Characterizing the Spectrum of Latent Mycobacterium tuberculosis in the Cynomolgus Macaque Model: Clinical, Immunologic, and Imaging Features of Evolution

Mycobacterium tuberculosis infection outcomes have been described as active tuberculosis or latent infection but a spectrum of outcomes is now recognized. We used a nonhuman primate model, which recapitulates human infection, to characterize the clinical, microbiologic, and radiographic patterns associated with developing latent M. tuberculosis infection. Four patterns were identified. "Controllers" had normal erythrocyte sedimentation rate (ESR) without M. tuberculosis growth in bronchoalveolar lavage or gastric aspirate (BAL/GA). "Early subclinicals" showed transient ESR elevation and/or M. tuberculosis growth on BAL/GA for 60 days postinfection, "mid subclinicals" were positive for 90 days, and "late subclinicals" were positive intermittently, despite the absence of clinical disease. Variability was noted regarding granuloma formation, lung/lymph node metabolic activity, lung/lymph node bacterial burden, gross pathology, and extrapulmonary disease. Like human M. tuberculosis infection, this highlights the heterogeneity associated with the establishment of latent infection, underscoring the need to understand the clinical spectrum and risk factors associated with severe disease.

Characterization of natural killer cells in the blood and airways of cynomolgus macaques during Mycobacterium tuberculosis infection

BACKGROUND

Tuberculosis (TB) is caused by Mycobacterium tuberculosis (Mtb) and kills more than 1.5 million people each year.

METHODS

We examine the frequency and function of NK cells in the blood and airways over the course of Mtb infection in a TB macaque model and demonstrate differences in NK marker expression between the two compartments. Flow cytometry and intracellular cytokine staining were utilized to identify NK cell subsets (expressing NKG2A, CD56, or CD16) and function (IL-10, TNF, IL-2, IFN-g, IL-17, and CD107a).

RESULTS

Blood and airway NK cell frequencies were similar during infection though there were differences in subset populations between blood and airway. Increased functional (cytokine/CD107a) parameters were observed in airway NK cells during the course of infection while none were seen in the blood.

CONCLUSIONS

This study suggests that NK cells in the airway may play an important role in TB host response.

SIV and Mycobacterium tuberculosis synergy within the granuloma accelerates the reactivation pattern of latent tuberculosis

Human immunodeficiency virus infection is the most common risk factor for severe forms of tuberculosis (TB), regardless of CD4 T cell count. Using a well-characterized cynomolgus macaque model of human TB, we compared radiographic, immunologic and microbiologic characteristics of early (subclinical) reactivation of latent M. tuberculosis (Mtb) infection among animals subsequently infected with simian immunodeficiency virus (SIV) or who underwent anti-CD4 depletion by a depletion antibody. CD4 depleted animals had significantly fewer CD4 T cells within granulomas compared to Mtb/SIV co-infected and Mtb-only control animals. After 2 months of treatment, subclinical reactivation occurred at similar rates among CD4 depleted (5 of 7 animals) and SIV infected animals (4 of 8 animals). However, SIV-induced reactivation was associated with more dissemination of lung granulomas that were permissive to Mtb growth resulting in greater bacterial burden within granulomas compared to CD4 depleted reactivators. Granulomas from Mtb/SIV animals displayed a more robust T cell activation profile (IFN-α, IFN-γ, TNF, IL-17, IL-2, IL-10, IL-4 and granzyme B) compared to CD4 depleted animals and controls though these effectors did not protect against reactivation or dissemination, but instead may be related to increased viral and/or Mtb antigens. SIV replication within the granuloma was associated with reactivation, greater overall Mtb growth and reduced Mtb killing resulting in greater overall Mtb burden. These data support that SIV disrupts protective immune responses against latent Mtb infection beyond the loss of CD4 T cells, and that synergy between SIV and Mtb occurs within granulomas.

SIV and CD4 depletion distinctly reactivate latent Mycobacterium. tuberculosis infection

Human immunodeficiency virus infection is the most common risk factor for severe forms of tuberculosis (TB) regardless of CD4 T cell count. Using a well-characterized cynomolgus macaque model, we compared reactivation of latent M. tuberculosis (Mtb) infection induced by simian immunodeficiency virus (SIV) or anti-CD4 antibody (αCD4). Reactivation, as defined by the appearance of a new lung lesion by PET CT, occurred in 5 of 7 αCD4 treated animals compared to 4 of 8 SIV infected animals within 2 months of treatment. αCD4 animals had significantly fewer CD4 T cells within granulomas compared to SIV/Mtb infected animals. However, compared to αCD4 groups, SIV infection caused more dissemination of lung granulomas and higher granuloma bacterial burdens. Within the granulomas, SIV replication was associated with greater Mtb growth and reduced Mtb killing. Granulomas from SIV/Mtb animals displayed a distinctly different profile of T cell cytokine and granzyme B expression compared to αCD4 animals and controls. PET CT imaging prior to treatment could predict reactivation in αCD4-treated animals, but not in SIV/Mtb animals. These data suggest that SIV infection disrupts protective immune responses against Mtb infection beyond the loss of CD4 T cells, and that synergy between SIV and Mtb occurs within granulomas.

Acceptance and commitment therapy as an adjunct to the MOVE! programme: a randomized controlled trial

OBJECTIVE

The current study tested the efficacy of an acceptance and commitment therapy (ACT) group intervention for disinhibited eating behaviour as an adjunct to the Veterans Affairs MOVE!© weight management programme.

METHODS

Veterans (N = 88) with overweight or obesity who completed the MOVE! weight management programme and self-identified as having problems with 'stress-related eating' were randomized to four 2-h weekly ACT sessions or a continued behavioural weight-loss (BWL) intervention. Assessments were completed at baseline, post-treatment and 3- and 6-month follow-up on outcomes of interest including measures of disinhibited eating patterns, obesity-related quality of life, weight-related experiential avoidance and weight.

RESULTS

The BWL group exhibited significantly greater reductions in binge eating behaviour at post-treatment compared with the ACT group. Significant improvements in other outcomes were found with minimal differences between groups. In both groups, decreases in weight-related experiential avoidance were related to improvements in binge eating behaviour.

CONCLUSIONS

Taken together, the continued BWL intervention resulted in larger improvements in binge eating behaviour than the ACT intervention. The two groups showed similar improvements in other disinhibited eating outcomes. Future studies are encouraged to determine if more integrated or longer duration of ACT treatment may maximize eating outcomes in MOVE.Trial Registration Number: This trial was registered with ClinicalTrials.gov database (NCT01757847).

CD4CD8 Double Positive T cell responses during Mycobacterium tuberculosis infection in cynomolgus macaques

BACKGROUND

Tuberculosis (TB) kills millions of people every year. CD4 and CD8 T cells are critical in the immune response against TB. T cells expressing both CD4 and CD8 (CD4CD8 T cells) are functionally active and have not been examined in the context of TB.

METHODS

We examine peripheral blood mononuclear cells (PBMC) and bronchoalveolar lavage cells (BAL) and lung granulomas from 28 cynomolgus macaques during Mycobacterium tuberculosis (Mtb) infection.

RESULTS

CD4CD8 T cells increase in frequency during early Mtb infection in PBMC and BAL from pre-infection. Peripheral, airway, and lung granuloma CD4CD8 T cells have distinct patterns and greater cytokine production than CD4 or CD8 T cells.

CONCLUSION

Our data suggest that CD4CD8 T cells transient the blood and airways early during infection to reach the granulomas where they are involved directly in the host response to Mtb.

Diversity of Human and Macaque Airway Immune Cells at Baseline and during Tuberculosis Infection

Immune cells of the distal airways serve as "first responders" of host immunity to the airborne pathogen Mycobacterium tuberculosis (Mtb). Mtb infection of cynomolgus macaques recapitulates the range of human outcomes from clinically silent latent tuberculosis infection (LTBI) to active tuberculosis of various degrees of severity. To further advance the application of this model to human studies, we compared profiles of bronchoalveolar lavage (BAL) cells of humans and cynomolgus macaques before and after Mtb infection. A simple gating strategy effectively defined BAL T-cell and phagocyte populations in both species. BAL from Mtb-naive humans and macaques showed similar differential cell counts. BAL T cells of macaques were composed of fewer CD4⁺cells but more CD8⁺ and CD4⁺CD8⁺ double-positive cells than were BAL T cells of humans. The most common mononuclear phagocyte population in BAL of both species displayed coexpression of HLA-DR, CD206, CD11b, and CD11c; however, multiple phagocyte subsets displaying only some of these markers were observed as well. Macaques with LTBI displayed a marked BAL lymphocytosis that was not observed in humans with LTBI. In macaques, the prevalence of specific mononuclear phagocyte subsets in baseline BAL correlated with ultimate outcomes of Mtb infection (i.e., LTBI versus active disease). Overall, these findings demonstrate the comparability of studies of pulmonary immunity to Mtb in humans and macaques. They also indicate a previously undescribed complexity of airway mononuclear phagocyte populations that suggests further lines of investigation relevant to understanding the mechanisms of both protection from and susceptibility to the development of active tuberculosis within the lung.

PET CT Identifies Reactivation Risk in Cynomolgus Macaques with Latent M. tuberculosis

Mycobacterium tuberculosis infection presents across a spectrum in humans, from latent infection to active tuberculosis. Among those with latent tuberculosis, it is now recognized that there is also a spectrum of infection and this likely contributes to the variable risk of reactivation tuberculosis. Here, functional imaging with 18F-fluorodeoxygluose positron emission tomography and computed tomography (PET CT) of cynomolgus macaques with latent M. tuberculosis infection was used to characterize the features of reactivation after tumor necrosis factor (TNF) neutralization and determine which imaging characteristics before TNF neutralization distinguish reactivation risk. PET CT was performed on latently infected macaques (n = 26) before and during the course of TNF neutralization and a separate set of latently infected controls (n = 25). Reactivation occurred in 50% of the latently infected animals receiving TNF neutralizing antibody defined as development of at least one new granuloma in adjacent or distant locations including extrapulmonary sites. Increased lung inflammation measured by PET and the presence of extrapulmonary involvement before TNF neutralization predicted reactivation with 92% sensitivity and specificity. To define the biologic features associated with risk of reactivation, we used these PET CT parameters to identify latently infected animals at high risk for reactivation. High risk animals had higher cumulative lung bacterial burden and higher maximum lesional bacterial burdens, and more T cells producing IL-2, IL-10 and IL-17 in lung granulomas as compared to low risk macaques. In total, these data support that risk of reactivation is associated with lung inflammation and higher bacterial burden in macaques with latent Mtb infection.

Abstract POSTER-BIOL-1320: Rho-family GTPases as therapeutic targets in ovarian cancer

Purpose of the study: Although Rac1 and Cdc42 are considered attractive therapeutic targets, no selective inhibitors of these GTPases are in clinical trials. The Ras-homologous (Rho) family GTPases Rac1 and Cdc42 contribute to metastatic dissemination through regulation of actin reorganization, cell motility, cell-cell and cell-extracellular matrix adhesion. Using high throughput screening and cheminformatics, we identified the R-enantiomer of ketorolac as a novel inhibitor of Rac1 and Cdc42. R-enantiomers of nonsteroidal anti-inflammatory drugs are poor inhibitors of cyclooxygenase (COX) activity, yet little is known about the pharmacologic activities or targets of the R-enantiomers. The purpose of this study was to investigate the effects of R-ketorolac on ovarian cancer.

Experimental procedures: GTPase target expression and activity was determined by immunohistochemistry, RT-PCR and enzymatic assays. The effects of racemic, R- and S-ketorolac on proliferation, adhesion and migration were investigated using human ovarian tumor cells (OvCA 429 and SKOV3ip). In vivo effect of ketorolac treatments was determined in a xenograft model using SKOV3ip cells. Pharmacokinetic and pharmacodynamic assessments of racemic R/S-ketorolac (Toradol®) in patients were conducted in women with suspected advanced stage ovarian, fallopian tube or primary peritoneal cancer with planned optimal cytoreductive surgery. Ascites samples were obtained for measurement of cell adhesion and drug inhibition of GTPase activity. After placement of an IP port the recommended dose of IV racemic ketorolac was administered and blood and peritoneal fluid were obtained at T=0, 1h, 6h and 24h. R- and S-ketorolac concentrations in serum and peritoneal fluid were measured by HPLC. GTPase inhibitory activity of ketorolac was assessed in peritoneal tumor cells.

Summary of the data: Elevation of Cdc42 protein and expression of the constitutively active Rac1b splice variant of Rac1 were detected in ovarian cancer specimens providing the first evidence for dysregulation of these GTPase targets in ovarian cancer. R-ketorolac, and not S-ketorolac, inhibits Rac1 and Cdc42 activity demonstrating an unexpected pharmacologic activity for the R-enantiomer. R-ketorolac, but not S-ketorolac, inhibits cell adhesion and migration, and reduced peritoneal tumor implantation in a mouse xenograft model. In the clinical studies using R/S-ketorolac for post-operative pain management, we found that ketorolac distributed to peritoneal fluids within 6 hours and fluids were highly enriched in the R-enantiomer compared to the S-enantiomer. Rac1 and Cdc42 activity was inhibited in ovarian tumor cells retrieved from the peritoneal cavity post-ketorolac administration. Cell adhesion was decreased by R-ketorolac in patient-derived ovarian tumor cells.

Conclusions: The findings show R-ketorolac is a novel inhibitor of Rac1 and/or Cdc42, and active in ovarian cancer model systems. The favorable distribution of R-ketorolac in the peritoneal cavity coupled with GTPase inhibition in cells retrieved from the intraperitoneal compartment support the potential benefit of R-ketorolac for ovarian cancer patients.

Citation Format: Hudson LG, Kenney SR, Guo Y, Adams S, Rutledge T, Muller CY, Wandinger-Ness A. Rho-family GTPases as therapeutic targets in ovarian cancer [abstract]. In: Proceedings of the 10th Biennial Ovarian Cancer Research Symposium; Sep 8-9, 2014; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2015;21(16 Suppl):Abstract nr POSTER-BIOL-1320.

Variability in tuberculosis granuloma T cell responses exists, but a balance of pro- and anti-inflammatory cytokines is associated with sterilization

Lung granulomas are the pathologic hallmark of tuberculosis (TB). T cells are a major cellular component of TB lung granulomas and are known to play an important role in containment of Mycobacterium tuberculosis (Mtb) infection. We used cynomolgus macaques, a non-human primate model that recapitulates human TB with clinically active disease, latent infection or early infection, to understand functional characteristics and dynamics of T cells in individual granulomas. We sought to correlate T cell cytokine response and bacterial burden of each granuloma, as well as granuloma and systemic responses in individual animals. Our results support that each granuloma within an individual host is independent with respect to total cell numbers, proportion of T cells, pattern of cytokine response, and bacterial burden. The spectrum of these components overlaps greatly amongst animals with different clinical status, indicating that a diversity of granulomas exists within an individual host. On average only about 8% of T cells from granulomas respond with cytokine production after stimulation with Mtb specific antigens, and few “multi-functional” T cells were observed. However, granulomas were found to be “multi-functional” with respect to the combinations of functional T cells that were identified among lesions from individual animals. Although the responses generally overlapped, sterile granulomas had modestly higher frequencies of T cells making IL-17, TNF and any of T-1 (IFN-γ, IL-2, or TNF) and/or T-17 (IL-17) cytokines than non-sterile granulomas. An inverse correlation was observed between bacterial burden with TNF and T-1/T-17 responses in individual granulomas, and a combinatorial analysis of pair-wise cytokine responses indicated that granulomas with T cells producing both pro- and anti-inflammatory cytokines (e.g. IL-10 and IL-17) were associated with clearance of Mtb. Preliminary evaluation suggests that systemic responses in the blood do not accurately reflect local T cell responses within granulomas.

The characteristic feature of Mycobacterium tuberculosis (Mtb) infection is the formation of lesions, which are organized structures of immune cells in the lungs called granulomas, which contain the bacteria. When the granuloma functions effectively, it can kill the bacteria. T cells (a type of immune cell, also present in granulomas) are known to play an important role in control of tuberculosis. However, functions of T cells at individual granuloma levels are unknown. Here, we studied the functional characteristics of T cells, which are defined by the production of chemical messengers (cytokines) at the granuloma level in a non-human primate model. We compared the relationship between cytokine response and the number of bacteria (Mtb) in each granuloma. Each granuloma was found to be unique, suggesting different types exist within an animal. Only a small proportion of T cells produced any cytokine, but different types of cytokines were observed within each granuloma. A balance between different types of cytokine was associated with more killing of bacteria in granulomas. Understanding how to improve the T cell responses to obtain killing of bacteria in the granuloma will be important for vaccine development.

Limited frequency of cytokine-producing T cells in tuberculosis lung granulomas (MPF6P.736)

Lung granulomas are the pathologic hallmark of Tuberculosis (TB). T cells are a major cellular component of tuberculosis lung granulomas and are known to play an important role in containment and progression of Mtb infection. We used cynomolgus macaques, a non-human primate model that recapitulates human TB, with clinically active disease and latent infection, to understand the functional characteristics and dynamics of T cells in individual granulomas and to correlate T cell cytokine response of granulomas to its bacterial burden and its systemic response. Our results suggest that each granuloma within an individual host is independent with respect to total cell numbers, proportion of T cells, pattern of cytokine response, and bacterial burden. The spectrum of these components overlaps greatly amongst various clinical status of these animals, indicating that a diversity of granulomas exist in individual hosts. Multi-parametric flow cytometry analysis of functional T cells in granulomas suggests that on average only ~6% of T cells respond to Mtb antigens with production of Th1/Th17 or IL-10 cytokines. An inverse correlation was observed between bacterial burden and Th1/Th17 response in individual granulomas. The systemic responses do not accurately reflect responses in granulomas, and suggests that, especially in active TB, the blood is a negative reflection of granuloma responses. Overall, these data provide insight into the local and systemic responses in tuberculosis.

CD4 T cell depletion exacerbates acute Mycobacterium tuberculosis while reactivation of latent infection is dependent on severity of tissue depletion in cynomolgus macaques

CD4 T cells are believed to be important in protection against Mycobacterium tuberculosis, but the relative contribution to control of initial or latent infection is not known. Antibody-mediated depletion of CD4 T cells in M. tuberculosis-infected cynomolgus macaques was used to study the role of CD4 T cells during acute and latent infection. Anti-CD4 antibody severely reduced levels of CD4 T cells in blood, airways, and lymph nodes. Increased pathology and bacterial burden were observed in CD4-depleted monkeys during the first 8 weeks of infection compared to controls. CD4-depleted monkeys had greater interferon (IFN)-γ expression and altered expression of CD8 T cell activation markers. During latent infection, CD4 depletion resulted in clinical reactivation in only three of six monkeys. Reactivation was associated with lower CD4 T cells in the hilar lymph nodes. During both acute and latent infection, CD4 depletion was associated with reduced percentages of CXCR3(+) expressing CD8 T cells, reported to be involved in T cell recruitment, regulatory function, and effector and memory T cell maturation. CXCR3(+) CD8 T cells from hilar lymph nodes had more mycobacteria-specific cytokine expression and greater coexpression of multiple cytokines compared to CXCR3(-) CD8 T cells. CD4 T cells are required for protection against acute infection but reactivation from latent infection is dependent on the severity of depletion in the draining lymph nodes. CD4 depletion influences CD8 T cell function. This study has important implications for human HIV-M. tuberculosis coinfection.

Phase II study of bevacizumab with liposomal doxorubicin for patients with platinum- and taxane-resistant ovarian cancer

BACKGROUND

Suppression of neoangiogenesis and pegylated liposomal doxorubicin (PLD) each contribute to the management of platinum-resistant/refractory ovarian cancer. The aim of this study is to test the combination of bevacizumab and PLD in women with resistant or refractory ovarian cancer.

METHODS

Eligibility criteria were no more than two prior treatments with platinum-containing regimens and one additional regimen, without anthracyclines. Treatment was administered every 3 weeks (bevacizumab 15 mg/kg beginning on cycle 2 and PLD 30 mg/m(2)). The primary end point was progression-free survival (PFS) at 6 months; the secondary end points included side-effects, overall response rates (ORR) and survival (OS).

RESULTS

Forty-six patients were enrolled. The average number of courses administered was 7. The median PFS was 6.6 months (range 1-24.6 months) according to Gynecologic Cancer Intergroup Committee (GCIC) criteria and 7.8 months (range 2-13.3 months) according to Response Evaluation Criteria in Solid Tumors (RECIST). The median OS was 33.2 months (range 3-37.5+ months). The ORR was 30.2% [95% confidence interval (CI) 17.2-46.1] and the clinical benefit rate (CBR) was 86.1% (95% CI 72.1-94.7). Adverse events included mucosal and dermal erosions (30% grade 3) and asymptomatic cardiac dysfunction. Additional toxic effects included hypertension, headache, renal dysfunction and proteinuria, wound healing delay, and one episode each of central nervous system (CNS) ischemia and hemolytic uremic syndrome.

CONCLUSION

PLD with bevacizumab has improved activity in recurrent ovarian cancer with increased toxicity.

Behavioural weight management for the primary careprovider

Primary care providers (PCPs) provide the majority of weight management care in clinical settings; however, they often lack the time or resources to apply strategies recommended in treatment guidelines. This review surveyed randomized clinical trials and prospective weight management studies from 1990 to present to identify evidence-based behavioural strategies for weight management applicable to the PCP treatment environment. Data supported, time-limited weight management strategies included self-monitoring, portion control, sleep hygiene, restaurant eating and television viewing. The current review suggests that a number of behavioural strategies are available to enhance the effectiveness of PCPs weight management interventions. Increasing PCP awareness of these evidence-based strategies may increase their attention to overweight and obesity concerns in clinical encounters and encourage more collaborative efforts with patients towards weight management goals.

Epidermal growth factor receptor as a biomarker for cervical cancer

This review focuses on the different modes of expression of the epidermal growth factor receptor (EGFR). All methods used to assess EGFR expression are critically analyzed and insights into the use of inhibitors of EGFR for treatment of cervical cancer are discussed. Currently, expression of EGFR as a biomarker for prognosis or for treatment of cervical cancer is not defined for clinical use.

Psychotropic medication use and risk of adverse cardiovascular events in women with suspected coronary artery disease: outcomes from the Women's Ischemia Syndrome Evaluation (WISE) study

OBJECTIVE

This study investigated the relation between psychotropic medication use and adverse cardiovascular (CV) events in women with symptoms of myocardial ischaemia undergoing coronary angiography.

METHOD

Women enrolled in the Women's Ischemia Syndrome Evaluation (WISE) were classified into one of four groups according to their reported antidepressant and anxiolytic medication usage at study intake: (1) no medication (n = 352); (2) anxiolytics only (n = 67); (3) antidepressants only (n = 58); and (4) combined antidepressant and anxiolytics (n = 39). Participants were followed prospectively for the development of adverse CV events (for example, hospitalisations for non-fatal myocardial infarction, stroke, congestive heart failure and unstable angina) or all-cause mortality over a median of 5.9 years.

RESULTS

Use of antidepressant medication was associated with subsequent CV events (HR 2.16, 95% CI 1.21 to 3.93) and death (HR 2.15, 95% CI 1.16 to 3.98) but baseline anxiolytic use alone did not predict subsequent CV events and death. In a final regression model that included demographics, depression and anxiety symptoms, and risk factors for cardiovascular disease, women in the combined medication group (that is, antidepressants and anxiolytics) had higher risk for CV events (HR 3.98, CI 1.74 to 9.10, p = 0.001 and all-cause mortality (HR 4.70, CI 1.7 to 2.97, p = 0.003) compared to those using neither medication. Kaplan-Meier survival curves indicated that there was a significant difference in mortality among the four medication groups (p = 0.001).

CONCLUSIONS

These data suggest that factors related to psychotropic medication such as depression refractory to treatment, or medication use itself, are associated with adverse CV events in women with suspected myocardial ischaemia.

Pegylated liposomal doxorubicin (PLD) with bevacizumab (B) in second-line treatment of ovarian cancer (OC): Pharmacokinetics (PK), safety, and preliminary outcome results

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Background: PLD activity in platinum-resistant OC is modest. B, with its activity in platinum(Plat)-sensitive and Plat-resistant patients (pts), has not been combined with PLD. PLD intratumoral concentrations, if affected by B, might be reflected in PLD PK. This phase II study of PLD + B was started in 2007 to accrue 48 pts, unless 4 serious (> grade 3) adverse events (AEs) supervened. Methods: Improvement in progression-free survival (PFS) at 6 m from 25 to 40% at 6 m in Plat-resistant OC is primary endpoint. PK of PLD alone at 1h, d 7 and d 21 (cycle 1) vs with B (cycle 2), safety, and response rates (RECIST and CA125 criteria) were secondary endpoints. Dosing: PLD 30 mg/m2 followed by B 15 mg/kg on cycles 2–7 (with option to continue) d 1 every 3 w. Pts recurring within 6 m of platinum-based treatment for OC after < 3 prior regimens (but no PLD or B) were eligible. Exclusions: bowel obstruction, prior perforation, uncontrolled hypertension, or vascular disease. Hematologic, mucocutaneous and renal toxicities were evaluated prior to each cycle, MUGA scans every third cycle; disease status by CA125 and/or RECIST every third cycle. Results: 21 of 24 pts enrolled to date are evaluable. Median age is 65, range 52–83; most had 2 prior chemotherapy regimens. Median 6 (range 3–12) cycles were given with 6 off study with progression at 3–7 cycles. RECIST and CA125 responses are under review; in 11 pts with baseline CA125 of > 40 IU/mL, median increase was 31% by cycle 2; later falling to -57%. AEs did not exceed grade 3; hand-foot syndrome led to PLD dose reduction in 8 pts (33%); asymptomatic decreases in left ventricular ejection fraction (LVEF) >10% in 3 pts were noted, with treatment discontinuation in 1. The mean (±SEM) secondary PK parameter estimates for Cmax, AUC, and elimination half life were 4.5 ± 0.5 ug/mL, 651.7 ± 61 ug/mL x h, and 93.3 ± 19.7 h, respectively. Conclusions: Cycles 1 and 2 PLD PK do not differ. PLD + B is tolerable with PLD dose modifications. Declines in LVEF in 1 institution have uncertain causality. Midway into the trial, safety and time on study encourage completion for study primary endpoint.

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Incidence, location, pathology, and significance of pulmonary homograft stenosis after the Ross operation

BACKGROUND

The Ross operation has several theoretical advantages. However, concern exists regarding evolving pathology in the pulmonary homograft.

METHODS AND RESULTS

Consecutive patients (n=144; mean age 31 years, range 2 months to 64 years) undergoing the Ross operation were studied between 1993 and 2000. Echocardiographic examination of the pulmonary homograft was performed immediately after surgery, then at yearly intervals for a mean interval of 48 months. Fifteen patients (mean age 37 years) in whom echocardiography revealed peak pulmonary gradients >/=30 mm Hg (mean 46+/-18 mm Hg) underwent MRI with velocity mapping in a Picker 1.5-T magnet. No patient had more than mild pulmonary regurgitation. Four patients required reoperation for rapidly progressive pulmonary homograft stenosis; in all 4, there was macroscopic and microscopic evidence of a pronounced chronic adventitial reaction, with perivascular infiltration producing extrinsic compression. Freedom from any pulmonary homograft stenosis at 7-year follow-up was 79.7%, with instantaneous hazard falling to zero after 4 years. Freedom from reoperation at 7 years was 96.7%. In those studied with MRI, there was evidence of narrowing of the whole homograft or distal suture line in 14 of 15 patients, with obvious excess surrounding tissue in 11. Mean minimum diameter and peak velocity by MRI were 11+/-2 mm and 3.2+/-0.7 m/s, respectively. Multivariate analysis of patient-, surgery-, and homograft-related variables did not reveal any significant risk factors for development of neopulmonary stenosis.

CONCLUSIONS

Pulmonary homograft stenosis after the Ross operation is clinically important and appears to represent an early postoperative inflammatory reaction to the pulmonary homograft that leads to extrinsic compression and/or shrinkage.

Psychosocial variables are associated with atherosclerosis risk factors among women with chest pain: the WISE study

OBJECTIVE

We investigated associations between atherosclerosis risk factors (smoking behavior, serum cholesterol, hypertension, body mass index, and functional capacity) and psychological characteristics with suspected linkages to coronary disease (depression, hostility, and anger expression) in an exclusively female cohort.

METHODS

Six hundred eighty-eight middle-aged women with chest pain warranting clinical investigation completed a comprehensive diagnostic protocol that included quantitative coronary angiography to assess coronary artery disease (CAD). Primary analyses controlled for menopausal status, age, and socioeconomic status variables (income and education).

RESULTS

High depression scores were associated with a nearly three-fold risk of smoking (odds ratio (OR) = 2.8, 95% confidence interval (CI) = 1.4-5.7) after covariate adjustment, and women reporting higher depression symptoms were approximately four times more likely to describe themselves in the lowest category of functional capacity (OR = 3.7, 95% CI = 1.7-7.8). High anger-out scores were associated with a four-fold or greater risk of low high-density lipoprotein cholesterol concentration (<50 mg/dl; OR = 4.0, 95% CI = 1.4-11.1) and high low-density lipoprotein cholesterol concentration (>160 mg/dl; OR = 4.8, 95% CI = 1.5-15.7) and a larger body mass index (OR = 3.5, 95% CI = 1.1-10.8) after covariate adjustment.

CONCLUSIONS

These results demonstrate consistent and clinically relevant relationships between psychosocial factors and atherosclerosis risk factors among women and may aid our understanding of the increased mortality risk among women reporting high levels of psychological distress.

History of anxiety disorders is associated with a decreased likelihood of angiographic coronary artery disease in women with chest pain: the WISE study

OBJECTIVES

We sought to evaluate the ability of psychiatric anxiety-disorder history to discriminate between women with and without angiographic coronary artery disease (CAD) in a population with chest pain.

BACKGROUND

A total of 435 women with chest pain underwent a diagnostic battery including coronary angiography in order to improve testing guidelines for women with suspected CAD.

METHODS

Women referred for coronary angiography completed questionnaires assessing prior treatment history for anxiety disorder and current anxiety-related symptoms. Analyses controlled for standard CAD risk factors.

RESULTS

Forty-four women (10%) reported receiving prior treatment for an anxiety disorder. This group acknowledged significantly higher levels of autonomic symptoms (e.g., headaches, muscle tension [F = 25.0, p < 0.0011 and higher behavioral avoidance scores (e.g., avoidance of open places or traveling alone by bus [F = 4.2, p < 0.05]) at baseline testing compared with women without prior anxiety problems. Women with an anxiety-disorder history did not differ from those without such a history with respect to the presence of inducible ischemia or use of nitroglycerin, although they were younger and more likely to describe both "tight" and "sharp" chest pain symptoms and to experience back pain and episodes of nocturnal chest pain. Logistic regression results indicated that the positive-anxiety-history group was more likely to be free of underlying significant angiographic CAD (odds ratio = 2.74, 95% confidence interval 1.15 to 6.5, p = 0.03).

CONCLUSIONS

Among women with chest pain symptoms, a history of anxiety disorders is associated with a lower probability of significant angiographic CAD. Knowledge of anxiety disorder history may assist in the clinical evaluation of women with chest pain.

Cardiovascular recovery from acute laboratory stress: reliability and concurrent validity

OBJECTIVE

We assessed the value of laboratory measures of cardiovascular recovery across four criteria: reliability across multiple tasks, reliability across a 3-year time interval, ability to predict daily ambulatory blood pressure, and interrelationships with coronary risk factors and psychosocial variables.

METHODS

Three hundred twenty-nine healthy adults (mean age = 27.1 years) completed a two-part protocol consisting of 1 day of laboratory testing and 1 day of ambulatory monitoring. The laboratory protocol included a 15-minute baseline assessment followed by three 5-minute laboratory challenges (mental arithmetic, speech, and handgrip). Five-minute recovery periods followed each exercise. One hundred twenty-five participants returned after 3 years to repeat the protocol.

RESULTS

When aggregated across tasks, cardiovascular recovery showed acceptable levels of internal consistency (alpha values = 0.7) and proved relatively stable across time (r values = 0.22-0.35). Recovery values statistically improved the prediction of daily ambulatory readings above baseline and stress reactivity laboratory values (p values < .001) but were largely unrelated to coronary risk factors or psychosocial measures.

CONCLUSION

These results suggest that cardiovascular recovery from acute laboratory stress can be treated as a stable individual difference variable that can -improve standard laboratory-based predictor models of ambulatory readings.

Psychological response styles and cardiovascular health: confound or independent risk factor?

Using results from 2 large cardiovascular studies, the authors examined the utility of treating psychological response styles as confounds (e.g., factors undermining relationships with other self-report variables) versus distinct personality traits in the prediction of cardiovascular health. Study 1 consisted of a 3-year prospective study of ambulatory blood pressure levels in healthy adults (N = 125). Study 2 comprised a 12-week drug treatment program for ischemic heart disease patients (N = 95). Participants completed measures of psychological factors and self-deception and impression management in each study. Results consistently favored using response styles as direct predictors. Self-deception scores predicted elevated 3-year diastolic and systolic blood pressure changes in Study 1 and poorer treatment outcomes in Study 2. Statistically controlling for response style effects within the psychological factors generally did not improve predictions. These findings argue against the conceptualization of response styles as stylistic confounds.

Defensiveness status predicts 3-year incidence of hypertension

OBJECTIVE

A growing body of research indicates that defensive personality styles (in particular, self-deception) may be related to higher resting blood pressure and stress reactivity levels. This study is the first, however, to examine the value of defensiveness as a prognostic indicator for the development of clinical hypertension.

METHODS

Participants were 127 initially normotensive male and female adults who completed a comprehensive protocol including psychological testing, assessment of smoking, physical activity and body fat levels, and 8-12 h ambulatory blood pressure monitoring. Participants returned 3-years later for an identical follow-up protocol. Defensiveness was assessed using the Balanced Inventory of Desirable Responding.

RESULTS

At 3-year testing, 15 of 127 participants (12%) met criteria for hypertension (i.e. ambulatory mean blood pressure > 140/90). Comparisons between defensiveness groups showed that 12 of 60 (20%) high defensiveness participants met hypertension criteria, whereas only three of 67 (4.5%) low defensiveness participants were hypertensive. Logistic regression equations adjusted for age, alcohol usage, bodyfat, self-reported exercise levels, smoking, and year-1 ambulatory blood pressure, revealed that membership in the high defensiveness group was associated with more than a sevenfold risk of 3-year hypertension (adjusted risk ratio, 7.5; 95% confidence interval, 1.5-39.2).

CONCLUSIONS

These findings link defensive characteristics to an increased prospective risk of hypertension using state of the art ambulatory monitoring techniques, and were robust after controlling for established risk factors. We conclude that the current results add to the hypertension literature by demonstrating associations between personality and clinically relevant blood pressure criteria.

Psychological risk factors may moderate pharmacological treatment effects among ischemic heart disease patients. Canadian Amlodipine/Atenolol in Silent Ischemia Study (CASIS) Investigators

BACKGROUND

Numerous research findings support the proposed connection between such psychological characteristics as stress and hostility and the manifestation of disease. However, less evidence is available concerning the role(s) psychological factors might play in the process of disease recovery.

METHODS

Eighty patients with known coronary disease and exercise-induced ischemia underwent treadmill exercise testing and 48-hour ambulatory electrocardiographic monitoring and completed a battery of standardized psychological tests assessing hostility, depression, and daily stress on four occasions during a 12-week pharmacological treatment study. After withdrawal of antiischemic drugs at baseline, patients returned for subsequent tests at 3-week intervals. During the second and third intervals, patients were prescribed one of two antiischemic medications, atenolol or amlodipine, or given a placebo. All patients were then placed on a combination treatment protocol for the 3 weeks before the final testing date.

RESULTS

The combination treatment produced highly significant benefits across all measured cardiac variables (20.3% improvement in exercise performance, 13% reduction in reported angina, 64.0% reduction in the frequency of ischemic episodes; for all, p < .01). However, results showed that high baseline levels of daily stress were associated with reliably smaller treatment effects on measures of ischemia frequency and treadmill exercise time and with a significantly greater likelihood of reporting angina after treatment (r = -0.24, -0.25, and -0.33, respectively; p <.05). In addition, high baseline hostility predicted significantly smaller diastolic blood pressure improvements (r = -0.29, p < .05).

CONCLUSIONS

These results indicate that psychological risk factors may have globally negative effects on the course of treatment and suggest particular factors that may warrant attention in trials targeting cardiac symptom reduction.

A case for the usefulness of laboratory social stressors

Although laboratory stress research is a popular and vibrant area of research activity, there is surprisingly little evidence that laboratory stress models are clinically useful (i.e. that they can explain and predict the development of disease). This article summarizes evidence that the usefulness of lab stress research can be improved with the use of social stressors. Two lines of evidence are presented in support of this argument: (a) studies comparing physiological reactivity to different lab stressors with ambulatory activity, and (b) a meta-analysis of investigations of cortisol responses to laboratory stressors. Further issues of importance in understanding social stressors are gender differences and the vulnerability (i.e. weak reliability) of social stressor impact to relatively small changes in the experimental protocol itself.

To eat or not to eat: affective and physiological mechanisms in the stress-eating relationship

The current study aggregated methods from the cardiovascular reactivity and dietary restraint paradigms in an attempt to advance our understanding of stress-induced eating behavior. Seventy-seven female subjects completed a protocol consisting of distinct baseline, stress-induction, and recovery phases during which we monitored blood pressure, heart rate, and self-reported affect. Food was inconspicuously made available to participants during the recovery phase. Our results replicated the restraint x affect level interaction observed in the restraint literature, while showing that physiological measures could further explain distressed eating behavior. Physiological arousal was found reliably to predict reduced food consumption, but only among unrestrained eaters. Analysis of the recovery data showed that food consumption was associated with impaired physiological recovery rates for restrained but not for unrestrained participants. We believe that our results help to reconcile findings in the stress, eating, and dietary restraint fields and offer support for recently developed theories of stress-induced overeating.

Social determinants of experienced anger

We investigated two social determinants (i.e., availability of social support and status differentials of the provocateur) for the degree of perceived anger in two populations. Because no suitable tool was available, the conceptual and psychometric development and validation of a new vignette-based measure for anger level (STandardized Experience of Anger Measure, STEAM) is described first. Two versions of STEAM were developed: one for students and one for community-living adults. Through a series of four studies, two sets of a 12-item vignette-based questionnaire were developed and validated. The resulting test had excellent test-retest stability and high internal consistency. Using the new STEAM measure, a variety of analyses were conducted to test the hypothesized influence of social determinants of anger. In the student sample, presence of social support was associated with lessened anger, and in both samples decreasing status of the provocateur also led to lessened anger arousal. In addition, findings in both samples revealed that social support reduced anger when the provocateur was of higher status relative to situations of equal and lesser status. In the community sample, the availability of support was associated with greater intensity of the anger experience in the lesser status condition than in the equal or greater status condition. No gender main effects or interactions were noted.

Transmembrane helical interactions: zeta chain dimerization and functional association with the T cell antigen receptor

Members of the zeta family of receptor subunits (zeta, eta and gamma) are structurally related proteins found as components of the T cell antigen receptor (TCR) and certain Fc receptors. These proteins share the ability to form disulfide-linked dimers with themselves and with other members of the family. Comparison of the amino acid sequences of zeta and gamma reveals a significant degree of homology, which is highest within their membrane-spanning domains. Analysis of their transmembrane sequences on a helical wheel projection suggests that all of the identical amino acids are clustered on one face of a potential alpha-helix. This face contains the only cysteine residue within zeta, suggesting that this conserved region may function to mediate dimerization. Indeed, replacing the transmembrane domain of the Tac antigen (alpha chain of the interleukin-2 receptor) by that of the zeta chain resulted in the formation of disulfide-linked dimers of Tac. The conserved aspartic acid residue found in the zeta and gamma transmembrane sequences was found to play a role in disulfide linkage. Replacing the aspartic acid with a lysine but not with an alanine or valine residue allowed formation of disulfide-linked dimers. The ability of the aspartic acid residue to support dimerization was dependent upon its position within the helix. Thus, these observations indicate that residues within the zeta transmembrane domain play a critical role in the formation of disulfide-linked dimers. Expression of zeta mutants in zeta-deficient T cells revealed that the zeta transmembrane domain is also responsible for reconstituting transport of functional TCR complexes to the cell surface and differentiated the requirements for disulfide-linked dimerization per se from assembly of the TCR complex.