The role of infiltrating lymphocytes in the neo-adjuvant treatment of women with HER2-positive breast cancer

Background

Pre-treatment tumour-associated lymphocytes (TILs) and stromal lymphocytes (SLs) are independent predictive markers of future pathological complete response (pCR) in HER2-positive breast cancer. Whilst studies have correlated baseline lymphocyte levels with subsequent pCR, few have studied the impact of neoadjuvant therapy on the immune environment.

Methods

We performed TIL analysis and T-cell analysis by IHC on the pretreatment and ‘On-treatment’ samples from patients recruited on the Phase-II TCHL (NCT01485926) clinical trial. Data were analysed using the Wilcoxon signed-rank test and the Spearman rank correlation.

Results

In our sample cohort (n = 66), patients who achieved a pCR at surgery, post-chemotherapy, had significantly higher counts of TILs (p = 0.05) but not SLs (p = 0.08) in their pre-treatment tumour samples. Patients who achieved a subsequent pCR after completing neo-adjuvant chemotherapy had significantly higher SLs (p = 9.09 × 10^–3) but not TILs (p = 0.1) in their ‘On-treatment’ tumour biopsies. In a small cohort of samples (n = 16), infiltrating lymphocyte counts increased after 1 cycle of neo-adjuvant chemotherapy only in those tumours of patients who did not achieve a subsequent pCR. Finally, reduced CD3 + (p = 0.04, rho = 0.60) and CD4 + (p = 0.01, rho = 0.72) T-cell counts in 'On-treatment' biopsies were associated with decreased residual tumour content post-1 cycle of treatment; the latter being significantly associated with increased likelihood of subsequent pCR (p < 0.01).

Conclusions

The immune system may be ‘primed’ prior to neoadjuvant treatment in those patients who subsequently achieve a pCR. In those patients who achieve a pCR, their immune response may return to baseline after only 1 cycle of treatment. However, in those who did not achieve a pCR, neo-adjuvant treatment may stimulate lymphocyte influx into the tumour.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06244-1.

Tools to Promote Shared Decision-Making in Lung Cancer Screening Using Low-Dose CT Scanning: A Systematic Review

BACKGROUND

Decisions about lung cancer screening are inherently complex and create a need for methods to convey the risks and benefits of screening to patients.

RESEARCH QUESTION

What kind of decision aids or tools are available to support shared decision-making for lung cancer screening? What is the current evidence for the effectiveness, acceptability, and feasibility of those tools?

STUDY DESIGN AND METHODS

We conducted a systematic review of studies and searched PubMed, MEDLINE, EMBASE, Cochrane Clinical Trials Register, and ClinicalTrials.gov from inception to December 2019 for studies that evaluated the effectiveness and acceptability of tools to promote shared decision-making for patients who are considering lung cancer screening.

RESULTS

After screening 2,427 records, we included one randomized control trial, two observational studies, 11 before/after studies of a decision aid or an educational tool. Fifteen distinct tools in various formats were evaluated in 14 studies. Most studies were of fair quality. Studies reported improvement in patients' knowledge of lung cancer screening (n = 9 studies), but improvements in specific areas of knowledge were inconsistent. Decisional conflict was low or reduced after the administration of the tools (n = 7 studies). The acceptability of tools was rated as "high" by patients (n = 7 studies) and physicians (n = 1 study). Low dose CT scan completion rates varied among studies (n = 6 studies).

INTERPRETATION

Evidence from 14 studies suggests that some elements of existing tools for lung cancer screening may help to prepare patients for decision-making by improving knowledge and reducing decisional conflict. Such tools generally are acceptable to patients and providers. Further studies that use consistent measures and reporting methods and assess relevant decisional and clinical outcomes are needed to determine the comparative effectiveness and feasibility of implementation of these tools.

CLINICAL TRIAL REGISTRATION

PROSPERO 2018 CRD4201874814.

Abstract OT3-06-01: Phase Ib clinical trial of coPANlisib in combination with Trastuzumab emtansine (T-DM1) in pre-treated unresectable locally advanced or metastatic HER2-positive breAst cancer (BC) “PANTHERA”-CTRIAL-IE 17-13

Background:The phosphoinositide 3 kinase (PI3K) pathway is important in the oncogenic function of HER2. Aberrant activation of PI3K is implicated in resistance to trastuzumab and other HER2-targeted therapies and is frequent, with up to 22% of HER2 positive breast cancer having a PIK3CA mutation. Copanlisib is a pan-class 1 PI3K inhibitor administered i.v. with low nanomolar activity against both PI3Kα and PI3Kβ. Copanlisib has been shown to re-sensitise trastuzumab resistant cell lines to trastuzumab with synergism seen in some cell lines between copanlisib and HER2 targeted therapy.

Trial design: This is a phase Ib open label, single arm adaptive, multi-centre trial of copanlisib in combination with T-DM1. Eligible patients will receive T-DM1 at 3.6mg/kg i.v. on day 1 of a 21-day cycle plus copanlisib. Copanlisib will be administered i.v. according to the dose escalation scheme (dose level 1 is 45mg on days 1 and 8, dose level 2 is 60mg on days 1 and 8, dose level 3 is 60mg on days 1, 8, and 15). Dose level -1 will be 45 mg on day 1 in case dose de-escalation is needed. We will enrol 3 to 6 patients per dose level. All patients in each level must have completed at least the first cycle of therapy before enrolment in the next dose level. Patients not completing the first cycle for a reason other than toxicity will be replaced. Dose escalation and determination of the Maximum Tolerated Dose (MTD) will be based on the occurrence of Dose Limiting Toxicities (DLT).

Eligibility criteria:Eligible patients are those with unresectable locally advanced or metastatic HER2-positive BC who previously received trastuzumab and a taxane, separately or in combination. Participants must have adequate organ function and ECOG PS ≤ 2

Objectives:The primary objective is to determine the MTD for copanlisib in combination with T-DM1 in patients with pre-treated unresectable locally advanced or metastatic HER2-positive BC. Secondary objectives include evaluating the safety, efficacy and cardiotoxicity in patients treated with this regimen. Exploratory objectives include examining for predictive biomarkers in tumour tissue and blood or plasma and to examine molecular tumour adaptation to clinical trial therapy.

Statistical methods: Patients will be accrued in cohorts of 3 patients according to a standard 3+3 algorithm, with dose escalation and determination of MTD based on the occurrence of DLT, using the usual threshold probability of 33%. The final dose level will be expanded to include a total of 6 additional patients (expansion cohort).

Present accrual and target accrual:The trial will start accrual in October 2018. Maximum of 24 patients will be enrolled.

Citation Format: Hassan A, Gullo G, O'Reilly S, Ruiz-Borrego M, Toomey S, Grogan L, Breathnach O, Morris PG, Walshe JM, Crown J, O'Mahony D, Falcon A, Egan K, Hernando A, Teiserskiene A, Kelly CM, Coate L, Hennessy BT. Phase Ib clinical trial of coPANlisib in combination with Trastuzumab emtansine (T-DM1) in pre-treated unresectable locally advanced or metastatic HER2-positive breAst cancer (BC) “PANTHERA”-CTRIAL-IE 17-13 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT3-06-01.

Recombinant PAPP-A resistant insulin-like growth factor binding protein 4 (dBP4) inhibits angiogenesis and metastasis in a murine model of breast cancer

BACKGROUND

The Insulin-like growth factor (IGF) pathway plays a role in tumour development and progression. In vivo, IGF1 activity is regulated by the IGF binding proteins (IGFBPs). IGFBP4 inhibits the activity of IGF1 but proteolytic cleavage by pregnancy-associated plasma protein-A (PAPP-A) releases active IGF1. A modified IGFBP4, dBP4, which was resistant to PAPP-A cleavage but retained IGF1 binding capacity, was engineered, expressed in Human Embryonic Kidney (HEK) 293 cells and purified. This study examined the effects of dBP4 on IGF1-induced cell migration, invasion and angiogenesis in vitro. The effect of intra-tumour injections of dBP4 on tumour angiogenesis and metastasis was examined using the 4T1.2luc orthotopic model of breast cancer.

METHODS

PAPP-A resistance and IGF binding capacity of dBP4 were characterized by Western blot and surface plasmon resonance, respectively. 4T1.2luc are mouse mammary adenocarcinoma cells transfected with luciferase to allow in vivo imaging. The effect of dBP4 on IGF1-induced Akt activation in 4T1.2luc cells was assessed by Western blot. Cell migration and invasion assays were performed using 4T1.2luc cells. Angiokit™ assays and Matrigel® implants were used to assess the effects of dBP4 on angiogenesis in vitro and in vivo, respectively. An orthotopic breast cancer model - 4T1.2luc cells implanted in the mammary fat pad of BALB/c mice - was used to assess the effect of intra tumour injection of purified dBP4 on tumour angiogenesis and metastasis. Tumour growth and lung metastasis were examined by in vivo imaging and tumour angiogenesis was evaluated by CD31 immunohistochemistry.

RESULTS

Our engineered, PAPP-A resistant IGFBP4 (dBP4) retained IGF1 binding capacity and inhibited IGF1 activation of Akt as well as IGF1-induced migration and invasion by 4T1.2 mammary adenocarcinoma cells. dBP4 inhibited IGF1-induced angiogenesis in vitro and in Matrigel implants in vivo. Direct intra-tumour injection of soluble dBP4 reduced angiogenesis in 4T1.2 luc mammary tumours tumour and reduced lung metastasis.

CONCLUSION

A PAPP-A resistant IGFBP4, dBP4, inhibits angiogenesis and metastasis in 4T1.2 mammary fat pad tumours. This study highlights the therapeutic potential of dBP4 as an approach to block the tumour-promoting actions of IGF1.

Abstract P5-11-03: Tumor CXCL16/CXCR6 expression and soluble CXCL16 in HER2+ breast cancer (BC)

Background: CXCL16 is a pro-inflammatory chemokine associated with chemotaxis of CXCR6-expressing lymphocytes (T cells, NKT cells, NK cells) and the promotion of breast cancer cell proliferation, migration, and invasion in vitro. CXCL16 exists in a transmembrane or a cleaved, soluble form. There is limited clinically relevant data available on the CXCL16/CXCR6 signaling axis in HER2+ BC. This preliminary study examines tumor CXCL16 and CXCR6 mRNA expression and patient outcome in publicly available datasets and examines soluble CXCL16 in the plasma of 32 HER2+ BC patients enrolled in ICORG 10-05 (neo-adjuvant chemotherapy (docetaxel/carboplatin) +/- trastuzumab, lapatinib or trastuzumab/lapatinib).

Methods: CXCL16 and CXCR6 mRNA expression was interrogated in publicly available datasets using BreastMark, a web-based tool for preliminary assessment of putative biomarkers in breast cancer.A median cut-off was used for all analyses. Pre-treatment and post-treatment (2 weeks pre-surgery) blood samples were collected from patients enrolled in ICORG 10-05. Plasma CXCL16 levels were determined by Luminex xMAP assay. Pre- and post-treatment levels of CXCL16 were compared directly or based on response (pathological complete response, CR, n=14 or non-pathological complete response, nCR, n=18). Stromal lymphocyte (SL) and tumor-infiltrating lymphocyte (TIL) levels were determined from Haematoxylin and Eosin-, AE1/AE3- and CD45FFPE- stained formalin-fixed paraffin embedded tissue. Pre-treatment lymphocyte levels were correlated with pre- and post-treatment levels of CXCL16 (Pearson's product-moment correlation).

Results: In BC as a whole, analysis of publicly available datasets reveals tumor CXCL16 expression is not associated with outcome (n=1238, HR=0.9953, p=0.9516) but high tumor CXCR6 expression is (n=2652, HR=1.127, p=0.0476). Within a HER2+ cohort, inverse correlative analysis suggests high CXCR6/low CXCL16 tumor expression is significantly associated with a worse outcome (n=61, HR=2.731, p=0.01). For ICORG 10-05 patients, circulating CXCL16 plasma levels were significantly higher post-treatment (p&lt;0.0001). The magnitude of this increase was significantly greater in CR than nCR patients (p&lt;0.009). Post-treatment circulating CXCL16 levels negatively correlate with pre-treatment total (SL+TIL) lymphocyte counts (correlation coefficient -0.50 (CI -0.75- -0.13), p=0.01) in ICORG 10-05 patients. SL and total lymphocyte (SL+TIL) counts were higher in CR (n=13) vs. nCR (n=13) patients but the difference was not significant (SL, p=0.22; SL+TIL, p=0.29).

Conclusions: Our preliminary results suggest tumor levels of CXCL16/CXCR6 are associated with patient outcome and circulating levels of soluble CXCL16 are altered by treatment and correlate with tumor immune infiltrate in HER2+ BC patients. Further examination of tumor CXCL16/CXCR6 expression and circulating CXCL16 as potential biomarkers of response is warranted in a larger cohort of HER2+ BC patients.

Citation Format: Collins DM, Madden SF, Eustace AJ, Toomey S, Kay EW, Fay J, O'Donovan N, Gallagher WM, Hennessy B, Crown J. Tumor CXCL16/CXCR6 expression and soluble CXCL16 in HER2+ breast cancer (BC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-11-03.

Abstract OT3-06-05: A phase Ib/II trial of coPANlisib in combination with tratuzumab in pretreated recurrent or metastatic HER2-positive breast cancer “PantHER”

Background

The phosphoinositide 3 kinase (PI3K) pathway is important in the oncogenic function of HER2. Aberrent activation of PI3K is implicated in resistance to trastuzumab and other HER2-targeted therapies and is frequent, with up to 22% of HER2 positive breast cancer having a PIK3CA mutation. Copanlisib is a pan-class 1 PI3K inhibitor that shows particular activity against PI3Kα, the isoform encoded by the PIK3CA gene. Copanlisib has been shown to re-sensitise trastuzumab resistant cell lines to trastuzumab with synergism seen in some cell lines between copanlisib and HER2 targeted therapy.

Trial design

The study is a phase Ib/II open label, single arm adaptive, multi-centre trial of copanlisib in combination with trastuzumab. Eligible patients are treated with a dose escalation schedule of copanlisib IV on Days 1, 8 and 15 of a 28 day cycle with trastuzumab 2 mg/kg weekly (loading dose of 4 mg/kg in cycle 1). The phase II dose will be based on the maximum tolerated dose (MTD) established in Phase Ib. Patients are treated until radiologic or symptomatic progression, unacceptable toxicity, consent withdrawal or physician's decision.

Eligibility criteria

Eligible patients must have recurrent incurable or metastatic HER2-positive breast cancer that has progressed on at least one prior line of trastuzumab or T-DM1-based treatment regimen in this setting. Patients with treated and controlled brain metastases are eligible. Participants must have adequate organ function and ECOG PS ≤ 2. Patients recruited for the Phase II part of the study must have a PIK3CA mutation. Patients with uncontrolled arterial hypertension, uncontrolled diabetes or recent clinically serious infections are excluded.

Specific aims

The primary end point for the phase Ib part of this study is to determine the MTD for the combination. For the phase II study is anti-tumour efficacy, measured by Clinical Benefit Rate (CBR).

Secondary end points are evaluation of safety and tolerability, progression-free survival, time to treatment failure, duration of response and overall survival. Incorporated translational endpoints include examination of molecular tumor adaptation in tissue and blood. Given the role of PI3K in cellular glucose metabolism, an additional exploratory objective is to determine if quantitive reduction in metabolic signal on Positron Emission Tomography-Computed Tomography (PET-CT) is predictive of benefit from therapy.

Statistical methods

To establish the MTD, we use a modified 3+3 design where 3 additional patients will be accrued even if the first 3 patients accrued experience no dose limiting toxicities (DLT) in sequential cohorts for a planned 12 patients. To determine the CBR, a one sample exact binomial test with a one sided significance level of 5%, 19 evaluable patients will provide &gt;80% power to detect a difference between the null hypothesis proportion of 30% for CBR versus the alternative hypothesis proportion of 65%.

Present accrual and target accrual

There are 9 patients recruited so far to the phase Ib part of this study. Target accrual is 12 and for phase II is 19 patients.

Contact information for people with a specific interest in the trial

Prof Bryan Hennessy, Beaumont Hospital, Dublin Ireland

Funded by Bayer

Citation Format: Keegan NM, Walshe J, Gullo G, Kennedy J, Bulger K, Kelly CM, Crown J, Toomey S, Egan K, Kerr J, Given M, Hernando A, Teiserskiene A, Grogan L, Breathnach O, Morris PG, Keane M, Hennessy BT. A phase Ib/II trial of coPANlisib in combination with tratuzumab in pretreated recurrent or metastatic HER2-positive breast cancer “PantHER” [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-06-05.

Stoichiometry and Change of the mRNA Closed-Loop Factors as Translating Ribosomes Transit from Initiation to Elongation

Protein synthesis is a highly efficient process and is under exacting control. Yet, the actual abundance of translation factors present in translating complexes and how these abundances change during the transit of a ribosome across an mRNA remains unknown. Using analytical ultracentrifugation with fluorescent detection we have determined the stoichiometry of the closed-loop translation factors for translating ribosomes. A variety of pools of translating polysomes and monosomes were identified, each containing different abundances of the closed-loop factors eIF4E, eIF4G, and PAB1 and that of the translational repressor, SBP1. We establish that closed-loop factors eIF4E/eIF4G dissociated both as ribosomes transited polyadenylated mRNA from initiation to elongation and as translation changed from the polysomal to monosomal state prior to cessation of translation. eIF4G was found to particularly dissociate from polyadenylated mRNA as polysomes moved to the monosomal state, suggesting an active role for translational repressors in this process. Consistent with this suggestion, translating complexes generally did not simultaneously contain eIF4E/eIF4G and SBP1, implying mutual exclusivity in such complexes. For substantially deadenylated mRNA, however, a second type of closed-loop structure was identified that contained just eIF4E and eIF4G. More than one eIF4G molecule per polysome appeared to be present in these complexes, supporting the importance of eIF4G interactions with the mRNA independent of PAB1. These latter closed-loop structures, which were particularly stable in polysomes, may be playing specific roles in both normal and disease states for specific mRNA that are deadenylated and/or lacking PAB1. These analyses establish a dynamic snapshot of molecular abundance changes during ribosomal transit across an mRNA in what are likely to be critical targets of regulation.

BCL2 protein signalling determines acute responses to neoadjuvant chemoradiotherapy in rectal cancer

In locally advanced rectal cancer, neoadjuvant chemoradiotherapy is performed prior to surgery to downstage the tumour. Thirty to 40 % of patients do not respond. Defects in apoptotic machinery lead to therapy resistance; however, to date, no study quantitatively assessed whether B cell lymphoma 2 (BCL2)-dependent regulation of mitochondrial apoptosis, effector caspase activation downstream of mitochondria or a combination of both predicts patient responses. In a cohort of 20 rectal cancer patients, we performed protein profiling of tumour tissue and employed validated ordinary differential equation-based systems models of apoptosis signalling to calculate the ability of cancer cells to undergo apoptosis. Model outputs were compared to clinical responses. Systems modelling of BCL2-signalling predicted patients in the poor response group (p = 0.0049). Systems modelling also demonstrated that rectal cancers depended on BCL2 rather than B cell lymphoma-extra large (BCL(X)L) or myeloid cell leukemia 1 (MCL1) for survival, suggesting that poor responders may benefit from therapy with selective BCL2 antagonists. Dynamic modelling of effector caspase activation could not stratify patients with poor response and did not further improve predictive power. We deliver a powerful patient stratification tool identifying patients who will likely not benefit from neoadjuvant chemoradiotherapy and should be prioritised for surgical resection or treatment with BCL2 antagonists.

KEY MESSAGES

Modelling BCL2-family proteins identifies patients unresponsive to therapy. Caspase activation downstream of mitochondria cannot identify these patients. Rectal tumours of poor responders are BCL2- but not BCL-XL-dependent. DR_MOMP allows clinicians to identify patients who would not benefit from therapy. DR_MOMP is also a useful patient stratification tool for BCL2 antagonists.

Use of the novel technique of analytical ultracentrifugation with fluorescence detection system identifies a 77S monosomal translation complex

A fundamental problem in proteomics is the identification of protein complexes and their components. We have used analytical ultracentrifugation with a fluorescence detection system (AU-FDS) to precisely and rapidly identify translation complexes in the yeast Saccharomyces cerevisiae. Following a one-step affinity purification of either poly(A)-binding protein (PAB1) or the large ribosomal subunit protein RPL25A in conjunction with GFP-tagged yeast proteins/RNAs, we have detected a 77S translation complex that contains the 80S ribosome, mRNA, and components of the closed-loop structure, eIF4E, eIF4G, and PAB1. This 77S structure, not readily observed previously, is consistent with the monosomal translation complex. The 77S complex abundance decreased with translational defects and following the stress of glucose deprivation that causes translational stoppage. By quantitating the abundance of the 77S complex in response to different stress conditions that block translation initiation, we observed that the stress of glucose deprivation affected translation initiation primarily by operating through a pathway involving the mRNA cap binding protein eIF4E whereas amino acid deprivation, as previously known, acted through the 43S complex. High salt conditions (1M KCl) and robust heat shock acted at other steps. The presumed sites of translational blockage caused by these stresses coincided with the types of stress granules, if any, which are subsequently formed.

Regression of pre-established atherosclerosis in the apoE−/− mouse by conjugated linoleic acid

Conjugated linoleic acid (CLA) refers to a group of positional and geometric isomers of linoleic acid that has been shown to suppress the development of atherosclerosis in a rabbit model. We investigated whether CLA acts as a cyclo-oxygenase (COX) inhibitor or as an agonist of the peroxisome-proliferator-activator receptor (PPAR) γ in the ApoE−/− mouse model. In vitro, a 9-cis, 11-trans isomer of CLA inhibited prostaglandin formation and oxygen consumption by both isoforms of COX, with no evidence by MS of alternative products being generated. In vivo, supplementation with CLA was found to induce resolution of atherosclerosis. The effect of CLA in vivo could not be explained by COX inhibition alone, as urinary prostaglandin levels were unchanged in animals receiving CLA supplementation, and administration of selective COX inhibitors did not induce lesion regression. There was however induction of PPARγ, a known response to agonists of this nuclear orphan receptor.

Reactivity and isotype profiling of monoclonal antibodies using multiple antigenic peptides

The characterisation of monoclonal antibodies (MAbs) is essential for the development of assay systems particularly where antigens have been developed using synthetic peptides. Indeed some peptide-carrier conjugates fail to induce immune responses and may not generate antibodies that bind to native protein. As an alternative to peptide-carrier conjugates, multiple antigenic peptides (MAPs) have been used for immunization strategies, but with little regard to the characteristics of the MAbs produced. In this study, we used 3 MAPs of Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) to immunise BALB/c mice. Overall, the polyclonal antibody responses from tail bleeds showed that MAPs evoked B-cell responses. However, on screening 144 hybridomas, 24 MAb supernatants exhibited weak to moderate reactivity in enzyme-linked immunosorbant assay (ELISA) and against cell cytospin preparations (B95.8 and AG876 LCL), respectively. Isotype profiling of hybridoma supernatants also showed that 11 out of 24 were IgM. Further characterization of 6 MAbs in Western blotting showed reactivity to recombinant LMP1 and only one MAb (B28D) showed weak reactivity to the malignant cells (Hodgkin/Reed-Sternberg; HRS cells) of an EBV+ Hodgkin's lymphoma using paraffin-embedded tissue. It is probable that these MAPs failed to augment T-cell help and contributed to the production of low affinity (IgM) antibodies. These observations may be of importance to future immunization strategies, where MAPs are used in the production of monoclonal reagents.

Ambient solar UVR, personal exposure and protection

Ambient solar ultraviolet radiation (UVR) has been monitored around Australia by the Australian Radiation Laboratory (ARL) and its successor ARPANSA since the mid 1980's using a network of radiometric detectors and a spectroradiometer (SRM) for spectral measurements, based in Melbourne. In a continent the size of Australia, the levels vary markedly, basically following a latitude gradient increasing towards the equator but with local geographical and weather effects also evident. ARL also conducts personal exposure studies of various population groups in collaboration with other research centres to gather information on what fraction of the ambient UVR people receive. ARL also undertakes studies on the UVR protection provided by sunscreens, clothing, hats, sunglasses and other materials in an attempt to improve UVR protection used by the public.

Working parents: what factors are involved in their ability to take time off from work when their children are sick?

BACKGROUND

A series of studies has demonstrated that sick children fare better when their parents are present.

OBJECTIVE

To examine working conditions that determine whether parents can spend time with and become involved in the care of their children when they are sick.

DESIGN

Survey with a multivariate analysis of factors influencing parental care of sick children.

PARTICIPANTS

Mixed-income urban working parents aged 26 to 29 years participating in the Baltimore Parenthood Study.

RESULTS

Only 42% of working parents in our sample cared for their young children when they became sick. A multivariate logistic regression analysis was conducted to predict which parents stayed at home when their children were sick. Those parents who had either paid sick or vacation leave were 5.2 times as likely to care for their children themselves when they were sick. Of parents with less than a high school education, 17% received paid leave, compared with 57% of parents with a general equivalency diploma, 76% of parents with a high school diploma, and 92% of parents with more than a high school education (P<.001).

CONCLUSIONS

The finding that many parents were unable to care for their sick children themselves is important for pediatric care. While low-income children are more likely to face marked health problems and to be in need of parental care, they are more likely to live in households in which parents lack paid leave and cannot afford to take unpaid leave.

The measurement of solar ultraviolet radiation

High skin cancer rates, stratospheric ozone depletion and increased public interest and concern have resulted in a strong demand for solar ultraviolet radiation measurements and information. The Australian Radiation Laboratory (ARL) has been involved since the mid-1980s in the measurement of solar ultraviolet radiation (UVR) using spectroradiometers (SRM) and a network of broadband detectors at 18 sites in Australia and Antarctica and in Singapore through a collaborative agreement with the Singapore Institute of Science and Forensic Medicine. Measurement locations range from equatorial (Singapore, 1.3 degrees N) through tropical (Darwin, 12.4 degrees S) to polar (Mawson, 67.6 degrees S) and as a result there are many difficulties associated with maintenance and calibration of the network detectors, and transfer of data to ensure an accurate and reliable data collection. Calibration procedures for the various detectors involve the comparison with simultaneous spectral measurements using a portable SRM incorporating a double monochromator, calibrated against traceable standard lamps. Laboratory measurements of cosine response and responsivity are also made. Detectors are intercompared at the Yallambie site for a number of months before installation at another location. As an additional check on the calibrations, computer models of solar UVR at the earth's surface for days with clear sky and known ozone are compared with the UV radiometer measurements.

Protection against solar ultraviolet radiation

Interest in protection against solar ultraviolet radiation (UVR) among the general public in Australia has been increasing steadily as a result of the 'SunSmart' campaigns run by the various state cancer councils. This increasing awareness is due in part to the requirements for occupational protection of outdoor workers and to provision of UVR protection for the recreational market. Behaviour outdoors can significantly affect exposure to solar UVR and use of items of personal protection can provide a substantial reduction in the UVR dose received. The protective properties of sunscreens, sunglasses, hats and clothing against UVR have been the subject of considerable research for some time, and over the last few years interest has extended to the provision of shade structures and the UVR protection provided by various commonly used materials. These materials include shadecloth, plastics, glass, windscreens and applicable tints. Australia has rigorous standards covering protection and UVR, in particular for sunscreens [Standards Australia/Standards New Zealand, Sunscreen products-evaluation and classification, Report No. AS 2604, Sydney/Wellington, 1993.], sunglasses [Standards Australia, Sunglasses and fashion spectacles-nonprescription types, Report No. AS 1067.1, Sydney, 1990.], protective eyewear [Standards Australia/Standards New Zealand, Eye protectors for industrial applications, Report No. AS/NZS 1337, Sydney/Wellington, 1992.] and shadecloth [Standards Australia, Synthetic shadecloth, Report No. AS 4174, Sydney, 1994.]. Compliance with the sunglass standard became mandatory in 1988 and UVR protection provided by sunglasses has increased substantially since then. In July 1996 a standard on 'sun protective textiles' [Standards Australia/Standards New Zealand, Sun protective clothing-evaluation and classification, Report No. AS/NZS 4399, Sydney, 1996.] incorporating ultraviolet protection factors (UPFs) and a rating scheme with protection categories, was introduced; this was the first of its kind in the world. Australian Radiation Laboratory (ARL) UPF swing tags with UVR protection advice from the Australian Cancer Society on the reverse side are used to denote the amount of protection against solar UVR provided by clothing. To date in excess of 5 million ARL swing tags have been issued. Work on the various standards is continuing. The maximum allowed 'sun protection factor' (SPF) limit for sunscreens may be increased to SPF 30 + in the near future, and additions to the sun protective textiles standard are also planned. This paper discusses measurement methods, results, the rationale used in formulating the Australian Standards and the current state of UVR protection in Australia.

Solar UVR exposures of primary school children at three locations in Queensland

The ultraviolet radiation (UVR) exposures of primary school children in Brisbane, Toowoomba and Mackay (latitudes 27 degrees 30', 27 degrees 33' and 21 degrees 15' south, respectively) were assessed over a period of 2 weeks at each location using UVR-sensitive polysulfone (PS) film badges attached at the shoulder. The students filled in questionnaires on their time spent outdoors for each day of the study. These data in conjunction with the ambient UVR measured by a detector/datalogger unit at each site were used to correlate the calculated exposures with those measured using the PS badges. Overall, the questionnaires indicated that the males spent more time outdoors and had higher measured UVR exposures than females. For both boys and girls at each location, there was a strong correlation between the mean measured UVR exposure and the ambient solar UVR at that location.

Posterior instrumentation of the unstable cervicothoracic spine

Fractures, tumors, and other causes of instability at the cervicothoracic junction pose diagnostic and treatment challenges. The authors report on 23 patients with instability of the cervicothoracic region, which was treated with posterior plate fixation and fusion between the lower cervical and upper thoracic spine. During operation AO reconstruction plates with 8- or 12-mm hole spacing were affixed to the spine using screws in the cervical lateral masses and the thoracic pedicles. Postoperative immobilization consisted of the patient's wearing a simple external brace for 2 months. The following parameters were analyzed during the pre- and postoperative treatment period: neurological status, spine anatomy and reconstruction, and complications. Follow up consisted of clinical and radiographic examinations (mean duration of follow up, 15.4 months; range, 6-41 months). No neurovascular or pulmonary complications arose from surgery. All patients achieved a solid arthrodesis based on flexion-extension radiographs. There was no significant change in angulation during the postoperative period, but one patient had an increase in translation that was not clinically significant. There were no hardware complications that required reoperation. One patient requested hardware removal in hopes of reducing postoperative pain in the cervicothoracic region. One postoperative wound infection required debridement but not hardware removal. The authors conclude that posterior plate fixation is a satisfactory method of treatment of cervicothoracic instability.

Cortical bone perfusion in plated fractured sheep tibiae

The limited contact dynamic compression plate and partial contact plate were designed to decrease contact with cortical bone in an attempt to decrease cortical ischemia, remodeling, and eventual porosis under the plate after use of standard dynamic compression plates. This study quantified cortical bone blood flow beneath the plate with these three different designs in a sheep tibia fracture model. In 18 skeletally immature sheep, the right tibia was fractured and then was internally fixed with an interfragmentary screw and a dynamic compression plate, limited contact dynamic compression plate, or partial contact plate. At 12 weeks, cortical bone perfusion was assessed with laser Doppler flowmetry in nine areas beneath the plate. The baseline (before fracture) cortical bone cell flux averaged 100 +/- 60 mV. After fracture, this decreased to 60 +/- 48 mV (p < 0.0003); immediately after plating, the perfusion averaged 29 +/- 25 mV (p < 0.01). Cortical bone perfusion then increased to 106 +/- 52, 165 +/- 71, and 163 +/- 71 mV at 2, 6, and 12 weeks after fracture (p < 0.001 for all when compared with values after plating). No significant differences in cortical perfusion were seen between the types of plate. Cortical porosity under the plate was assessed with digital density analysis of microradiographs of this region. No significant difference was seen between the types of plate in this analysis or in biomechanical and disulphine blue perfusion analysis. Thus, no significant advantage was seen for the new plate designs used in this model. This lack of advantage may be a result of the immature animals used in the study, the protocol for blood flow measurement, the invasive periosteal stripping employed to create the fracture, or all three. However, as advantages with the new plate designs have been seen in other studies, this area warrants further investigation.

Modulation of the functions of dengue virus-specific human CD8+ cytotoxic T cell clone by IL-2, IL-7 and IFN gamma

Lymphokines play an important role in immune responses to viruses by modulating functions of T lymphocytes. In the present study, we examined the effects of interleukin-2 (IL-2), interleukin-4 (IL-4), interleukin-6 (IL-6), interleukin-7 (IL-7), and interferon gamma (IFN gamma) on proliferation, cytotoxic activity and lymphokine production of a dengue virus-specific CD8+ human cytotoxic T lymphocyte (CTL) clone. IL-2 and IL-7 induced proliferation of the CD8+ CTL clone in the presence or absence of specific antigen, while IFN gamma suppressed proliferation of the clone. IL-7 and IFN gamma augmented dengue virus-specific cytotoxic activity without inducing non-specific cytotoxic activity, and IL-2 induced non-specific cytotoxic activity. IL-2 induced IFN gamma production by the CD8+ CTL clone. IL-4 and IL-6 did not modulate the functions of the CD8+ CTL clone in these experimental conditions. These results suggest that functions of dengue virus-specific CD8+ CTL are modulated by IL-2, IL-7 and IFN gamma, and that IL-7 is a lymphokine useful to induce growth and to maintain specific cytotoxic activity of CD8+ CTL clones in vitro.

UV-B radiometry and dosimetry for solar measurements

Biologically effective irradiance or dose of solar UV radiation was determined using a spectroradiometer, two broadband radiometers and two types of passive UV-dosimeters. The absolute erythema irradiance and the actinic irradiance were calculated from the solar spectrum measured with the spectroradiometer. It was demonstrated that the erythema irradiance is proportional to the actinic irradiance of solar radiation. The erythema irradiance was also determined using the two broadband radiometers which utilize a filter transmitting erythema spectra. Personal UV-dosimeters such as polysulphone and CR-39 were used to determine the erythema dose for a selected period of time. These results were used to estimate the accuracy of the broadband radiometers and UV-dosimeters. It was found that the results obtained from the broadband radiometers deviate from the absolute erythema irradiance by less than 20% during clear days between the hours of 11:00 and 13:00 Eastern Standard Time (EST) in Australia. The assessment of the erythema dose using passive dosimeters such as polysulphone and CR-39 could introduce an error as high as 40% if the calibration was not performed before undertaking experimental measurements.

Increased expression of the multidrug resistance-associated protein gene in relapsed acute leukemia

Quantitative reverse transcriptase polymerase chain reaction (RT-PCR) was used to determine relative levels of transcripts for MDR1 and the recently described multidrug resistance-associated protein (MRP) in normal lymphohematopoietic cells and in 62 bone marrow aspirates of newly diagnosed and recurrent acute leukemia. Levels of MRP expression in newly diagnosed AML samples were similar to those observed in normal bone marrow cells (CD34-negative and CD34-positive) and in unselected HL60 human promyelocytic leukemia cells, which were used as an internal control throughout this study. In contrast, samples of AML obtained at the time of relapse contained approximately twofold higher levels of MRP RNA (P < .01). Analysis of paired samples, the first obtained at diagnosis and the second at relapse, from 13 acute myelogenous leukemia (AML) and four acute lymphocytic leukemia (ALL) patients showed that MRP expression was increased at the time of relapse in greater than 80% of patients. In contrast, no consistent changes of MDR1 expression at relapse were observed. These results raise the possibility that increased MRP expression might contribute to leukemic relapse.