Molecular Subtypes and Outcomes in a Multi-Institutional Review of Rectal Cancer Patients

PURPOSE/OBJECTIVE(S)

Colorectal cancer (CRC) is a heterogeneous malignancy associated with a variety of genetic mutations. More recent data indicates that CRC can be broken down into unique biologically distinct consensus molecular subtypes (CMS) based on different pathological and genetic signatures. The purpose of this study is to evaluate the outcomes of rectal cancer patients in a multi-institutional network based on tumor mutational assessment and CMS group.

MATERIALS/METHODS

Patient exome and transcriptome sequencing data and clinical outcomes were collected under the Total Cancer Care Protocol and Avatar® project within the Oncology Research Information Exchange Network (ORIEN). A total of 101 patients with demographic and outcomes information had data for microsatellite instability (MSI), tumor mutation burden (TMB), transcriptome, and whole exome sequencing (WES). Molecular subclasses (CMS1, CMS2, CMS3, CMS4, CMS-Mixed) were assigned based on transcriptional signatures by the R package "CMS Caller." Survival analysis was performed with the R packages "Survival" and "Survminer."

RESULTS

A total of 101 rectal cancer patients, with a median age of 56.8, had a median follow up of 3.5 years (range 0.26-23.5). 78 patients were treated with curative intent for clinically localized disease and 35% of these patients developed metastatic disease. The remaining 23 patients had synchronous metastatic disease at presentation. There were 5 (5%) CMS1, 29 (29%) CMS2, 13 (13%) CMS 3, 49 (49%) CMS 4, and 5 (5%) CMS-Mixed patients in our cohort respectively. The cohort included 5 (5%) BRAF, 51 (50%) KRAS, and 63 (62%) TP53 mutated patients and 5 (5%) MSI high patients. Median survival was 18.8, 117.2, 125.7 and 119 months for CMS1, CMS2, CMS3, and CMS4 patients respectively, with insufficient events in CMS-mixed for calculation (p = 0.15). CMS1 patients had a significantly shorter survival compared to the other cohorts (p = 0.02), with 2 of 5 of these patients having received immunotherapy. 40% (2,0) CMS1, 52% (7,8) of CMS2, 15% (1,1) of CMS3, 59% (13,15) of CMS4, and 40% (1,1) of CMS-Mixed presented with or developed metastatic disease respectively. When divided into mutation groups, median survival was 43 versus 119, 119 versus 117, and 126 versus 119 months for BRAF, KRAS, and TP53 mutated and wild type patients respectively (p = 0.18, p = 0.48, p = 0.93). Evaluation of TMB and MSI status did not reveal significant differences in outcomes (p = 0.54, p = 0.7), with median survival of 126 months versus 117 in TMB high versus low patients and unreached versus 119 months in MSI versus MSS patients respectively. Of note, 3 of the 5 MSI patients were also CMS1, with the other two coming from CMS4 and CMS-mixed cohorts.

CONCLUSION

CMS classification and tumor mutation status are associated with differential outcomes for rectal cancer patients, with some groups having a large likelihood of developing metastatic disease. Further work on optimizing and personalizing treatments for these high-risk populations is necessary.

Outcomes associated with treatment to all sites of disease in patients with stage IVB cancer of the cervix

OBJECTIVE

The use of chemoradiation in patients with stage IVB cancer of the cervix was evaluated to determine if definitive treatment offers benefit.

METHODS

A database of 546 patients with cancer of the cervix treated between January 2005 and May 2021 at a tertiary academic medical center was reviewed retrospectively to identify patients with stage IVB disease. Log rank test, regression analysis, and the Kaplan-Meier method were used to identify and compare variables and estimate progression free survival and overall survival.

RESULTS

Thirty-three patients with stage IVB cervical cancer were identified. Median age was 53 years (range 28-78). Pathology subtypes were squamous cell (n=22, 67%), adenocarcinoma (n=8, 24%), and clear cell (n=3, 9%). Metastases were classified as lymphatic (n=14, 42%) or hematogenous (n=19, 58%). Following treatment to all sites with chemoradiotherapy and selected use of surgery (n=23), six patients (26%, lymphatic n=4, hematogenous n=2) remained disease free for a median duration of 4 years (range 3-17 years). Recurrences in the remaining patients were distant (n=13) or local (n=4). All patients in the chemotherapy group (n=10, 100%) progressed. Kaplan-Meier analysis showed that median progression free survival was longer for patients treated at all disease sites than for patients treated with chemotherapy alone (19 vs 11 months, p=0.01). However, this was not the case for overall survival (49 vs 33 months, p=0.15). Patients with metastases limited to lymph nodes also had longer median progression free survival (22 vs 11 months, p=0.04) but not overall survival (p=0.68).

CONCLUSIONS

Patients with stage IVB cancer of the cervix may benefit from treatment to all sites of disease, if feasible and safe, as demonstrated by improved progression free survival.

Feasibility of deploying a U.S. simulation-based gynecological brachytherapy educational workshop to an international setting

PURPOSE

A decline in brachytherapy (BT) use for cervical cancer has negatively affected cure rates in the United States and abroad. To improve trainee exposure to BT, a simulation-based educational curriculum incorporating a pelvic mannequin was developed and implemented at several U.S. residency programs. We sought to describe an initial experience with deployment of this curriculum to an international setting.

METHODS AND MATERIALS

The setting was in Israel, a middle eastern country with cervical cancer incidence of 5-8 cases per 100,000 women. Israel was selected for this pilot because of its desire to increase exposure to trainees, lack of mandatory BT case requirements, and few residencies nationally. In determining the feasibility of deployment to this setting, a partnership was formed between a U.S. and Israeli brachytherapist to understand cultural context and institutional and logistical needs. Feasibility was defined as successful completion of the workshop. Trainee comfort and knowledge with BT was assessed with preworkshop and postworkshop surveys, with changes compared.

RESULTS

The curriculum was incorporated into a 1-day course on gynecologic malignancies, with adaptation to local setting and routine. Among 15 attendees, eight were residents, from four programs. All completed the workshop. All domains assessed by the surveys improved and all respondents found the program to be helpful.

CONCLUSIONS

International deployment of the simulation-based educational BT curriculum was feasible and well-received. Further collaboration is needed to deploy and adapt the curriculum to countries of high cervical cancer incidence that could benefit from increased education.

Gastric neuroendocrine neoplasias: manifestations and comparative outcomes

Although gastric neuroendocrine neoplasias (gNEN) are an orphan disease, their incidence is rising. The heterogeneous clinical course powers the ongoing discussion of the most appropriate classification system and management. Prognostic relevance of proposed classifications was retrospectively analysed in 142 patients from a single tertiary referral centre. Baseline, management and survival data were acquired for statistical analyses. The distribution according to the clinicopathological typification was gNEN-1 (n = 86/60.6%), gNEN-2 (n = 7/4.9%), gNEN-3 (n = 24/16.9%) and gNEN-4 (n = 25/17.6%), while hypergastrinemia-associated gNEN-1 and -2 were all low-grade tumours (NET-G1/2), formerly termed sporadic gNEN-3 could be subdivided into gNEN-3 with grade 1 or 2 and gNEN-4 with grade 3 (NEC-G3). During follow-up 36 patients died (25%). The mean overall survival (OS) of all gNEN was 14.2 years. The OS differed statistically significant across all subgroups with either classification system. According to UICC 2017 TNM classification, OS differed for early and advanced stages, while WHO grading indicated poorer prognosis for NEC-G3. Cox regression analysis confirmed the independent prognostic validity of either classification system for survival. Particularly careful analysis of the clinical course of gNEN-1 (ECLomas, gastric carcinoids) confirmed their mostly benign, but recurrent and extremely slowly progressive behaviour with low risk of metastasis (7%) and an efficient long-term control by repetitive endoscopic procedures. Our study provides evidence for the validity of current classifications focusing on typing, grading and staging. These are crucial tools for risk stratification, especially to differentiate gNEN-1 as well as sporadic gNET and gNEC (gNEN-3 vs -4).

Comparative effectiveness of intensity modulated radiation therapy to 3-dimensional conformal radiation in locally advanced lung cancer: pathological and clinical outcomes

OBJECTIVE

Intensity-modulated radiotherapy (IMRT) has better normal-tissue sparing compared with 3-dimensional conformal radiation (3DCRT). We sought to assess the impact of radiation technique on pathological and clinical outcomes in locally advanced non-small cell lung cancer (LANSCLC) treated with a trimodality strategy.

METHODS

Retrospective review of LANSCLC patients treated from August 2012 to August 2018 at Sheba Medical Center, Israel. The trimodality strategy consisted of concomitant chemoradiation to 60 Gray (Gy) followed by completion surgery. The planning target volume (PTV) was defined by co-registered PET/CT. Here we compare the pathological regression, surgical margin status, local control rates (LC), disease free (DFS) and overall survival (OS) between 3DCRT and IMRT.

RESULTS

Our cohort consisted of 74 patients with mean age 62.9 years, male in 51/74 (69%), adenocarcinoma in 46/74 (62.1%), stage 3 in 59/74 (79.7%) and chemotherapy in 72/74 (97.3%). Radiation mean dose: 59.2 Gy (SD ± 3.8). Radiation technique : 3DCRT in 51/74 (68.9%), IMRT in 23/74 (31%). Other variables were similar between groups.Major pathological response (including pathological complete response or less than 10% residual tumor cells) was similar: 32/51 (62.7%) in 3DCRT and 15/23 (65.2%) in IMRT, p=0.83. Pathological complete response (pCR) rates were similar: 17/51 (33.3%) in 3DCRT and 8/23 (34.8%) in IMRT, p=0.9. Surgical margins were negative in 46/51 (90.1%) in 3DCRT vs. 17/19 (89.4%) in IMRT (p=1.0).The 2-year LC rates were 81.6% (95% CI 69-89.4%); DFS 58.3% (95% CI 45.5-69%) and 3-year OS 70% (95% CI57-80%). Comparing radiation techniques, there were no significant differences in LC (p=0.94), DFS (p=0.33) and OS (p=0.72).

CONCLUSION

When used to treat LANSCLC in the neoadjuvant setting, both IMRT and 3DCRT produce comparable pathological and clinical outcomes.

ADVANCES IN KNOWLEDGE

This study validates the real-world effectiveness of IMRT compared to 3DCRT.

Physiologic uptake of 18F-FDG in transposed ovaries may mimic metastasis on 18F-FDG PET/CT imaging

BACKGROUND

Ovarian transposition is aimed at preserving ovarian function before irradiation in pelvic malignancies. The extrapelvic location of the ovaries and their physiologic fluorine-18-fluorodeoxyglucose (F-FDG)-uptake is a potential source of misdiagnosis as metastasis on F-FDG PET/CT. We describe the F-FDG PET/CT characteristics of transposed ovaries and their changes over time.

PATIENTS AND METHODS

We reviewed F-FDG PET/CT studies of all consecutive women with pelvic malignancies who underwent ovarian transposition between 2007 and 2013. Studies were grouped according to the time period over which they were carried out. Findings were categorized by location, size, appearance (solid/mixed/cystic), presence of surgical clips, ovarian F-FDG uptake (maximum standardized uptake value), and attenuation values on CT (Hounsfield units). Group time-period differences were assessed.

RESULTS

Seventy-nine F-FDG PET/CT studies were reviewed, 30 before and 49 after transposition. Time-period groups after transposition were up to 4 months (18 studies), 4.1-12 months (n=14), and more than 12 months (n=17). After transposition, ovaries were located mainly in the paracolic gutter (n=32) and subhepatic regions (n=18). Surgical clips were present in 67%. Both ovaries appeared more solid 1 year after surgery than preoperatively (13.7% before vs. 61.3% after surgery; P<0.001). Transient F-FDG-avidity was observed in 11 ovaries. Hounsfield unit values were higher within 4 months after surgery than preoperatively, reverting thereafter to preoperative values.

CONCLUSION

After ovarian transposition, nonanatomic location, loss of cysts formation in favor of solid appearance over time, and intermittent F-FDG uptake of functioning transposed ovaries might mimic metastatic lesions. Careful interpretation of F-FDG PET/CT findings is mandatory in women with pelvic malignancies who have undergone ovarian transposition.

Stereotactic Ablative Body Radiation for Stage I Lung Cancer in Israel: A Retrospective Single-Center Report

BACKGROUND

Stereotactic ablative radiation therapy (SABR) is the application of a very high radiation dose to a small treatment volume. It is the new standard of care in medically inoperable early-stage lung cancer.

OBJECTIVES

To report the outcomes of SABR in stage I lung cancer at Sheba Medical Center since its introduction in 2009.

METHODS

We conducted a retrospective chart review of patients with stage I lung cancer treated during the period 2009-2015. Survival status was retrieved from the electronic medical records and confirmed with the national registry. Local failure was defined as increased FDG uptake on PETCT scan within a 2 cm radius of the treated region. Toxicity was estimated from medical records and graded according to common toxicity criteria for adverse events (CTCAE) version 4.03. Overall survival and local control were estimated by the Kaplan-Meier method.

RESULTS

During the study period 114 patients were treated for 122 stage I lung cancer lesions. Median follow-up time was 27 months (range 8.2-69.5 months), median age was 76 years. Eighty-two percent of the tumors were stage IA (size ≤ 3 cm). Median survival was 46 months; estimated 3 year overall survival was 59% (95%CI 47-69%) and local control was 88% (95%CI 78-94%). Toxicity included chest wall pain in 8.4% of patients, rib fracture in 0.9%, grade 1-2 pneumonitis in 12%, grade 3 in 12% and grade 5 (death) in 0.9%.

CONCLUSIONS

SABR has been successfully implemented at Sheba Medical Center for the treatment of stage I lung cancer in inoperable patients. It is associated with excellent local control, minor toxicity and an acceptable overall survival.

[Instruments for Measuring the Effects of Early Intervention on Maintaining and Restoring Ability to Work in Germany: Opinion of an Interdisciplinary Working Group]

OBJECTIVE

In projects on early intervention, a wide variety of instruments is used for the measurement of intervention effects on preservation or restoration of ability to work. The aim of the present work was to propose an appropriate instrument or a range of appropriate instruments that enable diverse interventional approaches to be compared, and data quality to be improved.

METHODS

A systematic literature search was conducted to map the currently existing measuring instruments. In addition, based on structured interviews with leaders of existing early intervention projects or representatives of other interventional approaches, knowledge and application of the measuring instruments in Germany were determined. In the context of a working meeting, a recommendation was formulated based on the results of the literature search and interviews.

RESULTS AND COMMENTS

There is currently no instrument that could be recommended without reservation for the stated purpose. Based on the results of the literature search and the interviews, the working group recommends using, as a first step, the Work Ability Index (WAI, focus on work ability) and the Work Productivity and Activity Impairment Questionnaire (WPAI, focus on absenteeism and presenteeism). German-language versions of both questionnaires are freely available and offer a good compromise in terms of psychometric quality criteria, as well as of practicality and applicability. The measuring instruments should be developed further, with the goal of establishing an optimized instrument that combines the strengths of the two instruments.

CONCLUSION

In Germany, use of WAI and the WPAI in as many early intervention approaches as possible will help improve the database, allowing better comparability. However, the focus of further research must be to develop an optimized instrument from elements of WAI and WPAI, in order to be able to measure ability to work as well as the effects of an intervention on preservation or restoration of the ability to work, regardless of the setting.

[Health care expenditures and the aging population]

The impact of a longer life on future health care expenditures will be quite moderate because of the high costs of dying and the compression of mortality in old age. If not age per se but proximity to death determines the bulk of expenditures, a shift in the mortality risk to higher ages will not significantly affect lifetime health care expenditures, as death occurs only once in every life. A calculation of the demographic effect on health care expenditures in Germany up until 2050 that explicitly accounts for costs in the last years of life leads to a significantly lower demographic impact on per-capita expenditures than a calculation based on crude age-specific health expenditures.

Zur Strategieanfälligkeit der Arzneimittelkomponente des IPHCC+RxGroups-Klassifikationssystems in einem morbiditätsorientierten Risikostrukturausgleich - Eine konzeptionelle und datengestützte Analyse

BACKGROUND

A report commissioned by the German Ministry of Health recommends to the existing scheme for calculating risk-adjusted transfers to sickness funds supplement with the IPHCC+RxGroups method. The method is based on inpatient diagnoses and prescribed drugs as health status measures deduced from prior use.

OBJECTIVE

The present study investigates the sickness fund's expected net return from gaming based on the drug component of the risk adjuster.

METHODS

The study explores three possible strategies using the RxGroups method. For the stimulations, insurees are assigned to additional indications or to higher valued RxGroups within the same indication. Then, costs and financial benefits attributable to the altered drug use are estimated and compared with the status quo. The study uses 2000 and 2001 sample data of more than 370,000 insurees of Germany's company-based sickness funds system (BKK).

RESULTS

While upgrading increases overall costs, it can be beneficial for the individual sickness funds. Their net return crucially depends on the number of sickness funds gaming the system: the more participating in the game, the smaller is the average net return. Moreover, not participating often is even worse, which in turn points to a prisoner's dilemma.

CONCLUSIONS

When extending the risk adjustment scheme in social health insurance, the German legislator should take into account the perverse incentives of risk adjusters such as the described prescription drug model.

Outcome prediction in critical care: physicians' prognoses vs. scoring systems

BACKGROUND AND OBJECTIVE

To compare the accuracy of prognoses made by intensive care physicians with the performance of two indicators, the original Simplified Acute Physiology Score (SAPS) II and a modified version optimized to the patient sample.

METHODS

Data from 412 patients consecutively admitted to intensive care units of Göttingen University Hospital, Germany, were collected according to the original score criteria. Information necessary for the computation of SAPS II and the vital status on hospital discharge was recorded. To customize the original SAPS II in our cohort, the database was randomly divided into two subgroups. Logistic regression analysis with physiological values as explanatory variables was used. A bootstrap procedure completed the process. Furthermore, physicians were asked to indicate their prognostic judgement concerning the patients' hospital mortality.

RESULTS

Discrimination analysis showed the following areas under receiver operating characteristic curves: physicians' prognoses 0.84 (confidence interval (CI): 0.79-89), SAPS II 0.75 (CI: 0.69-0.80) and customized SAPS 0.72 (CI: 0.66-0.78). The physician's forecast was significantly better, while the customized and the original SAPS were not substantially different as regards their accuracy.

CONCLUSIONS

Prognoses made by physicians are superior to objective models. This may result from more extensive knowledge and other kinds of information available to clinicians. A clinician's action also depends on his/her prognosis at the beginning of the treatment, giving raise to a possible correlation between medical outcome and the clinician's prognosis. Our findings indicate that physicians do not limit their prognosis to the objective factors at their disposal, but indicate that they base their decisions on experience and individual observations.

Kosten der Unterkieferfrakturversorgung: Eine prospektive Untersuchung

PURPOSE

Up to now in maxillofacial surgery almost all inpatient treatments were reimbursed at the hospital's per diem rate. The real treatment cost is unknown and there is a lack of publications in this sphere. This study calculates the cost of surgical treatment of mandibular fractures.

METHOD

The prospective study includes 104 patients whose mandibular fractures were treated using miniplate osteosynthesis. For each patient we took into account the time input by physicians and specialised nurses and calculated labour cost using the relevant wage rates. We added the cost for materials and drugs as well as for laboratory and radiographic examinations. Finally, we incorporated charges for the hotel and nursing components of inpatient treatment.

RESULTS

The cost for the surgical treatment of mandibular fractures varied between 642 euro; for single and 1,070 euro; for triple fractures. The share of labour cost is about 1/3. Treatment cost varies with the length of hospital stay: 1,132 euro; for four days and 1,628 euro; for seven days on average.

CONCLUSION

This prospective study can be compared with the recently published corresponding G-DRG rates. Moreover, the reported cost figures allow comparison with corresponding cost studies from other public health systems.

Reply to: Econometric issues in testing the age neutrality of health care expenditure

Salas and Raftery allege that in our paper, (1) remaining life expectancy is an endogenous explanatory variable of health care expenditure and (2) the parameter designed to correct for sample selection bias in fact represents a hidden relationship between health care expenditure and age. We argue that claim (1) is not supported by the available empirical evidence, while claim (2) seems to derive from a too cursory reading of our paper.

The nucleus-encoded HCF107 gene of Arabidopsis provides a link between intercistronic RNA processing and the accumulation of translation-competent psbH transcripts in chloroplasts

To understand the functional significance of RNA processing for the expression of plastome-encoded photosynthesis genes, we investigated the nuclear mutation hcf107 of Arabidopsis. The mutation is represented by two alleles, both of which lead to a defective photosystem II (PSII). In vivo protein labeling, in vitro phosphorylation, and immunoblot experiments revealed that the psbB gene product (CP47) and an 8-kD phosphoprotein, the psbH gene product (PsbH), are absent in mutant plants. PsbH and PsbB are essential requirements for PSII assembly in photosynthetic eukaryotes, and their absence in hcf107 is consistent with the PSII-less mutant phenotype. RNA gel blot hybridizations showed that the hcf107 mutation specifically impairs the accumulation of some but not all oligocistronic psbH transcripts that are released from the pentacistronic psbB-psbT-psbH-petB-petD precursor RNA by intergenic endonucleolytic cleavage. In contrast, neither the levels nor the sizes of psbB-containing RNAs are affected. S1 nuclease protection analyses revealed that psbH RNAs are lacking only where psbH is the leading cistron and that they are processed at position -45 in the 5' leader segment of psbH. These data and additional experiments with the cytochrome b(6)f complex mutant hcf152, which is defective in 3' psbH processing, suggest that only those psbH-containing transcripts that are processed at their -45 5' ends can be translated. Secondary structure analysis of the 5' psbH leader predicted the formation of stable stem loops in the nonprocessed transcripts, which are unfolded by processing at the -45 site. We propose that this unfolding of the psbH leader segment as a result of RNA processing is essential for the translation of the psbH reading frame. We suggest further that HCF107 has dual functions: it is involved in intercistronic processing of the psbH 5' untranslated region or the stabilization of 5' processed psbH RNAs, and concomitantly, it is required for the synthesis of CP47.

[Evaluation of the public health service law of the Saxony-Anhalt region--community affairs, transfer of power and loss of control]

AIM

In the state of Saxony-Anhalt, a new Public Health Service law came into force in 1998. Our study investigated whether this new legislation has led to an extension of duties performed by regional health departments and to a subsequent increase in expenditure.

METHODS

Guided interviews at all administrative levels of the public health system were conducted. The catalogue of duties was systematized and a questionnaire was developed and distributed to all regional health departments (response rate: 17 out of 24). Data concerning revenues and expenditures of the regional health departments were analysed on the basis of the administrative districts' budget data.

RESULTS

Regional health departments stated that there had been practically no change in their activities over the last few years. When questioned about the coverage of 58 specific duties, a considerable disparity was evident between departments. A core group of "classical" duties comprising environmental health and hygiene, child health protection, individual health appraisal, and public health supervision are carried out on an established basis. Some duties were handled by external institutions, others, mostly community health duties, were not performed on an extensive scale. When asked about the desired model for their health department, most departments preferred the model of being an executor of sovereign duties, however a corporate model was deemed to be almost as acceptable. The following fields will gain increasing significance in the future: environmental medicine, health reporting, preventive medicine, co-ordination of regional health care, and health promotion. Since 1995, staff has been reduced in all regional health departments (-10.4%; 1999: 2.92 employees per 10,000 inhabitants). In 1999, expenditures amounted to an average of 24.64 German Marks per capita (range 14.20-44.58 DM). The number of inhabitants and the revenue of the regional districts were determinants of their health budgets.

CONCLUSION

Our results showed that no uncompensated additional expenditure by regional authorities resulted from this law. So far, most districts have not perceived regional health as a community affair offering possible competitive advantages. The federal state lost considerable influence at the regional level. Recommended are regional health priorities, conjoint staff development, and state guidance by a head agency providing leadership and support, while leaving responsibility with the districts.

Health care expenditure in the last months of life

In OECD countries, a considerable share of health care expenditure (HCE) is spent for the care of the terminally ill. This paper derives the demand for HCE in the last 2 years of life from a model that accounts for age, mortality risk and wealth. The empirical tests are based on data of deceased members of a major Swiss sick fund. The empirical evidence confirms most of the hypotheses derived from the model, i.e., (i) HCE increases with closeness to death, (ii) for retired individuals, HCE decreases with age, and (iii) low-income individuals, as compared to high-income individuals, incur lower HCE in the last months of life.

Ageing of population and health care expenditure: a red herring?

This paper studies the relationship between health care expenditure (HCE) and age, using longitudinal rather than cross-sectional data. The econometric analysis of HCE in the last eight quarters of life of individuals who died during the period 1983-1992 indicates that HCE depends on remaining lifetime but not on calendar age, at least beyond 65+. The positive relationship between age and HCE observed in cross-sectional data may be caused by the simple fact that at age 80, for example, there are many more individuals living in their last 2 years than at age 65. The limited impact of age on HCE suggests that population ageing may contribute much less to future growth of the health care sector than claimed by most observers.

Combinatorial chemistry reveals a new motif that binds the platelet fibrinogen receptor, gpIIbIIIa

Among cell adhesion molecules, the classic Arg-Gly-Asp (RGD) motif is the best studied. We used combinatorial chemical and affinity immunochemical methods to find a novel motif of unnatural peptide ligands for the fibrinogen receptor of platelets, gpIIbIIIa (alphaIIbbeta3). The new d-amino acid motif, p(f/y)l, is unique among the ligands that bind the RGD pocket: It lacks the carboxylic acid group that is believed to coordinate with calcium in the MIDAS motif of the receptor. With an IC50 of 14 microM for the most potent compound, these linear p(f/y)l peptides had affinities similar to those of linear peptides containing RGD, and reversed sequences failed to compete with binding up to 1 mM. As the new motif was so different, molecular modeling was employed to suggest a model for molecular recognition. A reversed binding mechanism common for d-amino acid mimics of natural l-amino acid peptides offers an attractive hypothesis that suggests three points of contact similar to those made by the RGD-mimicking monoclonal antibody, OPG2. Interestingly, the model proposes that pi-electrons in the new motif may substitute for the carboxylate group present in all other RGD-types of ligands. Although modeling linear peptides is subjective, the pi-bonding model provides intriguing possibilities for medicinal chemistry after appropriate confirmatory studies.

Costs of dying: alternatives to rationing

In western industrialised countries, about 30% of health-care expenditure of retired people is incurred by individuals in their last year of life. The corresponding high costs of dying have led medical philosophers to ask for a rationing of health-care services according to age. By contrast, this paper pursues an individualistic approach. High costs of dying are identified as a consequence of moral hazard on both the demand and supply side of the health-care sector. Health insurance prevents demand for health-care services from decreasing when an individual's residual life expectancy shrinks. Age-related moral hazard can be limited by a coinsurance scheme with a deductible that increases with the age of the insured. Given the high costs of dying, the optimal insurance policy links the coinsurance rate to the age-specific mortality risk.

One-bead-one-structure combinatorial libraries

Combinatorial libraries employing the one-bead-one-compound technique are reviewed. Two distinguishing features characterize this technique. First, each compound is identified with a unique solid support, enabling facile segregation of active compounds. Second, the identity of a compound on a positively reacting bead is elucidated only after its biological relevance is established. Direct methods of structure identification (Edman degradation and mass spectroscopy) as well as indirect "coding" methods facilitating the synthesis and screening of nonpeptide libraries are discussed. Nonpeptide and "scaffold" libraries, together with a new approach for the discovery of a peptide binding motif using a "library of libraries," are also discussed. In addition, the ability to use combinatorial libraries to optimize initially discovered leads is illustrated with examples using peptide libraries.

Human neutrophil motility: time-dependent three-dimensional shape and granule diffusion

The locomotion of human polymorphonuclear leukocytes (PMNs) was studied with two complementary methods: Three-dimensional shapes were reconstructed from time series of optical sectioning microscopy using differential interference contrast (DIC) optics, and the diffusion of cytoplasm granules within individual cells was measured using quasielastic laser light scattering (QELS). The three-dimensional cell edges outlined in the optical sections were analyzed qualitatively in time-lapse film strips and quantitatively from morphometry. The fastest locomotion occurred in chemotactic gradient with cell velocity that oscillated between 10 and 30 microns/min with a period of 50-55 seconds. Within the periodic bursts of speed, a fibroblast-like locomotory cycle was observed, with leading lamella extended and contacts formed with the substrate surface, followed by rapid motion of the cell body and nucleus over the immobile contacts. Consistent with this apparent staged motion, correlation analysis revealed a phase lag of 2-3 seconds in velocities between the bottom (ventral) and the top layers of the cell. In addition there was a tendency to a lower cell profile at times of higher velocity. The diffusion of natural cytoplasmic granules within resting PMNs was not affected by cytoskeleton disrupting drugs. During the stage of most rapid motion, when cytoplasmic streaming could be seen, diffusion of the granules decreased two- to 2.5-fold, and then returned to resting levels. These observations suggest that PMN locomotion consists of extensions near the surface to form forward contacts and then stiffening or possibly contraction of the cytoskeleton when the body of the cell is moved forward. Three-dimensional movies of PMN cells are included in the video supplement.

One bead, one chemical compound: use of the selectide process for anticancer drug discovery

A technology for chemical synthesis and testing of libraries of millions of chemical entities has been developed for rapid molecular and cellular screening for drug leads. Each individual compound in the library is on a separate resin bead. Screening for binding activity can be conducted directly on the beads. Biological activity is assessed in solution phase assay by cleaving a portion of the compound from each bead. The molecular structure of the compound of interest is obtained by automated peptide sequencing from the bead of origin. We have applied this technology to anticancer drug discovery as well as to other pharmaceutical targets. For anticancer drug development, current molecular targets include B-cell lymphoma, the EGF receptor, and the HER2-neu receptor. Solution phase screening with dual cleavable libraries is being used for growth inhibition of human tumor cell lines. Initial in vitro leads have been identified in each of these areas of anticancer drug discovery.

Real-time measurements of kinetics of EGF binding to soluble EGF receptor monomers and dimers support the dimerization model for receptor activation

We have tested one aspect of the allosteric dimerization model for the activation of EGF receptor (EGFR) by EGF: whether EGF binding favors dimerization of the receptor. For this to be true, EGF molecules must bind with higher affinity to dimeric receptors than to monomeric receptors. We have tested this directly in a defined system using the soluble, extracellular ligand binding domain of EGFR monomers (sEGFR) and sEGFR dimers stabilized by treatment with a covalent cross-linking agent. We describe real-time kinetic measurements of EGF binding to receptor monomers and dimers employing the method of total internal reflection (surface plasmon resonance). Our data show that sEGFR dimers bound EGF with 30-40-fold higher affinity [KD = (2-3) x 10(-8) M] than did sEGFR monomers. The enhanced binding affinity of sEGFR dimers resulted mainly from a reduced off-rate with k(off) = 0.001 s-1 for sEGFR dimers as compared to k(off) = 0.06 s-1 for sEGFR monomers. These measurements indicate that dimerization of sEGFR increases its affinity for EGF by prolonging the amount of time that EGF remains bound to the receptor. This provides evidence that EGF binding stabilizes receptor dimerization and provides further support for the allosteric dimerization model as a mechanism for ligand induced receptor activation.

SH2 domains exhibit high-affinity binding to tyrosine-phosphorylated peptides yet also exhibit rapid dissociation and exchange

src homology 2 (SH2) domains of intracellular signaling molecules such as phospholipase C-gamma and phosphatidylinositol 3'-kinase-associated protein p85 represent recognition motifs for specific phosphotyrosine-containing regions on activated growth factor receptors. The binding of SH2 domains to activated growth factor receptors controls the interaction with signaling molecules and the regulation of their activities. In this report, we describe the kinetic parameters and binding affinities of SH2 domains of p85 toward short phosphotyrosine-containing peptides with the amino acid sequence motif YMXM, derived from a major insulin receptor substrate, IRS-1, by using real time biospecific interaction analysis (BIAcore). Associations were specific and of very high affinity, with dissociation constants of 0.3 to 3 nM, between phosphopeptides and the two separate SH2 domains contained within p85. Nonphosphorylated peptides showed no measurable binding, and the interactions were specific for the primary sequence very close to the phosphotyrosine residue. Moreover, the interactions between phosphopeptides and SH2 domains of other signaling molecules were of much lower affinity. Interestingly, the binding of the SH2 domains to the tyrosine-phosphorylated peptides was of high affinity as a result of a very high on rate, of 3 x 10(7) to 40 x 10(7)/M/s; at the same time, the rate of dissociation, of 0.11 to 0.19/s, was rapid, allowing for rapid exchange of associating proteins with the tyrosine phosphorylation sites.

Hypothalamic lesions that induce female precocious puberty activate glial expression of the epidermal growth factor receptor gene: differential regulation of alternatively spliced transcripts

Injury of the nervous system triggers a complex series of repair mechanisms that include production of neurotrophic and mitogenic factors by cells neighboring the injured area. While trauma of most parts of the brain results in loss of function, lesions of certain regions of the female hypothalamus enhance the secretory activity of a group of specialized neurons that produce luteinizing hormone-releasing hormone (LHRH), the neuropeptide that controls sexual development. The increased output of LHRH causes sexual precocity by prematurely activating the neuroendocrine reproductive axis. Recent studies have implicated transforming growth factor alpha (TGF alpha) produced by reactive astrocytes in the process by which lesions hasten sexual maturation, and have suggested that the stimulatory actions of TGF alpha on LHRH neurons require the intermediacy of epidermal growth factor receptors (EGFRs). In the present study, we examined the changes in EGFR gene expression following lesions of the preoptic-anterior hypothalamic area (POA-AHA) of immature female rats, identified the cell types where EGFR synthesis increases, and assessed the biochemical activity of the newly formed EGFR protein. RNase protection assays demonstrated that the lesion significantly increased the levels of a predominant mRNA transcript encoding the full-length, membrane-spanning EGFR, but did not affect those of a much less abundant, alternatively spliced mRNA that encodes a truncated, presumably secreted form of EGFR. Following lesions, antibody-induced EGFR kinase activity increased twofold. Antibodies directed against a peptide sequence contained within the carboxy terminus of EGFR showed intense EGFR immunoreactivity in cells surrounding the lesion site; double immunohistochemistry identified these cells as astrocytes since EGFR immunoreactivity was colocalized with that of glial fibrillary acidic protein, an astrocytic marker. That these changes result from an increase in EGFR gene expression was indicated by the elevated levels of EGFR mRNA detected by in situ hybridization in cells of the same area. Although POA-AHA lesions did not result in appearance of EGFR in LHRH neurons themselves, EGFR-positive cells and processes were seen in close proximity to LHRH neurons and their nerve terminals, particularly in the area surrounding the lesion. Since TGF alpha gene expression is also increased in reactive astrocytes of POA-AHA lesions and blockade of EGFR prevented the advancing effect of the lesion on puberty (Junier et al., 1991b), the present results support the concept that, in lesioned animals, TGF alpha stimulates LHRH secretion indirectly via a paracrine mechanism that involves its interaction with EGFRs located on astroglial cells.

Annexin I is phosphorylated in the multivesicular body during the processing of the epidermal growth factor receptor

We have previously shown that an active epidermal growth factor receptor (EGF-R) kinase is necessary for efficient sorting of the EGF-R to the lysosome, and we have shown that this occurs in the multivesicular body (MVB), where EGF-R are sorted away from recycling receptors by being removed to the internal vesicles of the MVB. The aim of the present study was to identify substrates of the EGF-R kinase associated with MVBs which might play a role in this sorting process. We used a density shift technique to isolate MVBs and show that the major substrates phosphorylated in vitro within MVBs which contain an active EGF-R kinase are the EGF-R itself and annexin I. Annexin I is associated with both plasma membrane and MVBs in a calcium-independent manner but can be phosphorylated in vitro only in MVBs. Phosphorylation of calcium-independent annexin I in isolated MVBs converts it to a form that requires calcium for membrane association. In cells with an active EGF-R kinase the amount of calcium-independent annexin I in MVBs is reduced, suggesting that a phosphorylation-induced conversion of the calcium independent to the calcium-dependent form also occurs in vivo. Our observations, together with the known properties of annexin I in mediating membrane fusion, suggest that inward vesiculation in MVBs is induced by the EGF-R and is mediated by phosphorylated annexin I.

Kinetics of binding, endocytosis, and recycling of EGF receptor mutants

This report describes analysis of factors which regulate the binding of EGF to EGF receptor, receptor internalization, and receptor recycling. Three different methods were used to inhibit high-affinity EGF binding as measured at equilibrium: treatment of cells with an active phorbol ester (PMA), binding of a mAb directed against the EGF receptor (mAb108), and truncation of most of the cytoplasmic domain of the receptor. These treatments reduced the rate at which low concentrations of EGF bound to cells, but did not affect the rate of EGF dissociation. We conclude that high-affinity EGF binding on living cells results from a difference in the apparent on rate of EGF binding. We then used these conditions and cell lines to test for the rate of EGF internalization at different concentrations of EGF. We demonstrate that internalization of the EGF receptor is stimulated roughly 50-fold at saturating concentrations of EGF, but is stimulated an additional two- to threefold at low concentrations (less than 1 nM). Four treatments reduce the rate of internalization of low concentrations of EGF to the rate seen at saturating EGF concentrations. Phorbol ester treatment and mAb108 binding to "wild type" receptor reduce this rate (and reduce high-affinity binding). Point mutation at Lys721 (kinase negative EGF receptor) and point mutation at Thr654 (removing a major site of protein kinase C phosphorylation) reduce the internalization rate, without affecting high-affinity binding. We suggest that while EGF stimulates endocytosis for all receptors, high-affinity receptors bind and are internalized more quickly than low-affinity receptors. Tyrosine kinase activity and the Thr654 region appear necessary for this response.

Cloning of the human serotonin 5-HT2 and 5-HT1C receptor subtypes

We report the cloning and the deduced amino acid sequence of cDNAs encoding both the human serotonin 5-HT2 and 5-HT1C receptors. The human 5-HT2 and 5-HT1C receptors shared 87% and 90% amino acid homology, respectively, with their rat counterparts. The most divergent regions of the 5-HT2 receptor between human and rat were the N-terminal extracellular domain (75% homology) and the C-terminal intracellular domain (67% homology between amino acids 426-474). The greatest variability between the human and rat 5-HT1C receptors were at the N-terminal extracellular domain (78% homology) and the third cytoplasmic loop (71% homology). The availability of the cloned human 5-HT2 and 5-HT1C receptors will help facilitate the further understanding of the molecular pharmacology and physiology of these receptors.

EGF induces increased ligand binding affinity and dimerization of soluble epidermal growth factor (EGF) receptor extracellular domain

The binding of epidermal growth factor (EGF) to its cell surface receptor (EGF-R) results in a number of intracellular responses including the activation of the receptor intracellular tyrosine kinase. Receptor oligomerization induced by ligand binding has been suggested to play an important role in signal transduction. However, the mechanisms involved in oligomerization and signal transduction are poorly understood. We have produced and purified several milligrams of recombinant extracellular domain of the EGF receptor (EGF-Rx) using the baculovirus/insect cell expression system. The baculovirus-generated EGF-Rx is glycosylated, has had its signal peptide correctly cleaved, and exhibits a dissociation constant for EGF similar to that for solubilized full-length receptor, of about 100 nM. The binding of EGF to EGF-Rx leads to the formation of receptor dimers and higher oligomerization states which are irreversibly captured using the covalent cross-linking agent disuccinimidyl suberate. Interestingly, purified receptor monomers and dimers, stabilized by the cross-linker in the presence of EGF, exhibit increased binding affinity toward EGF as compared with receptor monomers which have not been exposed to EGF. It appears that the high affinity state of receptor can be maintained by the covalent cross-linking agent. These results indicate that in addition to ligand binding, the extracellular domain of EGF receptor possesses the inherent ability to undergo ligand-induced dimerization and that the low affinity state is converted to a high affinity state by EGF.

Analysis of platelet-derived growth factor receptor domain function using a novel chimeric receptor approach

A chimeric receptor consisting of an epidermal growth factor (EGF) receptor ligand-binding domain and platelet-derived growth factor (PDGF) receptor transmembrane and cytoplasmic signalling domains has been constructed and shown to be fully functional in phosphorylation, mitogenesis, transformation, Ca2+ release, and pH change assays. Expression of this receptor in EGF receptor-deficient, PDGF-responsive NIH 3T3 cells allows the activation of PDGF signalling pathways by EGF. This system was used to examine the function of kinase insertion sequences (KIS). While a mutant with a KIS deletion of 83 amino acids displayed a significant but reduced ability to induce mitogenic, transforming, and Ca2+ release responses in transfected cells, deletion of 20 additional amino acids resulted in abolishment of such activities. This differential loss of signalling potential correlated with the reduced or abolished potential of these receptor mutants to phosphorylate cellular substrates such as PLC gamma. Our results suggest an integral role for KIS in PDGF receptor cytoplasmic domain conformation and an involvement in substrate interaction, but provide no evidence for an exclusive role of KIS in the mediation of biological signals.

Klippel-Trenaunay-Weber syndrome with recurrent pulmonary embolism

A man with Klippel-Trenaunay-Weber syndrome had worsening pulmonary hypertension secondary to recurrent multiple pulmonary embolism despite anticoagulation. Pulmonary thromboendarterectomy was done. However, the patient expired 10 days after surgery due to another bout of pulmonary embolism from his right arm or right chest wall.

Cloning and expression of the human substance K receptor and analysis of its role in mitogenesis

The primary structure of the human substance K receptor was established from the sequences of complementary DNA clones isolated from a human jejunal complementary DNA library. It consists of 398 amino acids, including seven putative transmembrane regions. The gene for the human substance K receptor was localized to chromosome region 10p13-10q23, a region with frequent chromosomal abnormalities. The human substance K receptor was expressed in transfected NIH-3T3 cells lacking endogenous substance K receptors, and Scatchard analysis of 125I-labeled substance K binding indicates approximately 100,000 receptors/cell with a single dissociation constant of 12 nM. Covalent cross-linking experiments utilizing 125I-substance K and three different chemical cross-linking reagents (disuccinimidyl suberate, disuccinimidyl tartrate, or 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide-HCl) demonstrate an apparent molecular weight of 45,000, consistent with little or no N-linked glycosylation. The binding of substance K to its receptor on transfected cells led to a rapid increase in the production of total inositol phosphates and the release of Ca2+ from internal stores. Growth of the cells transfected with the human substance K receptor is stimulated by the addition of substance K to the medium to a level similar to 10% serum. Therefore, the human substance K receptor can function as a growth factor receptor when expressed in mouse 3T3 cells.