Combination of flow cytometry and functional imaging for monitoring of residual disease in myeloma

The iliac crest is the sampling site for minimal residual disease (MRD) monitoring in multiple myeloma (MM). However, the disease distribution is often heterogeneous, and imaging can be used to complement MRD detection at a single site. We have investigated patients in complete remission (CR) during first-line or salvage therapy for whom MRD flow cytometry and the two imaging modalities positron emission tomography (PET) and diffusion-weighted magnetic resonance imaging (DW-MRI) were performed at the onset of CR. Residual focal lesions (FLs), detectable in 24% of first-line patients, were associated with short progression-free survival (PFS), with DW-MRI detecting disease in more patients. In some patients, FLs were only PET positive, indicating that the two approaches are complementary. Combining MRD and imaging improved prediction of outcome, with double-negative and double-positive features defining groups with excellent and dismal PFS, respectively. FLs were a rare event (12%) in first-line MRD-negative CR patients. In contrast, patients achieving an MRD-negative CR during salvage therapy frequently had FLs (50%). Multi-region sequencing and imaging in an MRD-negative patient showed persistence of spatially separated clones. In conclusion, we show that DW-MRI is a promising tool for monitoring residual disease that complements PET and should be combined with MRD.

Rationale and development of a business case for antimicrobial stewardship programs in acute care hospital settings

Background

Antimicrobial stewardship programs (ASPs) have been shown to reduce inappropriate antimicrobial use and its consequences. However, these programs lack legislative requirements in many places and it can be difficult to determine what human resources are required for these programs and how to create a business case to present to hospital administrators for program funding. The objectives of the current paper were to review legislative requirements and outline human resource requirements for ASPs, and to create a base business case for ASPs.

Methods

A working group of antimicrobial stewardship experts from across Canada met to discuss the necessary components for creation of a business case for antimicrobial stewardship. A narrative review of the literature of the regulatory requirements and human resource recommendations for ASPs was conducted. Informed by the review and using a consensus decision-making process, the expert working group developed human resource recommendations based on a 1000 bed acute care health care facility in Canada. A spreadsheet based business case model for ASPs was also created.

Results

Legislative and /or regulatory requirements for ASPs were found in 2 countries and one state jurisdiction. The literature review and consensus development process recommended the following minimum human resources complement: 1 physician, 3 pharmacists, 0.5 program administrative and coordination support, and 0.4 data analyst support as full time equivalents (FTEs) per 1000 acute care beds. Necessary components for the business case model, including the human resource requirements, were determined to create a spreadsheet based model.

Conclusions

There is evidence to support the negative outcomes of inappropriate antimicrobial use as well as the benefits of ASPs. Legislative and /or regulatory requirements for ASPs are not common. The available evidence for human resource recommendations for ASPs using a narrative review process was examined and a base business case modelling scenario was created. As regulatory requirements for ASPs increase, it will be necessary to create accurate business cases for ASPs in order to obtain the necessary funding to render these programs successful.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0396-z) contains supplementary material, which is available to authorized users.

In vitro and in vivo characterization of the bifunctional μ and δ opioid receptor ligand UFP-505

BACKGROUND AND PURPOSE

Targeting more than one opioid receptor type simultaneously may have analgesic advantages in reducing side-effects. We have evaluated the mixed μ opioid receptor agonist/ δ opioid receptor antagonist UFP-505 in vitro and in vivo.

EXPERIMENTAL APPROACH

We measured receptor density and function in single μ, δ and μ /δ receptor double expression systems. GTPγ35 S binding, cAMP formation and arrestin recruitment were measured. Antinociceptive activity was measured in vivo using tail withdrawal and paw pressure tests following acute and chronic treatment. In some experiments, we collected tissues to measure receptor densities.

KEY RESULTS

UFP-505 bound to μ receptors with full agonist activity and to δ receptors as a low efficacy partial agonist At μ, but not δ receptors, UFP-505 binding recruited arrestin. Unlike morphine, UFP-505 treatment internalized μ receptors and there was some evidence for internalization of δ receptors. Similar data were obtained in a μ /δ receptor double expression system. In rats, acute UFP-505 or morphine, injected intrathecally, was antinociceptive. In tissues harvested from these experiments, μ and δ receptor density was decreased after UFP-505 but not morphine treatment, in agreement with in vitro data. Both morphine and UFP-505 induced significant tolerance.

CONCLUSIONS AND IMPLICATIONS

In this study, UFP-505 behaved as a full agonist at μ receptors with variable activity at δ receptors. This bifunctional compound was antinociceptive in rats after intrathecal administration. In this model, dual targeting provided no advantages in terms of tolerance liability.

LINKED ARTICLES

This article is part of a themed section on Emerging Areas of Opioid Pharmacology. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.14/issuetoc.

Dietary factors and pediatric multiple sclerosis: A case-control study

BACKGROUND

The role of diet in multiple sclerosis (MS) is largely uncharacterized, particularly as it pertains to pediatric-onset disease.

OBJECTIVE

To determine the association between dietary factors and MS in children.

METHODS

Pediatric MS patients and controls were recruited from 16 US centers (MS or clinically isolated syndrome onset before age 18, <4 years from symptom onset and at least 2 silent lesions on magnetic resonance imaging). The validated Block Kids Food Screener questionnaire was administered 2011-2016. Chi-squared test compared categorical variables, Kruskal-Wallis test compared continuous variables, and multivariable logistic regression analysis was performed.

RESULTS

In total, 312 cases and 456 controls were included (mean ages 15.1 and 14.4 years). In unadjusted analyses, there was no difference in intake of fats, proteins, carbohydrates, sugars, fruits, or vegetables. Dietary iron was lower in cases ( p = 0.04), and cases were more likely to consume below recommended guidelines of iron (77.2% of cases vs 62.9% of controls, p < 0.001). In multivariable analysis, iron consumption below recommended guidelines was associated with MS (odds ratio = 1.80, p < 0.01).

CONCLUSION

Pediatric MS cases may be less likely to consume sufficient iron compared to controls, and this warrants broader study to characterize a temporal relationship. No other significant difference in intake of most dietary factors was found.

Lipidomic and Transcriptomic Basis of Lysosomal Dysfunction in Progranulin Deficiency

Defective lysosomal function defines many neurodegenerative diseases, such as neuronal ceroid lipofuscinoses (NCL) and Niemann-Pick type C (NPC), and is implicated in Alzheimer's disease (AD) and frontotemporal lobar degeneration (FTLD-TDP) with progranulin (PGRN) deficiency. Here, we show that PGRN is involved in lysosomal homeostasis and lipid metabolism. PGRN deficiency alters lysosome abundance and morphology in mouse neurons. Using an unbiased lipidomic approach, we found that brain lipid composition in humans and mice with PGRN deficiency shows disease-specific differences that distinguish them from normal and other pathologic groups. PGRN loss leads to an accumulation of polyunsaturated triacylglycerides, as well as a reduction of diacylglycerides and phosphatidylserines in fibroblast and enriched lysosome lipidomes. Transcriptomic analysis of PGRN-deficient mouse brains revealed distinct expression patterns of lysosomal, immune-related, and lipid metabolic genes. These findings have implications for the pathogenesis of FTLD-TDP due to PGRN deficiency and suggest lysosomal dysfunction as an underlying mechanism.

17-alpha Hydroxyprogesterone caproate did not reduce the rate of recurrent preterm birth in a prospective cohort study

BACKGROUND

17-alpha Hydroxyprogesterone caproate for prevention of recurrent preterm birth is recommended for use in the United States.

OBJECTIVE

We sought to assess the clinical effectiveness of 17-alpha hydroxyprogesterone caproate to prevent recurrent preterm birth ≤35 weeks compared to similar births in our obstetric population prior to the implementation of 17-alpha hydroxyprogesterone caproate.

STUDY DESIGN

This was a prospective cohort study of 17-alpha hydroxyprogesterone caproate in our obstetric population. The primary outcome was the recurrence of birth ≤35 weeks for the entire study cohort compared to a historical referent rate of 16.8% of recurrent preterm birth in our population. There were 3 secondary outcomes. First, did 17-alpha hydroxyprogesterone caproate modify a woman's history of preterm birth when taking into account her prior number and sequence of preterm and term births? Second, was recurrence of preterm birth related to 17-alpha hydroxyprogesterone caproate plasma concentration? Third, was duration of pregnancy modified by 17-alpha hydroxyprogesterone caproate treatment compared to a prior preterm birth?

RESULTS

From January 2012 through March 2016, 430 consecutive women with prior births ≤35 weeks were treated with 17-alpha hydroxyprogesterone caproate. Nearly two thirds of the women (N = 267) began injections ≤18 weeks and 394 (92%) received a scheduled weekly injection within 10 days of reaching 35 weeks or delivery. The overall rate of recurrent preterm birth was 25% (N = 106) for the entire cohort compared to the 16.8% expected rate (P = 1.0). The 3 secondary outcomes were also negative. First, 17-alpha hydroxyprogesterone caproate did not significantly reduce the rates of recurrence regardless of prior preterm birth number or sequence. Second, plasma concentrations of 17-alpha hydroxyprogesterone caproate were not different (P = .17 at 24 weeks; P = .38 at 32 weeks) between women delivered ≤35 weeks and those delivered later in pregnancy. Third, the mean (±SD) interval in weeks of recurrent preterm birth before 17-alpha hydroxyprogesterone caproate use was 0.4 ± 5.3 weeks and the interval of recurrent preterm birth after 17-alpha hydroxyprogesterone caproate treatment was 0.1 ± 4.7 weeks (P = .63). A side effect of weekly 17-alpha hydroxyprogesterone caproate injections was an increase in gestational diabetes. Specifically, the rate of gestational diabetes was 13.4% in 17-alpha hydroxyprogesterone caproate-treated women compared to 8% in case-matched controls (P = .001).

CONCLUSION

17-alpha Hydroxyprogesterone caproate was ineffective for prevention of recurrent preterm birth and was associated with an increased rate of gestational diabetes.

Impact of early palliative care on caregivers of patients with advanced cancer: cluster randomised trial

Background

Early palliative care improves the quality of life (QoL) and satisfaction with care of patients with advanced cancer, but little is known about its effect on caregivers. Here, we report outcomes of caregiver satisfaction with care and QoL from a trial of early palliative care.

Patients and methods

Twenty-four medical oncology clinics were cluster-randomised, stratified by tumour site (lung, gastrointestinal, genitourinary, breast and gynaecological), to early palliative care team referral, or to standard oncology care with palliative care only as needed. Caregivers of patients with advanced cancer (clinical prognosis of 6-24 months, Eastern Cooperative Oncology Group 0-2) in both trial arms completed validated measures assessing satisfaction with care (FAMCARE-19) and QoL [SF-36v2 Health Survey; Caregiver QoL-Cancer (CQoL-C)], at baseline and monthly for 4 months. We used a multilevel linear random-intercept mixed-effect model to test whether there was improvement in the intervention group relative to the control group over 3 and 4 months.

Results

A total of 182 caregivers completed baseline measures (94 intervention, 88 control); 151 caregivers (77 intervention, 74 control) completed at least one follow-up assessment. Satisfaction with care improved in the palliative intervention group compared with controls over 3 months (P = 0.007) and 4 months (P = 0.02). There was no significant improvement in the intervention group compared with controls for CQoL-C (3 months: P = 0.92, 4 months: P = 0.51), Physical Component Summary of the SF-36v2 Health Survey (3 months: P = 0.83, 4 months: P = 0.20), or Mental Component Summary of the SF-36v2 Health Survey (3 months: P = 0.87, 4 months: P = 0.60).

Conclusion

Early palliative care increased satisfaction with care in caregivers of patients with advanced cancer.

ClinicalTrials.gov identifier

NCT01248624.

Addressing metabolic heterogeneity in clear cell renal cell carcinoma with quantitative magnetic resonance imaging

460

Background: Dysregulated lipid and glucose metabolism has been implicated in clear cell renal cell carcinoma (ccRCC) progression. Pre-operative tissue-based assessment of tumor metabolic alterations is challenging due to the characteristic heterogeneity of ccRCC. Non-invasive prediction of metabolic alterations in the whole tumor with an imaging method would be appealing for optimal patient management and possibly selection of targeted neoadjuvant therapy. Methods: In this IRB-approved, HIPAA-compliant study, 43 patients (34 M, 9 F) with pathologically confirmed primary ccRCC underwent pre-surgical MRI to quantify whole-tumor intra-tumoral lipid accumulation (% fat fraction, FF) and tumor enhancement (% enhancement) with Dixon-based MRI and dynamic contrast-enhanced MRI, respectively. All patients signed informed consent. Quantitative MRI measures were also obtained from targeted regions of interest within tumors and correlated to lipid accumulation (Oil Red O, ORO) and mass spectrometry-based lipidomics and metabolomics of tissue samples isolated from anatomically co-registered locations in the same tumor using fiducial markers placed at the time of surgery. Linear regression was performed to correlate FF and ORO %. Univariate statistical differences of the metabolites between two groups were analyzed using Student’s t-test. Results: In vivo tumor FF correlated positively with histologic fat content (Spearman correlation coeff. ρ = 0.86, p <0.0001), spectrometric triglycerides (ρ = 0.56, p = 0.0007) and cholesterol (ρ = 0.47, p = 0.006), respectively; and negatively with spectrometric free fatty acids (ρ = -0.44, p = 0.01) and phospholipids (ρ = -0.65, p = 0.001), respectively. ISUP grade 2 and 3 tumors exhibited marked intra-tumoral FF heterogeneity, whereas grade 4 tumors had reduced lipid accumulation compared to grade 3 (p = 0.016). Aqueous metabolites were different in tumors compared to renal parenchyma and 11 metabolites showed significant correlation with tumor vascularity (FDR p <0.05). Conclusions: MRI-derived FF and tumor enhancement correlated with the altered metabolic features of ccRCC and the metabolic heterogeneity within a given tumor.

From science to action: Principles for undertaking environmental research that enables knowledge exchange and evidence-based decision-making

Effective conservation requires knowledge exchange among scientists and decision-makers to enable learning and support evidence-based decision-making. Efforts to improve knowledge exchange have been hindered by a paucity of empirically-grounded guidance to help scientists and practitioners design and implement research programs that actively facilitate knowledge exchange. To address this, we evaluated the Ningaloo Research Program (NRP), which was designed to generate new scientific knowledge to support evidence-based decisions about the management of the Ningaloo Marine Park in north-western Australia. Specifically, we evaluated (1) outcomes of the NRP, including the extent to which new knowledge informed management decisions; (2) the barriers that prevented knowledge exchange among scientists and managers; (3) the key requirements for improving knowledge exchange processes in the future; and (4) the core capacities that are required to support knowledge exchange processes. While the NRP generated expansive and multidisciplinary science outputs directly relevant to the management of the Ningaloo Marine Park, decision-makers are largely unaware of this knowledge and little has been integrated into decision-making processes. A range of barriers prevented efficient and effective knowledge exchange among scientists and decision-makers including cultural differences among the groups, institutional barriers within decision-making agencies, scientific outputs that were not translated for decision-makers and poor alignment between research design and actual knowledge needs. We identify a set of principles to be implemented routinely as part of any applied research program, including; (i) stakeholder mapping prior to the commencement of research programs to identify all stakeholders, (ii) research questions to be co-developed with stakeholders, (iii) implementation of participatory research approaches, (iv) use of a knowledge broker, and (v) tailored knowledge management systems. Finally, we articulate the individual, institutional and financial capacities that must be developed to underpin successful knowledge exchange strategies.

Fatty Acid Oxidation Mediated by Acyl-CoA Synthetase Long Chain 3 Is Required for Mutant KRAS Lung Tumorigenesis

KRAS is one of the most commonly mutated oncogenes in human cancer. Mutant KRAS aberrantly regulates metabolic networks. However, the contribution of cellular metabolism to mutant KRAS tumorigenesis is not completely understood. We report that mutant KRAS regulates intracellular fatty acid metabolism through Acyl-coenzyme A (CoA) synthetase long-chain family member 3 (ACSL3), which converts fatty acids into fatty Acyl-CoA esters, the substrates for lipid synthesis and β-oxidation. ACSL3 suppression is associated with depletion of cellular ATP and causes the death of lung cancer cells. Furthermore, mutant KRAS promotes the cellular uptake, retention, accumulation, and β-oxidation of fatty acids in lung cancer cells in an ACSL3-dependent manner. Finally, ACSL3 is essential for mutant KRAS lung cancer tumorigenesis in vivo and is highly expressed in human lung cancer. Our data demonstrate that mutant KRAS reprograms lipid homeostasis, establishing a metabolic requirement that could be exploited for therapeutic gain.

Evidence for nociceptin/orphanin FQ (NOP) but not µ (MOP), δ (DOP) or κ (KOP) opioid receptor mRNA in whole human blood

BACKGROUND

While it is well known that opioids depress the immune system, the site(s) of action for this depression is highly controversial. Immune modulation could occur directly at the immune cell or centrally via the hypothalamic-pituitary-adrenal axis. In a number of studies using individual enriched immune cell populations we have failed to detect classical µ (MOP), δ (DOP) and κ (KOP) receptors. The non-classical nociceptin/orphanin FQ (N/OFQ) receptor (NOP) is expressed on all cells examined thus far. Our hypothesis was that immune cells do not express classical opioid receptors and that using whole blood would definitively answer this question.

METHODS

Whole blood (containing all immune cell types) was incubated with opioids (morphine and fentanyl) commonly encountered in anaesthesia and with agents mimicking sepsis [lipopolysaccharide (LPS) and peptidoglycan G (PepG)]. Opioid receptor mRNA expression was assessed by endpoint polymerase chain reaction (PCR) with gel visualisation and quantitative PCR.

RESULTS

Classical MOP, DOP, and KOP receptors were not detected in any of the samples tested either at rest or when challenged with opioids, LPS or PepG. Commercial primers for DOP did not perform well in quantitative PCR, so the absence of expression was confirmed using a traditional gel-based approach. NOP receptors were detected in all samples; expression was unaffected by opioids and reduced by LPS/PepG combinations.

CONCLUSIONS

Classical opioid receptors are not expressed on circulating immune cells.

State-of-the-art three-dimensional analysis of soft tissue changes following Le Fort I maxillary advancement

We describe the comprehensive 3-dimensional analysis of facial changes after Le Fort I osteotomy and introduce a new tool for anthropometric analysis of the face. We studied the cone-beam computed tomograms of 33 patients taken one month before and 6-12 months after Le Fort I maxillary advancement with or without posterior vertical impaction. Use of a generic facial mesh for dense correspondence analysis of changes in the soft tissue showed a mean (SD) anteroposterior advancement of the maxilla of 5.9 (1.7) mm, and mean (SD) minimal anterior and posterior vertical maxillary impaction of 0.1 (1.7) mm and 0.6 (1.45) mm, respectively. It also showed distinctive forward and marked lateral expansion around the upper lip and nose, and pronounced upward movement of the alar curvature and columella. The nose was widened and the nostrils advanced. There was minimal forward change at the base of the nose (subnasale and alar base) but a noticeable upward movement at the nasal tip. Changes at the cheeks were minimal. Analysis showed widening of the midface and upper lip which, to our knowledge, has not been reported before. The nostrils were compressed and widened, and the lower lip shortened. Changes at the chin and lower lip were secondary to the limited maxillary impaction.

Abstract 617: Wnt-Containing Microvesicles Are Upregulated in Vascular Smooth Muscle Cell Cultures and Plasma From SM22-Cre;LRP6(fl/fl);LDLR-/- Mice

When fed a high fat diet (HFD) typical of westernized societies, male LDL receptor -deficient (LDLR-/-) mice develop obesity and insulin-resistant diabetes, with concomitant arteriosclerotic calcification and fibrosis. We recently demonstrated that noncanonical Wnt signals and ligands (including Wnt4, Wnt7b, and Wnt10a) were upregulated with LRP6 deficiency in aortic vascular smooth muscle (VSM) of LDLR-/- mice, with concomitant worsening of vascular disease. Because Wnt ligands are hydrophobic due to fatty acid acylation, we examined whether lipidaceous microvesicles (MVs) containing Wnt ligands were elaborated by VSM, and whether LRP6 impacted plasma MV numbers and contents. Microvesicles were isolated using both polymer based- and differential ultracentrifugation - based purification methods, and Malvern NS300 NanoSight nanoparticle tracking analysis implemented to quantify vesicle concentrations, focusing upon the 50-200 nm size range of exosomes and mineralizing vesicles. As compared to Cre-negative control cultures, SM22-Cre;LRP6(fl/fl);LDLR-/- VSM elaborated 2.9-fold fold higher numbers of MVs over a 2 day period (143 +/-27 million/ml +/- vs. 49+/- 5 million/ml; p = 0.01). ML141 -- a cdc42/rac1 antagonist that reduces VSM calcification and noncanonical Wnt signals activated with LRP6 deficiency — reduces MV numbers in VSM cultures (42+/- 10 million / ml with 10 uM ML141 vs.120 +/- 19 million/ ml vehicle; p< 0.001). Consistent with primary VSM results, a 2-fold increase in the circulating plasma MV concentration was observed in aging SM22-Cre;LRP6(fl/fl);LDLR-/- mice vs. LRP6(fl/fl);LDLR-/- sibling controls (4.7+/- 1.1 billion/ml vs. 2.3+/-0.3 billion/ml, p = 0.07, n = 7-8 per genotype). Western blot analysis of extracts prepared from plasma MVs confirmed the presence of Wnt5a/b, Wnt10a, Wnt4 in this circulating nanoparticle population, and that Wnt4 was significantly increased in the MV fraction with LRP6 deficiency (1.4-fold, p = 0.01). Thus, Wnt-containing microvesicles are elaborated by VSM in vitro and in vivo. Quantitative characterization of plasma MV protein and lipid composition may yield novel biomarkers of pro-sclerotic Wnt signaling in diabetic vascular disease.

Contribution of Accelerated Degradation to Feedback Regulation of 3-Hydroxy-3-methylglutaryl Coenzyme A Reductase and Cholesterol Metabolism in the Liver

Accumulation of sterols in endoplasmic reticulum membranes stimulates the ubiquitination of 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR), which catalyzes a rate-limiting step in synthesis of cholesterol. This ubiquitination marks HMGCR for proteasome-mediated degradation and constitutes one of several mechanisms for feedback control of cholesterol synthesis. Mechanisms for sterol-accelerated ubiquitination and degradation of HMGCR have been elucidated through the study of cultured mammalian cells. However, the extent to which these reactions modulate HMGCR and contribute to control of cholesterol metabolism in whole animals is unknown. Here, we examine transgenic mice expressing in the liver the membrane domain of HMGCR (HMGCR (TM1-8)), a region necessary and sufficient for sterol-accelerated degradation, and knock-in mice in which endogenous HMGCR harbors mutations that prevent sterol-induced ubiquitination. Characterization of transgenic mice revealed that HMGCR (TM1-8) is appropriately regulated in the liver of mice fed a high cholesterol diet or chow diet supplemented with the HMGCR inhibitor lovastatin. Ubiquitination-resistant HMGCR protein accumulates in the liver and other tissues disproportionately to its mRNA, indicating that sterol-accelerated degradation significantly contributes to feedback regulation of HMGCR in vivo Results of these studies demonstrate that HMGCR is subjected to sterol-accelerated degradation in the liver through mechanisms similar to those established in cultured cells. Moreover, these studies designate sterol-accelerated degradation of HMGCR as a potential therapeutic target for prevention of atherosclerosis and associated cardiovascular disease.