Abstract P6-12-21: Breast cancer survivors undergoing survivorship visits at Johns Hopkins are a high-risk population

Background: Survivorship care plans (SCPs) are strongly recommended for all breast cancer survivors to address sequelae of cancer care, plan cancer surveillance and screening, and encourage health promotion and care coordination. Ongoing studies are evaluating the impact of SCPs in cancer survivor populations and the role of survivorship visits (SVs) as an intervention. Here we describe characteristics and outcomes of patients who participated in SVs at Johns Hopkins (JH).

Methods: We retrospectively reviewed the charts of patients who participated in a SV with one of two nurse practitioners ˜1-3 months after completion of locoregional therapy and initial systemic therapy, as referred by their JH breast cancer provider. We collected patient demographics, comorbidity status, tumor characteristics, treatments received, and responses to GAD7 (generalized anxiety disorder 7-item), PHQ9 (patient health questionnaire-9), and a symptom questionnaire. Characteristics of SV participants were compared to analytical breast cancer cases from the JH Cancer Registry (JHCR 2010-2015), matched for stage.

Results: 87 women (stages I-III) who participated in a SV in 2010-2016 were identified. Compared to patients in the JHCR (n=2,942), the SV cohort was younger (age ≤50, 43% v 34%, p=0.14), more likely to be African American (33% v 22%, p=0.04), and more likely to have a higher TNM stage (I, 26% v 49%; II, 48% v 37%; III, 25% v 15%, p<0.001), node-positive status (60% v 33%, p<0.001), hormone receptor-negative disease (44% v 18%, p<0.001), and HER2-positive disease (38% v 14%, p<0.001). The SV cohort was also more likely to receive chemotherapy (94% v 43%, p<0.001) and undergo radiation therapy (78% v 54%, p<0.001). The SV cohort had a higher recurrence event rate than the JHCR cohort (11.5% v 8.0%) and a shorter median follow-up (886 v 1292 days), suggestive of a higher risk profile. In the SV cohort, a comparison of comorbidities at breast cancer diagnosis versus time of SV visit identified a significant increase in the prevalence of peripheral neuropathy (9% v 73%, p<.001), anemia (15% v 50%, p<.001), lymphedema (0% v 28%, p<.001), anxiety (15% v 38%, p<.001), and depression (13% v 29%, p<.001). Patients in the SV cohort were overweight at diagnosis (body mass index, median 29 [IQR 24, 32]). At the time of the SV, patients reported symptoms of sleep difficulty (53%), numbness or tingling (46%), weight changes (45%), muscle aches (44%), and pain (37%).

Conclusions: Patients who participated in SVs had high-risk cancers and, compared to baseline, a higher frequency of comorbidities that are potentially associated with breast cancer and its treatment. These data can inform future breast cancer survivorship care models as they describe a population that may be at greater risk for worse cancer and non-cancer outcomes, and that might benefit more from interventions like SCPs and SVs. Ongoing studies are identifying optimal target populations, appropriate timing of such interventions, and informative measures of patient-centered outcomes.

Funding: Komen Maryland/Komen Scholar SAC110053 (ACW).

Citation Format: Skuli SJ, Bantug ET, Zafman N, Riley C, Ruck JM, Sheng J, Smith KC, Snyder CF, Smith KL, Stearns V, Wolff AC. Breast cancer survivors undergoing survivorship visits at Johns Hopkins are a high-risk population [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-21.

Problems in the Development of New Instruments

Despite the complexity of much modern apparatus the responsibility for inventing new equipment still rests with the scientist. A high level of practical skill is not necessary, but working models play a valuable part. The instrument industry has an equally essential part to play in converting an innovation into a viable commercial product and must take great financial risks in doing so.

Midwives in India: a delayed cord clamping intervention using simulation

BACKGROUND

Iron deficiency is a prevalent health problem in India affecting women and newborns. Delayed umbilical cord clamping at birth is a safe and effective means for increasing serum iron levels in newborns up to 6 months of age.

AIM

The study aim was to increase the utilization of delayed cord clamping in a group of midwives working in Hyderabad, India.

METHODS

A single group pre- and post-test design was used to evaluate knowledge, beliefs and practice before and after a delayed cord clamping intervention including follow-up at 10 months after the original intervention. The intervention included lectures and simulation.

RESULTS

Results show significant increases in knowledge and positive beliefs about the practice of delayed cord clamping. Simulation was effective for eliciting important feedback related to learning.

LIMITATIONS

Results represent a small group of midwives working with a non-profit foundation in Southern India. Language discordancy and cultural norms in this group of midwives may have influenced results.

CONCLUSIONS

Knowledge, beliefs and practice related to delayed cord clamping were all significantly improved after the intervention. The Knowledge to Action framework using simulation is an effective cross-cultural method for implementing education about evidence-based practice. Midwives are invested in learning practices that promote public health.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Changing institutional policy may have limitations without first considering normative practice. Using simulation combined with institutional health policy appears to result in significant uptake of practice change. Qualitative studies exploring the interconnections between cultural norms and decision making may be informative about promoting practice change particularly in this setting. Upscaling midwifery has been recommended to improve maternal and child health in India.

Tumour-infiltrating lymphocytes predict for outcome in HPV-positive oropharyngeal cancer

BACKGROUND

Human papillomavirus (HPV)-positive oropharyngeal cancer (OPSCC) is associated with improved survival compared with HPV-negative disease. However, a minority of HPV-positive patients have poor prognosis. Currently, there is no generally accepted strategy for identifying these patients.

METHODS

We retrospectively analysed 270 consecutively treated OPSCC patients from three centres for effects of clinical, pathological, immunological, and molecular features on disease mortality. We used Cox regression to examine associations between factors and OPSCC death, and developed a prognostic model for 3-year mortality using logistic regression analysis.

RESULTS

Patients with HPV-positive tumours showed improved survival (hazard ratio (HR), 0.33 (0.21-0.53)). High levels of tumour-infiltrating lymphocytes (TILs) stratified HPV-positive patients into high-risk and low-risk groups (3-year survival; HPV-positive/TIL(high)=96%, HPV-positive/TIL(low)=59%). Survival of HPV-positive/TIL(low) patients did not differ from HPV-negative patients (HR, 1.01; P=0.98). We developed a prognostic model for HPV-positive tumours using a 'training' cohort from one centre; the combination of TIL levels, heavy smoking, and T-stage were significant (AUROC=0·87). This model was validated on patients from the other centres (detection rate 67%; false-positive rate 5.6%; AUROC=0·82).

INTERPRETATION

Our data suggest that an immune response, reflected by TIL levels in the primary tumour, has an important role in the improved survival seen in most HPV-positive patients, and is relevant for the clinical evaluation of HPV-positive OPSCC.

Altered language network activity in young people at familial high-risk for schizophrenia

BACKGROUND

Abnormalities in language and language neural circuitry are observed in schizophrenia (SZ). Similar, but less pronounced language deficits are also seen in young first-degree relatives of people with SZ, who are at higher familial risk (FHR) for the disorder than the general population. The neural underpinnings of these deficits in people with FHR are unclear.

METHODS

Participants were 43 people with FHR and 32 comparable controls. fMRI scans were collected while participants viewed associated and unrelated word pairs, and performed a lexical decision task. fMRI analyses conducted in SPM8 examined group differences in the modulation of hemodynamic activity by semantic association.

RESULTS

There were no group differences in demographics, IQ or behavioral semantic priming, but FHR participants had more schizotypal traits than controls. Controls exhibited the expected suppression of hemodynamic activity to associated versus unrelated word pairs. Compared to controls, FHR participants showed an opposite pattern of hemodynamic modulation to associated versus unrelated word pairs, in the left inferior frontal gyrus (IFG), right superior and middle temporal gyrus (STG) and the left cerebellum. Group differences in activation were significant, FWE-corrected for multiple comparisons (p<0.05). Activity within the IFG during the unrelated condition predicted schizotypal symptoms in FHR participants.

CONCLUSIONS

FHR for SZ is associated with abnormally increased neural activity to semantic associates within an inferior frontal/temporal network. This might increase the risk of developing unusual ideas, perceptions and disorganized language that characterize schizotypal traits, potentially predicting which individuals are at greater risk to develop a psychotic disorder.

Using quality indicators in anaesthesia: feeding back data to improve care

After recent UK policy developments, considerable attention has been focused upon how clinical specialties measure and report on the quality of care delivered to patients. Defining the right indicators alone is insufficient to close the feedback loop. This narrative review aims to describe and synthesize a diverse body of research relevant to the question of how information from quality indicators can be fed back and used effectively to improve care. Anaesthesia poses certain challenges in the identification of valid outcome indicators sensitive to variations in anaesthetic care. Metrics collected during the immediate post-anaesthetic recovery period, such as patient temperature, patient-reported quality of recovery, and pain and nausea, provide potentially useful information for the anaesthetist, yet this information is not routinely fed back. Reviews of the effects of feeding back performance data to healthcare providers suggest that this may result in small to moderate positive effects upon outcomes and professional practice, with stronger effects where feedback is integrated within a broader quality improvement strategy. The dominant model for use of data within quality improvement is based upon the industrial process control approach, in which care processes are monitored continuously for process changes which are rapidly detectable for corrective action. From this review and experience of implementing these principles in practice, effective feedback from quality indicators is timely, credible, confidential, tailored to the recipient, and continuous. Considerable further work is needed to understand how information from quality indicators can be fed back in an effective way to clinicians and clinical units, in order to support revalidation and continuous improvement.

Human labour is associated with decreased cytoplasmic FoxO4

Forkhead box O (FoxO) proteins function primarily as transcription factors in the nucleus where they bind to their cognate DNA targeting sequences. FoxO regulated genes include those involved in cellular stress responses, inflammation and apoptosis; all of which are involved in the processes of human labour and delivery. We have previously identified Forkhead box O4 (FoxO4) proteins in human gestational tissues; there is, however, no data is available on the role of FoxO4 in the processes of human labour and delivery. Thus the aim of this study was to determine the effect of (i) human labour, preterm chorioamnionitis and pro-inflammatory stimuli on the expression of FoxO4 in human placenta and fetal membranes; and (ii) FoxO4 knockdown by siRNA on the expression of pro-labour mediators. Quantitative RT-PCR (qRT-PCR), immunohistochemistry and/or Western blotting was used to analyse the expression of FoxO4 (n = 6 per group). Human labour and preterm chorioamnionitis significantly decreased cytoplasmic FoxO4 expression in placenta and/or choriodecidua. Knockdown of FoxO4 mRNA and protein in JEG-3 cells using siRNA was associated with decreased COX-2 mRNA expression concomitant with lower PGF(2α) secretion. However, in BeWo cells, siRNA inhibition of FoxO4 was not associated with inflammation, oxidative stress or apoptosis. In summary, human term labour and chorioamnionitis is characterised by lower FoxO4 mRNA and/or protein expression in placenta and/or choriodecidua. Although the exact role of FoxO4 in human pregnancy remains to be fully elucidated, our data demonstrate that it can regulate COX-2 expression and subsequent prostaglandin expression.

Expression and localisation of FoxO3 and FoxO4 in human placenta and fetal membranes

Forkhead box O (FoxO) proteins regulate inflammation, extracellular matrix (ECM) remodelling and apoptosis. We have previously identified FoxO1 proteins in human gestational tissues, and demonstrated a link between FoxO1 and rupture of fetal membranes. There is, however, no data available on the expression and localisation of FoxO3 and FoxO4 in human intrauterine tissues. Thus the aim of this study was to characterise the localisation and expression of FoxO3 and FoxO4 in (i) human placenta and fetal membranes before term spontaneous labour onset, and (ii) supracervical site (SCS) and distal site (DS) fetal membranes from non-labouring women. Immunohistochemistry, Western blotting and quantitative RT-PCR (qRT-PCR) was used to localise and quantitate FoxO3 and FoxO4 protein and mRNA expressions. Cytoplasmic and nuclear FoxO3 was localised in the syncytiotrophoblast layer, chorionic trophoblasts, amnion epithelium and decidua. Cytoplasmic FoxO4 was localised in the syncytiotrophoblasts and chorionic trophoblasts. No or very little FoxO4 protein and mRNA was present in amnion epithelium. The intensity and extent of staining of FoxO3 and FoxO4 was greater in fetal membranes obtained from the SCS compared to DS. Presence of FoxO3 and FoxO4 are expected to contribute to apoptosis and/or cell cycle regulation associated with fetal membrane rupture.

Localisation and expression of FoxO1 proteins in human gestational tissues

In non-gestational tissues, emerging data indicate that the FoxO1 family of Forkhead transcription factors play diverse roles in many cellular processes coordinating programs of gene expression that regulate apoptosis, oxidative stress resistance, and immune cell homeostasis. Successful outcome of human parturition rely on many of these processes, however there is no data available on FoxO1 proteins in human intrauterine tissues, nor their role in pregnancy complications such as pre-eclampsia. Thus the aim of this study was (i) to characterises the localisation and expression of FoxO1, acetylated (ac)-FoxO1 and phosphorylated (p)-FoxO1 in human placenta and fetal membranes obtained from term Caesarean sections (n=5); and (ii) to compare the expression of FoxO1 proteins in term placental samples from normal and pre-eclamptic pregnancies (n=5 per group). In placenta, weak FoxO1 staining was localised to the syncytiotrophoblast layer, whereas ac-FoxO1 and p-FoxO1 staining was mainly localised in the syncytiotrophoblasts and cytotrophoblasts. In fetal membranes, FoxO1, ac-FoxO1 and p-FoxO1 were localised to the trophoblast layer of the chorion, amnion epithelium and decidual cells. Quantitative RT-PCR (qRT-PCR) analysis showed a 6-fold and 12-fold higher mRNA expression in the choriodecidua compared to placenta and amnion, respectively. In both amnion and choriodecidua, FoxO1 protein expression was higher in the cytoplasmic fractions than in the nuclear fractions. On the otherhand, ac-FoxO1 and p-FoxO1 protein expression was higher in the nuclear fractions for all three tissues. There was no difference in the mRNA or protein expression of FoxO1 proteins in placental samples from normal and pre-eclamptic term pregnancies. The exact role of FoxO1 proteins in human pregnancy are unknown, however the finding that they are expressed in human gestational tissues warrants further research into their function in these tissues.

The presenting complaints of low income adults for emergency dental care: an analysis of 35,000 episodes in Victoria, Australia

OBJECTIVE

This study examined the mix of presenting problems faced by a large diverse dental service treating low-income Australian adults and provides a basis for communities to understand and manage demand for dental services.

DESIGN

A retrospective analysis in a state-wide multi-centre dental health service. Data for all patients (in all public adult dental clinics in the state of Victoria during May-Aug 2005) who used the emergency services in a 12 week period were recorded and analysed. A triage question tree was developed and embedded into a neural network based computer triage tool.

RESULTS

Approximately 52% of low income adults presenting for emergency treatment required treatment on the day of triage. The main problem was with natural teeth (89.6%). Of those with natural teeth problems, 41.3% had pain disturbing their sleep patterns and 14.7% had experienced a swelling. Metropolitan patients accessed the services 2.3 times more than rural patients.

CONCLUSION

These data clearly highlight that there is significant opportunity to reduce nearly 48% of on-day demand for emergency dental care through the application of appropriately clinical based triage.

Pathways for development of a biorenewables industry

The advanced energy initiative to reduce the nation's future demand for oil has resulted in the definition of a number of pathways for the development of the bio-renewables industry. This paper gives an overview of the pathways which could lead to both ethanol and other types of bio-products. The methods that would be used for cellulose conversion also apply to adding value for the co-products of ethanol production. Process milestones and pathways for research that would enable corn dry mill operations to improve are described. A corn dry mill improvement pathway is outlined, and introduces the topics that are covered in this particular special volume.

Humanized anti-CEACAM6 PEGylated scFv: A promising novel therapy for pancreatic cancer

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Background: Novel Therapies for pancreatic cancer (PC) based on biological insight are urgently needed. CEACAM6, a member of the carcinoembryonic antigen (CEA) family, is a cell surface oncogene on PC cells. It is a glycoprotein composed of 3 Ig-like domains (Mr ∼35.2kD) and is linked to the plasma membrane via a glycophospholipid linked anchor. It is over-expressed on ≥95% PC patients’ found irrespective of stage of disease and represents a target for antibody therapy. Methods: Murine anti-CEACAM6 monoclonal antibody (Mab) 13–1 was humanized by a structure-based approach and single chain variable fragments (scFv) designed consisting of a Gly/Ser-linker which includes a cysteine residue for PEGylation. Murine scFv and 4 humanized scFv fragments (Version.1, 2, 7, 8) were bacterially expressed, purified, PEGylated and evaluated for activity alone or in combination with gemcitabine in human PC cell lines and mouse xenograft tumors. Cell viability, apoptosis and in-cell Westerns were done for efficacy and binding. Mouse xenograft tumors were treated with scFv or PEGylated scFv or combination with gemcitabine. Tumors (treated Vs untreated) were analyzed by immunohistochemistry for Ki-67, CD31, CEACAM6 and Caspase 3 Results: Mab 13–1, murine and 4 humanized scFvs’ were cytotoxic to CEACAM6 expressing PC cells (BxPC-3, HPAF-2) and not to PC cells that lack CEACAM6 (CaPan-2) with increased PARP-cleavage that was dose dependent (IC50=10μg/mL). Western blotting of culture media and serum from xenograft mice showed that CEACAM6 is not shed. In-cell Western confirmed humanized V.7 to be the best binder (KD=1–10μg/mL) confirming protein-protein interaction studies performed in silico with homology models of murine and humanized scFvs’ and CEACAM6. The murine scFv alone or the humanized scFV (V.8) in combination with gemcitabine delayed tumor growth by >50%. This tumor reduction correlated well with the immunohistochemical markers of response. Conclusions: We have demonstrated that CEACAM6 is a clinically relevant target in PC and that a PEGylated humanized scFv is a novel effective therapy alone and/or in combination with gemcitabine. Humanized scFv V.7 is undergoing mouse xenograft evaluation and expect will be the most effective agent to take forward into clinical development.

No significant financial relationships to disclose.

A novel tyrosine kinase switch is a mechanism of imatinib resistance in gastrointestinal stromal tumors

KIT or alpha-platelet-derived growth factor receptor (alpha-PDGFR) activating mutations are the pathogenic mechanisms that characterize gastrointestinal stromal tumors (GIST). Despite excellent responses to imatinib mesylate (IM), patients are relapsing. We developed an IM-resistant GIST cell line (GIST-R) from the IM-sensitive GIST882 cell line (GIST-S) by growing these cells in IM. Gene expression profiling (GEP) of GIST-S, GIST-R cells and two IM resistant GIST patients demonstrated that KIT is downregulated implying a major role in IM resistance. Instead, GIST-R cells have acquired IM resistance by overexpressing the oncogenic receptor tyrosine kinase - AXL - in a 'kinase switch'. Further, the two IM resistant GIST patients express AXL and not c-Kit, seen by immunohistochemistry (IHC). Real time reverse transcriptase-polymerase chain reaction and Western blotting of the GIST-S and GIST-R cells confirmed the switch from Kit to AXL. In GIST-R, AXL is tyrosine phosphorylated and its ligand growth-arrest-specific gene 6 is overexpressed implying autocrine activation. The kinase switch is associated with a morphological change from spindle to epithelioid. Molecular modeling of the kinase domain of mutant c-Kit (V654A) and AXL showed no binding to IM but efficient binding to MP470, a novel c-Kit/AXL kinase inhibitor. MP470 synergizes with docetaxel (taxotere) and is cytotoxic to GIST cells.

Evolution of VHL tumourigenesis in nerve root tissue

Haemangioblastomas are the key central nervous system manifestation of von Hippel-Lindau (VHL) disease, which is caused by germline mutation of the VHL gene. We have recently shown that 'tumour-free' spinal cord from patients with VHL disease contains microscopic, poorly differentiated cellular aggregates in nerve root tissue, which we descriptively designated 'mesenchymal tumourlets'. Here we have investigated spinal cord tissue affected by multiple tumours. We show that a small subset of mesenchymal tumourlets extends beyond the nerve root to form proliferative VHL-deficient mesenchyme and frank haemangioblastoma. We thus demonstrate that tumourlets present potential, but true precursor material for haemangioblastoma. We further show that intraradicular tumourlets consist of scattered VHL-deficient cells with activation of HIF-2alpha and HIF-dependent target proteins including CAIX and VEGF, and are associated with an extensive angiogenic response. In contrast, activation of HIF-1alpha was only observed in the later stages of tumour progression. In addition, ultrastructural examination reveals gradual transition from poorly differentiated VHL-deficient cells into vacuolated cells with a 'stromal' cell phenotype. The evolution of frank haemangioblastoma seems to involve multiple steps from a large pool of precursor lesions.

Europe's Water Framework Directive: discovering hidden benefits

The water utility companies in the UK are regulated by the economic regulator to ensure that they do not abuse their monopoly powers and operate under high efficiency targets to minimise costs to their customers. The requirements for improved environmental performance are set by the Environment Agency and, once agreed, incorporated in a five-year plan. Prior to the Water Framework Directive the companies had little choice but to meet a rigorous programme to achieve higher discharge standards as end-of-pipe solutions. The catchment-based approach of the WFD, coupled with the requirement to achieve 'good status' for receiving waters and the requirement for stakeholder involvement, has introduced much needed flexibility into the process which is expected to lead to better and more cost effective solutions to water quality problems.

Ascites induces modulation of alpha6beta1 integrin and urokinase plasminogen activator receptor expression and associated functions in ovarian carcinoma

Interactions between cancer cells and the surrounding medium are not fully understood. In this study, we demonstrate that ascites induces selective changes in the expression of integrins and urokinase plasminogen activator/urokinase plasminogen activator receptor (uPA/uPAR) in ovarian cancer cells. We hypothesise that this change of integrin and uPA/uPAR expression triggers signalling pathways responsible for modulating phenotype-dependent functional changes in ovarian cancer cells. Human ovarian surface epithelial (HOSE) cell lines and epithelial ovarian cancer cell lines were treated with ascites for 48 h. Ascites induced upregulation of alpha6 integrin, without any change in the expression of alphav, beta1 and beta4 integrin subunits. Out of the four ovarian cancer cell lines studied, ascites induced enhancement in the expression of uPA/uPAR in the more invasive OVCA 433 and HEY cell lines without any change in the noninvasive OVHS1 and moderately invasive PEO.36 cell lines. On the other hand, no change in the expression of alpha6 integrin or uPAR, in response to ascites, was observed in HOSE cells. In response to ascites, enhancement in proliferation and in adhesion was observed in all four ovarian cancer cell lines studied. In contrast, no significant increase in proliferation or adhesion by ascites was observed in HOSE cells. Ascites-induced expression of uPA/uPAR correlated with the increased invasiveness of HEY and OVCA 433 cell lines but was not seen in OVHS1, PEO.36 and HOSE cell lines. Upregulation of alpha6 integrin and uPA/uPAR correlated with the activation of Ras and downstream Erk pathways. Ascites-induced activation of Ras and downstream Erk can be inhibited by using inhibitory antibodies against alpha6 and beta1 integrin and uPAR, consistent with the inhibition of proliferation, adhesion and invasive functions of ovarian cancer cell lines. Based on these findings, we conclude that ascites can induce selective upregulation of integrin and uPA/uPAR in ovarian cancer cells and these changes may modulate the functions of ovarian carcinomas.

Ascites induces modulation of alpha6beta1 integrin and urokinase plasminogen activator receptor expression and associated functions in ovarian carcinoma

Interactions between cancer cells and the surrounding medium are not fully understood. In this study, we demonstrate that ascites induces selective changes in the expression of integrins and urokinase plasminogen activator/urokinase plasminogen activator receptor (uPA/uPAR) in ovarian cancer cells. We hypothesise that this change of integrin and uPA/uPAR expression triggers signalling pathways responsible for modulating phenotype-dependent functional changes in ovarian cancer cells. Human ovarian surface epithelial (HOSE) cell lines and epithelial ovarian cancer cell lines were treated with ascites for 48 h. Ascites induced upregulation of alpha6 integrin, without any change in the expression of alphav, beta1 and beta4 integrin subunits. Out of the four ovarian cancer cell lines studied, ascites induced enhancement in the expression of uPA/uPAR in the more invasive OVCA 433 and HEY cell lines without any change in the noninvasive OVHS1 and moderately invasive PEO.36 cell lines. On the other hand, no change in the expression of alpha6 integrin or uPAR, in response to ascites, was observed in HOSE cells. In response to ascites, enhancement in proliferation and in adhesion was observed in all four ovarian cancer cell lines studied. In contrast, no significant increase in proliferation or adhesion by ascites was observed in HOSE cells. Ascites-induced expression of uPA/uPAR correlated with the increased invasiveness of HEY and OVCA 433 cell lines but was not seen in OVHS1, PEO.36 and HOSE cell lines. Upregulation of alpha6 integrin and uPA/uPAR correlated with the activation of Ras and downstream Erk pathways. Ascites-induced activation of Ras and downstream Erk can be inhibited by using inhibitory antibodies against alpha6 and beta1 integrin and uPAR, consistent with the inhibition of proliferation, adhesion and invasive functions of ovarian cancer cell lines. Based on these findings, we conclude that ascites can induce selective upregulation of integrin and uPA/uPAR in ovarian cancer cells and these changes may modulate the functions of ovarian carcinomas.

Ascites induces modulation of alpha6beta1 integrin and urokinase plasminogen activator receptor expression and associated functions in ovarian carcinoma

Interactions between cancer cells and the surrounding medium are not fully understood. In this study, we demonstrate that ascites induces selective changes in the expression of integrins and urokinase plasminogen activator/urokinase plasminogen activator receptor (uPA/uPAR) in ovarian cancer cells. We hypothesise that this change of integrin and uPA/uPAR expression triggers signalling pathways responsible for modulating phenotype-dependent functional changes in ovarian cancer cells. Human ovarian surface epithelial (HOSE) cell lines and epithelial ovarian cancer cell lines were treated with ascites for 48 h. Ascites induced upregulation of alpha6 integrin, without any change in the expression of alphav, beta1 and beta4 integrin subunits. Out of the four ovarian cancer cell lines studied, ascites induced enhancement in the expression of uPA/uPAR in the more invasive OVCA 433 and HEY cell lines without any change in the noninvasive OVHS1 and moderately invasive PEO.36 cell lines. On the other hand, no change in the expression of alpha6 integrin or uPAR, in response to ascites, was observed in HOSE cells. In response to ascites, enhancement in proliferation and in adhesion was observed in all four ovarian cancer cell lines studied. In contrast, no significant increase in proliferation or adhesion by ascites was observed in HOSE cells. Ascites-induced expression of uPA/uPAR correlated with the increased invasiveness of HEY and OVCA 433 cell lines but was not seen in OVHS1, PEO.36 and HOSE cell lines. Upregulation of alpha6 integrin and uPA/uPAR correlated with the activation of Ras and downstream Erk pathways. Ascites-induced activation of Ras and downstream Erk can be inhibited by using inhibitory antibodies against alpha6 and beta1 integrin and uPAR, consistent with the inhibition of proliferation, adhesion and invasive functions of ovarian cancer cell lines. Based on these findings, we conclude that ascites can induce selective upregulation of integrin and uPA/uPAR in ovarian cancer cells and these changes may modulate the functions of ovarian carcinomas.

A peptide preparation protects cells in organotypic brain slices against cell death after glutamate intoxication

Cerebrolysin has been shown to have neurotrophic and neuroprotective potential similar to NGF or BDNF. In the present study organotypic brain slices were utilized to determine the neuroprotective effects of Cerebrolysin, in a glutamate lesion paradigm mimicking a key event in ischemia. The study focused on the effects of Cerebrolysin on both necrotic and apoptotic cell death. Two specific DNA intercalating dyes were used to distinguish the type of cell death. The drug effect was evaluated both microscopically and quantitatively before, 24 hours after and then again 8 days after the lesion. Cerebrolysin was added either before and after the lesion or after the lesion only. The most pronounced effect was seen with the drug added both prior to and after the glutamate lesioning. A treatment after the lesion only also counteracted necrosis and apoptosis. The results render the drug relevant for treating acute as well as chronic neurodegenerative diseases.

Enhanced expression of peroxisome proliferator-activated receptor gamma in epithelial ovarian carcinoma

The peroxisome proliferator-activated receptors (PPARs) belong to a subclass of nuclear hormone receptor that executes important cellular transcriptional functions. Previous studies have demonstrated the expression of PPARγ in several tumours including colon, breast, bladder, prostate, lung and stomach. This study demonstrates the relative expression of PPARγ in normal ovaries and different pathological grades of ovarian tumours of serous, mucinous, endometrioid, clear cell and mixed subtypes. A total of 56 ovarian specimens including 10 normal, eight benign, 10 borderline, seven grade 1, nine grade 2 and 12 grade 3 were analysed using immunohistochemistry. Immunoreactive PPARγ was not expressed in normal ovaries. Out of eight benign and 10 borderline tumours, only one tumour in each group showed weak cytoplasmic PPARγ expression. In contrast, 26 out of 28 carcinomas studied were positive for PPARγ expression with staining confined to cytoplasmic and nuclear regions. An altered staining pattern of PPARγ was observed in high-grade ovarian tumours with PPARγ being mostly localized in the nuclei with little cytoplasmic immunoreactivity. On the other hand, predominant cytoplasmic staining was observed in lower-grade tumours. Significantly increased PPARγ immunoreactivity was observed in malignant ovarian tumours (grade 1, 2 and 3) compared to benign and borderline tumours (χ²=48.80, P<0.001). Western blot analyses showed significant elevation in the expression of immunoreactive PPARγ in grade 3 ovarian tumours compared with that of normal ovaries and benign ovarian tumours (P<0.01). These findings suggest an involvement of PPARγ in the onset and development of ovarian carcinoma and provide an insight into the regulation of this molecule in the progression of the disease.

Proteomic-based identification of haptoglobin-1 precursor as a novel circulating biomarker of ovarian cancer

Screening for specific biomarkers of early-stage detection of ovarian cancer is a major health priority due to the asymptomatic nature and poor survival characteristic of the disease. We utilised two-dimensional gel electrophoresis (2DE) to identify differentially expressed proteins in the serum of ovarian cancer patients that may be useful as biomarkers of this disease. In this study, 38 ovarian cancer patients at different pathological grades (grade 1 (n=6), grade 2 (n=8) and grade 3 (n=24)) were compared to a control group of eight healthy women. Serum samples were treated with a mixture of Affigel-Blue and protein A (5 : 1) for 1 h to remove high abundance protein (e.g. immunoglobulin and albumin) and were displayed using 11 cm, pH 4–7 isoelectric focusing strips for the first dimension and 10% acrylamide gel electrophoresis for the second dimension. Protein spots were visualised by SYPRO-Ruby staining, imaged by FX-imager and compared and analysed by PDQuest software. A total of 24 serum proteins were differentially expressed in grade 1 (P<0.05), 31 in grade 2 (P<0.05) and 25 in grade 3 (P<0.05) ovarian cancer patients. Six of the protein spots that were significantly upregulated in all groups of ovarian cancer patients were identified by nano-electrospray quadrupole quadrupole time-of-flight mass spectrometry (n-ESIQ(q)TOFMS) and matrix-assisted laser desorption ionisation time-of-flight mass spectrometry (MALDI-TOFMS) as isoforms of haptoglobin-1 precursor (HAP1), a liver glycoprotein present in human serum. Further identification of the spots at different pathological grades was confirmed by Western blotting using monoclonal antibody against a haptoglobin epitope contained within HAP1. Immunohistochemical localisation of HAP1-like activity was present in malignant ovarian epithelium and stroma but strong immunostaining was present in blood vessels, areas with myxomatous stroma and vascular spaces. No tissue localisation of HAP1-like immunoreactivity was observed in normal ovarian surface epithelium. These data highlight the need to assess circulating concentration of HAP1 in the serum of ovarian cancer patients and evaluate its potential as a biomarker in the early diagnosis of ovarian cancer.

Effect of albumin on brushite transformation to hydroxyapatite

Brushite (CaHPO(4) x 2H(2)O) is a precursor to hydroxyapatite [HA, Ca(5)(PO(4))(3)OH]. It has been shown that a modified form of brushite, with potassium substituting for calcium at specific sites, demonstrated accelerated transformation to HA when exposed to nonproteinaceous Hanks' balanced aqueous salt solutions (HBSS). The biocompatibility of a transforming material is related to cellular response to the process, which is initiated by protein adsorption. The effect of adsorbed protein on the kinetics and chemistry of brushite transformation to HA, when exposed to HBSS containing bovine serum albumin (BSA), was examined using Fourier transform IR spectroscopy, X-ray diffraction, and energy dispersive spectrometry techniques. The effect of solution pH was also studied. Results show that, in the presence of a protein-free environment, transformation is faster in buffered medium than in nonbuffered medium. Moreover, curve fitting and second derivatives of the IR spectra show that some bands shift depending on whether the brushite transforms in a buffered or nonbuffered medium. Therefore, variation in pH affects both transformation rate and the associated chemistry. The presence of BSA in either buffered or nonbuffered medium retards the transformation in comparison to the corresponding BSA-free medium. The extent of this retardation increases with the increase in bulk concentration of BSA but does not alter the transformation chemistry. This suggests the retardation on the transformation rate is due to BSA adsorption coverage on the calcium phosphate ceramic. This may be due to the shielding of Ca(2+) and PO(4)(-3) sites, preventing their interaction with the HBSS.

Managed care education in osteopathic medical schools: development of a fourth-year predoctoral healthcare management clerkship

This article describes the current managed care curricula in osteopathic medical schools and summarizes the development and implementation of a healthcare management clerkship for fourth-year osteopathic medical students at Ohio University College of Osteopathic Medicine. Results of a survey of the 19 osteopathic medical schools indicated that only three schools currently have a stand-alone, managed care elective. No schools have required managed care courses, clerkships, or rotations. The remaining osteopathic medical schools have incorporated managed care-related topics into courses in their schools' curricula. To produce physicians fully competent to succeed in the 21st century's managed healthcare environment, medical schools need to affiliate with managed care organizations, integrate more managed care components into their curricula, and develop required or elective stand-alone managed care courses and clerkships. This article describes content to be integrated in a predoctoral managed care clerkship, including goals and objectives. It also describes the components and learning activities of Ohio University College of Osteopathic Medicine's Healthcare Management Clerkship.

Development of a fish in vitro cell culture model to investigate oxidative stress and its modulation by dietary vitamin E

When cultured in Dulbecco's minimal essential medium the established epithelioma papulosum cyprini cell line from carp was found to be vitamin E-deficient due to the very low level of vitamin E in the medium and the foetal calf serum used as supplement. The toxicity of oxidative stressors to this cell line was evaluated by means of the neutral red cytotoxicity assay and it was found that an organic hydroperoxide, t-butylhydroperoxide was extremely cytotoxic and that the redox-cycling agents diquat and menadione were less toxic. When grown under vitamin E supplementation (25 microM), the toxicity of these chemicals was reduced by at least an order of magnitude in concentration demonstrating the protective effect of vitamin E. These data show the importance of vitamin E status for interpretation of in vitro and in vivo data and that this in vitro system is useful for mechanistic studies.

Transformation of modified brushite to hydroxyapatite in aqueous solution: effects of potassium substitution

Brushite (dicalcium phosphate dihydrate, DCPD, CaHPO4 x 2H2O) was deposited electrolytically from calcium dihydrogen phosphate solution with and without potassium chloride (KCl) as a supporting electrolyte. The kinetics of brushite transformation to hydroxyapatite (HA, Ca5(PO4)3OH) in the presence of calcium and protein free, aqueous body fluid (Hank's balanced salt solution, HBSS) was investigated. We present evidence that the deposition of brushite in a KCl-supported electrochemical bath yields a modified brushite where some of the calcium is substituted by potassium. Transformation of both normal (i.e. potassium free) and modified brushite to hydroxyapatite upon exposure to calcium and protein-free aqueous fluid (HBSS) was followed by reflectance Fourier Transform Infrared (FTIR) spectroscopy and X-ray diffraction (XRD) techniques. Changes in the morphology of the coatings were studied using scanning electron microscopy (SEM). Results indicate that modified brushite undergoes faster transformation to hydroxyapatite in HBSS in comparison to normal brushite. Our results show that the presence of potassium ions in the brushite not only favors the formation of different intermediate phases but also alters transformation rates to HA.

Electrodeposition of brushite coatings and their transformation to hydroxyapatite in aqueous solutions

In this study we examine the potential for using brushite (dicalcium phosphate dihydrate) as a coating for orthopedic implants. It was found that brushite is transformed into a more stable calcium phosphate (hydroxyapatite), regardless of the aqueous transforming media utilized. The transformation was carried out at room temperature in deionized water, deionized water with added calcium ions, and modified Hank's type solution without calcium and magnesium ions, modified Hank's type solution with calcium and magnesium ions, and modified Hank's type solution with added calcium ions. In several of the transformation systems it was noted that brushite provided an increased amount of calcium ions to the transforming media through solubility. The process was monitored using X-ray diffraction, X-ray photoelectron spectroscopy, and dissolution studies. Scanning electron microscopy and energy dispersive spectroscopy were also utilized for characterization. The brushite coatings can be easily achieved electrolytically on conducting substrates. The process is non line of sight, simple, and inexpensive; and when using an electrolyte that can sustain currents of approximately 100 mA/cm2, the necessary coating can be completed in about 3 min.

The effect of chlorambucil upon lysozyme activity

Chicken egg white lysozyme is progressively inhibited by diazoacetyl-DL-norleucine methyl ester (DANME) and by chlorambucil at concentrations of 3.4 x 10(-3) M and 5 x 10(-3) M respectively over a three-hour time period. DANME inhibits lysozyme activity to the extent of 87%, and chlorambucil inhibits the enzyme to the extent of 93%. N,N',N"-triacetylchitotriose [(NAG)3], which binds to subsites A, B and C of the enzyme protects lysozyme from DANME inhibition to the extent of 40% of the total activity when added to the enzyme at a concentration of 3.6 x 10(-3) M prior to the addition of DANME. (NAG)3 protects the enzyme from inhibition by chlorambucil to the extent of 14% of the total activity when added to the enzyme at a concentration of 5.6 x 10(-3) M prior to the addition of chlorambucil. Since DANME reacts exclusively with carboxyl groups, and since aspartic acid 101 is required for binding the carbohydrate substrate at site A, it is suggested that (NAG)3 may bind reversibly to the active site of the enzyme, thereby protecting aspartic acid 101 from esterification by DANME and subsequent inactivation. Chlorambucil, which may react with carboxyl, amino, imidazole and thiol groups, more likely acts upon a larger number of susceptible sites, thereby causing irreversible alkylation and conformation changes. As a bifunctional alkylating agent, it may also cross-link with two available nucleophiles. The K(m) for lysozyme with M. lysodeikticus as a substrate in wholly aqueous medium was determined to be 0.05 mg/mL. The inhibitor exhibits a partially uncompetitive upon pre-incubation with the enzyme, and a mixed inhibition between competitive and noncompetitive when pre-incubated with the substrate.

A cross-cultural study of reactivation of posttraumatic stress disorder symptoms: American and Cambodian psychophysiological response to viewing traumatic video scenes

A physiological hyperarousal state, which can be reactivated by traumatic stimuli, occurs frequently in patients with posttraumatic stress disorder (PTSD). The goals of this study were to determine whether physiological hyperarousal measured by increased heart rate is a specific response to reminders of a patient's own traumatic events or a more generalized hyperarousal state. Five brief videotape scenes of traumatic events (hurricane, auto accident, Cambodian refugee camp, domestic violence, and Vietnam War) were shown to two patient groups with PTSD (Vietnam veterans and Cambodian refugees) and three control groups (Vietnam veterans, Cambodian refugees, and nonpatient Americans). Observations of subjects' behavior, subjective ratings of distress, and heart rate change were recorded and evaluated. The results indicated that Cambodians with PTSD had the most reactions as measured by behavior and heart rate changes. These tended to occur during all scenes, not just the specific Cambodian scene, indicating a general nonspecific arousal. The Vietnam veterans had the fewest changes implying an inhibition of response. The control groups were intermediate in physiological response. The response in PTSD patients to reactivation scenes is complex and probably relates to type and degree of trauma, as well as to culture.

The anatomy of an OPTI: Part 2. The CORE system. Ohio Osteopathic Hospital Association. Ohio Association of Osteopathic Medical Directors. Ohio Osteopathic Association

In July 1995, the American Osteopathic Association (AOA) Board of Trustees passed new regulations regarding the accreditation of osteopathic graduate medical education (GME) by establishing the Osteopathic Postdoctoral Training Institutions (OPTI) system. This system must be phased in by July 1999. The principal changes resulting from the OPTI system include establishing requirements for college cosponsorship of GME programs and for the number of residency programs, interns, and residents to be trained by the OPTI. In essence, OPTI is an osteopathic acronym for consortium. Each OPTI must include at least one college of osteopathic medicine (COM) and one AOA-accredited hospital. The OPTIs will be subject to interval AOA inspections and will be required to demonstrate a governing system, mission statement, organizational structure, and the presence of faculty development programs. The first article in this two-part series, published in the October JAOA, provided a general blueprint for OPTI building and presented both positive and negative issues germane to the formation of OPTIs. Part 2 reinforces the considerations outlined in Part 1 by describing the formation of a large OPTI--the Ohio University College of Osteopathic Medicine (OU-COM) Centers of Osteopathic Regional Education (CORE) system. Key features are described, including the mission statement, organizational structure, committee system, governance, GME programs, operations, and budget.

Anatomy of an OPTI: Part I. Form, function, and relationships

In July 1995, the American Osteopathic Association (AOA) Board of Trustees passed new regulations for the accreditation of osteopathic graduate medical education (GME) programs by establishing the Osteopathic Postdoctoral Training Institutions (OPTI) system, to be implemented over 4 years. The resulting changes include requirements for college cosponsorship of GME programs and the establishment of standards for the minimum number of residency programs, interns, and residents. The OPTIs will be subject to AOA inspections at least every 5 years. Proponents of the OPTI system claim it will strengthen the profession by promoting educational collaboration, raising academic standards, and requiring appropriate resources to support osteopathic medical education. Opponents fear that it will be too resource intensive, create an additional layer of unnecessary bureaucracy, and have a negative impact on small colleges, hospitals, and states. Despite the controversy, a process for applying for OPTI status has been developed by the AOA, and a number of hospitals and colleges are already developing OPTIs. This article, the first in a two-part series, identifies issues and barriers to be considered in the formation of OPTIs and articulates principles underlying successful collaborations. In Part 2 these issues, principles, and barriers will be reinforced by describing the process used to form a large OPTI--the Ohio University College of Osteopathic Medicine (OU-COM) Centers for Osteopathic Regional Education (CORE) System.

The efficacy of local anaesthetics administered by general dental practitioners

AIM

To obtain empirical evidence for the efficacy of local anaesthesia in dentistry.

DESIGN

Retrospective analysis of serial administrations of local anaesthesia.

METHODS

Dentist and patient evaluations of the success of differing techniques (infiltration and block) of anaesthesia in a variety of general practice procedures. Results were analysed for correlation between dentist and patient using a 5-point scale.

RESULTS

Complete data were analysed for 331 administrations. In the hands of experienced dentists over 93% of operations were assessed by both dentist and patient as comfortable or completely comfortable. Dentists were generally able to judge patient comfort (P < 0.001). Administrations requiring repeat injections were less comfortable. Dentists judged infiltration administrations more comfortable than block administrations (P < 0.001), but patient judgements of comfort failed to distinguish between differing techniques at the P < 0.05 level.

CONCLUSIONS

Some variations in success rate exist between dentists the most dental procedures under local anaesthetic in general practice were assessed as being comfortable or better by both dentists and patients.

Videokeratography database of normal human corneas

AIM

To form a database of videokeratography patterns and quantitative indices describing normal human corneas using the absolute scale.

METHODS

Both eyes of 195 normal subjects were examined with a TMS-1 videokeratoscope. Videokeratographs were divided into 10 categories based on a classification scheme devised from the absolute scale and analysed with 10 quantitative indices devised to describe phenotypic features of keratoconus videokeratographs. Correlations were sought between videokeratograph patterns and quantitative indices. Additionally, data were analysed for differences in age, sex, and ethnicity.

RESULTS

For symmetric videokeratography patterns, analysis in the absolute scale was similar to a previous study done in the normalised scale. In the asymmetric categories, analyses differed markedly. Using the absolute scale and our classification scheme more variation in normal videokeratography patterns could be appreciated. There was good correlation between quantitative indices and videokeratography patterns. Neither videokeratography patterns nor indices differed significantly between sex, ethnic groups, or age using two way analysis of variance.

CONCLUSIONS

Pattern analysis of videokeratographs in the absolute scale using, a standard classification scheme, may be more useful in trying to determine whether a cornea is normal or represents subtle early disease than analysis in the normalised scale. Quantitative indices could remove the subjectivity from the decision making process thus facilitating universal reproducibility of videokeratography data interpretation.

Hydroxyapatite/metal composite coatings formed by electrocodeposition

Early bone infusion by cementless fixation of composite orthopedic and dental implants consisting of metallic substrates and bioceramics is well documented. Calcium phosphate ceramics in general and hydroxyapatite (HA) in particular have been the most popular of the bioceramics used for coating metals. Here, a non-line of sight coating procedure by electrocodeposition is reported for mechanically fixing HA particles in a metal matrix. Analyses of the coating showed excellent adhesion to the substrate and no structural transformation in either crystallinity or stoichiometry. Adhesion and surface coverage of HA depended upon the particle size. As a demonstration of the coating procedure's non-line of sight applicability, it was successfully used to coat titanium rods sintered with small titanium spheres.

A comparative study of family functioning among Vietnamese and Cambodian refugees

This study was designed to determine the extent of family problems among a clinic population of Cambodian and Vietnamese refugees, and to identify similarities and differences between the two groups. All 107 patients with adolescent children from a total clinic population of 298 were interviewed using a semistructured questionnaire, results were tabulated, and statistical methods were applied. The types of problems with children described by parents were classified into the dimensions of communication, personal behaviors, school performance, social behaviors, and antisocial behaviors. There were significantly more problems described by Vietnamese parents as compared with Cambodian parents. Vietnamese parents reported significantly more dissatisfaction with life in the United States. For both ethnic groups, parents' relationships with their adolescent children were a major source of concern and had a major impact on parents' perceptions of their own health. Yet, there were important ethnic differences between these refugee groups in how patients perceived their problems.

Ceroid granulomas in the female genital system

Three cases of ceroid granulomas of the female genital system are presented, involving the cervix in two and lesions in the ovaries and bowel serosa in the other. Ceroid granulomas are unusual and interesting lesions formed when suitable substrates accumulate within macrophages to such an extent that a relative lack of biological antioxidants results and auto-oxidation and conversion to ceroid is favoured. This may occur in the setting of haemorrhage and necrosis, whether from tumour necrosis or associated with endometriosis. Other sources of lipids and lipoproteins include bile, meconium and vernix caseosa.

Weekly and yearly rhythms in plasma fibrinogen in hospitalized male military veterans

The variation in plasma fibrinogen level demonstrating prominent circaseptan and circannual cycles is clinically relevant. There is a correlation between increasing level of fibrinogen and other hemostatic factors and risk of myocardial infarction and sudden death. The circaseptan and circannual cycles in fibrinogen concentration described in this study may help to explain further the variation in frequency of coronary events. Furthermore, the recent demonstration of a circadian pattern in the efficacy of tissue plasminogen activator, with peak efficacy occurring at 2000 hours--10 hours after the peak incidence of myocardial infarction--implies that further patterns to coronary artery syndromes may be predicted and the treatment efficacy may rely on demonstrated circaseptan and circannual cycles of these events.