Home Aerobic Training for Cerebellar Degenerative Diseases: a Randomized Controlled Trial

Balance training has shown some benefits in cerebellar ataxia whereas the effects of aerobic training are relatively unknown. To determine whether a phase III trial comparing home aerobic to balance training in ambulatory patients with cerebellar ataxia is warranted, we conducted a single-center, assessor-blinded, randomized controlled trial. Nineteen subjects were randomized to aerobic training and 17 subjects to balance training. The primary outcome was improvement in ataxia as measured by the Scale for the Assessment and Rating of Ataxia (SARA). Secondary outcomes included safety, training adherence, and balance improvements. There were no differences between groups at baseline. Thirty-one participants completed the trial, and there were no training-related serious adverse events. Compliance to training was over 70%. There was a mean improvement in ataxia symptoms of 1.9 SARA points (SD 1.62) in the aerobic group compared to an improvement of 0.6 points (SD 1.34) in the balance group. Although two measures of balance were equivocal between groups, one measure of balance showed greater improvement with balance training compared to aerobic training. In conclusion, this 6-month trial comparing home aerobic versus balance training in cerebellar ataxia had excellent retention and adherence to training. There were no serious adverse events, and training was not interrupted by minor adverse events like falls or back pain. There was a significant improvement in ataxia symptoms with home aerobic training compared to balance training, and a phase III trial is warranted. Clinical trial registration number: NCT03701776 on October 8, 2018.

FOSL1 promotes cholangiocarcinoma via transcriptional effectors that could be therapeutically targeted

BACKGROUND & AIMS

Cholangiocarcinoma (CCA) is a neoplasia of the biliary tract driven by genetic, epigenetic and transcriptional mechanisms. Herein, we investigated the role of the transcription factor FOSL1, as well as its downstream transcriptional effectors, in the development and progression of CCA.

METHODS

FOSL1 was investigated in human CCA clinical samples. Genetic inhibition of FOSL1 in human and mouse CCA cell lines was performed in in vitro and in vivo models using constitutive and inducible short-hairpin RNAs. Conditional FOSL1 ablation was done using a genetically engineered mouse (GEM) model of CCA (mutant KRAS and Trp53 knockout). Follow-up RNA and chromatin immunoprecipitation (ChIP) sequencing analyses were carried out and downstream targets were validated using genetic and pharmacological inhibition.

RESULTS

An inter-species analysis of FOSL1 in CCA was conducted. First, FOSL1 was found to be highly upregulated in human and mouse CCA, and associated with poor patient survival. Pharmacological inhibition of different signalling pathways in CCA cells converged on the regulation of FOSL1 expression. Functional experiments showed that FOSL1 is required for cell proliferation and cell cycle progression in vitro, and for tumour growth and tumour maintenance in both orthotopic and subcutaneous xenograft models. Likewise, FOSL1 genetic abrogation in a GEM model of CCA extended mouse survival by decreasing the oncogenic potential of transformed cholangiocytes. RNA and ChIP sequencing studies identified direct and indirect transcriptional effectors such as HMGCS1 and AURKA, whose genetic and pharmacological inhibition phenocopied FOSL1 loss.

CONCLUSIONS

Our data illustrate the functional and clinical relevance of FOSL1 in CCA and unveil potential targets amenable to pharmacological inhibition that could enable the implementation of novel therapeutic strategies.

LAY SUMMARY

Understanding the molecular mechanisms involved in cholangiocarcinoma (bile duct cancer) development and progression stands as a critical step for the development of novel therapies. Through an inter-species approach, this study provides evidence of the clinical and functional role of the transcription factor FOSL1 in cholangiocarcinoma. Moreover, we report that downstream effectors of FOSL1 are susceptible to pharmacological inhibition, thus providing new opportunities for therapeutic intervention.

Phase I randomized single-blinded controlled study investigating the potential benefit of aerobic exercise in degenerative cerebellar disease

OBJECTIVES

To investigate whether people with cerebellar degeneration can perform rigorous aerobic exercise and to assess the clinical impact of training.

DESIGN

Randomized single-blinded controlled, feasibility study comparing aerobic training to no training.

SETTING

Home intervention, assessments conducted at an academic medical center.

SUBJECTS

Twenty individuals with cerebellar degeneration caused by a range of genetic disorders.

INTERVENTION

Aerobic training consisted of four weeks of stationary bicycle training, five times per week for 30-minute sessions. Intensity ranged from 65% to 80% of the participant's maximal heart rate determined during cardiopulmonary exercise testing.

MAIN MEASURES

Primary outcome measure was change in the Scale for the Assessment and Rating of Ataxia scores. Recruitment rate, adherence, drop-out, and adverse events were also determined. The treatment was considered technically feasible if participants achieved target training frequency, duration, and intensity.

RESULTS

The 20 participants mean age was 50 years (standard deviation 15.65 years) and average Scale for the Assessment and Rating of Ataxia score was 9.6 (standard deviation 3.13). Ten participants were randomized to aerobic training and 10 to no training. Seven participants in the aerobic group attained target training duration, frequency, and intensity. There was a mean reduction in ataxia severity of 2.1 points (standard deviation 1.26) with four weeks of aerobic training, whereas ataxia severity increased by 0.3 (standard deviation 0.62) in the control group over the same period. Walking speed, balance measures, and fitness also improved in individuals who performed aerobic exercise.

CONCLUSIONS

Rigorous aerobic training is feasible in people with cerebellar degeneration. Improvements in ataxia, balance, and gait are promising.

Abstract WP206: Cognitive Functioning Predicts Engagement in Inpatient Stroke Rehabilitation

Introduction: Patient engagement during inpatient stroke rehabilitation (ISR) is critical to long-term outcomes. Cognitive deficits have demonstrated impact on engagement in rehabilitation. Here, we prospectively investigated the relationship between specific cognitive domains and patient engagement during ISR.

Methods: Of 423 patients completing ISR, 127 (30%) had complete data with mean age=67.63 + 15.46 years, NIHSS=6.78 + 5.68, and onset from stroke to ISR admission=8.55 + 7.72 days. The sample comprised 55% males and 56.7% had a college education or more. The National Institute of Neurologic Disorders - Canadian Stroke Network (NINDS-CSN) 30-minute cognitive screening battery was administered within 72 hours of ISR admission to assess verbal fluency, executive functioning, and memory. The Hopkins Rehabilitation Engagement Ratings Scale (HRERS; total score 0-30, higher=greater engagement) was completed by treating therapists at ISR discharge. Spearman rank-order correlations (r s ) examined the relationships between the HRERS total score and the NINDS-CSN total (the mean z-score across subtests) as well as its 8 subtests. Items with correlations p<.10 were entered into a logistic regression (controlling for age, comorbidity, and stroke severity) to predict low (HRERS ≤ 25) versus high engagers (HRERS > 26).

Results: NINDS-CSN total and 6 subtests assessing verbal fluency and executive function were weakly to moderately correlated with HRERS scores (r s =0.23-.38, all p’s <.01). Memory subtests were not associated with HRERS. Higher NINDS-CSN total score and subtests reflecting executive functions modestly increased the odds of being a high engager (Odds Ratios ranged from 1.03-1.08, 95% CIs ranged from 1.013-1.134, all p’s < .01).

Conclusion: Poor executive functioning may pose a barrier to patient engagement in ISR. Executive functions may impact patients’ ability to shift among activities, maintain attention, and rapidly process information during therapy. Rehabilitation therapists should consider making environmental modifications, providing more frequent guidance and positive reinforcement, and presenting simplified material to increase engagement in stroke patients with executive dysfunction.

Ultrasound Elastography to Assess Botulinum Toxin A Treatment for Post-stroke Spasticity: A Feasibility Study

The aim of the study was to evaluate the feasibility of using ultrasound elastography to assess the effect of botulinum toxin A (BoNT-A) treatment on post-stroke spasticity of the upper limb. In this prospective study, we performed ultrasound elastography (strain imaging and acoustic radiation force impulse-based shear wave elastography) of the spastic biceps brachii muscle in seven patients (five men and two women, mean age: 45y) who underwent BoNT-A injection treatment for post-stroke spasticity of the upper limb. We measured ultrasound elasticity parameters including axial strain ratio (SR) (SR = muscle strain/reference strain), longitudinal SR and shear wave velocity of the biceps muscle immediately before and 17-30 d (mean: 22 d) after BoNT-A injection. Statistical analyses included a two-tailed paired t-test to examine the difference in ultrasound elasticity parameters of bilateral biceps muscles before and after BoNT-A treatment and a Spearman rank correlation coefficient (r_s) to analyze the correlation of ultrasound elasticity parameters to clinical assessment with the Modified Ashworth Scale (MAS) and Tardieu Scale (TS). The difference in ultrasound elasticity parameters before and after BoNT-A treatment was significant (p < 0.05) in the treated spastic muscle. The correlation of ultrasound elasticity parameters with MAS and the angle of catch and range of motion in TS were also significant (r_s = 0.55-0.95, p < 0.05). Our results suggest that ultrasound elastography is feasible in assessment of the effectiveness of BoNT-A treatment for post-stroke spasticity of the upper limb.

Quantitative Ultrasound Imaging to Assess the Biceps Brachii Muscle in Chronic Post-Stroke Spasticity: Preliminary Observation

We prospectively investigated the feasibility of using quantitative ultrasound imaging (QUI) to assess the biceps brachii muscle (BBM) in individuals with chronic post-stroke spasticity. To quantify muscle echogenicity and stiffness, we measured QUI parameters (gray-scale pixel value and shear wave velocity [SWV, m/s]) of the BBM in three groups: 16 healthy BBMs; 12 post-stroke, non-spastic BBMs; and 12 post-stroke, spastic BBMs. The QUI results were compared with the Modified Ashworth Scale and Tardieu Scale. A total of 20 SWVs were measured in each BBM, once at elbow in 90° flexion and again at maximally achievable extension using acoustic radiation force impulse imaging. BBM pixel value was measured in gray-scale images captured at 90° elbow flexion using ImageJ software. Statistical analyses included analysis of variance for examining the difference in SWV and pixel values among the three groups; Bonferroni correction for testing the difference in SWV and pixel values in a paired group; t-test for examining the difference in SWV values measured at two elbow angles; and Pearson correlation coefficient for analyzing the correlation of QUI to Modified Ashworth Scale and Tardieu Scale. SWV significantly differed between spastic BBMs and non-spastic or healthy BBMs. For pixel values, each of the three groups significantly differed from the others at elbow 90° flexion. The difference in SWV measured between the two elbow angles was also significant (p <0.01). A strong negative correlation was found between SWV and passive range of motion (R² = -0.88, p <0.0001) in spastic upper limbs. These results suggest that the use of QUI is feasible in quantitative assessment of spastic BBM.

Ultrasound Strain Imaging to Assess the Biceps Brachii Muscle in Chronic Poststroke Spasticity

OBJECTIVES

The aim of the study was to assess the feasibility of ultrasound strain imaging in characterizing the biceps brachii muscle in chronic poststroke spasticity.

METHODS

We prospectively analyzed strain imaging data from bilateral biceps brachii muscles in 8 healthy volunteers and 7 patients with poststroke chronic spasticity. Axial deformations of the biceps brachii muscle and overlying subcutaneous tissue were produced by external compression using a sandbag (1.0 kg) attached to a transducer. The lengthening and shortening of the biceps brachii muscle and subcutaneous tissue were produced by manual passive elbow extension (from 90° to 0°) and flexion (from 0° to 90°), respectively. We used offline 2-dimensional speckle tracking to estimate axial and longitudinal strain ratios (biceps brachii strain/subcutaneous tissue strain), and the longitudinal tissue velocity of the biceps brachii muscle. Statistical analyses included analysis of variance for testing differences in strain imaging parameters among healthy, nonspastic, and spastic biceps brachii muscles, the Bonferroni correction for further testing differences in US strain imaging among paired groups (healthy versus spastic, nonspastic versus spastic, and healthy versus nonspastic), and the Pearson correlation coefficient for assessing the intraobserver reliability of performing strain imaging in stroke survivors.

RESULTS

The differences in strain imaging parameters between healthy and spastic and between nonspastic and spastic biceps brachii muscles were significant at both 90° elbow flexion and maximal elbow extension (P < .01). There was no significant difference in axial strain ratios at 90° of elbow flexion or longitudinal tissue velocities between healthy and nonspastic muscles (P > .05). The intraobserver reliability of performing strain imaging in stroke survivors was good (r = 0.85; P < .01).

CONCLUSIONS

Ultrasound strain imaging seems to be feasible for characterizing the biceps brachii muscle in chronic poststroke spasticity.

Mice with targeted KrasG12D and loss of p53 in the liver: A robust model for studying immunologic interventions for treating cholangiocarcinoma

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Background: Inflammation in the tumor microenvironment—chronically elevated cytokines, chemokines, and inflammatory cells—promotes tumorigenesis. Cholangiocarcinoma (CC) is the most common liver malignancy within the biliary tree with few treatment options and a poor 5-year survival. CC tumors are characterized with a dense tumor stroma and abundant inflammatory immune cell infiltrate, yet little is known about the immune dynamics underlying the disease. Here, we characterize immune signaling pathways in human CC and a spontaneous mouse model of the disease to identify potential targets susceptible to immune based therapies. Methods: Histology and immunohistochemistry (IHC) were performed on archived human specimens and tissue microarrays of 52 CC specimens constructed under an IRB approved protocol to identify the prognostic significance of cytokine and immune markers. Peripheral blood, bone marrow, and tissue from mice with targeted activation of KrasG12D and loss of p53 (Kras-p53-/-) in the liver that spontaneously developed CC tumors versus normal controls were collected and analyzed by histology, IHC, quantitative gene expression, and flow cytometry based studies. Results: High levels of inflammatory leukocytes in human CC were predominantly of monocytic and granulocytic origin including macrophages (TAM) and granulocytic-myeloid derived suppressor cells (G-MDSC) respectively. Malignant cells expressed high levels of CCL2 and TAM stained positive for its cognate receptor CCR2. In addition, CD8+ and CD4+ T cells expressing PD-1 were associated with PD-L1+ tumor cells. Kras-p53-/- mice developed CC tumors histologically similar to human disease: tumors had high levels of cytokines and induced myelopoiesis leading to significantly more monocytes and granulocytes in the bone marrow, blood, and spleen compared to normal liver controls. Tumors also expressed higher levels of CCL2 and PD-L1 with more CCR2+ TAMs and PD-1+ T cells compared to controls. Conclusions: Human CC utilizes immune signaling pathways and Kras-p53-/- mice recapitulate the immune dynamics of the disease representing a model to study immune based therapies for treating CC.

Effects of repeated abobotulinumtoxinA injections in upper limb spasticity

Introduction: The efficacy of single injections of abobotulinumtoxinA (Dysport) is established in adults with upper limb spasticity. In this study we assessed the effects of repeated injections of abobotulinumtoxinA over 1 year. Methods: Patients (n = 258, safety population) received 500 U, 1,000 U, or 1,500 U (1,500‐U dose included 500‐U shoulder injections) for up to 4 or 5 treatment cycles. Assessments included treatment‐emergent adverse events (TEAEs), muscle tone, passive and active range of motion (X_V1, X_A), angle of catch (X_V3), Disability Assessment Scale (DAS) score, Modified Frenchay Scale (MFS) score, and Physician Global Assessment (PGA) score. Results: The incidence of TEAEs decreased across cycles. Muscle tone reduction and X_V1 remained stable across cycles, whereas X_V3 and X_A continued to improve at the finger, wrist, and elbow flexors. DAS and PGA improved across cycles. MFS improved best with 1,500 U. Discussion: A favorable safety profile and continuous improvements in active movements and perceived and active function were associated with repeated abobotulinumtoxinA injections in upper limb muscles. Muscle Nerve57: 245–254, 2018

Ultrasound Strain Imaging in Assessment of Biceps Muscle Stiffness and Dynamic Motion in Healthy Adults

We prospectively evaluated the feasibility of using ultrasound strain imaging (USI) to assess biceps brachii muscle (BBM) stiffness and dynamic motion in 10 healthy adults. The BBM axial deformation was produced by external compression with a sandbag (1.0 kg) tied onto the transducer. The BBM lateral movement was produced by manual passive elbow flexion and extension. By use of 2-D speckle tracking, captured 5-s real-time ultrasound data of BBM were processed to estimate axial strain, representing muscle stiffness, and lateral strain and tissue velocity, representing muscle dynamic motion. Axial (lateral) strain ratio was defined as BBM strain divided by subcutaneous soft tissue strain. There was no significant difference in lateral strain or tissue velocity between the left and right BBM (lateral strain ratio: 4.69 ± 0.07 vs. 4.51 ± 0.08 for extension, 4.82 ± 0.09 vs. 4.69 ± 0.11 for flexion; tissue velocity: 1.58 ± 0.32 cm/s vs. 1.78 ± 0.85 cm/s for extension, -2.03 ± 0.63 vs. -2.03 ± 0.59 for flexion; all p values > 0.05) or between men and women (lateral strain ratio: 4.52 ± 0.06 vs. 4.67 ± 0.1 for extension, 4.71 ± 0.11 vs. 4.83 ± 0.09 for flexion; tissue velocity, cm/s: 1.76 ± 0.76 vs. 1.66 ± 0.65 for extension, -2.21 ± 0.65 vs. -1.88 ± 0.52 for flexion, all p values > 0.05). The difference in axial stain between men and women was significant (axial strain ratio: 3.09 ± 0.43 vs. 3.52 ± 0.26, p = 0.02). Inter- and intra-observer reliability in performing USI of the BBM was good (all intra-class correlation coefficients [ICCs] >0.75). Our results suggest that USI seems to be feasible for and reproducible in estimating BBM mechanical properties and motion dynamics in healthy adults.

Abstract 2951: The tumor microenvironment in cholangiocarcinoma is dominated by an immunosuppressive infiltrate

Purpose: To characterize the dynamics of the immune response to cholangiocarcinoma (CCA) in a genetically engineered mouse model of CCA in order to identify immune pathways susceptible to targeted immunotherapies.

Experimental Design: Genetically modified mice with targeted Kras activation and loss of p53 (Alb-Cre/LSL-KRASG12D /p53Lox/+) in the liver spontaneously develop CCA recapitulating the histopathologic features of human disease. To evaluate the in vivo immune response to CCA, tumors from Kras-p53 mice and normal livers were excised and processed for histologic examination, flow cytometry, and gene expression analysis. Immunohistochemistry (IHC) and flow cytometry were performed on myeloid and T cell markers to distinguish immune cell subsets. Cell lines established from isolated CCA tumors were used to assess the functional impact between the immune system and tumor cells in co-culture in-vitro studies.

Results: Kras-p53 murine hepatic tumors were highly desmoplastic with a heavy fibrotic stromal compartment. IHC analysis demonstrated a prominent inflammatory leukocyte infiltrate compared to normal liver. Flow cytometry of single cell tumor suspensions showed the immune reaction was dominated by CD11b+ monocytic (Ly6C+) and granulocytic (Ly6G+) myeloid cells, and Foxp3+ regulatory T cells (T reg). In vitro studies revealed tumor educated myeloid cells expressed higher levels of genes associated with an immunosuppressive phenotype, including Arginase 1 (p=&lt;0.007). Invasion assays analyzing the migration potential of CCA cell lines co-cultured with CD11b+ cells showed increased invasive properties in these tumor cells when compared to naive controls (p=&lt;0.0001). Additionally, increased tumor-initiating properties were seen by qRT-PCR in tumor cell lines having undergone similar co-culture experiments. These data suggest the immune response to CCA is predominantly immunosuppressive and tumor supportive.

Conclusion: CCA tumors from Alb-Cre/LSL-KRASG12D /p53Lox/+ mice have a prominent immunosuppressive infiltrate recapitulating features of the immune reaction in human disease. Thus, Kras-p53 mice provide an ideal model to test targeted immunotherapy for the treatment of CCA.

Citation Format: Nathania M. Figueroa, Brian Belt, Ankit Patel, Booyeon Han, Margaret Hill, William Alexander, Michael O'Dell, Aditi Murthy, Kelli Connolly, Scott A. Gerber, Aram Hezel, David Linehan. The tumor microenvironment in cholangiocarcinoma is dominated by an immunosuppressive infiltrate [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2951. doi:10.1158/1538-7445.AM2017-2951

Perspectives on Speech Timing: Coupled Oscillator Modeling of Polish and Finnish

This stud y was ai med at analyzing empirical duration data for Polish spoken at different tempos using an updated version of the Coupled Oscillator Model of speech timing and rhythm variability (O'Dell and Nieminen, 1999, 2009). We use Bayesian inference on parameters relating to speech rate to investigate how tempo affects timing in Polish. The model parameters found are then compared with parameters obtained for equivalent material in Finnish to shed light on which of the effects represent general speech rate mechanisms and which are specific to Polish. We discuss the model and its predictions in the context of current perspectives on speech timing.

Structural connectome disruption at baseline predicts 6-months post-stroke outcome

In this study, models based on quantitative imaging biomarkers of post-stroke structural connectome disruption were used to predict six-month outcomes in various domains. Demographic information and clinical MRIs were collected from 40 ischemic stroke subjects (age: 68.1 ± 13.2 years, 17 female, NIHSS: 6.8 ± 5.6). Diffusion-weighted images were used to create lesion masks, which were uploaded to the Network Modification (NeMo) Tool. The NeMo Tool, using only clinical MRIs, allows estimation of connectome disruption at three levels: whole brain, individual gray matter regions and between pairs of gray matter regions. Partial Least Squares Regression models were constructed for each level of connectome disruption and for each of the three six-month outcomes: applied cognitive, basic mobility and daily activity. Models based on lesion volume were created for comparison. Cross-validation, bootstrapping and multiple comparisons corrections were implemented to minimize over-fitting and Type I errors. The regional disconnection model best predicted applied cognitive (R(2)  = 0.56) and basic mobility outcomes (R(2)  = 0.70), while the pairwise disconnection model best predicted the daily activity measure (R(2)  = 0.72). These results demonstrate that models based on connectome disruption metrics were more accurate than ones based on lesion volume and that increasing anatomical specificity of disconnection metrics does not always increase model accuracy, likely due to statistical adjustments for concomitant increases in data dimensionality. This work establishes that the NeMo Tool's measures of baseline connectome disruption, acquired using only routinely collected MRI scans, can predict 6-month post-stroke outcomes in various functional domains including cognition, motor function and daily activities. Hum Brain Mapp, 2016. © 2016 Wiley Periodicals, Inc.

Understanding the role of the healthcare professional in patient self-management of allergic rhinitis

Objective:

Allergic rhinitis is a common, usually long-standing, condition that may be self-diagnosed or have a formal diagnosis. Our aim was to identify how allergic rhinitis sufferers self-manage their condition.

Methods:

A sample of 276 self-identified adult allergy sufferers pooled from social media completed an online survey comprising 13 questions. The survey was fielded by a professional research organization (Lab42). The main outcome measures included the use of prescription and/or non-prescription allergy medication, and interactions with physician and/or pharmacist with respect to medication use.

Results:

Of the respondents, 53% (146/276) indicated that they used both prescription and over-the-counter medication to manage their allergy symptoms. Of those who used prescription medication, 53% reported that they discussed their prescription medication in great detail with their physician when it was prescribed, while 42% spoke about it briefly. Following the initial prescription, few discussions about the prescription occur with the physician (45% indicate several discussions, 40% indicate one or two discussions, and 10% indicate no discussions). In most cases (~75% of the time), allergy prescription refills did not require a doctor visit with patients obtaining refills through phone calls to the doctor’s office or through the pharmacy. Two-thirds of patients (69%) report that they have discussed their prescription allergy medication with a pharmacist, with greater than half of respondents having discussed the use of the non-prescription medication with their doctor.

Conclusion:

Patients with diagnosed allergic rhinitis appear to be self-managing their condition with few interactions with their doctor about their allergy prescription. Interactions with a pharmacist about allergy medication (prescription and non-prescription) appear to be more common than interactions with a physician.

Abstract PR09: Plac8 links oncogenic mutations to regulation of autophagy and is critical to pancreatic cancer progression

A) Pancreatic ductal adenocarcinoma (PDA) depends on a marked reprogramming of metabolic pathways, including the acquisition of autophagy dependence, for survival and growth. How common mutations in PDA cause autophagy dependence as well as the timing of autophagy activation in the course of cancer progression, have not been established. Here we show how Plac8, a gene synergistically up-regulated in response to the common cooperating oncogenic mutations found in PDA (RAS activation and functional loss of p53), is critical to the growth of PDA by sustaining autophagy via facititating autophagosome-lysosome fusion. Furthermore, we delineate that Kras and p53 mutations cooperate to induce autophagic flux. B) To establish Plac8’s role in PDA growth and autophagy we use murine cell lines and human PDA cell lines to determine 1) the lysosomal localization of Plac8, 2) its role in regulating autophagy using both loss of function and gain of function approaches, 3) the impact on lysosomal biology, and 4) the relationship between Plac8 and other genetic pathways governing autophagy. Using genetically engineered models of PDA we determine the timing of autophagy activation in PDA progression and the impact of Plac8 mutation. C) We identify Plac8 as a novel regulator of autophagosome-lysosome fusion required for PDA growth, thus providing a mechanistic link between oncogenic mutations and the activation of autophagy in cancer. Plac8 expression is required for growth of human PDA cells as xenografts in mice, as well as activation of autophagy. We find that concurrent mutation of KRAS and p53 is critical for maximal induction of autophagy in vitro. Correspondingly, using genetically engineered mouse models of PDA (Pdx1-Cre; LSL-KrasG12D; p53L/+), in which loss of p53 function occurs in a step-wise manner relying on the spontaneous loss of a heterozygous WT p53 allele, we see a step-wise incremental increase in LC3 puncta in vivo with each histological stage through the course of PDA progression. Thus, we find that the cooperative effects of KRAS and p53 drive activation of autophagy rather than either mutation alone. The overall survival of a Pdx1-Cre; LSL-KrasG12D; p53L/+; Plac8null murine cohort (OS 27.9 wks) was significantly longer than a Pdx1-Cre; LSL-KrasG12D; p53L/+; Plac8wt cohort (OS 17.0 wks, p=0.0006) demonstrating in vivo that genetic inactivation of Plac8 impedes cancer progression and resulting death. Our data suggest that the role of Plac8 in facilitating autophagy is critical to cancer, as the requirement of Plac8 for both tumorigenicity and autophagy can be compensated by over-expression of Atg12, a gene critical for autophagosome formation or by constitutively activated Rab7, a gene encoding a GTP-binding protein stimulating autophagosome-lysosome fusion. D) We conclude that Plac8 may offer a potential therapeutic window and point of intervention, as Plac8 mutation in the engineered PDA model inhibits cancer progression and significantly improves survival while having a minimal impact on the overall fitness of the animals. In fact, Plac8, and regulation of autophagosome-lysosome fusion, has specific relevance to regulation of autophagy during malignant cell transformation as Plac8 and the processes it regulates, appear to be largely dispensable to many normal physiologic processes.

This abstract is also presented as Poster B36.

Citation Format: Vijaya Balakrishnan, Kinsey Conan, Michael O'Dell, Jing Li Huang, Laurel Newman, Christa Whitney-Miller, Hartmut Land, Aram Hezel. Plac8 links oncogenic mutations to regulation of autophagy and is critical to pancreatic cancer progression. [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Innovations in Research and Treatment; May 18-21, 2014; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2015;75(13 Suppl):Abstract nr PR09.

Exploring the brain's structural connectome: A quantitative stroke lesion-dysfunction mapping study

The aim of this work was to quantitatively model cross-sectional relationships between structural connectome disruptions caused by cerebral infarction and measures of clinical performance. Imaging biomarkers of 41 ischemic stroke patients (72.0 ± 12.0 years, 20 female) were related to their baseline performance in 18 cognitive, physical and daily life activity assessments. Individual estimates of structural connectivity disruption in gray matter regions were computed using the Change in Connectivity (ChaCo) score. ChaCo scores were utilized because they can be calculated using routinely collected clinical magnetic resonance imagings. Partial Least Squares Regression (PLSR) was used to predict various acute impairment and activity measures from ChaCo scores and patient demographics. Statistical methods of cross-validation, bootstrapping and multiple comparisons correction were implemented to minimize over-fitting and Type I errors. Multiple linear regression models based on lesion volume and lateralization information were constructed for comparison. All models based on connectivity disruption had lower Akaike Information Criterion and almost all had better goodness-of-fit values (R(2) : 0.26-0.92) than models based on lesion characteristics (R(2) : 0.06-0.50). Confidence intervals of PLSR coefficients identified brain regions important in predicting each clinical assessment. Appropriate mapping of eloquent functions, that is, language and motor, and replication of results across pathologies provided validation of this method. Models of complex functions provided new insights into brain-behavior relationships. In addition to the potential applications in prognostication and rehabilitation development, this quantitative approach provides insight into the structural networks underlying complex functions like activities of daily living and cognition. Quantitative analysis of big data will be invaluable in understanding complex brain-behavior relationships.

Exposure-Based CBT for Older Adults After Fall Injury: Description of a Manualized, Time-Limited Intervention for Anxiety

Fall accidents among older adults can be devastating events that, in addition to their physical consequences, lead to disabling anxiety warranting the attention of mental health practitioners. This article presents "Back on My Feet," an exposure-based cognitive-behavioral therapy (CBT) protocol that is designed for older adults with posttraumatic stress disorder (PTSD), subthreshold PTSD, or fear of falling resulting from a traumatic fall. The protocol can be integrated into care once patients have been discharged from hospital or rehabilitation settings back to the community. Following a brief description of its development, the article presents a detailed account of the protocol, including patient evaluation and the components of the eight home-based sessions. The protocol addresses core symptoms of avoidance, physiological arousal/anxiety, and maladaptive thought patterns. Because older patients face different coping challenges from younger patients (for whom the majority of evidence-based CBT interventions have been developed), the discussion ends with limitations and special considerations for working with older, injured patients. The article offers a blueprint for mental health practitioners to address the needs of patients who may present with fall-related anxiety in primary care and other medical settings. Readers who wish to develop their expertise further can consult the online appendices, which include a clinician manual and patient workbook, as well as guidance on additional resources.

Access to medications and intermediate markers of health outcomes of a clinic population of patients with diabetes

This study is a correlational analysis of the efficacy of a Medication Assistance Program (MAP) on intermediate physiologic markers of health outcomes of patients with diabetes, specifically blood pressure, HBA1c, and lipid levels.

METHODS

The sample included 72 patients enrolled in a MAP and 854 patients not enrolled in a MAP and with a diagnosis of diabetes whose key elements of care are tracked in a registry. RESULTS. For established clinic patients, when compared to MAP patients, the MAP group had a small but statistically significant lower mean systolic blood pressure and higher HbA1c. Comparing MAP patients new to the program and those that were established in the program, there were no significant differences on blood pressure, HbA1c, and lipid level.

CONCLUSIONS

Provision of medication alone is certainly necessary, but may not be sufficient, to address health outcomes for impoverished populations.

The binding of nuclear factors to the as-1 element in the CaMV 35S promoter is affected by cytosine methylation in vitro

Transcriptional gene silencing (TGS) is often associated with an increased level of cytosine methylation in the affected promoters. The effect of methylation of the cauliflower mosaic virus (CaMV) 35S promoter sequence on its binding to factors present in the nuclei was analyzed by electrophoretic mobility shift assays using extracts of petunia flowers. Specific DNA-protein interactions were detected in the region of the CaMV 35S promoter that contains the as-1 element and the region between - 345 and - 208. The binding of protein factor(s) to the as-1 element was influenced by cytosine methylation, whereas the binding to the region between - 345 and - 208 was unaffected. The results suggest that cytosine methylation of the as-1 element potentially affects the activity of the CaMV 35S promoter.

Epigenetic inactivation of chalcone synthase-A transgene transcription in petunia leads to a reversion of the post-transcriptional gene silencing phenotype

Petunia plants that exhibit a white-flowering phenotype as a consequence of chalcone synthase transgene-induced silencing occasionally give rise to revertant branches that produce flowers with wild-type pigmentation. Transcription run-on assays confirmed that the production of white flowers is caused by post-transcriptional gene silencing (PTGS), and indicated that transgene transcription is repressed in the revertant plants, providing evidence that induction of PTGS depends on the transcription rate. Transcriptional repression of the transgene was associated with cytosine methylation at CpG, CpNpG and CpNpN sites, and the expression was restored by treatment with either 5-azacytidine or trichostatin A. These results demonstrate that epigenetic changes occurred in the PTGS line, and these changes interfere with the initiation of transgene transcription, leading to a reversion of the PTGS phenotype.

Socio-ecological resources for diabetes self-management

BACKGROUND

This study describes the utility of the brief Chronic Illness Resources Survey (CIRS) in a family medicine clinic. The brief CIRS is a 22-item scale that assesses support for self-management tasks common to chronic illnesses. The scale is based on socio-ecological theory and measures seven levels of socio-environmental support.

METHODS

The sample included 31 males and females aged 38 - 86 years with a diagnosis of diabetes who presented for care at a family medicine residency clinic. After scheduled office visits, patients completed the brief CIRS, demographic indicators, and brief medical information.

RESULTS

The health care team, personal support, and media/policy subscales were rated the highest followed by family and friends, neighborhood, workplace, and community organizations. There were no significant differences in the t-tests between select demographic variables (gender, race, age, marital status, and work status) and CIRS total score. Females' higher total CIRS score was nearly statistically significant as compared to males' total CIRS score.

CONCLUSIONS

The health care team is of primary importance in diabetic patient self-management, and so, the brief CIRS may be a useful rapid assessment instrument in a medical clinic setting where additional resources may be identified and recommended as indicated by the physician.

Developmentally and transgene regulated nuclear processing of primary transcripts of chalcone synthase A in petunia

The introduction of chalcone synthase A transgenes into petunia plants can result in degradation of chalcone synthase A RNAs and loss of chalcone synthase, a process called cosuppression or post-transcriptional gene silencing. Here we show that the RNA degradation is associated with changes in premRNA processing, i.e. loss of tissue specificity in transcript cleavage patterns, accumulation of unspliced molecules, and use of template-specific secondary poly(A) sites. These changes can also be observed at a lower level in leaves but not flowers of nontransgenic petunias. Based on this, a model is presented of how transgenes may disturb the carefully evolved, developmentally controlled post-transcriptional regulation of chalcone synthase gene expression by influencing the survival rate of the endogenous and their own mRNA.

Prodrugs of CL316243: a selective beta3-adrenergic receptor agonist for treating obesity and diabetes

CL316243 is a highly selective and potent beta3-adrenergic receptor agonist, and has been shown in rodent models to be an effective agent for treating obesity and Type II diabetes. To improve the oral absorption and pharmacokinetic profiles of CL316243, a number of prodrugs have been synthesized and evaluated. Several ester-type prodrugs show significant improvements in oral bioavailability in both rodent and primate models.