A Practical Approach to Optimize Computerized Provider Order Entry Systems and Reduce Clinician Burden: Pre-Post Evaluation of Vendor-Derived "Order Friction" Data

Computerized provider order entry (CPOE) systems have been cited as a significant contributor to clinician burden. Vendor-derived measures and data sets have been developed to help with optimization of CPOE systems. We describe how we analyzed vendor-derived Order Friction (OF) EHR log data at our health system and propose a practical approach for optimizing CPOE systems by reducing OF. We also conducted a pre-post intervention study using OF data to evaluate the impact of defaulting the frequency of urine, stool and nasal swab tests and found that all modified orders had significantly fewer changes required per order (p<0.01). Our proposed approach is a six-step process: 1) understand the ordering process, 2) understand OF data elements contextually, 3) explore ordering user-level factors, 4) evaluate order volume and friction from different order sources, 5) optimize order-level design, 6) identify high volume alerts to evaluate for appropriateness.

A Computational Framework to Evaluate Emergency Department Clinician Task Switching in the Electronic Health Record Using Event Logs

Workflow fragmentation, defined as task switching, may be one proxy to quantify electronic health record (EHR) documentation burden in the emergency department (ED). Few measures have been operationalized to evaluate task switching at scale. Theoretically grounded in the time-based resource-sharing model (TBRSM) which conceives task switching as proportional to the cognitive load experienced, we describe the functional relationship between cognitive load and the time and effort constructs previously applied for measuring documentation burden. We present a computational framework, COMBINE, to evaluate multilevel task switching in the ED using EHR event logs. Based on this framework, we conducted a descriptive analysis on task switching among 63 full-time ED physicians from one ED site using EHR event logs extracted between April-June 2021 (n=2,068,605 events) which were matched to scheduled shifts (n=952). On average, we found a high volume of event-level (185.8±75.3/hr) and within-(6.6±1.7/chart) and between-patient chart (27.5±23.6/hr) switching per shift worked.

A Novel Approach to Support Quality Assurance (QA) of Intensity Modulated Neutron Therapy (IMNT)

PURPOSE/OBJECTIVE(S)

Neutron therapy is a form of high linear energy transfer (LET) radiation treatment shown to be beneficial for the treatment of locally advanced head and neck cancers (HNC) resistant to low LET x-ray and proton therapy treatments. The Clinical Neutron Therapy System (CNTS) at our institution has been in clinical operation for over 35 years, and over 3,400 patients have been treated using 3D conformal neutron radiation therapy. In October of 2022, the clinical commissioning of IMNT was completed and the first-ever patient was treated. A novel patient specific quality assurance (PSQA) program has been developed to support IMNT. We present an analysis of our early experiences and PSQA findings for the first 16+ patients treated with IMNT.

MATERIALS/METHODS

Our pre-treatment IMNT PSQA program includes (1) ionization chamber measurements, (2) a log-file analysis of treatment delivery, and (3) a γ-analysis of the expected and measured doses (fluences) from a novel positron emission portal imaging system based on 12C(n,2n)11C reactions. Patient setup is confirmed on a daily basis with kV portal imaging. We use a modulation factor (MF), defined as the total number of monitor units (MU)/prescribed dose (cGy) per fraction, to identify and help anticipate IMNT plans that may fail our PSQA program.

RESULTS

We have found that IMNT treatments for large, irregularly shaped treatment volumes (e.g., chest wall or head and neck cancers that require treatment of nodes in the lower neck) are more likely to fail PSQA when the MF exceeds 3 MU/cGy. For smaller, more spherical treatment volumes (e.g., base of tongue cancers), plans with a MF up to 3.5 MU/cGy pass our PSQA criteria. Re-optimized plans subsequently passed PSQA with insignificant or no change in tumor coverage and organ-at-risk (OAR) dose. Re-optimized plans also reduced the total number of MU and number of segments, which has the added benefit of decreasing the overall treatment time and patient time on the table. About 10% of early IMNT patients have required plan re-optimization.

CONCLUSION

Our pre-treatment clinical PSQA program and workflow provides useful information to guide IMNT treatment planning and delivery, and helps ensure the safe and accurate delivery of IMNT. Our early experiences suggest IMNT plans with smaller MF values are more likely to pass PSQA than plans with larger values of the MF.

Clinical Outcomes and Immunotoxicity in People with HIV (PWH) after Definitive Chemoradiation (CRT) for Anal Squamous Cell Carcinoma

PURPOSE/OBJECTIVE(S)

Anal cancer disproportionately affects PWH despite antiretroviral therapy. Data on CRT outcomes are limited. Modern IMRT CRT decreases acute toxicity but may exacerbate immune dysregulation from chronic HIV. Although historical CRT has been associated with prolonged CD4 count suppression, little is known about late immunotoxicity in PWH after contemporary CRT. We report clinical outcomes and long term immunotoxicity.

MATERIALS/METHODS

Single-center retrospective review of all PWH confirmed on chart review with anal squamous cell carcinoma without prior pelvic irradiation treated with definitive IMRT CRT. Patient and CRT factors including HIV suppression (<200 copies/mL), mean CD4 count (cells/µL), and receipt of capecitabine (C) or 5-fluorouracil (F) +/- mitomycin (M) were summarized with n (%) or median (interquartile range). Progression-free and overall survival (PFS; OS) were estimated per Kaplan-Meier with 95% confidence intervals and compared with log-rank tests. Mean CD4 count and CD4:CD8 were compared by HIV suppression status (Welch's t-test); longitudinal changes in median CD4 count and CD4:CD8 were compared between baseline vs. nadir (within 6 months of CRT start) and 1-year follow-up for patients with complete data (Wilcoxon signed-rank test).

RESULTS

A total of 23 PWH were treated between 2010-2022, median age 52, median 16 (13 - 19) years after HIV diagnosis; 4 had unsuppressed HIV; AJCC 8th stage I/II/III/IV 5/5/12/1. Radiation dose was median 54 Gy in 30 fractions over 42 (40 - 44) days. Most had C+M (57%); only 43% had 2×M with either C or F. One had neoadjuvant carboplatin/paclitaxel/pembrolizumab. With 2.9 (1.03 - 3.3) years follow-up, median OS was 6.6 (6.2 - unreached [UR]) years. With 2.2 (0.67 - 2.7) years follow-up, median PFS was UR. OS and PFS were similar regardless of HIV suppression status (both P ≥ 0.09). Overall baseline CD4 count was 458 (226 - 484), and CD4:CD8 was 0.54 (0.2 - 0.7). Nadir CD4 was 100 (59 - 126) and CD4:CD8 was 0.3 (0.2 - 0.4). Baseline and nadir CD4 count and CD4:CD8 were lower if HIV-unsuppressed (each P ≤ 0.04). One year after CRT, CD4 count was 252 (102 - 276), while CD4:CD8 was 0.5 (0.2 - 0.7). For 7 patients with repeated values the change in median from baseline to nadir, 6-, and 12-months post-CRT was -282, -549 (both P = 0.02), -480 (P = 0.9) for CD4 counts, and -0.7, -0.5, -0.4 (each P > 0.5) for CD4:CD8 ratios; none had unsuppressed HIV.

CONCLUSION

Definitive IMRT CRT with guideline-concordant doublet chemotherapy for anal cancer in PWH is effective despite unsuppressed HIV. Treatment leads to prolonged immunological changes that may increase the risk of HIV-related morbidity and mortality. Modifiable treatment-related causes of hematoimmunologic toxicity should be investigated further, and immune surveillance after CRT should be considered to better understand impact on quality of life.

Using Time Series Clustering to Segment and Infer Emergency Department Nursing Shifts from Electronic Health Record Log Files

Few computational approaches exist for abstracting electronic health record (EHR) log files into clinically meaningful phenomena like clinician shifts. Because shifts are a fundamental unit of work recognized in clinical settings, shifts may serve as a primary unit of analysis in the study of documentation burden. We conducted a proof- of-concept study to investigate the feasibility of a novel approach using time series clustering to segment and infer clinician shifts from EHR log files. From 33,535,585 events captured between April-June 2021, we computationally identified 43,911 potential shifts among 2,285 (74.2%) emergency department nurses. On average, computationally-identified shifts were 10.6±3.1 hours long. Based on data distributions, we classified these shifts based on type: day, evening, night; and length: 12-hour, 8-hour, other. We validated our method through manual chart review of computationally-identified 12-hour shifts achieving 92.0% accuracy. Preliminary results suggest unsupervised clustering methods may be a reasonable approach for rapidly identifying clinician shifts.

Understanding the perceived role of electronic health records and workflow fragmentation on clinician documentation burden in emergency departments

OBJECTIVE

Understand the perceived role of electronic health records (EHR) and workflow fragmentation on clinician documentation burden in the emergency department (ED).

METHODS

From February to June 2022, we conducted semistructured interviews among a national sample of US prescribing providers and registered nurses who actively practice in the adult ED setting and use Epic Systems' EHR. We recruited participants through professional listservs, social media, and email invitations sent to healthcare professionals. We analyzed interview transcripts using inductive thematic analysis and interviewed participants until we achieved thematic saturation. We finalized themes through a consensus-building process.

RESULTS

We conducted interviews with 12 prescribing providers and 12 registered nurses. Six themes were identified related to EHR factors perceived to contribute to documentation burden including lack of advanced EHR capabilities, absence of EHR optimization for clinicians, poor user interface design, hindered communication, increased manual work, and added workflow blockages, and five themes associated with cognitive load. Two themes emerged in the relationship between workflow fragmentation and EHR documentation burden: underlying sources and adverse consequences.

DISCUSSION

Obtaining further stakeholder input and consensus is essential to determine whether these perceived burdensome EHR factors could be extended to broader contexts and addressed through optimizing existing EHR systems alone or through a broad overhaul of the EHR's architecture and primary purpose.

CONCLUSION

While most clinicians perceived that the EHR added value to patient care and care quality, our findings underscore the importance of designing EHRs that are in harmony with ED clinical workflows to alleviate the clinician documentation burden.

Acute exacerbation of chronic obstructive pulmonary disease in a slaughterhouse

We describe the case of a 52-year-old male who presented with two episodes of acute exacerbations (AE) of chronic obstructive pulmonary disease (COPD) during work, while suspending live chickens for slaughter. The patient was exposed to high levels of bioaerosols, including endotoxins and microorganisms. Endotoxins can induce bronchoconstriction and airway inflammation, and COPD patients are more vulnerable to airway infections caused by microorganisms inhaled with bioaerosols. This study suggests that a high level of bioaerosols may induce airway infections, resulting in acute exacerbations of COPD.

Effect of supplementation of cryoprotectant solution with hydroxypropyl cellulose for vitrification of bovine oocytes

BACKGROUND

Successful cryopreservation of bovine oocytes is very important for research and commercial applications. However, the survival and development rate of vitrified-thawed (VT) oocytes are lower than those of non-vitrified-thawed (non-VT) oocytes.

OBJECTIVE

To investigate the effect of adding hydroxypropyl cellulose (HPC) to the vitrification solution for bovine oocytes.

MATERIALS AND METHODS

For vitrification, bovine metaphase II oocytes were pretreated with a solution containing 10% ethylene glycol supplemented with 0, 10, 50, or 100 ug/mL HPC for 5 min, exposed to a solution containing 30% ethylene glycol supplemented with 0, 10, 50, or 100 ug/mL HPC for 30 s, and then directly plunged into liquid nitrogen.

RESULTS

The survival rate of oocytes was significantly higher in the 50 HPC group than in the 0, 10, and 100 HPC groups. The reactive oxygen species level was lower in the non-VT and 50 HPC groups than in the other groups. The mRNA levels of proapoptotic genes (Bax) were lower in the non-VT, 0, and 50 HPC groups than in the other groups. The mRNA levels of antiapoptotic genes (BCl2) were higher in the non-VT than in the other groups. The development rates of embryos (day 8) obtained via parthenogenetic activation (PA) were determined in the non-VT, 0 HPC, and 50 HPC groups. The cleavage rate was significantly higher in the non-VT group.

CONCLUSION

Supplementation of vitrification solution with HPC improves the survival of VT bovine oocytes and the development capacity of embryos derived from these oocytes via PA. doi.org/10.54680/fr23110110212.

Effect of supplementation of cryoprotectant solution with hydroxypropyl cellulose for vitrification of bovine oocytes

BACKGROUND

Successful cryopreservation of bovine oocytes is very important for research and commercial applications. However, the survival and development rate of vitrified-thawed (VT) oocytes are lower than those of non-vitrified-thawed (non-VT) oocytes.

OBJECTIVE

To investigate the effect of adding hydroxypropyl cellulose (HPC) to the vitrification solution for bovine oocytes.

MATERIALS AND METHODS

For vitrification, bovine metaphase II oocytes were pretreated with a solution containing 10% ethylene glycol supplemented with 0, 10, 50, or 100 ug/mL HPC for 5 min, exposed to a solution containing 30% ethylene glycol supplemented with 0, 10, 50, or 100 ug/mL HPC for 30 s, and then directly plunged into liquid nitrogen.

RESULTS

The survival rate of oocytes was significantly higher in the 50 HPC group than in the 0, 10, and 100 HPC groups. The reactive oxygen species level was lower in the non-VT and 50 HPC groups than in the other groups. The mRNA levels of proapoptotic genes (Bax) were lower in the non-VT, 0, and 50 HPC groups than in the other groups. The mRNA levels of antiapoptotic genes (BCl2) were higher in the non-VT than in the other groups. The development rates of embryos (day 8) obtained via parthenogenetic activation (PA) were determined in the non-VT, 0 HPC, and 50 HPC groups. The cleavage rate was significantly higher in the non-VT group.

CONCLUSION

Supplementation of vitrification solution with HPC improves the survival of VT bovine oocytes and the development capacity of embryos derived from these oocytes via PA. doi.org/10.54680/fr23110110212.

A visual representation of microbiological culture data improves comprehension: a randomized controlled trial

OBJECTIVE

While the judicious use of antibiotics takes past microbiological culture results into consideration, this data's typical format in the electronic health record (EHR) may be unwieldy when incorporated into clinical decision-making. We hypothesize that a visual representation of sensitivities may aid in their comprehension.

MATERIALS AND METHODS

A prospective parallel unblinded randomized controlled trial was undertaken at an academic urban tertiary care center. Providers managing emergency department (ED) patients receiving antibiotics and having previous culture sensitivity testing were included. Providers were randomly selected to use standard EHR functionality or a visual representation of patients' past culture data as they answered questions about previous sensitivities. Concordance between provider responses and past cultures was assessed using the kappa statistic. Providers were surveyed about their decision-making and the usability of the tool using Likert scales.

RESULTS

518 ED encounters were screened from 3/5/2018 to 9/30/18, with providers from 144 visits enrolled and analyzed in the intervention arm and 129 in the control arm. Providers using the visualization tool had a kappa of 0.69 (95% CI: 0.65-0.73) when asked about past culture results while the control group had a kappa of 0.16 (95% CI: 0.12-0.20). Providers using the tool expressed improved understanding of previous cultures and found the tool easy to use (P < .001). Secondary outcomes showed no differences in prescribing practices.

CONCLUSION

A visual representation of culture sensitivities improves comprehension when compared to standard text-based representations.

Roles of OB-Fold Proteins in Replication Stress

Accurate DNA replication is essential for maintaining genome stability. However, this stability becomes vulnerable when replication fork progression is stalled or slowed - a condition known as replication stress. Prolonged fork stalling can cause DNA damage, leading to genome instabilities. Thus, cells have developed several pathways and a complex set of proteins to overcome the challenge at stalled replication forks. Oligonucleotide/oligosaccharide binding (OB)-fold containing proteins are a group of proteins that play a crucial role in fork protection and fork restart. These proteins bind to single-stranded DNA with high affinity and prevent premature annealing and unwanted nuclease digestion. Among these OB-fold containing proteins, the best studied in eukaryotic cells are replication protein A (RPA) and breast cancer susceptibility protein 2 (BRCA2). Recently, another RPA-like protein complex CTC1-STN1-TEN1 (CST) complex has been found to counter replication perturbation. In this review, we discuss the latest findings on how these OB-fold containing proteins (RPA, BRCA2, CST) cooperate to safeguard DNA replication and maintain genome stability.

Preoperative evaluation of mammographic microcalcifications after neoadjuvant chemotherapy for breast cancer

AIM

To assess the predictive value of preoperative residual mammographic microcalcifications for residual tumours after neoadjuvant chemotherapy (NAC) for breast cancer.

MATERIALS AND METHODS

This single-centre retrospective study included breast cancer patients who underwent NAC and demonstrated suspicious microcalcifications within or near the tumour bed on mammography from June 2015 to August 2018. The residual microcalcifications and remnant lesion on magnetic resonance imaging (MRI) were correlated with histopathological findings of residual tumours and immunohistochemical markers.

RESULTS

A total of 96 patients were included. Ten patients achieved pathological complete response (pCR) and previous suspicious microcalcifications were associated with benign pathology in 10.4% (10/96) of the patients. In the remaining 86 patients who did not achieve pCR, 61.5% (59/96) of the residual microcalcifications were associated with invasive or in situ carcinoma and 28.1% (27/96) with benign pathology. Hormone receptor-positive (HR⁺) patients had the highest proportion of residual malignant microcalcifications compared to HR^- patients (48.9% versus 13.5%, respectively; p=0.019). MRI correlated better than residual microcalcifications on mammography in predicting residual tumour extent in all subtypes (ICC=0.709 versus 0.365). MRI also showed higher correlation with residual tumour size for the HR^-/HER2⁺ and HR^-/HER2^- subtype (ICC=0.925 and 0.876, respectively).

CONCLUSION

The extent of microcalcifications on mammography after NAC did not correlate with the extent of residual cancer in 38.5% of women. Regardless of the extent of microcalcifications, residual tumour extent on MRI after NAC and molecular subtype could be an accurate tool in evaluating residual cancer after NAC.

A Novel Collateral Imaging Method Derived from Time-Resolved Dynamic Contrast-Enhanced MR Angiography in Acute Ischemic Stroke: A Pilot Study

BACKGROUND AND PURPOSE

Assessment of the collateral status has been emphasized for appropriate treatment decisions in patients with acute ischemic stroke. The purpose of this study was to introduce a multiphase MRA collateral imaging method (collateral map) derived from time-resolved dynamic contrast-enhanced MRA and to verify the value of the multiphase MRA collateral map in acute ischemic stroke by comparing it with the multiphase collateral imaging method (MRP collateral map) derived from dynamic susceptibility contrast-enhanced MR perfusion.

MATERIALS AND METHODS

From a prospectively maintained registry of acute ischemic stroke, MR imaging data of patients with acute ischemic stroke caused by steno-occlusive lesions of the unilateral ICA and/or the M1 segment of the MCA were analyzed. We generated collateral maps using dynamic signals from dynamic contrast-enhanced MRA and DSC-MRP using a Matlab-based in-house program and graded the collateral scores of the multiphase MRA collateral map and the MRP collateral map independently. Interobserver reliabilities and intermethod agreement between both collateral maps for collateral grading were tested.

RESULTS

Seventy-one paired multiphase MRA and MRP collateral maps from 67 patients were analyzed. The interobserver reliabilities for collateral grading using multiphase MRA or MRP collateral maps were excellent (weighted κ = 0.964 and 0.956, respectively). The agreement between both collateral maps was also excellent (weighted κ = 0.884; 95% confidence interval, 0.819-0.949).

CONCLUSIONS

We demonstrated that the dynamic signals of dynamic contrast-enhanced MRA could be used to generate multiphase collateral images and showed the possibility of the multiphase MRA collateral map as a useful collateral imaging method in acute ischemic stroke.

Abstract P4-11-03: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Kim EY, Park YL, Park CH, Suh BC. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-11-03.

Analysis of Pre-transplant Resuscitation Factors Influencing Immediate Graft Function After Deceased Donor Kidney Transplantation

BACKGROUND

The management of a deceased donor in the intensive care unit before organ transplantation is important for the outcome of the recipient. Herein, we analyze the pre-transplant resuscitation factors managed before procurement that could influence graft function immediately after deceased-donor kidney transplantation (DDKT).

METHODS

A total of 271 DDKTs performed at Seoul St. Mary's Hospital, Korea, from January 2009 to March 2016 were reviewed. We divided the patients into a delayed graft function (DGF) group and a non-DGF group, and compared postoperative outcomes between the 2 groups. We also analyzed the predisposing factors of DGF using multivariate analysis.

RESULTS

A total of 36 cases developed DGF while 235 patients did not, and the demographic characteristics of the recipients in the two groups had no significant difference. Of the pre-transplant resuscitation factors, preoperative polyuria, the maximal levels of serum sodium and BUN, and transfer times were significantly higher in the DGF group (P < .001). In a multivariable analysis, preoperative polyuria (odds ratio 4.835, P = .036), elevated preoperative level of sodium (odds ratio 1.227, P = .001), and extended transfer times (odds ratio 1.001, P < .001) were the independent risk factors of the donor in pre-transplant resuscitation management associated with DGF.

CONCLUSIONS

Polyuria, high levels of sodium before procurement, and prolonged transfer times are independent risk factors for DGF after a DDKT. Active intervention and early implementation of the intensivist can help in managing these factors effectively and thus ultimately improve graft function.

Modulation of autoimmune arthritis by environmental 'hygiene' and commensal microbiota

Observations in patients with autoimmune diseases and studies in animal models of autoimmunity have revealed that external environmental factors including exposure to microbes and the state of the host gut microbiota can influence susceptibility to autoimmunity and subsequent disease development. Mechanisms underlying these outcomes continue to be elucidated. These include deviation of the cytokine response and imbalance between pathogenic versus regulatory T cell subsets. Furthermore, specific commensal organisms are associated with enhanced severity of arthritis in susceptible individuals, while exposure to certain microbes or helminths can afford protection against this disease. In addition, the role of metabolites (e.g., short-chain fatty acids, tryptophan catabolites), produced either by the microbes themselves or from their action on dietary products, in modulation of arthritis is increasingly being realized. In this context, re-setting of the microbial dysbiosis in RA using prebiotics, probiotics, or fecal microbial transplant is emerging as a promising approach for the prevention and treatment of arthritis. It is hoped that advances in defining the interplay between gut microbiota, dietary products, and bioactive metabolites would help in the development of therapeutic regimen customized for the needs of individual patients in the near future.

Ursolic acid facilitates apoptosis in rheumatoid arthritis synovial fibroblasts by inducing SP1-mediated Noxa expression and proteasomal degradation of Mcl-1

Rheumatoid arthritis (RA) is characterized by hyperplastic pannus formation mediated by activated synovial fibroblasts (RASFs) that cause joint destruction. We have shown earlier that RASFs exhibit resistance to apoptosis, primarily as a result of enhanced expression of myeloid cell leukemia-1 (Mcl-1). In this study, we discovered that ursolic acid (UA), a plant-derived pentacyclic triterpenoid, selectively induces B-cell lymphoma 2 homology 3-only protein Noxa in human RASFs. We observed that UA-induced Noxa expression was followed by a consequent decrease in Mcl-1 expression in a dose-dependent manner. Subsequent evaluation of the signaling pathways showed that UA-induced Noxa is primarily mediated by the JNK pathway in human RASFs. Chromatin immunoprecipitation (IP) studies into the promoter region of Noxa indicated the role of transcription factor specificity protein 1 in JNK-mediated Noxa expression. Furthermore, the results from IP studies and proximity ligation assays indicated that UA-induced Noxa colocalizes and associates with Mcl-1 to prime it for proteasomal degradation through K48-linked ubiquitination by the selective recruitment of Mcl-1 ubiquitin ligase E3, a homologous to E6-associated protein C terminus domain-containing E3 ubiquitin ligase. These findings unveil a novel mechanism of inducing apoptosis in RASFs and a potential adjunct therapeutic strategy of regulating synovial hyperplasia in RA.-Kim, E. Y., Sudini, K., Singh, A. K., Haque, M., Leaman, D., Khuder, S., Ahmed, S. Ursolic acid facilitates apoptosis in rheumatoid arthritis synovial fibroblasts by inducing SP1-mediated Noxa expression and proteasomal degradation of Mcl-1.

Syndecans in chronic inflammatory and autoimmune diseases: Pathological insights and therapeutic opportunities

Syndecans (SDCs) are a family of heparan sulfate proteoglycans (HSPGs) glycoproteins ubiquitously expressed on the cell surfaces and extracellular matrix of all mammalian tissues. There are four mammalian syndecans, SDC-1 thorough 4, which play a critical role in cell adhesion, migration, proliferation, differentiation, and angiogenesis through independent and growth factor mediated signaling. An altered expression of SDCs is often observed in autoimmune disorders, cancer, HIV infection, and many other pathological conditions. SDCs modulate disease progression by interacting with a diverse array of ligands, receptors, and other proteins, including extracellular matrix, glycoproteins, integrins, morphogens, and various growth factors and chemokines, along with their receptors and kinases. Specifically, SDCs present on cell surface can bind directly to chemokines to enhance their binding to receptors, downstream signaling, and migration. Alternatively, SDCs can be cleaved and shed to mediate negative regulation of chemokine and growth factor signaling pathways and ligand sequestration. Importantly, SDC shedding may be a biomarker of inflammation, especially in chronic inflammatory diseases. While the current therapies for cancer and several autoimmune disorders have revolutionized treatment outcomes, understanding the pathophysiological role of SDCs and the use of HSPG mimetic or antagonists on cytokine signaling networks may uncover potentially novel targeted therapeutic approaches. This review mainly summarizes the current findings on the role of individual SDCs in disease processes, mechanisms through which SDCs mediate their biological functions, and the possibility of targeting SDCs as future potential therapeutic approaches.

Co-clinical trials demonstrate predictive biomarkers for dovitinib, an FGFR inhibitor, in lung squamous cell carcinoma

Background

We conducted co-clinical trials in patient-derived xenograft (PDX) models to identify predictive biomarkers for the multikinase inhibitor dovitinib in lung squamous cell carcinoma (LSCC).

Methods

The PDX01-02 were established from LSCC patients enrolled in the phase II trial of dovitinib (NCT01861197) and PDX03-05 were established from LSCC patients receiving surgery. These five PDX tumors were subjected to in vivo test of dovitinib efficacy, whole exome sequencing and gene expression profiling.

Results

The PDX tumors recapitulate histopathological properties and maintain genomic characteristics of originating tumors. Concordant with clinical outcomes of the trial enrolled-LSCC patients, dovitinib produced substantial tumor regression in PDX-01 and PDX-05, whereas it resulted in tumor progression in PDX-02. PDX-03 and -04 also displayed poor antitumor efficacy to dovitinib. Mutational and genome-wide copy number profiles revealed no correlation between genomic alterations of FGFR1-3 and sensitivity to dovitinib. Of note, gene expression profiles revealed differentially expressed genes including FGF3 and FGF19 between PDX-01 and 05 and PDX-02-04. Pathway analysis identified two FGFR signaling-related gene sets, FGFR ligand binding/activation and SHC-mediated cascade pathway were substantially up-regulated in PDX-01 and 05, compared with PDX-02-04. The comparison of gene expression profiles between dovitinib-sensitive versus -resistant lung cancer cell lines in the Cancer Cell Line Encyclopedia database also found that transcriptional activation of 18 key signaling components in FGFR pathways can predict the sensitivity to dovitinib both in cell lines and PDX tumors. These results highlight FGFR pathway activation as a key molecular determinant for sensitivity to dovitinib.

Conclusions

FGFR gene expression signatures are predictors for the response to dovitinib in LSCC.

Immunomodulation of autoimmune arthritis by pro-inflammatory cytokines

Pro-inflammatory cytokines promote autoimmune inflammation and tissue damage, while anti-inflammatory cytokines help resolve inflammation and facilitate tissue repair. Over the past few decades, this general feature of cytokine-mediated events has offered a broad framework to comprehend the pathogenesis of autoimmune and other immune-mediated diseases, and to successfully develop therapeutic approaches for diseases such as rheumatoid arthritis (RA). Anti-tumor necrosis factor-α (TNF-α) therapy is a testimony in support of this endeavor. However, many patients with RA fail to respond to this or other biologics, and some patients may suffer unexpected aggravation of arthritic inflammation or other autoimmune effects. These observations combined with rapid advancements in immunology in regard to newer cytokines and T cell subsets have enforced a re-evaluation of the perceived pathogenic attribute of the pro-inflammatory cytokines. Studies conducted by others and us in experimental models of arthritis involving direct administration of IFN-γ or TNF-α; in vivo neutralization of the cytokine; the use of animals deficient in the cytokine or its receptor; and the impact of the cytokine or anti-cytokine therapy on defined T cell subsets have revealed paradoxical anti-inflammatory and immunoregulatory attributes of these two cytokines. Similar studies in other models of autoimmunity as well as limited studies in arthritis patients have also unveiled the disease-protective effects of these pro-inflammatory cytokines. A major mechanism in this regard is the altered balance between the pathogenic T helper 17 (Th17) and protective T regulatory (Treg) cells in favor of the latter. However, it is essential to consider that this aspect of the pro-inflammatory cytokines is context-dependent such that the dose and timing of intervention, the experimental model of the disease under study, and the differences in individual responsiveness can influence the final outcomes. Nevertheless, the realization that pro-inflammatory cytokines can also be immunoregulatory offers a new perspective in fully understanding the pathogenesis of autoimmune diseases and in designing better therapies for controlling them.

Prognostic significance of cachexia score assessed by CT in male patients with small cell lung cancer

To determine the prognostic significance of CT-determined cachexia scores (CSs) in 127 consecutive male small cell lung cancer (SCLC) patients, cross-sectional areas of muscle and fat tissues at the third lumbar vertebra (L3) were retrospectively measured on baseline CT images. CSs were determined based on the presence of sarcopenia and/or adipopenia. According to the presence of sarcopenia (L3 muscle index <55 cm² /m² , 86.8%) and adipopenia (L3 fat index <22 cm² /m² , 11.8%), CSs were defined as follows: CS2 (sarcopenia and adipopenia, 11.8%), CS1 (sarcopenia only, 74.8%) and CS0 (13.4%). CS2 was significantly related to lower body mass index (p < .001) and poor performance status (p = .002), and patients with CS2 had shorter OS than patients with CS1 or CS0 (median OS, 5.0 months vs. 8.9 months vs. 18.3 months; p = .007). Multivariable analysis revealed that CS was an independent prognostic factor of poor survival (HR, 1.99 for CS1 and 2.59 for CS2, p = .036 and .023, CS0 as a reference), along with extensive stage (p < .001), supportive care only (p < .001) and an elevated lactate dehydrogenase (p = .005). CT-determined CSs, based on the presence of sarcopenia and/or adipopenia, could be used to predict prognosis in male SCLC.

Depression, Impulse Control Disorder, and Life Style According to Smartphone Addiction

We examined depression, impulse control disorder, and life style by degree of smartphone addiction. Chi-square tests and ANOVA were used to identify significant variables. CART was used to generate a decision making diagram of variables affecting smartphone addiction. The severe smartphone addiction group had rates of depression and impulse control disorder than the initial smartphone group.

Modulation of Adjuvant Arthritis by Cellular and Humoral Immunity to Hsp65

Heat shock proteins (Hsps) are highly conserved, and their expression is upregulated in cells by heat and other stressful stimuli. These proteins play a vital role in preserving the structural and functional integrity of cells under stress. Despite the ubiquitous expression of Hsps in an individual, the immune system is not fully tolerant to them. In fact, Hsps are highly immunogenic in nature, and immune response to these proteins is observed in various inflammatory and autoimmune diseases. Studies on the immunopathogenesis of autoimmune arthritis in the rat adjuvant arthritis (AA) model of human rheumatoid arthritis (RA) as well as observations in patients with RA and juvenile idiopathic arthritis (JIA) have unraveled immunoregulatory attributes of self-Hsp65-directed immunity. Notable features of Hsp65 immunity in AA include protection rather than disease induction following immunization of Lewis rats with self (rat)-Hsp65; the diversification of T cell response to mycobacterial Hsp65 during the course of AA and its association with spontaneous induction of response to self-Hsp65; the cross-reactive T cells recognizing foreign and self homologs of Hsp65 and their role in disease suppression in rats; the suppressive effect of antibodies to Hsp65 in AA; and the use of Hsp65, its peptides, or altered peptide ligands in controlling autoimmune pathology. The results of studies in the AA model have relevance to RA and JIA. We believe that these insights into Hsp65 immunity would not only advance our understanding of the disease process in RA/JIA, but also lead to the development of novel therapeutic approaches for autoimmune arthritis.

Increased Identification of Emergency Department 72-hour Returns Using Multihospital Health Information Exchange

OBJECTIVES

Emergency departments (EDs) commonly analyze cases of patients returning within 72 hours of initial ED discharge as potential opportunities for quality improvement. In this study, we tested the use of a health information exchange (HIE) to improve identification of 72-hour return visits compared to individual hospitals' site-specific data.

METHODS

We collected deidentified patient data over a 5-year study period from Healthix, an HIE in the New York metropolitan area. We measured site-specific 72-hour ED returns and compared these data to those obtained from a regional 31-site HIE (Healthix) and to those from a smaller, antecedent 11-site HIE. Although only ED visits were counted as index visits, either ED or inpatient revisits within 72 hours of the index visit were considered as early returns.

RESULTS

A total of 12,669,657 patient encounters were analyzed across the 31 HIE EDs, including 6,352,829 encounters from the antecedent 11-site HIE. Site-specific 72-hour return visit rates ranged from 1.1% to 15.2% (median = 5.8%) among the individual 31 sites. When the larger HIE was used to identify return visits to any site, individual EDs had a 72-hour return frequency of 1.8% to 15.5% (median = 6.8%). HIE increased the identification ability of 72-hour ED return analyses by a mean of 11.16% (95% confidence interval = 11.10% to 11.22%) compared with site-specific (no HIE) analyses.

CONCLUSION

This analysis demonstrates incremental improvements in our ability to identify early ED returns using increasing levels of HIE data aggregation. Although intuitive, this has not been previously described using HIE. ED quality measurement and patient safety efforts may be aided by using HIE in 72-hour return analyses.

Nigrosome 1 Detection at 3T MRI for the Diagnosis of Early-Stage Idiopathic Parkinson Disease: Assessment of Diagnostic Accuracy and Agreement on Imaging Asymmetry and Clinical Laterality

BACKGROUND AND PURPOSE

In the early stages of idiopathic Parkinson disease, motor symptoms are usually asymmetric. We aimed to assess the feasibility of nigrosome 1 detection at 3T MR imaging to analyze the agreement of its asymmetry and clinical laterality.

MATERIALS AND METHODS

High-resolution 3D multiecho imaging was performed at 3T MR imaging in 13 healthy subjects and 24 patients with idiopathic Parkinson disease confirmed by N-3-fluoropropyl-2-β-carbomethoxy-3-β-(4-iodophenyl) nortropane ((18)F-FP-CIT) PET. The nigrosome 1 detection findings by using the MR imaging data were rated as "normal," "possibly abnormal," and "abnormal" by 2 independent reviewers. The degree of (18)F-FP-CIT binding was visually assessed in the caudate nucleus and putamen on PET images. Clinical laterality was evaluated by scores of the Unified Parkinson Disease Rating Scale, Part III. Asymmetry of the affected nigrosome 1 and the degree of (18)F-FP-CIT binding were analyzed for agreement with clinical laterality.

RESULTS

The diagnostic sensitivity, specificity, and accuracy of the nigrosome 1 detection at 3T MR imaging was 100%, 84.6%, and 94.6%, respectively. Interrater agreements for the abnormality and asymmetry of nigrosome 1 were excellent (κ = 0.863 and 0.835, respectively). In patients with idiopathic Parkinson disease, the agreement of asymmetry between clinical laterality and nigrosome 1 detection was good (κ = 0.724). The degree of the (18)F-FP-CIT PET binding showed fair agreement (κ = 0.235) with clinical laterality.

CONCLUSIONS

The abnormality involving nigrosome 1 can be detected at 3T MR imaging with an accuracy of 94.6%. The clinical laterality is in high concordance with the laterality of the nigrosome 1 detection at 3T (κ = 0.724).

Early menarche increases the risk of Type 2 diabetes in young and middle-aged Korean women

AIMS

To investigate the association between early menarche (menarche age < 12 years) and Type 2 diabetes mellitus in young and middle-aged Korean women.

METHODS

We analysed data for 4657 women aged 20-50 years from the Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV) (2007-2009).

RESULTS

The prevalence of Type 2 diabetes was 2.8%. Women with early menarche had a higher prevalence of impaired fasting glucose than did women with later menarche (age ≥ 12 years) in the 20-30 age group (7.4% vs. 3.0%), and a higher prevalence of diabetes in the 30-40 (6.3% vs. 1.7%) and 40-50 (18.5% vs. 4.4%) age groups. The odds ratio (OR) of Type 2 diabetes in women with early menarche was 3.61 [95% confidence interval (CI), 1.90-6.88] after adjusting for age. In multivariate regression, the OR of Type 2 diabetes decreased to 2.52 (95% CI, 1.29-4.94) after further adjusting for BMI. However, the OR decreased to 2.04 (95% CI, 0.95-4.39) without significance after adjusting for HOMA-IR.

CONCLUSIONS

Early menarche increased the risk of Type 2 diabetes in young and middle-aged Korean women although adulthood adiposity attenuated the relationship. Knowledge of age at menarche is important in identifying women at risk for diabetes.

Effect of renal impairment and haemodialysis on the pharmacokinetics of gemigliptin (LC15-0444)

This study evaluated the effects of renal impairment (RI) and haemodialysis (HD) on the pharmacokinetics of gemigliptin, a novel dipeptidyl peptidase-4 (DPP-4) inhibitor. After a 100 mg administration to subjects with normal renal function (n = 23) or RI (n = 24), plasma, urine or dialysate samples were analysed. Control subjects were matched to patients based on age, gender and body mass index. Patients with mild, moderate, severe RI and end-stage renal disease (ESRD) showed 1.20, 2.04, 1.50 and 1.66-fold (1.10, 1.49, 1.22 and 1.21-fold) increase of mean area under the time-plasma concentration curve from 0 to infinity (AUCinf) [maximum plasma concentration (Cmax)] of gemigliptin, respectively. Pharmacokinetics of gemigliptin was comparable between HD and non-HD periods in ESRD patients. Less than 4% of the dose was removed by 4 h HD. RI appeared to have modest effect on the gemigliptin disposition. No dose adjustment in patients with RI is proposed on the basis of exposure-response relationship. Impact of HD on the removal of gemigliptin was negligible.

Association between vitamin D deficiency and tuberculosis in a Korean population

BACKGROUND

Several in vitro studies have been conducted regarding the immunomodulatory and mycobactericidal roles of vitamin D in tuberculous infection. However, discrepancies exist among epidemiological studies. We compared vitamin D deficiency between patients with tuberculosis (TB) and healthy control subjects and identified risk factors for vitamin D deficiency.

METHOD

This was an age- and sex-matched case-control analysis of 94 TB cohort and 282 Korean national survey participants.

RESULTS

The median baseline 25-hydroxyvitamin D (25[OH]D) level in the TB group (9.86 ng/ml, IQR 7.19-14.15) was lower than in controls (16.03 ng/ml, IQR 12.38-20.30, P < 0.001). The prevalence of severe vitamin D deficiency was higher in patients with TB (51.1%) than in controls (8.2%, P = 0.001). The median 25(OH)D level increased from 11.40 ng/ml (IQR 7.85-15.73) to 13.18 ng/ml (IQR 10.60-19.71) after treatment completion (P = 0.037). On multivariate analysis, presence of TB and history of TB were independently associated with severe vitamin D deficiency.

CONCLUSION

Patients with TB had a higher prevalence of vitamin D deficiency than control subjects in a Korean population. The median 25(OH)D level increased after TB treatment. Further studies are needed to establish a causal relationship.

Role of sphingosine kinase 1 and sphingosine-1-phosphate in CD40 signaling and IgE class switching

The tumor necrosis factor (TNF) receptor family member CD40 plays an essential role in the activation of antigen-presenting cells, B cell maturation, and immunoglobulin (Ig) class switching critical for adaptive immunity. Although the bioactive sphingolipid metabolite sphingosine-1-phosphate (S1P) and the kinase that produces it, sphingosine kinase 1 (SphK1), have long been implicated in the actions of TNF mediated by engagement of TNFR1, nothing is yet known of their role in CD40-mediated events. We have now found that ligation of CD40 activates and translocates SphK1 to the plasma membrane, leading to generation of S1P. SphK1 inhibition in human tonsil B cells, as well as inhibition or deletion of SphK1 in mouse splenic B cells, significantly reduced CD40-mediated Ig class switching and plasma cell differentiation ex vivo. Optimal activation of downstream CD40 signaling pathways, including NF-κB, p38, and JNK, also required SphK1. In mice treated with a SphK1 inhibitor or in SphK1(-/-) mice, isotype switching to antigen-specific IgE was decreased in vivo by 70 and 55%, respectively. Our results indicate that SphK1 is important for CD40-mediated B cell activation and regulation of humoral responses and suggest that targeting SphK1 might be a useful therapeutic approach to control antigen-specific IgE production.

Comparison of clinical outcomes in hepatitis B virus-positive kidney transplant recipients with or without pretransplantation antiviral therapy

BACKGROUND

Antiviral agents have improved the outcomes of hepatitis B virus (HBV)-positive kidney transplant recipients (KTRs). Preemptive therapy has been the main approach to forestall HBV reactivation. We sought to compare prophylactic and preemptive approaches.

METHODS

We divided the 69 HBV-positive KTRs into treatment and historical control groups, according to the time of starting pretransplantation antiviral therapy. The treatment group was further divided into prophylactic and preemptive therapy groups.

RESULTS

The treatment group showed a significant improvement in 10-year graft (82% vs 34%) and patient (91% vs 57%) survivals. Among the historical control group, the main causes of graft failure were patient deaths (68%), which were mostly caused by liver diseases. In contrast, there was no liver-related death in the treatment group. In addition, there was no difference in graft or patient survival between the prophylactic and preemptive groups, but the incidence of HBV reactivation was lower in the prophylactic group. Antiviral therapy was an independent factor for the improved patient survival (P = .005).

CONCLUSIONS

Pretransplantation antiviral therapy is essential to improve clinical outcomes. Prophylactic may be better than preemptive antiviral therapy to decrease HBV reactivation.

Validation of a scoring tool to predict drug-resistant pathogens in hospitalised pneumonia patients

BACKGROUND

Health care-associated pneumonia (HCAP) affects a heterogeneous group of patients in frequent contact with health care systems. However, HCAP criteria poorly predict infection with drug-resistant (DR) pathogens.

OBJECTIVE

To validate our previously reported risk-scoring model (predictive of DR pathogen infection) in patients admitted to hospital with pneumonia.

DESIGN

We evaluated 580 patients admitted with culture-positive bacterial pneumonia. We identified risk factors, evaluated the risk-scoring model's capacity to predict infection by DR pathogens and compared the model's diagnostic accuracy with that of current HCAP criteria.

RESULTS

DR pathogens were observed in 227/580 patients (39.1%). Of 269 HCAP patients, 153 (56.9%) were infected with DR pathogens. Overtreatment was more common in HCAP than in community-acquired pneumonia (58.7% vs. 41.2%, P < 0.001). Recent hospitalisation, admission from a long-term care facility, recent antibiotic treatment and tube feeding were independently associated with DR pathogens. For pathogen prediction, the risk-scoring model showed better diagnostic accuracy than HCAP criteria (area under receiver operating-characteristic curve = 0.723 vs. 0.673, P < 0.001).

CONCLUSION

According to current HCAP criteria, half of the HCAP patients were treated unnecessarily with broad-spectrum antibiotics. Risk scoring by stratifying risk factors could improve the identification of patients likely to be infected with DR pathogens.

Effect of Mn and P on the macroscopic texture of Ti-Nb stabilized interstitial free steels

The effect of Mn and P on the macroscopic texture of Ti-Nb stabilized IF steels was investigated. In order to examine the evolution of microstructure and macroscopic texture during the hot-rolling, cold-rolling and annealing processes, microstructure characterization was conducted for hot-rolled, cold-rolled and annealed specimens. The initial grain size of hot-rolled specimens was a main parameter in determining the development of the macroscopic texture of the annealed specimens.

Abstract 5000: Spinster 2 exports S1P, an important player in lymph node metastasis

Sphingosine-1-phosphate (S1P), a ligand for five specific receptors, is a potent lipid mediator that plays important roles in cancer cell proliferation, migration, and cancer-induced angiogenesis/lymphangiogenesis. S1P is produced inside cells and therefore must be secreted in order to exert its effects through these receptors. We have reported that E2-induced export of S1P mediated by ABCC1 and ABCG2 transporters and consequent activation of S1P receptors may contribute to nongenomic signaling of E2 important for breast cancer pathophysiology. Spinster 2 (Spns2) is one of the cell surface transporters thought to secrete S1P, thus it is important to elucidate its physiological role. Although lymphatic endothelial cells contribute to regulation of S1P levels in lymph, little is known how S1P levels are maintained in the lymphatic system. Spinster 2 knockout mice were used, and the lymphatic system was examined by flow cytometry and immunofluorescent staining. Sphingolipids in the blood, lymph, and organs were determined by liquid chromatography-electrospray ionization tandem mass spectrometry (LC-ESI-MS/MS). We found that S1P secreted by breast cancer cells promotes tumor progression in a syngeneic model by stimulating angiogenesis and lymphangiogenesis. Interestingly, suppression of tumor S1P production resulted in less lymph node metastasis. Further, we found that serum S1P levels are elevated in breast cancer patients with lymph node metastasis. We confirmed that Spns2 can export endogenous S1P from cells and also dihydro-S1P, which is active at all cell surface S1P receptors. Moreover, Spns2-/- mice have decreased levels of both of these phosphorylated sphingoid bases in blood, accompanied by increases in very long chain ceramide species, and have defective lymphocyte trafficking. Surprisingly, levels of S1P and dihydro-S1P were increased in lymph from Spns2-/- mice as well as in specific tissues, including lymph nodes, and interstitial fluid. Moreover, lymph nodes from Spns2-/- mice have aberrant lymphatic sinuses, which appear collapsed, with reduced numbers of lymphocytes. Our data suggest that Spns2 is a S1P transporter in vivo that regulate not only of blood S1P but also lymph node and lymph S1P levels, which may implicate a role in lymph node metastasis.

M.N. is a Japan Society for the Promotion of Science Postdoctoral Fellow. S.S. is supported by NIH R37GM043880, and K.T. by NIH R01CA160688 and Susan G. Komen for the Cure Investigator Initiated Research Grant.

Citation Format: Masayuki Nagahashi, Eugene Y. Kim, Akimitsu Yamada, Subramaniam Ramachandran, Jeremy C. Allegood, Nitai Hait, Michael Maceyka, Sheldon Milstien, Sarah Spiegel, Kazuaki Takabe. Spinster 2 exports S1P, an important player in lymph node metastasis. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 5000. doi:10.1158/1538-7445.AM2013-5000

Abstract LB-325: Sphingosine-1-phosphate links chronic intestinal inflammation to development of colitis-associated cancer

Inflammatory bowel disease is an important risk factor for colorectal cancer. The pro-inflammatory cytokines TNF-alpha and IL-6 and their downstream master transcription factors NF-kappaB and Stat3 are critical regulators of chronic inflammation and cancer. There is growing evidence that sphingosine-1-phosphage (S1P), a pleiotropic bioactive sphingolipid metabolite formed inside cells by two closely related sphingosine kinases, SphK1 and SphK2, is involved in inflammation and cancer. In this work, we have shown that S1P produced by upregulation of SphK1 links chronic intestinal inflammation to CAC and both are exacerbated by deletion of SphK2. S1P is essential for production of the multifunctional NF-kappaB-regulated cytokine IL-6, persistent activation of the transcription factor Stat3, and consequent upregulation of the S1P receptor, S1PR1. Adoptive transfer demonstrated that SphK2 deficiency in hematopoietic cells contributed to colitis severity, IL-6 production, and activation of Stat3 and NF-kappaB. The pro-drug FTY720 decreased SphK1 and S1PR1 and eliminated the NF-kappaB-IL-6-Stat3 amplification cascade and development of CAC even in SphK2-/- mice, suggesting that FTY720 may be useful in treating colon cancer in individuals with ulcerative colitis. Thus, the SphK1-S1P-S1PR1 axis is at the nexus between NF-kappaB and Stat3 and connects chronic inflammation and CAC.

This work was supported by NIH grants R37GM043880, R01CA61774 (to S.S.) and K12HD055881 and the Susan G. Komen for the Cure Research Foundation grant (to K.T.). M.N. is a Japan Society for the Promotion of Science Postdoctoral Fellow. E.Y.K. and J.C.A. were supported by NIH training grant T32HL094290.

Citation Format: Masayuki Nagahashi, Jie Liang, Eugene Y. Kim, Kuzhuvelil B. Harikumar, Akimitsu Yamada, Wei-Ching Huang, Nitai C. Hait, Jeremy C. Allegood, Megan M. Price, Dorit Avni, Kazuaki Takabe, Tomasz Kordula, Sheldon Milstien, Sarah Spiegel. Sphingosine-1-phosphate links chronic intestinal inflammation to development of colitis-associated cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr LB-325. doi:10.1158/1538-7445.AM2013-LB-325

Spns2, a transporter of phosphorylated sphingoid bases, regulates their blood and lymph levels, and the lymphatic network

Sphingosine-1-phosphate (S1P), a ligand for 5 specific receptors, is a potent lipid mediator that plays important roles in lymphocyte trafficking and immune responses. S1P is produced inside cells and therefore must be secreted to exert its effects through these receptors. Spinster 2 (Spns2) is one of the cell surface transporters thought to secrete S1P. We have shown that Spns2 can export endogenous S1P from cells and also dihydro-S1P, which is active at all cell surface S1P receptors. Moreover, Spns2 mice have decreased levels of both of these phosphorylated sphingoid bases in blood, accompanied by increases in very long chain ceramide species, and have defective lymphocyte trafficking. Surprisingly, levels of S1P and dihydro-S1P were increased in lymph from Spns2 mice as well as in specific tissues, including lymph nodes, and interstitial fluid. Moreover, lymph nodes from Spns2 mice have aberrant lymphatic sinus that appeared collapsed, with reduced numbers of lymphocytes. Our data suggest that Spns2 is an S1P transporter in vivo that plays a role in regulation not only of blood S1P but also lymph node and lymph S1P levels and consequently influences lymphocyte trafficking and lymphatic vessel network organization.

Sphingosine-1-phosphate links persistent STAT3 activation, chronic intestinal inflammation, and development of colitis-associated cancer

Inflammatory bowel disease is an important risk factor for colorectal cancer. We show that sphingosine-1-phosphate (S1P) produced by upregulation of sphingosine kinase 1 (SphK1) links chronic intestinal inflammation to colitis-associated cancer (CAC) and both are exacerbated by deletion of Sphk2. S1P is essential for production of the multifunctional NF-κB-regulated cytokine IL-6, persistent activation of the transcription factor STAT3, and consequent upregulation of the S1P receptor, S1PR1. The prodrug FTY720 decreased SphK1 and S1PR1 expression and eliminated the NF-κB/IL-6/STAT3 amplification cascade and development of CAC, even in Sphk2(-/-) mice, and may be useful in treating colon cancer in individuals with ulcerative colitis. Thus, the SphK1/S1P/S1PR1 axis is at the nexus between NF-κB and STAT3 and connects chronic inflammation and CAC.

Fulminant Type 1 diabetes in a pregnant woman as an initial manifestation of the insulin autoimmune syndrome

Fulminant Type 1 diabetes is a subtype of Type 1 diabetes characterized by (1) abrupt onset of diabetes, (2) very short duration of hyperglycaemia with mildly elevated HbA(1c) (< 69 mmol/mol, 8.5%), (3) rapid progression to diabetic ketoacidosis, (4) very low C-peptide level, and (5) often associated with elevated serum pancreatic enzymes, and absence of diabetes-related autoantibodies. We encountered a case of fulminant Type 1 diabetes that developed with an initial manifestation of the insulin autoimmune syndrome and rapidly progressed to diabetic ketoacidosis during pregnancy. A 31-year-old Korean woman presented with recurrent sudden onset of sweating and change of consciousness during sleep at 19 weeks gestation. During a 72-h fasting test, hypoglycaemia (1.72 mmol/l) occurred at 4 h after the start of the test. At that time, there was a high insulin level (370.2 μU/ml), a paradoxically low C-peptide level (0.01 nmol/l) and a positive insulin autoantibody test. An oral glucose tolerance test revealed postprandial hyperglycaemia. She was initially diagnosed as the insulin autoimmune syndrome. On the day 5 of admission, she developed diabetic ketoacidosis. Her HbA(1c) was 62 mmol/mol (7.8%). The rapid progression of diabetic ketoacidosis altered the diagnosis to fulminant Type 1 diabetes. This case differed from typical fulminant Type 1 diabetes because it presented with hypoglycaemia, and positive insulin and anti-phospholipid antibody tests. Her HLA typing was HLA-DQA1*0302, 0501, HLA-DRB1*0301 (DR3), 0901(DR9). Her glucose level was subsequently very well controlled with multiple insulin injections and she successfully delivered a healthy baby.

Preliminary studies with a new hypoxia-selective cytotoxin, KS119W, in vitro and in vivo

Agents with selective toxicity to hypoxic cells have shown promise as adjuncts to radiotherapy. Our previous studies showed that the bioreductive alkylating agent KS119 had an extremely large differential toxicity to severely hypoxic and aerobic cells in cell culture, and was effective in killing the hypoxic cells of EMT6 mouse mammary tumors in vivo. However, the limited solubility of that compound precluded its development as an anticancer drug. Here we report our initial studies with KS119W, a water-soluble analog of KS119. The cytotoxicity of KS119W to EMT6 cells in vitro was similar to that of KS119, with both agents producing only minimal cytotoxicity to aerobic cells even after intensive treatments, while producing pronounced cytotoxicity to oxygen-deficient cells. This resulted in large differentials in the toxicities to hypoxic and aerobic cells (>1,000-fold at 10 μM). Low pH had only minimal effects on the cytotoxicity of KS119W. Under hypoxic conditions, EMT6 cells transfected to express high levels of either human or mouse versions of the repair protein O(6)-alkylguanine-DNA alkyltransferase, which is also known as O(6)-methylguanine DNA-methyltransferase, were much more resistant to KS119W than parental EMT6 cells lacking O(6)-alkylguanine-DNA alkyltransferase, confirming the importance of DNA O-6-alkylation to the cytotoxicity of this agent. Studies with EMT6 tumors in BALB/c Rw mice using both tumor cell survival and tumor growth delay assays showed that KS119W was effective as an adjunct to irradiation for the treatment of solid tumors in vivo, producing additive or supra-additive effects in most combination regimens for which the interactions could be evaluated. Our findings encourage additional preclinical studies to examine further the antineoplastic effects of KS119W alone and in combination with radiation, and to examine the pharmacology and toxicology of this new bioreductive alkylating agent so that its potential for clinical use as an adjuvant to radiotherapy can be evaluated.

Histologically benign but clinically malignant neoplasms in the thorax: CT-pathological overview

The purpose of this article is to review the computed tomography (CT) and histopathological features of uncommon primary neoplasms of the thorax that can manifest clinically malignant features (multiplicity of pulmonary nodules, an invasive nature, and metastases or recurrence after surgery) with little evidence of histological malignancy.

Abstract 4364: S1P generated by SphK1 is important not only for primary tumor growth but also for tumor-induced hemangiogenesis and lymphangiogenesis

INTRODUCTION: Sphingosine-1-phosphate (S1P), a pleiotropic bioactive lipid mediator, regulates many cellular processes important for breast cancer progression. The aim of this study is to investigate a role for S1P produced by sphingosine kinase 1 (SphK1) in breast cancer progression and tumor-induced hemangiogenesis and lymphangiogenesis. METHODS: An isozyme-specific inhibitor of SphK1 (SK1-I) was used. Tumor burden were quantified using an in vivo imaging system (IVIS 2000). S1P and SK1-I levels were measured by LC-ESI-MS/MS. Hemangiogenesis and lymphangiogenesis are determined by morphological analysis of microvessel density as well as by flow cytometric analysis of endothelial cells. RESULTS: A significant dose dependent effect of SK1-I on inhibition of 4T1-luc2 murine breast cancer cell growth was observed. We confirmed that SK1-I decreased the enzymatic activity of SphK1 and that downregulation of SphK1 with specific siRNA also suppressed growth of these cells. We found that S1P levels increased in the tumor and in the circulation after orthotopic implantation of 4T1-luc2 cells. Similarly, serum S1P levels were significantly elevated in stage IIIA breast cancer patients who have lymph node metastases, compared to age/ethnicity-matched healthy volunteers. SK1-I blocked serum S1P increases in in vivo model and reduced lymph node and lung metastases and overall tumor burden in vivo as well. Importantly, SK1-I also decreased hem- and lymphangiogenesis not only in the primary tumor, but also in lymph nodes, the host tumor microenvironment. Whereas supernatants from 4T1-luc2 cells significantly stimulated tube formation of HUVECs and HLECs, shRNA knockdown of SphK1 markedly reduced them, indicating that S1P produced by SphK1 in 4T1-luc2 breast cancer cells is an important contributor to hem- and lymphangiogenesis. CONCLUSIONS: S1P generated by SphK1 is important for tumor progression, tumor-induced hemangiogenesis and lymphangiogenesis, and lymph node metastais. Therefore targeting SphK1 and its product S1P would be a multi-pronged attack against breast cancer. This work was supported by Sumitomo Life Social Welfare Services Foundation grant to MN, NIH (K12HD055881) and Susan G. Komen for the Cure (KG090510) to KT, and NCI (R01CA61774) to SS.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4364. doi:1538-7445.AM2012-4364

Abstract 5280: Activation of sphingosine kinase 1 is necessary for angiopoietin 2-induced hemangiogenesis and lymphangiogenesis

INTRODUCTION: Sphingosine kinase 1 (SphK1) is one of the two isoenzymes that generate the potent bioactive sphingolipid mediator, sphingosine-1-phosphate (S1P). S1P promotes cancer cell survival, proliferation and hemangiogenesis. The angiopoietin2 (Ang2)-Tie2 axis also plays a significant role in hemangiogenesis and lymphangiogenesis. The aim of this study was to investigate the involvement of SphK1 in Ang2-induced hem- and lymphangiogenesis. METHODS: Human umbilical vein endothelial cells (HUVECs) and human lymphatic endothelial cells (HLECs) were treated without or with an isozyme-specific inhibitor of SphK1 (SK1-I) and qPCR, western blot, ELISA, and tube formation assays carried out. We also used a new method we developed to quantify both hem- and lymphangiogenesis in the same sample in vivo by combining Directed In Vivo Angiogenesis Assays (DIVAA) with Fluorescence Activated Cell Sorting (DIVAA/FACS). RESULTS: qPCR revealed that human HLECs like HUVECs express high levels of SphK1 and the S1PR1 receptor. S1P rapidly stimulated xocytosis of Ang2 from HLEC storage granules determined by ELISA. Ang2 activated Tie2 in HLECs as demonstrated by its rapid phosphorylation on Tyr992, a major site responsible for its activation. Similar to Ang2, S1P also stimulated phosphorylation of Tie2, which may be due to secretion of Ang2. S1P is a potent hem- and lymphangiogenic factor for HUVECs and HLECs, respectively, as demonstrated by enhanced tube formation. Ang2-induced hem- and lymphangiogenesis was mediated at least in part by SphK1 as shown by the inhibitory effect of SK1-I. Furthermore, both S1P and Ang2 significantly induced hem- and lymphangiogenesis in vivo determined by DIVAA/FACS. Similar to its effect on in vitro hem- and lymphangiogenesis, inclusion of SK1-I in the angioreactors together with Ang2 completely abolished its ability to stimulate both of these processes. CONCLUSION: Activation of SphK1 is necessary for Ang2-induced hemangiogenesis and lymphangiogenesis through the SphK1/S1P and Ang2/Tie2 axes. This work was supported by NIH (K12HD055881) and Susan G. Komen for the Cure (KG090510) to KT, NCI (R01CA61774) to SS, and Sumitomo Life Social Welfare Services Foundation grant to MN.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5280. doi:1538-7445.AM2012-5280

Basal STAT3 activities are negatively correlated with tumor size in papillary thyroid carcinomas

BACKGROUNDS

Signal transducer and activators of transcription-3 (STAT3) plays a critical role in promoting survival and cell growth as well as facilitating angiogenesis and metastasis in several cancers.

AIM

This investigation focused on evaluation of STAT3 activities in human papillary thyroid cancers (PTC).

METHODS

STAT3 activities of nuclear extracts of tumor tissue were measured from 35 PTC patients using enzyme- linked immunosorbent assay-based kits.

RESULTS

STAT3 activities of PTC tissues were significantly lower than those of surrounding normal thyroid tissues [0.36 (interquartile range 0.24-0.72) vs 0.50 (0.29-1.11) arbitrary units, p<0.01]. We further analyzed the association between STAT3 activity and clinicopathologic factors in PTC tissue. Tumors with size ≥2 cm displayed significantly lower STAT3 activities than those <2 cm [0.25 (0.21-0.37) vs 0.53 (0.37-0.61) arbitrary units, p<0.01]. Notably, tumor size was inversely correlated with STAT3 activities in T1799A BRAF mutation-positive cases (Rs=-0.58, p<0.05), but not mutation-negative cases.

CONCLUSIONS

STAT3 activities of PTC measured via DNA binding are suppressed in contrast to other human cancers. Tumor size larger than 2 cm is the only clinicopathologic parameter associated with low STAT3 activity. Moreover, tumor size appears inversely correlated with STAT3 activity, specifically in T1799A BRAF mutation-positive cases.

Sphingosine-1-phosphate produced by sphingosine kinase 1 promotes breast cancer progression by stimulating angiogenesis and lymphangiogenesis

Sphingosine-1-phosphate (S1P) is a pleiotropic bioactive lipid mediator that promotes breast cancer progression by diverse mechanisms that remain somewhat unclear. Here we report pharmacologic evidence of a critical role for sphingosine kinase 1 (SphK1) in producing S1P and mediating tumor-induced hemangiogenesis and lymphangiogenesis in a murine model of breast cancer metastasis. S1P levels increased both in the tumor and the circulation. In agreement, serum S1P levels were significantly elevated in stage IIIA human breast cancer patients, compared with age/ethnicity-matched healthy volunteers. However, treatment with the specific SphK1 inhibitor SK1-I suppressed S1P levels, reduced metastases to lymph nodes and lungs, and decreased overall tumor burden of our murine model. Both S1P and angiopoietin 2 (Ang2) stimulated hemangiogenesis and lymphangiogenesis in vitro, whereas SK1-I inhibited each process. We quantified both processes in vivo from the same specimen by combining directed in vivo angiogenesis assays with fluorescence-activated cell sorting, thereby confirming the results obtained in vitro. Notably, SK1-I decreased both processes not only at the primary tumor but also in lymph nodes, with peritumoral lymphatic vessel density reduced in SK1-I-treated animals. Taken together, our findings show that SphK1-produced S1P is a crucial mediator of breast cancer-induced hemangiogenesis and lymphangiogenesis. Our results implicate SphK1 along with S1P as therapeutic targets in breast cancer.