3D genomic mapping reveals multifocality of human pancreatic precancers

Pancreatic intraepithelial neoplasias (PanINs) are the most common precursors of pancreatic cancer, but their small size and inaccessibility in humans make them challenging to study1. Critically, the number, dimensions and connectivity of human PanINs remain largely unknown, precluding important insights into early cancer development. Here, we provide a microanatomical survey of human PanINs by analysing 46 large samples of grossly normal human pancreas with a machine-learning pipeline for quantitative 3D histological reconstruction at single-cell resolution. To elucidate genetic relationships between and within PanINs, we developed a workflow in which 3D modelling guides multi-region microdissection and targeted and whole-exome sequencing. From these samples, we calculated a mean burden of 13 PanINs per cm3 and extrapolated that the normal intact adult pancreas harbours hundreds of PanINs, almost all with oncogenic KRAS hotspot mutations. We found that most PanINs originate as independent clones with distinct somatic mutation profiles. Some spatially continuous PanINs were found to contain multiple KRAS mutations; computational and in situ analyses demonstrated that different KRAS mutations localize to distinct cell subpopulations within these neoplasms, indicating their polyclonal origins. The extensive multifocality and genetic heterogeneity of PanINs raises important questions about mechanisms that drive precancer initiation and confer differential progression risk in the human pancreas. This detailed 3D genomic mapping of molecular alterations in human PanINs provides an empirical foundation for early detection and rational interception of pancreatic cancer.

Reproducibility of non-contrast enhanced multi breath-hold ultrashort echo time functional lung MRI

PURPOSE

To evaluate the intraindividual reproducibility of functional lung imaging using non-contrast enhanced multi breath-hold 3D-UTE MRI.

METHODS

Ten healthy volunteers underwent non-contrast enhanced 3D-UTE MRI at three time points for same-day and different-day measurements employing a stack-of-spirals trajectory at 3 T. At each time point, inspiratory and expiratory breathing states were acquired for tidal and deep breathing, each within a single breath-hold. For functional image analysis, fractional ventilation (FV) was calculated pixelwise after image registration from the MR signal change. To decouple FV from breathing depth, the individual lung volume was used for volume adjustment (rFV). Reproducibility evaluation was performed in eight lung segments. Statistical analyses included two way mixed intraclass correlation (ICC), sign-test, Friedman-test and modified Bland-Altman analyses.

RESULTS

FV from tidal breathing showed an ICC of 0.81, a bias of 1.3% and an interval of confidence (CI) ranging from -67.1 to 69.6%. FV from deep breathing was higher reproducible with an ICC of 0.92 (bias, -0.2%; CI, -34.2 to 33.7%). Following volume adjustment, reproducibility of rFV for tidal breathing improved (ICC, 0,86; bias, 2.0%; CI, -34.3 to 38.3%), whereas it did not bear significant benefits for deep breathing (ICC, 0.89; bias, 2.8%; CI, -24.9 to 30.5%). Reproducibility was independent from the examination day.

CONCLUSION

Non-contrast-enhanced multi breath-hold 3D-UTE MRI allows for highly reproducible ventilation imaging.

Three-dimensional genomic mapping of human pancreatic tissue reveals striking multifocality and genetic heterogeneity in precancerous lesions

Pancreatic intraepithelial neoplasia (PanIN) is a precursor to pancreatic cancer and represents a critical opportunity for cancer interception. However, the number, size, shape, and connectivity of PanINs in human pancreatic tissue samples are largely unknown. In this study, we quantitatively assessed human PanINs using CODA, a novel machine-learning pipeline for 3D image analysis that generates quantifiable models of large pieces of human pancreas with single-cell resolution. Using a cohort of 38 large slabs of grossly normal human pancreas from surgical resection specimens, we identified striking multifocality of PanINs, with a mean burden of 13 spatially separate PanINs per cm3 of sampled tissue. Extrapolating this burden to the entire pancreas suggested a median of approximately 1000 PanINs in an entire pancreas. In order to better understand the clonal relationships within and between PanINs, we developed a pipeline for CODA-guided multi-region genomic analysis of PanINs, including targeted and whole exome sequencing. Multi-region assessment of 37 PanINs from eight additional human pancreatic tissue slabs revealed that almost all PanINs contained hotspot mutations in the oncogene KRAS, but no gene other than KRAS was altered in more than 20% of the analyzed PanINs. PanINs contained a mean of 13 somatic mutations per region when analyzed by whole exome sequencing. The majority of analyzed PanINs originated from independent clonal events, with distinct somatic mutation profiles between PanINs in the same tissue slab. A subset of the analyzed PanINs contained multiple KRAS mutations, suggesting a polyclonal origin even in PanINs that are contiguous by rigorous 3D assessment. This study leverages a novel 3D genomic mapping approach to describe, for the first time, the spatial and genetic multifocality of human PanINs, providing important insights into the initiation and progression of pancreatic neoplasia.

Impact of myocardial infarction with non-obstructive coronary arteries (MINOCA) vs. classic myocardial infarction on hospital resources

Background

Due to the high volume and broad availability of troponin testing and invasive coronary diagnostic in Germany, the entity of myocardial infarction with non-obstructive coronary arteries (MINOCA) is gaining increasing clinical and economic significance. As a main feature, no detectable obstructive coronary artery can be found upon angiography despite clinical symptoms related to acute coronary syndrome. Our investigation focuses on the procedural and economic impact of MINOCA and related clinical outcomes in a single-center patient collective of a university heart center.

Methods

All patients who were admitted to our hospital under the suspicion of an acute coronary syndrome within a 12-month period (2017–2018) for further diagnostics and treatment were screened. Included patients showed a pathological troponin elevation and received invasive coronary angiography. Associated costs, procedural and various clinical parameters as well as timelines and parameters of work-flow were obtained.

Results

3021 patients were initially screened and 660 were included. Of those, 103 patients were attributed to the MINOCA group. 542 patients presented with a “classical” myocardial infarction, and thus formed the MIOCA (myocardial infarction with obstructive coronary arteries) group. Baseline characteristics were summarized in Table 1. MINOCA patients were less frail, less diabetic, more likely female and showed no relevant difference in age or other selected comorbidities. The emergency department was the primary point of hospital admission for >70% of the patients from both groups. 50% of the patients arrived in the afternoon on a weekday. MINOCA patients were less present during the weekend as MIOCA patients (8.5% vs. 19.7%; p=0.002). With regard to a potential seasonal occurrence, both MINOCA and MIOCA cases show a pattern with two peaks (Figure 1). In-hospital mortality (MIOCA vs. MINOCA: 59 (11.1%) vs. 0 (0%) patients; p<0.001), and 30-day mortality (MIOCA vs. MINOCA: 94 (17.3%) vs. 5 (4.2%) patients; p<0.001) after the clinical index event were significantly higher in the MIOCA group. MINOCA patients were more likely to receive coronary angiography later after admission (44.6±78.6 h vs. 25.4±69.5h; p=0.014). Conversely, overall length of hospital stay (9.5±8.7 days vs. 12.5±12.7 days; p=0.005) as well as mean duration of high care monitoring (ICU, IMC, CCU) (2.4±4.6 days vs. 4.7±7.7 days; p=0.006) were shorter in the MINOCA group compared to MIOCAs. With an average of 6871.5±5670.8 EUR per index, MINOCA treatment costs were lower compared to the real myocardial infarction group (14277.5±7896.9 EUR; p<0.001) with a mean difference of approximately 7406 EUR.

Conclusion

Despite MINOCA being mostly a benign syndrome with favorable clinical outcome, it still utilizes relevant financial and capacity resources including high care monitoring and an in-hospital treatment of relevant length.

Funding Acknowledgement

Type of funding sources: None.

Common Patient-Reported Outcomes Within the Food and Drug Administration Voice of the Patient Reports

OBJECTIVES

Proponents of disease-specific patient-reported outcome measurements (PROMs) often argue disease-agnostic measures do not adequately capture their patient population's experience. Patient-Reported Outcomes Measurement Information System (PROMIS) provides a disease-agnostic domain set that may adequately cover many diseases. This study seeks to investigate whether PROMIS's quality of life domain coverage can span patient-reported outcomes (PROs) elicited from patients across unrelated diseases.

METHODS

The Food and Drug Administration Voice of the Patient reports were an initiative to elevate patient voices regarding their condition and associated treatments. Two reviewers extracted patient-reported health-related (quality of life) domains from the reports and categorized them into PROMIS domains or non-PROMIS domains. Domain coverage was summarized for each report. Any extracted PROs not covered by PROMIS domains were placed in an "other" category and analyzed for common themes.

RESULTS

Across 26 reports, PROMIS covered 216 of 374 (70%) of the reports' PRO domains. The heritable bleeding disorders report had the highest coverage (82%). Human immunodeficiency virus had the lowest coverage (50%). The most common PROMIS domain, "ability to participate in social roles," appeared in 25 reports (96%). The most common domains not included in PROMIS were stigma, sensitivities, and sensory deficits as evident in 19 (73%), 18 (69%), and 18 reports (69%), respectively. If the top 3 unincluded domains were amended into PROMIS, the total domain coverage would increase to 84%.

CONCLUSIONS

PRO domains elicited in the Food and Drug Administration Voice of the Patient reports were widely captured by PROMIS, suggesting domains patients experience contain enough overlap to be recorded by appropriate PROMIS domains. PROMIS could increase its coverage by adding domains.

QUALITY OF LIFE IN BREAST CANCER SURVIVORS: AN ASSESSMENT OF INTERNATIONAL BREAST CANCER DRAGON BOAT RACERS

Resistance exercise is deemed safe for women recovering from conventional breast cancer therapies but few clinicians are aware that dragon boat racing, as a form of resistive exercise, is available to the breast cancer community. The objectives of this study were to 1) increase clinician awareness of dragon boat racing (DBR) in breast cancer survivors as a community-based physical activity, and 2) evaluate quality of life (QOL) in breast cancer survivors with or without lymphedema who participate in DBR. This prospective, observational study surveyed 1,069 international breast cancer dragon boat racers from eight countries to compare function, activity, and participation in women with and without self-reported lymphedema using the Lymph-ICF questionnaire. Seventy-one percent of women (n=758) completed the questionnaires. Results revealed significantly higher Lymph-ICF scores in the lymphedema participants, signifying reduced QOL, when compared to the nonlymphedema participants (p<0.05), except for "go on vacation" for which no statistical difference was reported (p=0.20). International breast cancer survivors with lymphedema participating in DBR at an international competition had reduced function, limited activity, and restricted participation compared to participants without lymphedema. Clinicians should consider utilizing DBR as a community-based activity to support exercise and physical activity after a breast cancer diagnosis.

Quality of life in breast cancer survivors: An assessment of international breast cancer dragon boat racers

Resistance exercise is deemed safe for women recovering from conventional breast cancer therapies but few clinicians are aware that dragon boat racing, as a form of resistive exercise, is available to the breast cancer community. The objectives of this study were to 1) increase clinician awareness of dragon boat racing (DBR) in breast cancer survivors as a community-based physical activity, and 2) evaluate quality of life (QOL) in breast cancer survivors with or without lymphedema who participate in DBR. This prospective, observational study surveyed 1,069 international breast cancer dragon boat racers from eight countries to compare function, activity, and participation in women with and without selfreported lymphedema using the Lymph-ICF questionnaire. Seventy-one percent of women (n=758) completed the questionnaires. Results revealed significantly higher Lymph-ICF scores in the lymphedema participants, signifying reduced QOL, when compared to the nonlymphedema participants (p<0.05), except for "go on vacation" for which no statistical difference was reported (p=0.20). International breast cancer survivors with lymphedema participating in DBR at an international competition had reduced function, limited activity, and restricted participation compared to participants without lymphedema. Clinicians should consider utilizing DBR as a community-based activity to support exercise and physical activity after a breast cancer diagnosis.

Abstract P4-21-18: Pre-clinical antitumor activity, tumor localization, and pharmacokinetics of MP0274, an apoptosis inducing, biparatopic HER2-targeting DARPin®

Background: HER2 positivity is an important predictive factor for treatment with anti-HER2 agents in several cancers. However, currently available monoclonal antibody and tyrosine kinase inhibitor drugs rarely achieve full disease control. We have developed a new HER2-targeting molecule with a unique pro-apoptotic mode of action that may provide additional benefit to patients. The DARPin® MP0274* binds to two distinct non-overlapping HER2 epitopes and to human serum albumin for half-life extension. As previously shown**, in vitro, MP0274 induces apoptosis and inhibits proliferation of cells expressing HER2 (IHC3+, IHC2+ and IHC1+) and potently inhibits HER2/HER3 downstream signaling. To support clinical development of MP0274, we tested the potency of MP0274 in several HER2 expressing patient-derived xenograft (PDX) models and investigated tumor localization. In addition, pharmacokinetics (PK) analysis was performed in cynomolgus monkeys.

Methods: Antitumor activity of MP0274 was tested in breast and gastric HER2 expressing PDX mouse models and was compared to standard of care therapies. Tumor localization of MP0274 was studied using an Indium-111 labeled version of MP0274 in a human ovarian adenocarcinoma (SKOV-3) xenograft model by whole-body SPECT/CT imaging. The PK of MP0274 was studied in cynomolgus monkeys (MP0274 is cross-reactive with cynomolgus HER2).

Results: In breast and gastric cancer PDX models, MP0274 showed superior efficacy compared to trastuzumab and lapatinib and equivalent efficacy compared to trastuzumab plus pertuzumab as measured by relative tumor volume. The imaging study with SPECT/CT demonstrated that MP0274 localizes effectively to the HER2-expressing human tumor within 24 h. The PK study in cynomolgus monkeys showed a half-life of ≥5 days at doses of 5 and 10 mg/kg while at the lowest dose tested (1 mg/kg) MP0274 had a terminal half-life of 0.4 days. The PK results are indicative of target-mediated clearance that becomes saturated at doses above 1 mg/kg.

Conclusions: MP0274, with its unique pro-apoptotic mode of action, demonstrates excellent activity in preclinical PDX models, fast localization to tumor and a long half-life in cynomolgus monkeys. MP0274 was well tolerated in all studies. These results suggest that MP0274 has the potential to provide additional clinical benefit to patients with HER2-expressing tumors. A GLP repeated dose toxicology study is ongoing and a phase I clinical trial is in preparation.

* DARPins are small repeat proteins, designed to bind targets with high affinity and specificity, which can be combined in a modular fashion to produce multi-functional agents.

** U. Fiedler et al. SABC 2013. Abstract# 1094 & Poster# P4-12-30.

Citation Format: Fiedler U, Metz C, Zitt C, Bessey R, Béhé M, Blanc A, Schibli R, Dolado I, Herbst J, Dawson KM, Kiemle-Kallee J. Pre-clinical antitumor activity, tumor localization, and pharmacokinetics of MP0274, an apoptosis inducing, biparatopic HER2-targeting DARPin® [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-18.

[Immunotherapy of uveal melanoma: vaccination against cancer. Multicenter adjuvant phase 3 vaccination study using dendritic cells laden with tumor RNA for large newly diagnosed uveal melanoma]

Uveal melanomas are the most common malignant tumors of the eye. With modern molecular biological diagnostic methods, such as chromosome 3 typing and gene expression analysis, these tumors can be categorized into highly aggressive (monosomy 3, class II) and less aggressive forms. This molecular biological stratification is primarily important for determining the risk of these tumors as no therapy is currently available that is able to prevent or delay metastases. A randomized study of patients with a poor prognosis (monosomy 3) is currently being carried out in order to determine whether a cancer vaccine prepared from autologous (patient's own) dendritic cells and uveal melanoma RNA can prevent or delay progression and further metastases of this extremely aggressive form of cancer. Inclusion in the uveal melanoma study, which hopes to provide a potential therapeutic option for patients, is only possible if patients are referred to an institution that is able to manufacture and provide this vaccination before the patient is operated on or treated with radiation. Untreated tumor material is necessary for producing the vaccine on an individualized patient basis.

Outcomes of denervation, joint lavage and capsular imbrication for painful thumb carpometacarpal joint osteoarthritis

Pain reduction remains the main aim in the treatment of thumb carpometacarpal joint osteoarthritis. We performed a retrospective analysis of a case series of patients with symptomatic thumb carpometacarpal joint arthritis treated with denervation, joint lavage and capsular imbrication. A total of 60 patients participated in this study. Follow-up, including a clinical examination, was performed on 37 patients at a mean of 46 months (range 12 to 81); an additional 23 patients were followed-up by telephone at a mean of 52 months (range 14 to 93) post-operatively. The patients assessed in person showed a significant decrease in pain and a significant improvement in thumb function. The information gathered by telephone gave similar results. The findings of our study indicate that the presented treatment approach could be a good alternative to more invasive surgical options in patients with earlier stages of thumb carpometacarpal joint osteoarthritis. Advantages include the low rate of complications and invasiveness, as well as short recovery times.

LEVEL OF EVIDENCE

IV.

[Uveal and iridociliary melanomas in young patients : A retrospective analysis of 57 cases]

BACKGROUND

Uveal melanomas (UM) are rare malignancies in young patients. It is unknown if UM in young patients significantly differs from those in older patients concerning tumor size and localization, metastasis and genetics. The aim of this study was to evaluate the clinical course and tumor characteristics in young patients with UM.

MATERIAL AND METHODS

All patients with UM below the age of 32 years who had been treated at our hospital were included in the study. Patient age and sex, duration of symptoms, visual impairment, tumor size and location, genetics, therapy, follow-up interventions and tumor-associated deaths were documented.

RESULTS

A total of 57 patients (67 % male, mean age 24.7 years) were included in the study with an average symptomatic course of 5 months. Of the patients 8 (14 %) had an initial visual acuity of ≥ 0.9, 16 (28 %) 0.5-0.8, 22 (39 %) 0.05-0.4 and 9 (16 %) < 0.05 (no data for 2 patients, 4 %). After therapy visual acuity was < 0.05 in 54 % and 53 % of the tumors were choroidal UM (70 % juxtapapillary/circumpapillary), whereas 47 % were ciliochoroidal (54 % with iridociliary involvement). The average tumor size was 12.7 ± 3.6 mm with an average prominence of 6.2 ± 3.2 mm. Genetic evaluation (n = 16) revealed disomy 3 in 64 % and 54 % of the patients received radiotherapy with local application of ruthenium 106. In 46 % of cases follow-up interventions were neccessary including 70 % due to radiogenic retinopathy.

CONCLUSION

In young patients UM did not show any preferred localization. The majority of genetically evaluated tumors revealed disomy 3 with no significant correlation to tumor location. Independent of tumor size, location and therapy, approximately half of the patients needed follow-up interventions, predominantly due to radiogenic retinopathy.

ARDS und schweres Schädelhirntrauma Therapiestrategien im Konflikt

The development of adult respiratory distress syndrome (ARDS) complicates the treatment of patients with severe head injury, since special therapeutic strategies for both conditions might lead to a "conflict of interest". We report on the intensive care treatment of a young man who suffered severe brain injury (Glasgow Coma Scale = 3) due to a traffic accident and simultaneously developed ARDS from the aspiration of gastric content. We performed extensive monitoring of cerebral hemodynamics and metabolism (intracranial pressure measurement, jugular bulb oxymetry, estimation of arterial-jugular bulb lactate concentration difference) to prevent cerebral hypoxia and to control cerebral hyperemia. The application of a "lung protective strategy" with "permissive hypercapnia" led to a conflict, since the development of cranial hyperemia combined with cranial hypertension a few days after trauma, warranted the concept of controlled, temporary hyperventilation. Therefore, we applied a pumpless extracorporeal lung assist to improve carbon dioxide elimination. Furthermore, we started the ventilation in the prone position, since arterial oxygenation continued to deteriorate, although there is a lack of data describing the effect of a prone position on acute cerebral injury. Positioning the patient prone, we observed a prompt increase in intracranial pressure, which resulted in pharmacological intervention (mannitol). Treating the patient by intermittent prone position, by continuous extracorporeal lung assist and aerosolized prostacyclin administration in the following period, lung function improved and ARDS was treated successfully. After withdrawing the analgo-sedation the patient's vigilance rose continuously. The patient was transferred to a rehabilitation ward 33 days after admission to the intensive care unit. The combination of ARDS and severe brain injury needs special treatment, which includes extensive monitoring techniques to find a solution for therapeutic conflicts.

Abstract P4-12-30: A bivalent Her2 targeting DARPin with high efficacy against Her2-low and Her2-positive tumors

The approval of Herceptin, Perjeta and Kadcyla has dramatically improved the outcome of the 15% of breast cancer patients with high expression of Her2 (Her2-positive, IHC3+). In contrast, up to 50% of women with breast cancer express low levels of Her2 (Her2-low, IHC+2 or +1) at diagnosis, and these patients do not derive benefit from approved Her2 targeted therapies. It is estimated that 5-10% of Her2-positive patients will also develop Her2-low metastases refractory to treatment. Therefore, new therapeutic strategies are needed to alleviate the high tumor burden of Her2-low patients.

We generated a bivalent Designed Ankyrin Repeat Protein (DARPin) containing two anti-Her2 moieties that target unique non-overlapping epitopes on Her2 (biparatopic). The biparatopic DARPin exerts a strong pro-apoptotic response on a panel of breast and gastric cancer cell lines, which cannot be fully recapitulated by treatment with Herceptin, Perjeta or both combined. DARPin treatment of Her2-positive breast cancer BT474 cells induces apoptosis (IC50 &lt; 1nM) in virtually all cells within 24 hours, whereas single or combined treatment with Herceptin and/or Perjeta reduces proliferation by 50% (IC50 = 2-4nM). The biparatopic DARPin inhibits as well the viability (via apoptosis) of Her2-low MDAMB175 cells with a 100-fold higher potency than Herceptin. Mechanistically, treatment with the anti-Her2 biparatopic DARPin inhibits both Her2 and Her3 signaling, which in turn results in the induction of apoptosis. Interestingly, cell treatment with the mix of the two individual anti-Her2 DARPin moieties does not recapitulate the apoptotic effect of the biparatopic molecule, indicating that both moieties must be linked for maximum efficacy. In vivo, the biparatopic DARPin shows efficient anti-tumor activity in established breast cancer Her2-positive xenografts and Her2-low PDX tumor models. DARPin treatment of Her2-positive BT474 xenograft in BALB/c mice results in rapid tumor regression (50% tumor shrinkage after one dose) that is sustained at least during one month after the last dose. The biparatopic DARPin strongly inhibits tumor growth as well in a Her2-low breast cancer PDX in NMRI mice, where it demonstrates superior efficacy compared to Herceptin (DARPin/Herceptin tumor volume ratio &lt; 30%).

In summary, biparatopic targeting of Her2 enables inhibition of both Her2 and Her3, and blocks a tumor driver and its resistance mechanism. As a result, the DARPin interferes with both the proliferation and survival of tumor cells and triggers durable anti-tumor responses in vivo. DARPin treatment of Her2 positive tumors in mice show equivalent efficacy to Herceptin with faster kinetics; an effect that is magnified in Her2-low PDX tumors where the DARPin provides superior tumor control to Herceptin. Altogether, our data demonstrate the potential for the biparatopic DARPin to surpass some of the limitations of approved Her2 targeted agents, and warrants clinical investigation.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-30.

Autoantibodies against galectin-8: their specificity, association with lymphopenia in systemic lupus erythematosus and detection in rheumatoid arthritis and acute inflammation

The role of autoantibodies in the pathogenesis of systemic lupus erythematosus (SLE) has not been completely defined. From more than a hundred autoantibodies described in SLE, relatively few have been associated with clinical manifestations. The glycan-binding proteins of the galectin family can modulate the immune system. Anti-galectin autoantibodies thus could have functional and/or pathogenic implications in inflammatory processes and autoimmunity. We previously reported function-blocking autoantibodies against galectin-8 (Gal-8) in SLE. Here we tested these autoantibodies against a series of other human galectins and demonstrated their specificity for Gal-8, being detectable in 23% of 78 SLE patients. Remarkably, they associated with lymphopenia (50% of 18 anti-Gal-8-positive versus 18% of 60 anti-Gal-8-negative cases, Fisher’s Exact test two-tailed: P < 0.012). Lymphopenia is a common clinical manifestation in SLE, yet of unknown mechanism. In addition, six of eight patients with both lymphopenia and malar rash had anti-Gal-8 in their sera. Occurrence of these autoantibodies was not confined to SLE as we also found them in sera of patients with rheumatoid arthritis (16%) and septicemia (20%). This study thus establishes occurrence of specific anti-Gal-8 autoantibodies in autoimmune rheumatic diseases and in acute inflammation, with an apparent association to a clinical subset in SLE.

Epidemiological studies of leukaemia in children and young adults around nuclear facilities: a critical review

The existence of an increased risk of childhood leukaemia near nuclear installations is a recurrent issue. A review of the related epidemiological literature is presented here. Results for 198 nuclear sites throughout 10 countries were included in the review. In addition to local studies, 25 multi-site studies have been published for eight countries. A large variability was noticed in the quality of the data as well as in the definition of the study population and in the methods of analysis. Many studies present important limits that make the results difficult to interpret. The review confirms that some clusters of childhood leukaemia cases exist locally. However, results based on multi-site studies around nuclear installations do not indicate an increased risk globally. Many studies were launched to investigate possible origins of the observed clusters around specific sites, but up to now, none of the proposed hypotheses have explained them.

[Possibilities for process optimization in orthopedic surgery]

It is mandatory to include all professions involved in the operating room (OR) in any attempt to improve the process. Early and detailed planning, short interruptions to change OR patients and a variable end of the day combined with transparent decision hierarchies help to ensure that things run smoothly. Parallel processes are essential for accelerating the change of patients. The different duties and responsibilities have to be documented. This can be done either in the records of quality management or in a special OR statutes. The evaluation and analysis of process critical parameters, including surgery as well as anesthesiology, are essential for maintaining the continuous process of improvement.

Problemfeld der Notfallverlegungen beim Schlaganfall

BACKGROUND

Specific stroke subtypes like subarachnoid hemorrhages or malignant brain infarcts require immediate interventions, but treatment options are offered mainly in specialized centers. For this reason, interhospital transfers from primary hospitals need to be done without delay.

METHODS

The telemedic pilot project for integrative stroke care (TEMPiS) connects 2 stroke centers and 12 regional hospitals in Bavaria (Germany). Core elements are the implementation of stroke wards, telemedic consultation and improvement of emergency interhospital transfers. Organization of patient transports is offered by the central telemedic service. During the first 12 months of the continuing project all interhospital transfers initiated by the central telemedic service were prospectively documented. Emergency transports were analysed according to diagnosis, type of transport, distance and time delays.

RESULTS

A total of 252 interhospital transfers were recommended in teleconsultations; finally 221 transports took place. Median total duration of transfers (including the necessary arrangements) was 134 min (interquartile range: 105-219) for intracerebral hemorrhages (N = 58), 138 min (95-157) for subarachnoid hemorrhages (N = 31), 161 min (100-230) for malignant infarcts (N = 22) and 147 min (109-180) for suspected basilar artery occlusion (N = 28). Time from admission in the primary hospital to initiation of interhospital transfer was 135 min (median; interquartile range: 86-172), transport time was 81 min (60-116). Helicopter transport did not save time for transfer distances up to 50 kilometres, compared to transport via ambulance (including assistance of hospital physicians). Transport using a special intensive care vehicle was much more time consuming because of the longer transport preparation time.

CONCLUSION

Emergency transfers of stroke patients are time consuming. This may contribute to additional harm being done to severely ill patients. Faster organization and conduct of transports is required.

Detection of an unexpected subtelomeric 15q26.2 --> qter deletion in a little girl: clinical and cytogenetic studies

Unlike the small proximal 15q deletions causing Prader-Willi and/or Angelman syndrome, distal deletions of the terminal long arm of chromosome 15 have rarely been described. To the best of our knowledge, only four patients with a pure terminal 15q deletion have been documented in the literature. We report here on an unexpected abnormal hybridization pattern for the 15q specific subtelomeric control probe (clone 154P1) of the commercial SNRPN probe in a girl referred for suspicion of Angelman syndrome. Investigation by fluorescent in situ hybridization (FISH) using bacterial artificial chromosome (BAC) clones defined a partial monosomy 15q26.2 --> 15qter for a minimal critical region of approximately 5.7 Mb, which is the most distal de novo 15qter deletion reported to date. All the de novo 15qter deletion cases, including ours, presented with pre- and post-natal growth retardation related to the loss of one copy of the IGF1R gene. Based on the comparaison with the previous published cases and owing to the clinical phenotype of our patient, we define a new subtelomeric 15qter syndrome which would be characterized by intrauterine growth retardation and global post-natal growth failure, variable mental retardation, facial anomalies including relative micrognathia and triangular facies and minor malformations of the extremities including proximally placed thumbs, cubitus valgus, and brachydactyly with tappering of the digits.

Tumour necrosis factor-α up-regulates macrophage migration inhibitory factor expression in endometrial stromal cells via the nuclear transcription factor NF-κB

BACKGROUND

A series of controlled changes including proliferation, secretion and menstrual shedding occur in the human endometrium during every normal menstrual cycle. Macrophage migration inhibitory factor (MIF), a multifunctional cytokine with numerous proinflammatory, immunomodulatory and angiogenic properties, appears to be expressed in the human endometrium and to follow a regulated cycle phase-dependent expression, but the mechanisms underlying endometrial MIF expression remain to be fully elucidated.

METHODS AND RESULTS

Results from enzyme-linked immunosorbent assay (ELISA) demonstrated a significant dose- and time-dependent increase in MIF secretion by human endometrial cells in response to tumour necrosis factor-alpha (TNF-alpha) (0.1-100 ng/ml). This increase was also observed at the mRNA level as shown by reverse transcription (RT)-PCR. Curcumin (10(-8) mol/l), a known nuclear factor (NF)-kappaB inhibitor, inhibited the TNF-alpha-induced pIkappaB phosphorylation as shown by western blotting, NF-kappaB translocation into the nucleus as shown by electrophoretic mobility shift assay, and MIF synthesis and secretion as measured by ELISA and RT-PCR. The expression of a dominant-negative NF-kappaB inhibitor (IkappaB) significantly decreased the TNF-alpha-induced MIF promoter activity as analysed by transient cell transfection.

CONCLUSIONS

These results indicate clearly that TNF-alpha up-regulates the expression of MIF in endometrial stromal cells. This took place possibly through NF-kappaB activation, and may play an important role in the physiology of the human endometrium.

Stimulation of Macrophage Migration Inhibitory Factor Expression in Endometrial Stromal Cells by Interleukin 1, beta Involving the Nuclear Transcription Factor NFκB1

Endometriosis, the ectopic development of endometrial tissue, is, particularly in peritoneal endometriosis, believed to result from tubal reflux of menstrual tissue. The release of cytokines and growth factors by refluxed endometrial cells in response to peritoneal inflammatory stimuli may enhance the capability of endometrial cells to implant and grow into the peritoneal host tissue. Herein we report that interleukin 1 (IL1), a major proinflammatory cytokine that is overproduced by endometriosis women-derived peritoneal macrophages and found in elevated concentrations in the peritoneal fluid of patients with endometriosis, stimulates the synthesis and the secretion of macrophage migration inhibitory factor (MIF) by human endometrial stromal cells. IL1B (0.1-100 ng/ml) exerted dose- and time-dependent effects of MIF protein secretion and mRNA synthesis, as shown by ELISA and reverse transcription-polymerase chain reaction, respectively. IL1B appeared to induce MIF gene transcription via the kappaB nuclear transcription factor (NFkappaB), as shown by electrophoretic mobility shift assay and Western blot analysis of IkappaB phosphorylation. Curcumin (10(-8) M), which is known for inhibiting NFkappaB activation, inhibited IL1B-induced MIF secretion as well as NFkappaB nuclear translocation and DNA binding. Taken together, these findings clearly show that IL1B up-regulates the expression of MIF in endometrial stromal cells in vitro and acts via NFkappaB. This may play an important role in the physiology of the human endometrium and the pathophysiology of endometriosis considering the immunomodulatory properties of MIF as well as its role in cell growth, angiogenesis and tissue remodeling.

Cycle-dependent expression of macrophage migration inhibitory factor in the human endometrium

BACKGROUND

Macrophage migration inhibitory factor (MIF) is a multifunctional cytokine that was shown to promote angiogenesis and tissue remodelling. Our previous studies identified MIF as one of the principal bioactive molecules involved in endothelial cell proliferation released by ectopic endometrial cells.

METHODS AND RESULTS

In the present study, we examined the expression of MIF in the human endometrium and found an interesting distribution and temporal pattern of expression throughout the menstrual cycle. Immunoreactive MIF was predominant in the glands and surface epithelium. Dual immunofluorescence analysis further identified endothelial cells, macrophages and T-lymphocytes as cells markedly expressing MIF in the stroma. Quantitative assessment of MIF protein showed a regulated cycle phase-dependent expression pattern. MIF expression increased in the late proliferative/early Secretory phase of the menstrual cycle was moderate during the receptive phase or what is commonly called the implantation window before increasing again at the end of the cycle. This pattern paralleled MIF mRNA expression determined by northern blot.

CONCLUSION

The cycle phase-specific expression of MIF suggests a tight regulation and perhaps different roles for this factor in the reparative, reproductive and inflammatory-like processes that occur in human endometrium during every menstrual cycle.

Congenital gonadotropin deficiency in boys: management during childhood

OBJECTIVE

To analyze the features of boys with congenital gonadotropin deficiency (CGD), and to determine the value of plasma inhibin B and anti-Müllerian hormone (AMH) for predicting testicular function and the effect of testosterone treatment.

PATIENTS

We followed 19 boys for CGD, including five with Kallmann syndrome.

RESULTS

The boys were seen before 14 years of age for micropenis (9 boys) or later for delayed puberty (10 boys). No testis was palpable in the scrotum in 13 patients, bilaterally in seven of them. Luteinizing hormone (LH) peak after a gonadotropin releasing hormone (GnRH) test was between 0.5 and 5.6 U/l. Plasma inhibin B was low in the four patients evaluated at less than 1 year old. AMH was low in one of them and normal in four others. Of the older patients, three lad low plasma inhibin B and four had normal concentrations; plasma AMH was low in three of them and increased in four. Testosterone treatment restored penis length to normal in all patients.

CONCLUSIONS

Low plasma inhibin B and AMH concentrations may indicate testicular damage in boys with CGD.

Macrophage migration inhibitory factor expression is increased in pituitary adenoma cell nuclei

Macrophage migration inhibitory factor (MIF) is an essential regulator of the macrophage responses to endotoxin. MIF also has the ability to override the anti-inflammatory actions of glucocorticoids during an immune response, and is thus an important pro-inflammatory factor. The presence of MIF in cells of the anterior pituitary has been described, and high levels of MIF in other rapidly proliferating tIssues have also been demonstrated. It has been hypothesised that MIF release from these cells is influenced by the hypothalamo-pituitary-adrenal axis, and that ACTH and MIF are released simultaneously to exert counter-regulatory effects on cortisol. However, another intracellular role for MIF has also been suggested as it has been shown that MIF exerts an effect on the inhibitory cell cycle control protein p27 through an interaction with Jab1, a protein implicated in p27 degradation. We studied MIF expression in different normal and adenomatous human pituitary samples using immunohistochemistry and RT-PCR. There was evidence of co-immunoprecipitation of MIF with Jab1, suggesting an interaction of the two proteins. Our results showed that there is increased expression of MIF protein in the nuclei of all pituitary adenomas compared with normal tIssue (P=0.0067), but there was no statistically significant difference in nuclear MIF expression between the different adenoma types. Nuclear MIF expression correlated positively with p27 and its phosphorylated form in normal tIssue (P=0.0028 and P<0.0001); however, this relationship was not seen in the adenoma samples. Cytoplasmic expression of MIF was found to be variable both in normal and adenomatous samples, with no consistent pattern. MIF mRNA was demonstrated to be present in all tumour and normal samples studied. Somatotroph tumours showed higher MIF mRNA expression compared with normal pituitary or other types of adenomas. In conclusion, MIF is expressed in cell nuclei in pituitary adenomas to a greater extent than in normal pituitary tIssue. We speculate that it may play a role in the control of the cell cycle, but whether its higher level in adenomas is a cause or a consequence of the tumorigenic process remains to be clarified.

Macrophage migratory inhibitory factor (MIF) expression in acute graft-versus-host disease (GVHD) in allogeneic hemopoietic stem cell transplant recipients

Graft-versus-host disease (GVHD) is a major complication after hemopoietic stem cell transplantation (HSCT), but its pathogenesis remains uncertain. Macrophage migratory inhibitory factor (MIF) is an important mediator in the allo-immune reaction during renal transplantation, yet its role in hemopoietic stem cell transplantation (HSCT) remains unexplored. This study investigated the potential role of MIF in acute graft-versus-host disease (aGVHD) following allogeneic HSCT. Forty-six randomly selected patients undergoing autologous or allogeneic HSCT were studied. Immunohistochemistry and in situ hybridization were performed to examine tissue MIF mRNA and protein expression on skin and colonic biopsy specimens. The associated T cell and macrophage activation was also studied by immunohistochemical studies. A semi-quantitative method was used to assess MIF staining, as well as T cell and macrophage staining. Serial blood samples were analyzed by ELISA for serum MIF levels. Immunohistochemistry and in situ hybridization performed in 15 skin and 19 colonic biopsies from 17 patients who developed moderate to severe aGVHD showed a significant increase in MIF mRNA and protein expression compared with normal controls (seven skin and five colonic biopsies). MIF was localized within the epidermis and the vascular area of skin, but diffusely expressed in the entire thickness of colon. Macrophage and T lymphocyte infiltration was confined to areas of strong MIF expression. Serial analysis by ELISA showed that only patients who developed aGVHD (n = 19) exhibited an increase (two- to three-fold) in serum MIF during HSCT, but not in the allogeneic HSCT recipients without aGVHD (n = 7) or those who received autologous HSCT (n = 8). In 14 out of 19 patients, serum MIF peaked before the onset of aGVHD. Local and systemic up-regulation of MIF expression is associated with the occurrence of acute GVHD. Its pathogenetic role remains to be further determined.

Macrophage migration inhibitory factor in rheumatoid arthritis: clinical correlations

OBJECTIVE

Cytokines play an important role in the pathology of rheumatoid arthritis (RA). Macrophage migration inhibitory factor (MIF) is a cytokine with a broad spectrum of actions, including induction of monocyte tumour necrosis factor alpha (TNF-alpha). Evidence of the expression and proinflammatory activity of MIF has recently been demonstrated in RA synovium and in animal models of RA. We wished to assess the relationship between MIF expression in synovium and clinical disease.

METHODS

Computer-assisted analysis of the cytokine content of arthroscopically obtained biopsies of RA synovium, using paired samples from eight patients with active and inactive/treated disease, was compared with documented clinical parameters.

RESULTS

Synovial MIF immunostaining correlated strongly with disease activity as measured by CRP concentration. Reductions in clinical disease parameters, including CRP, tender and swollen joint counts, were accompanied by significant reductions in synovial MIF. Synovial TNF-alpha, transforming growth factor beta (TGF-beta) and interleukin (IL) 10 also showed a significant reduction in association with reduced disease activity, while IL-1 beta and IL-1 receptor agonist did not.

CONCLUSION

The correlation of synovial MIF with disease activity corroborates existing evidence of the role of this cytokine in RA. The demonstration that only MIF and TNF-alpha show significant variation in synovial cytokine content with clinical remission suggests that MIF is an important member of the cytokine hierarchy in RA.

Response of serum macrophage migration inhibitory factor levels to stimulation or suppression of the hypothalamo-pituitary-adrenal axis in normal subjects and patients with Cushing's disease

Macrophage migration inhibitory factor (MIF) is a proinflammatory pituitary and immune cell cytokine and a critical mediator of septic shock. It has been reported that MIF is secreted in parallel with ACTH from the pituitary in response to stress or inflammatory stimuli. MIF release from immune cells is also induced rather than inhibited by glucocorticoids. It has therefore been suggested that MIF may be a novel counterregulatory hormone of glucocorticoid action that acts both as a paracrine and endocrine modulator of host responses. We have measured circulating MIF levels, using a human MIF ELISA, in normal subjects and patients under numerous pathophysiological conditions. Serum MIF was measured in normal subjects who underwent stimulation of the hypothalamo-pituitary-adrenal axis with an insulin tolerance test (n = 8), a CRH-stimulation test (n = 5), a short synacthen test (n = 5), and following a low-dose dexamethasone suppression test (n = 6). We also sampled from a peripheral vein and both inferior petrosal sinuses before and after CRH stimulation in four patients with a histologically proven diagnosis of Cushing's disease. Immunostaining of the pituitary tumors for MIF was also performed. In normal subjects serum MIF levels did not rise in parallel with cortisol during the insulin tolerance or CRH test or after administration of synthetic ACTH. In all subjects cortisol levels became undetectable after the low-dose dexamethasone suppression test, and no consistent change was observed in serum MIF levels during the test. In patients with Cushing's disease, there was no basal central-to-peripheral gradient in MIF, and no consistent changes occurred in serum MIF levels in either the left or right inferior petrosal sinus after CRH stimulation; however, immunostaining of the surgically removed pituitary tumors from the same patients showed strong staining for both ACTH and MIF. These results show that in humans acute modulation of the hypothalamo-pituitary-adrenal axis does not significantly alter circulating MIF levels. In addition, ACTH-secreting pituitary tumors that express MIF do not release MIF either spontaneously or in response to CRH stimulation, and there is no gradient for MIF in the venous drainage of the pituitary. Our study suggests that the pituitary gland is not the major contributor to circulating MIF; an autocrine or paracrine role for pituitary-derived MIF is more likely.