Breast Cancer Macrophage Heterogeneity and Self-renewal are Determined by Spatial Localization

Tumor-infiltrating macrophages support critical steps in tumor progression, and their accumulation in the tumor microenvironment (TME) is associated with adverse outcomes and therapeutic resistance across human cancers. In the TME, macrophages adopt diverse phenotypic alterations, giving rise to heterogeneous immune activation states and induction of cell cycle. While the transcriptional profiles of these activation states are well-annotated across human cancers, the underlying signals that regulate macrophage heterogeneity and accumulation remain incompletely understood. Here, we leveraged a novel ex vivo organotypic TME (oTME) model of breast cancer, in vivo murine models, and human samples to map the determinants of functional heterogeneity of TME macrophages. We identified a subset of F4/80highSca-1+ self-renewing macrophages maintained by type-I interferon (IFN) signaling and requiring physical contact with cancer-associated fibroblasts. We discovered that the contact-dependent self-renewal of TME macrophages is mediated via Notch4, and its inhibition abrogated tumor growth of breast and ovarian carcinomas in vivo, as well as lung dissemination in a PDX model of triple-negative breast cancer (TNBC). Through spatial multi-omic profiling of protein markers and transcriptomes, we found that the localization of macrophages further dictates functionally distinct but reversible phenotypes, regardless of their ontogeny. Whereas immune-stimulatory macrophages (CD11C+CD86+) populated the tumor epithelial nests, the stroma-associated macrophages (SAMs) were proliferative, immunosuppressive (Sca-1+CD206+PD-L1+), resistant to CSF-1R depletion, and associated with worse patient outcomes. Notably, following cessation of CSF-1R depletion, macrophages rebounded primarily to the SAM phenotype, which was associated with accelerated growth of mammary tumors. Our work reveals the spatial determinants of macrophage heterogeneity in breast cancer and highlights the disruption of macrophage self-renewal as a potential new therapeutic strategy.

Integration of whole transcriptome spatial profiling with protein markers

Spatial transcriptomics and proteomics provide complementary information that independently transformed our understanding of complex biological processes. However, experimental integration of these modalities is limited. To overcome this, we developed Spatial PrOtein and Transcriptome Sequencing (SPOTS) for high-throughput simultaneous spatial transcriptomics and protein profiling. Compared with unimodal measurements, SPOTS substantially improves signal resolution and cell clustering and enhances the discovery power in differential gene expression analysis across tissue regions.

Clinical Importance of Clonal Hematopoiesis in Metastatic Gastrointestinal Tract Cancers

Importance

Clonal hematopoiesis (CH) has been associated with development of atherosclerosis and leukemia and worse survival among patients with cancer; however, the association with cancer therapy efficacy, in particular immune checkpoint blockade (ICB), and toxicity has not yet been established. Given the widespread use of ICB and the critical role hematopoietic stem cell-derived lymphocytes play in mediating antitumor responses, CH may be associated with therapeutic efficacy and hematologic toxicity.

Objective

To determine the association between CH and outcomes, hematologic toxicity, and therapeutic efficacy in patients with metastatic gastrointestinal tract cancers being treated with systemic therapy, both in the first-line metastatic treatment setting and in ICB.

Design, Setting, and Participants

This retrospective cohort study included 633 patients with stage IV colorectal (CRC) and esophagogastric (EGC) cancer who were treated with first-line chemotherapy and/or ICB at Memorial Sloan Kettering Cancer Center. Patients underwent matched tumor and peripheral blood DNA sequencing using the Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets next-generation sequencing assay between January 1, 2006, and December 31, 2020.

Exposures

Clonal hematopoiesis-related genetic alterations were identified by next-generation sequencing of patients' tumor and normal blood buffy coat samples, with a subset of these CH alterations annotated as likely putative drivers (CH-PD) based upon previously established criteria.

Main Outcomes and Measures

Patients with CH and CH-PD in peripheral blood samples were identified, and these findings were correlated with survival outcomes (progression-free survival [PFS] and overall survival [OS]) during first-line chemotherapy and ICB, as well as baseline white blood cell levels and the need for granulocyte colony-stimulating factor (G-CSF) support.

Results

Among the 633 patients included in the study (390 men [61.6%]; median age, 58 [IQR, 48-66] years), the median age was 52 (IQR, 45-63) years in the CRC group and 61 (IQR, 53-69) years in the EGC group. In the CRC group, 161 of 301 patients (53.5%) were men, compared with 229 of 332 patients (69.0%) in the EGC group. Overall, 62 patients (9.8%) were Asian, 45 (7.1%) were Black or African American, 482 (76.1%) were White, and 44 (7.0%) were of unknown race or ethnicity. Presence of CH was identified in 115 patients with EGC (34.6%) and 83 with CRC (27.6%), with approximately half of these patients harboring CH-PD (CRC group, 44 of 83 [53.0%]; EGC group, 55 of 115 [47.8%]). Patients with EGC and CH-PD exhibited a significantly worse median OS of 16.0 (95% CI, 11.6-22.3) months compared with 21.6 (95% CI, 19.6-24.3) months for those without CH-PD (P = .01). For patients with CRC and EGC, CH and CH-PD were not associated with PFS differences in patients undergoing ICB or first-line chemotherapy. Neither CH nor CH-PD were correlated with baseline leukocyte levels or increased need for G-CSF support.

Conclusions and Relevance

These findings suggest CH and CH-PD are not directly associated with the treatment course of patients with metastatic gastrointestinal tract cancer receiving cancer-directed therapy.

Genome-wide mutational signatures in low-coverage whole genome sequencing of cell-free DNA

Mutational signatures accumulate in somatic cells as an admixture of endogenous and exogenous processes that occur during an individual’s lifetime. Since dividing cells release cell-free DNA (cfDNA) fragments into the circulation, we hypothesize that plasma cfDNA might reflect mutational signatures. Point mutations in plasma whole genome sequencing (WGS) are challenging to identify through conventional mutation calling due to low sequencing coverage and low mutant allele fractions. In this proof of concept study of plasma WGS at 0.3–1.5x coverage from 215 patients and 227 healthy individuals, we show that both pathological and physiological mutational signatures may be identified in plasma. By applying machine learning to mutation profiles, patients with stage I-IV cancer can be distinguished from healthy individuals with an Area Under the Curve of 0.96. Interrogating mutational processes in plasma may enable earlier cancer detection, and might enable the assessment of cancer risk and etiology.

Detection of mutational signatures in cell-free DNA (cfDNA) is challenging due to low sequence coverage and low mutant allele fractions. Here, the authors identify mutational signatures in plasma whole genome sequencing of cancer patients and use machine learning to distinguish them from healthy individuals.

Phase I/Ib Study of the Efficacy and Safety of Buparlisib and Ibrutinib Therapy in MCL, FL, and DLBCL with Serial Cell-Free DNA Monitoring

PURPOSE

Activation of Bruton tyrosine kinase (BTK) and phosphatidylinositol-3-kinase (PI3K) represent parallel, synergistic pathways in lymphoma pathogenesis. As predominant PI3Kδ inhibition is a possible mechanism of tumor escape, we proposed a clinical trial of dual BTK and pan-PI3K inhibition.

PATIENTS AND METHODS

We conducted a single-center phase I/Ib trial combining a BTK inhibitor (ibrutinib) and a pan-PI3K inhibitor (buparlisib) in 37 patients with relapsed/refractory (R/R) B-cell lymphoma. Buparlisib and ibrutinib were administered orally, once daily in 28-day cycles until progression or unacceptable toxicity. The clinical trial is registered with clinicaltrials.gov, NCT02756247.

RESULTS

Patients with mantle cell lymphoma (MCL) receiving the combination had a 94% overall response rate (ORR) and 33-month median progression-free survival; ORR of 31% and 20% were observed in patients with diffuse large B-cell lymphoma and follicular lymphoma, respectively. The maximum tolerated dose was ibrutinib 560 mg plus buparlisib 100 mg and the recommended phase II dose was ibrutinib 560 mg plus buparlisib 80 mg. The most common grade 3 adverse events were rash/pruritis/dermatitis (19%), diarrhea (11%), hyperglycemia (11%), and hypertension (11%). All grade mood disturbances ranging from anxiety, depression, to agitation were observed in 22% of patients. Results from serial monitoring of cell-free DNA samples corresponded to radiographic resolution of disease and tracked the emergence of mutations known to promote BTK inhibitor resistance.

CONCLUSIONS

BTK and pan-PI3K inhibition in mantle cell lymphoma demonstrates a promising efficacy signal. Addition of BCL2 inhibitors to a BTK and pan-PI3K combination remain suitable for further development in mantle cell lymphoma.

Cell‐free DNA profiling in retinoblastoma patients with advanced intraocular disease: An MSKCC experience

Purpose

The enucleation rate for retinoblastoma has dropped from over 95% to under 10% in the past 10 years as a result of improvements in therapy. This reduces access to tumor tissue for molecular profiling, especially in unilateral retinoblastoma, and hinders the confirmation of somatic RB1 mutations necessary for genetic counseling. Plasma cell‐free DNA (cfDNA) has provided a platform for noninvasive molecular profiling in cancer, but its applicability in low tumor burden retinoblastoma has not been shown. We analyzed cfDNA collected from 10 patients with available tumor tissue to determine whether sufficient tumorderived cfDNA is shed in plasma from retinoblastoma tumors to enable noninvasive RB1 mutation detection.

Methods

Tumor tissue was collected from eye enucleations in 10 patients diagnosed with advanced intra‐ocular unilateral retinoblastoma, three of which went on to develop metastatic disease. Tumor RB1 mutation status was determined using an FDA‐cleared tumor sequencing assay, MSK‐IMPACT. Plasma samples were collected before eye enucleation and analyzed with a customized panel targeting all exons of RB1.

Results

Tumor‐guided genotyping detected 10 of the 13 expected somatic RB1 mutations in plasma cfDNA in 8 of 10 patients (average variant allele frequency 3.78%). Without referring to RB1 status in the tumor, de novo mutation calling identified 7 of the 13 expected RB1 mutations (in 6 of 10 patients) with high confidence.

Conclusion

Plasma cfDNA can detect somatic RB1 mutations in patients with unilateral retinoblastoma. Since intraocular biopsies are avoided in these patients because of concern about spreading tumor, cfDNA can potentially offer a noninvasive platform to guide clinical decisions about treatment, follow‐up schemes, and risk of metastasis.

Circulating cell-free DNA for non-invasive cancer management

Cell-free DNA (cfDNA) was first identified in human plasma in 1948 and is thought to be released from cells throughout the body into the circulatory system. In cancer, a portion of the cfDNA originates from tumour cells, referred to as circulating-tumour DNA (ctDNA), and can contain mutations corresponding to the patient's tumour, for instance specific TP53 alleles. Profiling of cfDNA has recently become an area of increasing clinical relevance in oncology, in particular due to advances in the sensitivity of molecular biology techniques and development of next generation sequencing technologies, as this allows tumour mutations to be identified and tracked non-invasively. This has opened up new possibilities for monitoring tumour evolution and acquisition of resistance, as well as for guiding treatment decisions when tumour biopsy tissue is insufficient or unavailable. In this review, we will discuss the biology of cell-free nucleic acids, methods of analysis, and the potential clinical uses of these techniques, as well as the on-going clinical development of ctDNA assays.

The value of cell-free DNA for molecular pathology

Over the past decade, advances in molecular biology and genomics techniques have revolutionized the diagnosis and treatment of cancer. The technological advances in tissue profiling have also been applied to the study of cell-free nucleic acids, an area of increasing interest for molecular pathology. Cell-free nucleic acids are released from tumour cells into the surrounding body fluids and can be assayed non-invasively. The repertoire of genomic alterations in circulating tumour DNA (ctDNA) is reflective of both primary tumours and distant metastatic sites, and ctDNA can be sampled multiple times, thereby overcoming the limitations of the analysis of single biopsies. Furthermore, ctDNA can be sampled regularly to monitor response to treatment, to define the evolution of the tumour genome, and to assess the acquisition of resistance and minimal residual disease. Recently, clinical ctDNA assays have been approved for guidance of therapy, which is an exciting first step in translating cell-free nucleic acid research tests into clinical use for oncology. In this review, we discuss the advantages of cell-free nucleic acids as analytes in different body fluids, including blood plasma, urine, and cerebrospinal fluid, and their clinical applications in solid tumours and haematological malignancies. We will also discuss practical considerations for clinical deployment, such as preanalytical factors and regulatory requirements. Copyright © 2018 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Food safety objective approach for controlling Clostridium botulinum growth and toxin production in commercially sterile foods

As existing technologies are refined and novel microbial inactivation technologies are developed, there is a growing need for a metric that can be used to judge equivalent levels of hazard control stringency to ensure food safety of commercially sterile foods. A food safety objective (FSO) is an output-oriented metric that designates the maximum level of a hazard (e.g., the pathogenic microorganism or toxin) tolerated in a food at the end of the food supply chain at the moment of consumption without specifying by which measures the hazard level is controlled. Using a risk-based approach, when the total outcome of controlling initial levels (H(0)), reducing levels (ΣR), and preventing an increase in levels (ΣI) is less than or equal to the target FSO, the product is considered safe. A cross-disciplinary international consortium of specialists from industry, academia, and government was organized with the objective of developing a document to illustrate the FSO approach for controlling Clostridium botulinum toxin in commercially sterile foods. This article outlines the general principles of an FSO risk management framework for controlling C. botulinum growth and toxin production in commercially sterile foods. Topics include historical approaches to establishing commercial sterility; a perspective on the establishment of an appropriate target FSO; a discussion of control of initial levels, reduction of levels, and prevention of an increase in levels of the hazard; and deterministic and stochastic examples that illustrate the impact that various control measure combinations have on the safety of well-established commercially sterile products and the ways in which variability all levels of control can heavily influence estimates in the FSO risk management framework. This risk-based framework should encourage development of innovative technologies that result in microbial safety levels equivalent to those achieved with traditional processing methods.

Bone-anchored devices in single-sided deafness

Single sided deafness (SSD) implies sensorineural hearing loss in one ear with normal contralateral hearing function. Traditionally, SSD patients have been overlooked due to a belief that the preserved functioning of the contralateral ear compensates for the nonhearing side. SSD patients however experience multiple audiological difficulties, particularly when the sound source is situated on the non-hearing side or in the presence of competing sounds. Through reviewing current literature, we describe the role of bone-anchored devices (Baha) in the management of SSD patients. Recent publications for Baha in SSD have demonstrated consistent objective and subjective improvement in audiologic metrics when compared to unaided conditions. There is also evidence of benefit provided by Baha by the Abbreviated Profile of Hearing Aid Benefit, in global measures of ease of communication, reverberation, and background noise, but not typically in aversiveness to sounds. Interestingly, despite some patients gaining minimal objective or subjective benefits, the majority of these patients still report improved quality of life and would recommend the procedure. Despite increasing evidence for the role of Baha in the management of SSD in the literature, much of these data are based on older technology. Further reports should specify the processor type used and the etiology of the hearing loss to ensure accuracy of future data.

Chronic ulcerative stomatitis: Diagnostic and management challenges—four new cases and review of literature

Chronic ulcerative stomatitis (CUS) is a recently described mucocutaneous disease characterized by involvement of mucosal surfaces and skin. The disease usually presents in the form of painful oral ulcers and has been seen predominantly among older women. Clinically, CUS patients may exhibit erosive or ulcerative lesions of oral mucosa resembling erosive lichen planus and/or other vesiculobullous lesions. Routine histology may exhibit features of lichenoid mucositis and is often nondiagnostic. Direct immunofluorescence studies of mucosal or skin biopsies usually reveal a unique pattern of IgG bound to nuclei of keratinocytes of the basal and parabasal cell layers. Chronic ulcerative stomatitis exhibits a unique resistance to standard treatments available, including topical and systemic corticosteroids and immunomodulatory medications. However, long-lasting favorable clinical responses may be achieved with hydroxychloroquine pharmacotherapy. We present the clinicoimmunopathologic findings of four cases of CUS and discuss the varied clinical, microscopic spectrum, and treatment for this chronic, debilitating, and often recalcitrant condition. A systematic review of the literature, including 35 previously reported cases, is presented.

Solute-specific effects of osmotic stress on Staphylococcus aureus

AIM

To determine if cell death from osmotic stress is because of lack of sufficient energy to maintain cell metabolism. Additionally, the solute-specific effect of five humectants on bacterial osmoregulation and cell survival was examined.

METHODS AND RESULTS

Staphylococcus aureus was placed into 84% relative humidity (RH) broth (five humectants used individually). ATP, ADP and cell viability measurements were determined over time. The results indicate that ATP is not the limiting factor for cell survival under excessive osmotic stress. Although the same RH was achieved with various humectants, the rates of cell death varied greatly as did the sensitivities of the cell populations to osmotic stress.

CONCLUSIONS

The results from this study provide strong evidence that mechanisms of osmotic inactivation depend on the solute. The molecular mobility of the system may be an important means to explain these differences.

SIGNIFICANCE AND IMPACT OF THE STUDY

By bringing together an understanding of solute-specific effects, microbial physiology and genetics, the mechanisms of inactivation of micro-organisms by solute-specific osmotic stress may be elucidated, and this knowledge may then be exploited to ensure the production of high quality, safe foods.

Spike detection, characterization, and discrimination using feature analysis software written in LabVIEW

Rapid and accurate discrimination of single units from extracellular recordings is a fundamental process for the analysis and interpretation of electrophysiological recordings. We present an algorithm that performs detection, characterization, discrimination, and analysis of action potentials from extracellular recording sessions. The program was entirely written in LabVIEW (National Instruments), and requires no external hardware devices or a priori information about action potential shapes. Waveform events are detected by scanning the digital record for voltages that exceed a user-adjustable trigger. Detected events are characterized to determine nine different time and voltage levels for each event. Various algebraic combinations of these waveform features are used as axis choices for 2-D Cartesian plots of events. The user selects axis choices that generate distinct clusters. Multiple clusters may be defined as action potentials by manually generating boundaries of arbitrary shape. Events defined as action potentials are validated by visual inspection of overlain waveforms. Stimulus-response relationships may be identified by selecting any recorded channel for comparison to continuous and average cycle histograms of binned unit data. The algorithm includes novel aspects of feature analysis and acquisition, including higher acquisition rates for electrophysiological data compared to other channels. The program confirms that electrophysiological data may be discriminated with high-speed and efficiency using algebraic combinations of waveform features derived from high-speed digital records.

Case study: caudate glutamatergic changes with paroxetine persist after medication discontinuation in pediatric OCD

Proton magnetic resonance spectroscopy (1H-MRS) was used to examine glutamatergic (Glx) abnormalities in the caudate nucleus in pediatric obsessive-compulsive disorder (OCD), associated with severity of illness and response to acute (12 weeks) treatment with paroxetine. In this report, OCD symptoms improved markedly in an 8-year-old girl treated for 14 months with the selective serotonin reuptake inhibitor paroxetine (titrated from 10 to 40 mg/day). Paroxetine dose was then decreased in 10-mg decrements and discontinued without symptom recurrence. Serial 1H-MRS examinations were acquired before and after 12 weeks of paroxetine treatment (40 mg/day) and 3 months after medication discontinuation. A striking decrease in caudate Glx was observed after 12 weeks of treatment which persisted after medication discontinuation. These data provide further support for a reversible glutamatergically mediated dysfunction of the caudate nucleus in OCD that may serve as a pathophysiological and treatment response marker.

Home monitoring service improves mean arterial pressure in patients with essential hypertension. A randomized, controlled trial

BACKGROUND

Technological advances in the distribution of information have opened new avenues for patient care. Few trials, however, have used telemedicine to improve blood pressure in patients with essential hypertension.

OBJECTIVE

To determine the efficacy of a telecommunication service in reducing blood pressure.

DESIGN

Randomized, controlled trial.

SETTING

University-affiliated primary care outpatient clinics.

PATIENTS

121 adults with essential hypertension who were under evaluation for a change in antihypertensive therapy.

INTERVENTION

A home service consisting of automatic transmission of blood pressure data over telephone lines, computerized conversion of the information into report forms, and weekly electronic transmission of the report forms to physicians and patients.

MEASUREMENTS

24-hour ambulatory blood pressure monitoring at baseline and exit. The primary end point was change in mean arterial pressure from baseline to exit.

RESULTS

Mean arterial pressure decreased by 2.8 mm Hg in patients receiving the home service and increased by 1.3 mm Hg in patients receiving usual care (P = 0.013 for the difference). Mean diastolic blood pressure decreased by 2.0 mm Hg for home service but increased by 2.1 mm Hg for usual care (P = 0.012 for the difference). Mean systolic blood pressure decreased by 4.9 mm Hg for home service and 0.1 mm Hg for patients receiving usual care (P = 0.047 for the difference). Among African-American patients, mean arterial pressure decreased by 9.6 mm Hg in those receiving home service and increased by 5.25 mm Hg in those receiving usual care (P = 0.047). Part of the decrease in blood pressure for home service was due to more frequent changes in the type or dose of antihypertensive medications.

CONCLUSION

This telecommunication service was efficacious in reducing the mean arterial pressure of patients with established essential hypertension.

Modeling the growth boundary of Staphylococcus aureus for risk assessment purposes

Knowing the precise boundary for growth of Staphylococcus aureus is critical for food safety risk assessment, especially in the formulation of safe, shelf-stable foods with intermediate relative humidity (RH) values. To date, most studies and resulting models have led to the presumption that S. aureus is osmotolerant. However, most studies and resulting models have focused on growth kinetics using NaCl as the humectant. In this study, glycerol was used to investigate the effects of a glass-forming nonionic humectant to avoid specific metabolic aspects of membrane ion transport. The experiments were designed to produce a growth boundary model as a tool for risk assessment. The statistical effects and interactions of RH (84 to 95% adjusted by glycerol), initial pH (4.5 to 7.0 adjusted by HC1), and potassium sorbate (0, 500, or 1,000 ppm) or calcium propionate (0, 500, or 1,000 ppm) on the aerobic growth of a five-strain S. aureus cocktail in brain heart infusion broth were explored. Inoculated broths were distributed into microtiter plates and incubated at 37 degrees C over appropriate saturated salt slurries to maintain RH. Growth was monitored by turbidity during a 24-week period. Toxin production was explored by enterotoxin assay. The 1,280 generated data points were analyzed by SAS LIFEREG procedures, which showed all studied parameters significantly affected the growth responses of S. aureus with interactions between RH and pH. The resulting growth/no growth boundary is presented.

Decrease in caudate glutamatergic concentrations in pediatric obsessive-compulsive disorder patients taking paroxetine

OBJECTIVE

To measure in vivo neurochemical changes in the caudate nucleus in pediatric obsessive-compulsive disorder (OCD) before and after treatment.

METHOD

Single-voxel proton magnetic resonance spectroscopic (1H-MRS) examinations of the left caudate were conducted in 11 psychotropic drug-naive children, aged 8 to 17 years, with OCD before and after 12 weeks of monotherapy with the selective serotonin reuptake inhibitor paroxetine (10-60 mg/day) and 11 healthy children aged 8 to 17 years. A different sample of 8 pediatric OCD patients and 8 healthy children had a 1H-MRS examination of occipital cortex.

RESULTS

Caudate glutamatergic concentrations (Glx) were significantly greater in treatment-naive OCD patients than in controls but declined significantly after paroxetine treatment to levels comparable with those of controls. Decrease in caudate Glx was associated with decrease in OCD symptom severity. Occipital Glx did not differ between OCD patients and controls.

CONCLUSIONS

These preliminary findings provide new evidence of Glx abnormalities in the caudate nucleus in pediatric OCD and suggest that paroxetine treatment may be mediated by a serotonergically modulated reduction in caudate Glx.

Endobronchial photodynamic therapy: comparison of mTHPC and polyethylene glycol-derived mTHPC on human tumor xenografts and tumor-free bronchi of minipigs

BACKGROUND AND OBJECTIVE

Photodynamic therapy (PDT) with mTHPC and polyethylene glycol-derived mTHPC (pegylated mTHPC) was compared on nude mice bearing human squamous cell carcinoma and adenocarcinoma xenografts. The same treatment regimens were applied to the bronchi of tumor-free minipigs to assess injury to normal tissue.

STUDY DESIGN/MATERIALS AND METHODS

Laser light (652 nm, 20 J/cm2) was delivered as surface radiation to the xenografts 4 days after intraperitoneal administration of 0.1 mg/kg mTHPC or an equimolar dose of pegylated mTHPC, respectively. The extent of tumor necrosis was assessed by histomorphometry. Endobronchial PDT was performed on the bronchi of minipigs with the same drug and light doses at drug-light intervals ranging from 12-96 hr.

RESULTS

Both sensitizers produced larger necrosis of squamous cell carcinoma and adenocarcinoma xenografts than was observed in untreated controls (P < 0.005). Pegylated mTHPC led to larger tumor necrosis than mTHPC in squamous cell carcinoma (P < 0.001), but not in adenocarcinoma xenografts. mTHPC-PDT resulted in ulceration and necrosis of bronchial mucosa in minipigs at drug-light intervals ranging from 12-48 hr, which was not observed after use of pegylated mTHPC.

CONCLUSIONS

In this setting, pegylated mTHPC had advantages as a photosensitiser compared to mTHPC.

Decrease in thalamic volumes of pediatric patients with obsessive-compulsive disorder who are taking paroxetine

BACKGROUND

Thalamic dysfunction has been implicated in obsessive-compulsive disorder (OCD). While OCD frequently has its onset during childhood, to our knowledge, no prior study has measured neuroanatomical changes in the thalamus of patients with OCD near the onset of illness, and before and after treatment.

METHODS

Volumetric magnetic resonance imaging studies were conducted in 21 psychotropic drug-naive children, aged 8 to 17 years, with OCD and 21 case-matched healthy comparison subjects. Magnetic resonance imaging studies were also conducted in 10 of the 21 patients with OCD after 12 weeks of monotherapy with the selective serotonin reuptake inhibitor, paroxetine hydrochloride.

RESULTS

Thalamic volumes were significantly greater in treatment-naive patients with OCD than in controls but declined significantly after paroxetine monotherapy to levels comparable with those of controls. Decrease in thalamic volume in patients with OCD was associated with reduction in OCD symptom severity.

CONCLUSIONS

Our findings provide new evidence of thalamic abnormalities in pediatric OCD and further suggest that paroxetine treatment may be paralleled by a reduction in thalamic volume. These reductions may, however, not be specific to paroxetine treatment and could be due to a more general treatment response, and/or spontaneous improvement in symptoms. Our findings are preliminary given the small sample size and our inability to measure discrete thalamic nuclei.

Proton spectroscopic imaging of the thalamus in treatment-naive pediatric obsessive-compulsive disorder

BACKGROUND

Neurobiological abnormalities in the thalamus, particularly the dorsomedial nucleus of the thalamus, are believed to be involved in the pathophysiology of obsessive-compulsive disorder. Although obsessive-compulsive disorder commonly arises in childhood and adolescence, no prior study has examined the thalamus in pediatric obsessive-compulsive disorder patients.

METHODS

In this study, N-acetyl-aspartate, a putative marker of neuronal viability, creatine/phosphocreatine, and choline levels were measured in the lateral and medical subregions of the left and right thalami using a multislice proton magnetic resonance spectroscopic imaging sequence in 11 treatment-naive, nondepressed obsessive-compulsive disorder outpatients, 8-15 years old, and 11 case-matched control subjects.

RESULTS

A significant reduction in N-acetyl-aspartate/choline and N-acetyl-aspartate/(creatine/phosphocreatine + choline) was observed in both the right and left medial thalami in obsessive-compulsive disorder patients compared with control subjects. The N-acetyl-aspartate/choline and N-acetyl-aspartate/(creatine/phosphocreatine + choline) levels did not differ significantly between case-control pairs in either the left or the right lateral thalamus. Reduction in N-acetyl-aspartate levels in the left medial thalamus was inversely correlated with increased obsessive-compulsive disorder symptom severity.

CONCLUSIONS

These findings provide new evidence of localized functional neurochemical marker abnormalities in the thalamus in pediatric obsessive-compulsive disorder. Our results must be considered preliminary, however, given the small sample size.

Paroxetine open-label treatment of pediatric outpatients with obsessive-compulsive disorder

OBJECTIVE

Paroxetine is a selective serotonin reuptake inhibitor with demonstrated efficacy in treating obsessive-compulsive disorder (OCD) in adults. This study evaluates the safety and effectiveness of paroxetine in pediatric OCD patients.

METHOD

In a 12-week, open-label trial of paroxetine, 20 OCD outpatients, aged 8 to 17 years, were treated for OCD with daily doses ranging from 10 to 60 mg. Target symptoms were rated at regular intervals with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the Children's Global Assessment Scale, the Clinical Global Impression Scale, the Hamilton Anxiety Rating Scale, and the Yale Global Tic Severity Scale.

RESULTS

Paroxetine proved relatively safe in this brief trial with a small sample and appeared to be effective in patients with OCD; mean CY-BOCS scores decreased significantly (z = 3.49, p = .0005) from 30.6 +/- 3.5 to 21.6 +/- 6.8 on medication. The most common side effects (n > or = 2) were hyperactivity/behavioral activation, headache, insomnia, nausea, and anxiety. Paroxetine did not have to be discontinued in any of the patients because of side effects; the most serious side effects included hyperactivity/behavioral activation in 3 younger patients (< 10 years) necessitating dosage reduction but not discontinuation.

CONCLUSIONS

Preliminary evidence suggests that short-term treatment of pediatric OCD outpatients with paroxetine may be relatively safe and effective.

Risperidone augmentation of serotonin reuptake inhibitor treatment of pediatric obsessive compulsive disorder

In this case series, risperidone augmentation of treatment with a serotonin reuptake inhibitor (SRI) is described in four pediatric patients diagnosed with obsessive compulsive disorder (OCD). An improved treatment response was observed in all cases, albeit in different ways. All four of the patients had failed prior SRI monotherapy. Comorbid tics were observed in two cases and aggressive behavior or violent images were seen in three. Possible predictors of response to risperidone in patients with OCD and future research avenues are explored.

Comparison between saliva stimulants and a saliva substitute in patients with xerostomia and hyposalivation

The purpose of this study was to assess patient preference and product efficacy of three non-prescription products for the symptomatic relief of xerostomia. The study group consisted of 80 individuals with a complaint of chronic (> six months) xerostomia and an unstimulated salivary flow rate of < 0.1 mL/min. The three products--a sorbitol/xylitol-sweetened chewing gum, a sorbitol-sweetened sour lemon lozenge, and a sorbitol/xylitol-sweetened artificial saliva substitute spray--were assigned in a permuted block randomization scheme. Each product was used for two weeks with an interval of one week between trials. The study did not identify any product to be statistically significant in terms of patient preference. Kruskal-Wallis testing revealed no statistical significance (P > 0.589) among the products. No product demonstrated marked efficacy in stimulating salivary output. ANOVA analysis followed by Tukey HSD testing revealed no significant difference between the baseline paraffin-stimulated mean flow rate and the gum- and lozenge-stimulated flow rates.

Assessment of bromhexine as a treatment regimen in Sjögren's syndrome-like disease in the NOD (non-obese diabetic) mouse

OBJECTIVE

Bromhexine has been reported to alleviate the xerostomia and xerophthalmia associated with secondary Sjögren's syndrome. The aim of this study was to determine if it might prove useful in the treatment of Sjögren's syndrome-like disease of the NOD mouse model for autoimmune sialoadenitis.

METHODS

Groups of mice were divided into sets receiving 60 mg/kg bromhexine in drinking water and control pair-fed animals. The efficacy of drug treatment was assessed by weekly measurement of stimulated saliva volumes, protein concentration, and amylase activity. At termination (20 weeks) submandibular and lacrimal glands were removed to assess the levels of lymphocytic infiltration by histological evaluation under light microscopy.

RESULTS

Control and bromhexine-treated groups of mice showed no difference in the loss or rate of reduction in stimulated saliva flow over the 12 weeks of treatment. No differences were noted in the protein concentration and amylase loss with increasing age of the animals. Similar temporal changes in total protein profiles and aberrant expression of the 20 kDa parotid secretory protein isoform were observed by SDS-polyacrylamide gel profiles and Western bolt analysis. Histological evaluation of exocrine gland sections failed to detect any reduction in focal lymphocyte infiltration.

CONCLUSION

Bromhexine therapy did not alter the development or severity of Sjögren's syndrome-like disease in the NOD mouse model for autoimmune sialoadenitis.

Intraoperative photodynamic therapy with m-tetrahydroxyphenylchlorin for chest malignancies

BACKGROUND AND OBJECTIVE

Since there is no satisfactory treatment modality for diffuse malignant mesothelioma of the chest, we assessed surgical tumor resection followed by intraoperative photodynamic therapy with mTHPC in a phase I study.

STUDY DESIGN/MATERIALS AND METHODS

Since 1990, eight patients have undergone intraoperative photodynamic therapy with m-tetrahydroxyphenylchlorin (mTHPC-PDT) following thoracotomy and surgical tumor resection.

RESULTS

mTHPC-PDT-mediated tumor necrosis was characterized by tumor infarction due to tumor vessel necrosis and thrombosis, and its extent depended on drug-light conditions; 650 nm light delivered at 0.1 W/cm2 for 10 J/cm2 48 h after iv administration of 0.3 mg mTHPC/kg resulted in a 10-mm-deep complete tumor necrosis. Skin photosensitivity was related to the drug dose applied and occurred up to 17 days after iv administration of 0.3 mg mTHPC/kg, mTHPC-PDT of brachial plexus infiltrated by mesothelioma resulted in pain relief without deterioration of nerve function.

CONCLUSION

Tumor resection and intraoperative mTHPC-PDT of the chest cavity is feasible under clinical conditions and offers local tumor control of sites involved. However, distant tumor spread was not prevented by this combined treatment modality and optimization of mTHPC-PDT is warranted for further intraoperative application.

Effectiveness of nebulised salbutamol administered in ambulances to patients with severe acute asthma

BACKGROUND

Nebulised salbutamol can now be administered by ambulance personnel to patients with severe acute asthma en route to hospital. This treatment, however, is not yet available in all ambulances. The safety and effectiveness of allowing ambulance crews to initiate treatment with nebulised salbutamol has been assessed in patients with acute severe asthma.

METHODS

After a basic training course in the assessment of asthma and the use of a nebuliser, ambulance crews initiated treatment with nebulised salbutamol in asthmatic patients under the age of 40 years. Airflow obstruction was measured before and after treatment with a peak flow meter. A subjective assessment of any change in the patient's condition was also made.

RESULTS

Nebuliser treatment was associated with a significant increase in peak flow in almost 80% of patients who had recordable values before and after treatment. The mean percentage increase in peak flow was 56.5%. Subjective assessments correlated well with peak flow measurements. No unwanted side effects were recorded.

CONCLUSIONS

Nebulised salbutamol is an effective and safe treatment for acute asthma when administered by ambulance personnel after a short training course.

Percutaneous and mucous membrane exposure protocol in a southeastern dental school

A southeastern dental educational institution formalized a Percutaneous and Mucous Membrane Exposure Protocol in 1990. This article outlines the development, implementation, and administration of the protocol including risk assessment and rationale for testing health care workers and source persons. Pretest and posttest counseling for HIV testing is also discussed.

Degenerative joint disease. Part II: Symptoms and examination findings

From a pool of 1,279 consecutive patients referred to the Parker E. Mahan Facial Pain Center for complaints of head/neck pain, a subset of 215 patients with the diagnosis of osteoarthrosis of the temporomandibular joint (TMJ-DJD) have been identified. Data regarding patient age and sex, reported symptoms and examination results are presented from this subset of TMJ-DJD patients. From this data, common signs and symptoms of TMJ-DJD are proposed.

The Cytobrush Plus cell collector in oral cytology

The Cytobrush Plus cell collector (cytobrush) was compared with the wooden tongue depressor during oral exfoliative cytology. The degree of patient discomfort, the convenience to the clinician, and the quantity and distribution of epithelial cells collected were evaluated. Two-factor analysis of variance and parametric and nonparametric analyses were performed. Because of the favorable findings revealed in this study, we recommend that the cytobrush be considered for use when obtaining diagnostic cytologic smears from the oral mucosa.

Degenerative joint disease. Part I: Diagnosis and management considerations

Degenerative joint disease, primarily in the form of osteoarthrosis, affects the temporomandibular joints (TMJs) with symptoms similar to those found in other body joints. These symptoms include stiffness, pain, restriction of movement, inflammation, crepitus and radiographic changes. Symptoms can occur in both males and females at any age, starting with pre-adolescent, but most often occur in females age 30 and over. Most symptoms will last nine to 18 months (followed by remission) and are managed using anti-inflammatory medications, physical therapy, occlusal splints and dietary changes. Major areas for consideration in this article include epidemiology, signs and symptoms, radiography, etiopathology and symptom management.

Photodynamic therapy with m-tetrahydroxyphenylchlorin in vivo: optimization of the therapeutic index

The therapeutic index of meta-tetrahydroxyphenylchlorin-mediated photodynamic therapy (mTHPC-PDT) was assessed in BALB/c nude mice bearing human malignant mesothelioma xenografts. Equal doses of 650 nm laser light were delivered to the tumour and to an equal-sized area of the hind leg (control site) after i.p. administration of mTHPC. Twenty-one groups of 6 animals each were treated under various drug-light conditions and at drug-light intervals ranging from 4 hr to 6 days. After light delivery the extent of tumour necrosis and the depth of alterations in normal tissue were assessed by light microscopy of standardized histological sections. A therapeutic index (TI) of mTHPC-PDT was defined as the cross-sectional area of tumour necrosis per depth of visible tissue injury at the control site. This TI was strongly related to the conditions of treatment. In particular, it was increased by prolonging the drug-light interval up to 5 days and by increasing the dose of light for any dose of drug. The most profound increase of TI was obtained by increasing the intensity of light administered at the chosen interval while reducing the dose of drug. Our findings suggest that threshold conditions operate in PDT and have important implications for clinical application of the treatment.

An immunohistologic analysis of murine uterine T cells between birth and puberty

Murine uterine T cells were analysed on the basis of surface phenotype expression from birth to adulthood. T cells were rare in the uterus from birth until 2 weeks of age. In genetically immunocompetent mice, mature T cells expressing either TCR alpha/beta or TCR gamma/delta were first present as a major cell population at 3 weeks of age. The ratio of TCR alpha/beta to TCR gamma/delta was 1:1 at 3 weeks of age and this ratio did not change during sexual maturation. Almost all uterine T cells were CD8+ and the majority of these cells expressed CD8 alpha/beta rather than CD8 alpha/alpha. Cells expressing Thy1.2 were less frequent than cells expressing CD3 while cells expressing CD5 were rare. No major changes in T cell subsets occurred at puberty. Further, the microbial flora of the mice did not alter the time of appearance, frequency or subset distribution of uterine TCR+ cells. In the uteri of immunodeficient mice of genotype scid/scid TCR+ cells were found in low numbers and the initial appearance of TCR+ cells was delayed until 5 weeks of age.

Daily energy expenditure in free-living children: comparison of heart-rate monitoring with the doubly labeled water (2H2(18)O) method

Total energy expenditure (TEE) was measured simultaneously in 36 free-living children aged 7, 9, 12, and 15 y over 10-15 d by the doubly labeled water (DLW) method and for 2-3 separate days by heart-rate (HR) monitoring. The 95% confidence limits of agreement (mean difference +/- 2SD) were -1.99 to +1.44 MJ/d. HR TEE discrepancies ranged from -16.7% to +18.8% with 23 values lying within +/- 10% of DLW TEE estimates. Boys and girls spent 462 +/- 108 and 318 +/- 120 min/d, respectively, in total physical activity (P less than 0.01). Time spent in moderate and vigorous physical activity (MVPA) was 68 +/- 37 min/d by younger children (7-9 y) and 34 +/- 24 min/d by older children (12-15 y) (P less than 0.001). Younger boys engaged in MVPA (91 +/- 33 min/d) and vigorous physical activity (VPA) (35 +/- 15 min/d) significantly longer than younger girls (MVPA, 39 +/- 16 min/d, P less than 0.001; VPA, 10 +/- 4 min/d, P less than 0.01) as did older boys (MVPA, 52 +/- 21 min/d; VPA, 30 +/- 18 min/d) compared with older girls (MVPA, 15 +/- 10 min/d; VPA, 8 +/- 5 min/d). HR monitoring provides a close estimation of the TEE of population groups and objective assessment of associated patterns of physical activity.

Validation of estimates of energy intake by weighed dietary record and diet history in children and adolescents

Energy intakes assessed by 7-d weighted dietary records (EI-WDRs) and diet histories (EI-DHs) were compared with concurrent estimates of total energy expenditure (TEE) by the doubly labeled water method in 78 subjects aged 3-18 y. EI-WDRs were not obtained from the 3- and 5-y-old subjects. EI-WDRs in the 7- and 9-y-old children were 108 +/- 25% (n = 12) and 97 +/- 15% (n = 12), respectively, of corresponding TEE values showing good agreement. However in the 12-, 15-, and 18-y-old subjects EI-WDR averaged 89 +/- 12% (n = 12), 78 +/- 18% (n = 12), and 73 +/- 25% (n = 10), respectively, of corresponding TEE values. The difference was greater than or equal to 20% in 13 adolescents. Mean EI-DHs were 114 +/- 19% (3 y), 111 +/- 19% (5 y), 111 +/- 23% (7 y), 106 +/- 9% (9 y), 114 +/- 17% (12 y), 101 +/- 21% (15 y), and 98 +/- 21% (18 y) of TEE estimates. Differences were significant in the 3-, 9-, and 12-y-old subjects. Results suggest that 7-d EI-WDRs tend to underestimate food intake of adolescents. Although EI-DHs were biased towards overestimation in most age groups and individual measurements lacked precision, EI-DHs were more representative of habitual intake than were EI-WDRs.

Atypical odontalgia: phantom tooth pain

The findings in 30 cases diagnosed as atypical odontalgia are presented. The clinical characteristics of these cases are compared with other cases reported in the literature. Three cases are described in detail. Patient understanding and treatment with tricyclic antidepressants are discussed together with medication side effects and interactions. The importance of deferring invasive procedures is emphasized.

Experimental oral foreign body reactions. Commonly employed dental materials

Foreign bodies and tissue reactions to foreign materials are commonly encountered in the oral cavity. The more common lesions include apical deposition of endodontic materials, mucosal amalgam and graphite tattoos, myospherulosis, oil granulomas, and traumatically introduced dental materials and instruments. Since many foreign materials are unidentifiable histologically, commonly used dental materials were experimentally implanted subcutaneously in rats to assess local host responses and characterize the nature of these materials microscopically. The histologic characteristics of these foreign body reactions are detailed herein. The implanted materials corresponded to reactions seen in human subjects.

Electron microscopic observation of the aggregation of membrane proteins in human erythrocyte by melittin

Human erythrocytes and erythrocyte ghost membranes were treated with native and modified melittins, up to 250 nmol/mg membrane protein. Native melittin induced aggregation of intramembranous particles (IMPs, observed by freeze-fracture electron microscopy), and created large, smooth bilayer areas devoid of IMP. The degree of IMP aggregation increased with increasing concentration of melittin, corresponding to hemolysis results. Membrane ghosts were slightly more susceptible to IMP aggregation than membranes on intact cells. The potency of inducing IMP aggregation was ranked in the order of: native melittin greater than acetylated melittin greater than succinylated melittin = 0. The concentration range of melittin which caused IMP aggregation corresponded to that which caused the immobilization of band 3 proteins as detected by measurement of rotational mobility by transient dichroism (Dufton et al. (1984) Eur. J. Biophys. 11, 17-24). Because both IMP aggregation and band 3 protein immobilization decreased with decreasing positive charge of the melittins used, the nature of melittin-protein interaction is likely to be at least in part electrostatic in the case of human erythrocyte membranes. Possible roles of IMP aggregation and the consequent creation of 'exposed' bilayer areas in the cytotoxic reaction of melittins are discussed.

Association between keratoconus and atopy

Sixty-seven patients with keratoconus were classified according to atopic status. Keratoconus patients with and without atopy did not differ significantly with regard to sex, age of onset, or rate of keratoplasty, but patients with very high IgE levels were more prone to graft rejection. Atopy was less common in patients with unilateral keratoconus, and keratoconus occurred more frequently on the side of the dominant hand. There was a significantly lower frequency of HLA B7 in the keratoconus group than in the controls. No abnormalities of essential fatty acid metabolism were found in keratoconus patients with or without atopy. There was no social class bias in the group. The study included a brother and sister with keratoconus and atopy, and a non-atopic patient whose identical twin did not have keratoconus.

Effects on birth weight of smoking, alcohol, caffeine, socioeconomic factors, and psychosocial stress

OBJECTIVE

To investigate the effects of smoking, alcohol, and caffeine consumption and socio-economic factors and psychosocial stress on birth weight.

DESIGN

Prospective population study.

SETTING

District general hospital in inner London.

PARTICIPANTS

A consecutive series of 1860 white women booking for delivery were approached. 136 Refused and 211 failed to complete the study for other reasons (moved, abortion, subsequent refusal), leaving a sample of 1513. Women who spoke no English, booked after 24 weeks, had insulin dependent diabetes, or had a multiple pregnancy were excluded.

MEASUREMENTS

Data were obtained by research interviewers at booking (general health questionnaire, modified Paykel's interview, and Eysenck personality questionnaire) and at 17, 28, and 36 weeks' gestation and from the structured antenatal and obstetric record. Variables assessed included smoking, alcohol consumption, caffeine consumption, and over 40 indicators of socio-economic state and psychosocial stress, including social class, tenure of accommodations, education, employment, income, anxiety and depression, stressful life events, social stress, social support, personality, and attitudes to pregnancy. Birth weight was corrected for gestation and adjusted for maternal height, parity, and baby's sex.

MAIN RESULTS

Smoking was the most important single factor (5% reduction in corrected birth weight). Passive smoking was not significant (0.5% reduction). After smoking was controlled for, alcohol had an effect only in smokers and the effects of caffeine became non-significant. Only four of the socioeconomic and stress factors significantly reduced birth weight and these effects became non-significant after smoking was controlled for.

CONCLUSIONS

Social and psychological factors have little or no direct effect on birth weight corrected for gestational age (fetal growth), and the main environmental cause of its variation in this population was smoking.

Oral granular cell tumors: a clinicopathologic and immunocytochemical study

To investigate the histogenesis of the granular cell, a large series of granular cell tumors was studied for clinical and histopathologic features with emphasis on immunocytochemical markers. The nongingival granular cell tumors (NGGCT) were found to be more prevalent among females than males by a ratio of 2:1 and arose on the tongue (67%), the buccal mucosa (13%), the lips (8%), the soft palate (6%), and other sites (6%). With the use of the avidin-biotin-peroxidase method, polyclonal rabbit antisera were employed. The antisera were directed to the following antigens: S-100 protein, myoglobin, myosin, actin, desmin, alpha-1-antitrypsin, and muramidase. Results indicated that granular cell tumors are not homogenous for immunocytochemical markers. Nongingival granular cell tumors were universally positive for S-100 protein and failed to exhibit immunoreactivity for myogenous or histiocytic markers. Alternatively, the gingival granular cell tumor of infancy was negative for all markers, whereas rhabdomyoma was reactive with myogenous markers and a subpopulation of tumor cells displayed S-100 protein immunoreactivity. The granular cell ameloblastoma was reactive only with antiserum to alpha-1-antitrypsin. Ultrastructurally, granular cells from one of two NGGCT showed a direct evolution from skeletal muscle fibers. It is concluded that the oral NGGCT is a tumor positive for S-100 protein that may arise from muscle or nerve sheath.

Perinatal listeriosis. A report of six cases

The clinical and pathological findings in six patients with perinatal listeriosis are presented. One pregnancy resulted in a live-born infant who developed listerial septicaemia but made a complete recovery following prompt treatment. The other pregnancies ended in intrauterine death. Often antecedent maternal prodromal illness preceded expulsion of a macerated fetus by only a matter of hours making early diagnosis difficult. In all cases the diagnosis of listerial infection was apparent only after the birth of the fetus or new born.

Temporomandibular joint disk position as determined by a simple recorder

A method that will determine the condyle position necessary to keep the disk in place during splint fabrication has been described. The equipment used is simple and relatively inexpensive, and the entire procedure can be accomplished chairside in a matter of minutes. In those instances in which splint therapy does not result in significant improvement in symptoms, the Quick Set recorder can be used to repeat the initial condyle path recordings. A comparison of these sets of recordings can be used to determine whether the disk is in place. If doubt exists about the diagnosis, arthrography can be done to determine whether a closed locked disk position exists.