Language and gesture neural correlates: A meta-analysis of functional magnetic resonance imaging studies

BACKGROUND

Humans often use co-speech gestures to promote effective communication. Attention has been paid to the cortical areas engaged in the processing of co-speech gestures.

AIMS

To investigate the neural network underpinned in the processing of co-speech gestures and to observe whether there is a relationship between areas involved in language and gesture processing.

METHODS & PROCEDURES

We planned to include studies with neurotypical and/or stroke participants who underwent a bimodal task (i.e., processing of co-speech gestures with relative speech) and a unimodal task (i.e., speech or gesture alone) during a functional magnetic resonance imaging (fMRI) session. After a database search, abstract and full-text screening were conducted. Qualitative and quantitative data were extracted, and a meta-analysis was performed with the software GingerALE 3.0.2, performing contrast analyses of uni- and bimodal tasks.

MAIN CONTRIBUTION

The database search produced 1024 records. After the screening process, 27 studies were included in the review. Data from 15 studies were quantitatively analysed through meta-analysis. Meta-analysis found three clusters with a significant activation of the left middle frontal gyrus and inferior frontal gyrus, and bilateral middle occipital gyrus and inferior temporal gyrus.

CONCLUSIONS

There is a close link at the neural level for the semantic processing of auditory and visual information during communication. These findings encourage the integration of the use of co-speech gestures during aphasia treatment as a strategy to foster the possibility to communicate effectively for people with aphasia.

WHAT THIS PAPER ADDS

What is already known on this subject Gestures are an integral part of human communication, and they may have a relationship at neural level with speech processing. What this paper adds to the existing knowledge During processing of bi- and unimodal communication, areas related to semantic processing and multimodal processing are activated, suggesting that there is a close link between co-speech gestures and spoken language at a neural level. What are the potential or actual clinical implications of this work? Knowledge of the functions related to gesture and speech processing neural networks will allow for the adoption of model-based neurorehabilitation programs to foster recovery from aphasia by strengthening the specific functions of these brain networks.

Effects of home-based virtual reality telerehabilitation system in people with multiple sclerosis: A randomized controlled trial

BACKGROUND AND OBJECTIVE

Multiple sclerosis is an inflammatory and neurodegenerative disorder of the central nervous system that can lead to severe motor disability. The aim of this study was to verify the health care effects of an integrated telerehabilitation approach involving dual-domains (motor and cognitive) in people with multiple sclerosis using a virtual reality rehabilitation system compared to a home-based conventional rehabilitative intervention usual care for patient-relevant outcomes (motor, cognitive and participation).

METHODS

This multicentre interventional, randomized controlled trial included 70 participants with multiple sclerosis, 35 in the telerehabilitation group (30 sessions of home-based virtual reality rehabilitation system training, five sessions for week each lasting 45 min) and 35 in the usual care group (30 sessions of conventional treatment, five sessions for week). Participants completed the assessment of motor, cognitive and participation outcomes at baseline and after 6 weeks of treatment.

RESULTS

In total, 63.3% of the telerehabilitation group exhibited improvement in the physical domain of the quality of life (p = 0.045). The telerehabilitation group showed greater improvement than the usual care group in Mini-BESTest domains of balance (p = 0.014), postural control (p = 0.024), and dynamic walking (p = 0.020) at post-treatment. Higher adherence was registered for telerehabilitation compared with usual care (86.67% vs. 80.0%).

DISCUSSION

This study provides evidence that people with multiple sclerosis can benefit from telerehabilitation treatment in the physical domain of the quality of life and motor symptoms. Moreover, considering the persistent COVID-19 emergency, telerehabilitation can represent an effective telemedicine solution for safely delivering effective rehabilitation care to people with multiple sclerosis.

TRIAL REGISTRATION NUMBER AND TRIAL REGISTER

This trial was registered at ClinicalTrials.gov (NCT03444454).

Telerehabilitation for Neurological Motor Impairment: A Systematic Review and Meta-Analysis on Quality of Life, Satisfaction, and Acceptance in Stroke, Multiple Sclerosis, and Parkinson's Disease

Telerehabilitation (TR) seems to be a viable and feasible solution to face the rehabilitative challenges posed by neurological impairments and to improve patients' quality of life (QoL). This review aims to synthesize and analyze the evidence on the impact of physiotherapy intervention through TR on QoL in patients with stroke, Parkinson's disease (PD), and multiple sclerosis (MS), together with an evaluation of their satisfaction and technology acceptance levels. Through a systematic search of the literature and a screening process, treatment effects were assessed with meta-analyses using the standardized mean difference, setting the confidence interval at 95%. We included 28 studies in the review, which were analyzed for methodological quality, whereas 16 studies were included in the meta-analyses. The results suggest a significant improvement in QoL in patients who underwent TR. We were unable to perform analyses for satisfaction and technology acceptance outcomes due to insufficient data. Overall, motor TR has a positive impact on the QoL of patients with neurological diseases, especially in stroke patients; although caution is needed in the interpretation of the results due to the high heterogeneity found. For PD and MS, TR seems to yield comparable results to in-person treatment.

Effects of Immersive Virtual Reality on Upper-Extremity Stroke Rehabilitation: A Systematic Review with Meta-Analysis

Virtual reality (VR) is an innovative rehabilitation tool increasingly used in stroke rehabilitation. Fully immersive VR is a type of VR that closely simulates real-life scenarios, providing a high level of immersion, and has shown promising results in improving rehabilitation functions. This study aimed to assess the effect of immersive VR-based therapy for stroke patients on the upper extremities, activities of daily living (ADLs), and pain reduction and its acceptability and side effects. For this review, we gathered all suitable randomized controlled trials from PubMed, EMBASE, Cochrane Library, Scopus, and Web of Science. Out of 1532, 10 articles were included, with 324 participants. The results show that immersive VR offers greater benefits in comparison with conventional rehabilitation, with significant improvements observed in ADLs (SMD 0.58, 95% CI 0.25 to 0.91, I2 = 0%, p = 0.0005), overall function as measured by the Fugl-Meyer Assessment (MD 6.33, 95% CI 4.15 to 8.50, I2 = 25%, p = 0.00001), and subscales for the shoulder (MD 4.96, 95% CI-1.90-8.03, I2 = 25%, p = 0.002), wrist (MD 2.41, 95% CI-0.56-4.26, I2 = 0%, p = 0.01), and hand (MD 2.60, 95% CI-0.70-4.5°, I2 = 0%, p = 0.007). These findings highlight the potential of immersive VR as a valuable therapeutic option for stroke survivors, enhancing their ADL performance and upper-limb function. The immersive nature of VR provides an engaging and immersive environment for rehabilitation.

A scoping review of scientific concepts concerning motor recovery after stroke as employed in clinical trials

The scientific literature on poststroke rehabilitation is remarkably vast. Over the last decades, dozens of rehabilitation approaches have been investigated. However, sometimes it is challenging to trace new experimental interventions back to some of the known models of motor control and sensorimotor learning. This scoping review aimed to investigate motor control models' diffusion among the literature on motor recovery after stroke. We performed a literature search on Medline, Cochrane, Web of Science, Embase, and Scopus databases. The last search was conducted in September 2023. This scoping review included full-text articles published in English in peer-reviewed journals that provided rehabilitation interventions based on motor control or motor learning frameworks for at least one individual with stroke. For each study, we identified the theoretical framework the authors used to design the experimental treatment. To this aim, we used a previously proposed classification of the known models of motor control, dividing them into the following categories: neuroanatomy, robotics, self-organization, and ecological context. In total, 2,185 studies were originally considered in this scoping review. After the screening process, we included and analyzed 45 studies: 20 studies were randomized controlled trials, 12 were case series, 4 were case reports, 8 were observational longitudinal pilot studies, and 1 was an uncontrolled trial. Only 10 studies explicitly declared the reference theoretical model. Considering their classification, 21 studies referred to the robotics motor control model, 12 to the self-organization model, 8 to the neuroanatomy model, and 4 to the ecological model. Our results showed that most of the rehabilitative interventions purposed in stroke rehabilitation have no clear theoretical bases on motor control and motor learning models. We suggest this is an issue that deserves attention when designing new experimental interventions in stroke rehabilitation.

Telerehabilitation for Stroke: A Personalized Multi-Domain Approach in a Pilot Study

Stroke, a leading cause of long-term disability worldwide, manifests as motor, speech language, and cognitive impairments, necessitating customized rehabilitation strategies. In this context, telerehabilitation (TR) strategies have emerged as promising solutions. In a multi-center longitudinal pilot study, we explored the effects of a multi-domain TR program, comprising physiotherapy, speech therapy, and neuropsychological treatments. In total, 84 stroke survivors (74 analyzed) received 20 tailored sessions per domain, addressing individual impairments and customized to their specific needs. Positive correlations were found between initial motor function, cognitive status, independence in activities of daily living (ADLs), and motor function improvement after TR. A lower initial health-related quality of life (HRQoL) perception hindered progress, but improved ADL independence and overall health status, and reduced depression correlated with a better QoL. Furthermore, post-treatment improvements were observed in the entire sample in terms of fine motor skills, upper-limb functionality, balance, independence, and cognitive impairment. This multi-modal approach shows promise in enhancing stroke rehabilitation and highlights the potential of TR in addressing the complex needs of stroke survivors through a comprehensive support and interdisciplinary collaboration, personalized for each individual's needs.

Efficacy of non-immersive virtual reality-based telerehabilitation on postural stability in Parkinson's disease: a multicenter randomized controlled trial

BACKGROUND

The implementation of regular prolonged, and effective rehabilitation in people with Parkinson's disease is essential for ensuring a good quality of life. However, the continuity of rehabilitation care may find barriers related to economic, geographic, and social issues. In these scenarios, telerehabilitation could be a possible solution to guarantee the continuity of care.

AIM

To investigate the efficacy of non-immersive virtual reality-based telerehabilitation on postural stability in people with Parkinson's disease, compared to at-home self-administered structured conventional motor activities.

DESIGN

Multicenter randomized controlled trial.

SETTING

Five rehabilitation hospitals of the Italian Neuroscience and Rehabilitation Network.

POPULATION

Individuals diagnosed with Parkinson's disease.

METHODS

Ninety-seven participants were randomized into two groups: 49 in the telerehabilitation group (non-immersive virtual reality-based telerehabilitation) and 48 in the control group (at-home self-administered structured conventional motor activities). Both treatments lasted 30 sessions (3-5 days/week for, 6-10 weeks). Static and dynamic balance, gait, and functional motor outcomes were registered before and after the treatments.

RESULTS

All participants improved the outcomes at the end of the treatments. The primary outcome (mini-Balance Evaluation Systems Test) registered a greater significant improvement in the telerehabilitation group than in the control group. The gait and endurance significantly improved in the telerehabilitation group only, with significant within-group and between-group differences.

CONCLUSIONS

Our results showed that non-immersive virtual reality-based telerehabilitation is feasible, improves static and dynamic balance, and is a reasonably valuable alternative for reducing postural instability in people with Parkinson's disease.

CLINICAL REHABILITATION IMPACT

Non-immersive virtual reality-based telerehabilitation is an effective and well-tolerated modality of rehabilitation which may help to improve access and scale up rehabilitation services as suggested by the World Health Organization's Rehabilitation 2030 agenda.

How Lung Volume Recruitment Maneuvers Enhance Respiratory Function in Multiple Sclerosis Patients: A Quasi-Randomized Pilot Study

Background and Objectives: In patients with multiple sclerosis (MS), a decrease in muscle strength can lead to limitations in pulmonary functions, potentially causing respiratory complications. To address these challenges, the lung volume recruitment (LVR) maneuver has emerged as a potential intervention. This study sought to evaluate the impact of a four-week LVR protocol on respiratory function in secondary progressive MS patients. Materials and Methods: In a quasi-randomized pre/post-controlled trial, 24 patients with secondary progressive MS were recruited. Participants aged 20-70 years with an EDSS score of 2 to 9 were alternately allocated to intervention (n = 12) or control groups (n = 12). The intervention group underwent a 4-week respiratory rehabilitation training focused on LVR, using a standardized cough machine treatment protocol twice daily. The control group received no respiratory intervention. Outcomes measured included forced vital capacity (FVC), maximal insufflation capacity (MIC), and peak cough flow (PCF), using turbine spirometry and other associated equipment. All measurements were taken at baseline (T0) and after 4 weeks (T1) by a blinded assessor. Results: For the intervention group, the mean difference pre/post-treatment in MIC (mL) was 0.45 (SD 1.13) (p = 0.02), and in MIC (%), it was 0.13 (SD 0.24) (p = 0.03). Compared to the control group (n = 10), the between-group mean difference for MIC (mL) was 0.54 (p = 0.02), and for MIC (%), it was 0.15 (p = 0.02). Conclusions: The short-term daily LVR protocol notably improved passive lung capacity, despite minimal changes in active lung capacity or cough force. The LVR maneuver offers promise for enhancing respiratory function, especially passive lung capacity, in secondary progressive MS patients. Further research should explore optimal treatment durations and frequencies for more extensive respiratory gains.

Paediatric Strategy Forum for medicinal product development of DNA damage response pathway inhibitors in children and adolescents with cancer: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration

DNA damage response inhibitors have a potentially important therapeutic role in paediatric cancers; however, their optimal use, including patient selection and combination strategy, remains unknown. Moreover, there is an imbalance between the number of drugs with diverse mechanisms of action and the limited number of paediatric patients available to be enrolled in early-phase trials, so prioritisation and a strategy are essential. While PARP inhibitors targeting homologous recombination-deficient tumours have been used primarily in the treatment of adult cancers with BRCA1/2 mutations, BRCA1/2 mutations occur infrequently in childhood tumours, and therefore, a specific response hypothesis is required. Combinations with targeted radiotherapy, ATR inhibitors, or antibody drug conjugates with DNA topoisomerase I inhibitor-related warheads warrant evaluation. Additional monotherapy trials of PARP inhibitors with the same mechanism of action are not recommended. PARP1-specific inhibitors and PARP inhibitors with very good central nervous system penetration also deserve evaluation. ATR, ATM, DNA-PK, CHK1, WEE1, DNA polymerase theta and PKMYT1 inhibitors are early in paediatric development. There should be an overall coordinated strategy for their development. Therefore, an academia/industry consensus of the relevant biomarkers will be established and a focused meeting on ATR inhibitors (as proof of principle) held. CHK1 inhibitors have demonstrated activity in desmoplastic small round cell tumours and have a potential role in the treatment of other paediatric malignancies, such as neuroblastoma and Ewing sarcoma. Access to CHK1 inhibitors for paediatric clinical trials is a high priority. The three key elements in evaluating these inhibitors in children are (1) innovative trial design (design driven by a clear hypothesis with the intent to further investigate responders and non-responders with detailed retrospective molecular analyses to generate a revised or new hypothesis); (2) biomarker selection and (3) rational combination therapy, which is limited by overlapping toxicity. To maximally benefit children with cancer, investigators should work collaboratively to learn the lessons from the past and apply them to future studies. Plans should be based on the relevant biology, with a focus on simultaneous and parallel research in preclinical and clinical settings, and an overall integrated and collaborative strategy.

Non-Immersive Virtual Reality Telerehabilitation System Improves Postural Balance in People with Chronic Neurological Diseases

BACKGROUND

People with chronic neurological diseases, such as Parkinson's Disease (PD) and Multiple Sclerosis (MS), often present postural disorders and a high risk of falling. When difficulties in achieving outpatient rehabilitation services occur, a solution to guarantee the continuity of care may be telerehabilitation. This study intends to expand the scope of our previously published research on the impact of telerehabilitation on quality of life in an MS sample, testing the impact of this type of intervention in a larger sample of neurological patients also including PD individuals on postural balance.

METHODS

We included 60 participants with MS and 72 with PD. All enrolled subjects were randomized into two groups: 65 in the intervention group and 67 in the control group. Both treatments lasted 30-40 sessions (5 days/week, 6-8 weeks). Motor, cognitive, and participation outcomes were registered before and after the treatments.

RESULTS

All participants improved the outcomes at the end of the treatments. The study's primary outcome (Mini-BESTest) registered a greater significant improvement in the telerehabilitation group than in the control group.

CONCLUSIONS

Our results demonstrated that non-immersive virtual reality telerehabilitation is well tolerated and positively affects static and dynamic balance and gait in people with PD and MS.

Antigen cross-presentation in young tumor-bearing hosts promotes CD8+ T cell terminal differentiation

The immune system undergoes a progressive functional remodeling with age. Understanding how age bias shapes antitumor immunity is essential in designing effective immunotherapies, especially for pediatric patients. Here, we explore antitumor CD8⁺ T cell responses generated in young (prepubescent) and adult (presenescent) mice. Using an MHCI-deficient tumor model, we observed that tumor-reactive CD8⁺ T cells expanded in young tumor-bearing (TB) mice acquired a terminally differentiated phenotype characterized by overexpression of inhibitory receptors and the transcription factor Tox1. Furthermore, tumor-infiltrating CD8⁺ T cells from young tumors yielded a poor cytokine response compared with CD8⁺ T cells infiltrating adult tumors. Young migratory dendritic cells (migDCs) from the draining lymph nodes (dLNs), and mononuclear phagocytic cells (MPCs) infiltrating young tumors, were more competent in capturing and cross-presenting tumor antigen, leading to enhanced priming of CD8⁺ T cells in dLNs and their subsequent terminal differentiation in the tumors. Single-cell transcriptional profiling of tumor-infiltrating MPCs demonstrated that young MPCs are polarized toward an inflammatory, effector phenotype. Consistent with our observations in young versus adult TB mice, analysis of immune infiltrates from pediatric solid tumors showed a correlation between tumor-infiltrating CD8⁺ T cells with an exhaustion phenotype and the frequency of PD-L1-expressing monocytes/macrophages. Collectively, these data indicate that a young tissue microenvironment contributes to the generation of an immune response skewed toward a less pliable terminal effector state, thus narrowing the window for immunotherapeutic interventions.

Telerehabilitation for people with aphasia: A systematic review and meta-analysis

OBJECTIVES

To evaluate effectiveness or non-inferiority of telerehabilitation for people with aphasia when compared to conventional face-to-face speech and language therapy.

MATERIALS AND METHODS

Five electronic databases (PUBMED, EMBASE, WEB OF SCIENCE, SCOPUS and the Cochrane Library) were searched. We extrapolated data from the included studies and evaluated the methodological quality using the Revised Cochrane risk-of-bias tool for Randomized Trials (RoB 2) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I). A meta-analysis compared effects of intervention, and it was conducted using the Review Manager 5.3 software. GRADE profile to assess overall quality of evidence was carried out.

RESULTS

Out of a total of 1157 records, five studies met the inclusion criteria and were eligible for meta-analysis with a total of 132 participants with post-stroke aphasia.

DISCUSSION

Results revealed that telerehabilitation and face-to-face speech and language treatment are comparable with respect to the gains achieved in auditory comprehension (SMD = -0.02; 95% CI -0.39, 0.35), naming accuracy (SMD = -0.09; 95% CI -0.44, 0.25), Aphasia Quotient (MD = -2.18; 95% CI -16.00, 11.64), generalization (SMD = 0.77; 95% IC -0.95, 2.49) and functional communication skills (SMD = -0.08; 95% IC -0.54, 0.38).

CONCLUSION

Although evidence is still insufficient to guide clinical decision making due to the relatively low quality of the evidence identified, the analysis of the results suggest that telerehabilitation training for aphasia seems to be as effective as the conventional face-to-face treatment.

Altered postural stability in elderly women following a single session of head-mounted display virtual reality

Purpouse: The aim of this study was to evaluate the effect of a single session of head-mounted display virtual reality on postural stability in elderly women. Methods: Forty-seven female subjects underwent a 20-minute virtual reality session. The mean age of the subjects was 70.12 years. As an immersive source, we used a relaxing virtual reality game with a head-mounted display device. The postural stability test was conducted using a Nintendo Wii force plate. Participants completed a set of three 30-s trials in which they took a quiet bipedal eyes-open stance while standing on a hard surface: before the virtual reality session, immediately after the virtual reality session, and 2 minutes after the virtual reality session. Centre of pressure parameters were analysed in the sagittal and frontal planes. Results: Analysing the results obtained immediately after the virtual reality session, significant differences were observed in almost all examined parameters. In the sagittal plane, centre of pressure path velocity increased by 10% (p < 0.01) and path standard deviation by 15% (p < 0.05). In the frontal plane, centre of pressure path velocity increased by 14% (p < 0.01). After 2 minutes, all examined parameters showed no significant difference compared to before the virtual reality session. Conclusions: Immediately after the virtual reality session, there was an increase in almost all examined parameters. However, after 2 minutes, all examined parameters had returned to baseline. Therefore, to reduce fall risk after a virtual reality session, it is recommended that the subject spend at least 2 minutes in a sitting position.

Altered postural stability in elderly women following a single session of head-mounted display virtual reality

Purpouse: The aim of this study was to evaluate the effect of a single session of head-mounted display virtual reality on postural stability in elderly women.

METHODS

Forty-seven female subjects underwent a 20-minute virtual reality session. The mean age of the subjects was 70.12 years. As an immersive source, we used a relaxing virtual reality game with a head-mounted display device. The postural stability test was conducted using a Nintendo Wii force plate. Participants completed a set of three 30-s trials in which they took a quiet bipedal eyes-open stance while standing on a hard surface: before the virtual reality session, immediately after the virtual reality session, and 2 minutes after the virtual reality session. Centre of pressure parameters were analysed in the sagittal and frontal planes.

RESULTS

Analysing the results obtained immediately after the virtual reality session, significant differences were observed in almost all examined parameters. In the sagittal plane, centre of pressure path velocity increased by 10% ( p < 0.01) and path standard deviation by 15% ( p < 0.05). In the frontal plane, centre of pressure path velocity increased by 14% ( p < 0.01). After 2 minutes, all examined parameters showed no significant difference compared to before the virtual reality session.

CONCLUSIONS

Immediately after the virtual reality session, there was an increase in almost all examined parameters. However, after 2 minutes, all examined parameters had returned to baseline. Therefore, to reduce fall risk after a virtual reality session, it is recommended that the subject spend at least 2 minutes in a sitting position.

Abstract LB-074: Antigen-cross presentation promotes development of terminally differentiated CD8 T cells in young individuals

Recent advances in T cell-based immunotherapies have revolutionized treatment strategies for several types of cancers; however, approaches that rely on endogenous T cell responses have experienced limited success in pediatric populations, a pattern primarily attributed to the relatively low mutational burden characteristic of pediatric tumors. Here, we report our analysis of CD8 T cells isolated from a diverse set of pediatric solid tumors, documenting an enrichment of CD8 T cells with an antigen-experienced phenotype (i.e., high PD1 expression). The limited ability of immune checkpoint blockade therapy (ICBT) to trigger anti-tumor responses in pediatric populations, despite the presence of activated CD8 T cells in these tumors prompted us to explore alternative mechanisms restricting the endogenous T cell response. Using a novel, transplantable mouse tumor model that expresses a well-characterized epitope coupled to a mCherry marker, we identified antigen cross-presentation by tumor-infiltrating myeloid cells as a key mediator of CD8 T cell effector function in tumors. Specifically, we show that tumor microenvironment (TME)-mediated suppression of CD8 T cell polyfunctionality occurs even in the absence of direct antigen-presentation by tumor cells, suggesting that antigen cross-presentation is sufficient to enforce this dysfunctional state. Strikingly, age-related changes in the TME had a significant impact on the differentiation of tumor-specific CD8 T cells. Cross-presentation of tumor antigens in the young animals skewed the effector differentiation of tumor-specific CD8 T cells toward a TCF7lowGzmBhi terminally differentiated state. Profiling of tumor-infiltrating antigen-presenting cells by scRNAseq revealed the differential polarization of the myeloid compartment towards M1 and M2 phenotypes between the young and adult tumors, respectively. Consistent with our mouse findings, analysis of immune infiltrates from human pediatric solid tumors revealed a strong correlation between the expression of PDL1 on myeloid cells and enrichment of tumor-associated CD8 T cells with an exhaustion phenotype (PD1hiTim3+). Collectively, these data indicate that the “young” microenvironment of an actively developing tissue/individual contributes to the generation of an immune response skewed towards a terminally differentiated state with limited plasticity, thus narrowing the window for immunotherapeutic interventions.

Citation Format: Ardiana Moustaki, Jeremy Chase Crawford, Shanta Alli, Anthony Zamora, Yiping Fan, Shannon Boi, Natalie M. McDonald, Paul G. Thomas, Alberto S. Pappo, Michael A. Dyer, Elizabeth Stewart, Sara Federico, Ben Youngblood. Antigen-cross presentation promotes development of terminally differentiated CD8 T cells in young individuals [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-074.

Antigen-cross presentation promotes development of terminally differentiated CD8 T cells in young individuals

Cancer immunotherapeutic approaches that rely on endogenous T cell responses have shown limited success in children, a pattern attributed to the low mutational burden of pediatric tumors. Here, we report that CD8 T cells isolated from a diverse set of pediatric solid tumors are enriched for an antigen-experienced phenotype. The limited ability of immune checkpoint blockade therapy (ICBT) to trigger anti-tumor responses in children, despite the presence of activated CD8 T cells, prompted us to explore alternative underlying mechanisms restricting anti-tumor responses. Using a novel mouse tumor model that expresses a well-characterized epitope coupled to an mCherry marker, we identified antigen cross-presentation by tumor infiltrating myeloid cells as a key regulator of CD8 T cell effector function in tumors. Strikingly, age-related changes in the TME resulted in a skewing of the CD8 T cell effector fate toward a terminally differentiated state in young tumor-bearing mice. Profiling of tumor infiltrating antigen presenting cells by scRNAseq revealed a proinflammatory M1 macrophage polarization in young tumors but a predominant M2 “wound healing” response in adult tumors. Consistent with our mouse findings, analysis of immune infiltrates from human pediatric solid tumors revealed a strong correlation between the expression of PDL1 on myeloid cells and enrichment of tumor-associated CD8 T cells with an exhaustion phenotype. Collectively, these data indicate that the “young” microenvironment of an actively developing tissue/individual contributes to the generation of an immune response skewed towards a terminally differentiated state with limited plasticity, thus narrowing the window for immunotherapeutic interventions.

MYCN amplification and ATRX mutations are incompatible in neuroblastoma

Aggressive cancers often have activating mutations in growth-controlling oncogenes and inactivating mutations in tumor-suppressor genes. In neuroblastoma, amplification of the MYCN oncogene and inactivation of the ATRX tumor-suppressor gene correlate with high-risk disease and poor prognosis. Here we show that ATRX mutations and MYCN amplification are mutually exclusive across all ages and stages in neuroblastoma. Using human cell lines and mouse models, we found that elevated MYCN expression and ATRX mutations are incompatible. Elevated MYCN levels promote metabolic reprogramming, mitochondrial dysfunction, reactive-oxygen species generation, and DNA-replicative stress. The combination of replicative stress caused by defects in the ATRX-histone chaperone complex, and that induced by MYCN-mediated metabolic reprogramming, leads to synthetic lethality. Therefore, ATRX and MYCN represent an unusual example, where inactivation of a tumor-suppressor gene and activation of an oncogene are incompatible. This synthetic lethality may eventually be exploited to improve outcomes for patients with high-risk neuroblastoma.

Case Report: Management Approach and Use of Extracorporeal Membrane Oxygenation for Diffuse Alveolar Hemorrhage After Pediatric Hematopoietic Cell Transplant

Introduction: Diffuse alveolar hemorrhage (DAH) is an early pulmonary complication of hematopoietic cell transplantation (HCT) associated with severe hypoxemic respiratory failure and mortality. Extracorporeal membrane oxygenation (ECMO) support is often used for respiratory failure refractory to conventional interventions; however, its use has been limited in HCT patients with DAH due to potential for worsening alveolar hemorrhage and reported high mortality. Case Presentation: We report two cases of DAH following HCT who developed refractory hypoxemic respiratory failure despite cessation of bleeding and were successfully supported with ECMO. Conclusion: DAH after HCT should not automatically preclude ECMO support; rather, these patients must be evaluated individually for ECMO within the context of their overall clinical picture.

ATRX In-Frame Fusion Neuroblastoma Is Sensitive to EZH2 Inhibition via Modulation of Neuronal Gene Signatures

ATRX alterations occur at high frequency in neuroblastoma of adolescents and young adults. Particularly intriguing are the large N-terminal deletions of ATRX (Alpha Thalassemia/Mental Retardation, X-linked) that generate in-frame fusion (IFF) proteins devoid of key chromatin interaction domains, while retaining the SWI/SNF-like helicase region. We demonstrate that ATRX IFF proteins are redistributed from H3K9me3-enriched chromatin to promoters of active genes and identify REST as an ATRX IFF target whose activation promotes silencing of neuronal differentiation genes. We further show that ATRX IFF cells display sensitivity to EZH2 inhibitors, due to derepression of neurogenesis genes, including a subset of REST targets. Taken together, we demonstrate that ATRX structural alterations are not loss-of-function and put forward EZH2 inhibitors as a potential therapy for ATRX IFF neuroblastoma.

Secondary hemophagocytic syndrome after autologous hematopoietic cell transplant and immune therapy for neuroblastoma

Secondary hemophagocytic syndrome (HPS) has been described after autologous hematopoietic cell transplant (AutoHCT). We report two cases of secondary HPS after novel consolidation therapy for high-risk neuroblastoma as part of an institutional phase 2 trial incorporating immunotherapy into a "standard" AutoHCT regimen. Both patients developed liver dysfunction beyond expected course of hepatic veno-occlusive disease, coagulopathy, hyperferritinemia, and when evaluated, elevated soluble interleukin-2 receptor and hemophagocytosis. These cases highlight the need for clinicians to have a high index of suspicion for immune-related complications in patients receiving immune therapies.

De novo DNA methylation programs regulate T cell exhaustion and limit T cell-based immunotherapies

T cell-based immunotherapies have emerged as one of the most promising frontiers in the fight against cancer and chronic infections. However, it has become clear that prolonged exposure of T cells to their cognate antigen drives them toward a terminally differentiated state, limiting their capacity to mount an effector response. The commitment of T cells to this “exhausted” fate is currently a major barrier in the advancement of T cell immunotherapy efforts. To better understand mechanisms that reinforce the T cell exhaustion gene expression program, we investigated the role of de novo epigenetic programming in establishing exhausted T cells that are non-responsive during immune checkpoint blockade (ICB) therapy. Using mouse models of tumor and chronic viral infection, we observed that genetic deletion of the de novo DNA methyltransferase, Dnmt3a, in antigen-specific T cells that are chronically stimulated allowed them to remain highly functional despite expressing high levels of the checkpoint inhibitory receptor PD-1. Furthermore, PD-1 blockade treatment resulted in massive expansion of PD-1+ Dnmt3a-deficient antigen-specific T cells. Building upon the findings from our murine studies, we have generated whole-genome DNA methylation profiles of human CD8 T cells from a wide array of differentiation states, and established an epigenetic-based human T cell multipotency index. Using this index, we report that tumor-associated PD-1hi CD8 T cells from pediatric solid tumors acquire an epigenetically reinforced terminal differentiation program. Collectively, these data establish Dnmt3a-mediated de novo DNA methylation programming as a key factor in limiting CD8 T cell-based immunotherapuetic approaches.

Abstract IA18: MYCN amplification and ATRX mutations are incompatible in neuroblastoma

Age and stage of disease at diagnosis are associated with outcome in neuroblastoma. A previous study identified ATRX point mutations and in-frame deletions in older patients with stage 4 disease. To validate the frequency of ATRX mutations and assess the relation of mutations and known prognostic variables, we collaborated with the Children’s Oncology Group and sequenced the entire ATRX genomic locus in 475 neuroblastoma tumor samples to validate the frequency of ATRX mutations and assess the relation of mutations and known prognostic variables. Older age at diagnosis, stage 4 disease, and unfavorable histology were significantly associated with mutations in the ATRX gene; MYCN amplification was mutually exclusive from ATRX mutations. To directly test if ATRX mutations and MYCN amplification are incompatible in neuroblastoma, we mutated the ATRX gene in MYCN amplified neuroblastoma cell lines and ectopically expressed MYCN in ATRX mutant neuroblastoma cell lines. Both approaches showed that ATRX and MYCN amplification are incompatible in neuroblastoma in culture and in vivo. To gain a better understanding of the underlying molecular and cellular mechanisms of this incompatibility, we performed a series of experiments including telomere analysis, epigenetic profiling, electron microscopic analysis of dying cells, and metabolic profiling. We discovered that induction of MYCN expression in ATRX mutant neuroblastoma cells leads to metabolic reprogramming, mitochondrial dysfunction, increased reactive oxygen species, and replicative stress. We propose that this leads to synthetic lethality in ATRX mutant neuroblastomas because of the underlying replicative stress in those cells as a result of dysfunction of this essential histone chaperone complex.

Citation Format: Maged Zeineldin, Sara Federico, Xiang Chen, Beisi Xu, Elizabeth Stewart, Arlene Naranjo, Michael D. Hogarty, Michael A. Dyer. MYCN amplification and ATRX mutations are incompatible in neuroblastoma [abstract]. In: Proceedings of the AACR Special Conference: Pediatric Cancer Research: From Basic Science to the Clinic; 2017 Dec 3-6; Atlanta, Georgia. Philadelphia (PA): AACR; Cancer Res 2018;78(19 Suppl):Abstract nr IA18.

Abstract SY07-02: Epigenetic regulation of T-cell exhaustion: Implications for cancer immunotherapy

Immune checkpoint blockade (ICB)-mediated rejuvenation of CD8 T-cell effector functions has emerged as one of the most promising frontiers for treating cancer and chronic infections. However, antigen-specific T cells that have experienced prolonged antigen exposure are often terminally differentiated, and have a limited capacity to mount an effector response during ICB treatment. Such exhaustion of effector potential is a major impediment of current T cell-based immunotherapy efforts. Using in vivo mouse models of tumor and chronic viral infection, we assessed the role of de novo epigenetic programming in establishing ICB-refractory exhausted T cells. We observed that genetic deletion of the de novo DNA methyltransferase, Dnmt3a, in T cells at the effector stage of an immune response to chronic lymphocytic choriomeningitis virus (LCMV) infection allowed antigen-specific T cells to remain highly functional despite expressing high levels of PD-1 and having prolonged exposure to antigen. Quite strikingly, PD-1 blockade treatment of chronically infected animals resulted in massive expansion of PD-1+ Dnmt3a-deficient antigen-specific T cells. Whole-genome methylation profiling of WT and Dnmt3a-deficient LCMV-specific CD8 T cells identified de novo DNA methylation programs that are coupled to development of ICB-nonresponsive virus and tumor-specific T cells. Building upon these findings, we have identified de novo epigenetic programs acquired in human tumor-associated PD-1hi CD8 T cells. Collectively, these data establish Dnmt3a-mediated de novo DNA methylation programming as a key regulator in establishing ICB-refractory exhausted CD8 T cells and highlight epigenetic reprogramming of T cells as a novel approach to enhance T cell-based cancer therapies.

Citation Format: Benjamin A. Youngblood, Hazem Ghoniem, Ardiana Moustaki, Hossam Abdelsamed, Yiping Fan, Paul Thomas, Elizabeth Stewart, Sara Federico. Epigenetic regulation of T-cell exhaustion: Implications for cancer immunotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr SY07-02.

De novo DNA methylation programs restrain T cell rejuvenation during immune checkpoint blockade therapy

Immune-checkpoint blockade (ICB)-mediated rejuvenation of CD8 T cell effector functions has emerged as one of the most promising frontiers for treating cancer and chronic infections. However, antigen-specific T cells that have experienced prolonged antigen exposure are often terminally differentiated, and have a limited capacity to mount an effector response during ICB treatment. Such exhaustion of effector potential is a major impediment of current T cell based immunotherapy efforts. Using in vivo mouse models of tumor and chronic viral infection, we assessed the role of de novo epigenetic programming in establishing ICB-refractory exhausted T cells. We observed that genetic deletion of Dnmt3a in T cells at the effector stage of an immune response to chronic lymphocytic choriomeningitis virus (LCMV) infection allowed antigen-specific T cells to remain highly functional despite expressing high levels of PD-1 and having prolonged exposure to antigen. Quite strikingly, PD-1 blockade treatment of chronically infected animals resulted in massive expansion of PD-1+ Dnmt3a-deficient antigen-specific T cells. Whole-genome methylation profiling of WT and Dnmt3a-deficient LCMV-specific CD8 T cells identified de novo DNA methylation programs that are coupled to development of ICB-nonresponsive virus and tumor-specific T cells. Building upon these findings, we have identified de novo epigenetic programs acquired in human tumor-associated PD-1hi CD8 T cells. Collectively, these data establish Dnmt3a-mediated de novo DNA methylation programming as a key regulator in establishing ICB-refractory exhausted CD8 T cells and highlights epigenetic reprogramming of T cells as a novel approach to enhance T cell-based cancer therapies.

Radiomics Features Differentiate Between Normal and Tumoral High-Fdg Uptake

Identification of FDGavid- neoplasms may be obscured by high-uptake normal tissues, thus limiting inferences about the natural history of disease. We introduce a FDG-PET radiomics tissue classifier for differentiating FDGavid- normal tissues from tumor. Thirty-three scans from 15 patients with Hodgkin lymphoma and 68 scans from 23 patients with Ewing sarcoma treated on two prospective clinical trials were retrospectively analyzed. Disease volumes were manually segmented on FDG-PET and CT scans. Brain, heart, kidneys and bladder and tumor volumes were automatically segmented on PET images. Standard-uptake-value (SUV) derived shape and first order radiomics features were computed to build a random forest classifier. Manually segmented volumes were compared to automatically segmented tumor volumes. Classifier accuracy for normal tissues was 90%. Classifier performance was varied across normal tissue types (brain, left kidney and bladder, hear and right kidney were 100%, 96%, 97%, 83% and 87% respectively). Automatically segmented tumor volumes showed high concordance with the manually segmented tumor volumes (R² = 0.97). Inclusion of texture-based radiomics features minimally contributed to classifier performance. Accurate normal tissue segmentation and classification facilitates accurate identification of FDGavid tissues and classification of those tissues as either tumor or normal tissue.

Consolidation Therapy for Newly Diagnosed Pediatric Patients with High-Risk Neuroblastoma Using Busulfan/Melphalan, Autologous Hematopoietic Cell Transplantation, Anti-GD2 Antibody, Granulocyte-Macrophage Colony-Stimulating Factor, Interleukin-2, and Haploidentical Natural Killer Cells

The treatment of pediatric high-risk neuroblastoma is intensive and multimodal. Despite the introduction of immunotherapy for minimal residual disease, survival rates remain suboptimal and new therapies are needed. As part of a phase 2 trial, we are using a consolidation therapy regimen that combines a busulfan/melphalan conditioning schema, autologous hematopoietic cell transplantation (AHCT), and experimental immunotherapy with hu14.18K322A (a humanized anti-GD2 monoclonal antibody), granulocyte-macrophage colony-stimulating factor (GM-CSF), and IL-2, with or without the adoptive transfer of haploidentical natural killer cells (NKs). Here we report on 30 patients who have undergone AHCT with this experimental immunotherapy regimen, 21 of whom received haploidentical NKs. The median time to neutrophil engraftment was 13 days (range, 10 to 28 days) and to platelet engraftment of at least 20  ×  103/mm³ was 36.5 days (range, 0 to 102 days); no clinical difference was seen in those who did or did not receive NKs. Eight patients developed veno-occlusive disease, with 3 having multiorgan dysfunction. Toxicities were similar for patients who did or did not receive NKs. We conclude that this consolidation regimen is feasible and has an acceptable acute toxicity profile.

Visual Diagnosis: New Lung Nodules in a 3-year-old Girl with Wilms Tumor

The most significant oncologic concern with finding new pulmonary nodules on imaging in a pediatric patient who has anaplastic Wilms tumor is progressive disease with new pulmonary metastases. This case emphasizes the importance of employing a creative clinical differential diagnosis, even for patients with known underlying oncologic disease.

Complicated diverticulitis in kidney transplanted patients: analysis of 717 cases

INTRODUCTION

This study aims to investigate possible risk factors for diverticulitis in kidney transplant recipients affected by colonic diverticulosis.

METHODS AND RESULTS

We investigated 717 patients transplanted between 2000 and 2010. Diverticular disease was endoscopically diagnosed in 17 of 717 examined patients. Eight patients were diagnosed with autosomal dominant polycystic kidney disease (ADPKD); 9 of 17 patients underwent emergency surgery. We performed Hartmann's procedure on all patients, with a second stage performed at least 6 months later.

DISCUSSION

Although the incidence of colonic diverticular perforation in kidney transplanted patients is similar to that observed in the general population, perforation in immunosuppressed patients is associated with a higher morbidity/mortality rate. In our study, the incidence of perforation is 1.25% (9 of 717), with almost half of the cases observed in patients with ADPKD (4 of 9). Such an observation is consistent with published data, in which patients with ADPKD are reported to more frequently develop colonic diverticulosis and its complications. One possible explanation might be related to a belated diagnosis of diverticulitis, which could initially simulate an inflammatory disease as a consequence of renal cysts. Also, steroids seem to be a predisposing factor for colonic perforation in these patients.

CONCLUSIONS

A timely surgery can significantly reduce mortality. In cases of elective surgery, mortality and morbidity are similar to those of immunocompetent patients; accordingly, this is the goal to be pursued. Early signs and symptoms are often masked by immunosuppressive therapy. In these patients, surgeons should always perform (1) abdominal computed tomography scanning and, in the presence of diverticulitis, reduce or withdraw immunosuppressive therapy; and (2) early surgery, with Hartmann's procedure being, in our opinion, the best choice. Before transplantation, elective surgery for colonic resection should be considered in patients with ADPKD or with a history of 1 or more episodes of acute diverticulitis who then regressed with medical therapy.

Oscillatory mTOR inhibition and Treg increase in kidney transplantation

Intracellular metabolic pathways dependent upon the mammalian target of rapamycin (mTOR) play a key role in immune-tolerance control. In this study, we focused on long-term mTOR-dependent immune-modulating effects in kidney transplant recipients undergoing conversion from calcineurin inhibitors (CNI) to mTOR inhibitors (everolimus) in a 1-year follow-up. The conversion to everolimus is associated with a decrease of neutrophils and of CD8(+) T cells. In addition, we observed a reduced production of interferon (IFN)-γ by CD8(+) T cells and of interleukin (IL)-17 by CD4(+) T lymphocytes. An increase in CD4(+) CD25(+) forkhead box protein 3 (FoxP3)(+) [regulatory T cell [(Treg)] numbers was also seen. Treg increase correlated with a higher proliferation rate of this regulatory subpopulation when compared with the CD4(+) FoxP3(-) effector counterpart. Basal phosphorylation level of S6 kinase, a major mTOR-dependent molecular target, was substantially maintained in patients treated with everolimus. Moreover, oscillations in serum concentration of everolimus were associated with changes in basal and activation-dependent S6 kinase phosphorylation of CD4(+) and CD8(+) T cells. Indeed, T cell receptor (TCR) triggering was observed to induce significantly higher S6 kinase phosphorylation in the presence of lower everolimus serum concentrations. These results unveil the complex mTOR-dependent immune-metabolic network leading to long-term immune-modulation and might have relevance for novel therapeutic settings in kidney transplants.

The Childhood Solid Tumor Network: A new resource for the developmental biology and oncology research communities

Significant advances have been made over the past 25 years in our understanding of the most common adult solid tumors such as breast, colon, lung and prostate cancer. Much less is known about childhood solid tumors because they are rare and because they originate in developing organs during fetal development, childhood and adolescence. It can be very difficult to study the cellular origins of pediatric solid tumors in developing organs characterized by rapid proliferative expansion, growth factor signaling, developmental angiogenesis, programmed cell death, tissue reorganization and cell migration. Not only has the etiology of pediatric cancer remained elusive because of their developmental origins, but it also makes it more difficult to treat. Molecular targeted therapeutics that alter developmental pathway signaling may have devastating effects on normal organ development. Therefore, basic research focused on the mechanisms of development provides an essential foundation for pediatric solid tumor translational research. In this article, we describe new resources available for the developmental biology and oncology research communities. In a companion paper, we present the detailed characterization of an orthotopic xenograft of a pediatric solid tumor derived from sympathoadrenal lineage during development.

Forecasting wind power production from a wind farm using the RAMS model

Abstract. The importance of wind power forecast is commonly recognized because it represents a useful tool for grid integration and facilitates the energy trading. This work considers an example of power forecast for a wind farm in the Apennines in Central Italy. The orography around the site is complex and the horizontal resolution of the wind forecast has an important role. To explore this point we compared the performance of two 48 h wind power forecasts using the winds predicted by the Regional Atmospheric Modeling System (RAMS) for the year 2011. The two forecasts differ only for the horizontal resolution of the RAMS model, which is 3 km (R3) and 12 km (R12), respectively. Both forecasts use the 12 UTC analysis/forecast cycle issued by the European Centre for Medium range Weather Forecast (ECMWF) as initial and boundary conditions. As an additional comparison, the results of R3 and R12 are compared with those of the ECMWF Integrated Forecasting System (IFS), whose horizontal resolution over Central Italy is about 25 km at the time considered in this paper. v Because wind observations were not available for the site, the power curve for the whole wind farm was derived from the ECMWF wind operational analyses available at 00:00, 06:00, 12:00 and 18:00 UTC for the years 2010 and 2011. Also, for R3 and R12, the RAMS model was used to refine the horizontal resolution of the ECMWF analyses by a two-years hindcast at 3 and 12 km horizontal resolution, respectively. The R3 reduces the RMSE of the predicted wind power of the whole 2011 by 5% compared to R12, showing an impact of the meteorological model horizontal resolution in forecasting the wind power for the specific site.

Development and characterization of a human orthotopic neuroblastoma xenograft

Neuroblastoma is a pediatric cancer of the developing sympathoadrenal lineage. The tumors are known to develop from the adrenal gland or paraspinal ganglia and have molecular and cellular features of sympathetic neurons such as dense core vesicles and catecholamine production. Here we present the detailed molecular, cellular, genetic and epigenetic characterization of an orthotopic xenograft derived from a high-risk stage 4 neuroblastoma patient. Overall, the xenografted tumor retained the high risk features of the primary tumor and showed aggressive growth and metastasis in the mouse. Also, the genome was preserved with no additional copy number variations, structural variations or aneuploidy. There were 13 missense mutations identified in the xenograft that were not present in the patient's primary tumor and there were no new nonsense mutations. None of the missense mutations acquired in the xenograft were in known cancer genes. We also demonstrate the feasibility of using the orthotopic neuroblastoma xenograft to test standard of care chemotherapy and molecular targeted therapeutics. Finally, we optimized a new approach to produce primary cultures of the neuroblastoma xenografts for high-throughput drug screening which can be used to test new combinations of therapeutic agents for neuroblastoma.

Efficacy of subcutaneous epoetin-zeta on anemia in renal transplant recipients: a single-center experience

BACKGROUND

Persistent or "de novo" anemia (plasma hemoglobin<11 g/dL) may complicate the graft outcome in a significant number of renal transplant recipients. We describe a single-center experience with epoetin-zeta (EPO-Z), the biosimilar form for epoetin-alfa.

METHODS

Twenty patients were included in the study, 10 in treatment with different erythropoiesis-stimulating agents (ESA) and shifted to EPO-Z (shift group) and 10 who started EPO-Z treatment for anemia (naive group). All the patients had stable renal function and normal values of main inflammation markers and were prospectively followed up for 12 months. Iron supplements were administered during the study, as needed.

RESULTS

In the shift group, mean plasma hemoglobin levels>11 g/dL were maintained for the entire 1-year follow-up period, with average EPO-Z doses 3.4% higher than the corresponding doses of previous ESA; in the naive group, the target value was reached between the first and third months and remained stable throughout the study. Mean corpuscular volume did not vary in either group. No change was observed in glomerular filtration rate, nor in proteinuria or in main laboratory data. No drug-related side effect was reported.

CONCLUSIONS

EPO-Z may be considered a valid alternative to different ESAs in renal transplant recipients, with an interesting pharmaco-economic profile, considering its lower cost.

Association of age at diagnosis and genetic mutations in patients with neuroblastoma

CONTEXT

Neuroblastoma is diagnosed over a wide age range from birth through young adulthood, and older age at diagnosis is associated with a decline in survivability.

OBJECTIVE

To identify genetic mutations that are associated with age at diagnosis in patients with metastatic neuroblastoma.

DESIGN, SETTING, AND PATIENTS

Whole genome sequencing was performed on DNA from diagnostic tumors and their matched germlines from 40 patients with metastatic neuroblastoma obtained between 1987 and 2009. Age groups at diagnosis included infants (0-<18 months), children (18 months-<12 years), and adolescents and young adults (≥12 years). To confirm the findings from this discovery cohort, validation testing using tumors from an additional 64 patients obtained between 1985 and 2009 also was performed. Formalin-fixed, paraffin-embedded tumor tissue was used for immunohistochemistry and fluorescence in situ hybridization. Telomere lengths were analyzed using whole genome sequencing data, quantitative polymerase chain reaction, and fluorescent in situ hybridization.

MAIN OUTCOME MEASURE

Somatic recurrent mutations in tumors from patients with neuroblastoma correlated with the age at diagnosis and telomere length.

RESULTS

In the discovery cohort (n = 40), mutations in the ATRX gene were identified in 100% (95% CI, 50%-100%) of tumors from patients in the adolescent and young adult group (5 of 5), in 17% (95% CI, 7%-36%) of tumors from children (5 of 29), and 0% (95% CI, 0%-40%) of tumors from infants (0 of 6). In the validation cohort (n = 64), mutations in the ATRX gene were identified in 33% (95% CI, 17%-54%) of tumors from patients in the adolescent and young adult group (9 of 27), in 16% (95% CI, 6%-35%) of tumors from children (4 of 25), and in 0% (95% CI, 0%-24%) of tumors from infants (0 of 12). In both cohorts (N = 104), mutations in the ATRX gene were identified in 44% (95% CI, 28%-62%) of tumors from patients in the adolescent and young adult group (14 of 32), in 17% (95% CI, 9%-29%) of tumors from children (9 of 54), and in 0% (95% CI, 0%-17%) of tumors from infants (0 of 18). ATRX mutations were associated with an absence of the ATRX protein in the nucleus and with long telomeres.

CONCLUSION

ATRX mutations were associated with age at diagnosis in children and young adults with stage 4 neuroblastoma.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00588068.

Surface high-resolution temperature forecast in southern Italy

Abstract. Since June 2008, 1-h temperature forecasts for the Calabria region (Southern Italy) are issued at 2.5 km horizontal resolution at CRATI/ISAC-CNR. Forecasts are available online at http://meteo.crati.it/previsioni.html (every 6-h). This paper shows the forecast performance out to three days for one climatological year (from 1 December 2008 to 30 November 2009, 365 run) for minimum, mean and maximum temperature. The forecast is evaluated against gridded analyses at the same horizontal resolution. Gridded analysis is based on Optimal Interpolation (OI) and uses a de-trending technique for computing the background field. Observations from 87 thermometers are used in the analysis system. In this paper cumulative statistics are shown to quantify forecast errors out to three days.

Preclinical models for neuroblastoma: establishing a baseline for treatment

Background

Preclinical models of pediatric cancers are essential for testing new chemotherapeutic combinations for clinical trials. The most widely used genetic model for preclinical testing of neuroblastoma is the TH-MYCN mouse. This neuroblastoma-prone mouse recapitulates many of the features of human neuroblastoma. Limitations of this model include the low frequency of bone marrow metastasis, the lack of information on whether the gene expression patterns in this system parallels human neuroblastomas, the relatively slow rate of tumor formation and variability in tumor penetrance on different genetic backgrounds. As an alternative, preclinical studies are frequently performed using human cell lines xenografted into immunocompromised mice, either as flank implant or orthtotopically. Drawbacks of this system include the use of cell lines that have been in culture for years, the inappropriate microenvironment of the flank or difficult, time consuming surgery for orthotopic transplants and the absence of an intact immune system.

Principal Findings

Here we characterize and optimize both systems to increase their utility for preclinical studies. We show that TH-MYCN mice develop tumors in the paraspinal ganglia, but not in the adrenal, with cellular and gene expression patterns similar to human NB. In addition, we present a new ultrasound guided, minimally invasive orthotopic xenograft method. This injection technique is rapid, provides accurate targeting of the injected cells and leads to efficient engraftment. We also demonstrate that tumors can be detected, monitored and quantified prior to visualization using ultrasound, MRI and bioluminescence. Finally we develop and test a “standard of care” chemotherapy regimen. This protocol, which is based on current treatments for neuroblastoma, provides a baseline for comparison of new therapeutic agents.

Significance

The studies suggest that use of both the TH-NMYC model of neuroblastoma and the orthotopic xenograft model provide the optimal combination for testing new chemotherapies for this devastating childhood cancer.

Targeting the p53 pathway in retinoblastoma with subconjunctival Nutlin-3a

Retinoblastoma is a rare childhood cancer of the retina that begins in utero and is diagnosed in the first years of life. The goals of retinoblastoma treatment are ocular salvage, vision preservation, and reduction of short- and long-term side effects without risking mortality because of tumor dissemination. To identify better chemotherapeutic combinations for the treatment of retinoblastoma, several groups have developed genetic mouse models and orthotopic xenograft models of human retinoblastoma for preclinical testing. Previous studies have implicated the MDMX protein in the suppression of the p53 pathway in retinoblastoma and shown that the MDM2/MDMX antagonist, Nutlin-3a, can efficiently induce p53-mediated cell death in retinoblastoma cell lines. However, Nutlin-3a cannot be administered systemically to treat retinoblastoma, because it has poor penetration across the blood-ocular barrier. Therefore, we developed an ocular formulation of Nutlin-3a, Nutlin-3a(OC), and tested the pharmacokinetics and efficacy of this new formulation in genetic and human retinoblastoma orthotopic xenograft models of retinoblastoma. Here, we show that Nutlin-3a(OC) specifically and efficiently targets the p53 pathway and that the combination of Nutlin-3a(OC) with systemic topotecan is a significantly better treatment for retinoblastoma than currently used chemotherapy in human orthotopic xenografts. Our studies provide a new standardized approach to evaluate and prioritize novel agents for incorporation into future clinical trials for retinoblastoma.

Long-term assessment of plasma lipids in transplant recipients treated with tacrolimus in relation to fatty liver

Immunosuppression has improved graft and recipient survival in transplantation but is associated with possible adverse effects including cardiovascular diseases. The impact of tacrolimus on the lipidic profile has been debated for several years. Twenty-nine kidney transplant recipients on tacrolimus treatment were monitored for six years, and multiple laboratory parameters investigating the lipid asset, as well as glucose profile, were carried out. Tacrolimus has been responsible for significant changes in plasma lipid concentrations only for the first six months, but not for the remaining time of observation. Similarly, in the same periods, glycemic imbalance was highlighted. The liver enzyme activity showed a modest derangement during the tacrolimus treatment, suggesting the presence of lipid accumulation in the liver. Fatty liver reversed in the long term follow-up. Tacrolimus, although it is not a completely safe option in the first months of the immunosuppressive protocols in organ transplanted recipients, still retains a certain role in the long-term post-transplantation immunosuppressive approach with high cardiovascular risks.

Subconjunctival carboplatin and systemic topotecan treatment in preclinical models of retinoblastoma

BACKGROUND

The authors demonstrated previously that the combination of topotecan (TPT) and carboplatin (CBP) was more effective than current chemotherapeutic combinations used to treat retinoblastoma in an orthotopic xenograft model. However, systemic coadministration of these agents is not ideal, because both agents cause dose-limiting myelosuppression in children.

METHODS

To overcome the toxicity associated with systemic TPT and CBP, the authors explored subconjunctival delivery of TPT or CBP in an orthotopic xenograft model and in a genetic mouse model of retinoblastoma (Chx10-Cre;Rb(lox/lox);p107(-/-);p53(lox/lox)). The effects of combined subconjunctival CBP (CBP(subcon)) and systemic TPT (TPT(syst)) were compared with the effects of combined TPT(subcon) and CBP(syst.) at clinically relevant dosages.

RESULTS

Pharmacokinetic and tumor-response studies, including analyses of ocular and hematopoietic toxicity, revealed that CBP(subcon)/TPT(syst) was more effective and had fewer side effects than TPT(subcon)/CBP(syst).

CONCLUSIONS

For the first time, retinoblastoma was ablated and long-term vision was preserved in a mouse model by using a clinically relevant chemotherapy regimen. These results eventually may be translated into a clinical trial for children with this debilitating cancer.

The seasonal characteristics of the breeze circulation at a coastal Mediterranean site in South Italy

Abstract. We present a study on the characteristics of the sea breeze flow at a coastal site located in the centre of the Mediterranean basin at the southern tip of Italy. This study is finalized to add new data on breeze circulations over a narrow peninsula and present a unique experimental coastal site at about 600 m from the coastline in a flat open area at the foot of a mountain chain located in a region of complex orography. We study the seasonal behaviour of the sea-land breeze circulation by analysing two years of hourly data of wind speed and direction, temperature, radiation and relative humidity from a surface meteorological station, eighteen-months data from a wind profiler, and two-year data from the ECMWF analysis. Results show that breezes dominate the local circulation and play a major role for the local climate. They are modulated by the season, through the sea-land temperature difference and the large-scale flow. The large-scale forcing acts in phase with the diurnal breeze and opposes the nocturnal breeze. In summer, the daytime difference between the land surface temperature and the SST (Sea Surface Temperature) reaches its maximum, while the nigh-time difference has its minimum. This causes a strong, frequent and intense diurnal breeze and a weak nocturnal breeze. In winter and fall the nocturnal difference between the sea and land surface temperature reaches a maximum value, while the diurnal difference is at its minimum value. This causes a strong, frequent and intense nocturnal breeze despite of the large-scale forcing that is usually opposed to local-scale flow.

Effects of voriconazole on tacrolimus metabolism in a kidney transplant recipient

Infection occurs frequently in the organ transplant recipients during the post-transplant period because of immunosuppression. Therefore, prophylactic antimicrobial agents are often used. The azole antifungals, widely prescribed prophylactically, are known to have many drug-drug interactions. This report presents a case of drug-drug interaction between voriconazole and tacrolimus in a kidney transplant recipient. Voriconazole treatment led to a dramatic increase in tacrolimus concentration that required its discontinuation in spite of the manufacturer's guidelines that recommend a reduction of tacrolimus dosage by one-third. The present drug-drug interaction can be attributed to a strong inhibitory effect on cytochrome P450-3A4 activity by voriconazole. When voriconazole and tacrolimus are coadministered, close monitoring of tacrolimus blood levels is recommended as the rule-of-thumb reduction of tacrolimus dose by one-third may not be satisfactory.

Correlation between large-scale atmospheric fields and the olive pollen season in Central Italy

Olives are one of the largest crops in the Mediterranean and in central and southern Italy. This work investigates the correlation of the Olea europaea L. pollen season in Perugia, the capital city of the region of Umbria in central Italy, with atmospheric parameters. The aim of the study is twofold. First, we study the correlation between the pollen season and the surface air temperature of the spring and late spring in Perugia. Second, the correlation between the pollen season and large-scale atmospheric patterns is investigated. The average surface temperature in the spring and late spring has a clear impact on the pollen season in Perugia. Years with higher average temperatures have an earlier onset of the pollen season. In particular, a 1 degrees C higher (lower) average surface temperature corresponds to an earlier (later) start of the pollen season of about 1 week. The correlation between the pollen season and large-scale atmospheric patterns of sea level pressure and 500-hPa geopotential height shows that the cyclonic activity in the Mediterranean is unequivocally tied to the pollen season in Perugia. A larger than average cyclonic activity in the Mediterranean Basin corresponds to a later than average pollen season. Larger than average cyclonic activity in Northern Europe and Siberia corresponds to an earlier than average pollen season. A possible explanation of this correlation, that needs further investigation to be proven, is given. These results can have a practical application by using the seasonal forecast of atmospheric general circulation models.

Quantification of sirolimus and everolimus by immunoassay techniques: test specificity and cross-reactivity evaluation

The possible cross-reactivity of immunoassays with structurally-related drugs was investigated. Innofluor Certican (FPIA) calibrators were measured by using IMx Sirolimus assay (MEIA) and MEIA Sirolimus calibrators were analysed by using FPIA Certican assay. Drug concentrations were measured in 95 and 100 samples from renal transplanted patients (RTP) on sirolimus or everolimus treatment by using immunoassays and LC/ESI-MSMS. A high cross-reactivity was found both for MEIA and FPIA. High correlation degrees, confirmed by the Bland-Altman and the Eksborg tests, were found between drug concentrations measured in real samples by both immunoassays (r = 0.909 and r = 0.970, respectively). LC/ESI-MSMS analysis of samples containing sirolimus showed no positivity for everolimus. Similarly, samples from patients on treatment with everolimus resulted negative as far as regards sirolimus. MEIA and FPIA could be considered mutually reliable and accurate alternatives for the specific-drug immunoassay. It should be noticed that in patients switching from one drug to the other unreal overestimation of the blood levels of the current administered immunosuppressant can occur.

Stability of sirolimus and everolimus measured by immunoassay techniques in whole blood samples from kidney transplant patients

The measurement of blood concentration of immunosuppressive drugs is strongly recommended because of the narrow therapeutic range. An important aspect in the therapeutic monitoring of a drug is its possible degradation. This paper is aimed at investigating the stability of two widely-used immunosuppressants, sirolimus and everolimus. Short (storage at 30 degrees C for 3 or 7 days) and long term (storage at -20 degrees C for 0-90 days with a single freeze-thaw cycle) stability of sirolimus and everolimus in whole blood samples from kidney transplant patients were examined by using MEIA and FPIA. Sirolimus and everolimus samples stored at 30 degrees C in light for up to a week showed a decrement in concentration of 5.2 percent and 6.1 percent, respectively. Our findings on long term stability for both sirolimus and everolimus highlight the possibility of storing samples at -20 degrees C for up to 90 days, without the need to use lower storage temperatures. The results have important implications for patients living far from laboratories where drug concentration is measured or when the storing of blood samples is needed for pharmacokinetic studies.