A validated composite comorbidity index predicts outcomes of CAR T-cell therapy in patients with diffuse large B-cell lymphoma

Chimeric antigen receptor T-cell therapy (CART) has extended survival of patients with relapsed/refractory diffuse large B-cell lymphoma (DLBCL). However, limited durability of response and prevalent toxicities remain problematic. Identifying patients who are at high risk of disease progression, toxicity, and death would inform treatment decisions. Although the cumulative illness rating scale (CIRS) has been shown to correlate with survival in B-cell malignancies, no prognostic score has been independently validated in CART recipients. We retrospectively identified 577 patients with relapsed/refractory DLBCL indicated for CART at 9 academic centers to form a learning cohort (LC). Random survival forest modeling of overall survival (OS) and progression-free survival (PFS) was performed to determine the most influential CIRS organ systems and severity grades. The presence of a severe comorbidity (CIRS score ≥ 3) in the respiratory, upper gastrointestinal, hepatic, or renal system, herein termed "Severe4," had the greatest impact on post-CART survival. Controlling for other prognostic factors (number of prior therapies, Eastern Cooperative Oncology Group performance status, BCL6 translocation, and molecular subtype), Severe4 was strongly associated with shorter PFS and OS in the LC and in an independent single-center validation cohort (VC). Severe4 was also a significant predictor of grade ≥3 cytokine release syndrome in the LC, while maintaining this trend in the VC. Thus, our results indicate that adverse outcomes for patients with DLBCL meant to receive CART can be predicted using a simplified CIRS-derived comorbidity index.

Functional connectivity analysis of the depression connectome provides potential markers and targets for transcranial magnetic stimulation

BACKGROUND

Despite efforts to improve targeting accuracy of the dorsolateral prefrontal cortex (DLPFC) as a repetitive transcranial magnetic stimulation (rTMS) target for Major Depressive Disorder (MDD), the heterogeneity in clinical response remains unexplained.

OBJECTIVE

We sought to compare the patterns of functional connectivity from the DLPFC treatment site in patients with MDD who were TMS responders to those who were TMS non-responders.

METHODS

Baseline anatomical T1 magnetic resonance imaging (MRI), resting-state functional MRI, and diffusion weighted imaging scans were obtained from 37 participants before they underwent a course of rTMS to left Brodmann area 46. A novel machine learning method was utilized to identify brain regions associated with each item of the Beck's Depression Inventory II (BDI-II), and for 26 participants who underwent rTMS treatment over the left Brodmann area 46, identify regions differentiating rTMS responders and non-responders.

RESULTS

Nine parcels of the Human Connectome Project Multimodal Parcellation Atlas matched to at least three items of the Beck's Depression Inventory II (BDI-II) as predictors of response to rTMS, with many in the temporal, parietal and cingulate cortices. Additionally, pre-treatment mapping for 17 items of the BDI-II demonstrated significant variability in symptom to parcel mapping. When parcels associated with symptom presence and symptom resolution were compared, 15 parcels were uniquely associated with resolution (potential targets), and 12 parcels were associated with both symptom presence and resolution (blockers or biomarkers).

CONCLUSIONS

Machine learning approaches show promise for the development of pathoanatomical diagnosis and treatment algorithms for MDD. Prospective studies are required to facilitate clinical translation.

Genomic analysis of early-stage lung cancer reveals a role for TP53 mutations in distant metastasis

Patients with non-small cell lung cancer (NSCLC) who have distant metastases have a poor prognosis. To determine which genomic factors of the primary tumor are associated with metastasis, we analyzed data from 759 patients originally diagnosed with stage I-III NSCLC as part of the AACR Project GENIE Biopharma Collaborative consortium. We found that TP53 mutations were significantly associated with the development of new distant metastases. TP53 mutations were also more prevalent in patients with a history of smoking, suggesting that these patients may be at increased risk for distant metastasis. Our results suggest that additional investigation of the optimal management of patients with early-stage NSCLC harboring TP53 mutations at diagnosis is warranted in light of their higher likelihood of developing new distant metastases.

Nephrotic syndrome with minimal change disease after the Pfizer-BioNTech COVID-19 vaccine: two cases

We present two cases of nephrotic syndrome with minimal change disease after the Pfizer-BioNTech COVID-19 vaccine. We discuss the initial presentation, investigation and management of these patients along with a discussion around the current evidence base for vaccine-induced nephrotic syndrome.

Advancing the Assessment of Mindfulness-Based Meditation Practice: Psychometric Evaluation of the Mindfulness Adherence Questionnaire

Background

Mindfulness-based meditation practice (MBP) can be assessed in terms of time spent (quantity) or skill acquisition (quality), but these components have rarely been delineated in adherence measures. Individuals may also engage in MBP through everyday life (informal practice) and dedicate specific time for MBP (formal practice).

Method

The Mindfulness Adherence Questionnaire, a scale designed to assess quantity and quality of formal and informal MBP was evaluated. Study 1 used a cross-sectional design to examine internal reliability and construct validity (N = 282). Study 2 examined test–retest reliability and sensitivity (N = 55) during a 4-week mindfulness intervention.

Results

A nested-factor model showed adequate fit: MAQ items loaded on both the general factor (Practice) and specific factors (Formal and Informal). Discriminant validity analyses revealed the MAQ captured MBP adherence distinct from trait mindfulness. Quality of both formal and informal mindfulness practice was more strongly associated with higher levels of trait mindfulness than quantity. Changes in MAQ Quantity scores were observed over time.

Conclusions

The MAQ is reliable and has a meaningful scale structure, may usefully distinguish both quality versus quantity and formal versus informal MBP, and is sensitive to variations in MBP and does not solely measure trait mindfulness.

Assessment of the Efficacy of Therapies Following Venetoclax Discontinuation in CLL Reveals BTK Inhibition as an Effective Strategy

PURPOSE

Venetoclax-based therapy is a standard-of-care option in first-line and relapsed/refractory chronic lymphocytic leukemia (CLL). Patient management following venetoclax discontinuation remains nonstandard and poorly understood.

EXPERIMENTAL DESIGN

To address this, we conducted a large international study to identify a cohort of 326 patients who discontinued venetoclax and have been subsequently treated. Coprimary endpoints were overall response rate (ORR) and progression-free survival for the post-venetoclax treatments stratified by treatment type [Bruton's tyrosine kinase inhibitor (BTKi), PI3K inhibitor (PI3Ki), and cellular therapies].

RESULTS

We identified patients with CLL who discontinued venetoclax in the first-line (4%) and relapsed/refractory settings (96%). Patients received a median of three therapies prior to venetoclax; 40% were BTKi naïve (n = 130), and 81% were idelalisib naïve (n = 263). ORR to BTKi was 84% (n = 44) in BTKi-naïve patients versus 54% (n = 30) in BTKi-exposed patients. We demonstrate therapy selection following venetoclax requires prior novel agent exposure consideration and discontinuation reasons.

CONCLUSIONS

For BTKi-naïve patients, selection of covalently binding BTKis results in high ORR and durable remissions. For BTKi-exposed patients, covalent BTK inhibition is not effective in the setting of BTKi resistance. PI3Kis following venetoclax do not appear to result in durable remissions. We conclude that BTKi in naïve or previously responsive patients and cellular therapies following venetoclax may be the most effective strategies.See related commentary by Rogers, p. 3501.

Data Resource Profile: the Scottish Social Care Survey (SCS) and the Scottish Care Home Census (SCHC)

Introduction

Linked health care datasets have been used effectively in Scotland for some time. Use of social care data has been much more limited, partly because responsibility for these services is distributed across multiple local authorities. However, there are substantial interactions between health and social care (also known internationally as long-term care) services, and keen policy interest in better understanding these. We introduce two social care resources that can now be linked to health datasets at a population level across Scotland to study these interdependencies. These data emerge from the Scottish Government’s centralised collation of data from mandatory returns provided by local authorities and care homes.

Methods

Deterministic and Probabilistic methods were used to match the Social Care Survey (SCS) and Scottish Care Home Census (SCHC) to the Community Health Index (CHI) number via the National Records of Scotland (NRS) Research Indexing Spine.

Results

For the years 2010/11 to 2015/16, an overall match rate of 91.2% was achieved for the SCS to CHI from 31 of Scotland’s 32 local authority areas. This rate varied from 76.7% to 98.5% for local authority areas. A match rate of 89.8% to CHI was achieved for the SCHC in years 2012/13 to 2015/16 but only 52.5% for the years 2010/11 to 2011/12.

Conclusion

Indexing of the SCS and SCHC to CHI offers a new and rich resource of data for health and social care research.

Tumor Lysis, Adverse Events, and Dose Adjustments in 297 Venetoclax-Treated CLL Patients in Routine Clinical Practice

PURPOSE

Clinical trials of venetoclax reported negligible rates of clinical tumor lysis syndrome (TLS) in patients with chronic lymphocytic leukemia (CLL) when using an extended dose escalation schedule. We aimed to understand TLS prophylaxis, rates of select adverse events (AE), and impact of dosing modifications in routine clinical practice.

EXPERIMENTAL DESIGN

This retrospective cohort study included 297 CLL venetoclax-treated patients outside of clinical trials in academic and community centers. Demographics, baseline disease characteristics, venetoclax dosing, TLS risk and prophylaxis, and AEs were collected.

RESULTS

The group was 69% male, 96% had relapsed/refractory CLL, 45% had deletion chromosome 17p, 84% had unmutated IGHV, 80% received venetoclax monotherapy, and median age was 67. TLS risk was categorized as low (40%), intermediate (32%), or high (28%), and 62% had imaging prior to venetoclax initiation. Clinical TLS occurred in 2.7% of patients and laboratory TLS occurred in 5.7%. Pre-venetoclax TLS risk group and creatinine clearance independently predict TLS development in multivariable analysis. Grade 3/4 AEs included neutropenia (39.6%), thrombocytopenia (29.2%), infection (25%), neutropenic fever (7.9%), and diarrhea (6.9%). Twenty-two patients (7.4%) discontinued venetoclax due to an AE. Progression-free survival was similar regardless of number of dose interruptions, length of dose interruption, and stable venetoclax dose.

CONCLUSIONS

These data provide insights into current use of venetoclax in clinical practice, including TLS rates observed in clinical practice. We identified opportunities for improved adherence to TLS risk stratification and prophylaxis, which may improve safety.

Real-world outcomes and management strategies for venetoclax-treated chronic lymphocytic leukemia patients in the United States

Venetoclax is a BCL2 inhibitor approved for 17p-deleted relapsed/refractory chronic lymphocytic leukemia with activity following kinase inhibitors. We conducted a multicenter retrospective cohort analysis of patients with chronic lymphocytic leukemia treated with venetoclax to describe outcomes, toxicities, and treatment selection following venetoclax discontinuation. A total of 141 chronic lymphocytic leukemia patients were included (98% relapsed/refractory). Median age at venetoclax initiation was 67 years (range 37-91), median prior therapies was 3 (0-11), 81% unmutated IGHV, 45% del(17p), and 26.8% complex karyotype (≥ 3 abnormalities). Prior to venetoclax initiation, 89% received a B-cell receptor antagonist. For tumor lysis syndrome prophylaxis, 93% received allopurinol, 92% normal saline, and 45% rasburicase. Dose escalation to the maximum recommended dose of 400 mg daily was achieved in 85% of patients. Adverse events of interest included neutropenia in 47.4%, thrombocytopenia in 36%, tumor lysis syndrome in 13.4%, neutropenic fever in 11.6%, and diarrhea in 7.3%. The overall response rate to venetoclax was 72% (19.4% complete remission). With a median follow up of 7 months, median progression free survival and overall survival for the entire cohort have not been reached. To date, 41 venetoclax treated patients have discontinued therapy and 24 have received a subsequent therapy, most commonly ibrutinib. In the largest clinical experience of venetoclax-treated chronic lymphocytic leukemia patients, the majority successfully completed and maintained a maximum recommended dose. Response rates and duration of response appear comparable to clinical trial data. Venetoclax was active in patients with mutations known to confer ibrutinib resistance. Optimal sequencing of newer chronic lymphocytic leukemia therapies requires further study.

Organizational communication and awareness: a novel solution for health informatics

As organizations grow larger and more distributed, the problems of maintaining corporate awareness and effective communication channels escalate. The clinical domain poses particular challenges to maintaining good corporate communications because users have limited time to access information and often have negative technology perceptions. This article highlights how a screen saver application, initially designed to increase privacy and security, developed into a new communication medium improving corporate communication across the organization. An ethnographic study of the application within a hospital setting, analysed using grounded theory methods, details the iterative and organic development of the design through ‘community of practice’ involvement. This application and the evolutionary process through which it was developed were found to not only increase awareness of resources, activities and hospital changes but also positively influence users’ perceptions of, involvement in and ownership of general IT developments. User involvement also raised the importance, for the designers, of application usability, quality and aesthetics.

Preliminary investigation of the effects of γ-tACS on working memory in schizophrenia

Working memory impairment in schizophrenia has been strongly associated with abnormalities in gamma oscillations within the dorsolateral prefrontal cortex (DLFPC). We recently published the first ever study showing that anodal transcranial direct current stimulation (tDCS) to the left DLPFC was able to significantly improve working memory in schizophrenia and did so seemingly via restoring normal gamma oscillatory function. Transcranial alternating current stimulation (tACS) is a form of electrical brain stimulation that delivers stimulation at a specific frequency and has been shown to entrain endogenous cortical oscillations. Therefore, gamma (γ) tACS may be even more effective than tDCS in improving working memory in schizophrenia. In a randomized repeated-measures study we compared the effects of γ-tACS, tDCS and sham stimulation on the performance of the two back working memory tasks in ten patients with schizophrenia. There was a significant time by stimulation interaction, with tDCS and sham showing trend-level improvements in working memory, while γ-tACS, contrary to our hypothesis, showed no change. The results are discussed in light of posited divergent effects of tACS and tDCS on the pathophysiology of working memory impairment in schizophrenia.

Is that a rodent in your luggage? A mixed method approach to describe bushmeat importation into the United States

Bushmeat, defined as meat derived from wild animals, is a potential source of zoonotic pathogens. Bushmeat from restricted animals is illegal to import into the United States under US federal regulations. We reviewed US Centers for Disease Control and Prevention (CDC) port of entry surveillance records from September 2005 through December 2010 and conducted focus group studies to describe trends in and reasons for bushmeat importation into the United States. In total, 543 confiscated bushmeat items were recorded. Half of the confiscated bushmeat items identified were rodents. Africa was the most frequent continent of origin. Seasonality was evident, with bushmeat confiscations peaking in late spring to early summer. Four times more bushmeat was confiscated during an enhanced surveillance period in June 2010 compared with the same period in previous years, suggesting that routine surveillance underestimated the amount of bushmeat detected at US Ports of Entry. Focus groups held in three major US cities revealed that bushmeat importation is a multifaceted issue. Longstanding cultural practices of hunting and eating bushmeat make it difficult for consumers to acknowledge potential health and ecologic risks. Also, US merchants selling African goods, including bushmeat, in their stores have caused confusion among importers as to whether importation is truly illegal. Enhancing routine surveillance for bushmeat and consistent enforcement of penalties at all ports of entry, along with health education aimed at bushmeat importers, might be useful to deter illegal importation.

The (Eigen)value of diffusion tensor imaging to investigate depression after traumatic brain injury

BACKGROUND

Many people with a traumatic brain injury (TBI), even mild to moderate, will develop major depression (MD). Recent studies of patients with MD suggest reduced fractional anisotropy (FA) in dorsolateral prefrontal cortex (DLPFC), temporal lobe tracts, midline, and capsule regions. Some of these pathways have also been found to have reduced FA in patients with TBI. It is unknown whether the pathways implicated in MD after TBI are similar to those with MD without TBI. This study sought to investigate whether there were specific pathways unique to TBI patients who develop MD.

METHODS

A sample of TBI-MD subjects (N = 14), TBI-no-MD subjects (N = 12), MD-no-TBI (N = 26), and control subjects (no TBI or MD, N = 23), using a strict measurement protocol underwent psychiatric assessments and diffusion tensor brain Magnetic Resonance Imaging (MRI).

RESULTS

The findings of this study indicate that (1) TBI patients who develop MD have reduced axial diffusivity in DLPFC, corpus callosum (CC), and nucleus accumbens white matter tracts compared to TBI patients who do not develop MD and (2) MD patients without a history of TBI have reduced FA along the CC. We also found that more severe MD relates to altered radial diffusivity.

CONCLUSIONS

These findings suggest that compromise to specific white matter pathways, including both axonal and myelination aspects, after a mild TBI underlie the susceptibility of these patients developing MD.

Water and sanitation issues for persons with disabilities in low- and middle-income countries: a literature review and discussion of implications for global health and international development

The critical importance of unrestricted access to clean drinking water and basic sanitation for all is highlighted in Millennium Development Goal 7, which calls for the reduction by half of the proportion of people without such access by 2015. Unfortunately, little attention has been paid to the needs of such access for the one billion people living with a disability worldwide, despite the fact that the right to equal access for all international development initiatives is guaranteed in the new United Nations Convention on the Rights of Persons with Disabilities. In this paper, we review what is currently known about access to water and sanitation for persons with disabilities in low- and middle-income countries from the perspective of both international development and global health, and identify existing gaps in research, practice and policy that are of pressing concern if the water and sanitation needs of this large - and largely overlooked - population are to be addressed.

Cytoplasmic beta-catenin accumulation is a good prognostic marker in upper and lower gastrointestinal adenocarcinomas

AIMS

beta-Catenin is an important molecule in cancer biology. Membranous beta-catenin enhances cellular differentiation and inhibits invasion by its action on E-cadherin. The aim was to ascertain whether the cellular expression of these molecules in colorectal and oesophageal cancer specimens is associated with survival in patients with gastrointestinal cancer.

METHODS AND RESULTS

Tumour samples from 149 patients undergoing resection for colorectal adenocarcinoma and 147 patients undergoing resection for oesophageal adenocarcinoma were retrospectively analysed using immunohistochemical techniques to assess beta-catenin expression. Increasing beta-catenin expression in the cytoplasm was associated with improved survival for colorectal cancer cases on both univariate (P = 0.003) and multivariate (P = 0.01) analysis. In addition, increased expression in the most recent cohort of oesophageal adenocarcinoma patients was associated with improved TNM staging (P = 0.007). Membrane expression was weakly associated with survival in colorectal cancer on univariate analysis (P = 0.09), but not on multivariate analysis (P = 0.21). Complete absence of beta-catenin expression at all three sites was associated with reduced 5-year survival in colorectal cancer.

CONCLUSIONS

This is one of the largest prognostic studies of beta-catenin in gastrointestinal adenocarcinoma. It shows that low levels of cytoplasmic beta-catenin expression are associated with reduced survival in patients with colorectal cancer as well as worse TNM staging in oesophageal adenocarcinoma (a recognized surrogate end-point for survival). We believe this is the first time that this has been reported. This finding should be tested prospectively in oncological trials to validate whether the presence of cytoplasmic beta-catenin could be used as a prognostic marker for less aggressive disease.

The "Black Turbinate" sign: An early MR imaging finding of nasal mucormycosis

Rhinocerebral mucormycosis is a rare angioinvasive fungal infection that has a strong predilection for patients with poorly controlled diabetes and immunosuppression. Initial presenting symptoms are nonspecific and frequently are attributed to more mundane sinonasal and orbital pathologies. Early diagnosis and treatment are essential for survival and minimizing neurologic sequelae. CT and MR imaging are often used in the diagnostic work-up; however, CT findings are nonspecific.

Modelling soil series data to facilitate targeted habitat restoration: a polytomous logistic regression approach

Habitat restoration at a landscape scale is becoming increasingly important in environmental management. In this context, geographical information systems are well suited as they can store and integrate many of the abiotic and biotic criteria used to assess the ecological worth of a site. However, this capacity can be limited by the availability or suitability of spatial data sets. A classic example of the latter case is the National Soil Map of England and Wales, which groups soils of a varied nature into associations. Consequently the national soil map has proved to be a poor predictor of habitat suitability. Using polytomous logistic regression we put forward a method for separating soil associations into their constituent soils within the Chilterns Natural Area. This approach used soil association, aspect, slope and relative height as variables for this analysis. Whilst the model's performance is likely to have been limited by the accuracy of the soil association data set, a predictive accuracy of between 47 and 65% is sufficient to facilitate better targeting of habitat restoration when combined with other abiotic factors such as climate and topography.

Using Geographical Information Systems to identify and target sites for creation and restoration of native woodlands: a case study of the Chiltern Hills, UK

Rare and threatened habitats in Europe must be restored and enhanced in accordance with the European Union's Habitats and Species Directive. In the United Kingdom, conservation and expansion objectives for species and habitats are outlined in the Species Action Plans and Habitat Action Plans. Site identification for these measures has to date been ad hoc without consideration of either the existing "stock" of the natural resource or the ability of the surrounding land use to deliver the enhancement (enlargement) of a given habitat. Using a Geographical Information System, we outline a targeting system for creating new woodland in association with existing ancient woodland in the Chiltern Hills Area of Outstanding Natural Beauty. The aim was to create woodland blocks of at least 100 ha, as being of the most benefit to biodiversity. We identified existing patches of woodland between 20 and 50 ha as cores for habitat expansion and classified land use in terms of its suitability and proximity to these core areas for tree planting to meet the targets of the statutory body. Our results suggest that the targeting method employed is a useful tool for habitat restoration.

In vivo effect of coronary laser angioplasty on atherosclerotic plaques: histopathologic analysis

Information from histopathologic examination of coronary arterial atherosclerotic plaques treated with in vivo laser energy is sparse. Directional atherectomy provides biopsies for study of tissue changes (injury) due to coronary arterial debulking devices, including laser. Sixteen patients who presented with acute ischemic coronary syndromes underwent debulking of a total of 17 obstructive intracoronary lesions with pulsed-wave holmium:YAG laser (2.1 microm wavelength). Laser was performed with the "pulse and retreat" technique which incorporates slow catheter advancement (0.5-1 mm/s) with controlled emission of energy. Immediately postlasing, directional atherectomy was utilized to obtain irradiated plaque tissue for pathologic examination. Extent of laser-induced tissue injury to plaques was graded as 0 (no tissue damage), 1 (small foci or charring and vacuoles), 2 (large amount of charring, edge disruption and vacuoles) and 3 (extensive tissue damage). Angiographically and clinically, all 17 lesions were successfully debulked with the laser energy (mean 47+/-25 pulses), with a reduction of target lesion percent diameter stenosis from 92+/-6% to 47+/-25%. Adjunct balloon dilations further reduced the target lesions to a final of 10+/-10% stenosis. The histopathologic examination of the lased specimens demonstrated that 13 lesions (76%) had no evidence of laser-induced injury (Grade 0). Four lesions had low-level injury (Grade 1), and none had evidence of Grade 2 or 3 laser-induced trauma. Therefore, a laser debulking technique, which incorporates slow catheter advancement with controlled emission of pulses, does not cause significant injurious effects to the irradiated plaque.

An analysis of swimming performance in the Norway lobster, Nephrops norvegicus L. infected by a parasitic dinoflagellate of the genus Hematodinium

Various components of swimming performance were measured in uninfected Norway lobsters (Nephrops norvegicus) and compared to animals at different stages of infection by a parasitic dinoflagellate (Hematodinium sp.). Animals showed a progressive decline in overall swimming performance as infection severity increased, with reductions in the number of tail-flips performed, the number of swimming bouts and the total distance travelled by swimming. The velocity of the first (giant-fibre mediated) tail flip and average velocity over the swimming bout were also significantly reduced in infected lobsters. Possible reasons for this decreased swimming performance are suggested and the implications of this for predator avoidance of infected lobsters in the benthic habitat, and for capture of Nephrops by trawl rigs are discussed.

Carboplatin and paclitaxel, alone and in combination: dose escalation, measurement of renal function, and role of the p53 tumor suppressor gene

In this pharmacokinetic and dose-escalation study of the carboplatin/paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) combination, patients were randomly assigned to receive paclitaxel either as a 1-hour or a 3-hour infusion. The 1-hour infusion was feasible, with maximum tolerated doses similar to those previously reported for a 3-hour infusion. Using patients' age, height, plasma creatinine, and plasma creatine kinase provided an improved estimate of the glomerular filtration rate compared with the more traditional creatinine-based formulas according to population analysis of data derived from glomerular filtration rate estimates performed by an isotope method. Studies of the p53 gene sequence of ovarian tumors at diagnosis suggest that p53 mutations are a potent predictor of response to subsequent treatment with carboplatin.

Renal replacement by regular haemodialysis therapy and renal transplantation in Barbados: 1979 to 1997

We have reviewed our delivery of highly sophisticated medical therapy, haemodialysis and renal transplantation in a Caribbean setting. The purpose has been to reflect local outcomes in relation to mortality and survival, but comparisons with a vastly larger database have been attempted. Such comparisons are extremely difficult due to methodological differences and the fact that facilities contributing to that database vary considerably with regard to patient age, gender, ethnicity and comorbidity. Nonetheless, the crude data available provide important justification for the existence of regular haemodialysis and its adjunctive therapy of renal transplantation in the Caribbean.

Lactoferrin expression in mammary epithelial cells is mediated by changes in cell shape and actin cytoskeleton

Lactoferrin is a secreted iron binding protein which is expressed during normal functional development of mammary epithelium. Murine mammary epithelial cell lines competent for milk protein expression were used to identify microenvironmental factors that regulate lactoferrin expression. While lactoferrin was not expressed in adherent monolayer cultures under standard subconfluent conditions on plastic, lactoferrin mRNA and protein steadily accumulated when the cells aggregated to form spheroids on a reconstituted basement membrane gel. However, unlike other milk proteins such as beta-casein, lactoferrin expression was also induced at high cell density in the absence of exogenously added basement membrane or prolactin. These results led us to examine whether changes in cell growth, cell-cell interactions and/or cell shape were responsible for regulation of lactoferrin gene expression. Rounded, non-proliferating cells in suspension in serum-free medium expressed lactoferrin even as single cells. Conversely, lactoferrin expression could be inhibited in non-proliferative cells in serum-free medium by maintaining them in contact with an air-dried extracellular matrix which caused the cells to retain flat, spread morphologies. These findings indicated that cessation of cell growth was not sufficient, that cell-cell interactions were not required, and that cell culture conditions which minimize cell spreading may be important in maintaining lactoferrin expression. Additional data supporting this latter concept were generated by treating spread cells with cytochalasin D. The resulting disruption of microfilament assembly induced both cell rounding and lactoferrin expression. Shape-dependent regulation of lactoferrin mRNA was both transcriptional and post-transcriptional. Surprisingly, treatment of rounded cells with a transcription inhibitor, actinomycin D, produced a stabilization of lactoferrin mRNA, suggesting that transcription of an unstable factor is required for degradation of lactoferrin mRNA. Importantly, lactoferrin mRNA expression was regulated similarly in early passage normal human mammary epithelial cells. In vivo, the changing extracellular matrix components of the mammary gland during different stages of normal and abnormal growth and differentiation may provide different physical constraints on the configurations of cell surface molecules. These physical constraints may be communicated to the cell interior through mechanical changes in the cytoskeleton. Unlike beta-casein whose expression is upregulated by specific integrin-mediated signals, lactoferrin may be representative of a class of proteins synthesized in the mammary gland using basal transcriptional and translational machinery. The suppression of lactoferrin expression that is observed in monolayer culture and in malignant tissues may reflect inappropriate cell shapes and cytoskeletal structures that are manifested under these conditions.

A phase I clinical study of the antipurine antifolate lometrexol (DDATHF) given with oral folic acid

Lometrexol is an antifolate which inhibits glycinamide ribonucleotide formyltransferase (GARFT), an enzyme essential for de novo purine synthesis. Extensive experimental and limited clinical data have shown that lometrexol has activity against tumours which are refractory to other drugs, notably methotrexate. However, the initial clinical development of lometrexol was curtailed because of severe and cumulative antiproliferative toxicities. Preclinical murine studies demonstrated that the toxicity of lometrexol can be prevented by low dose folic acid administration, i.e. for 7 days prior to and 7 days following a single bolus dose. This observation prompted a Phase I clinical study of lometrexol given with folic acid supplementation which has confirmed that the toxicity of lometrexol can be markedly reduced by folic acid supplementation. Thrombocytopenia and mucositis were the major toxicities. There was no clear relationship between clinical toxicity and the extent of plasma folate elevation. Associated studies demonstrated that lometrexol plasma pharmacokinetics were not altered by folic acid administration indicating that supplementation is unlikely to reduce toxicity by enhancing lometrexol plasma clearance. The work described in this report has identified for the first time a clinically acceptable schedule for the administration of a GARFT inhibitor. This information will facilitate the future evaluation of this class of compounds in cancer therapy.

Clinical pharmacokinetic and pharmacodynamic studies with the nonclassical antifolate thymidylate synthase inhibitor 3, 4-dihydro-2-amino-6-methyl-4-oxo-5-(4-pyridylthio)-quinazolone dihydrochloride (AG337) given by 24-hour continuous intravenous infusion

3,4-Dihydro-2-amino-6-methyl-4-oxo-5-(4-pyridylthio)-quinazolon e dihydrochloride (AG337) is a nonclassical inhibitor of thymidylate synthase (TS) designed to avoid potential resistance mechanisms that can limit the activity of classical antifolate antimetabolites. A clinical pharmacokinetic and pharmacodynamic study of AG337 given as a 24-h i.v. infusion was performed. Thirteen patients received 27 courses over the dose range 75-1350 mg/m2. Plasma AG337 concentrations were achieved which, in preclinical models, were associated with antitumor effects. AG337 clearance was saturable, and the pharmacokinetics of the drug at doses above 300 mg/m2 was best described by a one-compartment model with saturable elimination (median Km = 6.5 microgram/ml; range, 4.1-13 microgram/ml; median Vmax = 2.0 microgram/ml/h/m2; range, 0.96-5.6 microgram/ml/h/m2). Following the end of the infusion, AG337 was cleared rapidly (t1/2, 53-193 min), and levels were less than 0.2 microgram/ml in all patients by 48 h. Plasma protein binding was 96-98%, and the urinary excretion of AG337 as unchanged drug did not exceed 30% of the dose administered. Measurements of plasma deoxyuridine (dUrd) concentrations showed that doses of 600 mg/m2 and above of AG337 produced a consistent elevation in plasma dUrd levels (60-290%), suggesting that TS inhibition was being achieved in patients. However, in all cases dUrd concentrations had returned to pretreatment levels 24 h after the end of the infusion, suggesting that TS inhibition was not maintained. Local toxicity, probably due to the infusate pH, was the only significant adverse effect observed. These studies have shown that cytotoxic AG337 plasma concentrations can be readily achieved without acute toxicity and that these concentrations are associated with elevations in plasma dUrd levels. The lack of prolonged dUrd elevations indicates that extended administration should be explored using central line or p.o. administration to avoid local toxicity.

Cellular growth and survival are mediated by beta 1 integrins in normal human breast epithelium but not in breast carcinoma

We previously established a rapid three-dimensional assay for discrimination of normal and malignant human breast epithelial cells using a laminin-rich reconstituted basement membrane. In this assay, normal epithelial cells differentiate into well-organized acinar structures whereas tumor cells fail to recapitulate this process and produce large, disordered colonies. The data suggest that breast acinar morphogenesis and differentiation is regulated by cell-extra-cellular matrix (ECM) interactions and that these interactions are altered in malignancy. Here, we investigated the role of ECM receptors (integrins) in these processes and report on the expression and function of potential laminin receptors in normal and tumorigenic breast epithelial cells. Immunocytochemical analysis showed that normal and carcinoma cells in a three-dimensional substratum express profiles of integrins similar to normal and malignant breast tissues in situ. Normal cells express alpha 1, alpha 2, alpha 3, alpha 6, beta 1 and beta 4 integrin subunits, whereas breast carcinoma cells show variable losses, disordered expression, or downregulation of these subunits. Function-blocking experiments using inhibitory anti-integrin subunit antibodies showed a > 5-fold inhibition of the formation of acinar structures by normal cells in the presence of either anti-beta 1 or anti-alpha 3 antibodies, whereas anti-alpha 2 or -alpha 6 had little or no effect. In experiments where collagen type I gels were used instead of basement membrane, acinar morphogenesis was blocked by anti-beta 1 and -alpha 2 antibodies but not by anti-alpha 3. These data suggest a specificity of integrin utilization dependent on the ECM ligands encountered by the cell. The interruption of normal acinar morphogenesis by anti-integrin antibodies was associated with an inhibition of cell growth and induction of apoptosis. Function-blocking antibodies had no inhibitory effect on the rate of tumor cell growth, survival or capacity to form colonies. Thus under our culture conditions breast acinar formation is at least a two-step process involving beta 1-integrin-dependent cellular growth followed by polarization of the cells into organized structures. The regulation of this pathway appears to be impaired or lost in the tumor cells, suggesting that tumor colony formation occurs by independent mechanisms and that loss of proper integrin-mediated cell-ECM interaction may be critical to breast tumor formation.

Laminin mediates tissue-specific gene expression in mammary epithelia

Tissue-specific gene expression in mammary epithelium is dependent on the extracellular matrix as well as hormones. There is good evidence that the basement membrane provides signals for regulating beta-casein expression, and that integrins are involved in this process. Here, we demonstrate that in the presence of lactogenic hormones, laminin can direct expression of the beta-casein gene. Mouse mammary epithelial cells plated on gels of native laminin or laminin-entactin undergo functional differentiation. On tissue culture plastic, mammary cells respond to soluble basement membrane or purified laminin, but not other extracellular matrix components, by synthesizing beta-casein. In mammary cells transfected with chloramphenicol acetyl transferase reporter constructs, laminin activates transcription from the beta-casein promoter through a specific enhancer element. The inductive effect of laminin on casein expression was specifically blocked by the E3 fragment of the carboxy terminal region of the alpha 1 chain of laminin, by antisera raised against the E3 fragment, and by a peptide corresponding to a sequence within this region. Our results demonstrate that laminin can direct tissue-specific gene expression in epithelial cells through its globular domain.

Testing the FOCOMETER--A new refractometer

The FOCOMETER, an optometer which measures spherical refractive errors, is intended to provide rural or economically disadvantaged populations spherical prescriptions without the need for complicated protocols, expensive equipment, or electricity. FOCOMETER readings were compared with the spherical equivalent determined from autorefraction and subjective trial lens refractions in children, and with retinoscopy in adults. Over the range of refractive errors tested (-4 to +5 D) reasonably close readings, within one-half a diopter, were found for comparisons with autorefraction and retinoscopy and about one-tenth of a diopter difference was found between subjective refractions and the FOCOMETER.