Persistent non-neoplastic gammadelta-T cells in cerebrospinal fluid of a patient with hepatosplenic (gammadelta) T cell lymphoma: a case report with 6 years of flow cytometry follow-up

Hepatosplenic (gammadelta) T-cell lymphoma (HSTCL) is an uncommon T-cell lymphoma with an aggressive clinical course and poor prognosis. Bone marrow and peripheral blood are frequently involved, with central nervous system involvement less common. We describe a case of a 31-year old man diagnosed with a gammadelta HSTCL in 2003, successfully treated with chemotherapy and allogeneic stem cell transplantation, and followed from 2003 to present. Four-color flow cytometry (FC) was performed on a BD FACSCalibur and data analyzed with CellQuest Pro and FCS Express software. For cerebrospinal fluid (CSF), all cells were acquired due to limited material. Cytological correlation was available on all specimens. Molecular studies for T-cell gene rearrangement were non-contributory. By FC, the diagnostic HSTCL immunophenotype was CD3 (+), CD7 (+), CD2 (+), CD5 (-), CD4 (-), CD8 (-), TCR gammadelta (+). Subsequent CSF FC analysis revealed a distinct population of gammadelta T-cells in all specimens, ranging from <1% to 13% of lymphocytes. Consistently, the gammadelta T-cells exhibited a different immunophenotypic profile from the reported diagnostic immunophenotype; they expressed CD5, and exhibited a heterogeneous pattern of CD8 expression. Comparison to in-house cases from patients with hairy cell leukemia and concomitant increases in non-neoplastic gammadelta T-cells was performed. The persistent gammadelta T-cells from the CSF of the patient with HSTCL were immunophenotypically consistent with non-neoplastic gammadelta T-cells. We describe an unusual case of persistent gammadelta T-cells in the CSF of a patient during 6 years of flow cytometric follow-up after treatment for gammadelta HSTCL. By cytology, non-neoplastic and malignant gammadelta T-cells are often difficult to distinguish. FC analysis helps to make this distinction, even with a limited panel. By FC, the gammadelta-T cells in the CSF of this patient are immunophenotypically consistent with non-neoplastic gammadelta T-cells. Remarkably, this finding is underscored by the patient's unusual clinical picture; he remains well and disease free.

On the thermodynamical admissibility of the triphasic theory of charged hydrated tissues

The triphasic theory on soft charged hydrated tissues (Lai, W. M., Hou, J. S., and Mow, V. C., 1991, "A Triphasic Theory for the Swelling and Deformation Behaviors of Articular Cartilage," ASME J. Biomech. Eng., 113, pp. 245-258) attributes the swelling propensity of articular cartilage to three different mechanisms: Donnan osmosis, excluded volume effect, and chemical expansion stress. The aim of this study is to evaluate the thermodynamic plausibility of the triphasic theory. The free energy of a sample of articular cartilage subjected to a closed cycle of mechanical and chemical loading is calculated using the triphasic theory. It is shown that the chemical expansion stress term induces an unphysiological generation of free energy during each closed cycle of loading and unloading. As the cycle of loading and unloading can be repeated an indefinite number of times, any amount of free energy can be drawn from a sample of articular cartilage, if the triphasic theory were true. The formulation for the chemical expansion stress as used in the triphasic theory conflicts with the second law of thermodynamics.

Ongoing phase I studies of ABT-263: Mitigating Bcl-XL induced thrombocytopenia with lead-in and continuous dosing

3505

Background: ABT-263, a novel, oral BH3 mimetic, potently inhibits multiple antiapoptotic Bcl-2 family proteins. Ongoing phase 1 studies of ABT-263 show anti-tumor activity in CLL and some lymphomas (Wilson W et al, ASH. 2008). However, thrombocytopenia (TCP) due to on-target Bcl-XL inhibition-induced platelet apoptosis is also observed. Platelet nadir occurred on days 3–5 on 14/21 d dosing with each exposure to drug, was proportional to starting platelet count and recovered during therapy due to compensatory increased megakaryopoiesis. TCP was a dose limiting toxicity (DLT) in 3 patients (pts) in CLL study M06–873 (N = 15) where starting platelet counts tend to be low. We tested 2 strategies to mitigate variability in circulating platelet levels and achieve higher cumulative exposure: introducing a lower lead-in dose and using a continuous dosing (CD) (21/21 d schedule). Methods: CD with a 7 d lead-in dose was explored (150, 150 or 100 mg lead-in doses) with dosing at 200 and 275 mg, 225 and 325 mg, or 125 and 250 mg in studies M06–814 (NHL), M06–822 (SCLC), and M06 873 (CLL), respectively. Results: 22 pts on 21/21 d dosing enrolled to date in the 3 studies. Cmax & AUC at steady-state were comparable between pts at the same dose on 21/21 and 14/21 d schedules. Lead-in followed by CD appears to minimize platelet nadir and cycle variability. At 200 mg and grouping data from 200 and 225 mg doses, median platelet nadir in Cycle 1 was 46% and 42% of baseline on the CD schedule after lead-in vs 33% and 36% on the 14/21 schedule, respectively. For pts receiving 150 mg lead-in, nadir occurred during this phase, and platelet levels remained relatively stable on CD for doses up to 225 mg. 2 DLTs were observed for CD, 1 pt per study M06–814 (275 mg) and M06–873 (200 mg) experienced grade 4 (TCP). While CD enrollment and time on study is still limited, anti-tumor activity includes 1 unconfirmed partial response (68% CT regression) in a SLL pt at 275 mg and 3 CLL pts with ≥50% lymphocyte reduction for ≥2 months. Conclusions: Dosing schedule moderates early platelet nadir. Optimal dosing regimens may vary between tumor types especially where marrow infiltration is a feature.

[Table: see text]

ABT-263 activity and safety in patients with relapsed or refractory lymphoid malignancies in particular chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL)

8574

Background: ABT-263, a novel, orally bioavailable, BH3 mimetic, binds with high affinity (Ki ≤ 1nM) and inhibits multiple antiapoptotic Bcl-2 family proteins. ABT-263 displays activity (EC50 ≤ 1μM) against human lymphoid and small cell lung cancer cell lines. Mechanism based preclinical toxicities include reductions in circulating lymphocytes, apoptosis of circulating platelets, and decreased spermatogenesis, mediated by inhibition of Bcl-2, Bcl-XL, and Bcl-w, respectively. Methods: Safety and activity of ABT-263 in 2 enrolling phase I studies in relapsed/refractory lymphoid malignancies (M06–814) and CLL (M06–873) was evaluated. Patients (pts) were dosed on days 1–14 of a 21 d cycle, 10–440mg (M06–814) or 10–250mg (M06–873). Continuous 21/21 d dosing (CD) post lead-in dose is being explored in both studies. Results: 55 pts, 14/21 d dosing, enrolled in the 2 studies. ABT-263 PK were linear from 10 - 440mg (N=55) and the terminal half-life was 14 - 20 h (n=35). Among 27 CLL/SLL pts, 3 have confirmed radiographic partial responses (PR) (99%, 92% and 72%) and 2 have unconfirmed regressions, 51% and 72%. 6 pts maintained a ≥50% decrease in circulating lymphocytes for ≥ 2 months and 11 pts have stable disease; of these 5 experienced minor radiographic responses (range of 36% to 49%). In addition, among 40 (M06–814) lymphoma pts, 3 with follicular lymphoma achieved PR and one had a minor response (49% regression). With CD dosing (16 pts), activity includes 1 unconfirmed PR in SLL & and 3 CLL pts with ≥50% lymphocyte reduction for ≥2 months duration. Pharmacodynamic toxicities included dose-dependent thrombocytopenia (TCP) resulting from on-target activity against Bcl-XL. Dose limiting toxicities, 14/21 d dosing, in M06–814 occurred at 160mg (bronchitis), 315mg (elevated ALT and grade 4 TCP) and 440mg (worsening pleural effusion in a pt with underlying afib), and in M06–873 at 110mg (tumor lysis and grade 4 TCP) and 250mg (grade 4 TCP). Conclusions: ABT-263 showed favorable PK and safety profiles with anti-tumor activity in relapsed/refractory CLL/SLL and follicular lymphoma. Identification of optimal dose and schedule for phase II trials continues.

[Table: see text]

Variable CD52 expression in mature T cell and NK cell malignancies: implications for alemtuzumab therapy

The anti-CD52 antibody alemtuzumab has been explored as a novel targeted therapy in T cell malignancies. To assess the suitability of alemtuzumab therapy, we carried out a comprehensive study of CD52 expression using flow cytometry (FC) in 78 untreated patients diagnosed with mature T/natural killer (NK) cell neoplasms, including 34 adult T cell leukaemia/lymphomas (ATLL), two anaplastic large cell lymphomas (ALCL), three angioimmunoblastic T cell lymphomas (AITL), 16 cutaneous T cell lymphomas (CTCL), four extra-nodal T/NK cell lymphomas (ENT/NKCL), four hepatosplenic T cell lymphomas (HSTCL), 13 peripheral T cell lymphomas, not otherwise specified (PTCL-NOS) and two T-prolymphocytic leukaemia (T-PLL). The level of CD52 expression was quantified using QuantiBRITE standard beads. The level of CD52 expression varied widely within each diagnostic category. All AITL, HSTCL and T-PLL cases were CD52-positive and the frequency of CD52 expression was high in PTCL-NOS (92.3%), ATLL (94.1%) and CTCL (87.5%), implying a rational role for alemtuzumab in the treatment of these diseases; however, CD52 expression was low in ALCL (50%) and ENT/NKCL (25%). FC testing for cell surface expression of CD52 is indicated in patients with T/NK cell malignancies being considered for alemtuzumab therapy. Further studies are necessary to determine if the level of CD52 expression correlates with response to therapy.

Novel CD19 expression in a peripheral T cell lymphoma: A flow cytometry case report with morphologic correlation

BACKGROUND

Peripheral T-cell lymphomas are uncommon lymphomas that show T-cell antigenic loss and clonal T-cell receptor (TCR) gene rearrangement. Rare cases of T-cell lymphomas with aberrant expression of CD20 have been described. However, CD19 coexpression in a mature T-cell neoplasm has not been reported.

METHODS

Histology, immunohistochemistry (IHC), and PCR for TCR gene rearrangement were performed on an excised lymph node specimen and a subsequent fine needle aspiration (FNA) of an additional lymph node. Flow cytometry (FC) was performed on FNA and peripheral blood specimen.

RESULTS

The lymph node's architecture was effaced by a diffuse atypical lymphoid proliferation that, by IHC, was positive for CD3, CD2, and CD43 and negative for CD4, CD5, CD8, TdT, CD1a, and B-cell-associated antigens PAX-5, CD20, and CD79a. A clonal TCR gene rearrangement was detected. FC was performed on a subsequent FNA, and peripheral blood specimen demonstrated an aberrant T-cell population with expression of CD2, CD3, CD27, TCR alpha/beta, CD52, CD38, CD45, and CD26 (partial expression) and negative for CD4, CD5, CD7, CD8, CD10, CD30, and CD56. The aberrant T-cell population also expressed bright CD19.

CONCLUSIONS

Using FC, we describe the first case of peripheral T-cell lymphoma with aberrant coexpression of CD19.

Immunophenotypic features distinguishing familial chronic lymphocytic leukemia from sporadic chronic lymphocytic leukemia

BACKGROUND

Familial chronic lymphocytic leukemia (CLL) has the most frequent familial aggregation among hematological malignancies. Familial CLL families have been studied to identify susceptibility genes and other factors that contribute in the etiology of CLL. To date no study has been conducted to evaluate and compare patterns of cell surface antigen expression in familial CLL and sporadic CLL.

METHODS

The pattern of cell surface antigen expression was studied in familial and sporadic CLL to determine if unique identifiers of familial CLL could be detected. Survival in familial CLL verses sporadic CLL was compared and the association between prognosis and CD38 expression studied.

RESULTS

Familial and sporadic CLL demonstrated the same characteristic immunophenotype (positive for surface immunoglobulin, CD5, CD19, and CD23 with dim CD20, and CD22). CD2 and CD13 expression, however, were more frequent (30% of cases) in familial CLL (P = 0.0003 for CD2, P = 0.006 for CD13) than in sporadic CLL (2-6%). There was no significant difference in survival in the two groups studied. Although the incidence of CD38 expression was similar in familial and sporadic CLL (47% and 44% respectively) the association with prognosis differed. There was a trend to decreased survival in CD38 positive sporadic (P = 0.06) but not familial CLL patients.

CONCLUSIONS

We conclude that detection of CD2 or CD13 expression in CLL suggests familial CLL and examination of family history for additional affected members is warranted. Furthermore, CD38 expression does not carry the negative prognosis observed in sporadic CLL.

Oropharyngeal shedding of Epstein-Barr virus in the absence of circulating B cells

Infection with Epstein-Barr virus (EBV) results in lifelong infection of B cells in the peripheral blood and in episodic shedding of virus from the oropharynx. We monitored patients treated with rituximab (anti-CD20 monoclonal antibody) and found that several had both no detectable B cells and no EBV in the blood but shed EBV from the throat. Although some models postulate that EBV traffics from the B cells in the blood to the throat, where it is subsequently shed, our findings indicate that circulating EBV in B cells is not necessary for the virus to persist in, and to be shed from, the oropharynx.

Experimental and model determination of human intervertebral disc osmoviscoelasticity

Finite element (FE) models have become an important tool to study load distribution in the healthy and degenerated disc. However, model predictions require accurate constitutive laws and material properties. As the mechanical properties of the intervertebral disc are regulated by its biochemical composition and fiber-reinforced structure, the relationship between the constitutive behavior of the tissue and its composition requires careful consideration. While numerous studies have investigated the annulus fibrosus compressive and tensile properties, specific conditions required to determine model parameters for the osmoviscoelastic model are unavailable. Therefore, the objectives of this study were (1) to complement the existing material testing in the literature with confined compression and tensile tests on human annulus fibrosus and (2) to use these data, together with existing nucleus pulposus compression data to tune a composition-based, osmoviscoelastic material constitutive law. The osmoviscoelastic material constitutive law and the experimental data were used to describe the fiber and nonfiber properties of the human disc. The compressive material properties of normal disc tissue were G(m) = 1.23 MPa, M = 1.57, and alpha = 1.964 x 10(-16) m(4)/Ns; the tensile fiber material parameters were E(0) = 77.0 MPa; E(epsilon) = 500 MPa, and eta = 1.8 x 10(3) MPa(-s). The goodness of fit ranged from 0.88 to 0.96 for the four experimental conditions evaluated. The constitutive law emphasized the interdependency of the strong swelling ability of the tissue and the viscoelastic nature of the collagen fibers. This is especially important for numerical models to further study the load sharing behavior with regard to disc degeneration and regeneration.

Flow cytometric immunophenotyping of cerebrospinal fluid

Leptomeningeal disease is an important adverse complication occurring in patients with B and T cell lymphomas and acute leukemias of lymphoid and myeloid origin. Recent reports suggest that multiparameter flow cytometry immunophenotypic assessment of spinal fluid samples could improve the efficiency of detection of CNS involvement, due to its high specificity and greater sensitivity. However, spinal fluid samples are frequently paucicellular with a rapidly decreasing cell viability. Staining of spinal fluid therefore requires dedicated sample storage/transport, staining, and preparation protocols. The Basic Protocol in this unit outlines a consensus multiparameter (3- to 8-color) flow cytometry immunophenotypic protocol for the evaluation of CNS involvement of cerebrospinal fluid (CSF) samples by neoplastic cells. A Support Protocol describing the simultaneous assessment of surface and cytoplasmic antigens is also provided. Finally, in the Alternate Protocol, we describe a method to calculate absolute numbers of both normal and pathological cell subpopulations by adding counting beads to the assay.

A Conceptual Multivariate Modelling Approach for Integrating Epidemiologic and Psychosocial Determinants to Examine the Epidemiology of Diseases in Under-served Populations

Epidemiologic research involves the study of a complex set of host, environment and causative agent factors as these interact to impact health and diseases in any population. A conceptual multivariate modelling approach for integrating epidemiologic and psychosocial determinants to examine the epidemiology of chronic and infectious diseases in under-served populations in the USA was developed. Our approach relies upon systems analysis, i.e. integrating concepts and methods in epidemiology with mathematics and statistics along with computational methods and tools to rigorously examine the dynamics of diseases such as the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) in a community. We used a multifactorial and quantitative epidemiologic (static) model that interrelates multiple determinants including biomedical, behavioral, and socioeconomic factors to analyze morbidity and mortality due to HIV/AIDS. The research involved participation of the community in the collection of socioeconomic, demographic, environmental, epidemiologic and biomedical data. In collaboration with Montgomery AIDS Outreach (MAO), a community based Organization in Montgomery, Alabama; blood samples were collected and tested using Orasure HIV testing kits to establish infection status with HIV/AIDS. Using these models, evaluations of various intervention scenarios with the objective of recommending effective strategies to minimize the risk of new HIV infections and/or manage existing diseases in a community can be generated.

Developing a Generic Risk Assessment Simulation Modelling Software Tool for Assessing the Risk of Foot and Mouth Virus Introduction

Foot and Mouth disease (FMD) is a highly contagious viral disease that affects all cloven-hoofed animals. Because of its devastating effects on the agricultural industry, many countries take measures to stop the introduction of FMD virus into their countries. Decision makers at multiple levels of the United States Department of Agriculture (USDA) use Risk Assessments (RAs) (both quantitative and qualitative) to make better and more informed scientifically based decisions to prevent the accidental or intentional introduction of the disease. There is a need for a generic RA that can be applied to any country (whether FMD free or non-FMD free) and for any product (FMD infected animals and animal products). We developed a user-friendly generic RA tool (software) that can be used to conduct and examine different scenarios of quantitative/qualitative risk assessments for the different countries with their varying FMD statuses in relation to reintroduction of FMD virus into the USA. The program was written in Microsoft Visual Basic 6.0 (Microsoft Corporation, Redmond, Washington, USA). The @Risk 6.1 Developer Kit (RDK) and @Risk 6.1 Best Fit Kit library (Palisade Corporation, Newfield, NY.USA) was used to build Monte Carlo simulation models. Microsoft Access 2000 (Microsoft Corporation, Redmond, Washington, USA) was used and SQL to query the data. Different input probability distributions can be selected for the nodes in the scenario tree and different output for each end-state of the simulation is given in different graphical formats and statistical values are used in describing the likelihood of FMD virus introduction. Sensitivity Analysis in determining which input factor has more effect on the total risk outputs is also given. The developed generic RA tools can be eventually extended and modified to conduct RAs for other animal diseases and animal products.

Finite Element Analysis of Meniscal Anatomical 3D Scaffolds: Implications for Tissue Engineering

Solid Free-Form Fabrication (SFF) technologies allow the fabrication of anatomical 3D scaffolds from computer tomography (CT) or magnetic resonance imaging (MRI) patients’ dataset. These structures can be designed and fabricated with a variable, interconnected and accessible porous network, resulting in modulable mechanical properties, permeability, and architecture that can be tailored to mimic a specific tissue to replace or regenerate. In this study, we evaluated whether anatomical meniscal 3D scaffolds with matching mechanical properties and architecture are beneficial for meniscus replacement as compared to meniscectomy. After acquiring CT and MRI of porcine menisci, 3D fiber-deposited (3DF) scaffolds were fabricated with different architectures by varying the deposition pattern of the fibers comprising the final structure. The mechanical behaviour of 3DF scaffolds with different architectures and of porcine menisci was measured by static and dynamic mechanical analysis and the effect of these tissue engineering templates on articular cartilage was assessed by finite element analysis (FEA) and compared to healthy conditions or to meniscectomy. Results show that 3DF anatomical menisci scaffolds can be fabricated with pore different architectures and with mechanical properties matching those of natural menisci. FEA predicted a beneficial effect of meniscus replacement with 3D scaffolds in different mechanical loading conditions as compared to meniscectomy. No influence of the internal scaffold architecture was found on articular cartilage damage. Although FEA predictions should be further confirmed by in vitro and in vivo experiments, this study highlights meniscus replacement by SFF anatomical scaffolds as a potential alternative to meniscectomy.

Treatment and biology of lymphomatoid granulomatosis

8029

Background: LYG is a rare angiocentric-destructive process with EBV+ B-cells and reactive T-cells. LYG is graded with grades I-II showing rare-moderate large EBV+ B-cells (usually polyclonal or oligoclonal) and grade III showing numerous large EBV+ B-cells (usually monoclonal), likely reflecting progressive transformation. Historically, steroids and/or chemotherapy have a 14 mos median survival. Methods: We are investigating Interferon-a (I-a) for grade I/II and dose-adjusted EPOCH ±Rituximab (R) for grade III LYG. Results: Characteristics of 53 pts are: male sex 68%; median age (range) 46 (17–67) and median ECOG P.S. 1 (0–3). Disease sites include lung 98%, CNS 38%, kidney 15%, skin 17%, liver 19% and nodes 4%. On study LYG grades are I-30%, II-26% and III-44%. Prior treatment was none-28%, chemotherapy± R-34%, and steroids alone-40% of pts. For grades I/II, I-a is begun at 7.5 million IUs TIW and escalated as tolerated until disease regression and continued 1 yr after CR. Of 31 patients treated with I-a, PFS is 62% at the median f/u of 5.3 yrs. Of 25 evaluable pts (3 NE; 3 TE), 60% had sustained CR for a median of 60 mos (4–175). In 9 pts who progressed on I-a, grade III was found in 5. Thus, in 20 pts with only grade I/II, 75% had sustained CR with I-a. In 11 evaluable pts with CNS disease, 81% achieved remission with I-a alone. The median time to remission is 9 mos (3–40) and median I-a dose is 20 MIU (7–40). Among 24 pts receiving DA-EPOCH±R, PFS is 40% at the median f/u of 28 mos. Of 21 evaluable pts (2 NE, 1 TE), 66% achieved CR. OS of all 53 pts is 68% at the median f/u of 4 yrs. Median EBV viral loads in 29 pts at study entry were 18 copies/10e6 genome equivalents (0–22727) (normal<200). Lymphocyte subsets in 30 pts showed a median CD4–428 (24–2322) and CD8–165 cells/mm3 (42–1316). In 12 pts in CR and with serial values, the mean CD8 cells (131 ± 44) (p2= 0.013) but not CD4 cells (65 ± 75) increased with treatment. Conclusions: High dose I-a produces sustained remissions in grade I/II LYG and is effective in CNS LYG. DA-EPOCH±R can produce durable CRs in grade III LYG. We hypothesize LYG emerges in a compromised immune milieu and undergoes progressive transformation if not effectively treated. Historical results suggest steroids may allow transformation by compromising immune function.

No significant financial relationships to disclose.

A phase I pharmacokinetic study of PR-104, a hypoxia-targeting agent, in patients with solid tumors

3516

Background: PR-104 is a novel pre-prodrug (precursor of a prodrug) designed to form a cytotoxic nitrogen mustard (alkylating agent) in hypoxic regions of tumors. Following IV administration, PR-104 is converted by systemic phosphatases to the alcohol intermediate PR-104A, which, under hypoxic conditions, is reduced to form the active DNA-crosslinking mustard species PR-104H. This phase I trial defines a Maximally Tolerated Dose (MTD) and pharmacokinetics (PK) for this schedule. Methods: Patients (pts) with relapsed/recurrent solid tumors received PR-104 as a 1-hour IV infusion every 3 weeks with PK sampling on days 1–2 of cycle 1. Cohorts of ≥3 pts were treated starting at 135 mg/m2. Results: 23 pts have been enrolled: median age 51 years (range 29–72); 13 (57%) male. Most pts had received prior radiation or chemotherapy and had metastatic disease. Six dose levels (135, 216, 354, 550, 770, and 1,100 mg/m2) have been evaluated. Dose-limiting toxicity (DLT) was observed in one patient at 1,100 mg/m2 (grade 3 fatigue) and this dose level was expanded to 6 pts. In the first 4 cohorts, 54 adverse events (AEs) were considered drug-related by the investigator including nausea (26% of all AEs), fatigue (19%), vomiting (11%) and anorexia (6%); remaining AEs each constituted < 3% of the total. Of 16 grade 3 AEs, 3 were considered drug-related by the investigator (anemia, dehydration and vomiting). Prophylactic anti-emetics largely prevented nausea and vomiting at higher doses, at which dose-related decreases in neutrophils and platelets were seen. Conclusions: PR-104 has shown manageable toxicities similar to other cytotoxic agents, with no serious mucositis, diarrhea or alopecia. DLT is likely to be myelosuppression based on preclinical and current clinical data, with the MTD close to 1,100 mg/m2. The preclinical PK target for the alcohol intermediate has been exceeded at higher doses and, while no objective responses have been documented, reductions in tumor volume have been seen at these doses.

[Table: see text]

No significant financial relationships to disclose.