Short-term decreased post transplant lymphoproliferative disorder risk after kidney transplantation using two novel regimens

BACKGROUND

Belatacept is employed alongside calcineurin inhibitor (CNI) therapy to prevent graft rejection in kidney transplant patients who are Epstein-Barr virus (EBV) seropositive. Preliminary data suggested that rates of post-transplant lymphoproliferative disorder (PTLD) were higher in individuals treated with belatacept compared to CNI therapy alone.

METHODS

The records of 354 adults who underwent kidney only transplantation from January 2015 through September 2021 at one medical center were evaluated. Patients underwent treatment with either low-doses of mycophenolate, tacrolimus and sirolimus (B⁰, n = 235) or low-doses of mycophenolate, tacrolimus and belatacept (B¹, n = 119). All recipients underwent induction with antithymocyte globulin and a rapid glucocorticosteroid taper. Relevant donor and recipient information were analyzed and endpoints of PTLD were assessed.

RESULTS

There were no cases of PTLD in either cohort within the study period. Recipients in the belatacept cohort experienced lower estimated glomerular filtration rates at 12 months (B⁰: 67.48 vs. B¹: 59.10, p = 0.0014). Graft failure at 12 (B⁰: 1.28% vs. B¹: 0.84%, p = 1.0) and 24 months (B⁰:2.55% vs. B¹: 0.84%, p = 0.431) were similar. There was no difference in rejection rates at 12 (B⁰: 1.27% vs. B¹: 2.52%, p = 0.408) or 24 months (B⁰: 2.12% vs. B¹: 2.52%, p = 1.000). Both groups had similar rates of malignancy, mortality and CMV/BK viremia.

CONCLUSION

Non-belatacept (MMF, tacrolimus and sirolimus) and belatacept-based (MMF, tacrolimus and belatacept) regimens do not appear to pose any increased risk of early onset PTLD. Both cohorts benefited from low rates of rejection, malignancy, mortality and graft failure. Recipients will continue to be monitored as PTLD can manifest as a long-term complication.

Costs of delivering human papillomavirus vaccination in Tanzania

Background

Cervical cancer caused by human papillomavirus (HPV) is the most frequent cancer in women in many low-income countries.Tanzania implemented a national HPV vaccination program in 2018 using a two-dose quadrivalent HPV vaccine. This study aimed to (1) estimate financial and economic costs of a two-dose vaccination program based on experiences with the national vaccination program, (2) estimate costs of a one-dose vaccination schedule to enable future cost-effectiveness analyses, and (3) assess the effect of alternative assumptions for future vaccination coverage rates on estimated costs of vaccination.

Methods

The WHO Cervical Cancer Prevention and Control Costing (C4P) tool was used to estimate the incremental costs of the national vaccination programme from the perspective of the Tanzanian government using data collected via surveys, workshops, and interviews with local stakeholders. Deterministic sensitivity analyses were performed to estimate the effect of alternative assumptions for coverage rates and delivery strategies and to assess the impact of a potential one-dose vaccination schedule.

Results

The total financial and economic costs were US$10,117,455 and US$45,683,204, respectively, at a financial cost of $5.17 per two-dose fully immunized girl (FIG), and an economic cost of $23.34 per FIG. Under the assumption of a one-dose vaccination schedule, costs per FIG would reduce to financial costs of $2.51 and economic costs of $12.18.

Conclusions

The overall cost of Tanzania’s HPV vaccination program was lower per vaccinee than previous demonstration projects in the region suggest. These data provide important baseline data for Tanzania’s HPV vaccination program to date and may serve as a guide for improving coverage going forward. The findings may also aid in the prioritization of funding for countries that have not yet added HPV vaccines to their routine immunizations.

Key messages

• If a single dose regimen were found to be as effective as a two-dose series, it would result in significant cost savings as well as an increase in the number of girls that could be reached.

• School-based vaccinations resulted in the lowest price per fully immunized girl, but other settings are needed to achieve equitable high coverage of HPV vaccination in Tanzania.

Rice Big Grain 1 promotes cell division to enhance organ development, stress tolerance and grain yield

Grain/seed yield and plant stress tolerance are two major traits that determine the yield potential of many crops. In cereals, grain size is one of the key factors affecting grain yield. Here, we identify and characterize a newly discovered gene Rice Big Grain 1 (RBG1) that regulates grain and organ development, as well as abiotic stress tolerance. Ectopic expression of RBG1 leads to significant increases in the size of not only grains but also other major organs such as roots, shoots and panicles. Increased grain size is primarily due to elevated cell numbers rather than cell enlargement. RBG1 is preferentially expressed in meristematic and proliferating tissues. Ectopic expression of RBG1 promotes cell division, and RBG1 co-localizes with microtubules known to be involved in cell division, which may account for the increase in organ size. Ectopic expression of RBG1 also increases auxin accumulation and sensitivity, which facilitates root development, particularly crown roots. Moreover, overexpression of RBG1 up-regulated a large number of heat-shock proteins, leading to enhanced tolerance to heat, osmotic and salt stresses, as well as rapid recovery from water-deficit stress. Ectopic expression of RBG1 regulated by a specific constitutive promoter, GOS2, enhanced harvest index and grain yield in rice. Taken together, we have discovered that RBG1 regulates two distinct and important traits in rice, namely grain yield and stress tolerance, via its effects on cell division, auxin and stress protein induction.

Comparison of brain microstructure after prenatal spina bifida repair by either laparotomy-assisted fetoscopic or open approach

OBJECTIVE

To compare prenatal and postnatal brain microstructure between infants that underwent fetoscopic myelomeningocele (MMC) repair and those that had open-hysterotomy repair.

METHODS

This was a longitudinal retrospective cohort study of 57 fetuses that met the Management of Myelomeningocele Study (MOMS) trial criteria and underwent prenatal MMC repair, by a fetoscopic (n = 27) or open-hysterotomy (n = 30) approach, at 21.4-25.9 weeks' gestation. Fetoscopic repair was performed under CO₂ insufflation, according to our protocol. Diffusion-weighted magnetic resonance imaging (MRI) was performed before surgery in 30 cases (14 fetoscopic and 16 open), at 6 weeks postsurgery in 48 cases (24 fetoscopic and 24 open) and within the first year after birth in 23 infants (five fetoscopic and 18 open). Apparent diffusion coefficient (ADC) values from the basal ganglia, frontal, occipital and parietal lobes, mesencephalon and genu as well as splenium of the corpus callosum were calculated. ADC values at each of the three timepoints (presurgery, 6 weeks postsurgery and postnatally) and the percentage change in the ADC values between the timepoints were compared between the fetoscopic-repair and open-repair groups. ADC values at 6 weeks after surgery in the two prenatally repaired groups were compared with those in a control group of eight healthy fetuses that underwent MRI at a similar gestational age (GA). Comparison of ADC values was performed using the Student's t-test for independent samples (or Mann-Whitney U-test if non-normally distributed) and multivariate general linear model analysis, adjusting for GA or age at MRI and mean ventricular width.

RESULTS

There were no differences in GA at surgery or GA/postnatal age at MRI between the groups. No significant differences were observed in ADC values in any of the brain areas assessed between the open-repair and fetoscopic-repair groups at 6 weeks after surgery and in the first year after birth. No differences were detected in the ADC values of the studied areas between the control and prenatally repaired groups, except for significantly increased ADC values in the genu of the corpus callosum in the open-hysterotomy and fetoscopic-repair groups. Additionally, there were no differences between the two prenatally repaired groups in the percentage change in ADC values at any of the time intervals analyzed.

CONCLUSIONS

Fetoscopic MMC repair has no detectable effect on brain microstructure when compared to babies repaired using an open-hysterotomy technique. CO₂ insufflation of the uterine cavity during fetoscopy does not seem to have any isolated deleterious effects on fetal brain microstructure. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Early Hemodynamic Response Assessment of Stereotactic Radiosurgery for a Cerebral Arteriovenous Malformation Using 4D Flow MRI

Brain AVMs treated with stereotactic radiosurgery typically demonstrate a minimum latency period of 1-3 years between treatment and nidus obliteration. Assessment of treatment response is usually limited to evaluation of AVM nidus structural changes using conventional MR imaging and MRA techniques. This report describes the use of 4D Flow MRI to also measure radiation-induced hemodynamic changes in a Spetzler-Martin grade III AVM, which were detectable as early as 6 months after treatment.

Using a scripted data entry process to transfer legacy immunization data while transitioning between electronic medical record systems

BACKGROUND

Transitioning between Electronic Medical Records (EMR) can result in patient data being stranded in legacy systems with subsequent failure to provide appropriate patient care. Manual chart abstraction is labor intensive, error-prone, and difficult to institute for immunizations on a systems level in a timely fashion.

OBJECTIVES

We sought to transfer immunization data from two of our health system's soon to be replaced EMRs to the future EMR using a single process instead of separate interfaces for each facility.

METHODS

We used scripted data entry, a process where a computer automates manual data entry, to insert data into the future EMR. Using the Center for Disease Control's CVX immunization codes we developed a bridge between immunization identifiers within our system's EMRs. We performed a two-step process evaluation of the data transfer using automated data comparison and manual chart review.

RESULTS

We completed the data migration from two facilities in 16.8 hours with no data loss or corruption. We successfully populated the future EMR with 99.16% of our legacy immunization data - 500,906 records - just prior to our EMR transition date. A subset of immunizations, first recognized during clinical care, had not originally been extracted from the legacy systems. Once identified, this data - 1,695 records - was migrated using the same process with minimal additional effort.

CONCLUSIONS

Scripted data entry for immunizations is more accurate than published estimates for manual data entry and we completed our data transfer in 1.2% of the total time we predicted for manual data entry. Performing this process before EMR conversion helped identify obstacles to data migration. Drawing upon this work, we will reuse this process for other healthcare facilities in our health system as they transition to the future EMR.

Abstract P6-11-03: Site-Specific, Concomitant Delivery of Rapamycin and Paclitaxel in Breast Cancer: Consequent Synergistic Efficacy Enhancement

Background: The phosphatidylinositol 3-kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR) (PI3k/Akt/mTOR) pathway is dysregulated in certain breast cancers. Ongoing clinical trials aim to therapeutically exploit this pathway through administration of rapamycin (RAP), an mTOR inhibitor, in combination with paclitaxel (PTX). However, actual drug synergy in clinical settings may not be fully realized due to disparate pharmacokinetic parameters of individual drug formulations, wherein drugs or their effects may never be present in the tumor at the same time. Our objective was to generate a nanoparticle platform capable of site-specifically delivering precise amounts of rapamycin and paclitaxel to breast tumors with hopes of increasing synergistic targeting of the PI3k/Akt/mTOR pathway.

Materials and Methods: Drug-containing nanoparticles composed of amphiphilic block copolymers of pegylated poly(∈-caprolactone) (PEG-PCL, MW = 5k-5k) were fabricated and nanoparticle size and drug loading efficiency was determined. In vitro growth inhibition of nanoparticle formulations of varying ratios was evaluated in MCF-7 and MDA-MB-468 breast cancer cells via sulforhodamine B assays, after which median-effect plot analyses and combination index calculations were conducted. Antitumor efficacy studies were performed in female nude mice bearing MDA-MB-468 tumors, in which nanoparticles were administered intravenously twice a week for the duration of three weeks. Biodistribution of drug-containing nanoparticles in extracted tumors were examined, as well as reverse phase protein array (RPPA) analysis to gain insights into site-specific synergy.

Results: Nanoparticles were spherical, with an average diameter of 9 nm. Both rapamycin and paclitaxel loaded favorably, allowing for customization of different ratios within nanoparticles. Combination indices demonstrated that a 3:1 ratio of RAP:PTX had the most synergy in MDA-MB-468 breast cancer cells in vitro, a synergy found to be preserved in vivo. Significant tumor regression (> 1.5 fold reduction from initial tumor volume) was observed in vivo upon administration of 3:1 RAP:PTX (15:5 mg/kg) nanoparticles. The precise ratio of rapamycin and paclitaxel (3:1) was found maintained in tumors 24 h after administration, an effect not achievable with free drug formulations. RPPA analysis demonstrated effective blocking of mTOR and Akt 24 h after administration of nanoparticles, key events in drug synergy.

Discussion: Site-specific delivery of synergistic agents in precisely-controlled drug ratios, possible through their incorporation into nanoparticles, was shown to be highly efficacious against breast tumors. Findings demonstrate the ability to deliver specific drug ratios to tumors, potentially precluding the need to administer maximal doses of both agents in order to achieve synergy, lessening patient side-effects. This study demonstrates the potential for prediction of in vivo therapeutic outcomes from in vitro synergistic findings. Nanoparticle delivery of drugs may also yield enhanced understanding of mechanisms of synergy between molecular-targeted drugs and traditional chemotherapeutics in vivo, resulting in novel and more efficacious treatment regimens.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-11-03.

Abstract P6-11-11: Multistage Delivery of Paclitaxel: Increased Drug Stability and Sustained Release Results in Enhanced Efficacy in Breast Cancer

Background: A significant challenge for effectively treating cancer is overcoming biological barriers that reduce circulation times and increase degradation of possible treatments. We established an innovative approach to address this issue by embedding drug-containing nanoparticles within the pores of a larger mesoporous silicon particle (MSP) in order to optimize site-specific localization and release of therapeutic agents. The objective is to develop a nanotherapeutic-based multistage platform for breast cancer treatment, wherein paclitaxel, a mitotic inhibitor used in the treatment of breast tumors, will be loaded into polymeric micelles, which in turn will be loaded within MSPs. We hypothesize that this nested incorporation of drugs within MSPs, combined with enhanced tumor transport, will result in a more pronounced and sustained antitumor effect.

Materials and Methods: Micelles were assembled from amphiphilic block copolymers consisting of poly(ethylene glycol)-poly(∈-caprolactone) (PEG-PCL, MW = 5k-5k). Nanoparticle size, zeta potential, and morphology was determined, and PTX loading and release kinetics from micelles analyzed. Drug-containing micelles were incorporated into MSPs by a previously established dry-loading method, wherein nanoparticles were incorporated into pores via capillary action. Loading of fluorescent micelles was used to verify loading within MSPs via fluorescence microscopy and flow cytometry analysis. Sulforhodamine B assays were used to evaluate the in vitro antitumor efficacy of the platform in MCF-7 and MDA-MB-468 breast cancer cells. In vivo efficacy was evaluated in MDA-MB-468 breast tumors in female nu/nu mice.

Results: Resulting micelles had an average size of 20 nm, as confirmed through TEM, with paclitaxel loaded into micelles very effectively. Release kinetics showed that 50% of the drug was released within 4 hours and 80% released within 24 hours. Loading of micelles into MSPs depended largely on electrostatic interactions, with micelles loading better within pores of MSPs displaying increased positive charge. Micelle loading into MSPs was successful as demonstrated by flow cytometry, and release was significantly retarded (< 30% of drug released over 4 d). Incubation of micelle-containing MSPs with breast cancer cells in vitro showed that MSPs could be internalized by cells, after which a sustained and delayed release of the payload was observed in cells. Breast tumors treated with MSPs demonstrated sustained tumor suppression (169 mm3 compared to initial starting volume of 200 mm3) at day 35 following a single injection. It is important to note that sustained tumor efficacy was achieved with nanoparticle and free drug formulations, however, with the caveat of repeated administrations.

Discussion: A novel multistage approach to chemotherapy effectively allows a secondary payload to be loaded and preserved within the MSPs until reaching the tumor site. This prevents premature release of the drug and allows for a sustained release which may potentially result in fewer patient side effects. Future studies will involve loading of multiple nanoparticle types into MSPs and addition of targeting and diagnostic components.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-11-11.

Extracranial venous drainage patterns in patients with multiple sclerosis and healthy controls

BACKGROUND AND PURPOSE

CCSVI hypothesizes an association between impaired extracranial venous drainage and MS. Published sonographic criteria for CCSVI are controversial, and no MR imaging data exist to support the CCSVI hypothesis. Our purpose was to evaluate possible differences in the extracranial venous drainage of MS and healthy controls using both TOF and contrast-enhanced TRICKS MRV.

MATERIALS AND METHODS

Healthy subjects (n = 20) and patients with MS (n = 19) underwent axial 2D-TOF neck MRV (to assess flattening) and TRICKS MRV (to assess collaterals) at 3T. Two neuroradiologists blinded to cohort status scored IJV flattening and the severity of non-IJV collaterals by using a 4-point qualitative scale (normal = 0, mild = 1, moderate = 2, severe = 3). κ was used to assess reader agreement. Comparisons between groups were performed by using the Wilcoxon rank sum test. The Spearman rank correlation was used to assess the relationship between IJV flattening and collateral scores and, in patients with MS, EDSS scores.

RESULTS

The 2 groups were matched for age and sex (MS, 45 ± 8 years, 79% female; healthy controls, 47 ± 10 years, 65% female). Reader agreement for IJV flattening and collateral severity was good (κ = 0.74) and moderate (κ = 0.58), respectively. While IJV flattening was seen in both patients with MS and healthy controls, scores for the patients with MS were significantly higher (P = .002). Despite a trend, there was no significant difference in collateral scores between groups (P = .063). There was a significant positive correlation between flattening and collateral scores (ρ = 0.32, P = .005) and EDSS and flattening scores (ρ = 0.45, P = .004) but not between EDSS and collateral scores (ρ = 0.01, P = .97).

CONCLUSIONS

These results indicate that patients with MS have greater IJV flattening and a trend toward more non-IJV collaterals than healthy subjects. The role that this finding plays in the pathogenesis or progression of MS, if any, requires further study.

Crystallization and Nanocrystallization Kinetics of Fe-Based Amorphous Alloys

In this work we describe crystallization kinetics as inferred from time-dependent magnetization studies and thermal analysis for an Allied Signal amorphous Fe-based METGLAS® 2605SA-1 alloy and a NANOPERM (Fe88Zr7B4Cu1) alloy. We illustrate and contrast several phenomena important to understanding crystallization kinetics in particular to the NANOPERM alloy system. In METGLAS® 2605SA-1 primary and secondary crystallization events are observed in differential scanning calorimetry data (DSC) at temperatures of 504 °C and 549 °C, respectively for data taken at a 10 °C/min scan rate. Both temperatures are greater than the Curie temperature of the amorphous alloy. For the NANOPERM alloy primary crystallization (as determined from differential thermal analysis (DTA)) occurs at 500 °C and secondary crystallization at 730 °C and M(t) at temperatures near the primary crystallization temperature is dominated (at short times < 1 hour) by the primary crystallization event. Using the Johnson-Mehl-Avrami equation for isothermal transformations and the Kissinger equation for constant heating transformations, we find corresponding models for the crystallization kinetics of the NANOPERM alloy.

Variance-modeled posterior inference of microarray data: detecting gene-expression changes in 3T3-L1 adipocytes

MOTIVATION

Microarrays are becoming an increasingly common tool for observing changes in gene expression over a large cross section of the genome. This experimental tool is particularly valuable for understanding the genome-wide changes in gene transcription in response to thiazolidinedione (TZD) treatment. The TZD class of drugs is known to improve insulin-sensitivity in diabetic patients, and is clinically used in treatment regimens. In cells, TZDs bind to and activate the transcriptional activity of peroxisome proliferator-activated receptor gamma (PPAR-gamma). Large-scale array analyses will provide some insight into the mechanisms of TZD-mediated insulin sensitization. Unfortunately, a theoretical basis for analyzing array data has not kept pace with the rapid adoption of this tool. The methods that are commonly used, particularly the fold-change approach and the standard t-test, either lack statistical rigor or resort to generalized statistical models that do not accurately estimate variability at low replicate numbers.

RESULTS

We introduce a statistical framework that models the dependence of measurement variance on the level of gene expression in the context of a Bayesian hierarchical model. We compare several methods of parameter estimation and subsequently apply these to determine a set of genes in 3T3-L1 adipocytes that are differentially regulated in response to TZD treatment. When the number of experimental replicates is low (n = 2-3), this approach appears to qualitatively preserve an equivalent degree of specificity, while vastly improving sensitivity over other comparable methods. In addition, the statistical framework developed here can be readily applied to understand the implicit assumptions made in traditional fold-change approaches to array analysis.

Translation, adaptation, and validation of the SF-36 Health Survey for use in Japan

Development of the Japanese SF-36 was completed in two phases: Phase 1: Japanese version 1.1 was produced according to International Quality of Life Assessment (IQOLA) project guidelines, but some results of psychometric tests were unexpected. First, scores varied little across physical-functioning items. Second, using factor analysis, we could not clearly distinguish the scales designed to measure the "physical" component of quality of life from those designed to measure the "mental" component. Phase 2: Focus-group discussions revealed that limited had often been interpreted as limited by a doctor. Therefore, is difficult to do was used instead (version 1.2). Results of two surveys indicated that version 1.2 yields scores that are reliable by internal consistency and test-retest standards and yields two principal components. In Japan, however, the pattern of correlations between some scales and the principal components differs from that in the United States. Iterative use of qualitative and quantitative methods was very important in developing the Japanese SF-36.

Injection of ultrasmall samples and single molecules into tapered capillaries

A novel injection scheme is described in which ultrasmall samples in the attoliter (10(-18) L) and low femtoliter (10(-15) L) range, or even single molecules, are controllably introduced into a tapered capillary so that electrophoretic separation can be carried out. To match the dimensions of the capillary inlet with that of the sample, capillary tips are tapered to an inside diameter ranging from hundreds of nanometers to a few micrometers. To inject an ultrasmall sample, optical trapping is used to immobilize and manipulate the sample in order to place it inside or next to the capillary inlet. A small controlled suction results in the loading of the sample into the capillary.