Qualitatively speaking: Deciding how much data and analysis is enough

As I traverse my (post) doctoral journey, reworking my thesis into publications, I was immersed again in a debate around the utility of the concept of data saturation. I believe this debate to be emblematic of the process of unlearning and relearning that unfolded during my doctoral journey, coming from a biomedical sciences background into qualitative educational research.

Disease modifying agent related skin reactions in multiple sclerosis: prevention, assessment, and management

Background: The objective for this article is to highlight some of the adverse skin manifestations associated with injectable disease modifying therapy for multiple sclerosis (MS). Early identification and intervention can often lead to minimal consequences and prolonged patient tolerance and compliance with these agents. A t the University of Texas Southwestern Medical C enter at Dallas and Texas Neurology in Dallas we actively follow appro ximately 5000 MS patients. The majority of our patients with relapsing-remitting MS (RRMS) or secondary progressive MS (SPMS) are treated with one of the currently available disease modifying agents (DMA s). O ur experience with these patients, and the challenges they face in continuing long-term treatment, constitutes the basis of our proposed treatment strategies. Conclusion: Skin reactio ns in response to injectable DMA therapy in MS are generally mild. However, some reactio ns can evolve into potentially serious lesions culminating in infection, necro sis, and in some circumstances requiring surgical repair.

Prevalence and predictors of hospital prealerting in acute stroke: a mixed methods study

Background

Thrombolysis can significantly reduce the burden of stroke but the time window for safe and effective treatment is short. In patients travelling to hospital via ambulance, the sending of a ‘prealert’ message can significantly improve the timeliness of treatment.

Objective

Examine the prevalence of hospital prealerting, the extent to which prealert protocols are followed and what factors influence emergency medical services (EMS) staff's decision to send a prealert.

Methods

Cohort study of patients admitted to two acute stroke units in West Midlands (UK) hospitals using linked data from hospital and EMS records. A logistic regression model examined the association between prealert eligibility and whether a prealert message was sent. In semistructured interviews, EMS staff were asked about their experiences of patients with suspected stroke.

Results

Of the 539 patients eligible for this study, 271 (51%) were recruited. Of these, only 79 (29%) were eligible for prealerting according to criteria set out in local protocols but 143 (53%) were prealerted. Increasing number of Face, Arm, Speech Test symptoms (1 symptom, OR 6.14, 95% CI 2.06 to 18.30, p=0.001; 2 symptoms, OR 31.36, 95% CI 9.91 to 99.24, p<0.001; 3 symptoms, OR 75.84, 95% CI 24.68 to 233.03, p<0.001) and EMS contact within 5 h of symptom onset (OR 2.99, 95% CI 1.37 to 6.50 p=0.006) were key predictors of prealerting but eligibility for prealert as a whole was not (OR 1.92, 95% CI 0.85 to 4.34 p=0.12). In qualitative interviews, EMS staff displayed varying understanding of prealert protocols and described frustration when their interpretation of the prealert criteria was not shared by ED staff.

Conclusions

Up to half of the patients presenting with suspected stroke in this study were prealerted by EMS staff, regardless of eligibility, resulting in disagreements with ED staff during handover. Aligning the expectations of EMS and ED staff, perhaps through simplified prealert protocols, could be considered to facilitate more appropriate use of hospital prealerting in acute stroke.

Abstract P2-11-12: Novel protocol combining metronomic nant-paclitaxel with HER2-targeted natural killer cells (innate immunotherapy) for HER2-positive metastatic breast cancer

Background. Natural killer (NK) cells are an important effector cell type for adoptive cancer immunotherapy. Phase 1 clinical trials in patients with advanced cancers demonstrated the safety of unmodified, activated NK-92 cells (aNK), with no evidence of cytokine storm from 18 infusions delivered over 6 months; clinical responses were observed in a subset of patients. Like T cells, NK cells can be engineered to express chimeric antigen receptors (CARs) to enhance their antitumor activity. A stable clonal HER2-specific NK-92 cell line (HER2.taNK) mediated selective and sequential killing of HER2-expressing MDA-MB-453 cells in vitro (Schönfeld. MolTher. 2015;23:330-338). In addition, HER2.taNK cells were enriched in MDA-MB-453/EGFP xenografts and reduced the number of pulmonary metastasis in a renal cell carcinoma model, suggesting that HER2.taNK cells are a promising clinical candidate for use in adoptive cancer immunotherapy. Metronomic (low-dose, continuous) chemotherapy can be more effective than high-dose therapy in patients with advanced breast cancer (Montagna. Canc. Treat. Rev. 2014;40:922-950). Here we evaluate HER2.taNK cells in combination with metronomic nant-paclitaxel (lyophilized polymeric micellar formulation of paclitaxel) in a mouse model of HER2-positive breast cancer to determine the feasibility of a human clinical trial of HER2.taNK in combination with metronomic nant-paclitaxel.

Methods. HER2.taNK cells were generated as described previously (Schönfeld. MolTher. 2015;23:330-338). MDA-MB-453 cells were implanted into the mammary fat pads of female nude mice. When tumors reached 100 mm3, mice were divided into 6 groups of 5 mice and dosed (IV) with saline (10 mL/kg, qd x 15), nant-paclitaxel (2.5-4 mg/kg q2d x 15), γ-irradiated (5 Gy) HER2.taNK cells (1 x 107 cells, days 1, 3, 5, and 8), or nant-paclitaxel + γ-irradiated (5 Gy) HER2.taNK cells–γ-irradiation is a potential safety measure for clinical application and prevents HER2.taNK cell replication while preserving antitumor activity. Tumor size and animal weights were measured every other day post-implantation.

Results: Results obtained 20 days post-treatment are shown in the table. Nant-paclitaxel alone and HER2.taNK alone significantly inhibited tumor growth. The combination of nant-paclitaxel + HER2.taNK led to significant tumor regressions (p&lt;0.05).

Treatment Dose T/C (%) P-ValueSalinenant-paclitaxel5 mg/kg-26.7 P &lt; 0.05 (vs saline) HER2.taNK1 x 107 cells-22.2 P &lt; 0.05 (vs saline)nant-paclitaxel +5 mg/kg +-60.0P &lt; 0.05 (vs nant-paclitaxel)HER2.taNK1 x 107 cellsP &lt; 0.05 (vs HER2.taNK)

Conclusions: Single agent nant-paclitaxel and HER2.taNK were similarly effective at inhibiting tumor growth in this mouse model of HER2+ breast cancer. The combination of nant-paclitaxel + HER2.taNK appeared to be synergistic resulting in tumor regressions and significantly better efficacy vs each agent alone. This study illustrates the potential for combining metronomic low-dose chemotherapy with NK-based immunotherapy in a clinical trial of patients with metastatic breast cancer.

Citation Format: Rabizadeh S, Simon B, Klingemann H, Sims D, Weiss R, Soon-Shiong P. Novel protocol combining metronomic nant-paclitaxel with HER2-targeted natural killer cells (innate immunotherapy) for HER2-positive metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-11-12.

Care of children with diabetes as inpatients: frequency of admissions, clinical care and patient experience

AIM

Hospital inpatient care for children with diabetes is frequently mentioned by parents as unsatisfactory. The aim of this study was to examine the reasons for inpatient admission of children with diabetes and to understand patient and carer experience in order to improve services.

METHODS

Questionnaires were given to medical teams, parents and children during admissions of children with diabetes under 16 years of age in three regions of England.

RESULTS

There were 401 admissions over 6 months from 3247 patients: 334 (83%) emergency admissions and 59 (15%) elective; the reason is unknown in eight (2%). One hundred and forty-three (36%) were emergency admissions with diabetic ketoacidosis/hyperglycaemia. Clinical teams reported adverse events around insulin administration in 25, hypoglycaemia (sometimes recurrent) in 120 and food provision in 14 admissions. Others included seven incidents around elective surgery. Diabetes clinical teams were not always informed about admissions and only 33% were informed within 2 h. Parents and children reported fewer problems: 62% were involved in care most of the time and 87% were able to give insulin. Most negative comments were about poor staff management of out-of-range blood glucose levels, knowledge of insulin pumps and care of children waiting in the emergency department.

CONCLUSIONS

There were a large number of admissions and the majority were emergencies. Parents generally felt that they receive good care, although with some lack of knowledge amongst the ward staff. There were an unacceptable number of adverse incidents reported. We recommend that education of ward staff in diabetes is carried out regularly with reference to the standards of care.

Integrative molecular and functional profiling of ERBB2-amplified breast cancers identifies new genetic dependencies

Overexpression of the receptor tyrosine kinase ERBB2 (also known as HER2) occurs in around 15% of breast cancers and is driven by amplification of the ERBB2 gene. ERBB2 amplification is a marker of poor prognosis, and although anti-ERBB2-targeted therapies have shown significant clinical benefit, de novo and acquired resistance remains an important problem. Genomic profiling has demonstrated that ERBB2+ve breast cancers are distinguished from ER+ve and 'triple-negative' breast cancers by harbouring not only the ERBB2 amplification on 17q12, but also a number of co-amplified genes on 17q12 and amplification events on other chromosomes. Some of these genes may have important roles in influencing clinical outcome, and could represent genetic dependencies in ERBB2+ve cancers and therefore potential therapeutic targets. Here, we describe an integrated genomic, gene expression and functional analysis to determine whether the genes present within amplicons are critical for the survival of ERBB2+ve breast tumour cells. We show that only a fraction of the ERBB2-amplified breast tumour lines are truly addicted to the ERBB2 oncogene at the mRNA level and display a heterogeneous set of additional genetic dependencies. These include an addiction to the transcription factor gene TFAP2C when it is amplified and overexpressed, suggesting that TFAP2C represents a genetic dependency in some ERBB2+ve breast cancer cells.

Abstract P5-05-02: Whole Genome In Vivo RNA Interference Screening Identifies the Leukemia Inhibitory Factor Receptor as a Novel Breast Tumor Suppressor

Background: Cancer is caused by mutations in oncogenes and tumor suppressor genes resulting in the deregulation of processes fundamental to the normal behavior of cells. The identification and characterization of oncogenes and tumor suppressors has led to new treatment strategies that have significantly improved cancer outcome. The advent of next generation sequencing has allowed the elucidation of the fine structure of cancer genomes, however, the identification of pathogenic changes is complicated by the inherent genomic instability of cancer cells. Therefore, functional approaches for the identification of novel genes involved in the initiation and development of tumors are critical. Methods: In order to identify functionally important tumor suppressor genes we have conducted the first human whole genome in vivo RNA interference (RNAi) screen. Partially transformed human mammary epithelial cells (HMLEs), which do not form tumors in immunodeficient mice, were infected with the Expression Arrest™ GIPZ lentiviral shRNA library consisting of 62,000 shRNAs targeting the whole human genome, and injected into the mammary fat pad of immunodeficient mice. shRNAs that silenced tumor suppressor genes fully transformed the mammary epithelial cells resulting in tumor formation. Candidate tumor suppressor genes were identified by PCR amplification and sequencing of tumor integrated shRNAs. For validation, candidate tumor suppressor genes were silenced in HMLEs and ectopically expressed in fully transformed breast cancer cells. The effect of modifying gene expression on the transformed phenotype was assessed using soft agar colony formation assays. Clinical significance was determined by comparing expression in normal and cancerous human breast tissue using Oncomine Research. Results and Discussion: Using our novel approach, we identify previously validated tumor suppressor genes including TP53 and MNT, as well as several novel candidate tumor suppressor genes including leukemia inhibitory factor receptor (LIFR). Silencing LIFR expression with multiple shRNA constructs fully transformed human mammary epithelial cells resulting in enhanced colony formation in soft agar (P&lt;0.05). Furthermore, overexpression of LIFR significantly inhibited colony formation in soft agar of fully transformed MDA231 and MCF7 breast cancer cells (P&lt;0.01). In addition, our analysis of clinical data revealed that LIFR expression is significantly decreased in a large percentage of human cancers including breast (P&lt;0.0001), lung (P&lt;0.0001), hepatocellular (P&lt;0.0001) and gastrointestinal tumors (P&lt;0.0001). These results validate LIFR as a previously unidentified highly significant tumor suppressor, and also demonstrate the power of whole genome in vivo RNAi screens as a method for identifying novel genes regulating tumorigenesis.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-05-02.

Protective effect of vitamin E on intraventricular haemorrhage in the newborn

Forty-four consecutively born babies of birth weights under 1751 g were randomly selected to receive a daily intramuscular injection of vitamin E (all-rac-alpha-tocopheryl acetate) from the day of birth (Day 0) until Day 3, or were allocated to a non-supplemented control group. Frequent ultrasound examinations of the brain were made during the first week of life and babies were classified as having 'no haemorrhage', 'subependymal haemorrhage (SEH) only' or 'intraventricular haemorrhage' (IVH). The incidence of SEH or IVH was similar in supplemented (42.9%) and control babies (43.5%). SEH or IVH was observed only in babies of less than 32 weeks gestation; when only babies under 32 weeks were considered, IVH was less common in those supplemented (18.8%) than in the controls (56.3%). Babies with IVH had lower median plasma vitamin E concentrations when compared with babies without any haemorrhage and compared with those with only SEH. Three supplemented babies suffered IVH and they were the three with the lowest plasma vitamin E concentrations among the babies supplemented with vitamin E from Day 0 to Day 3. We speculate that vitamin E protects endothelial cell membranes of capillaries in the subependymal layer of the brain against oxidative damage and disruption and thereby limits the magnitude of haemorrhage in the subependymal layer, and reduces the risk of extension into the ventricles.

The effects of paclitaxel (PTX) and 2-methoxyestradiol (2-ME2) on tumor oxygenation and HIF-1α in breast cancer

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Background: Radiation activates HIF-1a via a free radical mediated mechanism associated with reoxygenation. This response could be inhibited, resulting in reduced tumor vascularity and proliferation. Preclinical breast cancer models and a Phase Ib clinical trial (CT) were employed to look at the effects of chemo with or without an oral HIF-1a inhibitor, 2-ME2 (EntreMed) on tumor oxygenation and HIF-1a. Methods: Preclinical models of chemo effects on HIF-1a/oxygenation used 4T1 tumors and either doxorubicin (DOX) or cyclophosphamide (CTX). In addition, MDA-MB-231 tumors were treated with 2-ME2 (5days), and HIF-1a/MVD was assessed. In the CT, up to 15 pts with metastatic breast cancer, and biopsiable (>2 cm) non-bone sites were eligible. Tx was: D 1: PTX, 90 mg/m2; D 8: PTX, 90 mg/m2 with 2-ME2 (cohorts of 1,000/1,250/1,500 mg, qid). PTX was given 3 out of 4 wks. Bxs were done at enrollment, D8 (post-PTX), and D22 (post-PTX/2-ME2). Tumors were examined for changes in HIF-1a and CA9 levels, MVD, and genomic signatures of hypoxia. Plasma was obtained for osteoponin, PAI-1, and VEGF. Results: DOX and CTX both led to increases in HIF-1a, oxygenation, vascularity, and proliferation 4–10 days post treatment in the 4T1 model, while 2-ME2 reduced HIF-1a and MVD post treatment (5 d) in the MDA-MB-231 model. The CT opened in 6–2006, 9 pts have consented and 8 pts have undergone sequential biopsies and accrual continues. No DLT have been seen. Biopsy sites include chest wall, liver, and LN. Sufficient tissue/RNA/plasma has been obtained and the planned analyses will be presented. Conclusions: HIF-1a and tumor oxygenation appear to be modulated as a response to chemotherapy. The combination of PTX and 2-ME2 is clinically active, well-tolerated, and could serve as one of the first approaches to target HIF-1a in order to optimize therapy. Supported by Komen Grant BCTR0504044.

[Table: see text]

The human auditory brainstem response to high click rates: aging effects

In 1999 J. Walton, M. Orlando, & R. Burkard (Hearing Research, 127, 86-94) investigated aging effects on auditory brainstem response (ABR) wave V latency using a tone-on-toneburst forward-masking paradigm. They found that at short forward-masking intervals, wave V latency shift was greater in normal-hearing older adults than in normal-hearing young adults for moderate level, high-frequency toneburst maskers and probes. It was not possible to evaluate wave I latency because stimulation and recording procedures did not produce a consistently observable wave I. In order to optimize the recording of wave I, the present study used a high-level (115 dB pSPL) click stimulus, combined with a tympanic membrane inverting electrode, and investigated the latencies and amplitudes of waves I and V across click rate. Young adults had hearing thresholds within normal limits, whereas older adults had normal hearing or mild threshold elevation. All data were collected and analyzed with a Nicolet Bravo. Using conventional recording procedures, ABRs were obtained at click rates of 11, 25, 50, and 75 Hz. Using maximum length sequences (MLSs), ABRs were obtained at 100, 200, 300, 400, and 500 Hz. Results across age groups were very similar. With increasing click rate, peak latencies increased, the I-V interval increased and peak amplitudes decreased. The most notable difference between age groups was that wave I amplitude was substantially smaller in the older subjects. It appears that changes in the ABR with increasing rate are remarkably similar in young and older adults when audiometric thresholds are normal or near-normal in both age groups.

Drosophila transcription factor AP-2 in proboscis, leg and brain central complex development

We report loss- and gain-of-function analyses that identify essential roles in development for Drosophila transcription factor AP-2. A mutagenesis screen yielded 16 lethal point mutant alleles of dAP-2. Null mutants die as adults or late pupae with a reduced proboscis, severely shortened legs (~30% of normal length) lacking tarsal joints, and disruptions in the protocerebral central complex, a brain region critical for locomotion. Seven hypomorphic alleles constitute a phenotypic series yielding hemizygous adults with legs ranging from 40–95% of normal length. Hypomorphic alleles show additive effects with respect to leg length and viability; and several heteroallelic lines were established. Heteroallelic adults have moderately penetrant defects that include necrotic leg joints and ectopic growths (sometimes supernumerary antennae) invading medial eye territory. Several dAP-2 alleles with DNA binding domain missense mutations are null in hemizygotes but have dominant negative effects when paired with hypomorphic alleles. In wild-type leg primordia, dAP-2 is restricted to presumptive joints. Ectopic dAP-2 in leg discs can inhibit but not enhance leg elongation indicating that functions of dAP-2 in leg outgrowth are region restricted. In wing discs, ectopic dAP-2 cell autonomously transforms presumptive wing vein epithelium to ectopic sensory bristles, consistent with an instructive role in sensory organ development. These findings reveal multiple functions for dAP-2 during morphogenesis of feeding and locomotor appendages and their neural circuitry, and provide a new paradigm for understanding AP-2 family transcription factors.