Adenosine/TGFβ axis in regulation of mammary fibroblast functions

Cancer associated fibroblasts (CAF) play a key role in cancer progression and metastasis. Diminished TGFβ response on CAF correlates with poor outcome and recurrence in cancer patients. Mechanisms behind lost TGFβ signaling on CAF are poorly understood, but, utilizing MMTV-PyMT mouse model, we have previously demonstrated that in tumor microenvironment myeloid cells, producing adenosine, contribute to downregulated TGFβ signaling on CAFs. In the current work, we performed serial in vitro studies to investigate the role of adenosine/TGFβ axis in mouse mammary fibroblast functions, i.e., proliferation, protein expression, migration, and contractility. We found that adenosine analog NECA diminished TGFβ-induced CCL5 and MMP9 expression. Additionally, we discovered that NECA completely inhibited effect of TGFβ to upregulate αSMA, key protein of cytoskeletal rearrangements, necessary for migration and contractility of fibroblasts. Our results show that TGFβ increases contractility of mouse mammary fibroblasts and human fibroblast cell lines, and NECA attenuates theses effects. Using pharmacological approach and genetically modified animals, we determined that NECA effects on TGFβ pathway occur via A_2A/A_2B adenosine receptor—AC—PKA dependent manner. Using isolated CD11b⁺ cells from tumor tissue of CD73-KO and CD39-KO animals in co-culture experiments with ATP and AMP, we confirmed that myeloid cells can affect functions of mammary fibroblasts through adenosine signaling. Our data suggest a novel mechanism of interaction between adenosine and TGFβ signaling pathways that can impact phenotype of fibroblasts in a tumor microenvironment.

Disparities and guideline adherence for HPV testing among patients with oropharyngeal squamous cell carcinoma, NCDB, and SEER

BACKGROUND

Human papilloma virus testing for oropharyngeal squamous-cell carcinoma has been recommended by the National Comprehensive Cancer Network since 2012. We examine disparities, reported rates of human papillomavirus (HPV) testing, and the impact on these findings of limitations with the variable in database registries.

METHODS

The HPV variable was queried for patients with oropharyngeal squamous carcinoma (OPSCC) from 2013 to 2016 in National Cancer Data Base (NCDB) and Surveillance, Epidemiology, and End Results (SEER). Multivariable regression was used to identify disparities based on sociodemographic variables. Sensitivity analyses were used to investigate limitations of the variable.

RESULTS

Despite limitations in the HPV variable in the databases, there was less than 100% adherence to recommended testing, and there were significant disparities in multiple sociodemographic variables. For example, in NCDB 70% of white versus 60.4% of black patients were tested (odds ratio [OR] 0.75, confidence interval [CI] 0.66-0.85, p ≤ 0.0001); in SEER 59.8% of white and 47.6% of black patients were tested (OR 0.73, CI 0.67-0.81; p ≤ 0.0001).

CONCLUSIONS

Disparities exist among patients undergoing testing for HPV-associated OPSCC and adherence to guideline recommended HPV testing has been suboptimal. In addition, the HPV variable definition, especially as it relates to p16 positivity, and use in these two registries should be improved.

Abstract 1714A: TGF-beta signaling on myeloid cells regulates ECM deposition in mammary carcinoma via adenosine dependent mechanisms

TGF-beta plays a crucial role in tumor microenvironment by regulating cell-cell and cell-stroma interactions. We previously demonstrated that TGF-beta signaling on myeloid cells regulates expression of CD73, a key enzyme for production of adenosine, a pro-tumorigenic metabolite implicated in regulation of tumor cell behaviors, immune response and angiogenesis. Using MMTV-PyMT mouse mammary tumor model, we discovered that deletion of TGF-beta signaling on myeloid cells (PyMT/TGFbRII-LysM) affects ECM formation in tumor tissue, specifically increases collagen and decreases fibronectin deposition, and these changes associate with mitigated tumor growth and reduced metastases. Using multiplexed five-color immunofluorescent staining and spatial analysis on a single-cell level, we discovered that reduced TGF-beta signaling on fibroblasts associates with their proximity to CD73 positive myeloid cells in tumor tissue. Consistent with these findings, in vitro gel contraction assay and Western blotting for Collagen I and pSMAD proteins confirmed that adenosine significantly downregulates TGF-beta signaling on fibroblasts. Using in vitro pharmacological approach, we found that this effect is regulated by A2a and A2b adenosine receptors. TCGA data base analysis revealed that patients with triple negative breast cancer and basal type have similar signature of adenosine and ECM profiles: high expression of A2b adenosine receptors correlates with decreased expression of Col1 and is associates with poor outcome. Taken together, our studies reveal a new role for TGF-beta signaling on myeloid cells in tumorigenesis. Discovered crosstalk between TGF-beta/CD73 on myeloid cells and TGF-beta signaling on fibroblasts can contribute to ECM remodeling and pro-tumorigenic actions of CAFs.

Citation Format: Georgii Vasiukov, Tatiana Novitskaya, Samantha Schwager, Harold Moses, Timothy Blackwell, Igor Feoktistov, Sergey Novitskiy. TGF-beta signaling on myeloid cells regulates ECM deposition in mammary carcinoma via adenosine dependent mechanisms [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1714A.

Abstract A15: Noncanonical NF-kappaB signaling is associated with poor ovarian cancer prognosis

Objective: Mediated by a family of transcription factors, the canonical and noncanonical nuclear factor-kappaB (NF-kB) signaling pathways have key roles in inflammation, innate immunity, and cancer development and progression. As prior ovarian cancer studies have evaluated only canonical NF-kB transcription factors in relation to survival, this study was undertaken to evaluate both canonical and noncanonical NF-kB pathway components in tumor samples from epithelial ovarian cancer cases from the Vanderbilt Tissue Repository for Ovarian Cancer (TROC).

Methods: We abstracted clinical data from electronic medical records and assayed p65 (representing the canonical NF-kB pathway) and p52 (representing the noncanonical NF-kB pathway) by immunohistochemistry for 197 TROC samples. Nuclear and cytoplasmic staining in tumor cells was semiquantified by H-scores and dichotomized at median values. Associations with progression-free survival (PFS) and overall survival (OS) were quantified by hazard ratios (HR) and 95% confidence intervals (CI) using Cox proportional-hazards regression.

Results: Median cytoplasmic and nuclear p65 and p52 H-scores were significantly higher among high-grade and serous cases; median p52 H-scores were also significantly higher among late-stage cases and patients treated with chemotherapy (all Wilcoxon rank sum p<0.05). In unadjusted regression models, higher nuclear p65 and higher nuclear p52 were associated with approximately 40% and 70% shorter PFS and OS, respectively, but these associations were attenuated by adjustment for age, stage, tumor type, race, chemotherapy, and residual disease. In multivariable adjusted models, higher cytoplasmic p52 was associated with more than 50% shorter PFS (HR 1.68, 95% CI 1.18-2.39) and OS (HR 1.53, 95% CI 1.06-2.21). Furthermore, when cytoplasmic and nuclear staining were combined, and mutually adjusted models included both p52 and p65, only p52 remained associated with worse PFS (HR 1.57, 95% CI 1.10-2.37) and OS (HR 1.51, 95% CI 1.05-2.15).

Conclusions: This is the first study to demonstrate that p52, representing noncanonical NF-kB signaling, may be an independent prognostic factor for epithelial ovarian cancer. Approaches to inhibit noncanonical NF-kB signaling should be explored as novel therapies for ovarian cancer are needed.

Citation Format: Demetra Hufnagel, Andrew J. Wilson, Jamie Saxon, Dineo Khabele, Timothy Blackwell, Marta A. Crispens, Fiona Yull, Alicia Beeghly-Fadiel. Noncanonical NF-kappaB signaling is associated with poor ovarian cancer prognosis [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research; 2019 Sep 13-16, 2019; Atlanta, GA. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(13_Suppl):Abstract nr A15.

1145 Longitudinal Association Between Circadian Activity Rhythms And Risk Of Incident Parkinson’s Disease In Older Men

Introduction

Disruption in circadian activity rhythms are very common in older adults, particularly among those with neurodegenerative diseases. However, the longitudinal association between circadian disruption and subsequent risk of developing neurodegenerative diseases, including Parkinson’s disease (PD), is unclear.

Methods

We examined rest-activity rhythms in 2930 community-dwelling older men (mean age 76.3 ± 5.5 years) without PD and followed them for incident PD over the next 11 years. 24-h rest-activity rhythm parameters (amplitude, mesor, robustness, acrophase) were generated by wrist actigraphy-extended cosinor analysis. Incident PD cases were identified based on physician-diagnosed PD between 2005 and 2016. Logistic regression was used to determine the association between quartiles of rest-activity parameters and risk of incident PD.

Results

78 (2.7%) men developed PD during 11 years of follow-up. The risk of PD increased with decreasing circadian amplitude (strength of the rhythm), mesor (mean level of activity) or robustness (how closely activity follows a cosine 24h pattern); p for trend across quartiles <0.05. After accounting for demographics, clinic site, education, depressive symptoms, body mass index, physical activity, benzodiazepine use, alcohol, caffeine, smoking, comorbidities and baseline cognition, those in the lowest quartile of amplitude, mesor or robustness had approximately three times the risk of developing PD compared to those in the highest quartile of amplitude [ORs (95% CI)= 3.11 (1.54-6.29)], mesor [3.04 (1.54-6.01)] and robustness [2.65 (1.24-5.66)]. The association remained after further adjustment for nighttime sleep disturbances and sleep duration. These associations were somewhat attenuated, but the pattern remained similar after excluding PD cases developed within 2 years after baseline. Acrophase was not significantly associated with risk of PD.

Conclusion

Older men with reduced circadian rhythmicity had an increased risk of incident PD over 11 years. Circadian disruption in the elderly may represent an important prodrome or risk factor for PD. Randomized trials should evaluate whether strategies to improve circadian function impact risk of PD.

Support

This work was supported by the NIA, NIAMS, NCATS, NIH Roadmap for Medical Research and the NHLBI under the grant numbers: U01AG027810, U01AG042124, U01AG042139, U01AG042140, U01AG042143, U01AG042145, U01AG042168, U01AR066160, UL1TR000128, R01HL071194, R01HL070848, R01HL070847, R01HL070842, R01HL070841, R01HL070837, R01HL070838, and R01HL070839.

0388 Predictors of Incident Reduced Sleep Efficiency in Community-Dwelling Older Women

Introduction

There is a paucity of longitudinal studies with sleep efficiency (SE) as an outcome measure. Our objective was to examine potential risk factors for incident reduced SE among community-dwelling women in late life.

Methods

We studied 700 women (mean age 82.5 [SD=3.0] years) with a SE ≥70% at the Year 16 (2002-04) visit of the Study of Osteoporotic Fractures with a follow-up measure of SE at the Year 20 (2006-08) visit. SE (percentage of time sleeping while in bed) at both visits was measured using a wrist actigraph with data collected for an average of four 24-hour periods. Women were classified as having incident reduced SE if they had SE <70% at Year 20. Logistic regression was used to estimate the associations between potential risk factors (demographics, lifestyle, use of medications, self-reported medical conditions, functional impairment, frailty, mental and physical health) at Year 16 and reduced SE at Year 20. The association of each candidate risk factor with reduced SE at Year 20 was examined in models adjusted for age, clinical site and continuous SE at Year 16. Candidate risk factors with Benjamin Hochberg false-discovery rate q-values <0.10 were included in a final multivariate model.

Results

Among the 700 eligible women, 62 (8.9%) developed incident reduced SE between the Year 16 and Year 20 visits. After adjusting for age, site and baseline SE, antidepressant use [OR=3.06; 95% CI: 1.50-6.25], benzodiazepine use [OR=2.97; 95% CI: 1.30-6.80] and the presence of hypertension [OR=2.83; 95% CI: 1.47-5.45] at Year 16 were independently associated with a higher odds of having reduced SE at follow-up.

Conclusion

These findings suggest that antidepressant use, benzodiazepine use and hypertension are risk factors or markers for the development of reduced sleep efficiency in older women. Future studies are warranted to examine the underlying mechanisms for these associations.

Support

The Study of Osteoporotic Fractures (SOF) is supported by National Institutes of Health funding. The National Institute on Aging (NIA) provides support under the following grant numbers: R01 AG005407, R01 AR35582, R01 AR35583, R01 AR35584, R01 AG005394, R01 AG027574, and R01 AG027576.

Myeloid Cell-Derived TGFβ Signaling Regulates ECM Deposition in Mammary Carcinoma via Adenosine-Dependent Mechanisms

TGFβ plays a crucial role in the tumor microenvironment by regulating cell-cell and cell-stroma interactions. We previously demonstrated that TGFβ signaling on myeloid cells regulates expression of CD73, a key enzyme for production of adenosine, a protumorigenic metabolite implicated in regulation of tumor cell behaviors, immune response, and angiogenesis. Here, using an MMTV-PyMT mouse mammary tumor model, we discovered that deletion of TGFβ signaling on myeloid cells (PyMT/TGFβRII^LysM) affects extracellular matrix (ECM) formation in tumor tissue, specifically increasing collagen and decreasing fibronectin deposition. These changes were associated with mitigated tumor growth and reduced metastases. Reduced TGFβ signaling on fibroblasts was associated with their proximity to CD73⁺ myeloid cells in tumor tissue. Consistent with these findings, adenosine significantly downregulated TGFβ signaling on fibroblasts, an effect regulated by A_2A and A_2B adenosine receptors. METABRIC dataset analysis revealed that patients with triple-negative breast cancer and basal type harbored a similar signature of adenosine and ECM profiles; high expression of A_2B adenosine receptors correlated with decreased expression of Col1 and was associated with poor outcome. Taken together, our studies reveal a new role for TGFβ signaling on myeloid cells in tumorigenesis. This discovered cross-talk between TGFβ/CD73 on myeloid cells and TGFβ signaling on fibroblasts can contribute to ECM remodeling and protumorigenic actions of cancer-associated fibroblasts. SIGNIFICANCE: TGFβ signaling on fibroblasts is decreased in breast cancer, correlates with poor prognosis, and appears to be driven by adenosine that accelerates tumor progression and metastasis via ECM remodeling.

Abstract 1573: Non-canonical NF-kappaB signaling in the tumor microenvironment in relation to ovarian cancer survival

Introduction: Despite advances in treatment, ovarian cancer associated mortality has not substantially improved over the last 50 years. Understanding mechanisms that underlie disease progression is crucial to the development of new treatments for ovarian cancer. Mediated by a family of transcription factors, the canonical and non-canonical nuclear factor-kappaB signaling pathways have known roles in cell proliferation, as well as immune, inflammatory, and neoplastic processes. Non-canonical NF-kappaB signaling requires processing of a cytoplasmic p100/RelB dimer to a mature p52/RelB complex, capable of nuclear translocation to activate transcription of target genes. Prior studies on canonical NF-kappaB expression and ovarian cancer survival have been inconsistent, but no studies to date have evaluated the role of non-canonical NF-kappaB transcription factors.

Methods: We conducted immunohistochemical staining for p52, a component of the non-canonical NF-kappaB signaling pathway, on a clinically annotated tissue microarray of ovarian tumors collected from 1994-2004 at the Vanderbilt University Medical Center. Nuclear and cytoplasmic p52 staining in tumors was semi-quantified by H-score and expression was dichotomized at median values. Associations with progression-free survival (PFS) and overall survival (OS) were quantified by hazard ratios (HR) and 95% confidence intervals (CI) using Cox proportional-hazards regression.

Results: Among 194 ovarian cancer cases, p52 expression was predominantly cytoplasmic, with a relatively smaller proportion of tumor cells showing nuclear staining (median H-scores: 135.6 vs. 1.0). Cytoplasmic and nuclear p52 H-scores were significantly higher among high grade, advanced stage, and serous tumors (all Wilcoxon rank sum p<0.01). Kaplan-Meier survival analysis showed that cases with high nuclear p52 expression had significantly shorter time to disease progression (5-year PFS high vs. low: 72% vs. 17%, log-rank p<0.001). In regression models that included adjustment for age, stage, grade, and histologic subtype, high nuclear p52 was associated with a more than two-fold shorter PFS (HR 2.30, 95% CI 1.44-4.67). Significance of this finding was unaltered by additional adjustment for race, debulking, and platinum sensitivity (HR 2.26, 95% CI 1.15-4.45). In contrast, significant associations between high nuclear p52 and worse OS, and all associations for cytoplasmic p52 staining were attenuated after adjustment for clinical covariates.

Conclusions: This is the first study to demonstrate that nuclear p52, representing active non-canonical NF-kappaB signaling, may be an independent prognostic factor for epithelial ovarian cancer. Thus, interventions that inhibit non-canonical NF-kappaB signaling should be explored as novel therapies to limit ovarian cancer progression.

Citation Format: Demetra Hufnagel, Andrew J. Wilson, Jamie Saxon, Timothy Blackwell, Dineo Khabele, Marta A. Crispens, Alicia Beeghly-Fadiel, Fiona Yull. Non-canonical NF-kappaB signaling in the tumor microenvironment in relation to ovarian cancer survival [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1573.

Novel mouse model of indwelling pleural catheter in mice with malignant pleural effusion

Malignant pleural effusion (MPE) is an indicator of advanced stage malignancy. There are an estimated 150 000 to 200 000 cases of MPE diagnosed annually in the USA [1]. During the past 10 years, the types of cancer treatment and pleural procedures available for MPE have expanded leading to improved stratification and better individualisation of treatment [2]. A recently published prognostic score (PROMISE score) improved prediction of the 3 month risk of death in patients with MPE, thereby improving the selection of appropriate management strategies [3].

This novel mouse model mimics malignant pleural effusion drainage using an indwelling pleural catheter in humans, and provides direct access to the pleural space potentially enabling the testing of intrapleural therapies in the treatment of MPE.bit.ly/2W2kzO0

Long-term functional and esthetic outcomes after fibula free flap reconstruction of the mandible

BACKGROUND

The goal of this study is to report functional and esthetic outcomes, after fibula free flap (FFF) reconstruction of the mandible for oral cancer, assessed by physicians, nonclinicians, and patients.

METHODS

Twenty-five long-term survivors from oral cancer after FFF reconstruction were recalled for head and neck examination by surgeons, for photographs and patient-reported outcomes, using EORTC, QLQ-C30, H&N35, and FACE-Q questionnaires.

RESULTS

Physicians reported 64% restoration of functionality compared to normal. Patients reported high scores on QLQ-C30 but lower scores on H&N35. Esthetic scores were reported higher by clinicians than nonclinicians. The decline in function and appearance was attributed to loss of lower dentition, trismus, malocclusion, xerostomia, and tissue atrophy.

CONCLUSION

To minimize the decline in function and appearance, immediate dental implants in FFF, better reconstruction of the temporomandibular joint, newer methods of radiotherapy to minimize xerostomia and oral exercises to prevent trismus should be considered.

Tobacco smoking induces cardiovascular mitochondrial oxidative stress, promotes endothelial dysfunction, and enhances hypertension

Tobacco smoking is a major risk factor for cardiovascular disease and hypertension. It is associated with the oxidative stress and induces metabolic reprogramming, altering mitochondrial function. We hypothesized that cigarette smoke induces cardiovascular mitochondrial oxidative stress, which contributes to endothelial dysfunction and hypertension. To test this hypothesis, we studied whether the scavenging of mitochondrial H₂O₂ in transgenic mice expressing mitochondria-targeted catalase (mCAT) attenuates the development of cigarette smoke/angiotensin II-induced mitochondrial oxidative stress and hypertension compared with wild-type mice. Two weeks of exposure of wild-type mice with cigarette smoke increased systolic blood pressure by 17 mmHg, which was similar to the effect of a subpresssor dose of angiotensin II (0.2 mg·kg^-1·day^-1), leading to a moderate increase to the prehypertensive level. Cigarette smoke exposure and a low dose of angiotensin II cooperatively induced severe hypertension in wild-type mice, but the scavenging of mitochondrial H₂O₂ in mCAT mice completely prevented the development of hypertension. Cigarette smoke and angiotensin II cooperatively induced oxidation of cardiolipin (a specific biomarker of mitochondrial oxidative stress) in wild-type mice, which was abolished in mCAT mice. Cigarette smoke and angiotensin II impaired endothelium-dependent relaxation and induced superoxide overproduction, which was diminished in mCAT mice. To mimic the tobacco smoke exposure, we used cigarette smoke condensate, which induced mitochondrial superoxide overproduction and reduced endothelial nitric oxide (a hallmark of endothelial dysfunction in hypertension). Western blot experiments indicated that tobacco smoke and angiotensin II reduce the mitochondrial deacetylase sirtuin-3 level and cause hyperacetylation of a key mitochondrial antioxidant, SOD2, which promotes mitochondrial oxidative stress. NEW & NOTEWORTHY This work demonstrates tobacco smoking-induced mitochondrial oxidative stress, which contributes to endothelial dysfunction and development of hypertension. We suggest that the targeting of mitochondrial oxidative stress can be beneficial for treatment of pathological conditions associated with tobacco smoking, such as endothelial dysfunction, hypertension, and cardiovascular diseases.

Abstract 576: LDL-Trafficked Small RNAs Promote Atherosclerosis through TLR Signaling in Macrophages

Atherosclerosis is a chronic inflammatory disease, and despite resounding success in lipid management to reduce cardiovascular events, most heart attacks in the US occur in patients with clinically normal LDL-C levels. The next generation of therapies for cardiovascular disease (CVD) will include inflammation-based targets; however, systemic immune suppression has limitations. Thus, the critical barrier for successful targeting of inflammation in CVD is the identification of vascular ligands that drive immune cell activation. Previously, we demonstrated that low-density lipoproteins (LDL) transport microRNAs. Here, we report that LDL traffic a wide-diversity of small non-coding RNAs (sRNA) in circulation, many of which are derived from exogenous species, e.g. bacteria and fungi. Moreover, using high-throughput sRNA sequencing, we found that LDL-sRNA signatures are influenced primarily by environmental microbiota, as opposed to commensal bacteria in the gut microbiome. Using a mouse model of compromised mucosal immunity, we identified a process by which LDL accumulates bacterial sRNAs. Next, we demonstrated that native LDL potently stimulated cytokine release from macrophages through activation of single-stranded RNA (ssRNA)-sensing toll-like receptor (TLR) signaling, which was blunted by partial silencing of ssRNA-sensing TLRs in macrophages. Most importantly, preliminary results in mice suggest that targeting ssRNA-sensing TLRs is a potential strategy to suppress atherosclerosis. Taken together, we put forth a novel paradigm in which, LDL scavenge microbial sRNAs to promote clearance during health, yet serve as TLR-ligands that propagate macrophage inflammation in hypercholesterolemia, which likely contributes to the underlying inflammation in the pathogenesis of CVD.

Abstract 294: A novel cancer therapeutic strategy: inducing cytotoxic functions in tumor-associated macrophages

Macrophages are recognized as an important component of the tumor microenvironment. Previous studies have shown that they promote tumor growth and participate in the initiation and progression of metastatic spread. Methods are being developed to eliminate macrophages from the tumor, thereby inhibiting their negative effects. However, we believe that the best approach would be to transform the tumor-helping macrophages into tumor-killing macrophages that would both eliminate tumor cells directly and re-invigorate other immune cells around them to better fight the tumor. Our data indicates that we have found a way to induce this transformation.

We utilized a novel transgenic mouse model to determine the effects of activating Nuclear Factor Kappa-B (NF-κB) signaling specifically in macrophages in vivo during different stages of tumor progression. Our data shows that activated macrophages not only inhibit primary tumor growth but also reduce tumor cell seeding and colonization of distant organs, such as the lung. This is accomplished at least in part through direct tumor cell killing by the macrophages. We have further modeled this mechanism in vitro through co-culture assays of macrophages and a variety of tumor cell lines, including breast, ovarian, and melanoma. In each case, activation of NF-κB in macrophages induces a tumoricidal phenotype, in which macrophages directly attack the tumor cells significantly depleting them by three days of co-culture. Having established macrophage NF-κB activation as a promising strategy, we have turned our focus to translating these findings into a therapy that can be delivered to patients in the clinic. We are testing two different approaches. The first is liposomal-encapsulated mifamurtide, a synthetic peptide that mimics a component of bacterial cell walls and thus activates NF-κB in macrophages. This drug is approved for use in osteosarcoma patients, and could be rapidly moved into clinical trials if our studies prove its efficacy in other tumor models. We are currently determining the most advantageous liposome formulation and delivery method in the setting of breast and ovarian cancer. The second strategy is to employ novel, polymeric nanoparticles to deliver siRNA against the inhibitor of kappa-B alpha (IκBα) to tumor associated macrophages (TAMs). We have synthesized these particles and determined that they can be safely delivered to mice in vivo. Furthermore, our studies indicate that the nanoparticles are preferentially taken-up by TAMs and that siRNA inhibition of IκBα induces an anti-tumor macrophage phenotype. Taken together, we have generated convincing evidence that activation of NF-κB in macrophages is a promising strategy to convert TAMs into cytotoxic macrophages. We are actively developing novel tools to translate this approach into immunotherapy that could be effective across a wide spectrum of solid tumors and metastatic disease.

Citation Format: Whitney Barham, Oleg Tikhomirov, Ryan Ortega, Jeannette Saskowski, Courtney S. Thompson, Andrew Wilson, Timothy Blackwell, Zahra Mirafzali, Dineo Khabele, Todd Giorgio, Fiona E. Yull. A novel cancer therapeutic strategy: inducing cytotoxic functions in tumor-associated macrophages. [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 294. doi:10.1158/1538-7445.AM2015-294

Abstract 3667: Attenuation of NF-κB signaling in myeloid cells enhances urethane-induced lung tumorigenesis via neutrophil-derived IL-1β

The transcription factor Nuclear Factor κB (NF-κB) is a master regulator of inflammation, and its activation is associated with tumorigenesis in a variety of cancers. Our group and others have shown that NF-κB signaling in lung epithelial cells is critical for lung carcinogenesis. However, pharmaceutical inhibition of NF-κB signaling has not been effective for the treatment of lung tumorigenesis in animals or humans for reasons that remain unknown. We hypothesized that attenuation of NF-κB signaling in myeloid cells contributes to inefficacy of NF-κB-targeted therapies by unmasking pro-tumorigenic characteristics of inflammatory cells. For our studies, we utilized mice with IKKβ deleted specifically in myeloid cells (IKKβΔmye) and induced lung tumorigenesis with a single intraperitoneal injection of the lung carcinogen urethane (1g/kg). We found that IKKβΔmye mice developed more atypical adenomatous hyperplasia (AAH) lesions at 6 weeks and more lung tumors at 16 weeks after urethane compared to WT mice. These histological differences were correlated with enhanced lung inflammation in IKKβΔmye mice which was observed 1 week after urethane and persisted for up to 6 weeks. Flow cytometric analysis of myeloid cell populations revealed that IKKβΔmye mice contained more pulmonary neutrophils at 1 and 6 weeks after urethane compared to WT mice. In bone marrow chimeras generated by transplantation of bone marrow from IKKβΔmye or WT donors into recipient NF-κB reporter mice, we showed that depletion of neutrophils using Ly6G antibody treatment (100 ug/twice weekly IP injection) during the first 6 weeks of lung carcinogenesis blocked NF-κB activation in stromal cells and reduced tumor multiplicity in IKKβΔmye mice to levels observed in urethane-treated WT mice. Thus, these studies indicated that neutrophils play an important role in lung tumorigenesis during early tumor development and may do so by limiting NF-κB activation in lung epithelial cells. Evaluation of cytokines in the lungs of WT and IKKβΔmye mice at 1 week after urethane revealed higher levels of IL-1β in IKKβΔmye mice compared to WT mice. Further examination of myeloid cells sorted 1 week after urethane identified neutrophils as the key producers of IL-1β in the lungs of IKKβΔmye mice. Neutralization of IL-1 signaling by IL-1 receptor antagonist (IL-1ra) treatment during the first 4 weeks of carcinogenesis decreased the number of AAH lesions in IKKβΔmye mice 6 weeks after urethane and reduced the number of tumors at 16 weeks in IKKβΔmye mice. Taken together, our data suggest that neutrophils can support tumor promotion through production and secretion of IL-1β, which may activate pro-tumorgenic NF-κB signaling in the lung epithelium. We speculate that the paradoxical increase in inflammation and IL-1β production resulting from NF-κB inhibition in myeloid cells contributes to the lack of effectiveness of NF-κB inhibitors in patients with lung cancer.

Citation Format: Allyson McLoed, Rinat Zaynagetdinov, Taylor Sherrill, Fiona Yull, Timothy Blackwell. Attenuation of NF-κB signaling in myeloid cells enhances urethane-induced lung tumorigenesis via neutrophil-derived IL-1β. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3667. doi:10.1158/1538-7445.AM2014-3667

Abstract 1673: Alternative NF-κB signaling promotes inflammatory cell recruitment and lung tumor formation

Nuclear factor-κB (NF-κB) is a transcription factor that can be activated through either the classical or alternative signaling pathways. In lung tumors, high levels of classical and alternative pathway components have been observed. While many studies have demonstrated that classical NF-κB signaling is a central pathway regulating inflammation and tumorigenesis, the role of alternative NF-κB signaling remains undefined. We hypothesize that alternative NF-κB signaling in the lung epithelium plays a key role in inflammation and lung tumor formation through paracrine signaling to the inflammatory microenvironment. To investigate alternative NF-κB signaling in the lung epithelium, we generated a transgenic mouse model with doxycycline (dox)-inducible expression of the alternative pathway component p52 in airway epithelial cells (designated ALTA for alternative pathway trans-activated). When placed on dox, nuclear p52 is increased in the lungs of ALTA mice with no effect on activation of other NF-κB components. Surprisingly, alternative pathway activation alone did not cause a significant increase in inflammatory cell recruitment. However, in conjunction with the inflammatory stimulus lipopolysaccharide (LPS), alternative pathway activation caused increased mortality, which was associated with a significant increase in inflammation and increased lung permeability. To determine the effect of alternative pathway activation on lung tumor formation, mice were injected with the lung carcinogen urethane. Six weeks after urethane administration, ALTA mice demonstrated an increased number of bronchoalveolar lavage neutrophils, and by 6 months post-urethane, ALTA mice had an increased number of tumors, increased tumor size, and more advanced lesions. Together, these data suggest that alternative NF-κB signaling plays an important role in stimulus-induced inflammatory cell recruitment and that alternative pathway activation can promote lung tumor formation and progression. By defining the role of alternative NF-κB signaling in tumor formation, we hope to gain insight into the role of inflammation in lung carcinogenesis and to identify novel pathways and signaling targets that could potentially serve as therapeutic targets.

Citation Format: Jamie Alicyn Ausborn, Dong-Sheng Cheng, Vasiliy Polosukhin, Wei Han, Fiona Yull, Timothy Blackwell. Alternative NF-κB signaling promotes inflammatory cell recruitment and lung tumor formation. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1673. doi:10.1158/1538-7445.AM2014-1673

Prostaglandin D2 ameliorates acute lung inflammation by activating Nrf2 independent of 15-deoxy-Δ12,14-PGJ2. (P5040)

Since anti-inflammatory activity of prostaglandin D2 (PGD2) is attributed to 15-deoxy-Δ12,14-PGJ2, a byproduct of PGD2, we explored the hypothesis that PGD2, independent of 15-deoxy-Δ12,14-PGJ2, activates NF-E2-related factor 2 (Nrf2), an anti-inflammatory transcription factor, contributing to suppression of lung inflammation in acute lung injury (ALI). Intratracheal delivery of PGD2 decreased neutrophilic infiltration, MPO activity, and the production of pro-inflammatory cytokines in LPS-treated lungs. In contrast, lipocalin-prostaglandin D synthase (L-PGDS) KO mice that produce less PGD2 showed prolonged lung inflammation, highlighting the importance of L-PGDS and PGD2 in suppressing lung inflammation. Two log10 less of PGD2 than 15-deoxy-Δ12,14-PGJ2 was sufficient for activating Nrf2 in RAW 264.7. Similarly, PGD2 was more potent than 15-deoxy-Δ12,14-PGJ2 in expressing Nrf2 dependent genes in mouse lungs. While overexpression of DP1, a receptor of PGD2, enhanced PGD2-mediated Nrf2 activation, siRNA silencing DP1 expression reduced its activation, suggesting that PGD2 uses DP1 in activating Nrf2. Furthermore, PGD2 synergistically suppressed neutrophil infiltration when nrf2 was functionally complemented to the lung of the nrf2-/- mice. Our results show that PGD2 activated Nrf2 independent of 15-deoxy-Δ12,14-PGJ2 and involved DP1. We suggest that PGD2 has a potent anti-inflammatory activity, which is at least in part mediated by activating Nrf2.

Abstract 2873: Epithelial NF-κB signaling is required for different functions in Kras- and EGFR-mediated lung tumorigenesis

The transcription factor nuclear factor-κB (NF-κB) is a key mediator of the inflammatory response, and its activation correlates with poor prognosis in non-small cell lung cancer patients. Oncogenic KRAS and epidermal growth factor receptor (EGFR) mutations occur frequently in lung adenocarcinoma and are associated with increased NF-κB activation in lung tumors. Recent papers have shown that inhibition of epithelial NF-κB signaling in a mouse model of Kras-mediated lung tumorigenesis decreases tumor formation. However, the mechanisms linking NF-κB signaling to tumor formation remain unclear. We hypothesize that epithelial NF-κB signaling is a common requirement for lung tumorigenesis. For our studies, we used mice that inducibly express oncogenic KrasG12D or EGFRL858R+T790M as well as a dominant negative inhibitor of κB signaling (DN-IκB) in Clara Cell Specific Protein (CCSP)-expressing lung epithelium (designated KrasDN or EGFRDN mice). EGFRDN mice developed smaller and fewer tumors after two months of doxycycline administration compared to mice expressing EGFRL858R+T790M alone, while KrasDN mice did not develop any tumors. In KrasDN mice, loss of Kras transgene expression and increased cell death were observed after one week of doxycycline, suggesting that NF-κB signaling may be required for survival of Kras mutant cells in vivo. In EGFRDN mice, NF-κB inhibition led to a significant reduction in the percentage of BAL neutrophils when compared to mice expressing EGFRL858R+T790M alone. In addition, NF-κB inhibition led to reduced expression of CXCR2 ligands CXCL1 and CXCL2, which are known NF-κB-regulated neutrophil chemoattractants. In vitro inhibition of CXCR2 did not affect proliferation of EGFR-mutant cells, suggesting that the critical function of CXCL1 and CXCL2 may be inflammatory cell recruitment/activation. Future studies will investigate the effects of CXCR2 inhibition and neutrophil depletion on EGFR-mediated tumor formation in vivo. Together, these results suggest that NF-κB signaling is required for both Kras- and EGFR-mediated lung tumorigenesis, but NF-κB's function in a tumor may depend on the driver mutation. From these studies, we hope to identify NF-κB-regulated genes critical for tumor formation as potential targets for the development of better therapeutic strategies for lung cancer patients.

Citation Format: Jamie A. Ausborn, Taylor Sherrill, Rinat Zaynagetdinov, Vasiliy Polosukhin, Frank McMahon, Fiona Yull, Timothy Blackwell. Epithelial NF-κB signaling is required for different functions in Kras- and EGFR-mediated lung tumorigenesis. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2873. doi:10.1158/1538-7445.AM2013-2873

Abstract 2875: NF-κB signaling in myeloid cells limits urethane-induced lung tumorigenesis

The transcription factor Nuclear Factor κB (NF-κB) is a master regulator of inflammation, and its activation is associated with tumorigenesis in a variety of cancers. Our group has shown that NF-κB signaling in lung epithelial cells is critical for lung tumor formation. However, the role of NF-κB in other cell types, such as myeloid cells, during lung carcinogenesis is uncertain. We hypothesized that NF-κB signaling in myeloid cells (macrophages, monocytes, and neutrophils) promotes lung tumorigenesis by facilitating lung inflammation. Surprisingly, we found that mice with myeloid cell-targeted IKKβ deletion (IKKβΔmye mice) developed significantly more tumors than wild-type (WT) mice 4 months following a single intraperitoneal (IP) injection of the lung carcinogen urethane (1g/kg). IKKβΔmye mice exhibited a paradoxical increase in the proinflammatory cytokines IL-1β, TNFα, and CXCL1 at 1 and 2 weeks after urethane treatment, and a more than 3-fold higher influx of CD11b+Ly-6G+ cells into IKKβΔmye lungs compared to WT lungs was observed by flow cytometry 1 week post-urethane. By 6 weeks after urethane, IKKβΔmye mice developed more lung inflammation than WT mice, which was accompanied by an increased burden of atypical adenomatous hyperplasia lesions. Flow cytometric analysis of inflammatory cell populations at this time point revealed a sustained increase in granulocytic cells, indicated by significantly higher numbers of CD11b+Gr-1hi cells in the lungs of IKKβΔmye mice compared to WT mice. Depletion of granulocytic cells using Ly-6G antibody treatment (50ug/weekly IP injection) during the first 6 weeks of urethane-induced lung carcinogenesis reduced lung NF-κB activation and lung tumor incidence in IKKβΔmye mice to levels observed in urethane-treated WT mice, indicating that granulocytic cells play an important role in lung tumorigenesis during early tumor development and may do so by limiting NF-κB activation in lung epithelial cells. Together, our data suggest that the impact of NF-κB signaling on lung tumorigenesis is cell type specific and that myeloid NF-κB signaling limits urethane-induced inflammation and lung tumorigenesis. Granulocytes are important players during early lung tumor promotion, and we propose that they promote lung carcinogenesis through interactions that increase survival and/or proliferation of mutated lung epithelial cells.

Citation Format: Allyson McLoed, Rinat Zaynagetdinov, Taylor Sherrill, Fiona Yull, Timothy Blackwell. NF-κB signaling in myeloid cells limits urethane-induced lung tumorigenesis. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2875. doi:10.1158/1538-7445.AM2013-2875

Performance of FRAX in a cohort of community-dwelling, ambulatory older men: the Osteoporotic Fractures in Men (MrOS) study

We evaluated performance of FRAX in older men who participated in the Osteoporotic Fractures in Men (MrOS) study.

INTRODUCTION

FRAX has been extensively studied in women, but there are few studies of its performance in men.

METHODS

FRAX estimates for 10-year hip fracture and major osteoporotic fracture (MOF; either hip, clinical spine, forearm, or shoulder) were calculated from data obtained from MrOS participants and compared to observed 10-year fracture cumulative incidence calculated using product limit estimate methods, accounting for competing mortality risk.

RESULTS

Five thousand eight hundred ninety-one men were followed for an average of 8.4 years. Without bone mineral density (BMD) in the FRAX model, the mean 10-year predicted fracture probabilities for hip and MOF were 3.5% and 8.9%, respectively; addition of BMD to the calculations reduced these estimates to 2.3% and 7.6%. Using FRAX without BMD, predicted quintile probabilities closely estimated cumulative incidence of hip fracture (range of observed to predicted ratios 0.9-1.1). However, with BMD in the FRAX calculation, observed to predicted hip fracture probabilities were not close to unity and varied markedly across quintiles of predicted probability. For MOF, FRAX without BMD overestimated observed cumulative incidence (range of observed to predicted ratios 0.7-0.9) and addition of BMD did not improve this discrepancy (range of observed to predicted ratios 0.7-1.1). Addition of BMD to the calculation had mixed effects on the discriminatory performance of FRAX, depending on the analysis tool applied.

CONCLUSION

Among this cohort of community-dwelling older men, the FRAX risk calculator without BMD was well calibrated to hip fracture but less well to MOF.

Abstract 5262: Disruption of alternative and classical NF-kappaB signaling patterns: Connections to branching morphogenesis and mammary tumorigenesis

NF-kappaB transcription factors including p65 (RelA), RelB, p105/p50, and p100/p52 play roles in mammary development and tumorigenesis. While most studies have focused on classical NF-kappaB signaling (p65/p50), alternative NF-kappaB signaling is elevated in human primary breast tumors and in human breast cancer cell lines. In addition, we have reported that overexpression of p100 within the mouse mammary epithelium during pregnancy and lactation led to ductal thickening and hyperplastic foci. To determine the contribution of alternative NF-kappaB signaling to mammary development and tumorigenesis, we have developed murine transgenic models that enable us to inducibly express activators or inhibitors of classical or alternative NF-kappaB signaling in the mammary epithelium by adding doxycycline to the drinking water of mice. Modulation of both the classical and alternative pathways will enable us to determine the roles that each arm plays independently or synergistically. Using immunoflourescent staining we have identified distinct patterns of expression of the alternative and classical pathways in mammary epithelium, a previously undescribed phenomenon. Classical p65 signaling was found within the luminal cell population and p100/p52 signaling was observed almost exclusively within the basal cell layer. Upon induction of constitutively activated IKK2 or a dominant negative IKBalpha, two regulators of the classical NF-κB pathway, alterations in branching morphogenesis were observed within the developing virgin gland. These branching phenotypes were associated with a break down in the previously observed classical/alternative signaling pattern, as luminal cells were now expressing low levels of p100/p52. Furthermore, this patterning is disrupted during the development of polyoma middle T oncogene induced tumors in which we also observe alternative signaling no longer confined to the basal layer. Ongoing experiments with our newest transgenic model are designed to determine the effects of inducing alternative signaling, through overexpression of p52, within the mammary epithelium. Our models may reveal novel roles for the alternative NF-kappaB pathway in maintaining the basal/luminal structure of mammary epithelial ducts and connect aberrant p100/p52 signaling to tumor progression, potentially identifying a novel therapeutic target.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5262. doi:1538-7445.AM2012-5262

Abstract 2841: Inducible modulation of NF-kappaB in macrophages reveals that timing of intervention may be critical to therapeutic outcome during mammary tumorigenesis

Elevated levels of NF-kappaB signaling are associated with multiple cancers. Therefore, it is not surprising that inhibitors of NF-kappaB are being investigated as potential therapeutics. While extensive efforts are being made to identify inhibitors there is less focus on investigating the effects of inhibition in specific cell types and during defined stages of tumor progression. We have developed murine transgenic models that enable us to induce expression of an activator or inhibitor of NF-kappaB in macrophages, by adding doxycycline to the drinking water of mice. We have combined these with the Polyoma model of mammary cancer to investigate the effects of modulation of NF-kappaB signaling specifically within macrophages. Given several recent publications we were predicting that activation of NF-kappaB would have pro-tumor effects. However, using a tail vein injection model, our data identifies a stage during progression in which activation of NF-kappaB in macrophages significantly limits metastasis. Activation of NF-kappaB alters immune cell populations and results in rapid killing of tumor cells during the seeding phase. In this model inhibition of NF-kappaB in macrophages during this critical stage of metastasis is pro-tumor. This suggests that while inhibition of NF-kappaB at later stages of tumor progression may have therapeutic benefit, inhibition during the seeding phase my lead to the opposite effect. Our studies highlight the importance of continued investigation into aspects of cell specificity and timing that may change the potential outcome of a clinical trial using NF-kappaB inhibitors.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 2841. doi:10.1158/1538-7445.AM2011-2841

Outcomes and predicting response in anaemic chemotherapy patients treated with epoetin alfa. A multicentre, 4-month, open-label study in Australia and New Zealand

BACKGROUND

The aim of the study was to evaluate the effectiveness, safety, and clinical outcomes of erythropoietin therapy in the treatment of anaemic cancer subjects receiving chemotherapy and to examine hypochromic red blood cell measurement as an indicator of functional iron sufficiency and as a predictor of responsiveness or non-responsiveness to erythropoietin therapy.

METHODS

Patients who had a non-myeloid malignancy, had Hb < or = 11.0 g/dL, had a life expectancy of more than 6 months, were 18 years or older, were receiving chemotherapy and would continue to be treated for at least 2 months were given s.c. epoetin alfa three times a week.

RESULTS

Haemoglobin levels increased significantly at all time periods compared with baseline and the number of transfusions received decreased significantly at all time periods compared with baseline. Quality of life as measured by Functional Assessment of Cancer Therapy-Anaemia showed significant increases at months 2 and 4 and there were significant improvements in the fatigue subscale at both time points (P < 0.05). Significant improvements at end-point were observed for the physical, emotional and functional well-being, and additional concern subscales (all P < 0.05). Haematocrit and reticulocytes increased significantly at end-point compared with at baseline (haematocrit 33.4 vs 28.3%, P < 0.001; reticulocytes 105.8 vs 78.6 x 10(9)/dL, P = 0.005). The percentage of hypochromic red blood cells did not show predictive value for response to treatment status.

CONCLUSION

Epoetin alfa improved haemoglobin levels and quality of life in anaemic cancer patients receiving chemotherapy.

Preclinical cognitive decline and subsequent sleep disturbance in older women

OBJECTIVE

To determine whether longitudinal cognitive decline is associated with increased risk of sleep disturbance in older, nondemented, community-dwelling women.

METHODS

We studied 2,474 women (mean age 68.9 years) who were part of a prospective study started in 1986; women with baseline or follow-up evidence of possible dementia were excluded. Cognitive data were gathered over 15 years for modified Mini-Mental State Examination (mMMSE) and 13 years for Trails B; cognitive decline was defined as declining >1.5 SDs on the mMMSE (> or =3 points) or Trails B (>92 seconds). Sleep disturbance was measured objectively using actigraphy (Sleepwatch-O, Ambulatory Monitoring) at the 15-year follow-up visit; measures included total sleep hours, sleep efficiency, sleep latency, napping, and time awake after sleep onset (WASO).

RESULTS

During follow-up, 11% of women declined on mMMSE and 15% on Trails B. Cognitive decliners were more likely than non-decliners to experience sleep disturbance at follow-up on most measures. For women who declined on mMMSE, adjusted ORs (aOR) (95% CI) were 1.71 (1.24, 2.37) for sleep efficiency <70%, 1.57 (1.12, 2.21) for sleep latency > or =1 hour, and 1.43 (1.07, 1.92) for WASO > or =90 minutes. Results were similar for women who declined on Trails B; in addition, these women were more likely to nap >2 hours per day (aOR: 1.73; 95% CI: 1.28, 2.33). Cognitive decline on either test was not associated with total sleep time.

CONCLUSIONS

Cognitive decline is associated with sleep disturbance in nondemented community-dwelling elderly women.

Glycosylated hemoglobin level and development of mild cognitive impairment or dementia in older women

BACKGROUND

Biological mechanisms linking diabetes and cognition continue to grow, yet the association remains controversial in elders. Whether glycosylated hemoglobin (HbA1C) level, a marker of glucose control, is predictive of the development of cognitive impairment or dementia is unknown. We determined the association between HbA1C level and risk of developing cognitive impairment in older women, mostly without diabetes.

METHODS

We studied 1983 postmenopausal women (mean age, 67.2 years) with osteoporosis who had HbA1C level measured at baseline. Development of mild cognitive impairment (MCI) or dementia over 4 years was determined as part of a dementia ancillary study. We analyzed risk of MCI or dementia for every 1% of HbA1C as well as risk associated with HbA1C >or= 7%.

RESULTS

The mean level of HbA1C was 5.8% (range 3.0% to 12.1%) and 86 (4.3%) women developed MCI or dementia. For every 1% increase in HbA1C, women had a greater age-adjusted likelihood of developing MCI (OR= 1.50; 95% CI 1.14-1.97) and of developing MCI or dementia (OR=1.40; 95% CI 1.08 - 1.83). For those with HbA1C level >or= 7% (n=49), the age-adjusted risk for developing MCI was increased nearly 4-fold (OR= 3.70; 95% CI 1.51-9.09) and was increased nearly 3-fold for developing MCI or dementia (OR=2.86; 95% CI 1.17-6.98). When we excluded women with diagnosed diabetes (n=53), the association between HbA1C and MCI lessened somewhat but remained elevated (unadjusted OR=1.59; 95% CI 1.01-2.50; age-adjusted OR=1.42; 95% CI 0.89-2.28). Multivariate analyses adjusted for age, education, race, depression, alcohol use and treatment with raloxifene yielded similar results.

INTERPRETATION

We found an association between HbA1C level and risk of developing MCI or dementia in postmenopausal osteoporotic women primarily without diabetes. Our findings support the hypothesis that glucose dysregulation is a predictor for cognitive impairment.

Diabetes, impaired fasting glucose, and development of cognitive impairment in older women

OBJECTIVE

To investigate the association between diabetes and impaired fasting glucose (IFG) and cognition and risk of developing both dementia and mild cognitive impairment (MCI) in older women.

METHODS

The authors analyzed data from a 4-year randomized trial of raloxifene among 7,027 osteoporotic postmenopausal women (mean age, 66.3 years) at 178 sites. Diabetes was defined by history, fasting blood glucose > or =7.0 mmol/L (> or =126 mg/dL), or use of hypoglycemic agents; IFG was defined as fasting glucose <7.0 mmol/L but >6.11 mmol/L (110 mg/dL); all others were considered to have normal glucose (NG). The main outcome was baseline and 4-year change on five standardized cognitive tests (z scores with lower scores indicating worse performance) and risk of developing clinically significant impairment (dementia, mild cognitive impairment, or very low cognitive score).

RESULTS

A total of 267 (3.8%) women had diabetes and 297 (4.2%) had IFG. Women with IFG had worse baseline cognitive scores compared to women with NG but better scores than diabetics (age-adjusted composite z score based on five tests: NG 0.40, 95% CI 0.30 to 0.49; IFG 0.14, 95% CI -0.36 to 0.64; diabetics -0.78, 95% CI -1.23 to -0.33; p < 0.001). There was greater 4-year decline among diabetics (age and treatment-adjusted composite z score: NG -0.05, 95% CI -0.16 to 0.05; IFG 0.11, 95% CI -0.53 to 0.75; diabetics -1.00, 95% CI -1.50 to -0.50; p = 0.001). Further adjustment for education, race, and depression led to similar results. Risk of developing cognitive impairment among women with IFG or diabetes was increased by almost twofold (age and treatment-adjusted OR = 1.64; 95% CI 1.03 to 2.61 for IFG; OR = 1.79; 95% CI 1.14 to 2.81 for diabetics).

CONCLUSIONS

Diabetic as well as pre-diabetic women have impaired cognitive performance and greater risk of developing cognitive impairment.

Antiepileptic drug use increases rates of bone loss in older women: A prospective study

OBJECTIVE

To test the hypothesis that older women with antiepileptic drug (AED) use have increased rates of bone loss.

METHODS

AED use was ascertained and calcaneal and hip bone mineral density (BMD) measured in a cohort of 9,704 elderly community-dwelling women enrolled in the Study of Osteoporotic Fractures, and they were followed prospectively for changes in BMD. Current use of AED was assessed by interview, with verification of use from medication containers at baseline and follow-up examinations. Women were classified as continuous users, partial (intermittent) users, or nonusers. Rates of change in BMD were measured at the total hip and two subregions (average 4.4 years between examinations) and at the calcaneus (average 5.7 years between examinations).

RESULTS

After adjustment for confounders, the average rate of decline in total hip BMD steadily increased from -0.70%/year in nonusers to -0.87%/year in partial AED users to -1.16%/year in continuous AED users (p value for trend = 0.015). Higher rates of bone loss were also observed among continuous AED users at subregions of the hip and at the calcaneus. In particular, continuous phenytoin users had an adjusted 1.8-fold greater mean rate of loss at the calcaneus compared with nonusers of AED (-2.68 vs -1.46%/year; p < 0.001) and an adjusted 1.7-fold greater mean rate of loss at the total hip compared with nonusers of AED (-1.16 vs -0.70%/year; p = 0.069).

CONCLUSIONS

Continuous AED use in elderly women is associated with increased rates of bone loss at the calcaneus and hip. If unabated, the rate of hip bone loss among continuous AED users is sufficient to increase the risk of hip fracture by 29% over 5 years among women age 65 years and older.

Changes in biochemical markers of bone turnover in women treated with raloxifene: influence of regression to the mean

Measures with extreme magnitude are most likely to be the result of measurement variability. Repeated measurements genuinely lessen such variability, leading to a phenomenon known as regression to the mean (RTM), which may affect biochemical markers of bone turnover. We therefore studied four markers of bone turnover in the Multiple Outcomes of Raloxifene Evaluation (MORE) trial--serum procollagen type I C-propeptide (PICP), osteocalcin (OC), bone-specific alkaline phosphatase (BAP) and urinary type I collagen breakdown product (CTX)--among the 1704 women treated with raloxifene who had marker measurements and were at least 70% adherent, and among 915 control group patients. We examined the existence of RTM, and applied a method of adjustment for RTM of both baseline and follow-up results. We found that women who had the most extreme values tended to go in the opposite direction with the subsequent measurement, i.e., exhibited a pattern of RTM. For example, among women whose urinary CTX decreased at least 60% in the first 6 months, 61% had an increase in the next 6 months; and among those who had an increase in the first 6 months, 81% had a decrease in the next 6 months. We found a similar pattern for each of the four markers. When adjusting for RTM we obtained estimated true values of both baseline values and change in markers. These estimated true values were substantially different from the observed value when the latter was further from the mean. For example, for a 10% increase in urinary CTX in the first 6 months, after accounting for RTM we estimate that there was in fact a 3% decrease (80% confidence interval: -38% to 53%). We conclude that the few initial extreme marker responses observed in women treated with raloxifene represent RTM, and that one practical consequence is that patients with an increase in markers during the first 6 months should be continued on raloxifene therapy, because the values usually decrease later on.

Resuscitation in the out-of-hospital setting: medical futility criteria for on-scene pronouncement of death

The complete and irreversible cessation of life is often difficult to determine with complete confidence in the dynamic environment of out-of-hospital emergency care. As a result, resuscitation efforts often are initiated and maintained by emergency medical services (EMS) providers in many hopeless situations. Medical guidelines are reviewed here to aid EMS organizations with respect to decisions about: 1) initiating or waiving resuscitation efforts; 2) the appropriate duration of resuscitation efforts; and 3) recommended procedures for on-scene or prehospital pronouncement of death (termination of resuscitation). In cases of nontraumatic cardiac arrest, few unassailable criteria, other than certain physical signs of irreversible tissue deterioration, exist for determining medical futility at the initial encounter with the patient. Thus, the general medical recommendation is to attempt to resuscitate all patients, adult or child, in the absence of rigor mortis or dependent lividity. Conversely, wellfounded guidelines now are available for decisions regarding termination of resuscitation in such patients once they have received a trial of advanced cardiac life support. In practice, however, the final decision to proceed with on-scene pronouncement of death for these patients may be determined more by family and provider comfort levels and the specific on-scene environment. For patients with posttraumatic circulatory arrest, the type of injury (blunt or penetrating), the presence of vital signs, and the electrocardiographic findings are used to determine the futility of initiating or continuing resuscitation efforts. In general, patients who are asystolic on-scene are candidates for on-scene pronouncement, regardless of mechanism. With a few exceptions, blunt trauma patients with a clearly associated mechanism of lethal injury are generally candidates for immediate cessation of efforts once they lose their pulses and respirations. Regardless of the medical futility criteria, specialized training of EMS providers and targeted related testing of operational issues need to precede field implementation of on-scene pronouncement policies. Such policies also must be modified and adapted for local issues and resources. In addition, although the current determinations of medical futility, as delineated here, are important to establish for societal needs, the individual patient's right to live must be kept in mind always as new medical advances are developed.

Spinal immobilization in the field: clinical clearance criteria and implementation

Awareness of the health and financial repercussions of unnecessary immobilization has made cervical spinal immobilization controversial in out-of-hospital care. Clinical criteria for clearance of the cervical spine in the hospital based on mechanism of injury have been supported by many trauma centers. However, implementation of clinical criteria for cervical spinal clearance in out-of-hospital settings is not as well validated by multicenter studies or accepted by many emergency departments. This consensus group recommends that clinical criteria to determine "low-risk" patients be available for use by emergency medical services providers in out-of-hospital settings; however, training, audits, quality management, integration into the medical community, and extent of program implementation should be decided based on individual emergency medical services systems.

Concepts and application of prehospital ventilation

Airway management and optimal ventilation are crucial aspects of managing out-of-hospital medical emergencies. The goals in these situations are controlled ventilation and optimized inspiratory time, expiratory time, and airflow. Numerous techniques and devices are available to deliver oxygen-enriched air to patients during resuscitation. The bag-valve-mask (BVM) is one of the most common devices used to provide ventilation, although the American Heart Association ranks BVM devices lower in preference than other ventilation adjuncts, such as emergency and transport ventilators (ETVs) and pocket masks. The clearly documented limitations of BVM ventilation and its widespread use in the United States underscore the need to improve ventilation practices during care provided by emergency medical services (EMS) personnel. As part of that improvement, ETVs clearly have a role in the prehospital setting. These devices should be available on every ambulance, and the ability to use ETVs should be part of each EMS provider's skill set. Furthermore, all patients requiring emergency ventilation must be adequately monitored, including continuous monitoring of end-tidal carbon dioxide concentrations. As with any other skill, ventilation requires attention during initial training, continuing education and skill reinforcement, and quality review.

Dehydration activates an NF-kappaB-driven, COX2-dependent survival mechanism in renal medullary interstitial cells

Renal prostaglandin (PG) synthesis is mediated by cyclooxygenase-1 and -2 (COX1 and COX2). After dehydration, the maintenance of normal renal function becomes particularly dependent upon PG synthesis. The present studies were designed to examine the potential link between medullary COX1 and COX2 expression in hypertonic stress. In response to water deprivation, COX2, but not COX1, mRNA levels increase significantly in the renal medulla, specifically in renal medullary interstitial cells (RMICs). Water deprivation also increases renal NF-kappaB-driven reporter expression in transgenic mice. NF-kappaB activity and COX2 expression could be induced in cultured RMICs with hypertonic sodium chloride and mannitol, but not urea. RMIC COX2 expression was also induced by driving NF-kappaB activation with a constitutively active IkappaB kinase alpha (IKKalpha). Conversely, introduction of a dominant-negative IkappaB mutant reduced COX2 expression after hypertonicity or IKKalpha induction. RMICs failed to survive hypertonicity when COX2 was downregulated using a COX2-selective antisense or blocked with the selective nonsteroidal anti-inflammatory drug (NSAID) SC58236, reagents that did not affect cell survival in isotonic media. In rabbits treated with SC58236, water deprivation induced apoptosis of medullary interstitial cells in the renal papilla. These results demonstrate that water deprivation and hypertonicity activate NF-kappaB. The consequent increase in COX2 expression favors RMIC survival in hypertonic conditions. Inhibition of RMIC COX2 could contribute to NSAID-induced papillary injury.

Rate of bone loss is associated with mortality in older women: a prospective study

Older women with low bone density have an increased risk of fracture, cardiovascular disease, and mortality. However, it is not known whether this association is caused by ongoing bone loss or by lower bone mass earlier in life. To determine whether rate of bone loss is associated with total and cause-specific mortality, we prospectively studied 6046 women aged 65 years or older who had serial bone mineral density (BMD) measurements as a part of the Study of Osteoporotic Fractures. Rates (mean +/- SD) of loss of BMD at the heel (for a mean of 5.7 years) and hip (for a mean of 3.5 years) were estimated. Cause-specific mortality was ascertained from death certificates and hospital records. BMD loss at the heel was 5.9 +/- 6.0 mg/cm2 per year (1.5 +/- 1.5%) and BMD loss at the hip was 4.1 +/- 10.2 mg/cm2 per year (0.6 +/- 1.4%). During an average follow-up of 3.2 years after the second measurement of BMD, 371 deaths occurred. Each SD increase in BMD loss at the hip was associated with a 1.3-fold (95% CI, 1.1-1.4) increase in total mortality, adjusted for age, baseline BMD, diabetes, hypertension, incident fractures, smoking, physical activity, health status, weight loss, and calcium use. In particular, hip BMD loss was associated with increased mortality from coronary heart disease (relative hazard [RH] = 1.3 per SD; 95% CI, 1.0-1.8) and pulmonary diseases (RH = 1.6 per SD; 95% CI, 1.1-2.5). The findings were similar for bone loss at the heel, except there was no significant association with pulmonary mortality. These results raise the possibility that bone loss may share common etiologies with coronary and pulmonary diseases.