Simulated resections and RNS placement can optimize post-operative seizure outcomes when guided by fast ripple networks

In medication-resistant epilepsy, the objective of epilepsy surgery is to render a patient seizure free with a resection/ablation that is as small as possible to minimize morbidity. The standard of care in planning the margins of epilepsy surgery involves electroclinical delineation of the seizure onset zone (SOZ) in the epilepsy monitoring unit (EMU) by an expert epileptologist, and incorporation of neuroimaging findings from MRI, PET, SPECT, and MEG modalities. Resecting cortical tissue generating high-frequency oscillations (HFOs) has been investigated as a more efficacious alternative to targeting the SOZ. In this study, we used support vector machines (SVMs) to compare the resection volumes of actual resections, defined using the clinical standard of care, with virtual resections of fast ripple (FR 350-600 Hz) networks. Cross-validation of the SVM that labeled patients as seizure free or not seizure free using FR metrics as factors demonstrated an accuracy of 0.78. In all the patients rendered seizure free after surgery, we found that the virtual resection, defined using FR generator sites with highest rate and greatest autonomy, was larger than the actual resection. In the patients who experienced seizures after the actual resection, a virtual resection that included the SOZ and other FR generating regions rendered half of these patients virtually seizure free. We also examined patients implanted with the responsive neurostimulator system (RNS) and virtually targeted the RNS stimulation contacts proximal to sites generating FR. We used the simulations to investigate if the likelihood of a RNS super response (>90% seizure reduction) would be increased.

Demographics of Youth With Newly Diagnosed Acute/Recent HIV Infection in Adolescent Trials Network 147: Early Treatment of Acute HIV Infection

PURPOSE

Gay, bisexual, and other cisgender men who have sex with men, and racial minority youth are at elevated risk of acquiring HIV infection. The Adolescent Trials Network 147 recruited youth with acute/recent HIV-infection for early antiretroviral treatment. The cohort make-up is described here.

METHODS

Treatment-naïve, recently identified HIV + youth, aged 12-24 years, from Los Angeles and New Orleans were recruited from community centers, clinics, social media, and a high-risk seronegative cohort (n = 1,727, the Adolescent Trials Network 149) using point-of-care assays. Acute HIV infection was determined by Fiebig staging. HIV RNA viral load (VL) and CD4 cell counts, along with demographic and behavioral data were assessed at enrollment.

RESULTS

Between July 2017 and July 2021, 103 newly diagnosed youth were enrolled, initiating antiretroviral treatment within a week. Mean age was 20.8 years (standard deviation: 2.4); 90.3% identified as cis male, 83.5% were single or in casual relationships, 71.8% were gay, bisexual, and other cisgender men who have sex with men; 60.2% were Black. One-fourth (24.3%) reported homelessness ever; 10.7% within last 4 months. At enrollment, median plasma VL was 37,313 HIV RNA copies/ml (interquartile range: 5,849-126,162) and median CD4 count 445.5 cells/mm3 (interquartile range: 357-613). 40% of youth reported acute retroviral symptoms before or at enrollment. Acutely infected, seroconverting youth had the highest VL. Sexually transmitted coinfections were present at enrollment in 56% of the cohort, with syphilis being most frequent (39%).

DISCUSSION

Early identification and treatment of HIV can increase positive HIV outcomes. A high sexually transmitted infection burden was present in recently HIV-infected youth. Acute retroviral symptoms were not reported by most participants, demonstrating that broad universal HIV screening is needed for identification of recent infection in youth.

Near-Peer Supervision in Primary Care: Bringing Teaching Teams From the Wards to the Clinic

Background

Teaching near-peers yields numerous benefits to residents. Opportunities for near-peer teaching are typically restricted to hospital settings. Little is known about the educational potential of outpatient near-peer teaching.

Objective

To describe Primary Care Teaching (PC Teach), a novel outpatient near-peer teaching experience for residents in a large, urban, internal medicine residency program; characterize its feasibility and acceptability; and evaluate changes in residents' self-reported confidence in outpatient teaching and attitudes toward teaching and primary care/outpatient medicine.

Methods

In 2020-2021, following a didactic workshop, 43 postgraduate year 3 (PGY-3) residents at continuity clinics assigned to PC Teach completed a series of half-day sessions acting as preceptor to interns under attending supervision. Worksheets facilitated post-session feedback for residents and interns. Eighteen PGY-3s at nonparticipating clinics, who also completed the workshop, served as controls. We assessed process measures for feasibility and acceptability and analyzed resident attitudes using pre-post surveys.

Results

Participating residents completed 2 to 8 sessions each. Post-intervention scores for confidence in outpatient teaching and attitudes toward teaching were greater, relative to pre-intervention group means, for intervention residents (median pre-post changes +0.60 [IQR 0.26, 1.26] and +0.46 [-0.04, 0.46], respectively) vs controls (-0.15 [-0.48, 0.85] and -0.36 [-0.86, 0.39]; between-group differences +0.75 [P=.03] and +0.82 [P=.02]). Changes in attitudes toward primary care/outpatient medicine did not differ significantly between intervention and control groups (+0.43 [-0.07, 0.68] and 0.04 [-0.58, 0.42]; between-group difference +0.39 [P=.12]). In multivariable analyses, odds of gains in confidence in outpatient teaching remained significantly larger for intervention residents vs controls.

Conclusions

Implementing PC Teach with existing resources was feasible and acceptable, with program flexibility highlighted as a strength. Resident participation was associated with greater confidence in outpatient teaching.

Characterizing physiological high-frequency oscillations using deep learning

Objective.Intracranially-recorded interictal high-frequency oscillations (HFOs) have been proposed as a promising spatial biomarker of the epileptogenic zone. However, HFOs can also be recorded in the healthy brain regions, which complicates the interpretation of HFOs. The present study aimed to characterize salient features of physiological HFOs using deep learning (DL).Approach.We studied children with neocortical epilepsy who underwent intracranial strip/grid evaluation. Time-series EEG data were transformed into DL training inputs. The eloquent cortex (EC) was defined by functional cortical mapping and used as a DL label. Morphological characteristics of HFOs obtained from EC (ecHFOs) were distilled and interpreted through a novel weakly supervised DL model.Main results.A total of 63 379 interictal intracranially-recorded HFOs from 18 children were analyzed. The ecHFOs had lower amplitude throughout the 80-500 Hz frequency band around the HFO onset and also had a lower signal amplitude in the low frequency band throughout a one-second time window than non-ecHFOs, resembling a bell-shaped template in the time-frequency map. A minority of ecHFOs were HFOs with spikes (22.9%). Such morphological characteristics were confirmed to influence DL model prediction via perturbation analyses. Using the resection ratio (removed HFOs/detected HFOs) of non-ecHFOs, the prediction of postoperative seizure outcomes improved compared to using uncorrected HFOs (area under the ROC curve of 0.82, increased from 0.76).Significance.We characterized salient features of physiological HFOs using a DL algorithm. Our results suggested that this DL-based HFO classification, once trained, might help separate physiological from pathological HFOs, and efficiently guide surgical resection using HFOs.

Admission Source Is Associated With the Risk of Rapid Response Team Activation in a Children's Hospital

OBJECTIVE

To evaluate source of admission to a children's hospital as a predictor of rapid response team (RRT) activation, both in the first 48 hours of admission and over the entire hospitalization.

METHODS

Retrospective cohort study of all patients admitted to the pediatric ward between March 1, 2013 and December 31, 2015. Source of admission was categorized as from the emergency department, transfer from another hospital facility, admission following a planned surgery, direct admission planned in advance, or unplanned direct admission. Information was collected including whether or not the patient had a RRT activation and survival to discharge. A Fisher's exact test was used to assess the association between source of admission and risk of rapid response.

RESULTS

Of 8083 admissions included in the study, 194 had at least one RRT event. The odds of having an RRT was significantly associated with source of admission (P < .001). Using admission from the emergency department as a reference group, planned elective admissions (odds ratio [OR] 0.27; P < .001) and admissions following planned surgery (OR 0.07; P < .001) were significantly associated with reduced odds of having at least one RRT activation during the admission. Planned elective admissions also demonstrated reduced odds of RRT in the first 48 hours of hospitalization (OR 0.14; P = .002). Source of admission was also associated with survival to discharge (P < .05).

CONCLUSION

Source of admission is associated with likelihood of RRT activation as well as with survival to discharge and should be considered by providers when assessing inpatient risk of decompensation.

Peripheral CRF-R1/CRF-R2 antagonist, astressin C, induces a long-lasting blockade of acute stress-related visceral pain in male and female rats

Peptide CRF antagonists injected peripherally alleviate stress-induced visceral hypersensitivity (SIVH) to colorectal distension (CRD) in rodents. Here we further evaluated the dose and time-dependent inhibitory activity of several long-acting peptide CRF receptor antagonists related to astressin on SIVH, focusing on astressin C (AstC), which previously showed high efficacy on stress-related alterations of HPA axis and gut secretomotor functions. Male and female Sprague-Dawley rats pretreated subcutaneously (SC) with AstC were injected intraperitoneally (IP) with CRF 15 min later. The visceromotor responses (VMR) to graded phasic CRD (10, 20, 40 and 60 mmHg) were monitored at basal, 15 min and up to 1-8 days after pretreatment. Two other astressin analogs, hexanoyl-astressin D (Hex-AstD) and [CαMeVal^19,32]-AstC, were also tested. The response to IP CRF was sex-dependent with female rats requiring a higher dose to exhibit visceral hyperalgesia. Pretreatment with AstC (30-1000 µg/kg) resulted in a dose-related inhibition of IP CRF-induced SIVH and diarrhea in both sexes. The highest dose prevented SIVH and diarrhea up to 5-7 days after a single SC injection and was lost on day 7 (females) and day 8 (males) but reinstated after a second injection of AstC on day 8 or 9 respectively. [CαMeVal^19,32]-AstC and Hex-AstD (1000 µg/kg in males) also prevented SIVH. These data show the potent long-lasting anti-hyperalgesic effect of AstC in an acute model of SIVH in both male and female rats. This highlights the potential of long-acting peripheral CRF antagonists to treat stress-sensitive irritable bowel syndrome.

Automated preprocessing and phase-amplitude coupling analysis of scalp EEG discriminates infantile spasms from controls during wakefulness

OBJECTIVE

Delta-gamma phase-amplitude coupling in EEG is useful for localizing epileptic sources and to evaluate severity in children with infantile spasms. We (1) develop an automated EEG preprocessing pipeline to clean data using artifact subspace reconstruction (ASR) and independent component (IC) analysis (ICA) and (2) evaluate delta-gamma modulation index (MI) as a method to distinguish children with epileptic spasms (cases) from normal controls during sleep and awake.

METHODS

Using 400 scalp EEG datasets (200 sleep, 200 awake) from 100 subjects, we calculated MI after applying high-pass and line-noise filters (Clean 0), and after ASR followed by either conservative (Clean 1) or stringent (Clean 2) artifactual IC rejection. Classification of cases and controls using MI was evaluated with Receiver Operating Characteristics (ROC) to obtain area under curve (AUC).

RESULTS

The artifact rejection algorithm reduced raw signal variance by 29-45% and 38-60% for Clean 1 and Clean 2, respectively. MI derived from sleep data, with or without preprocessing, robustly classified the groups (all AUC > 0.98). In contrast, group classification using MI derived from awake data was successful only after Clean 2 (AUC = 0.85).

CONCLUSIONS

We have developed an automated EEG preprocessing pipeline to perform artifact rejection and quantify delta-gamma modulation index.

Refining epileptogenic high-frequency oscillations using deep learning: a reverse engineering approach

Intracranially recorded interictal high-frequency oscillations have been proposed as a promising spatial biomarker of the epileptogenic zone. However, its visual verification is time-consuming and exhibits poor inter-rater reliability. Furthermore, no method is currently available to distinguish high-frequency oscillations generated from the epileptogenic zone (epileptogenic high-frequency oscillations) from those generated from other areas (non-epileptogenic high-frequency oscillations). To address these issues, we constructed a deep learning-based algorithm using chronic intracranial EEG data via subdural grids from 19 children with medication-resistant neocortical epilepsy to: (i) replicate human expert annotation of artefacts and high-frequency oscillations with or without spikes, and (ii) discover epileptogenic high-frequency oscillations by designing a novel weakly supervised model. The ‘purification power’ of deep learning is then used to automatically relabel the high-frequency oscillations to distill epileptogenic high-frequency oscillations. Using 12 958 annotated high-frequency oscillation events from 19 patients, the model achieved 96.3% accuracy on artefact detection (F1 score = 96.8%) and 86.5% accuracy on classifying high-frequency oscillations with or without spikes (F1 score = 80.8%) using patient-wise cross-validation. Based on the algorithm trained from 84 602 high-frequency oscillation events from nine patients who achieved seizure-freedom after resection, the majority of such discovered epileptogenic high-frequency oscillations were found to be ones with spikes (78.6%, P < 0.001). While the resection ratio of detected high-frequency oscillations (number of resected events/number of detected events) did not correlate significantly with post-operative seizure freedom (the area under the curve = 0.76, P = 0.06), the resection ratio of epileptogenic high-frequency oscillations positively correlated with post-operative seizure freedom (the area under the curve = 0.87, P = 0.01). We discovered that epileptogenic high-frequency oscillations had a higher signal intensity associated with ripple (80–250 Hz) and fast ripple (250–500 Hz) bands at the high-frequency oscillation onset and with a lower frequency band throughout the event time window (the inverted T-shaped), compared to non-epileptogenic high-frequency oscillations. We then designed perturbations on the input of the trained model for non-epileptogenic high-frequency oscillations to determine the model’s decision-making logic. The model confidence significantly increased towards epileptogenic high-frequency oscillations by the artificial introduction of the inverted T-shaped signal template (mean probability increase: 0.285, P < 0.001), and by the artificial insertion of spike-like signals into the time domain (mean probability increase: 0.452, P < 0.001). With this deep learning-based framework, we reliably replicated high-frequency oscillation classification tasks by human experts. Using a reverse engineering technique, we distinguished epileptogenic high-frequency oscillations from others and identified its salient features that aligned with current knowledge.

Thrombomodulin is associated with increased mortality and organ failure in mechanically ventilated children with acute respiratory failure: biomarker analysis from a multicenter randomized controlled trial

BACKGROUND

Acute respiratory failure (ARF) can progress to acute respiratory distress syndrome and death. Biomarkers may allow for risk stratification and prognostic enrichment in ARF. Thrombomodulin (TM) is a transmembrane antithrombotic mediator expressed in endothelial cells. It is cleaved into its soluble form (sTM) during inflammation and vascular injury. Levels of sTM correlate with inflammation and end organ dysfunction.

METHODS

This was a prospective observational study of 432 patients aged 2 weeks-17 years requiring invasive mechanical ventilation. It was ancillary to the multicenter clinical trial, Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE). After consent, patients had up to 3 plasma samples collected at 24-h intervals within 5 days after intubation. sTM was assayed by ELISA. The Hazard ratio (HR) for 90-day mortality was determined by Cox regression. Mixed effect models (MEM) were used to test for association with extrapulmonary multiorgan failure (MOF) and oxygenation index (OI). Age, race, sex and PRISM-III scores were used as confounding variables for multivariable analyses.

RESULTS

sTM values ranged from 16.6 to 670.9 ng/ml within 5 days after intubation. Higher sTM was associated with increased 90-day mortality (n = 432, adjusted HR = 1.003, p = 0.02) and worse OI in the first 5 days after intubation (n = 252, Estimate = 0.02, p < 0.01). Both initial and slope of sTM were associated with increased extrapulmonary MOF in unadjusted and adjusted analyses (Intercept, Estimate = 0.003, p < 0.0001; and slope, Estimate = 0.01, p = 0.0009, n = 386).

CONCLUSIONS

Plasma sTM is associated with mortality, severity of hypoxic respiratory failure and worsening extrapulmonary MOF in children with ARF. This suggests a role of vascular injury in the pathogenesis of ARF and provides potential applicability towards targeted therapies.

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT00814099 . In healthy lung endothelium, thrombomodulin (TM) recruits thrombin to activate Protein-C (PC/APC), that inhibits plasminogen activator-1 (PAI-1) and thrombosis. In inflamed and damaged endothelium, TM is cleaved into its soluble form (sTM), precluding its usual regulation of thrombosis. In this study, we measured plasma sTM levels in pediatric patients with respiratory failure and found that sTM correlated with mortality and other clinical markers of poor outcomes.

Severe Retinopathy of Prematurity Is Not Independently Associated With Worse Neurodevelopmental Outcomes in Preterm Neonates

Purpose: To evaluate the relationship between retinopathy of prematurity (ROP) severity and neurodevelopmental outcomes in premature neonates at 0-36 months corrected age. Methods: A retrospective chart review was performed on 228 neonates screened for ROP at the UCLA Mattel Children's Hospital between 2011 and 2018. Demographic information, clinical outcomes, ROP severity (no ROP, type 1 ROP, type 2 ROP), and Bayley-III neurodevelopmental scores were collected. Infants were grouped into corrected age cohorts (0-12, 12-24, and 24-36 months) to assess neurodevelopmental outcomes with increasing age. Within each age cohort, ANOVA and Chi-Square testing were used to detect differences in birth characteristics and neurodevelopmental scores between infants with type 1 ROP, type 2 ROP, or no ROP. Univariable analyses assessed the relationship between ROP severity and neurodevelopmental outcomes within each age cohort. A multivariable analysis was then performed to determine if ROP severity remained significantly associated with worse neurodevelopmental scores after controlling for birth weight (BW), intraventricular hemorrhage grade (IVH), health insurance type, male sex, and age at Bayley testing. Results: Without controlling for factors associated with prematurity, neonates with type 1 ROP had poorer cognition (p = 0.001) and motor (p = 0.006) scores at ages 0-12 months and poorer cognition (p = 0.01), language (p = 0.04) and motor (p = 0.04) scores at ages 12-24 months than infants without ROP, but no significant differences were detected at ages 24-36 months. After adjusting for BW, IVH, insurance type, male sex, and age at Bayley testing, ROP severity was no longer associated with worse neurodevelopmental scores in any domain. Conclusion: This study emphasizes that poorer neurodevelopmental outcomes in preterm neonates are most likely related to lower birthweight, associated co-morbidities of prematurity, and socioeconomic factors such as health insurance, not severity of ROP itself.

Filgrastim associations with CAR T-cell therapy

Little is known about the benefits and risks of myeloid growth factor administration after chimeric antigen receptor (CAR) T‐cell therapy for diffuse large B‐cell lymphoma (DLBCL). We present a retrospective analysis among 22 relapsed/refractory DLBCL patients who received CAR T‐cell therapy with axicabtagene ciloleucel. Filgrastim was administered by physician discretion to seven patients (31.8%), and the median duration of neutropenia after lymphodepleting therapy was significantly shorter for those patients who received filgrastim (5 vs 15 days, P = .016). Five patients (22.7%) developed infection in the 30 days post‐CAR T‐cell therapy with three patients being Grade 3 or higher. There was no difference in the incidence and severity of infection based on filgrastim use (P = .274, P = .138). Among the seven patients that received filgrastim, six patients (85.7%) and four patients (57.1%) had evidence of cytokine release syndrome (CRS) and immune effector cell‐associated neurotoxicity syndrome (ICANS), respectively. Among the 15 patients that did not receive filgrastim, 8 patients (53.3%) and 7 patients (46.7%) had evidence of CRS and ICANS, respectively. There was no significant difference in the incidence of developing CRS or ICANS between the group of patients that received filgrastim and those that did not (P = .193, P = .647). However, there was a significant increase in the severity of CRS for patients that received filgrastim compared to those that did not (P = .042). Filgrastim administration after CAR T‐cell therapy may lead to an increase in severity of CRS without decreasing infection rates.

What's new

Chimeric antigen receptor (CAR) T‐cell therapy in patients with relapsed/refractory diffuse large B‐cell lymphoma is limited by associated cytokine release syndrome, neurotoxicity, and cytopenias. Little is known about the benefits and risks of myeloid growth factor administration in CAR T‐cell therapy. This retrospective analysis reveals a significant increase in the severity but not the incidence of cytokine release syndrome in those patients that received filgrastim. There was no association of filgrastim use with the severity or incidence of neurotoxicity and infection rates. The findings call for caution in the use of myeloid growth factors in patients undergoing CAR T‐cell therapy.

Prevalence of Seizures and Risk Factors for Mortality in a Continuous Cohort of Pediatric Extracorporeal Membrane Oxygenation Patients

OBJECTIVES

To evaluate the risk factors for mortality in pediatric extracorporeal membrane oxygenation patients.

DESIGN

Retrospective, single-center study.

SETTING

PICU and Pediatric cardiothoracic ICU in an urban, quaternary care center.

PATIENTS

All neonatal and pediatric patients requiring extracorporeal membrane oxygenation at our institution between January 2014 and December 2018, who underwent a standardized continuous electroencephalogram neuromonitoring protocol during most of the duration of extracorporeal membrane oxygenation support. We excluded patients who had extracorporeal membrane oxygenation initiated at another institution.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-six children required extracorporeal membrane oxygenation support during this period. Four patients were excluded, three due to lack of electroencephalogram data, one with extracorporeal membrane oxygenation initiated at other institution. In the remaining 62, 11 patients (17%) had seizures, of which 5 (45%) had status epilepticus. Eight of 11 patients (72%) had exclusively electrographic seizures. A total of 33 patients (53.2%) died, of which 22 died during extracorporeal membrane oxygenation course, and one died 3 years after hospital discharge. Mean survival from extracorporeal membrane oxygenation initiation was 766.9 days (standard deviation, 691.7; median, 546.5; interquartile range 1-3, 97.7-1255.0). In multivariate analysis, increased risk of mortality was associated with the use of extracorporeal cardiopulmonary resuscitation (hazard ratio, 4.33; 95% CI, 1.75-10.72; p = 0.002), imaging findings of cerebral edema (hazard ratio, 14.31; 95% CI, 5.18-39.54; p < 0.001), high lactate level (> 100 mg/dL within 2 hr preextracorporeal membrane oxygenation) (hazard ratio, 1.22; 95% CI, 1.03-1.44; p = 0.022), and prolonged deep hypothermic circulatory arrest (hazard ratio, 3.43; 95% CI, 1.65-7.13; p < 0.001). Presence of seizures was associated with imaging findings of cerebral edema (hazard ratio, 4.16; 95% CI, 1.04-16.58; p = 0.04).

CONCLUSIONS

Seizures are common in children requiring extracorporeal membrane oxygenation support, with a high rate of electrographic seizures and status epilepticus, as in prior studies. Presence of cerebral edema is both risk factor for mortality and seizures. Other risk factors for mortality include extracorporeal cardiopulmonary resuscitation, high lactate levels, and prolonged deep hypothermic circulatory arrest.

Prenatal intrauterine growth restriction and risk of retinopathy of prematurity

Low birthweight and decreased postnatal weight gain are known predictors of worse retinopathy of prematurity (ROP) but the role of prenatal growth patterns in ROP remains inconclusive. To distinguish small for gestational age (SGA) from intrauterine growth restriction (IUGR) as independent predictors of ROP, we performed a retrospective cohort study of patients who received ROP screening examinations at a level IV neonatal intensive care unit over a 7-year period. Data on IUGR and SGA status, worst stage of and need for treatment for ROP, and postnatal growth was obtained. 343 infants were included for analysis (mean gestational age = 28.6 weeks and birth weight = 1138.2 g). IUGR infants were more likely to have a worse stage of ROP and treatment-requiring ROP (both p < 0.0001) compared to non-IUGR infants. IUGR infants were more likely to be older at worst stage of ROP (p < 0.0001) and to develop postnatal growth failure (p = 0.01) than non-IUGR infants. Independent of postnatal growth failure status, IUGR infants had a 4-5 × increased risk of needing ROP treatment (p < 0.001) compared to non-IUGR infants. SGA versus appropriate for gestational age infants did not demonstrate differences in retinopathy outcomes, age at worst ROP stage, or postnatal growth failure. These findings emphasize the importance of prenatal growth on ROP development.

Receipt of Corrective Lenses and Academic Performance of Low-Income Students

OBJECTIVE

Untreated vision problems are associated with poor school performance. Whether providing glasses alone improves performance, however, remains unknown. We sought to test whether receiving glasses was associated with improved school performance for low-income minority students in Los Angeles.

METHODS

From 2017 to 2018, we analyzed achievement marks in mathematics and language arts from 406 first to fifth grade students attending 24 public elementary schools who received glasses through a free school-based vision program between February and May 2014, and 23,393 of their nonparticipating same-school, same-grade peers. We calculated students' percentile rank during each grading period in 1 year before and 2 years since they received glasses. Multilevel linear regressions tested whether percentile rank differed from baseline at each subsequent grading period. Models accounted for clustering at the school level and controlled for gender, grade level, and baseline class rank. Interaction terms tested whether associations differed by gender and class rank.

RESULTS

Students increased 4.5 percentile points (P = .02) in language arts in the second year after receiving glasses. There was no change in math achievement overall; however, those with baseline performance in the bottom tercile had an immediate and sustained improvement of 10 to 24 percentile points from baseline (interaction term P < .001). Class rank for behavior marks decreased during the fourth grading period after receiving glasses but subsequently returned to baseline. There were no significant changes in work habits and no variation in results by gender.

CONCLUSIONS

Ensuring access to vision care may be a simple, scalable strategy to improve language arts performance for low-income minority children.

Age-Related Changes in HAPLN1 Increase Lymphatic Permeability and Affect Routes of Melanoma Metastasis

Older patients with melanoma have lower rates of sentinel lymph node (LN) metastases yet paradoxically have inferior survival. Patient age correlated with an inability to retain Technetium radiotracer during sentinel LN biopsy in more than 1,000 patients, and high Technetium counts correlated to better survival. We hypothesized that loss of integrity in the lymphatic vasculature due to extracellular matrix (ECM) degradation might play a role. We have implicated HAPLN1 in age-dependent ECM degradation in the dermis. Here, we queried whether HAPLN1 could be altered in the lymphatic ECM. Lymphatic HAPLN1 expression was prognostic of long-term patient survival. Adding recombinant HAPLN1 to aged fibroblast ECMs in vitro reduced endothelial permeability via modulation of VE-cadherin junctions, whereas endothelial permeability was increased following HAPLN1 knockdown in young fibroblasts. In vivo, reconstitution of HAPLN1 in aged mice increased the number of LN metastases, but reduced visceral metastases. These data suggest that age-related changes in ECM can contribute to impaired lymphatics. SIGNIFICANCE: Our studies reveal that changes in the stroma during aging may influence the way tumor cells traffic through the lymphatic vasculature. Aging may dictate the route of metastatic dissemination of tumor cells, and understanding these changes may help to reveal targetable moieties in the aging tumor microenvironment.See related commentary by Marie and Merlino, p. 19.This article is highlighted in the In This Issue feature, p. 1.

Bevacizumab at first recurrence after standard radio-chemotherapy is associated with improved overall survival in glioblastoma patients with large tumor burden

Background

Since its approval for use in recurrent glioblastoma (GBM), the survival benefit of bevacizumab (Bev) remains to be demonstrated. To address this issue, we retrospectively examined survival from first recurrence in patients treated with Bev, lomustine (CCNU), or Bev/CCNU.

Methods

We identified 168 primary GBM patients diagnosed at UCLA and Kaiser Permanente LA who received upfront radio-chemotherapy, followed by Bev and/or CCNU at first recurrence. Three patient groups, contemporaneously diagnosed from 2009 through 2015, were identified: (1) patients treated with Bev alone (n = 49), (2) CCNU alone (CCNU 09-15) (n = 36), and (3) Bev/CCNU (n = 53). Another CCNU control group (n = 30) diagnosed from 2001 through 2004 (CCNU 01-04) was also derived. We measured tumor size at first recurrence treatment initiation, using bidimensional (2D) and volumetric (3D) techniques, and analyzed overall survival (OS) from first recurrence.

Results

Among the entire cohort, larger tumor size at first recurrence was associated with poorer survival. The CCNU 01-04 group had similar tumor size as the Bev arms and low Bev crossover (7%). Treatment with Bev was associated with improved survival in patients with large tumor 2D measurements: Median OS for Bev and Bev/CCNU groups were 6.71 mo (n = 27) and 6.97 mo (n = 36) vs 4.03 mo (n = 10) in CCNU 01-04. Analysis by 3D measurement yielded similar results. Interestingly, the CCNU 09-15 group showed the highest survival, likely due to smaller tumor size and crossover to Bev (69%).

Conclusion

Survival advantage from Bev treatment was observed only among patients with large tumor burden as determined by either 2D or 3D measurement.

The prognostic importance of scalp location in primary head and neck melanoma

BACKGROUND AND OBJECTIVES

For patients with cutaneous melanoma, primary tumors located in the head and neck is associated with poor outcomes. The reason for this difference and whether it is applicable to all locations within the head and neck remains unclear. We hypothesized that scalp melanoma is uniquely distinguished from other anatomic sites and is independently responsible for the poor prognosis of head and neck melanoma.

METHODS

Query and analysis of a prospectively maintained melanoma database of all patients treated for primary cutaneous melanoma from 1971 to 2010.

RESULTS

Of 11 384 patients identified, 7% (n = 799) of lesions originated on the scalp. Scalp primaries were more often found in males and were associated with increased Breslow thickness and were more frequently ulcerated compared to all other anatomic sites (P = 0.0001). On multivariate analysis, scalp location was an independent predictor of worse melanoma-specific (HR 1.75; CI 1.50-2.04; P < 0.0001) and overall survival (HR 1.62; CI 1.41-1.86; P < 0.0001).

CONCLUSIONS

This, the largest series examining scalp melanoma, confirms that scalp location is independently responsible for the negative prognosis associated with head and neck melanoma. Although the pathophysiology of this difference remains to be determined, these data argue for more rigorous surveillance of this anatomic location.

Clinical Implications of the T790M Mutation in Disease Characteristics and Treatment Response in Patients With Epidermal Growth Factor Receptor (EGFR)-Mutated Non-Small-Cell Lung Cancer (NSCLC)

BACKGROUND

The secondary T790M mutation accounts for more than 50% of acquired tyrosine kinase inhibitor (TKI) resistance in patients with EGFR-mutated non-small-cell lung cancer (NSCLC). Recent reports suggest this resistance mutation may be more common among patients with longer progression-free survival (PFS) on first-line TKI therapy, but much is still unknown.

MATERIALS AND METHODS

Our group collected medical records from patients who underwent a biopsy for T790M mutation testing while screening for clinical trials involving the drug rociletinib (CO-1686), a T790M mutation-specific TKI. Medical records were retrospectively analyzed for demographic data, PFS, and best response to previous therapies.

RESULTS

Our patient cohort included 69 T790M⁺ patients and 28 T790M^- patients. Patients who later developed a T790M mutation had a longer PFS on first-line TKI therapy (12.0 vs. 9.0 months, P = .021), but overall response rate (ORR) was the same (75.0% vs. 81.0%, P = .76). There was no difference in PFS on TKI rechallenge (4.0 vs. 3.0 months, P = .94), although there was a trend toward higher ORR in T790M⁺ patients (22.2% vs. 0%, P = .12). T790M⁺ patients had a longer PFS on initial chemotherapy treatment (5.0 vs. 4.0 months, P = .025) and a trend toward higher ORR (40.0% vs. 21.4%, P = .31).

CONCLUSION

Our study confirms that tumors expressing T790M have a more indolent progression of disease compared with their T790M^- counterparts when treated with both first-line TKI and cytotoxic chemotherapy.

Bevacizumab (Bev) to reduce the negative impact of glioblastoma (GBM) tumor size on survival from first recurrence

2052

Background: Bev was FDA approved for recurrent GBM in 2009. However, the survival benefit from Bev in GBM remains to be demonstrated. Methods: We retrospectively identified 168 primary GBM patients diagnosed between 2001-2015 at UCLA and Kaiser Permanente LA, who received upfront radio-chemotherapy, followed with Bev and/or Lomustine (CCNU) at 1st recurrence. We measured tumor size at 1st recurrent treatment initiation, using bi-dimensional (2D) and volumetric (3D) techniques. We analyzed overall survival (OS) from 1st recurrence by Kaplan-Meier analysis. Results: Three groups of patients diagnosed from 2009-2015 were identified: patients treated with Bev alone (n = 49), CCNU alone (n = 36), and concurrent Bev/CCNU (n = 53). Patients were statistically different in performance status at 1st recurrence and tumor size; the CCNU alone group had smaller tumor sizes at diagnosis compared to the Bev groups. The CCNU group showed substantially greater survival (median OS (mOS) = 14.1 mo) compared to the Bev and Bev/CCNU groups (mOS = 6.9 and 7.1 mo, respectively), which may be explained by the imbalance in tumor sizes among the groups, and high rate of crossover (69%) to Bev in subsequent recurrences. To minimize selection bias, we identified another control group (n = 30) diagnosed from 2001-2004 who received CCNU only (CCNU 01-04). These patients had tumor size and KPS more comparable to both Bev groups, and a low rate of crossover (7%). OS for CCNU 01-04 (mOS = 5.7 mo) was similar to the Bev groups. Across all patients, we observed poor OS associated with larger 2D size vs. those with small tumors (mOS = 6.7 vs. 8.8 mo; p = 0.003). In separate stratification of each treatment group by tumor size, this association was retained in the CCNU 01-04 group (mOS = 4.0 vs. 8.4 mo, p < 0.001), but not in either Bev (mOS = 6.7 vs. 7.3 mo) or BEV/CCNU (mOS = 7.0 vs. 8.8 mo). Analysis of effect of tumor size by 3D measurement yielded similar results. Conclusions: Bev appears to reduce the negative impact of large tumor size on GBM patient survival from 1st recurrence. 2D and 3D measurements were correlated, suggesting the adequacy of use of conventional tumor bi-dimensional measurement to predict benefit of Bev in patients based on tumor size.

Clinical implications of the T790M mutation in disease characteristics and treatment response in patients with EGFR-mutated NSCLC

9031

Background: The secondary T790M mutation accounts for more than 50% of acquired tyrosine kinase inhibitor (TKI) resistance in epidermal growth factor receptor (EGFR)-mutant NSCLC patients. Recent reports suggest this resistance mutation may be more common among patients with longer progression-free survival (PFS) on first-line TKI therapy, but much is still unknown about this resistance mechanism’s association with response to other therapies. Methods: Our group collected medical records from patients who underwent a biopsy for T790M mutation testing in the process of screening for clinical trials involving third generation EGFR inhibitors. Medical records were retrospectively analyzed for demographic data, PFS, best response (BR) to previous therapies, and presence or absence of an acquired T790M mutation. Progression-free survival was estimated using the Kaplan-Meier method and compared across two groups using the log-ranked test followed by univariate and multivariate cox proportional hazard regression analysis. Response rates were compared using Fisher’s exact test. Results: Out of 102 patients who obtained a diagnostic biopsy, 73 patients had a T790M mutation. Patients who later developed a T790M mutation had a longer PFS on first-line TKI therapy (12.0 months in T790M+ vs. 8.0 months in T790M-, p = 0.038, HR 1.66, 95% CI 1.03-2.67), though there was no difference in response rate (75.5% in T790M+ vs 77.3% in T790M-, p = 1.00). T790M+ patients also had a longer PFS on initial chemotherapy treatment (5.0 months in T790M+ vs. 4.0 months in T790M-, p = 0.020, HR 1.97, 95% CI 1.11-3.49) and a higher response rate to chemotherapy (22.7% in T790M+ vs 0% in T790M-, p = 0.033). Median PFS was short (3.0 months) for patients treated with immunotherapy with no difference based on T790M mutation status (p = 0.33). Conclusions: Our study confirms that tumors expressing T790M have a more indolent progression of disease compared to their T790M negative counterparts when treated with both first-line TKI and cytotoxic chemotherapy. This data provides context for therapeutic decision making in EGFR-mutant NSCLC patients.

Abstract B02: Immune events in the sentinel lymph node in melanoma predict local and systemic response to disease

Background: The sentinel node (SN) has become the standard diagnostic tool for staging cutaneous melanoma. With the recent development of anti-CTLA-4 and anti-PD-1 antibodies as immunotherapies we hypothesized that the early immune events in melanoma maybe first observed in the SN and be related to the response to disease.

Methods: 81 SN from 79 patients were evaluated with microarray technology, qPCR, routine H&E & IHC. We identified 10 immune genes that are present by qPCR in SNs from a random section of the SN. Statistical analysis assessed the utility of these markers to predict tumor-positive SN and survival.

Results: Of the 79 patients, 48 (61%) were men. Median age was 59 (range 6-95 years). Primary melanomas were most commonly from the trunk (51%) and extremities (40%). The median thickness of the primaries was 0.95mm. 13% of the patients had ulcerated primaries. 29% of the primary tumors had at least 1 mitosis/mm2 . 9 (11%) patients had SN metastasis, as determined by conventional H&E and IHC. The incidence of SN positivity was directly related to tumor thickness; the higher the T-stage the greater percentage of SN positivity: 2% T1, 19% T2, 20% T3 and 60% T4 melanoma. 33% of ulcerated primaries and 30% with increased mitotic rate had a tumor-positive SN. The microarray did not identify specifc immune related genes when comparing tumor-positive to tumor-negative SN. We then evaluated the gene expression of CD80, CD86, CD28, CD40, IDO, Arginase, IL-2, IL-10, PD-1 and CTLA-4 by qPCR. By univariate analyses: patient age (p&lt;0.001), primary site (&lt;0.001), decreasing gene expression of CTLA-4 (p&lt;0.001) and PD-1 (p&lt;0.001) in SN were predictive of SN positivity. Multivariate analyses confirmed the down-regulation of CTLA-4 and PD-1 gene expression in the SN were predictive of metastases in the SN and the AUC values of predicting SN positivity were 0.808 and 0.731 respectively . The positive and negative predictive values of the tests were 100 and 89.5%. Further the down-regulation of CTLA-4 and PD-1 gene expression in the SN correlated with diminished survival, while the up-regulation of IL-10 correlated with poor survival.

Conclusions: Our results demonstrate the significance of CTLA-4, PD-1 and IL-10 gene expression in the SN of melanoma patients. The expression of these genes may be early events in the immune dysfunction that occurs with melanoma metastases.

Citation Format: Richard Essner, Ke-Wei Gong, David Z. Kaufman, Alexandra Gangi, Myung Shin Sim. Immune events in the sentinel lymph node in melanoma predict local and systemic response to disease. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2016 Oct 20-23; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2017;5(3 Suppl):Abstract nr B02.

Relationship of ACL Injury and Posterior Tibial Slope With Patient Age, Sex, and Race

BACKGROUND

Posterior tibial slope (PTS) has been proposed as a potential risk factor for anterior cruciate ligament (ACL) injury; however, studies that have examined this relationship have provided inconclusive and sometimes contradictory results. Further characterization of this relationship may enable the medical community to identify individuals at greater risk for ACL injury and possibly characterize an anatomic target during surgical reconstruction.

PURPOSE

The primary goal was to investigate the relationship between PTS and ACL injury. The secondary goal was to determine whether there are any patient factors, such as age, race, or sex, that correlate with ACL injury and PTS.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Medical records of 221 patients who underwent magnetic resonance imaging (MRI) of the knee between January 2003 and December 2009 were reviewed. Patients were separated into 2 groups: a study group of those subjects who had undergone surgery for ACL injury (n = 107) and a control group of patients diagnosed with patellofemoral syndrome (n = 114). Demographic data were collected, and MRI images from both groups were analyzed using imaging software to obtain medial and lateral tibial slope measurements. Data were then analyzed using analysis of variance (ANOVA) comparison and a multivariable regression model to determine which, if any, patient factors were related to probability of having an ACL injury.

RESULTS

ANOVA comparison demonstrated that the study group had significantly greater values for lateral PTS (6° ± 4°; P < .001) and medial PTS (7° ± 4°; P = .002) compared with controls (5° ± 3° and 5° ± 4°, respectively). After stepwise elimination of nonsignificant variables, the final multivariable logistic regression model determined that age (odds ratio [OR], 0.94; P < .001) and lateral PTS (OR, 1.12; P = .002) had statistically significant relationships with ACL injury. Medial PTS, race, and sex were not demonstrated to be significant predictors of ACL injury in this final model.

CONCLUSION

This study demonstrates a relationship between increased lateral PTS and ACL injury, which corroborates the findings of previously published studies. The findings presented in this article may help identify patients who are at greater risk of ACL injury and could potentially benefit from treatments aimed at modification of PTS.

Overall Survival Is Impacted by Birthplace and Not Extent of Surgery in Asian Americans with Resectable Gastric Cancer

Survival from gastric cancer in the USA still lags behind Asia. Genetic, environmental, and tumor biology differences, along with extent of surgery have been implicated. Our aim was to evaluate survival outcomes in Asian-American gastric cancer patients undergoing surgical resection by comparing place of birth and clinicopathologic characteristics (including evaluation of 15 lymph nodes).The Surveillance, Epidemiology, and End Results database was queried to identify patients treated surgically for gastric cancer with curative intent in the USA (2000-2010). US-born versus foreign-born Asian-American patients were analyzed for survival. Secondary comparison was made to non-Asian patients. Stage IV and non-surgical patients were excluded. Of 10,089 patients identified, 1467 patients were Asian: 271 were born in the USA, and 1196 were born outside the USA. Median survival was 32 months for non-Asians and 29 months for US-born Asians versus 61 months for Asian immigrants (p < 0.001). On multivariable analysis of overall survival in Asian patients, only US birthplace, older age, and higher stage yielded a significantly poorer outcome. Asian-American patients have a worse prognosis if born in the USA. Anatomic and surgical differences do not explain this disparity; environmental factors may be responsible.

Abstract 1315: High IFNγ and perforin and low GM-CSF and sCD40L production correlate with CD8 TIL growth in breast cancer

Introduction: Adoptive cell therapy (ACT) with expanded autologous tumor-infiltrating lymphocytes (TIL) shows promise in melanoma but has not been developed for breast cancer (BC) because BC-TIL have not demonstrated consistent antitumor potency. This study examined the characteristics and potency of BC-TIL generated by using TIL culture techniques established for our ACT protocol in melanoma.

Methods: Clinically annotated fresh specimens of tumor tissue were collected during surgical treatment of 8 patients with breast cancer and 26 patients with melanoma. TIL for each specimen were grown from 3-24 tumor fragments, depending on tumor size. After several weeks of cell growth, the expression of CD3, CD4 and CD8 on TIL was measured by flow cytometry. Then TIL were co-cultured with autologous tumor cells, and IFNγ expression level was measured by ELISA as an indicator of antitumor potency. Luminex assay was used to measure the expression of 18 immune mediators (GM-CSF, IFNγ, IL-1α, IL-1Rα, IL-4, IL-5, IL-6, IL-9, IL-10, IL-13, IL-17a, IP-10, sCD40L, MCP-1, TNFβ, sCD137, granzyme-B, and perforin) in the BC-TIL culture supernatant. Mixed effect model with random intercept was used for univariable and multivariable analysis to determine which immune mediators were associated with high CD8 cell percentage in TIL cultures.

Results: TIL were successfully grown from 62 of 64 (97%) BC fragments and from 487 of 622 (78%) melanoma fragments (p = 0.004). TIL reached a sufficient number for co-culture in 16±3 days for BC-TIL and in 25±9 days for melanoma-TIL (p&lt;0.0001). In the successful TIL cultures, 6 of 62 (9.6%) BC-TIL and 290 of 487 (60.0%) melanoma-TIL showed antitumor potency: 47.0% BC-TIL and 70.7% melanoma-TIL contained more CD8 cells than CD4 cells. The total number of expanded BC-TIL was inversely associated with MCP-1 expression (p&lt;0.0001) and AJCC stage (p&lt;0.0007). In univariable analysis, low expression of IL-10 and sCD40L, and high expression of perforin were associated with increased CD8 cell percentage in TIL cultures (P&lt;0.001, P&lt;0.03, and P&lt;0.0001, respectively). In multivariable analysis, low GM-CSF and sCD40L, and high IFNγ and perforin were associated with high CD8 cell percentage in TIL cultures (P&lt;0.002, P&lt;0.008, P = 0.02, and P&lt;0.001, respectively).

Conclusions:

Antitumor potency of BC-TIL was less frequently but BC fragments can grow TIL faster than melanoma fragments. The CD4:CD8 cell ratio was higher in BC-TIL than in melanoma-TIL. Blocking antibodies against IL-10, GM-CSF and sCD40L should be investigated to improve CD8 expansion from BC-TIL. In addition, because BC-TIL contained more CD4, it might be possible to promote tumor regression via mediation of a BC antigen by CD4 cells.

Citation Format: Hitoe Torisu-Itakura, Yueqin Quan, Myung Shin Sim, Maggie L. DiNome, Peter A. Sieling, Delphine J. Lee, Mark B. Faries. High IFNγ and perforin and low GM-CSF and sCD40L production correlate with CD8 TIL growth in breast cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1315. doi:10.1158/1538-7445.AM2015-1315

Immunoprofiling for prognostic assessment of colon cancer: a novel complement to ultrastaging

BACKGROUND

Although AJCC/TNM staging remains the gold standard for prognostic assessment of colon cancer, stage-specific outcomes vary. We therefore prospectively evaluated the prognostic role of immunoprofiling.

METHODS

Our cohort included 35 patients from an ongoing prospective trial of ultrastaging for colon cancer. Specimens were analyzed for T cell markers (CD3, CD4, CD8, and FoxP3). The number of tumor-infiltrating lymphocytes was analyzed at the tumor's margin and center and correlated with AJCC/TNM stage, clinicopathologic variables, and disease-free survival.

RESULTS

There was a significant inverse association between number of CD3(+) cells in the tumor center and tumor stage (P = 0.05). The tumor center/margin ratio of CD3(+) cells also showed an inverse but non-significant relationship with nodal involvement (P = 0.07). Body mass index was inversely associated with numbers of CD3(+)(P = 0.04) and CD8(+)(P = 0.02) cells. Longer disease-free survival was correlated with higher CD8+ counts (P = 0.07), lower CD4(+)/CD8(+) ratios (P = 0.008), and higher CD8(+)/FoxP3(+) ratios (P = 0.02).

CONCLUSIONS

This is the first prospective validation of immunoprofiling in patients whose colon cancer is staged with strict surgical and pathology quality measures. The apparent correlation between immunophenotypic response and clinical outcome warrants evaluation in a larger prospective trial.

Increased use of partial-breast irradiation has not improved radiotherapy utilization for early-stage breast cancer

BACKGROUND

Radiotherapy (RT) reduces local recurrence after breast-conserving surgery (BCS) for breast cancer, but under-utilization of RT has been reported. Accelerated partial-breast irradiation (PBI) improves RT accessibility, but it is uncertain if this has improved RT utilization.

METHODS

The Surveillance, Epidemiology and End Results registry was used to identify women who underwent BCS for stage 0 or 1 breast cancer from 2000 to 2009. Temporal trends in RT utilization and RT modality were determined. Chi-square analysis and multivariate logistic regression identified predictors of RT utilization and modality.

RESULTS

Of 180,219 study patients, 131,343 (73 %) received RT; 123,703 (94 %) of RT recipients received whole-breast irradiation (WBI) and 6,251 (5 %) received PBI. PBI rates increased dramatically during the study period (0.32 % in 2000 vs. 6.5 % in 2009), but overall RT utilization remained relatively stable because of a decline in WBI (69.8 % in 2000 vs. 62.4 % in 2009). RT utilization was unchanged in rural counties, and declined for women <40 and ≥70 years of age, and for Native American, Asian and Hispanic patients. White and Black women used PBI most frequently (4 % each) and were the only race groups with improved RT utilization over time. Predictors of RT usage included age, race, marital status, tumor size, grade, hormone receptor status, lymph node evaluation, geographic region, metropolitan status, education, and employment status.

CONCLUSIONS

Women who undergo RT are opting for PBI more frequently, but the increased use of this modality has not improved overall RT utilization for patients with early-stage breast cancer.

Epigenetic regulation of REG1A and chemosensitivity of cutaneous melanoma

Regenerating gene 1A (REG1A) plays an important role in tissue regeneration and in cell proliferation in epithelium origin tumors; however, its role in melanoma has not been explored in details. The objective of this study was to identify whether REG1A is expressed in cutaneous melanoma and if REG1A expression status can predict prognosis in cutaneous melanoma patients with metastasis. We also determined whether epigenetic regulation of the promoter region regulates REG1A expression. AJCC stage III cutaneous melanoma specimens with clinically well annotated stage III lymph node melanoma metastasis tissue microarray were assessed by IHC. MALDI-TOF-mass spectrometry and HM450K array were used to identify REG1A promoter region CpG site methylation. Chemotherapeutic agent response by melanoma cells as related to REG1A protein expression was assessed. Post-surgery melanoma patients followed by adjuvant chemotherapy with high REG1A expression had a significantly better prognosis (disease-specific survival) compared with patients with low REG1A expression (log rank test; p = 0.0013). The demethylating reagent 5-Aza-2'-deoxycytidine activated REG1A promoter region resulting in enhanced REG1A mRNA and protein expression in melanoma cell lines. Promoter region CpG methylation was shown to regulate REG1A expression in melanoma cells. Moreover, melanoma lines with high REG1A mRNA expression were more susceptible to Dacarbazine and Cisplatin, as compared with those with low REG1A mRNA expression. In conclusion, REG1A expression status may be useful as a biomarker in melanoma patients for sensitivity to these chemotherapeutic agents. The epigenetic regulation of the REG1A promoter region may offer a potential therapeutic approach to improve chemotherapy for metastatic melanoma patients.

Cyanobacterial diversity and activity in modern conical microbialites

Modern conical microbialites are similar to some ancient conical stromatolites, but growth, behavior and diversity of cyanobacteria in modern conical microbialites remain poorly characterized. Here, we analyze the diversity of cyanobacterial 16S rRNA gene sequences in conical microbialites from 14 ponds fed by four thermal sources in Yellowstone National Park and compare cyanobacterial activity in the tips of cones and in the surrounding topographic lows (mats), respectively, by high-resolution mapping of labeled carbon. Cones and adjacent mats contain similar 16S rRNA gene sequences from genetically distinct clusters of filamentous, non-heterocystous cyanobacteria from Subsection III and unicellular cyanobacteria from Subsection I. These sequences vary among different ponds and between two sampling years, suggesting that coniform mats through time and space contain a number of cyanobacteria capable of vertical aggregation, filamentous cyanobacteria incapable of initiating cone formation and unicellular cyanobacteria. Unicellular cyanobacteria are more diverse in topographic lows, where some of these organisms respond to nutrient pulses more rapidly than thin filamentous cyanobacteria. The densest active cyanobacteria are found below the upper 50 μm of the cone tip, whereas cyanobacterial cells in mats are less dense, and are more commonly degraded or encrusted by silica. These spatial differences in cellular activity and density within macroscopic coniform mats imply a strong role for diffusion limitation in the development and the persistence of the conical shape. Similar mechanisms may have controlled the growth, morphology and persistence of small coniform stromatolites in shallow, quiet environments throughout geologic history.

Formation and stability of oxygen-rich bubbles that shape photosynthetic mats

Gas release in photic-zone microbialites can lead to preservable morphological biosignatures. Here, we investigate the formation and stability of oxygen-rich bubbles enmeshed by filamentous cyanobacteria. Sub-millimetric and millimetric bubbles can be stable for weeks and even months. During this time, lithifying organic-rich laminae surrounding the bubbles can preserve the shape of bubbles. Cm-scale unstable bubbles support the growth of centimetric tubular towers with distinctly laminated mineralized walls. In environments that enable high photosynthetic rates, only small stable bubbles will be enclosed by a dense microbial mesh, while in deep waters extensive microbial mesh will cover even larger photosynthetic bubbles, increasing their preservation potential. Stable photosynthetic bubbles may be preserved as sub-millimeter and millimeter-diameter features with nearly circular cross-sections in the crests of some Proterozoic conical stromatolites, while centrimetric tubes formed around unstable bubbles provide a model for the formation of tubular carbonate microbialites that are not markedly depleted in (13)C.

Basic cardiac life support education for non-medical hospital employees

BACKGROUND

The International Liaison Committee on Resuscitation (ILCOR) recommends that strategies should be implemented that promote cardiopulmonary resuscitation (CPR) training in the workplace. Non-medical employees at a hospital were therefore trained to conduct basic life support (BLS). Subject background information, test results and survey findings were examined and factors affecting BLS skill acquisition were studied.

METHODS

Of 1432 non-medical employees at a hospital trained to conduct BLS, 880 agreed to participate in the survey. The training course consisted of a single session of 3 h of lectures, practice and testing. Skill acquisition was assessed using a 13-item skill checklist and a 5-point overall competency scale. The effects of age, gender, type of job, educational status, a previous history of CPR training and level of subject-perceived training difficulty were examined.

RESULTS

According to total checklist scores, subjects achieved a mean (SD) score of 8.66 (3.57). 22.3% performed all 13 skills. Based on 5-point overall competency ratings, 43.7% of subjects were rated as "competent", "very good" or "outstanding". Age (<40 years and >or=40 years) was the only factor that significantly affected skill acquisition (skill acquisition by those >or=40 years of age was poorer than by those aged <40 years).

CONCLUSION

Traditional BLS training is less effective in individuals aged >or=40 years.

Cellular and humoral immune responses to a tetanus toxoid booster in perinatally HIV-1-infected children and adolescents receiving highly active antiretroviral therapy (HAART)

BACKGROUND

Human immunodeficiency virus type 1 (HIV-1) infected children treated with highly active antiretroviral therapy (HAART) may develop a significant reduction of plasma viremia associated with an increase in CD4+ T-cell counts. Functional capacity of this reconstituted immune system in response to recall antigens is important to maintain protective immunity to vaccine-preventable diseases. We therefore determined cellular and humoral immune responses to tetanus toxoid (TT) booster in perinatally HIV-1-infected children and adolescents receiving HAART.

METHODS

Immune responses were prospectively evaluated pre- and post-tetanus booster using lymphocyte proliferation assay (LPA) stimulation index (SI > or = 3.0) and tetanus antibody (TAb > or = 0.15) in 15 patients. The median interval from primary tetanus immunization series was 6 years (range 2-12 years). We compared patients by their virological response to HAART (complete responders, CR, n=7; incomplete responders, ICR, n=8).

RESULTS

There were no significant differences in median age 12.6 years (CR: 12.9; ICR: 10.6) or median CD4 T-cell pre-booster (CR: 35%/819; ICR: 26%/429) between groups. Tetanus LPA responses were observed in one patient prior to booster and in seven patients post-booster. In contrast, 38% of patients had protective TAb pre-booster, but 92% developed protective TAb post-booster. All of the CR and 5/6 ICR patients developed protective TAb.

CONCLUSIONS

HIV-1-infected children and adolescents had modest LPA responses to tetanus following booster, similar to HIV-1-infected adults. However, the majority of patients developed protective TAb levels after booster and maintained the response. Shorter intervals may need to be considered for TT immunization boosters in HIV-1-infected pediatric patients, as only 38% had protective TAb at baseline.

Smad4 expression in gastric adenoma and adenocarcinoma: frequent loss of expression in diffuse type of gastric adenocarcinoma

Smads are signal transducers for the members of the TGF-beta superfamily. Of these Smads, Smad4 is essential for TGF-beta signaling. The purpose of this study was to elucidate Smad4 expression and localization in 65 gastric adenomas, 49 intestinal-type and 39 diffuse type of gastric adenocarcinomas (including 12 cases of fresh frozen tissue) using Real-time RT-PCR and immunohistochemistry. Real-time RT-PCR showed that intestinal type gastric adenocarcinomas have higher Smad4 mRNA expression than diffuse type gastric adenocarcinomas. Immunohistochemical stain for Smad4 revealed that expression of Smad4 was significantly lower in diffuse-type gastric adenocarcinoma than intestinal-type gastric adenocarcinomas. Also, higher Smad4 protein expression in intestinal type gastric adenocarcinomas than overall gastric adenoma was noted. The rate of reduced Smad4 expression was higher in advanced gastric cancer than early gastric cancer. These results suggest that Smad4 might play different roles in human gastric carcinogenesis, especially between intestinal type and diffuse type of gastric adenocarcinoma.

Correlation of Ultrasonographic Findings and Pathologic Prognostic Predictions in Breast Cancer

PURPOSE

Increased technologic capabilities have allowed for the expanded use of ultrasound beyond simple differentiation of a lesion as solid versus cystic nature, allowing us to classify lesions into various categories based on a number of descriptive features. The purpose of this study was to investigate whether to predict the preoperative prognosis of breast cancer through the correlation between ultrasonographic images and the grade of malignancy.

MATERIALS AND METHODS

The patient population for this study consisted of 107 patients with infiltrative ductal carcinoma who were evaluated using ultrasound technology. Ultrasonographic findings were divided as follows: Type I, round or oval shape and regular border; Type II, partially round or oval shape and partially irregular border; and Type III, irregular shape and irregular border.

RESULTS

1. The frequency of grade 1 (G1) was significantly higher in the Type I group than the othergroups. 2. In the 2.0 cm sized mass, the lymph node metastasis rate was significantly lower in the Type I group than the other groups. 3. In all the groups, Estrogen receptor (ER) positivity was insignificant regardless of tumor size and type. 4. In the 2.0 cm sized mass, c-erbB-2 positivity was significantly lower in the Type I than the other groups. There was no clear difference among the three groups in tumors greater than 2.0 cm in size.

CONCLUSION

These results show that our classification of ultrasonographic images reflect the grade of malignancy in terms of clinicopathological features in breast cancers less than 2.0 cm in size. Therefore, ultrasonographic findings may help predict the preoperative prognosis in T1 size breast cancer, although further study is required.

Recovery of replication-competent virus from CD4 T cell reservoirs and change in coreceptor use in human immunodeficiency virus type 1-infected children responding to highly active antiretroviral therapy

Highly active antiretroviral therapy (HAART) suppresses plasma viremia in most patients with human immunodeficiency virus (HIV) infection. Prospective study of HIV-infected children (n=27) shows that, in 8 of 12 who responded to HAART (>/=0.5 log reduction in plasma HIV RNA), HAART restricted the number of coreceptors used by the predominant HIV isolate (mean number of coreceptors used at baseline was 4, vs. 1 coreceptor used at 6 months after treatment). This decrease was most striking in 6 of 8 children whose HIV coreceptor tropism changed from X4-tropic at baseline to R5-tropic. In 6 of 10 children tested, with plasma HIV RNA levels of <50 copies/mL, R5-tropic virus was isolated from CD4 T cell reservoirs. All the responding children had a significant increase in naive CD4 T cells (P<.05). These results show that persistent HIV T cell reservoirs are present in children and that HAART may influence the number and type of coreceptors used by the predominant virus isolate.

Antiperistaltic ileostomy using the long terminal ileal segment

PURPOSE

This study was undertaken to determine whether reversed terminal ileal segments can be used to decrease ileostomy output in patients who have undergone total proctocolectomy and ileostomy for ulcerative colitis or familial adenomatous polyposis.

METHODS

An approximately 25-cm length of terminal ileum was reversed in an antiperistaltic manner, and the new terminal ileal end was used for the ileostomy constructed in the usual manner. Six patients underwent this procedure and were compared with six patients who had conventional total proctocolectomy and ileostomy. Variables studied included weight of ileostomy output and the weight of the filtered fluid component. Data were obtained on seven different occasions during a two-month period beginning three months after the operation. Analysis was done using Student's t-test.

RESULTS

There was a statistically significant decrease in the weight of the average 24-hour ileostomy effluent in those patients undergoing reversed antiperistaltic loop procedures. There was also a statistically significant decrease in the filterable liquid proportions.

CONCLUSIONS

The antiperistaltic ileostomy is effective in reducing the daily amount of ileostomy effluent and facilitates stoma care, owing to its diminished liquid component.

Identification of levels of maternal HIV-1 RNA associated with risk of perinatal transmission. Effect of maternal zidovudine treatment on viral load

OBJECTIVE

To determine if there are levels of human immunodeficiency virus type 1 (HIV-1) associated with a high or low risk of perinatal transmission and to ascertain the mechanism by which zidovudine treatment reduces perinatal transmission.

DESIGN

A nonrandomized prospective cohort study.

SETTING

University medical center and two general hospital affiliates from May 1989 to September 1994.

PATIENTS

Ninety-two HIV-1-seropositive women (95 pregnancies) and their 97 infants.

INTERVENTION

Forty-two mothers (43 pregnancies) received zidovudine therapy during pregnancy and/or during labor and delivery. Eleven infants received prophylactic zidovudine for the first 6 weeks after delivery.

MAIN OUTCOME MEASURE

HIV-1 infection status of the infant.

RESULTS

Twenty of the 97 infants were perinatally infected with HIV-1. Transmitting mothers were more likely to have plasma HIV-1 RNA levels higher than 50000 copies per milliliter at delivery than nontransmitting mothers (15 [75.0%] of 20 transmitters vs four [5.3%] of 75 nontransmitters; P < .001). None of the 63 women with less than 20000 HIV-1 RNA copies per milliliter transmitted. Twenty-two women treated with open-label oral zidovudine during gestation showed an eightfold median decrease in plasma RNA levels (median [25th and 75th percentile], 43043 [5699 and 63053] copies per milliliter before zidovudine vs 4238 [603 and 5116] HIV-1 RNA copies per milliliter at delivery; P < .001) and none transmitted. Four zidovudine-treated women with high HIV-1 levels transmitted despite the presence of zidovudine-sensitive virus in vitro in both the mothers and their infants.

CONCLUSIONS

Maternal HIV-1 RNA levels were highly predictive of perinatal transmission risk and suggest that certain levels of virus late in gestation and/or during labor and delivery are associated with both a high risk and a low risk of transmission. Our results also suggest that zidovudine exerts a major protective effect by reducing maternal HIV-1 RNA levels prior to delivery and that further strategies are needed to prevent perinatal transmission in women with high or increasing virus levels and/or zidovudine-resistant virus.

Correlation of clinical progression in human immunodeficiency virus-infected children with in vitro zidovudine resistance measured by a direct quantitative peripheral blood lymphocyte assay

A rapid method for determination of zidovudine resistance was developed and results were correlated with clinical outcome in human immunodeficiency virus (HIV)-infected children. The zidovudine susceptibilities of HIV-1 isolates from 34 children were determined through a direct quantitative peripheral blood lymphocyte assay and compared with results of the AIDS Clinical Trials Group resistance assay. Patients' peripheral blood lymphocytes were 5-fold diluted and cocultured with donor lymphocytes and varying concentrations of zidovudine. Isolates were defined as sensitive if inhibited by < or = 1.0 microM zidovudine and resistant at > 1.0 microM. Children (n = 21) with zidovudine-resistant virus had greater evidence of disease progression than did those with zidovudine-sensitive virus (n = 11) as demonstrated by failure to thrive (57% vs. 9%, P = .01) and opportunistic infections (48% vs. 0, P = .006). This assay may be useful as a screening tool for development of clinically relevant zidovudine resistance.

Quality of life in adult survivors of lung, colon and prostate cancer

In a cross-sectional study design, a disease free sample of 57 lung, 117 colon, and 104 prostate cancer survivors who represented short, intermediate and long-term survivors completed a detailed assessment of quality of life (QOL) and rehabilitation needs using the CAncer Rehabilitation Evaluation System (CARES). Demographic and medical data, social support, and a global QOL rating were also assessed. Lung cancer patients showed no differences in QOL with respect to their period of survival. QOL improved for survivors of colon cancer as they lived for longer periods, but declined with time for survivors of prostate cancer. The best predictor of QOL for all groups was KPS, although other variables such as type of hospital, gender, and work status were predictive for survivors of colon cancer. For survivors of prostate cancer comorbidity with other medical illnesses, time since diagnosis and comorbidity due to psychiatric difficulties were predictive of QOL. All groups had significant rehabilitation problems in the domains of physical, psychosocial, sexual, medical interaction, and marital relationships. Lung cancer survivors had more problems than the other cancer survivors. We conclude that patients who survive cancer do not return to a state of normal health. They demonstrate a variety of difficulties with which they must cope as they continue to survive. Greater efforts need to be made early in diagnosis and treatment to understand rehabilitation problems and target interventions in the hope of reducing later sequelae.

Predicting psychosocial risk in patients with breast cancer

Breast cancer is the most common neoplasm in North American women. The psychosocial impact of breast cancer has been extensively studied, and a number of investigators have attempted to characterize women who are at high risk for increased psychosocial morbidity. Although a detailed interview performed by a professional is the clinical standard for psychosocial assessment, such interviews are usually time-consuming and expensive, and thus are rarely performed. This study was designed to develop a strategy for the rapid identification of newly-diagnosed breast cancer patients at risk for psychosocial morbidity. A sample of 227 newly diagnosed breast cancer patients were interviewed systematically by a clinical social worker and were subsequently classified for risk of psychosocial distress in the year after diagnosis. In addition, these women completed a battery of standardized instruments designed to assess quality of life, rehabilitation needs and psychological distress. A logistic regression procedure was used to examine a wide range of variables for their ability to correctly classify the risk of psychosocial distress in this sample. The final model included the Cancer Rehabilitation Evaluation System (CARES) Psychosocial Summary Scale, the Karnofsky Performance Status score and age as the best predictors of psychosocial risk. Subsequently these three variables were used to construct a clinically usable risk prediction model. Additional research should be performed to validate this predictive model.

Exploring the influence of multiple variables on the relationship of age to quality of life in women with breast cancer

This paper explores the relationship between age, psychosocial status and quality of life in a community based sample (n = 229) of newly-diagnosed breast cancer patients. A casement display methodology is used to examine the influence of demographic and medical variables on the outcome variables of interest (psychosocial status and quality of life) and their relationship to age. Based on the literature, a positive relationship between age and psychosocial status was predicted, but the relationship between age and quality of life was uncertain. For the whole sample, a weakly positive relationship between age and measures of psychosocial status and quality of life was observed. In the exploratory studies using the casement plots, the positive relationship between age and quality of life was most strong and significant in married women and in women who had received segmental mastectomy. Among sub-groups examined according to marital status and type of surgery, a positive relationship between age, psychosocial status and quality of life was observed only in married women who received segmental mastectomy. Additional preliminary observations were made about the relationship of household income and age to the outcome variables being studied. The casement plot methodology permits the simultaneous evaluation of multiple variables as a preliminary step before hypothesis development and should be considered when complex clinical problems are being evaluated.

The CARES: a generic measure of health-related quality of life for patients with cancer

In spite of the prevalence of neoplastic disorders as a cause of chronic illness, very few of the currently available generic measures of health-related quality of life or health status have been utilized with cancer patients. In this paper we reviewed our studies with the Cancer Rehabilitation Evaluation System (CARES), a cancer-specific measure of rehabilitation needs and quality of life. We present data to demonstrate that the CARES is a generic measure of health-related quality of life, suitable for use in the many different diseases called cancer. The data that form the basis for this paper were collected during a decade of research on the CARES. This paper represents the first discussion of the performance of the CARES across separate cancer sites and phases of the disease. In addition, we demonstrated that the CARES is responsive to changes in health-related quality of life over time. Finally, we will discuss the application of the CARES in clinical and research settings.