as the mandibular condyle, calvarial bone, cranial suture, and subcutaneous adipose tissue--have been engineered from mesenchymal stem cells, growth factor, and/or gene therapy approaches. As a departure from the reliance of current clinical practice on durable materials such as amalgam, composites, and metallic alloys, biological therapies utilize mesenchymal stem cells, delivered or internally recruited, to generate craniofacial structures in temporary scaffolding biomaterials. Craniofacial tissue engineering is likely to be realized in the foreseeable future, and represents an opportunity that dentistry cannot afford to miss.

Tissue-engineered rabbit cranial suture from autologous fibroblasts and BMP2

Craniosynostosis is a congenital disorder of premature ossification of cranial sutures, occurring in one of approximately every 2500 live human births. This work addressed a hypothesis that a cranial suture can be tissue-engineered from autologous cells. Dermal fibroblasts were isolated subcutaneously from growing rabbits, culture-expanded, and seeded in a gelatin scaffold. We fabricated a composite tissue construct by sandwiching the fibroblast-seeded gelatin scaffold between two collagen sponges loaded with recombinant human BMP2. Surgically created, full-thickness parietal defects were filled with the composite tissue construct in the same rabbits from which dermal fibroblasts had been obtained. After four-week in vivo implantation, there was de novo formation of tissue-engineered cranial suture, microscopically reminiscent of the adjacent natural cranial suture. The tissue-engineered cranial suture showed radiolucency on radiographic images, in contrast to radio-opacity of microscopically ossified calvarial defects filled with fibroblast-free, BMP2-loaded constructs. This approach may be refined for tissue engineering of cranial sutures for craniosynostosis patients.

Tissue-engineered neogenesis of human-shaped mandibular condyle from rat mesenchymal stem cells

The temporomandibular joint is susceptible to diseases and trauma that may ultimately lead to structural degeneration. Current approaches for replacing degenerated mandibular condyles suffer from deficiencies such as donor site morbidity, immunorejection, implant wear and tear, and pathogen transmission. The hypothesis of this study was that a human-shaped mandibular condyle can be tissue-engineered from rat mesenchymal stem cells (MSCs) encapsulated in a biocompatible polymer. Rat bone marrow MSCs were isolated and induced to differentiate into chondrogenic and osteogenic cells in vitro, and encapsulated in poly(ethylene glycol)-based hydrogel in two stratified layers molded into the shape of a cadaver human mandibular condyle. Eight weeks following in vivo implantation of the bilayered osteochondral constructs in the dorsum of immunodeficient mice, mandibular condyles formed de novo. Microscopic evaluation of the tissue-engineered mandibular condyle demonstrated two stratified layers of histogenesis of cartilaginous and osseous phenotypes. The current approach is being refined for ultimate therapeutic applications.

Nanomechanical properties of facial sutures and sutural mineralization front

The mechanical properties of craniofacial sutures have rarely been investigated. Three facial sutures-the pre-maxillomaxillary (PMS), the nasofrontal (NFS), and the zygomaticotemporal (ZTS)-and their corresponding sutural mineralization fronts in 8 young New Zealand White rabbits were subjected to nano-indentation with atomic force microscopy as a test of the hypothesis that they have different mechanical properties. The average elastic modulus of the PMS was 1.46 +/- 0.24 MPa (mean +/- SD), significantly higher than both the ZTS (1.20 +/- 0.20) and NFS (1.16 +/- 0.18). The average elastic moduli of sutural mineralization fronts 30 micro m away were significantly higher than their corresponding sutures and had the same distribution pattern: the PMS (2.07 +/- 0.24 MPa) significantly higher than both the ZTS (1.56 +/- 0.29) and NFS (1.71 +/- 0.22). Analysis of these data suggests that facial sutures and their immediately adjacent sutural mineralization fronts have different capacities for mechanical deformation. The elastic properties of sutures and sutural mineralization fronts are potentially useful for improving our understanding of their roles in development.

Mechanobiology of craniofacial sutures

Craniofacial sutures are soft connective-tissue joints between mineralized skull bones. Suture mechanobiology refers to the understanding of how mechanical stimuli modulate sutural growth. This review's hypothesis is that novel mechanical stimuli can effectively modulate sutural growth. Exogenous forces with static, sinusoidal, and square waveforms induce corresponding waveforms of sutural strain. Sutural growth is accelerated upon small doses of oscillatory strain, as few as 600 cycles delivered 10 min/day over 12 days. Interestingly, both oscillatory tensile and compressive strains induce anabolic sutural responses beyond natural growth. Mechanistically, oscillatory strain likely turns on genes and transcription factors that activate cellular machinery via mechanotransduction pathways. Thus, sutural growth is determined by hereditary and mechanical signals via the common pathway of genes. It is concluded that small doses of oscillatory mechanical stimuli have the potential to modulate sutural growth effectively: either accelerating it or initiating net sutural bone resorption for various therapeutic objectives.

Chondrocyte proliferation of the cranial base cartilage upon in vivo mechanical stresses

Whereas the growth of the cranial base cartilage is thought to be regulated solely by genes, epiphyseal growth plates are known to respond to mechanical stresses. This disparity has led to our hypothesis that chondrocyte proliferation is accelerated by mechanical stimuli above natural growth. Two-Newton tensile forces with static and cyclic waveforms were delivered in vivo to the premaxillae of actively growing rabbits for 20 min/day over 12 consecutive days. The average number of BrdU-labeled chondrocytes in the proliferating zone treated with cyclic forces was significantly higher than both static forces of matching peak magnitude and sham controls representing natural chondral growth. Cyclic forces also evoked greater area of the proliferating zone than both static forces and sham controls. Thus, chondrocyte proliferation is enhanced by mechanical stresses in vivo, especially those with oscillatory waveform. Analysis of these data suggests that genetically coded chondral growth is up-regulated by mechanical signals.

Bone strain patterns of the zygomatic complex in response to simulated orthopedic forces

Craniofacial bone strain upon orthopedic loading has rarely been characterized, despite its fundamental importance in our understanding of the anabolic and catabolic effects of orthopedic forces. The present study tested the hypothesis that zygomatic bone strain is modulated upon loading by headgear, a device widely used in craniofacial orthopedics. Ramp forces from 0 to 50 Newtons were applied via headgear attached to the permanent maxillary first molars in four juvenile and five adult human skulls. The average peak bone strain of the juvenile temporal articular eminence was significantly higher than the adult articular eminence (p < 0.05). Contrasting bone strain patterns were identified in the zygomatic arch: tensile in its lateral surface but compressive in its medial surface. The peak bone strain of the temporal articular eminence and the zygomatic arch both depend upon loading direction. Thus, headgear-generated orthopedic forces evoke bending of the zygomatic arch and stresses of the temporal articular eminence in vitro, suggesting the need to verify whether bone strain induces in vivo bone modeling and remodeling.

Regional structural and viscoelastic properties of fibrocartilage upon dynamic nanoindentation of the articular condyle

Fibrocartilage,a tissue with macromaterial properties between dense fibrous tissue and hyaline cartilage, is not well understood in its ultrastructure and regional viscoelastic properties. Here nanoindentation with atomic force microscopy was performed on fresh fibrocartilage samples of rabbit jaw joint condyles. Each sample was divided into anteromedial, anterolateral, posteromedial, and posterolateral regions for probing and topographic imaging in 2 x 2 microm and 10 x 10 microm scan sizes. Young's moduli differed significantly among these regions in a descending gradient from the anteromedial (2.34 +/- 0.26 MPa) to the posterolateral (0.95 +/- 0.06 MPa). The Poisson ratio, defined as lateral strain over axial strain, had the same gradient distribution: highest for the anteromedial region (0.46 +/- 0.05) and lowest for the posterolateral region (0.31 +/- 0.05). The same four regions showed a descending gradient of surface roughness: highest for the anteromedial (321.6 +/- 13.8 nm) and lowest for the posterolateral (155.6 +/- 12.6 nm). Thus, the regional ultrastructural and viscoelastic properties of fibrocartilage appear to be coregulated. Based on these region-specific gradient distributions, fibrocartilage is constructed to withstand tissue-borne shear stresses, which likely propagate across its different regions. A model of shear gradient and concentric gradient is proposed to describe the region-specific capacity of fibrocartilage to sustain shear stresses in tendons, ligaments, joints, and the healing bone across species.

The relationship between alphaB-crystallin and neurofibrillary tangles in Alzheimer's disease

AlphaB-crystallin is known as a small heat shock protein with a cytoprotective function. This study was undertaken to investigate the relationship between alphaB-crystallin and changes seen in Alzheimer's disease. The distribution and immunohistochemical characteristics of alphaB-crystallin positive neurones in the cerebral cortices of 4 patients with Alzheimer's disease were examined. AlphaB-crystallin positive neurones were mainly distributed in the limbic and paralimbic regions, namely parahippocampal gyrus, fusiform gyrus, cingulate cortex, middle and superior frontal gyrus, and insular cortex, which corresponded to commonly affected regions in Alzheimer's disease. Moreover, such neurones were present predominantly in the III or V layer of the cerebral cortex. The number of alphaB-crystallin positive neurones increased in parallel with the neuronal loss. Logistic regression analysis revealed a significant relation between the density of alphaB-crystallin positive neurones and that of extracellular neurofibrillary tangles (NFTs), with a correlation coefficient (r) of 0.57 and P < 0.0001 in 14 regions of the cerebral cortex. In contrast, the relation was not statistically significant between the density of alphaB-crystallin positive neurones and that of classical senile plaques, diffuse plaques or intracellular NFTs. Modified Gallyas-Braak (GB) staining on alphaB-crystallin positive neurone demonstrated several patterns of the structures: faint GB positive structures in the swollen perikaryon with straight neurites, fine granules compressed and contorted into fuzzy bundles, intensely GB positive filamentous structures together with fine granules and very intensely GB positive ring-like NFTs in a swollen perikaryon with curved neurites. In positive neurones, the density of ring-like NFTs correlated with that of atrophic perikaryon, or bent neurites and a decrease in the immunoreactivity of alphaB-crystallin. These data suggest that a close relationship exists between the appearance of alphaB-crystallin in neurones, extracellular NFTs, and neurofibrillary formation in alphaB-crystallin positive neurones in Alzheimer brain.

Gallyas-positive argyrophilic and ubiquitinated filamentous inclusions in rapidly progressive motor neuron disease: immunohistochemical and electron microscopic studies

In an autopsy case of sporadic rapidly progressive lower motor neuron disease (MND), Gallyas-positive argyrophilic and ubiquitinated filamentous intracytoplasmic inclusions were found in the neurons. Clinically, 7 months prior to death, a 68-year-old woman experienced a history of rapidly progressive muscle weakness of all four extremities and bulbar sign, without sensory and autonomic disturbance. Two months later, she became unable to stand or walk. Four months after onset, she needed respiratory support, and subsequently died due to cardiorespiratory arrest. Neuropathological examinations revealed neuronal loss and associated gliosis in the lower motor neurons, except for ocular motor nuclei, Clark's column, and accessory cuneate nucleus, and tract degeneration was observed in the middle root zone of the posterior column and spinocerebellar tract. No Bunina bodies or Lewy body-like hyaline inclusions were found in the anterior horns. Gallyaspositive argyrophilic filamentous inclusions were found in the lower motor neurons and in nerve cells of the Clark's column, intermediate zone, posterior horn and accessory cuneate nucleus. These were positive with anti-ubiquitin antibody but negative with anti-tau (tau-2 and AT8) and neurofilament antibodies. Electron microscopic examinations disclosed randomly arranged tubular-like filamentous profiles, with a diameter of 12-14 nm, sometimes with amorphous granules in the perikaryon. This is the first report on the Gallyas-positive argyrophilic and ubiquitinated filamentous inclusions in neurons in MND.

Slowly progressive L-DOPA nonresponsive pure akinesia due to nigropallidal degeneration: a clinicopathological case study

We report an autopsy case of a 51-year old man who showed slowly progressive pure akinesia: freezing phenomenon and festination during 21 years of illness without tremor, rigidity, upward gaze palsy, bradykinesia and dementia, which were not responded to L-DOPA clinically. Neuropathological findings revealed the circumscribed regions in the substantia nigra and middle portion of the internal globus pallidus (GPi), without neurofibrillary tangles, neuropil threads, and glial fibrillary tangles. So this case was clearly distinguished with progressive nuclear palsy and pallidonigroluisian atrophy. It was first reported to describe that L-DOPA nonresponsive pure akinesia can arise from nigopallidal atrophy.

Proteoglycan expression in the rat temporomandibular joint in response to unilateral bite raise

The vertebrate articular tissue consists of collagen fibers embedded in a ground substance. Collagen resists tensile forces, while proteoglycans in the ground substance provide resilience and resistance to compression. It was hypothesized that unilateral bite raise would induce increasing expression of proteoglycans in TMJ articular tissues. As a test of this hypothesis, six- and nine-week-old Sprague-Dawley rats received unilateral bite-raising appliances bonded to their right upper molars for 4 wks. A group of nine-week-old rats was housed for an additional 4 wks after removal of the appliances they had worn for 4 wks. Proteoglycans that carry abundant chondroitin sulfate and keratan sulfate side-chains, most likely aggrecans, were detected by safranin O in the fibrocartilaginous zone of the condyle in parasagittal sections. A monoclonal antibody against a large chondroitin sulfate proteoglycan related to versican reacted strongly in the surface fibrous layer of the mandibular condyle and moderately in the discs of the treated specimens. Computer quantification for safranin O and anti-versican antibody staining revealed that the average intensities of the treated specimens were significantly higher than those of their corresponding sham-operated controls, and the average intensities of the treatment-reversal specimens had no significant differences from their corresponding sham-operated controls. Thus, unilateral bite raise appeared to have induced an increase in the expression of aggrecan in the condylar cartilage and a proteoglycan related to versican in the TMJ disc and the articular surface of the condyle. The elevated proteoglycan expression is interpreted to suggest that unilateral bite raise leads to an increase in the magnitude of compressive forces in the rat temporomandibular joint.

Argyrophilic structures stimulate glial reactions in neurofibrillary tangles and senile plaques

Neurofibrillary tangles (NFT) and senile plaques (SP) contain various pathological structures, and the majority of these pathological structures are argyrophilic. To investigate the glial reactions of the argyrophilic substance, we performed immunohistochemistry for microglia or for astroglia after Gallyas-Braak staining, which is one of the most sensitive silver impregnation techniques detecting argyrophilic structures in NFT and SP. We found that extracellular argyrophilic structures in NFT and SP showed glial reactions, and we observed reactive microglia in the center of NFT and SP in contrast to astroglia, which were situated in the periphery. These findings suggest that the exposed argyrophilic components in the extracellular space stimulate both glial reactions, but that there is a striking difference in localization between microglia and astroglia.

Coupling electrical and mechanical outputs of human jaw muscles undertaking multidirectional bite-force tasks

Previous studies have identified both linear and curvilinear relations between increasing bite-force magnitude and the integrated electromyogram (EMG) of jaw-closing muscles. In an attempt to explain the discrepancy, bite forces of incrementally increasing magnitude were produced on the right-hand side in five specified directions by eight humans. Linear regression lines were fitted to normalized EMG activities of the left and right masseter and temporalis muscles against increasing bite-force magnitude in each direction. The grand mean of linear correlation coefficients was 0.79 (+/- 0.11 SD), suggesting an overall linear relation. Each set of individual data was fitted with polynomial lines up to the third order. The best fit was selected by statistical significance of coefficients and the least-square analysis of the sum of residues for each fitted line; 62% of individual data-sets were best fitted with linear regression lines, 31% with quadratic lines and the remaining 7% with cubic lines. Repeated analysis of residue variance of the pooled data showed that either a linear or quadratic line fitted every data set except one, for which a cubic line had the best fit. Working-side muscles had significantly larger linear correlation coefficients than corresponding balancing-side muscles for most bite-force directions. Analysis of variance of linear correlation coefficients revealed that the degree of linearity often depended upon the roles played by a muscle in producing forces in different directions. It appears that linearity or non-linearity of the EMG force relation is a determinant, among other variables, of the direction of the resultant force.