Abstract PO007: Tumor-immune communication via extracellular vesicles

Emerging evidence suggests that tumor-derived extracellular vesicles (tEVs) can influence immune cell behavior both locally within the tumor microenvironment and remotely by accessing the lymphatic and systemic circulation. The in vivo effects of such interactions before and after immunotherapy remain largely unappreciated. In this study, we aimed to develop a sensitive but stringent approach to identify host cells that interact with tEVs, with the ultimate goal of studying how tEV influence immune cells in their native microenvironment. Investigation of tEVs’ roles in cancer has been hampered by the need to isolate them before intravenous reinfusion in animals, which can introduce biases such as homogenization of tEV diversity, judgement of amount to reinfuse and assumptions on blood vs lymph biodistribution. To circumvent these issues, we and others pioneered the use of genetically engineered tumor cells to express membrane-bound reporters, which allow to label untouched, endogenously released tEVs and follow their interactions with immune cells. Still, the amount of reporter proteins that tEVs can carry is relatively small and thus the sensitivity of the approach is suboptimal. Here we addressed this issue by engineering tEVs to display a membrane-bound form of Sortase A, a bacterial transpeptidase that catalyzes the transfer of reporter proteins on the much bigger surface of tEV-binding cells. SrtA catalyzes the formation of a peptide bond between a consensus peptide and an N-terminal glycine of a nearby cell surface proteins (e.g. MHC-I, MHC-II, VE-Cadherin, CD19, integrins). We tested 4 different SrtA protein designs and selected the best performing construct for tEV studies. We genetically encoded SrtA in parental tumor cell lines, which then release SrtA as a tEV-bound transmembrane protein. Once a SrtA+ tEV interacts with a target cell in the presence of the consensus peptide (conjugated to a fluorescent reporter), SrtA catalyzes the formation of a covalent bond between the reporter and surface proteins of the tEV-binding cell. As expected, we observed significant increase in labeling when target cells were engineered to express a surface protein carrying 5 N-terminal glycine residues, which confirms that labeling of tEV-binding cells is due to actual transfer of fluorescent reporter – and not due to acyl intermediate formation. As compared to indirect labeling of EV-binding cells (e.g. using the EV marker CD63 fused to GFP), SrtA-based approach shows 1-2 log increase in sensitivity, depending on the EV-producing cell type. Overall, the catalytic nature of our EV reporter system lowers the amount of tEVs a host cell needs to bind before being detectable, thereby increasing sensitivity. We are currently testing our SrtA-based approach in vivo, where endogenous tEVs mainly accumulate in sentinel lymph nodes. We expect to unearth the full set of lymph node immune cells interacting with native tEVs and to identify whether immunecheckpoint blockade therapy affects tEV tropism toward immune cells.

Citation Format: Ferdinando Pucci, Nicklas Hamilton, Natalie Claudio, Randall Armstrong. Tumor-immune communication via extracellular vesicles [abstract]. In: Abstracts: AACR Virtual Special Conference: Tumor Immunology and Immunotherapy; 2020 Oct 19-20. Philadelphia (PA): AACR; Cancer Immunol Res 2021;9(2 Suppl):Abstract nr PO007.

0801 Sleep, Nightmares, and the Maintenance of Posttrauma Symptoms

Introduction

Most individuals will experience at least one traumatic event in their lifetime. Although most individuals who experience a trauma will exhibit some posttrauma symptoms, only a small subset will experience long-lasting symptoms. In fact, most research suggests that posttrauma symptoms will gradually reduce over time. However, some individuals can exhibit posttrauma symptoms for an extended period of time. Although research has demonstrated that poor overall sleep quality may explain why some people have trouble gradually recovering from posttrauma symptoms, research has yet to examine specific aspects of sleep that can impair the gradual remission of posttrauma symptoms. This study examined how individual facets of sleep quality (such as nightmares and sleep duration) impact posttrauma symptoms over time.

Methods

944 college students completed an online survey battery that included measures of traumatic experiences, time since trauma (TST), posttrauma symptoms, sleep quality, and the presence of nightmares. Regression analyses were used to examine the interaction of sleep quality sub-facets and time since trauma on posttrauma nightmares (PNMs).

Results

Out of 944 participants, 637 (67%) reported at least one trauma. Of those students, time since trauma (TST) and all other sleep variables significantly predicted posttrauma symptoms (p < 0.05). However, the only significant interaction was nightmares and TST (p < 0.01) where individuals who experienced PNMs had significantly (p < 0.01) higher posttrauma symptom intercept (48.19) than individuals who did not experience PNMs (31.19). Furthermore, individuals who experienced PNMs demonstrated statistically significant flatter slopes than those without nightmares (p < 0.01).

Conclusion

The results reveal that time since trauma predicts a decrease in posttrauma symptoms, whereas nightmares impede this symptom reduction. Interestingly, the interaction finding suggests that nightmares play a critical role in initial symptom expression and recovery. These results demonstrate the importance of identifying and treating nightmares immediately following a trauma.

Support

“none”

Cell Surface Labeling by Engineered Extracellular Vesicles

Extracellular vesicles (EVs) can mediate local and long-range intercellular communication via cell surface signaling. In order to perform in vivo studies of unmanipulated, endogenously released EVs, sensitive but stringent approaches able to detect EV-cell surface interactions are needed. However, isolation and reinfusion of EVs can introduce biases. A rigorous way to study EVs in vivo is by genetically engineering membrane-bound reporters into parental cells. Still, the amount of reporter molecules that EVs can carry is relatively small, and thus, the sensitivity of the approach is suboptimal. This work addresses this issue by engineering EVs to display a membrane-bound form of Sortase A (SrtA), a bacterial transpeptidase that can catalyze the transfer of reporter molecules on the much bigger surface of EV-binding cells. SrtA design and reaction requirements are optimized and validated. Efficient in vitro labeling of EV-binding cells is achieved, even in the presence of only one N-terminal glycine on cell surface proteins. As compared to indirect labeling of EV-binding cells (e.g., using CD63-GFP fusion), the SrtA-based approach shows 1-2 log increase in sensitivity, depending on the EV source. This novel approach will be useful to identify and study the full set of host cells interacting with native EVs in vivo.

A population genetic study of feral cats on Christmas Island

Feral and stray cats are a major threat for endemic species on Christmas Island and have been contributing to their decline. Cats were introduced to Christmas Island in 1888 and are now distributed across the whole island. We analysed the genetic population structure and diversity of feral and stray cats on Christmas Island to evaluate connectivity across the island and the possibility of discernible populations that could be targeted separately. Results indicate no differentiated population structure across the island, with cats facing no habitat obstacles to reduce their dispersal abilities across the island. We found high kin structure, suggesting individuals breeding successfully on the whole island. With the management of domestic and feral/stray cats since 2010, removal efforts targeting the whole island have successfully reduced the effective population size of feral/stray cats in the last five years. We suggest the use of various management techniques to facilitate future removal efforts, especially in areas on the island that are difficult to access.

Development of consensus-based international antimicrobial stewardship competencies for undergraduate nurse education

BACKGROUND

There is growing recognition by national and international policymakers of the contribution nurses make towards antimicrobial stewardship. Although undergraduate education provides an ideal opportunity to prepare nurses for antimicrobial stewardship roles and activities, only two-thirds of undergraduate nursing programmes incorporate any antimicrobial stewardship teaching and only 12% cover all the recommended antimicrobial stewardship principles. Nurses also report that they do not have a good knowledge of antibiotics, and many have not heard of the term antimicrobial stewardship.

AIM

To provide international consensus on the antimicrobial stewardship competency descriptors appropriate for undergraduate nurse education.

METHODS

A modified Delphi approach comprising two online surveys delivered to an international panel of 15 individuals reflecting expertise in prescribing and medicines management in the education and practice of nurses; and antimicrobial stewardship. Data collection took place between February and March 2019.

FINDINGS

A total of 15 participants agreed to become members of the expert panel, of whom 13 (86%) completed round 1 questionnaire, and 13 (100%) completed round 2. Consensus was achieved, with consistently high levels of agreement across panel members, on six overarching competency domains and 63 descriptors, essential for antimicrobial stewardship practice.

CONCLUSION

The competency descriptors should be used to direct undergraduate nurse education and the antimicrobial stewardship practices of qualified nurses (including those working in new roles such as Nursing Associates) due to the high levels of agreement reached on competency descriptors.

Continuous intraoperative nerve monitoring in thyroidectomy using automatic periodic stimulation in 256 at-risk nerves

INTRODUCTION

Automatic periodic stimulation of the vagal nerve during thyroidectomy provides real-time feedback of recurrent laryngeal nerve function intraoperatively. To assess the validity of this device, the ability of monitoring to predict recurrent laryngeal nerve palsy was determined and the incidence of recurrent laryngeal nerve palsy recorded.

MATERIALS AND METHODS

All thyroidectomies using APS® (Automatic Periodic Stimulation, Medtronic) nerve monitoring were reviewed over a 27-month period. Changes in signal amplitude and latency during thyroidectomy were recorded from saved data. Postoperative fibreoptic laryngoscopy determined the incidence of vocal cord immobility and recovery of nerve function was assessed from follow-up letters.

RESULTS

A total of 256 at-risk nerves were examined (132 hemi- and 62 total thyroidectomies) in cases involving benign and malignant disease. Permanent recurrent laryngeal nerve palsy occurred in six (2.3%) lobectomies and transient recurrent laryngeal nerve palsy occurred in two lobectomies (< 1%). Sensitivity for detecting postoperative vocal cord immobility was 100% and specificity 85% if the end amplitude was 50% below baseline. The positive predictive value when amplitude was 50% below baseline was 18%. The negative predictive value when amplitude was 50% above or equal to baseline was 100%. Intraoperatively, the amplitude was 50% below baseline more frequently in the vocal cord immobility group (t-test, P < 0.015). No vagal nerve complications occurred.

CONCLUSION

Whilst the incidence of recurrent laryngeal nerve palsy is comparable to rates in the literature, the incidence of transient palsy is lower than published averages. APS is able to reliably predict recurrent laryngeal nerve palsy based on end amplitude.

Challenges Faced in Translating the Benefits of Surfactant Replacement Therapy to a Resource-Limited Setting

Aim To determine the challenges, if any, in translating the benefits of surfactant replacement therapy (SRT) to a resource-limited setting. Method This was a retrospective descriptive study comparing the outcome of 75 cases who received surfactant and 69 controls who did not at the University Hospital of the West Indies during the period 2001 to 2011. Descriptive analyses were performed. Statistical significance was taken at the level p < 0.05. Results Only 13% of neonates with respiratory distress syndrome received surfactant therapy. The median time of surfactant administration was 16.5 hours (interquartile range: 6-37 hours). The mean ± standard deviation time between repeat doses was 19.1 ± 14 hours. There was no difference in mortality between cases (67%) and controls (59%) (p = 0.32). However, the cases who survived were less mature (28.3 ± 2 weeks) and less clinically stable (CRIB II [Clinical Risk Index for Babies] score: 8.2 ± 3) than their controls who survived (30.0 ± 2 weeks; CRIB II score: 6.0 ± 3) (p = 0.01). There was no difference in mean gestational age or CRIB II scores between nonsurviving cases and controls. A high incidence of sepsis, pneumothoraces, and pulmonary hemorrhage was noted in both cases and controls. Conclusion SRT did not improve the overall outcome in preterm neonates treated with RDS. Challenges encountered in optimizing SRT included affordability and accessibility of surfactant, supportive equipment, and supportive therapies, as well as a high incidence of complications related to prematurity.

Abstract P6-10-05: A pilot study of radiation (RT) and CTLA4-mediated checkpoint blockade with tremelimumab for the treatment of breast cancer brain metastases (BCBM)

This abstract was withdrawn by the authors.

Gluconeogenesis in Leishmania mexicana: contribution of glycerol kinase, phosphoenolpyruvate carboxykinase, and pyruvate phosphate dikinase

Gluconeogenesis is an active pathway in Leishmania amastigotes and is essential for their survival within the mammalian cells. However, our knowledge about this pathway in trypanosomatids is very limited. We investigated the role of glycerol kinase (GK), phosphoenolpyruvate carboxykinase (PEPCK), and pyruvate phosphate dikinase (PPDK) in gluconeogenesis by generating the respective Leishmania mexicana Δgk, Δpepck, and Δppdk null mutants. Our results demonstrated that indeed GK, PEPCK, and PPDK are key players in the gluconeogenesis pathway in Leishmania, although stage-specific differences in their contribution to this pathway were found. GK participates in the entry of glycerol in promastigotes and amastigotes; PEPCK participates in the entry of aspartate in promastigotes, and PPDK is involved in the entry of alanine in amastigotes. Furthermore, the majority of alanine enters into the pathway via decarboxylation of pyruvate in promastigotes, whereas pathway redundancy is suggested for the entry of aspartate in amastigotes. Interestingly, we also found that l-lactate, an abundant glucogenic precursor in mammals, was used by Leishmania amastigotes to synthesize mannogen, entering the pathway through PPDK. On the basis of these new results, we propose a revision in the current model of gluconeogenesis in Leishmania, emphasizing the differences between amastigotes and promastigotes. This work underlines the importance of studying the trypanosomatid intracellular life cycle stages to gain a better understanding of the pathologies caused in humans.

Outcome of kidney transplantation from elderly donors after cardiac death

BACKGROUND

The rate of renal transplantation is limited by the number of donor organs available. A valuable source of organs is currently supplied by donation after cardiac death (DCD). At the Richard Bright Renal Unit, we have expanded our criteria for DCD, increasing the upper age limit for donation from 65 to 70.

METHOD

We performed a retrospective analysis of all DCD recipients between 2003 and 2009. We compared outcomes for patients age<60 versus >60 as measured by delayed graft function and estimated glomerular filtration rate (eGFR) and incidence of graft failure.

RESULTS

One hundred thirty-six DCD transplantations took place. Our early data showed excellent results for non-heart-beating donation. Over the last 7 years, the average age of DCD donors has increased from 43 in 2003 to 50 in 2009. The increase in age has been correlated with a decrease in average recipient eGFR from 59 in 2003 to 32 in 2009. Recipients of kidneys from older DCD donors (>60) have significantly lower eGFRs at 1 month and 1 year compared to kidneys from donors aged <60. The incidence of delayed graft function in recipients of kidneys from donors aged>60 was 71% compared to 40% for <60 age group. Despite this, we have not found any evidence of higher graft failure rates in the recipients of grafts from the >60 donor age group.

CONCLUSIONS

Expanding the age limits of our DCD donor program has led to an increased average donor age, reduced average eGFR, and increased delayed graft function. There is no evidence of reduced graft survival.

Insulin-like growth factor-2 (IGF-2) activates estrogen receptor-α and -β via the IGF-1 and the insulin receptors in breast cancer cells

The estrogen receptor (ER) is a primary target for breast cancer (BC) treatment. As BC progresses to estrogen-independent growth, the insulin-like growth factor-1 receptor (IGF-1R) and the ER interact in synergistic cross-talk mechanisms, which result in enhanced activation of both receptors' signaling cascades. Insulin-like growth factor-2 (IGF-2) is critical in BC progression and its actions are mediated by the IGF-1R. Our previous studies showed that IGF-2 regulates survival genes that protect the mitochondria and promote chemoresistance. In this study, we analyzed BC cells by subcellular fractionation, Western-Blot, qRT-PCR, and siRNA analysis. Our results demonstrate that IGF-2 activates ER-α and ER-β, and modulates their translocation to the nucleus, membrane organelles, and the mitochondria. IGF-2 actions are mediated by the IGF-1R and the insulin receptor. This novel mechanism of IGF-2 synergistic cross-talk signaling with ER-α and ER-β can promote estrogen-independent BC progression and provide new therapeutic targets for the treatment of BC patients.

Development and clinical validation of a molecular diagnostic assay to detect CTX-M-type beta-lactamases in Enterobacteriaceae

Enterobacterial isolates producing CTX-M beta-lactamases have recently emerged worldwide in the community and hospital settings. Because of the significant public health implications, the spread of organisms producing CTX-M enzymes merits close monitoring with enhanced surveillance efforts. A molecular diagnostic assay using two different sets of primers simultaneously for the detection of all bla(CTX-M)-like beta-lactamase genes was developed. This assay repeatedly demonstrated 100% sensitivity, specificity and positive and negative predictive values for detecting different CTX-M enzymes in well-characterised strains that included producers of VEB-, TEM- and SHV-type extended-spectrum beta-lactamases (ESBLs) and plasmid-mediated AmpC enzymes. The majority (132/240; 55%) of ESBL-producing enterobacterial isolates recovered in the Calgary Health Region during 2003 and 2004 were positive for bla(CTX-M) genes, including 81 (61%) positive for the CTX-M-9 group, 49 (37%) for the CTX-M-1 group, and two (2%) for the CTX-M-2 group. The CTX-M-specific PCR assay was reproducible and easy to use. It can be introduced in a clinical or reference laboratory to track and monitor the spread of organisms producing CTX-M enzymes in the community and hospital settings.

Sensitization to king scallop (Pectin maximus) and queen scallop (Chlamys opercularis) proteins

OBJECTIVE

To report a case of occupational asthma and urticaria due to the queen scallop (Chlamys opercularis) and king scallop (Pectin maximus).

BACKGROUND

A 40-year-old female worked in a shellfish-processing plant, handling king and queen scallops for 5 years. At the time of investigation, she described a 2-year history of work-related respiratory symptoms.

METHODS

Serial peak expiratory flow rate readings were recorded and an OASYS study completed. A workplace visit was undertaken and specific immunoglobulin (IgE) radioallergosorbent (RAST) testing of scallop extracts was performed.

RESULTS

The OASYS study was consistent with occupational asthma. RAST testing demonstrated evidence of specific sensitization (IgE) to queen and king scallop. There was also some cross-reactivity observed with other shellfish (prawns and crabs).

CONCLUSION

Workers exposed to aerosols from scallop species are at risk of occupational asthma and require effective respiratory health surveillance.

Global economic restructuring and international migration: some observations based on the Mexican and Central American experience

"The purpose of this article is to explore the relationship between processes of global economic restructuring and international migration through an examination of Mexican and Central American immigration to the U.S. and the experiences of Central American and Mexican immigrants in the U.S. This relationship is analysed as one of mutual causation: on the one hand, global restructuring affects conditions in both sending and receiving countries (it is not only a factor in emigration but also in the economic and political receptivity to immigrants at their point of destination); on the other, international migration in turn has an important impact on countries of origin, receiving countries, and the relationship between them." (SUMMARY IN FRE AND SPA)

Water-soluble propofol analogues with intravenous anaesthetic activity

Propofol (2,6-diisopropylphenol) is a widely used intravenous anaesthetic that is formulated as an emulsion since it lacks water solubility. We report a range of water-soluble analogues of propofol, containing a para-alkylamino substituent, which retain good intravenous anaesthetic activity in rodents.

Challenges in the dietary treatment of cystic fibrosis related diabetes mellitus

Cystic fibrosis related diabetes mellitus is an increasingly recognized problem as survival in patients with cystic fibrosis improves. In a 5 year retrospective study of 627 children and adults attending Toronto cystic fibrosis clinics, we identified 57 (9%) patients with cystic fibrosis related diabetes mellitus; four (1.3%) of 301 children (<18 years) and 53 (16%) of 326 adults. The development of this complication of cystic fibrosis is associated with increased mortality, deteriorations in both respiratory and nutritional status, and the development of late microvascular, but not macrovascular, diabetic complications. Unfortunately, systematic review of the literature provides few well designed studies that provide sound evidence for clinical practice. Recommendations are therefore often based on anecdote, rather than physiological or outcomes research. Dietary therapy combines the principles of the dietary management of both cystic fibrosis and diabetes mellitus, but emphasizes the need for a high energy diet (> 100% of recommended daily intake) in patients with cystic fibrosis related diabetes mellitus. The importance of calories from fat is emphasized, with no restriction on total carbohydrate intake. Insulin intake mirrors carbohydrate intake. Routine dietary therapy is straightforward, but challenges occur due to both complications of cystic fibrosis and advancing disease. If a patient with cystic fibrosis related diabetes mellitus is malnourished, overnight enteral tube feeding is often used, with an adjusted insulin regimen. There is a great need for both physiological and outcomes research to provide sound scientific evidence for the dietary treatment of cystic fibrosis related diabetes mellitus.

Randomised controlled trial comparing effectiveness of touch screen system with leaflet for providing women with information on prenatal tests

OBJECTIVE

To compare the effectiveness of touch screen system with information leaflet for providing women with information on prenatal tests.

DESIGN

Randomised controlled trial; participants allocated to intervention group (given access to touch screen and leaflet information) or control group (leaflet information only).

SETTING

Antenatal clinic in university teaching hospital.

SUBJECTS

875 women booking antenatal care.

INTERVENTIONS

All participants received a leaflet providing information on prenatal tests. Women in the intervention arm also had access to touch screen information system in antenatal clinic.

MAIN OUTCOME MEASURES

Women's informed decision making on prenatal testing as measured by their uptake of and understanding of the purpose of specific tests; their satisfaction with information provided; and their levels of anxiety.

RESULTS

All women in the trial had a good baseline knowledge of prenatal tests. Women in the intervention group did not show any greater understanding of the purpose of the tests than control women. However, uptake of detailed anomaly scans was significantly higher in intervention group than the control group (94% (351/375) v 87% (310/358), P=0.0014). Levels of anxiety among nulliparous women in intervention group declined significantly over time (P<0.001).

CONCLUSIONS

The touch screen seemed to convey no benefit over well prepared leaflets in improving understanding of prenatal tests among the pregnant women. It did, however, seem to reduce levels of anxiety and may be most effective for providing information to selected women who have a relevant adverse history or abnormal results from tests in their current pregnancy.

A pilot study of interpersonal psychotherapy by telephone with cancer patients and their partners

A single-arm pilot study explored the feasibility of adapting in Interpersonal Psychotherapy (IPT) by telephone to reduce psychological distress and to enhance coping during cancer treatment. Therapy focuses on role transitions, interpersonal conflicts, and grief precipitated by cancer. Breast cancer patients receiving high-dose chemotherapy received weekly sessions with a psychologist throughout chemotherapy and for 1 month afterwards. Patients could invite one 'partner' to receive individual telephone IPT. Psychosocial functioning was assessed using standardized measures at study entry, after chemotherapy, and following telephone IPT. Accrual and participation supplied evidence of feasibility: 14 patients and 10 partners were recruited, 82.5% of those eligible. Patients had a mean of 16 sessions; partners had a mean of 11. Participants rated their satisfaction with the program between 'good' and 'excellent'. A test of the efficacy of telephone IPT requires a larger, randomized trial. In order to standardize the intervention, a treatment manual was developed. This study indicated the importance of outreach to family members as well as to cancer patients, intensive patient education about oncology treatment and the medical care setting, and psychosocial services that continue after cancer treatment has been completed.

Developing a sociological framework for dually diagnosed women

This exploratory study was conducted with the purpose of enumerating both particular social stressors (e.g., the presence of trauma) and the incidence of a comorbid diagnosis (i.e., personality disorder[s] and substance abuse) on a sample of women in a residential therapeutic community. The women in the study were assessed within the first 3 weeks following admission into drug treatment, and then again 6 months after leaving the program. The initial assessment generally took 2 hours and consisted of the Structured Clinical Inventory for DSM-III-R-Patient edition (SCID-II), Addiction Severity Index (ASI), and the Millon Clinical Multiaxial Inventory-II (MCMI-II). Clinically significant scores on the MCMI-II antisocial and borderline personality scales were noted in this study. This study found women with histories of delinquent and/or criminal behavior before drug use were more likely to have used more types of drugs and have used multiple drugs together. These women also tended to have had a history of being abused, either emotionally, physically, or sexually. This group was also less successful on all outcome measures during 6-month follow-up. Moreover, the lifetime incidence of emotional, physical, and sexual abuse reported for this group at the baseline assessment was high--57.1% emotional abuse, 48.9% physical abuse, and 39.7% sexual abuse. These results are consistent with the research literature that indicates abuse plays a central role in the development and chronic effect of personality disorders and, in particular, posttraumatic stress disorder.

The genotoxicity and cytotoxicity of dermally-administered cadmium: effects of dermal cadmium administration

Cadmium, unlike zinc, selenium and copper, has no known biological importance, and therefore, it is classified as a carcinogen in humans, as well as in animals. The effect(s) of levels of dermally-administered cadmium on cadmium genotoxicity and cytotoxicity was investigated in Harlan Sprague-Dawley rats for 14, 21, 28, 35 and 42 days at concentrations of 14 and 28 mg/kg/day. Exposure of rats to cadmium via dermal application caused lesions on the skin (hyperkeratosis, acanthosis and scabbing, alopecia and erythema) and tumors in the scrotum. Anatomical changes, such as distention of the stomach, atrophy of kidney and liver and loss of body weight were also observed in these rats. The toxic effects of cadmium on cell ultrastructure were nuclear membrane damage, chromatin condensation, regression of mitochondrial cristae and ultimately cell death. Analyses of the brain, kidney and liver cells of rats exposed to cadmium, clearly showed DNA damage. Of the three organs examined, DNA from kidney cells sustained the most damage followed by DNA in liver cells. There is a positive correlation between Cd dose(s) and duration of exposure and the extent of DNA damage.

Patient preferences for control in medical decision making: a scenario-based approach

OBJECTIVE

This study evaluated patient preferences about involvement in medical decision making and factors that might influence these preferences.

METHODS

A questionnaire was used that had one general question and 10 different clinical scenarios, followed by a list of seven options that described varying degrees of patient participation in the clinical decision-making process. The participants were patients presenting to a family practice residency clinic.

RESULTS

Using paired t tests, patient responses to seven of 10 clinical scenarios (70%) were statistically significantly different from their responses as predicted by the general question. Six responses showed a positive relationship, ie, patients wanted to give the physician more control than they indicated by their response to the general question. Paired t tests then compared responses to each scenario with responses to every other scenario; 26 of 45 (58%) were significantly different. A factor analysis suggested groupings of scenarios. Significant differences for decision-making preferences were found among age groups and among educational levels. Cronbach's alpha, a measure of internal consistency, was calculated at .81.

CONCLUSIONS

Although preference for level of control in medical decision making varied by scenario, our patients most often preferred physicians to play the primary role in decision making. Patient preferences for general decision making correlated poorly with preferences in specific scenarios.

Source document position as it affects head position and neck muscle tension

Measurements of head position, mechanical load at C7, and level of muscle EMG activity in the muscles of the neck were compared across six document positions in both a reading task and a typing (word processing) task. Source documents, identified as a primary visual task, were placed in two positions in front of the subject, flat on the table to each side of the keyboard, and on a document stand at each side of the keyboard. Each of the 20 subjects performed both a reading task and a typing task in each of these document positions while measurements were taken. It was found that the greatest variations in head position occurred in head rotation with documents flat on the table. This document position on each side also produced the greatest level of muscle tension in both the neck extensors and, to a lesser degree, the sternocleidomastoid muscles. In addition, greater variability between document position measures was found in the typing condition.

The anaesthetic action and modulation of GABAA receptor activity by the novel water-soluble aminosteroid Org 20599

The anaesthetic profile of a novel water-soluble aminosteroid, Org 20599 [(2 beta, 3 alpha, 5 alpha)-21-chloro-3-hydroxy-2-(4-morpholinyl)pregnan-20-one methanesulphonate], and the ability of the compound to allosterically regulate the activity of the GABAA receptor, have been studied in comparison to the properties of established intravenous general-anaesthetic agents. Intravenously administered Org 20599 produced a rapid onset, short duration loss of the righting reflex in mice. The anaesthetic potency of Org 20599 was comparable to that of the steroids 5 alpha-pregnan-3 alpha-ol-20-one or alphaxalone, and exceeded that of propofol, thiopentone or pentobarbitone. Org 20599 and the reference anaesthetic agents allosterically displaced the binding of [35S]-t-butylbicyclophosphorothionate (TBPS) from GABAA receptors of rat-brain membranes with the order of potency: 5 alpha-pregnan-3 alpha-ol-20-one > Org 20599 > alphaxalone > propofol > thiopentone > pentobarbitone. At human recombinant alpha 1, beta 2, gamma 2L subunit-containing GABAA receptors expressed in Xenopus laevis oocytes, the anaesthetic agents produced a concentration-dependent and reversible potentiation of the peak amplitude of GABA-evoked currents. A similar positive allosteric action of Org 20599 was observed for the GABAA receptors expressed by bovine adrenal chromaffin cells maintained in culture. The rank order of potency in the aforementioned assays was identical to that determined from the displacement of TBPS binding. At concentrations greater than those required for potentiation of GABA, the anaesthetics exhibited GABA-mimetic effects with a rank order of potency that paralleled their modulatory activity. Such direct agonism varied greatly in maximal effect between compounds. The modulatory and direct agonist actions of Org 20599 were additionally confirmed utilizing rat hippocampal neurones in culture. The results indicate Org 20599 to be a potent and short-acting intravenous anaesthetic agent in mice and suggest positive allosteric regulation of GABAA receptor function to be a plausible molecular mechanism of action for the drug.

High-dose chemotherapy of breast cancer

High-dose chemotherapy (HDC) with stem cell autografting produces complete remission (CR) rates far in excess of those reported for lower-dose chemotherapy, or for any form of endocrine manipulation in patients with metastatic breast cancer. In early studies involving patients with resistant disease, HDC produced CR rates of as high as 25%. Most contemporary HDC trials accrue patients who are responding to "conventional" chemotherapy, and hence, few untreated patients have been studied in phase II evaluations. In one case, a CR rate of 54% (25% of which remained durable) was reported. In a randomized trial of high-dose versus conventionally dosed therapy, investigators in South Africa reported complete response rates of 50% and 6% respectively. In trials in which HDC is applied as a form of consolidation therapy following "conventional" chemotherapy, complete remission rates as high as 70% are reported.

Rapidly cycled courses of high-dose alkylating agents supported by filgrastim and peripheral blood progenitor cells in patients with metastatic breast cancer

Our purpose was to determine the feasibility of a regimen of multiple, rapidly cycled courses of high-dose alkylating agents, including paired courses of escalating doses of thiotepa, supported by peripheral blood progenitor cells and filgrastim, in patients with responding stage IV breast cancer. The regimen consisted of two courses of cyclophosphamide (3.0 g/m2/course) followed by two courses of thiotepa (500-700 mg/m2/course). All courses were supported by filgrastim. Leukaphereses were performed after each cyclophosphamide course to harvest peripheral blood progenitors (PBPs) for use as rescue following thiotepa administration. The planned interval for all courses was 14 days. Forty-two patients were enrolled. Thirty-eight received all four courses, and four did not receive the second thiotepa cycle due to poor PBP mobilization. The maximum dose of thiotepa that was administered was 700 mg/m2 x 2. At this dose, one patient developed encephalopathy, which resolved over several weeks. The median number of days to an absolute neutrophil count of 0.5 x 10(9)/liter after PBP reinfusion for cycles 1 and 2 of thiotepa were 9 (range, 7-16) and 9 (range, 8-13) days, respectively. The corresponding values for platelet recovery to >20 x 10(9)/liter were 11 (range, 8-39) and 12 (range, 10-28) days, respectively. There were no treatment-related deaths. Hospitalization was required following 28 of 84 cyclophosphamide courses and 76 of 80 thiotepa courses. Four patients developed grade III-IV mucositis. The median interval between courses of treatment was 15 (range, 13-29) days. Of 19 patients who entered the protocol with measurable disease in partial response from prior therapy, 8 (42%) achieved complete response following the high-dose therapy. Nine (21%) of 42 remain progression free at a median follow-up of 28 (range, 20-32) months. Therefore, we concluded that the administration of multiple, rapidly cycled courses of high-dose alkylating agents is feasible.

High-intensity chemotherapy with peripheral blood progenitor cell support

In a series of clinical studies at Memorial Sloan-Kettering Cancer Center, we have used hematopoietic growth factors and peripheral blood-derived hematopoietic progenitor cells to facilitate delivery of multiple courses of high-dose chemotherapy at abbreviated treatment intervals. In these studies, we have demonstrated the feasibility of cross-over regimens involving induction chemotherapy with high-dose cyclophosphamide, supported by granulocyte colony-stimulating factor and followed by multiple peripheral blood leukapheresis to harvest progenitor cells. These cells are then used as rescue for the consolidation component of treatment, which, in the earlier-generation studies, consisted of a single course of high-dose carboplatin/etoposide/cyclophosphamide chemotherapy. In subsequent studies, patients received either four courses of high-dose carboplatin or carboplatin/cyclophosphamide or tandem courses of thiotepa. In all cases, the planned interval between treatments was 14 days, and the achieved median was approximately 16 days. These studies show that the administration of high-intensity regimens that deliver multiple courses of very high-dose chemotherapy at relatively brief intervals is feasible. Our current research focuses on exploiting these findings to devise disease-specific regimens for breast and ovarian cancer.

High-intensity chemotherapy with hematopoietic support in breast cancer

Chemotherapy can produce excellent palliation for many patients with metastatic breast cancer. Survival impact is, however, limited, and permanent remission is extremely rare. There is increasing evidence that dose and dose intensity may be important determinants of outcome in the chemotherapy of breast cancer. Single courses of chemotherapy in doses requiring autologous bone marrow support produce high rates of objective response in patients with metastatic disease that was refractory to prior standard-dose therapy. When used as first chemotherapy for metastases or as consolidation in patients whose disease is responding to lower-dose therapy, high-dose chemotherapy can result in prolonged disease-free survival for some patients. The major cause of treatment failure is relapse from a chemotherapy-induced complete response. Kinetic models suggest that multiple, rapidly cycled courses of high-dose chemotherapy might be superior to single applications or to multiple treatments that are widely spaced in time. Heretofore, the substantial toxicity of high-dose chemotherapy (up to 20% mortality in some early trials) has largely precluded the consideration of timely retreatment; however, the risk appears to have been reduced through the use of hematopoietic growth factors and peripheral blood progenitor cells. Our group has used these new technologies to develop regimens consisting of multiple cycles of high-dose chemotherapy that are rapidly administered. We are currently refining these regimens in preparation for phase II and III studies.

Rapid administration of multiple cycles of high-dose myelosuppressive chemotherapy in patients with metastatic breast cancer

PURPOSE

To determine the feasibility and safety of a rapidly cycled sequence of high-dose myelosuppressive chemotherapy courses.

PATIENTS AND METHODS

Seventeen patients with metastatic breast cancer were treated with two courses of cyclophosphamide (CPA; 3.0 g/m2) supported by granulocyte colony-stimulating factor (G-CSF). Following the first CPA treatment, peripheral-blood leukaphereses commenced when the leukocyte count recovered to 1.0 x 10(9)/L. After hematologic recovery from the second dose of CPA, patients were treated with carboplatin 1,500 mg/m2, etoposide 1,200 mg/m2, and CPA 5.0 g/m2 administered over 3 days. The peripheral-blood progenitors (PBPs) were reinfused 3 days later, and G-CSF was recommenced.

RESULTS

All patients received the three courses. The median interval between treatments was 14 days (range, 13 to 21). Sixteen of the 34 courses of CPA resulted in admissions for fever. Following the third course, neutrophil counts recovered to 0.5 x 10(9)/L at a median of 9 days (range, 8 to 18) after PBP reinfusion and platelets recovered to 50 x 10(9)/L at a median of 12 days (range, 9 to 102). There were no treatment-related deaths. Flow-cytometric analysis was performed on the leukapheresis collections of eight patients. Seven patients with at least 2.0 x 10(6) CD34+ CD33- cells per kilogram body weight exhibited prompt hematologic recovery. One patient with 0.03 x 10(6) CD34+ CD33- cells was still cytopenic on day 21, and required reinfusion of her back-up marrow. Among seven patients with measurable or assessable disease, there were two complete responses (CRs) and four partial responses (PRs).

CONCLUSION

These preliminary results suggest that multiple, rapidly cycled courses of high-dose myelosuppressive chemotherapy can be administered. PBPs, harvested during the G-CSF-augmented rebound from CPA-induced cytopenia, produce rapid hematologic recovery in patients undergoing high-dose chemotherapy (HDC). Further follow-up will be necessary to assess the efficacy of this specific regimen in the treatment of metastatic breast cancer.

Beneficial impact of peripheral blood progenitor cells in patients with metastatic breast cancer treated with high-dose chemotherapy plus granulocyte-macrophage colony-stimulating factor. A randomized trial

BACKGROUND

This study compared the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF) alone or in combination with peripheral blood-derived hematopoietic progenitor cells (PBP) as support for patients receiving high-dose chemotherapy and assessed the adequacy of these strategies as alternatives to autologous bone marrow rescue.

METHODS

The authors studied patients with metastatic breast carcinoma who had a major response to conventional chemotherapy or had achieved a complete remission by surgical resection of all known metastases. They were treated with carboplatin 1500 mg/m2, etoposide 1200 mg/m2, and cyclophosphamide 5.0 g/m2. Before this high-dose chemotherapy, the patients had been randomly assigned to one of two hematopoietic support strategies: GM-CSF alone (Group 1) or GM-CSF-primed PBP and GM-CSF (Group 2). Autologous bone marrow was harvested from all patients for use only in the event of persistent pancytopenia with marrow aplasia on day 15.

RESULTS

A total of 18 patients were treated. Randomization was halted after the initial 10 patients because of the significant advantages for patients in Group 2 in comparison with those in Group 1 in regard to (1) the median number of days to absolute neutrophil count 0.5 x 10(9)/l (12 versus 21) and platelet count to 50 x 10(9)/l (13 versus 23), (2) platelet transfusions (3 versus 15.5), and (3) episodes of neutropenic sepsis (0 versus 4, respectively). One patient in Group 1 died from treatment-related complications. All patients in Group 1 required bone marrow reinfusion. No patient in Group 2 required bone marrow reinfusion, and no early mortality was observed in this group. Eight subsequent patients were treated with PBP and GM-CSF (Group 3). This group was more heavily pretreated than Groups 1 or 2 and had a slower hematologic recovery than Group 2. However, none of these patients required bone marrow reinfusion. The four patients in Group 1 that did not have early bone marrow rescue all had neutrophil counts of 0.0 on day 15. For Groups 2 and 3, the neutrophil counts on day 15 ranged from 0.3-2.1 x 10(9)/l (median, 1.9) and from 0.2-2.1 x 10(9)/l (median 0.6), respectively.

CONCLUSIONS

The use of PBP plus GM-CSF accelerated hematologic recovery after this chemotherapeutic regimen compared with GM-CSF alone; there were reduced morbidity and platelet transfusion requirements. Recovery was sufficiently rapid that PBP were an acceptable alternative to autologous bone marrow transplantation in patients receiving high-dose carboplatin, etoposide, and cyclophosphamide.

Energy status of the rapidly paced canine myocardium in congestive heart failure

Rapid ventricular pacing (RVP) is used as an experimental model of congestive heart failure (CHF). The purpose of this study was to determine the energy status of the dog myocardium after the development of CHF via chronic RVP. The myocardium had a significantly lower (P < 0.05) energy charge (EC) during CHF (0.63 +/- 0.01) than in sham-operated controls (0.82 +/- 0.02). This was due to significant differences in concentrations in ATP (-48%), ADP (29%), and AMP (275%) in the RVP group. However, the total adenine nucleotide pool was not different between groups. Myocardial lactate concentration was also similar. Glycogen was significantly lower (P < 0.05) by 20% at peak CHF. The adenine nucleotides were similar among the different myocardial layers (endo-, mid-, and epicardium). The administration of enalapril (an inhibitor of angiotension-converting enzyme) to decrease vascular resistance had no effect on the myocardial energy status of CHF dogs. These findings suggest that the lower EC in CHF animals is not the result of subendocardial ischemia. Also, lower EC is not associated with endogenous glycogen depletion or increased lactate concentration. The energy status of the myocardium in RVP-induced CHF is unlike that seen in ischemia-induced heart failure. This suggests that CHF in RVP is not vascular in origin.

Cell size of mammalian myocardia is not related to physiological demand

Morphological characteristics of myocardial ventricular myocytes have been evaluated from 5 mammalian orders with resting heart rates ranging from 51 to 475 bpm. The purpose was to determine if morphological characteristics of the myocardia are related to the functional demand imposed on the cell as represented by the resting heart rate. Cell size is a constant among mammals of different sizes which have different physiological demands. In contrast, there is more mitochondrial area and less myofibrillar area per cell in animals with rapidly beating hearts than in animals with slower heart rates. Additionally, the mean cross sectional area of individual myofibrils is 30% larger in the cow as compared to the mouse. These findings combined with our previous studies indicate that the different functional requirements of myocardia from different mammalian orders are satisfied by intracellular adaptations of both a structural and biochemical nature.

Contractile and calcium regulating capacities of myocardia of different sized mammals scale with resting heart rate

The purpose of this study was to determine if selected biochemical parameters representing the contractile and calcium regulating systems of cardiac muscle scaled among mammals having inherently different resting heart rates (RHR). Eight mammalian species with RHR ranging from 51 to 475 beats per minute (bpm) were studied. The oxidative capacity of the myocardium is highly correlated with the RHR. The hypothesis of the present study was that the capacities of the energy utilizing processes of contraction and calcium regulation would also be correlated to the functional demand imposed on the muscle as represented by the RHR. Myosin (M) and myofibrillar (MF) ATPase activities, myosin isoenzyme distribution and sarcoplasmic reticulum (SR) ATPase activity were determined. Animals with RHR above 300 bpm express V1 myosin while animals with lower RHR express primarily V3. M and MF ATPase activities correlated with RHR, but the major difference in activities occurred at the 'threshold' RHR of about 300 bpm at which the switch from V3 to V1 appears to occur. SR ATPase activity per mg of microsomal protein was for the most part constant among different mammals, but the SR ATPase activity per g of heart tissue was significantly correlated with RHR as slower beating hearts tended to yield less SR protein per unit mass. We conclude that both the contractile and calcium regulating systems are scaled to the functional parameter of RHR among different mammals. The contractile system uses a slow myosin ATPase isoform at low resting heart rates whereas above the postulated threshold RHR of about 300 bpm a switch in gene expression to a fast myosin ATPase isoform occurs.(ABSTRACT TRUNCATED AT 250 WORDS)

Biochemical characterization of exercise-trained porcine myocardium

The purpose of this study was to determine whether cardiac biochemical adaptations are induced by chronic exercise training (ET) of miniature swine. Female Yucatan miniature swine were trained on a treadmill or were cage confined (C) for 16-22 wk. After training, the ET pigs had increased exercise tolerance, lower heart rates during exercise at submaximal intensities, moderate cardiac hypertrophy, increased coronary blood flow capacity, and increased oxidative capacity of skeletal muscle. Myosin from both the C and ET hearts was 100% of the V3 isozyme, and there were no differences between the myosin adenosine triphosphatase (ATPase) or myofibrillar ATPase activities of C and ET hearts. Also, the sarcoplasmic reticulum Ca(2+)-ATPase activity and Na(+)-Ca2+ exchange activity of sarcolemmal vesicles were the same in cardiac muscle of C and ET hearts. Finally, the glycolytic and oxidative capacity of ET cardiac muscle was not different from control, since phosphofructokinase, citrate synthase, and 3-hydroxyacyl-CoA dehydrogenase activities were the same in cardiac tissue from ET and C pigs. We conclude that endurance exercise training does not provide sufficient stress on the heart of a large mammal to induce changes in any of the three major cardiac biochemical systems of the porcine myocardium: the contractile system, the Ca2+ regulatory systems, or the metabolic system.

Competitive control of myosin expression: hypertrophy vs. hyperthyroidism

The competition between two opposing influences on the phenotypic expression of skeletal muscle myosin were studied to determine which was the dominant regulator. Experimental hyperthyroidism, which induces fast myosin expression, was produced by subcutaneous implantation of a 40-day constant-time-release triiodothyronine pellet. Compensatory hypertrophy, which induces slow myosin expression, was produced by surgical removal of a synergistic hindlimb muscle. Hyperthyroidism increased the percentage of type II fibers and the fast myosin isoforms in both the plantaris and soleus muscles. Hypertrophy significantly increased the percentage of type I fibers and the slow myosin type in the plantaris and soleus muscles. However, with the simultaneous introduction of hyperthyroidism and hypertrophy, only the hyperthyroid effects were observed. Hyperthyroidism and not physiological demand was found to be the dominant regulator of skeletal muscle myosin expression.