Treatment patterns and outcomes of high-grade immune checkpoint inhibitor-related pneumonitis in an oncology hospitalist service

PURPOSE

Immune checkpoint inhibitors (ICI) have become standard of care for some types of lung cancer. Along with expanding usage comes the emergence of immune-related adverse events (irAEs), including ICI-related pneumonitis (ICI-P). Treatment guidelines for managing irAEs have been developed; however, how clinicians manage irAEs in the real-world setting is less well known. We aimed to describe the outcomes and care patterns of grade ≥ 3 ICI-P in an onco-hospitalist service.

PATIENTS AND METHODS

We included patients with lung cancer treated with ICI who were admitted to an oncology hospitalist service with a suspicion of ICI-P. We described the hospitalization characteristics, treatment patterns, discharge practices, and clinical outcomes of patients with confirmed ICI-P. The primary outcome was time to start treatment for ICI-P.

RESULTS

Among 49 patients admitted with a suspicion of ICI-P, 31 patients were confirmed to have ICI-P and subsequently received ICI-P directed treatment. Pulmonology was consulted in 97% of patients. Median time to start treatment for ICI-P was 1 day (IQR 0-3.5 days). All 31 patients received corticosteroids. Inpatient mortality was 32%. Majority of patients discharged with steroids were prescribed prophylaxis for gastritis and opportunistic infections. Thirty-eight percent of patients were seen by pulmonology and 86% were seen by the oncology team post-discharge.

CONCLUSION

Our study confirms prior findings of high mortality among patients with high-grade ICI-P. Early diagnosis and treatment are key to improving clinical outcomes. Understanding the care patterns and adherence to treatment guidelines of clinicians caring for this patient population may help identify ways to further standardize management practices and improve patient outcomes.

Monitoring of Triple Negative Breast Cancer After Neoadjuvant Chemotherapy

Triple negative breast cancer (TNBC) is an aggressive disease with a poor prognosis that disproportionately affects young women and African Americans, and represents a major unmet need in the field. TNBCs display a more aggressive growth pattern with an increased risk of advanced disease and high recurrence risk in patients with early stage TNBC. The addition of immunotherapy to chemotherapy for the treatment of patients with early stage TNBC in the (neo) adjuvant setting per the pivotal KEYNOTE 522 significantly improved pCR rates. Despite this advancement, however, approximately 35% of patients had residual disease at the time of surgery and reduced event free survival. Further techniques to assess for molecular residual disease after completion of neoadjuvant chemotherapy (NAC) may allow us to identify patients at high risk of relapse who may benefit from salvage adjuvant systemic therapy, while also potentially de-escalating treatment in those achieving a molecular complete response.

Abstract P1-04-14: Predicting the likelihood of response in PDL-1 positive metastatic triple negative breast cancer treated with an immune checkpoint inhibitor

Background: Patients with metastatic triple negative breast cancer (mTNBC) have a poor prognosis with median survival of 18 months or less. While the combination of immune checkpoint inhibitors (ICIs) and chemotherapy has shown promise in mTNBC, biomarkers beyond PDL-1 are needed to better predict which individuals will benefit from this treatment approach. In this study, we assessed the ability of spatial characteristics in predicting clinical best response in patients with PDL-1 positive mTNBC treated with an ICI and chemotherapy. Methods: Women with advanced unresectable or mTNBC treated with an ICI plus chemotherapy at Emory University between 2019 and 2021 with available biopsy specimens were retrospectively evaluated. Different cell types (tumor, stroma, immune cells) were identified by morphology on H&E staining. A cellular network was created by connecting each cell centroid to its adjacent centroids within a 30-μm distance. The resulting spatial neighborhood network was used to assess tumor density and quantify immune infiltration. The immune infiltration score was defined as the number of immune to tumor cell neighbors divided by the total number of immune cell neighbors in a region of 75-μm. A final immunoscore was calculated for each patient by averaging the immune infiltration scores in regions with high tumor cell density. Tumor infiltrating lymphocytes (TILs) were manually quantified. Responders were defined as those with a complete response (CR), partial response (PR), or stable disease (SD), while those with progressive disease (PD) were categorized as non-responders. A continuous response score was developed from tumor measurements of a target lesion on serial imaging. Pearson’s correlation coefficients were used to assess the relationship between continuous response scores and tumor characteristics. Responders and non-responders were compared using Mann-Whitney U tests. Results: Fifteen women with PDL-1 positive mTNBC treated with ICI plus chemotherapy and available tissue were included. All patients had relapsed disease, and 10 patients (67%) received an ICI and chemotherapy as first line treatment for mTNBC. Eight patients (53%) received atezolizumab and nab-paclitaxel while the remaining 7 (47%) patients received pembrolizumab with an approved chemotherapeutic agent. Seven patients (47%) experienced a PR, 3 (20%) with a CR, and 1 (7%) had SD. Four patients (27%) had PD with no clinical benefit. Higher immunoscores (-0.17, p=0.6) and TILs (-0.21, p=0.5) were numerically associated with continuous response scores. However, there were no significant differences in immunoscores (0.28 vs 0.26, p=0.6) or TIL counts (2 vs 5, p=0.6) between responders (N=11) and non-responders (N=4). Interestingly, patients with response to treatment had lower tumor densities compared to non-responders (7.5 vs 17.3, p=0.02). Conclusions: Spatial analysis of tumor density and immune infiltration, including immunoscore shows evidence of correlation with response. Tumor density was the only parameter significantly associated with response. The study identified novel tumor characteristics that need to be considered in the prediction of response to ICIs plus chemotherapy in mTNBC. The current findings are hypothesis generating and need validation in additional tissue samples to determine the role of tumor density as a predictor of response to ICI.

Citation Format: Jeffrey Aldrich, Thomas Hu, Jeffrey Switchenko, Ahmet Coskun, Yesim Gokmen-Polar, Sunil Badve, Manali Bhave. Predicting the likelihood of response in PDL-1 positive metastatic triple negative breast cancer treated with an immune checkpoint inhibitor [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-04-14.

Racial Disparities in Clinical Outcomes on Investigator-Initiated Breast Cancer Clinical Trials at an Urban Medical Center

BACKGROUND

Black women are 40% more likely to die of breast cancer compared to White women. Inadequate representation of Black patients in clinical trials may contribute to health care inequity. We aimed to assess breast cancer clinical outcomes in Non-Hispanic Black (Black) versus Non-Hispanic White (White) women with metastatic breast cancer (MBC) enrolled on investigator-initiated clinical trials at Winship Cancer Institute at Emory University, given the significant number of patients from underrepresented minority groups seen at Winship.

MATERIALS AND METHODS

Black and White women with MBC on investigator-initiated trials at Emory between 2009 and 2019 were retrospectively evaluated. Univariate analyses and multiple logistic regression models were used to assess clinical response and treatment toxicities. Differences in overall survival between groups was assessed using quantile analysis.

RESULTS

Sixty-two women with MBC were included (66% White vs. 34% Black). Black patients had less clinical benefit from the trial therapy as only 57% had partial response or stable disease as best response compared to 78% of White women (P = .09). Quantile analysis showed significant difference in mean survival between Whites and Blacks by the end of follow up (64 vs. 38 months). There were no significant differences in toxicities between groups.

CONCLUSION

Participation rates of Black women with MBC on investigator-initiated clinical trials at an urban cancer center were higher compared to key national trials. Black women had worse treatment response and survival. These results reinforce the need for assessment of tumor differences by ancestry and continued improvement in minority representation on clinical trials.

Spatially variant immune infiltration scoring in human cancer tissues

The Immunoscore is a method to quantify the immune cell infiltration within cancers to predict the disease prognosis. Previous immune profiling approaches relied on limited immune markers to establish patients’ tumor immunity. However, immune cells exhibit a higher-level complexity that is typically not obtained by the conventional immunohistochemistry methods. Herein, we present a spatially variant immune infiltration score, termed as SpatialVizScore, to quantify immune cells infiltration within lung tumor samples using multiplex protein imaging data. Imaging mass cytometry (IMC) was used to target 26 markers in tumors to identify stromal, immune, and cancer cell states within 26 human tissues from lung cancer patients. Unsupervised clustering methods dissected the spatial infiltration of cells in tissue using the high-dimensional analysis of 16 immune markers and other cancer and stroma enriched labels to profile alterations in the tumors’ immune infiltration patterns. Spatially resolved maps of distinct tumors determined the spatial proximity and neighborhoods of immune-cancer cell pairs. These SpatialVizScore maps provided a ranking of patients’ tumors consisting of immune inflamed, immune suppressed, and immune cold states, demonstrating the tumor’s immune continuum assigned to three distinct infiltration score ranges. Several inflammatory and suppressive immune markers were used to establish the cell-based scoring schemes at the single-cell and pixel-level, depicting the cellular spectra in diverse lung tissues. Thus, SpatialVizScore is an emerging quantitative method to deeply study tumor immunology in cancer tissues.

Real-world outcomes of Black women versus non-Hispanic White women with advanced triple-negative breast cancer treated with immune checkpoint inhibitors at an urban cancer center

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Background: Black women (BW) are disproportionately diagnosed with metastatic triple negative breast cancer (mTNBC) compared to Non-Hispanic White women (NHW). Median overall survival (OS) in mTNBC remains poor at 12-18 months. While immune checkpoint inhibitors (ICIs) are a promising treatment strategy, BW were significantly underrepresented in pivotal clinical trials that led to the approval of ICIs in mTNBC. Therefore, the efficacy, safety, and optimal biomarkers of ICI response in BW remain unknown. We sought to compare baseline characteristics and outcomes between BW and NHW with mTNBC treated with an ICI and chemotherapy at an urban tertiary care institution. Methods: BW and NHW with advanced unresectable or mTNBC treated with an ICI plus chemotherapy at Emory University between 2019 and 2021 were retrospectively evaluated. Baseline characteristics, including next generation sequencing (NGS), as well as clinical outcomes between BW and NHW were compared using Kruskal-Wallis tests and Fisher’s exact tests. Progression free survival (PFS) and OS were analyzed with the Kaplan-Meir method. Results: Forty-one women with PDL-1 positive mTNBC treated with an ICI and chemotherapy were identified [BW, n = 26 (63%) and NHW, n = 15 (37%)]. A majority of patients had relapsed disease (73%); however BW were more likely to have de novo metastatic disease compared to NHW (38% vs 7%, p = 0.03). Twenty-seven (66%) patients received atezolizumab and 14 (34%) were treated with pembrolizumab. Of the 23 (56%) patients with NGS testing, alterations in TP53, PIK3CA, and BRCA were seen in 23 (100%), 5 (31%), and 1 (6%) patient, respectively. Median tumor mutational burden was similar between BW and NHW (5 vs 7, p = 0.8). BW had numerically lower median PDL-1 (SP142) compared to NHW (1% vs 2%, p = 0.5). Rates of immune and dose-limiting chemotherapy-related adverse events were similar between BW and NHW (Table). There were no differences in ICI response between groups, though BW had fewer complete responses and a shorter median PFS compared to NHW. Median OS was 12 months in BW compared to 28 months in NHW (p = 0.1). Conclusions: Our experience with real-world use of this regimen showed that BW had fewer complete responses and a trend towards worse OS compared to NHW. BW had numerically lower median PDL-1 expression compared to NHW, suggesting further investigation of biomarkers, potentially by Race, are needed to better identify responders to ICI in mTNBC. [Table: see text]

Activity of decitabine as maintenance therapy in core binding factor acute myeloid leukemia

Background

Posttherapy measurable residual disease (MRD) positivity in core binding factor acute myeloid leukemia (CBF‐AML) is associated with shorter relapse‐free survival (RFS). Elimination of MRD measured via quantitative reverse transcription polymerase chain reaction (qRTPCR) for disease specific transcripts can potentially lead to better outcomes in CBF‐AML.

Methods

We prospectively monitored the MRD using qRTPCR and flow cytometry on bone marrow samples in patients with newly diagnosed CBF‐AML who received decitabine (DAC) maintenance therapy after fludarabine/cytarabine/G‐CSF (FLAG)‐based induction/consolidation regimen. Negative qRTPCR (CMR) was defined as fusion transcript <0.01%.

Results

Thirty‐one patients with CBF‐AML including 14 with t(8;21) and 17 with inv(16) received parenteral DAC as maintenance therapy. Fifteen patients (48.3%) had completed FLAG‐based induction/consolidation but with positive MRD (0.35%, range = 0.01%–0.91%) (Group 1). Sixteen patients (51.7%) could not complete recommended consolidations with FLAG‐based regimen (due to older age or complications) and were switched to DAC maintenance (Group 2). In Group 2, eight patients (50%) had undetectable MRD (Group 2A) (all had qRTPCR ≤ 0.01%) and the other eight patients (50%) had residual fusion product by qRTPCR (0.1%, range = 0.02%–0.36%) (Group 2B) prior to starting DAC. Amongst the 23 patients who had a PCR ≥ 0.01% before maintenance therapy (Groups 1 and 2B), 12 patients (52%) attained a CMR as their best response (responders). The median pre‐DAC qRTPCR amongst responders were 0.03% compared to 0.14% in nonresponders (p = .002). The median estimated molecular RFS amongst responders were 93.9 months. At a median follow‐up of 59.3 months (13.2–106 months) from DAC initiation, 16 patients (51.6%) had to be initiated on a second line of therapy (40%, 25%, and 100% patients, respectively, in Groups1, 2A, and 2B). The median estimated time to new treatment between responders was 112.4 versus 5.8 months in nonresponders (hazard ratio = 0.16, 95% confidence interval = 0.04–0.54); however, there were no difference in overall survival between these groups (p = .37).

Conclusion

DAC is an effective maintenance therapy for CBF‐AML patients with persistent fusion transcript at a low level after FLAG‐based regimen. Attainment of CMR with DAC maintenance can lead to long‐term remission in patients who have persistent MRD positive after FLAG‐based regimen or are unable to receive the full course of consolidation therapy.

Spatially-resolved nanometer-scale measurement of cartilage extracellular matrix mobility

OBJECTIVE

Tissues have complex structures, comprised of solid and fluid phases. Improved understanding of interactions between joint fluid and extracellular matrix (ECM) is required in models of cartilage mechanics. X-ray photon correlation spectroscopy (XPCS) directly measures nanometer-scale dynamics and can provide insight into biofluid-biosolid interactions in cartilage. This study applies XPCS to evaluate dynamic interactions between intact cartilage and biofluids.

DESIGN

Cartilage biopsies were collected from bovine femoral condyles. During XPCS measurements, cartilage samples were exposed to different fluids: deionized water, PBS, synovial fluid, or sonicated synovial fluid. ECM-biofluid interactions were also assessed at different length scales and different depths from the cartilage surface.

RESULTS

Using XPCS, cartilage ECM mobility was detected at length scales from 50 to 207 nm. As length scale decreased, time scale for autocorrelation decay decreased, suggesting smaller ECM components are more mobile. ECM dynamics were slowed by dehydrating the sample, demonstrating XPCS assesses matrix mobility in hydrated environments. At all length scales, the matrix was more mobile in deionized water and slowest in synovial fluid. Using the 207 nm length scale assessment, ECM dynamics in synovial fluid were fastest at the cartilage surface and progressively slowed as depth into the sample increased, demonstrating XPCS can assess spatial distribution of ECM dynamics. Finally, ECM mobility increased for degraded synovial fluid.

CONCLUSIONS

This study demonstrates the potential of XPCS to provide unique insights into nanometer-scale cartilage ECM mobility in a spatially resolved manner and illustrates the importance of biosolid-biofluid interactions in dictating ECM dynamics.

Immune checkpoint inhibitor (ICI)-related pneumonitis among patients with lung cancer admitted to an Oncology Hospitalist Service: Treatment patterns and hospitalization outcomes

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Background: Immune checkpoint inhibitors (ICI) have gained success in the treatment of multiple malignancies including lung cancer. However, immune-related adverse events (irAE) are common with pneumonitis being one of the most fatal having a 10% mortality rate. As such, early identification and treatment of irAEs are important. We describe the treatment patterns and hospitalization outcomes of patients with lung cancer with grade ≥3 ICI-related pneumonitis (ICI-P) admitted to an oncology hospitalist service at a comprehensive cancer center. Methods: We performed a retrospective review of patients with lung cancer admitted to our oncology hospitalist service with a suspicion of ICI-P between January 1, 2019 and November 30, 2019. ICI-P was confirmed if the patient received irAE-specific management, or if there was multidisciplinary consensus among treating providers. Descriptive statistics were utilized. Here we present the demographic and clinical characteristics of the study population as well as hospitalization outcomes. Results: We identified 49 patients with lung cancer who received at least one dose of ICI before being admitted with a suspicion of ICI-P. The mean age was 67y, with 63% being male and 86% having a diagnosis of non-small cell lung cancer. The most common ICI received by patients was pembrolizumab (67%). 84% were on active ICI treatment at the time of hospitalization and the median time from the 1st ICI dose to hospitalization was 3.5 months. Pulmonology was consulted in 88% of patients. Only 63% (n=31) of those admitted with a suspicion of ICI-P were confirmed to have ICI-P. The mean time to first ICI-P directed treatment was 2.2 days from admission with all 31 patients receiving corticosteroids. 23% required infliximab and 10% required IVIG. Patients with confirmed ICI-P had a median length of stay of 8 days, with 19% requiring ICU stay. The ICI-P inpatient mortality rate was 32%. Of those discharged alive (n=21), 90% were discharged on oral corticosteroids. GI and PJP prophylaxis were prescribed for 95% and 81% of the discharged patients, respectively. The 30-day readmission rate for this subgroup was 29%. 86% were seen by their oncologist within a median time of 8 days from discharge. Conclusions: Studies have shown that patients with grade ≥3 ICI-related pneumonitis (i.e. requiring hospitalization) have high mortality rates and this was consistent with our findings. Treatment for ICI-related pneumonitis was started >2 days from admission in our study population. A high index of suspicion is necessary to expedite work-up, and a multidisciplinary approach is key to confirm diagnosis and promptly initiate treatment. Readmission rate was high. Care coordination and strategies for safe transitions of care at discharge should be ensured to improve the overall outcome.

Inflammatory Myositis in Cancer Patients Receiving Immune Checkpoint Inhibitors

OBJECTIVE

To estimate the incidence of immune checkpoint inhibitor-related myositis (ICI-myositis) in cancer patients receiving ICIs, and to report associated clinical manifestations, patterns of care, and outcomes.

METHODS

We identified a retrospective cohort of patients receiving ICIs between 2016 and 2019 seen at the University of Texas MD Anderson Cancer Center. Cases of ICI-myositis were identified using International Classification of Disease codes and confirmed by reviewing medical records and pathology, as available.

RESULTS

A total of 9,088 patients received an ICI. Thirty-six patients (0.40%) were identified as having ICI-myositis: 17 patients (47%) with ICI-myositis alone and 19 (53%) with overlap manifestations (5 patients with myocarditis, 5 with myasthenia gravis, and 9 with both). The incidence of ICI-myositis was 0.31% in those receiving ICI monotherapy and 0.94% in those receiving combination ICI therapy (relative risk 3.1 [95% confidence interval 1.5-6.1]). Twenty-five patients (69%) received ≥1 treatment in addition to glucocorticoids: plasmapheresis in 17 patients (47%), intravenous immunoglobulin in 12 (33%), and biologics in 11 (31%). Patients with overlap conditions had worse outcomes than those with myositis alone, and 79% of them developed respiratory failure. Eight patients died as a result of ICI-myositis, and all had overlap syndrome with myasthenia gravis or myocarditis (P < 0.05); 75% of these patients had a concomitant infection.

CONCLUSION

ICI-myositis is a rare but severe adverse event. More than half of the patients presented with overlap manifestations and had deleterious outcomes, including respiratory failure and death. None of the patients with ICI-myositis alone died as a result of adverse events. Optimal treatment strategies have yet to be determined.

THU0336 IMMUNE CHECKPOINT INHIBITOR-RELATED MYOSITIS: A RETROSPECTIVE COHORT STUDY

Background:

Myositis is a rare immune checkpoint inhibitor (ICI)-related adverse event frequently associated with myasthenia gravis (MG) and myocarditis (MC) leading to mortality rates up to 52%.1

Objectives:

To characterize the presentation, course and outcomes of patients with ICI-related myositis alone or with overlap syndrome (myositis with MG or MC or both).

Methods:

We retrospectively identified a cohort of patients treated with ICI at MD Anderson Cancer Center between 2016 and 2019. Suspected myositis was identified using International Classification of Disease version 10 codes and confirmed by electronic medical record review of muscle enzymes, pathology, and other tests, when available. Patients with myositis alone or with overlap syndrome were compared using Fischer’s exact tests and t tests.

Results:

During the study period 8,636 patients received ICI, of which 31 (0.36%) were diagnosed with myositis: 14 (45%) with myositis alone and 17 (55%) with overlap (MG in 5, MC in 4, MG and MC in 8). Twenty patients received programmed death-1 (PD-1) or programmed death-ligand-1 (PDL-1) inhibitors, and 10 received combination PD-1/PDL-1 inhibitor with a cytotoxic T-lymphocyte associated antigen 4 (CTLA-4) inhibitor. One patient received single agent CTLA-4 inhibitor (excluded from pooled data). For the entire cohort the median age at diagnosis was 69 years (range: 40-95 years); the most common presenting symptoms were fatigue in 27 (90%) patients, weakness in 24 (80%), and myalgia in 23 (77%); median CK was 2,236 U/L (range: 23-19,794 U/L). For treatment, 22 of 30 (73%) patients received at least one therapy in addition to steroids: plasmapheresis in 15 (50%) patients, intravenous immune globulin (IVIG) in 12 (40%), biologics in 9 (30%) (rituximab in 6, infliximab in 5, tocilizumab in 3), tacrolimus in 6 (20%), and mycophenolate mofetil in 4 (13%). Median length of exposure to steroids was 47 days (range: 1-250 days). Five (17%) patients were rechallenged with ICI after myositis resolution (3 with myositis alone, 2 with overlap), of which 1 (20%) patient experienced a myositis flare. Twenty-five (83%) patients were not rechallenged on ICI and 3 (12%) of those patients had a flare. Differences between patients with myositis alone compared to those with overlap are shown in Table 1. Patients with overlap more often received a second therapy, specifically plasmapheresis and IVIG, had longer hospitalizations and greater symptom burden at discharge. Overall death between groups was similar; however death attributed to the adverse event occurred only in those with overlap.

Table 1.

Myositis alone vs. Overlap

Myositis alone(N=13)Overlap(N=17)PvalueN(%)/median days [range]Time to symptom onset42 [10-161]22 [9-149]0.234Initial steroid dose (mg/kg day)1.71.80.187Second therapy7 (54)15 (88)0.049 Plasmapheresis3 (23)12 (71)0.025 IVIG1 (8)11 (65)0.002Outcomes Hospitalization length5 [2-50]24 [7-92]0.019 Respiratory failure0 (0)13 (76) Symptoms at discharge0.047 Improved8 (62)6 (35) Resolved3 (23)1 (6)Death Overall8 (62)12 (71)0.706 Adverse event0 (0)7 (41)

Conclusion:

Our results represent the largest cohort of ICI-related myositis to date. Patients with overlap syndrome are treated more aggressively and have worse outcomes than those with myositis alone. Prospective studies are warranted to determine risk factors for developing myositis or overlap syndrome and to determine optimal treatment.

References:

[1]Anquetil BC, Salem LJ-E, Lebrun-Vignes JB, et al. Immune Checkpoint Inhibitor–Associated Myositis: Expanding the Spectrum of Cardiac Complications of the Immunotherapy Revolution.Circulation. 2018;138(7):743-745.

Disclosure of Interests:

None declared

Activity of decitabine as maintenance therapy in core binding factor acute myeloid leukemia

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Background: Real-time quantitative (RTPCR) based minimal residual disease (MRD) monitoring provides prognostic information in core binding factor acute myeloid leukemia (CBF-AML). Earlier we reported on the activity of decitabine (DAC) as maintenance therapy in a smaller cohort of patients with CBF AML. Methods: We have summarized the results in patients (pts) with CBF who received DAC maintenance for persistent RTPCR positivity or because of inability to complete all planned consolidation in a fludarabine, GCSF, cytarabine (FLAG) based regimen. The planned number of DAC cycles was 12 but could be adjusted at the discretion of the treating physician based on RTPCR response. Serial RTPCR was obtained approximately every 2-3 months. Results: Thirty-four pts with CBF-AML [t(8;21)=14 and inv(16)=20] received DAC as maintenance. Eighteen pts (53%) completed a full course (7 cycles) of FLAG based regimen before DAC for persistent PCR positivity (group 1). Sixteen pts (47%) were switched to DAC as they did not complete planned consolidation (group 2). In group 2, 9 pts (56%) had negative PCR (group 2A) and 7 pts (46%) had positive PCR (group 2B) prior to starting DAC. Patient characteristics are summarized in table. The median follow up was 59.2 [15.4-107.2] and 32.47 [8.5-86.3] months for group 1 and 2, respectively. In Group 1 and group 2A only 1 patient each had relapse, while 5 pts (72%) from group 2B had relapse. All the patients in group 2B with relapse were at suboptimal RTPCR response (>0.1%). Conclusions: Our study shows DAC is an effective maintenance for CBF-AML pts who have persistent PCR positively after FLAG based induction consolidation and those unable to tolerate a full course, but have negative PCR. However patients with high levels of MRD persistence should be considered for stem cell transplant. [Table: see text]

Incidence and outcomes of immune checkpoint inhibitor-related myositis

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Background: Data from immune checkpoint inhibitor (ICI) clinical trials show a higher incidence of ICI-related myositis with single agent ICI compared to combination therapy, but the true frequency in clinical practice is unknown. We sought to determine the incidence and clinical course of patients with ICI-related myositis at our institution. Methods: We performed a retrospective cohort study of patients treated with ICIs at MD Anderson Cancer Center between 2016 and 2019. Suspected cases of ICI-related myositis were identified using International Classification of Disease version 10 codes and confirmed by reviewing medical records, muscle enzymes and pathology. Patients treated with single agent anti-programmed death-1/ligand-1 (monotherapy) were compared to patients treated with nivolumab and ipilimumab (combination therapy) with Fischer’s exact tests, t tests, and Kaplan Meier analysis. Results: A total of 8,705 patients received ICI (7,428 monotherapy and 1,277 combination therapy), of which 31 (0.36%) were diagnosed with myositis. Estimated incidence of myositis was 0.28% and 0.78% (p=0.004), in the monotherapy and combination therapy groups, respectively. One patient was treated with ipilimumab alone (excluded from pooled data). Overall median age was 69 years (range: 40-95) with median follow up of 4 months after presentation for myositis. Thirteen (43%) patients had myositis alone and 17 (57%) had overlap with myasthenia gravis or myocarditis or both. After myositis resolution, 5 (17%) patients were rechallenged on ICI, of which 1 (20%) patient experienced a myositis flare. Differences between combination and monotherapy are summarized in the table. Patients treated with combination had shorter time to symptoms, but similar symptom grade at presentation, median length of hospitalization, and initial tumor response, compared to patients given monotherapy. Median overall survival (OS) was longer in combination vs monotherapy. Conclusions: Patients receiving combination ICI therapy had higher incidence of myositis with earlier onset than monotherapy; however, no differences in cancer outcomes or hospitalizations were observed between groups. Creation of multi-center databases are needed to develop treatment guidelines for ICI-related adverse events that will improve outcomes. [Table: see text]

Abstract P1-07-09: A multi-OMIC analysis to explore the impact of “actionable” genomic alterations on protein pathway activation: Clinical implication for precision medicine in metastatic breast cancer

Background: While genomic alterations are central players in tumor progression, proteins are the targets for precision therapy. The degree by which “actionable” genomic alterations translate into activated/altered proteins and pathway is still under investigation. Using a multi-OMIC approach from the SideOut 2 metastatic breast cancer (MBC) trial, this study explored the concordance between selected “actionable” genomic alterations and protein expression/activation.

Methods: Snap frozen biopsies from 29 MBC patients enrolled in a prospective phase II trial were used for this analysis. Exome WES and RNASeq data was processed using an in-house developed pipeline and identified amplification of CCND1 (6/29), FGFR1 (4/29), and FGF 3, 4, 5, and 19 (4/29) as some of most frequent “actionable” genomic alterations in our MBC cohort. Signaling analysis of the 29 cases was performed using Reverse Phase Protein Microarray coupled with Laser Capture Microdissection. Protein expression/phosphorylation was measured in a continuous scale and classified based on quartile distribution. Concordance between CCND1 amplification and Cyclin D1 expression, along with the activation of FOXM1 T600 and Rb S780, was explored. Amplification of the FGFR1 locus or its ligands was correlated with the level of activation/phosphorylation of FGFR1 Y653/654.

Results: While Cyclin D1 protein expression was greater than the population mean for 4/6 (67%) patients with CCND1 amplification, only 2/6 (33%) patients with CCND1 amplification had Cyclin D1 level within the top quartile of the population (n=29). FOXM1 T600 activation was independent from CCND1 amplification, with high levels of FOXM1 T600 predominantly in the CCND1 wild-type population. Only 1/6 (17%) patients with CCND1 amplification had FOXM1 T600 level similar to the top quartile of the population while a second patient was above the population median. Activation of Rb S780 was above the population median, but below the top quartile, in 2/6 (33%) CCND1 amplified patients. Similarly, none of the patients with activation of FGFR Y653/654 equal to the top quartile harbored an FGFR1 amplification. Only 1/4 (25%) patients carrying an FGFR1 amplification had an activation of FGFR Y653/654 above the population median. Similarly, 1/4 (25%) patients with FGF ligand amplification showed FGFR Y653/654 level within the top quartile while three patients had FGFR Y653/654 activation below the population median. No significant results were found between proteomic (below/above the median) and genomic characteristics by Fisher test (p&gt;0.05).

Conclusion: Molecular genotyping of “actionable” cancer targets alone may be insufficient in predicting whether the actual drug target protein is expressed and/or activated in any given patient's tumor. Although these results need further validation, the combination of genomic and proteomic data may represent a more informative approach for identifying real molecular drivers of individual lesions as well as “actionable” protein/phosphoprotein targets in the absence of genomic events. Multi-OMIC approaches may lead to more effective stratification in precision medicine trials.

Citation Format: Pierobon M, Wong S, Reeded A, Anthony S, Robert N, Northfelt DW, Jahanzeb M, Vocila L, Wulfkuhle J, Dunetz B, Aldrich J, Byron S, Craig D, Liotta L, Carpten J, Petricoin EF. A multi-OMIC analysis to explore the impact of “actionable” genomic alterations on protein pathway activation: Clinical implication for precision medicine in metastatic 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 P1-07-09.

Abstract P2-05-21: The AKT-mTOR pathway as a potential organ-specific drug target signature of hepatic metastases from breast cancer

Background: The identification of organ-specific targetable signatures may help design more effective treatment for patients with metastatic breast cancer (MBC). We took a multi-OMIC approach to assess whether the AKT-mTOR pathway is globally activated during metastatic progression or whether it represents an organ-specific target.

Methods: Snap frozen biopsies from 25 MBC patients enrolled in a prospective phase II trial were used. Sites of metastasis were classified as liver (n=8) and others (n=17), the latter including cutaneous, lung, lymph nodes, and intra-abdominal lesions. Signaling analysis of the 25 cases was performed using Reverse Phase Protein Microarray (RPPA) coupled with Laser Capture Microdissection. Activation of the AKT-mTOR pathway was quantified as phosphorylation of AKT (S473) and the mTOR target p70S6 (T389). Matched exome (WES) and RNASeq data were available for 17 of 25 patients, five with liver metastases. Sequencing data was processed using an in-house developed pipeline to identify somatic events including coding mutations, copy number alterations, gene fusions, and differential expression. Activation of the AKT-mTOR pathway and sequencing data were compared between hepatic and non-hepatic lesions using an integrated RPPA and genomic approach.

Results: Among liver metastases, AKT was activated in 4 of the 8 (50.0%) patients, while 6 of the 8 cases (75.0%) showed activation of p70S6. Sequencing data revealed mutation of PIK3CA in 4 of the 5 liver metastases (80.0%). Three of the PIK3CA mutated specimens with catalytic domain mutations (codons 1023 and 147) demonstrated co-activation of AKT and p70S6, while the fourth case, containing a helical domain mutation (E542K), had activation of p70S6 only. The PIK3CA wild-type liver metastasis demonstrated low activation of AKT and p70S6. For non-hepatic metastases AKT was activated in 2 of the 17 cases (11.8%) and p70S6 in 5 of the 17 patients (29.4%).

Discussion: Although these results need further validation, activation of the AKT-mTOR pathway appears to be a hepatic specific signature in MBC and could be used for the selection of targeted agents for hepatic lesions.

Citation Format: Pierobon M, Wong S, Reeder A, Anthony SP, Robert NJ, Northfelt DW, Jahanzeb M, Vocila L, Wulfkuhle J, Dunetz B, Aldrich J, Byron S, Craig D, Liotta L, Petricoin EF, Carpten J. The AKT-mTOR pathway as a potential organ-specific drug target signature of hepatic metastases from breast cancer. [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 P2-05-21.

First Report of Xanthomonas axonopodis Causing Bacterial Leaf Spot on Crape Myrtle

Crape myrtle (Lagerstroemia sp.) is a popular ornamental tree in the United States and the industry produced 2,781,089 trees in 2010 with a value exceeding US $42.8 million (1,4). A new disorder of crape myrtle has been observed since 2011 in numerous nurseries in Florida, which was characterized by dark brown, angular to irregularly shaped, oily-looking spots surrounded by yellow halos. The disease primarily affects lower leaves that eventually turn yellow and can lead to rapid defoliation of susceptible cultivars. Plants examined in field surveys at the University of Florida, North Florida Research and Education Center, Quincy, FL in 2012 and 2013 also had similar symptoms on cvs. Arapaho, Carolina Beauty, Tuscarora, Whit IV Red Rocket, Whit VIII Rhapsody in Pink, and White Chocolate. The disease severity ranged from 20 to 70% and all the plants were infected. A yellow-pigmented, gram-negative, oxidase negative bacterium was consistently isolated from symptomatic leaves (two leaves from each of five plants). Pathogenicity tests were performed using five isolated bacterial strains on potted crape myrtle cv. Arapaho. Three plants were inoculated with a 10⁸ CFU/ml suspension of bacterial strains in sterile deionized water, and covered with transparent plastic bag for 48 h. Two control plants were inoculated with sterile distilled water. The inoculated plants were then incubated in a greenhouse at 30 to 34°C for 14 days. Symptoms of dark brown, angular to irregularly shaped lesions were observed only on the inoculated plants after 7 days. The bacterium was re-isolated from the inoculated symptomatic plants as described above, thus fulfilling Koch's postulates. Fatty acid methyl ester profiling of the five isolated bacteria using GC-MIDI (Microbial IDentification Inc, Newark, DE) revealed the identity of the bacterium as Xanthomonas axonopodis with an identity index of ~0.80, but matched multiple pathovars. Total genomic DNA was extracted from the pure bacterial culture using UltraClean Microbial DNA Isolation Kit (MO BIO Laboratories, Carlsbad, CA). The genomic DNA was subjected to PCR assay using universal primers 27f/1492R (3) targeting the complete 16S rRNA gene and primers 16F945/23R458 (2), which target the partial 16S-23S internal transcribed spacer region. PCR amplification using primer pairs 27f/1492R and 16F945/23R458 resulted in amplicons of 1,450 and 1,500 bp, respectively. The amplicons were gel purified and sequenced directly at Florida State University. BLAST analysis of the sequences (Accession Nos. KF926678, KF926679, KF926680, KF926681, and KF926682) revealed the identity of the bacterium as X. axonopodis, ranging from 98 to 99%, with several strains in the NCBI database. Phylogenetic analysis using the neighbor-joining method showed that our strains were distantly clustered with X. axonopodis pv. dieffenbachiae when compared to other available strains in the database. To our knowledge, this is the first worldwide report of a bacterial leaf spot on crape myrtle caused by X. axonopodis. This information should aid in the development of breeding lines with resistance to bacterial leaf spot and effective disease management practices. References: (1) C. S. Furtado. Garden Bull. 24:185, 1969. (2) C. Guasp. Int. J. Syst. Evol. Microbiol. 50:1629, 2000. (3) D. J. Lane. Page 115 in: Nucleic Acid Techniques in Bacterial Systematics, 1991. (4) USDA. 2007 Census of Agriculture, Washington, DC. 3:25, 2010.

S3-5: Next Generation Sequencing Reveals Co-Activating Events in the MAPK and P13K/AKT Pathways in Metastatic Triple Negative Breast Cancers

INTRODUCTION: The clinical application of next generation sequencing to comprehensively characterize groups of driving mutations in individual metastatic triple negative breast cancer (mTNBC) genomes has the potential to reveal therapeutically relevant pathway dependencies. Towards this end, we harvested tissue from 14 patients with mTNBC and are conducting deep whole genome and transcriptome sequencing for each case to identify mutations that can guide therapeutic targeting within available phase I/II clinical trials.

METHODS: Metastatic tumor tissue was harvested from 14 mTNBC patients, and 7 samples have undergone total genome and transcriptome sequencing with the others currently underway. We are utilizing the Life Technologies SOLiD® system to sequence germline and tumor DNA to sufficient depth to identify somatic genome alterations including point mutations, indels, and structural events including translocations. Furthermore, RNA-seq is being performed on these tumors, along with a series of age- and ethnicity-matched normal breast controls to perform deep differential expression analysis, isoform expression analysis, and fusion transcript detection. Our team of genome scientists and clinical oncologists are evaluating the sequencing findings and are prioritizing the investigational therapeutic options for each patient.

RESULTS: Our whole genome and transcriptome sequencing study has revealed numerous known and novel mutations in mTNBC. However, all patients’ cancers analyzed to date had alterations that would activate the MAPK pathway, but through various mechanisms in different patients. These include BRAF amplification and overexpression, NF1 homozygous deletion, and consistent IQGAP3 overexpression. Furthermore, all patients’ cancers also harbor mutations that would activate the PI3K/AKT pathway including PTEN homozygous deletion or down-regulation, consistent INPP4B down-regulation, FBXW7 homozygous deletion, and ERAS overexpression. Moreover, although we and others show ERBB4 down-regulation in breast tumors, we are the first to report unique somatic genomic events that significantly alter the ERBB4 locus leading to its loss in the majority (5/7) of our patients’ tumors. Importantly, we are beginning to use these insights to prioritize therapeutic targeting and have observed that one chemotherapy-refractory mTNBC patient, with a high-level BRAF amplification/overexpression along with down-regulation of PTEN and INPP4B, had a major response to combined mek plus akt inhibitors on a phase I study.

CONCLUSIONS: Comprehensive genomic and transcriptomic interrogation of mTNBCs has revealed events supporting co-activation of the MAPK and PI3K/AKT pathways in all the tumors albeit by different mutational mechanisms and supports potential effectiveness of combination therapy in the treatment of mTNBC. We plan to treat these patients with combined mek plus akt inhibitors on a new phase I study beginning in August 2011 to determine the effectiveness of co-inhibition of these pathways based on this frequent genomic context.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr S3-5.

Early diagnosis of bubonic plague using F1 antigen capture ELISA assay and rapid immunogold dipstick

Plague is still prevalent in more than 20 countries. Two F1 antigen diagnostic assays (an immunocapture ELISA and an immunogold chromatography dipstick) were evaluated using bubo aspirates, serum and urine specimens from patients suspected with plague. The specificity of the two F1 assays was found 100%. Using bacteriology as a gold reference diagnostic assay, 52 patients were Yersinia pestis culture positive and 141 negative. The sensitivity of the F1 ELISA test was 100% in bubo, 52% in serum and 58% in urine specimens. In culture negative patients, the F1 antigen could be found in 10% bubo aspirates, 5% serum and 7% urine specimens of culture negative patients for whom a seroconversion for anti-F1 antibodies was also observed. The sensitivity of the dipstick assay was 98% on bubo aspirates specimens. Compared to the ELISA test, the agreement rate was 97.5% and the correlation coefficient tau = 0.90 (p < 10(-3)). In conclusion, the diagnosis of bubonic plague has to be performed on bubo fluid rather than on serum or urine specimens. Both the F1 ELISA and the dipstick assays are valuable tools for an early diagnosis and for the surveillance of plague.

Detection of Francisella tularensis in biological specimens using a capture enzyme-linked immunosorbent assay, an immunochromatographic handheld assay, and a PCR

The early detection of Francisella tularensis, the causative agent of tularemia, is important for adequate treatment by antibiotics and the outcome of the disease. Here we describe a new capture enzyme-linked immunosorbent assay (cELISA) based on monoclonal antibodies specific for lipopolysaccharide (LPS) of Francisella tularensis subsp. holarctica and Francisella tularensis subsp. tularensis. No cross-reactivity with Francisella tularensis subsp. novicida, Francisella philomiragia, and a panel of other possibly related bacteria, including Brucella spp., Yersinia spp., Escherichia coli, and Burkholderia spp., was observed. The detection limit of the assay was 10(3) to 10(4) bacteria/ml. This sensitivity was achieved by solubilization of the LPS prior to the cELISA. In addition, a novel immunochromatographic membrane-based handheld assay (HHA) and a PCR, targeting sequences of the 17-kDa protein (TUL4) gene of F. tularensis, were used in this study. Compared to the cELISA, the sensitivity of the HHA was about 100 times lower and that of the PCR was about 10 times higher. All three techniques were successfully applied to detect F. tularensis in tissue samples of European brown hares (Lepus europaeus). Whereas all infected samples were recognized by the cELISA, those with relatively low bacterial load were partially or not detected by PCR and HHA, probably due to inhibitors or lack of sensitivity. In conclusion, the HHA can be used as a very fast and simple approach to perform field diagnosis to obtain a first hint of an infection with F. tularensis, especially in emergent situations. In any suspect case, the diagnosis should be confirmed by more sensitive techniques, such as the cELISA and PCR.

Recombinant antibodies: a new reagent for biological agent detection

Antibodies are critical reagents used in several biodetection platforms for the identification of biological agents. Recent advances in phage display technology allow isolation of high affinity recombinant antibody fragments (Fabs) that may bind unique epitopes of biological threat agents. The versatility of the selection process lends itself to efficient screening methodologies and can increase the number of antigen binding clones that can be isolated. Pilot scale biomanufacturing can then be used for the economical production of these immunoglobulin reagents in bacterial fermentation systems, and expression vectors with hexahistidine tags can be used to simplify downstream purification. One such Fab reagent directed against botulinum neurotoxin A/B has been shown to be sensitive in a variety of assay formats including surface plasmon resonance (SPR), flow cytometry, enzyme linked immunosorbent assay (ELISA), and hand-held immunochromatographic assay. Recombinant antibodies can provide another source of high quality detection reagents in our arsenal to identify or detect pathogens in environmental samples.

Cloning and characterization of Physarum polycephalum tectonins. Homologues of Limulus lectin L-6

Previous investigators have reported the presence of two dominant proteins, tectonin I (25 kDa) and tectonin II (39 kDa), in nuclei and nuclear matrix from plasmodia of Physarum polycephalum. We demonstrate, by a modification of the nuclear isolation protocol and by protease sensitivity, that the tectonins are not nuclear proteins but rather are located on the exterior surface of the plasma membrane. We report the sequences of cDNAs of tectonins I and II, which encode 217 and 353 amino acids, respectively. Tectonin I is homologous to the C-terminal two-thirds of tectonin II. Both proteins contain six tandem repeats that are each 33-37 amino acids in length and define a new consensus sequence. Homologous repeats are found in L-6, a bacterial lipopolysaccharide-binding lectin from horseshoe crab hemocytes. The repetitive sequences of the tectonins and L-6 are reminiscent of the WD repeats of the beta-subunit of G proteins, suggesting that they form beta-propeller domains. Tectonin II has an additional N-terminal domain that includes a 47-residue sequence highly similar to the galactoside-binding sequence of the B-chain of ricin. The tectonins may be lectins that function as part of a transmembrane signaling complex during phagocytosis.

Central nervous system disorders after renal transplantation in cats

OBJECTIVE

This study describes the incidence and severity of postoperative central nervous system (pCNS) disorders in feline renal transplant recipients.

STUDY DESIGN

A retrospective study based on the medical records of cats that received renal allografts from 1987 to 1996.

ANIMALS OR SAMPLE POPULATION

Fifty-seven client-owned cats received renal allografts for the treatment of renal failure.

METHODS

The frequency, duration, severity, and treatment of episodes of pCNS disorders were recorded from the medical records.

RESULTS

Twelve (21%) of 57 cats had pCNS disorders 1 hour to 5 days after the surgical procedure. Seven cats survived; four had single or multiple seizure episodes, and two had seizure episodes or disorientation followed by a period of coma. One cat became temporarily ataxic and blind after restraint for venipuncture. Five cats died; all had episodes of disorientation or seizures, or both, that progressed to a nonrecoverable comatose state, respiratory arrest or cardiac arrest, or both. There were no significant differences between the two groups in preoperative serum creatinine, blood urea nitrogen, or cholesterol levels, and intraoperative blood pressure measurements. There were no significant differences in the postoperative serum glucose levels, electrolytes levels, or osmolality between the two groups. The cats with pCNS disorders had a mean preoperative trough cyclosporine A (CyA) whole blood level of 429 ng/mL; cats without pCNS disorders had a significantly (P = .0116) higher mean preoperative trough CyA whole blood level of 736 ng/mL.

CONCLUSION

Central nervous system disorders are a common and often fatal complication of renal transplantation in cats.

CLINICAL RELEVANCE

Recognition of pCNS disorders, and possible causes, will help develop hypotheses to investigate the problem.

Silica-containing urinary calculi in dogs (1981-1993)

Silica-containing urinary calculi obtained from 773 dogs and submitted by veterinarians throughout the United States were analyzed by quantitative crystallographic analysis to determine mineral composition. Specimens were composed of either multiple mineral layers (535 specimens) or 1 mineral layer (238 specimens). Most multiple-layer calculi were composed of 80% or greater silica (300 of 535, 56%) or 20% to 79% silica (184 of 535, 34%) in any mineral layer. Most 1-layer calculi were composed of 100% silica (212 of 238, 89%). Most dogs forming silica-containing calculi were of male gender (679 of 773, 88%). Bacterial cultures of calculus or urine or both were performed on 49% (376 of 773) of the specimens, and bacterial growth was obtained from 37% (139 of 376) of samples cultured. The prevalence of calculus-associated urinary tract infection was 35% (113 of 321) in males and 47% (26 of 55) in females. The gender prevalence for infection with Staphylococcus species was 16% (51 of 321) in males and 33% (18 of 55) in females. The breed and gender of dogs that formed calculi (silica population) were compared with the hospital population (Veterinary Medical Teaching Hospital [VMTH] population) and with a population of calculus-forming dogs (Stonelab population) to determine risk factors for silica calculus formation. For all breeds compared, the ratio of males to females was higher in the silica population. The German Shepherd Dog and Old English Sheepdog were significantly overrepresented when the silica population was compared with either the VMTH population or the Stonelab population. We conclude that male German Shepherd Dogs and Old English Sheepdogs are at increased risk for formation of silica-containing urinary calculi.

Radiological sciences, past and present

Few observations can have been as rapidly and widely disseminated in medicine as the diagnostic X-ray (radiograph). The first few decades after Röntgen's discovery saw technical developments that made radiography more practical, quicker, safer for both imager and patient, and able to achieve greater contrast. This article reviews the history of imaging but it also looks to the future and begins to open up some of the issues that radiology faces in the 21st century--issues that the next six articles in this Lancet series will enlarge upon. The conventional radiograph remains the most common medical image but a host of new techniques have come along. Are they research tools, clinical methods, or both--and how, in an age of sensitivity about the costs of health care, do they stand up?

The flax ribosomal RNA-encoding genes are arranged in tandem at a single locus interspersed by 'non-rDNA' sequences

The ribosomal RNA (rRNA)-encoding genes (rDNA) in flax, estimated to be present in about 2400 copies per diploid nucleus, have been reported as a single homogeneous repeat unit of 8.6 kb. In situ hybridization analysis indicated that these genes were located at a single site on one pair of chromosomes. However, an analysis of a flax variety, CI 1303, has revealed heterogeneity in the intergenic spacer of the rDNA repeat unit. A genetic analysis of rDNA inheritance in two flax lines, Stormont Cirrus and CI 1303, has again supported the observation that there is a single rDNA locus in this plant species. Screening of four different genomic libraries made in methylation-sensitive and -insensitive systems, and the analysis of 40 phage clones, demonstrate a much higher number than that expected of junctions between rDNA and non-rDNA. Direct evidence of rRNA-encoding genes being present in tandem comes from a few phage clones that contain more than two rDNA repeats. The evidence presented here indicates that rDNA, although present at a single locus in tandem arrays, may be interrupted frequently by other non-rDNA sequences, thus giving rise to questions about their organization into long tandem arrays.

Cardioplegic arrest of the myocardium with calcium blocking agents

This study was designed to compare the effects of the calcium slow channel blocking agents verapamil (0.15 mg/kg), diltiazem (0.15 mg/kg), and nifedipine (50 micrograms/kg) on the myocardium after global ischemia and reperfusion in the in situ canine model. Animals were subjected to 120-min normothermic global ischemia, followed by 45-min reperfusion. Cardioplegic arrest of the myocardium was achieved by administering one of the three calcium antagonists in a multidose fashion. Superior preservation (p less than 0.01) of left ventricular (LV) systolic function was achieved in group I (verapamil cardioplegia). dP/dt, at an intraventricular balloon volume of 25 cc, was 83% of control after reperfusion in group I. Group II (diltiazem) and group III (nifedipine) achieved only 55 and 63% of their preischemic dP/dt values. LV chamber stiffness was increased in hearts protected with nifedipine. The exponential constant m was increased from 0.04 +/- 0.01 to 0.08 +/- 0.01. Coronary blood flow after reperfusion increased from 120 to 184 cc/100 gr/min in group I (p less than 0.01). The hyperemic response in group III was negligible. The O2 consumption of the reperfused myocardium was not significantly altered in any of the treatment groups. Lactate metabolism during ischemia and after reperfusion was similar in all groups. ATP values were markedly reduced in all groups (p less than 0.05). Immediately after ischemia, ATP was 50, 28, and 44% of control in group I, II, and III, respectively. The excellent preservation of systolic function and a physiologic hyperemic response by verapamil could not be correlated with improved preservation of high-energy compounds or with significant changes in myocardial O2 consumption.(ABSTRACT TRUNCATED AT 250 WORDS)

Sequence analysis of the junction of the large single copy region and the large inverted repeat in the petunia chloroplast genome

We have determined the nucleotide sequence at the junction of the large single copy (LSC) region and the right and left members of the large inverted repeat, IRA and IRB, respectively, of the petunia chloroplast (cp) genome. As in Nicotiana debneyi and spinach (Zurawski et al. 1984), coding sequences of rps19 of petunia overlap the junction of IRB and LSC. Immediately into the LSC region upstream of IRA in the petunia cp genome are two small insertions relative to N. debneyi that occur at sites just inside IRA of N. debneyi. We discuss how these additions in one copy of the large inverted repeat of an N. debneyi-like ancestor to petunia resulted in shortening of the petunia large inverted repeat by 8 bases and in the resultant slight movement of rps19 farther into LSC. On a larger scale, the large inverted repeat in the tobacco, N. debneyi and petunia lineage relative to a spinach-like ancestor may have sustained several contractions due to deletions between short direct repeats found within IRA and the IRA/LSC junction. We also show how the large inverted repeat of N. debneyi instead may have been expanded relative to a tobacco-like ancestor by insertion into the large inverted repeat of bases between short inverted repeat sequences in LSC and the LSC/IRB junction.

The role of insertions/deletions in the evolution of the intergenic region between psbA and trnH in the chloroplast genome

TrnH and the intergenic region between trnH and psbA of the chloroplast genomes of alfalfa (Medicago sativa), Fabaceae, and petunia (Petunia hybrida), Solanaceae, were sequenced and compared to published sequences of that region from other members of those families. A striking feature of these comparisons is the occurrence of insertions/deletions between short, nearly perfect AT-rich direct repeats. The directionality of these mutations in the petunia, tobacco and Nicotiana debneyi lineages within the Solanaceae cannot be discerned. However, we present several alternative hypotheses that are consistent with Goodspeed's 1954 evolutionary treatment of the genus Nicotiana and family Solanaceae. Within the Fabaceae, the major size differences in the intergenic region between alfalfa, pea and soybean are due to insertions/deletions between direct repeats. The alfalfa intergenic region has an inverted repeat stem-loop structure of 210 bases directly 5' to trnH. This structure is an insert relative to the liver-wort. Marchantia polymorpha. Portions of the insert are found also in pea and soybean as well as in published sequences from other dicots representing diverse orders: petunia, tobacco, N. debneyi (Scrophulariales), spinach (Caryophyllales), and Brassica napus (Capparales). Some of the regions of the insert that are missing in these plants appear to have resulted from deletions of sequences between different imperfect direct repeats within, or 5' to and within the insert. Other deletions are not flanked by repeated sequences. A short insert flanked by imperfect direct repeats in B. napus occurs just within the longer alfalfa insert suggesting that both alfalfa and B. napus have remnants of an even longer insert relative to M. polymorpha. From these analyses we hypothesize the insertion of a stem-loop structure into an M. polymorpha-like ancestral land plant, followed by deletions of sequences, often between different imperfect direct repeats within and upstream of the insert, leading to the psbA-trnH intergenic sequences represented by the present-day plants examined.

The Camberwell Collaborative Depression Study. II. Investigation of family members

Out of a consecutive series of 130 potential probands with recent onsets of depression, 124 were deemed 'in scope' for a family interview study of social and genetic influences on depression. We were able to interview first-degree relatives of 83 probands (67% of those families 'in scope'). Unexpectedly, interviewed first-degree relatives had, on average, a significantly lower occupational status than the depressed probands. However, the rates of depression among the first-degree relatives were high. Based on a PSE-Catego classification, 17.2% of 244 relatives were current 'cases' of depression at the time of interview. This was significantly greater than the estimated population prevalence. Using a Past History Schedule in combination with the PSE, the lifetime prevalence of depressive illness, expressed as the proportion who had ever fulfilled PSE-Catego case criteria, was 38.9%. High rates of psychiatric treatment were also found in family members. The lifetime prevalence of any form of hospital treatment for depression in 315 first-degree relatives was 15.5%. This gives an age-corrected morbidity risk to age 65 years of 24.6%, as compared with a population estimate of 8.9%. In common with previous studies, significantly higher rates of depression were found among female than among male first-degree relatives for broader categories of disorder, but there was a small and nonsignificant excess of men among those relatives who had received in-patient treatment for depression. This apparent lessening of sex differences with more severe categories was not supported by an examination of 'lifetime ever' depressive symptoms, where severity was expressed as highest ever PSE-Catego-ID level.(ABSTRACT TRUNCATED AT 250 WORDS)

Past and present state examination: the assessment of 'lifetime ever' psychopathology

A Past History Schedule (PHS) for use in conjunction with the Present State Examination (PSE) is described. The PHS/PSE interview enables a rating of 'lifetime ever' psychopathology to be performed. It provides good inter-rater reliability, as well as a satisfactory agreement between retrospective interviews and casenote-based assessment of past psychopathology. The PHS has been devised specifically for use in a family-genetic study of affective illness, but the general approach may be applicable to other categories of psychiatric disorder.

Orthostatic effect of imipramine and doxepin in depressed geriatric outpatients

Blood pressure measurements were collected from 36 depressed geriatric outpatients (ages 55 to 81 years) enrolled in a double-blind, placebo-controlled study of the efficacy of doxepin and imipramine. Mean systolic postural changes were 25.9 mm Hg for imipramine, significantly higher than the 10.5 mm Hg for doxepin, and 12.4 mm Hg for placebo. The orthostatic drop in the imipramine group was only weakly related to dose and did not correlate with amount of pretreatment orthostatic hypotension or with duration of treatment. The increased orthostatic hypotension occurred early in treatment and at low doses of imipramine. Accordingly, caution is advised in the use of imipramine for the elderly.

The effects of a partially purified fraction of an ant venom in rheumatoid arthritis

A partially purified extract of an ant venom from the South American tree ant Pseudomyrmex sp. was tested in a double-blind, controlled study of patients with rheumatoid arthritis. Venom treated patients demonstrated an improvement in global efficacy and a decrease in the number of tender/painful joints and swollen joints. Swollen joint index improved in 60% of venom treated patients. Other parameters did not demonstrate significant change. Reduction of joint swelling was followed by symptomatic improvement that was sometimes delayed by weeks. Reactions were limited to erythema at the injection site (all patients), local pruritus (two-thirds of the patients), and fever with malaise (one-third of the patients). Further study of this venom in rheumatoid arthritis appears warranted in view of its apparent favorable efficacy-to-toxicity ratio.

Purchasing power of U.S. Social Security benefits abroad, 1970-82

This article examines whether the small number of Social Security beneficiaries living abroad enjoy a higher standard of living than they would with the same benefits if they lived in the United States. The article addresses this question using two methods. First, absolute comparisons of U.S. dollar purchasing power abroad are made using "purchasing power parities," a method recently developed to allow international comparisons of real standards of living. Second, the effects of changes in Social Security benefit levels, exchange rates, and rates of inflation on the relative value of benefits abroad are measured. Both methods show considerable instability in purchasing power of Social Security benefits in the 1970's. Although beneficiaries in 1970 generally could live better abroad than in the United States, this advantage eroded considerably during the 1970's, followed by some improvement in 1981-82.

The earnings replacement rate of old-age benefits in 12 countries, 1969-80

This article reports the findings of the first cross-national study since 1975 of earnings replacement rates--the proportion of immediate preretirement earnings replaced by social security retirement benefits. In the countries studied--Austria, Canada, Denmark, France, the Federal Republic of Germany, Italy, Japan, the Netherlands, Sweden, Switzerland, the United Kingdom, and the United States--the replacement rates in recent years seem to have continued their upward trend, although they appear to be rising more slowly than before, and under some interpretations seem to be leveling off. In 1980, the United States was fifth among the countries studied in replacement rates for retired couples (one working spouse, one nonworking spouse) and fell within the middle range for single aged beneficiaries: Six countries provided higher benefit levels, four provided lower benefits, and one provided benefits at the same level.

Extranuclear DNA of a Marine Chromophytic Alga : RESTRICTION ENDONUCLEASE ANALYSIS

Two extranuclear DNA species have been isolated from the marine alga Olisthodiscus luteus. Rapid lysis of cells followed by the immediate addition of CsCl to the lysate was critical to the preservation of these satellite DNA species. Restriction endonuclease analysis demonstrates a molecular weight of 99 x 10(6) for chloroplast DNA and 23 x 10(6) for a second satellite species. The origin of the second satellite is not known. However, this smaller satellite DNA which originates from a nonnuclear, DNAse insensitive cellular component, displays no sequence homology with ctDNA by hybridization experiments. Constancy of restriction endonuclease fragment patterns of chloroplast and second satellite species during all phases of the growth cycle, whether cultures were maintained synchronously or asynchronously, was demonstrated.

Kinetic Complexity, Homogeneity, and Copy Number of Chloroplast DNA from the Marine Alga Olisthodiscus luteus

The kinetic complexity of chloroplast DNA isolated from the chromophytic alga Olisthodiscus luteus has been determined. Using optical reassociation techniques, it was shown that the plastid DNA of this alga reacted as a single component with a second order rate constant of 4.1 molar(-1) and second(-1) (Cot((1/2)) 0.24 molar second) under conditions equivalent to 180 millimolar Na(+) and 60 degrees C. Given the 92 x 10(5) dalton complexity calculated for this chloroplast genome, an Olisthodiscus cell contains 650 plastome copies. Although this complement remains constant throughout the growth cycle of the organism, the ploidy level of an individual chloroplast shows significant plasticity and is dependent upon the number of chloroplasts present per cell. Experiments with the DNA fluorochrome Hoechst dye 33258 (bisbenzimide) demonstrate that plastids isolated from all phases of cell growth each possess a ring-shaped nucleoid containing detectable DNA. Olisthodiscus chloroplast DNA showed no sequence mismatch when thermal denaturation profiles of reassociated chloroplast DNA were examined, thus all plastome copies are essentially identical. Finally, reassociation studies demonstrated that no foldback (short inverted repeat) sequences were present in the plastid genome although significant hairpin loop structures were observed in control nuclear DNA samples.

Isolation and Characterization of Chloroplast DNA from the Marine Chromophyte, Olisthodiscus luteus: Electron Microscopic Visualization of Isomeric Molecular Forms

Chloroplast DNA (ctDNA) from the marine chromophytic alga, Olisthodiscus luteus, has been isolated using a whole cell lysis method followed by CsCl-Hoechst 33258 dye gradient centrifugation. This DNA, which has a buoyant density of 1.691 grams per cubic centimeter was identified as plastidic in origin by enrichment experiments. Inclusion of the nuclease inhibitor aurintricarboxylic acid in all lysis buffers was mandatory for isolation of high molecular weight DNA. Long linear molecules (40 to 48 micrometers) with considerable internal organization comprised the majority of the ctDNA isolated, whereas supertwisted ctDNA and open circular molecules averaging 46 micrometers were occasionally present. Also observed in this study were folded ctDNA molecules with electron dense centers ("rosettes") and plastid DNA molecules which have a tightly wound "key-ring" center. The ctDNA of Olisthodiscus has a contour length that is median to the size range reported for chlorophytic plants.A minor component of the total cellular DNA, which originates from a DNase insensitive cellular structure, has a buoyant density of 1.694 grams per cubic centimeter. This DNA consists predominantly of linear molecules, but open circles 11.5 micrometers in length and rare 22-micrometer dimers were also present.This study represents the first analysis of the extranuclear DNA of a chromophytic alga.

Urogenital tract abnormalities in sons of women treated with diethylstilbestrol

Since in utero exposure to diethylstilbestrol (DES) is known to cause abnormalities of the female genital tract later in life, exposed male offspring were located, surveyed by mail, and compared with unexposed male offspring from the same period and medical practices. The exposed and unexposed respondents appeared comparable and did not differ in their response to most medical questions. However, a larger proportion of exposed than of unexposed boys had experienced problems in passing urine (12.9% vs. 1.8%, P = .0003) and abnormalities of the penile urethra (4.4% vs. 0%; P = .017).