Combination of computational new approach methodologies for enhancing evidence of biological pathway conservation across species

The ability to predict which chemicals are of concern for environmental safety is dependent, in part, on the ability to extrapolate chemical effects across many species. This work investigated the complementary use of two computational new approach methodologies to support cross-species predictions of chemical susceptibility: the US Environmental Protection Agency Sequence Alignment to Predict Across Species Susceptibility (SeqAPASS) tool and Unilever's recently developed Genes to Pathways - Species Conservation Analysis (G2P-SCAN) tool. These stand-alone tools rely on existing biological knowledge to help understand chemical susceptibility and biological pathway conservation across species. The utility and challenges of these combined computational approaches were demonstrated using case examples focused on chemical interactions with peroxisome proliferator activated receptor alpha (PPARα), estrogen receptor 1 (ESR1), and gamma-aminobutyric acid type A receptor subunit alpha (GABRA1). Overall, the biological pathway information enhanced the weight of evidence to support cross-species susceptibility predictions. Through comparisons of relevant molecular and functional data gleaned from adverse outcome pathways (AOPs) to mapped biological pathways, it was possible to gain a toxicological context for various chemical-protein interactions. The information gained through this computational approach could ultimately inform chemical safety assessments by enhancing cross-species predictions of chemical susceptibility. It could also help fulfill a core objective of the AOP framework by potentially expanding the biologically plausible taxonomic domain of applicability of relevant AOPs.

Genes-to-Pathways Species Conservation Analysis: Enabling the Exploration of Conservation of Biological Pathways and Processes Across Species

The last two decades have witnessed a strong momentum toward integration of cell-based and computational approaches in safety assessments. This is fueling a global regulatory paradigm shift toward reduction and replacement of the use of animals in toxicity tests while promoting the use of new approach methodologies. The understanding of conservation of molecular targets and pathways provides an opportunity to extrapolate effects across species and ultimately to determine the taxonomic applicability domain of assays and biological effects. Despite the wealth of genome-linked data available, there is a compelling need for improved accessibility, while ensuring that it reflects the underpinning biology. We present the novel pipeline Genes-to-Pathways Species Conservation Analysis (G2P-SCAN) to further support understanding on cross-species extrapolation of biological processes. This R package extracts, synthetizes, and structures the data available from different databases, that is, gene orthologs, protein families, entities, and reactions, linked to human genes and respective pathways across six relevant model species. The use of G2P-SCAN enables the overall analysis of orthology and functional families to substantiate the identification of conservation and susceptibility at the pathway level. In the present study we discuss five case studies, demonstrating the validity of the developed pipeline and its potential use as species extrapolation support. We foresee this pipeline will provide valuable biological insights and create space for the use of mechanistically based data to inform potential species susceptibility for research and safety decision purposes. Environ Toxicol Chem 2023;42:1152-1166. © 2023 UNILEVER GLOBAL IP LTD. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Are non-animal systemic safety assessments protective? A toolbox and workflow

An important question in toxicological risk assessment is whether non-animal new approach methodologies (NAMs) can be used to make safety decisions that are protective of human health, without being overly conservative. In this work, we propose a core NAM toolbox and workflow for conducting systemic safety assessments for adult consumers. We also present an approach for evaluating how protective and useful the toolbox and workflow are by benchmarking against historical safety decisions. The toolbox includes physiologically based kinetic (PBK) models to estimate systemic C_max levels in humans, and 3 bioactivity platforms, comprising high-throughput transcriptomics, a cell stress panel, and in vitro pharmacological profiling, from which points of departure are estimated. A Bayesian model was developed to quantify the uncertainty in the C_max estimates depending on how the PBK models were parameterized. The feasibility of the evaluation approach was tested using 24 exposure scenarios from 10 chemicals, some of which would be considered high risk from a consumer goods perspective (eg, drugs that are systemically bioactive) and some low risk (eg, existing food or cosmetic ingredients). Using novel protectiveness and utility metrics, it was shown that up to 69% (9/13) of the low risk scenarios could be identified as such using the toolbox, whilst being protective against all (5/5) the high-risk ones. The results demonstrated how robust safety decisions could be made without using animal data. This work will enable a full evaluation to assess how protective and useful the toolbox and workflow are across a broader range of chemical-exposure scenarios.

Real-world treatment sequencing and survival in previously treated advanced renal cell carcinoma patients receiving nivolumab monotherapy: a UK retrospective cohort study

Background

The CheckMate 025 trial established nivolumab monotherapy as one of the standards of care in previously treated advanced or metastatic renal cell carcinoma (aRCC). However, supporting real-world data is lacking. This study investigated characteristics, treatment sequences and clinical outcomes of patients who received nivolumab monotherapy for previously treated aRCC in the UK.

Methods

This was a retrospective cohort study of aRCC patients treated with nivolumab at second line or later (2L +) at 4 UK oncology centres. Eligible patients commenced nivolumab (index date) between 01 March 2016 and 30 June 2018 (index period). Study data were extracted from medical records using an electronic case report form. Data cut-off (end of follow-up) was 31 May 2019.

Results

In total, 151 patients were included with median follow-up of 15.2 months. Mean age was 66.9 years, male preponderance (72.2%), and mostly Eastern Cooperative Oncology Group performance status grade 0–1 (71.5%). Amongst 112 patients with a known International Metastatic RCC Database Consortium score, distribution between favourable, intermediate, and poor risk categories was 20.5%, 53.6%, and 25.9% respectively.

The majority of patients (n = 109; 72.2%) received nivolumab at 2L, and these patients had a median overall survival (OS) of 23.0 months [95% confidence interval: 17.2, not reached]. All patients who received nivolumab at 2L had received TKIs at 1L. Amongst the 42 patients (27.8%) who received nivolumab in third line or later (3L +) the median OS was 12.4 months [95% CI: 8.8, 23.2]. The most common reasons for nivolumab discontinuation were disease progression (2L: 61.2%; 3L: 68.8%) and adverse events (2L: 34.7%; 3L: 28.1%).

Conclusion

This study provides real-world evidence on the characteristics, treatment sequences, and outcomes of aRCC patients who received 2L + nivolumab monotherapy in the UK. Nivolumab-specific survival outcomes were similar to those achieved in the CheckMate 025 trial.

AB0347 TREATMENT RESPONSE WITH ABATACEPT PLUS METHOTREXATE TREATMENT FOR RHEUMATOID ARTHRITIS: REAL-WORLD EVIDENCE FROM THE UK

Background

A previous real-world study has reported the characteristics, treatment patterns and clinical outcomes of patients with rheumatoid arthritis (RA) who received abatacept in UK clinical practice.1,2 However, many of the eligible population received abatacept monotherapy rather than as indicated. A subgroup analysis of patients treated with abatacept in combination with methotrexate (ABA + MTX) was therefore undertaken to explore the treatment effect in this specific patient population.

Objectives

Present a subgroup analysis describing the clinical outcomes of patients with RA treated with ABA + MTX in UK real-world clinical practice.

Methods

A multi-centre, retrospective observational study was undertaken in patients with RA treated with abatacept at any line of therapy between 1 January 2013 and 31 December 2017, across four UK centres. Data were collected from patient medical records from index date, defined as the date of first bDMARD initiation, to most recent RA clinic visit, death or end of study (31 December 2017). Clinical outcomes (disease activity and response to treatment) were measured using the 28-joint Disease Activity Score based on erythrocyte sedimentation rate (DAS28-ESR) and European League Against Rheumatism (EULAR) response criteria. Patients that received abatacept outside indication (i.e., without concomitant methotrexate) were retrospectively excluded from the analysis dataset. Statistical analyses for the ABA + MTX subgroup were repeated in line with the methodology previously reported.1,2

Results

This subgroup analysis included 133 patients, of 213 patients included in the original study, with RA that received ABA + MTX (mean age 54.6 years, 77.4% female, 7.5 years mean duration of RA at index date). At index date, 64.8% of patients were positive for both anti-citrullinated protein antibodies (ACPA) and rheumatoid factor (RF), where data were available. In total, 77.8% of patients were categorised with high disease activity at index, with mean DAS28-ESR of 6.2 (SD 1.1).

Irrespective of line of treatment (LOT), patients tended to have a more favourable distribution of good/moderate/no EULAR response when receiving ABA + MTX (31.8%/34.1%/34.1%; n=44) compared with receipt of other bDMARDs (12.7%/36.4%/50.9%; n=55) at 6 months. Similarly, a favourable distribution of good/moderate/no EULAR response in favour of those receiving ABA + MTX compared with other bDMARDs was observed at 12 months (30.6%/41.7%/27.8% versus 20.0%/35.0%/45.0%, respectively).

Patients receiving ABA + MTX remained on treatment for significantly longer than patients in receipt of other bDMARDs as first LOT (median time on treatment 53.4 vs 18.1 months; p<0.01). A similar trend was observed at second LOT, although differences were not statistically significant (median time on treatment 40.1 vs 19.7 months; p =0.08).

Conclusion

Patients with RA who received treatment with any bDMARDs, including ABA + MTX, experienced reduced disease activity. However, those receiving ABA + MTX persisted with treatment significantly longer than when receiving other bDMARDs.

References

[1]Choy, E. et al. Outcomes in rheumatoid arthritis patients treated with abatacept: a UK multi-centre observational study. BMC Rheumatology5, 3, doi:10.1186/s41927-020-00173-0 (2021).

[2]Henning, S. et al. AB0295 CHANGE IN DISEASE ACTIVITY AND TREATMENT RESPONSE AFTER ABATACEPT TREATMENT FOR RHEUMATOID ARTHRITIS: REAL-WORLD EVIDENCE FROM THE UK. Annals of the Rheumatic Diseases79, 1446-1447, doi:10.1136/annrheumdis-2020-eular.1069 (2020).

Acknowledgements

This analysis was supported by Bristol-Myers Squibb.

Disclosure of Interests

Ernest Choy Speakers bureau: Abbvie, Amgen, Bristol Myer Squibbs, Chugai Pharma, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, Regeneron, Roche, Sanofi, and UCB, Consultant of: Abbvie, Amgen, Biogen, Biocon, Chugai Pharma, Eli Lilly, Gilead, Janssen, Merck Serono, Novartis, Pfizer, Regeneron, Roche, R-Pharm and Sanofi, Grant/research support from: Bio-Cancer, Biogen, Novartis, Pfizer, Roche, Sanofi and UCB, Sadie Henning Shareholder of: Bristol Myers Squibb, Employee of: Yes, Bristol Myers Squibb, Marie Brazil Shareholder of: Bristol Myers Squibb, Employee of: Currently an employee of Bristol Myers Squibb, Kevin Pollock Shareholder of: Yes - Bristol Myers Squibb, Speakers bureau: Yes - Merck Sharp & Dohme and Glaxo Smith Kline, Consultant of: Yes - Merck Sharp & Dohme, Employee of: Yes – currently employed by Bristol Myers Squibb, Lara Groves Grant/research support from: I am an employee of Health Economics and Outcomes Research Ltd., Cardiff, UK, who received fees from Bristol Myers Squibb in relation to this study, Daniel Sugrue Grant/research support from: I am an employee of Health Economics and Outcomes Research Ltd., Cardiff, UK, who received fees from Bristol Myers Squibb in relation to this study, John Houghton Grant/research support from: I am an employee of Health Economics and Outcomes Research Ltd., Cardiff, UK, who received fees from Bristol Myers Squibb in relation to this study

Latent Variables Capture Pathway-Level Points of Departure in High-Throughput Toxicogenomic Data

Estimation of points of departure (PoDs) from high-throughput transcriptomic data (HTTr) represents a key step in the development of next-generation risk assessment (NGRA). Current approaches mainly rely on single key gene targets, which are constrained by the information currently available in the knowledge base and make interpretation challenging as scientists need to interpret PoDs for thousands of genes or hundreds of pathways. In this work, we aimed to address these issues by developing a computational workflow to investigate the pathway concentration–response relationships in a way that is not fully constrained by known biology and also facilitates interpretation. We employed the Pathway-Level Information ExtractoR (PLIER) to identify latent variables (LVs) describing biological activity and then investigated in vitro LVs’ concentration–response relationships using the ToxCast pipeline. We applied this methodology to a published transcriptomic concentration–response data set for 44 chemicals in MCF-7 cells and showed that our workflow can capture known biological activity and discriminate between estrogenic and antiestrogenic compounds as well as activity not aligning with the existing knowledge base, which may be relevant in a risk assessment scenario. Moreover, we were able to identify the known estrogen activity in compounds that are not well-established ER agonists/antagonists supporting the use of the workflow in read-across. Next, we transferred its application to chemical compounds tested in HepG2, HepaRG, and MCF-7 cells and showed that PoD estimates are in strong agreement with those estimated using a recently developed Bayesian approach (cor = 0.89) and in weak agreement with those estimated using a well-established approach such as BMDExpress2 (cor = 0.57). These results demonstrate the effectiveness of using PLIER in a concentration–response scenario to investigate pathway activity in a way that is not fully constrained by the knowledge base and to ease the biological interpretation and support the development of an NGRA framework with the ability to improve current risk assessment strategies for chemicals using new approach methodologies.

A Next-Generation Risk Assessment Case Study for Coumarin in Cosmetic Products

Next-Generation Risk Assessment is defined as an exposure-led, hypothesis-driven risk assessment approach that integrates new approach methodologies (NAMs) to assure safety without the use of animal testing. These principles were applied to a hypothetical safety assessment of 0.1% coumarin in face cream and body lotion. For the purpose of evaluating the use of NAMs, existing animal and human data on coumarin were excluded. Internal concentrations (plasma Cmax) were estimated using a physiologically based kinetic model for dermally applied coumarin. Systemic toxicity was assessed using a battery of in vitro NAMs to identify points of departure (PoDs) for a variety of biological effects such as receptor-mediated and immunomodulatory effects (Eurofins SafetyScreen44 and BioMap Diversity 8 Panel, respectively), and general bioactivity (ToxCast data, an in vitro cell stress panel and high-throughput transcriptomics). In addition, in silico alerts for genotoxicity were followed up with the ToxTracker tool. The PoDs from the in vitro assays were plotted against the calculated in vivo exposure to calculate a margin of safety with associated uncertainty. The predicted Cmax values for face cream and body lotion were lower than all PoDs with margin of safety higher than 100. Furthermore, coumarin was not genotoxic, did not bind to any of the 44 receptors tested and did not show any immunomodulatory effects at consumer-relevant exposures. In conclusion, this case study demonstrated the value of integrating exposure science, computational modeling and in vitro bioactivity data, to reach a safety decision without animal data.

100 Prevalence of Cognitive Impairment in Vascular Surgery Patients: Preliminary Results of A Systematic Review and Meta-Analysis

Introduction

Single-centre studies have shown a high prevalence of undiagnosed cognitive impairment in patients undergoing vascular surgery. The aim of this meta-analysis was to estimate the pooled prevalence of cognitive impairment in vascular surgery patients.

Methods

A systematic review and meta-analysis was performed of studies reporting cognitive impairment in vascular surgery patients (PROSPERO registration: CRD42019134684). Databases searched included: Medline, Embase, Emcare, CINAHL, PsychINFO and Scopus. Studies were excluded if they: did not use a validated cognitive assessment tool, included patients with asymptomatic or sub-threshold (for treatment) disease, or excluded patients with cognitive impairment. Quality of included studies was assessed using Newcastle-Ottawa scores (NOS), risk of bias was assessed using the ROBINS-E tool, and quality of evidence assessed using GRADE criteria. A pooled estimate of prevalence was calculated using the inverse-variance method separately for carotid artery disease (CAD), lower extremity arterial disease (LEAD), and studies including patients with multiple vascular surgery presentations. Data were pooled using random effects models and estimated prevalence presented with 95% confidence intervals (95%CI). Subgroup analyses were performed by cognitive assessment tool used.

Authors of 24 studies meeting inclusion criteria that did not report numbers of cognitively impaired patients were contacted to enable inclusion: responses are awaited.

Results

After de-duplication of search results, 7,169 records were screened and 11 studies (911 patients) included in the meta-analysis. Nine studies were deemed high quality (NOS ≥7) however 8 studies had a serious risk of bias. Only one study explicitly stated provision for recruiting patients without capacity. Six different tools were used to assess cognitive function (MoCA, MMSE, ACE-R, HDS-R, Mini-Cog and a global cognitive score). Two studies found an association of cognitive impairment with post-op delirium whilst one did not, and a further study showed an association with increased length of stay.

Pooled estimate of prevalence of cognitive impairment in CAD patients was 38% (95%CI 17%, 62%; 7 studies), and in “vascular surgery patients” was 61% (95%CI 47%, 74%, 3 studies). Only one study reported prevalence of cognitive impairment in LEAD patients alone of 19% (95%CI 14%, 24%). Quality of evidence was moderate to very low.

Conclusions

Cognitive impairment is highly prevalent in vascular surgery patients highlighting the need for close collaboration between vascular surgeons and geriatricians.

Does sensory relearning improve tactile function after carpal tunnel decompression? A pragmatic, assessor-blinded, randomized clinical trial

Despite surgery for carpal tunnel syndrome being effective in 80%-90% of cases, chronic numbness and hand disability can occur. The aim of this study was to investigate whether sensory relearning improves tactile discrimination and hand function after decompression. In a multi-centre, pragmatic, randomized, controlled trial, 104 patients were randomized to a sensory relearning ( n = 52) or control ( n = 52) group. A total of 93 patients completed a 12-week follow-up. Primary outcome was the shape-texture identification test at 6 weeks. Secondary outcomes were touch threshold, touch localization, dexterity and self-reported hand function. No significant group differences were seen for the primary outcome (Shape-Texture Identification) at 6 weeks or 12 weeks. Similarly, no significant group differences were observed on secondary outcomes, with the exception of self-reported hand function. A secondary complier-averaged-causal-effects analysis showed no statistically significant treatment effect on the primary outcome. Sensory relearning for tactile sensory and functional deficits after carpal tunnel decompression is not effective.

LEVEL OF EVIDENCE

II.

Spatial variability in photosynthetic and heterotrophic activity drives localized δ13C org fluctuations and carbonate precipitation in hypersaline microbial mats

Modern laminated photosynthetic microbial mats are ideal environments to study how microbial activity creates and modifies carbon and sulfur isotopic signatures prior to lithification. Laminated microbial mats from a hypersaline lagoon (Guerrero Negro, Baja California, Mexico) maintained in a flume in a greenhouse at NASA Ames Research Center were sampled for δ(13) C of organic material and carbonate to assess the impact of carbon fixation (e.g., photosynthesis) and decomposition (e.g., bacterial respiration) on δ(13) C signatures. In the photic zone, the δ(13) C org signature records a complex relationship between the activities of cyanobacteria under variable conditions of CO2 limitation with a significant contribution from green sulfur bacteria using the reductive TCA cycle for carbon fixation. Carbonate is present in some layers of the mat, associated with high concentrations of bacteriochlorophyll e (characteristic of green sulfur bacteria) and exhibits δ(13) C signatures similar to DIC in the overlying water column (-2.0‰), with small but variable decreases consistent with localized heterotrophic activity from sulfate-reducing bacteria (SRB). Model results indicate respiration rates in the upper 12 mm of the mat alter in situ pH and HCO3- concentrations to create both phototrophic CO2 limitation and carbonate supersaturation, leading to local precipitation of carbonate minerals. The measured activity of SRB with depth suggests they variably contribute to decomposition in the mat dependent on organic substrate concentrations. Millimeter-scale variability in the δ(13) C org signature beneath the photic zone in the mat is a result of shifting dominance between cyanobacteria and green sulfur bacteria with the aggregate signature overprinted by heterotrophic reworking by SRB and methanogens. These observations highlight the impact of sedimentary microbial processes on δ(13) C org signatures; these processes need to be considered when attempting to relate observed isotopic signatures in ancient sedimentary strata to conditions in the overlying water column at the time of deposition and associated inferences about carbon cycling.

A multiplex technology platform for the rapid detection of relevant mutations in the EGFR signaling pathway

386

Background: Determination of the mutational status of key gene effectors along the EGFR signaling pathway plays a critical role in the management of metastatic colorectal cancer (mCRC) and other cancer types. We previously reported the rapid, multiplex, and sensitive detection of 7 common KRAS mutations in mCRC FFPE specimens using the Signature KRAS Mutations (RUO) kit. We show here that the same technology platform can be applied to the detection of additional clinically relevant mutations in the EGFR, BRAF, KRAS, NRAS and HRAS genes.

Methods: Mutation panels were designed for multiplex PCR amplification of an internal control gene and discrete mutation regions in independent target genes. PCR products were hybridized on a liquid bead array carrying target-specific probes and sorted by flow cytometry using a Luminex 200 system. Genomic DNA was extracted from cell lines and representative flash frozen, FFPE or FNA clinical specimens using laboratory-validated extraction methods.

Results: Using model plasmids and cell lines we developed specific assays for distinct mutations in KRAS codon 12/13, KRAS 3' UTR (rs61764370), BRAF codon 600/601, HRAS codon 12/61, NRAS codon 61, and EGFR exon 19/20/21. The various assays reached 0.1 to 5% analytical sensitivity and could be further combined in multiplex panels relevant to specific applications. The Signature KRAS/BRAF Mutations (RUO) kit, an assay for 12 KRAS mutations in codon 12/13 and BRAF V600E, was validated in over 250 mCRC FFPE specimens with >99% agreement with clinically validated methods. Specific detection of these 13 mutations and 6 HRAS/NRAS mutations was also demonstrated in thyroid nodule FNA specimens. Single-well detection of EGFR deletions in exon 19 together with the point mutations L858R and T790M was also successfully evaluated in lung specimens.

Conclusions: The Signature technology platform is a specific, sensitive and flexible tool for the assessment of various mutations in different tissue types. The development and validation of broader mutation panels would likely facilitate the rapid molecular characterization of individual tumor specimens and the optimization of personalized treatments for mCRC and other cancer types.

[Table: see text]

A EuroPrevall review of factors affecting incidence of peanut allergy: priorities for research and policy

Peanuts are extensively cultivated around the world, providing a foodstuff that is both cheap to produce and nutritious. However, allergy to peanuts is of growing global concern, particularly given the severity of peanut-allergic reactions, which can include anaphylaxis and death. Consequently, it is important to understand the factors related to the prevalence of peanut allergy in order to inform efforts to ameliorate or pre-empt the condition. In this article we review evidence for the relevance of factors hypothesized to have some association with allergy prevalence, including both genetic and environmental factors. Although our analysis does indicate some empirical support for the importance of a number of factors, the key finding is that there are significant data gaps in the literature that undermine our ability to provide firm conclusions. We highlight these gaps, indicating questions that need to be addressed by future research.

The high prevalence of unrecognized anaemia in patients with diabetes and chronic kidney disease: a population-based study

BACKGROUND

Anaemia occurs early in the course of diabetes-related chronic kidney disease (CKD). There is little evidence about the prevalence of anaemia in people with diabetes. The aim of this study was to assess the prevalence of anaemia, by stage of CKD, in the general diabetic population.

METHODS

Haemoglobin (Hb) was measured on all glycated haemoglobin (HbA1c) samples and the most recent (< 4 months) estimated glomerular filtration rate (eGFR) was obtained. Anaemia (at treatment level) was defined as Hb < 110 g/l or the use of erythropoetic stimulating agents (ESA).

RESULTS

Twelve per cent (10-14%) of people had Hb < 110 g/l. The prevalence of anaemia increased progressively with worsening CKD. People with CKD stage 3 accounted for the largest number of people with anaemia; 18% (95% CI 13-24%) had Hb < 110 g/l. Those with eGFR < 60 ml/min/1.73 m2 and not on ESA or dialysis were four (2-7) times more likely than patients with better renal function to have Hb < 110 g/l. The relation between Hb and eGFR became approximately linear below an eGFR of 83 ml/min/1.73 m2, where, for every 1 ml/min/1.73 m2 fall in eGFR, there was a 0.4 (0.3-0.5) g/l fall in haemoglobin.

CONCLUSIONS

This study demonstrates that anaemia, at levels where treatment is indicated, occurs commonly in people with diabetes and CKD stage 3 or worse. The screening for anaemia in current diabetes management should be extended.

Investigation of DAZ and RBMY1 gene expression in human testis by quantitative real-time PCR

This study developed quantitative real-time PCR assays for the DAZ and RBMY1 genes to determine the copy number of RNA extracted from testicular biopsies from a cohort of normospermic controls (n=6) and azoospermic males (n=17) including two males with Y-chromosome microdeletions (AZFc and AZFb + c). All patients underwent testicular sperm extraction (TESE) for intracytoplasmic sperm injection (ICSI). Forty percent of the azoospermic cohort showed a significant reduction in the copies of at least one of the genes (DAZ P=0.003; RBMY1 P=0.009). The histopathology of these patients ranged from Sertoli cell only (SCO) to severe hypospermatogenesis with interstitial fibrosis. The patient with the AZFb + c deletion lacked expression of DAZ and RBMY1 and had a histopathology of SCO. The patient with the AZFc deletion had reduced expression of RBMY1 and no DAZ expression with a histopathology of spermatocyte arrest. The quantitative real-time PCR assays for DAZ and RBMY1 gave positive predictive values of 78% and 70%, respectively for the recovery of sperm from testicular biopsy.

A detailed analysis of the risk factors influencing local and distant breast cancer recurrence during adjuvant endocrine therapy

562

Background: The ‘Arimidex’, Tamoxifen, Alone or in Combination (ATAC; ISRCTN18233230 ) trial compared the efficacy and safety of 5 years’ anastrozole, tamoxifen, or combination as adjuvant therapy for 9366 postmenopausal women with early invasive breast cancer. Here, risk factors influencing local and distant recurrences during the trial, independent of trial treatment, are assessed. Methods: The influence of standard baseline factors such as hormone receptor status, nodal involvement, tumor size, grade and age were evaluated on both local and distant recurrence rates. The use of other treatments (adjuvant chemotherapy, radiotherapy) and surgical status (mastectomy and axillary surgery) were also included. In addition, weight, body mass index, hysterectomy and prior hormone- replacement therapy were added. Cox models were used to analyze events by prognostic factors, and subsequently adjusted by country, before the production of confirmatory models. Results: For both local and distant recurrence, the highest risk correlated with poorer tumor differentiation, larger tumor size, increased nodal involvement and a negative hormone receptor status (see table ). While surgical status also affected the risk of developing a recurrence, previous treatments were less important, but residence in the USA showed a significant advantage. No association was seen with hysterectomy or weight for any recurrence. Conclusions: Although the pattern of risk varied for local and distant recurrence, tumor grade, size, and nodal involvement were the strongest risk factors for both. In comparison, the impact of previous treatments on hazard risk was lower. These data from a large international clinical trial confirm that women with less differentiated or larger tumors, and those with involved nodes, are at an increased risk of recurrence.

[Table: see text]

[Table: see text]

Homogeneity of mesothelial cells with lymphatic endothelium: expression of lymphatic endothelial markers by mesothelial cells

BACKGROUND

Mesothelial cell monolayers cover the serous cavities and internal organs, and provide a protective low-friction interface between apposed organs and tissues. The mesothelium also regulates inflammation, fluid and cell exchange, and tissue repair in these compartments and possibly tumor metastasis. In the present study, a stable pleural mesothelial cell line (MIM) was isolated and characterized, and the expression of several lymphatic specific markers by these cells examined.

METHODS AND RESULTS

MIM were isolated from mice stably expressing a temperature-sensitive SV40 large T antigen ('Immortomouse', strain: H-2K(b)-tsA58). These cells were compared with lymphatic endothelial cells (LEC) derived from the mesenteric adventitia of the Immortomouse. MIM and LEC expression of lymphatic-specific markers (Flt-4, LYVE-1, and Prox-1) was examined, and the tight junction protein (ZO-1) was studied by immunofluorescence and immunoblotting in these cells.

RESULTS

LYVE-1, Prox-1, and Flt-4 were detected in both MIM and LEC, with Prox-1 and LYVE-1 more strongly expressed on LEC than MIM. Conversely, Flt-4 was more densely expressed on MIM than on LEC. Spatially, ZO-1 was prominent at MIM junctions, but was less well organized in LEC.

CONCLUSION

MIM and LEC share several characteristic markers usually associated with lymphatic endothelium. MIM might be useful for studying the biology and pathology of mesothelial cells in vitro and help in the development of therapies for mesothelial-related diseases, such as mesothelioma and pleural effusion.

Comprehensive side-effect profile of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: long-term safety analysis of the ATAC trial

BACKGROUND

The Arimidex (anastrozole), Tamoxifen, Alone or in Combination (ATAC) trial was designed to compare the efficacy and safety of anastrozole with tamoxifen as adjuvant treatment for postmenopausal women with early-stage breast cancer. After an extended follow-up beyond the 5 years of treatment, we aimed to assess the safety, tolerability, and risk-benefit indices of these compounds.

METHODS

We analysed postmenopausal women (mean age 64 years [SD 9]) with localised breast cancer randomly assigned to anastrozole (n=3125) or tamoxifen (n=3116). Efficacy measures, including death and risk-benefit indices, were analysed by intention to treat. Safety analyses were based on treatment first received (n=3092 for anastrozole and n=3094 tamoxifen). We calculated a risk-benefit analysis using the two global indices for the Women's Health Initiative and for Disease-Free Survival and Serious Adverse Events. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN18233230.

FINDINGS

At median follow-up of 68 months (range 1-93), treatment-related adverse events occurred significantly less often with anastrozole than with tamoxifen (1884 [61%] vs 2117 [68%]; p<0.0001), as did treatment-related serious adverse events (146 [5%] vs 277 [9%]; p<0.0001) and adverse events leading to withdrawal (344 [11%] vs 442 [14%]; p=0.0002). Patients given anastrozole had significantly fewer overall events for the Global Index of the Women's Health Initiative (744 [24%] vs 851 [27%]; hazard ratio 0.85 [95% CI 0.77-0.94], p=0.001) and the Global Index of Disease-Free Survival and Serious Adverse Events (1453 [46%] vs 1594 [51%]; 0.88 [0.82-0.94]; p=0.0004).

INTERPRETATION

Anastrozole is tolerated better than tamoxifen by postmenopausal women with early-stage breast cancer, and results in fewer serious adverse events. Furthermore, it has a more favourable overall risk-benefit profile and lower recurrence rate than tamoxifen.

Adjuvant goserelin in pre-menopausal patients with early breast cancer: Results from the ZIPP study

The Zoladex In Pre-menopausal Patients (ZIPP) study was designed to determine whether addition of goserelin ('Zoladex') and/or tamoxifen to adjuvant therapy (radiotherapy and/or chemotherapy), provided benefit to pre- or peri-menopausal women with operable, early breast cancer. A combined analysis of four randomised trials using a core protocol was performed. Patients (n = 2710) were randomised into a 2 x 2 factorial trial based on goserelin and tamoxifen (n = 1800) or randomised to receive goserelin or not (n = 910; some received elective tamoxifen) for 2 years. The analysis presented here compares women who did (n = 1354) or did not (n = 1356) receive goserelin. After a median follow-up of 5.5 years, goserelin provided a significant benefit for event-free survival (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.69, 0.92; P = 0.002) and overall survival (HR 0.81; 95% CI 0.67, 0.99; P = 0.038). Goserelin was well tolerated. These data show that the addition of goserelin to standard adjuvant therapy is more effective than standard therapy alone in pre-menopausal women with early breast cancer.

Benefit from adjuvant tamoxifen therapy in primary breast cancer patients according oestrogen receptor, progesterone receptor, EGF receptor and HER2 status

BACKGROUND

Most women with oestrogen receptor (ER) positive primary breast cancer receive adjuvant tamoxifen after surgery. The measurement of tumour biomarkers should allow better selection of patients for such treatment or for therapies such as aromatase inhibitors.

PATIENTS AND METHODS

Histopathological blocks of primary breast cancer patients who had been randomized to receive 2-years tamoxifen or no adjuvant therapy in two mature randomised clinical trials were retrieved. Immunohistochemical staining for ER, progesterone receptor (PgR), HER2 and epidermal growth factor receptor (EGFR) was undertaken. The primary endpoint was relapse free survival.

RESULTS

813 patients were included in the study. Benefit from tamoxifen was seen in ER-positive patients [Relative risk (rr) 0.77, ci 0.63-0.93]. ER-negative patients also showed a strong trend to benefit from tamoxifen (rr 0.73, ci 0.52-1.02) which was largely confined to the PgR-positive group. Amongst the ER-positive group, PgR-positive and PgR-negative patients showed similar benefit (rr 0.81; ci 0.65-1.02 and 0.70; ci 0.49-0.99, respectively). Patients positive for HER2 did not benefit significantly (rr 1.14; ci 0.75-1.73) but this group was small.

CONCLUSIONS

Measurement of PgR status in ER-negative patients defines a group of patients that benefit from tamoxifen but would be excluded from tamoxifen therapy on the basis of ER status alone. The data are consistent with HER2 positive tumours being resistant to tamoxifen.

Patients' preferences for adjuvant endocrine therapy in early breast cancer: what makes it worthwhile?

Adjuvant endocrine therapy improves recurrence and survival rates, but has side effects and is inconvenient. The aim of this study was to determine the preferences of premenopausal women who had adjuvant endocrine therapy in a randomised trial. In all, 85 (or eighty-five) women completed semistructured interviews 6–30 months after finishing adjuvant endocrine therapy. Hypothetical scenarios based on known potential survival times (5 or 15 years) and rates (60% or 80% at 5 years) without adjuvant endocrine therapy were used to determine the smallest gains women judged necessary to make their adjuvant endocrine therapy worthwhile. Although a third of the women considered gains of 1% in survival rates or 6 months in survival times sufficient to make their adjuvant endocrine therapy worthwhile, more than half the women required gains of at least 5% in survival rates or 3 years in survival time as necessary to make adjuvant endocrine therapy worthwhile. Larger benefits were required by women who had longer treatment, worse side effects, and by those who were treated with goserelin alone. The route of administration (tablet vs injection) did not affect preferences and some women judged small benefits sufficient to make their adjuvant endocrine therapy worthwhile, but many women required larger benefits than their counterparts in similar studies of preferences for adjuvant chemotherapy.

Isolation and Characterization of A Novel Mouse Lymphatic Endothelial Cell Line: SV-LEC

BACKGROUND

The lymphatic system regulates interstitial fluid and protein balance and modulates immune responses by regulating leukocyte and antigen traffic to lymph nodes. The present article describes a stable mouse lymphatic endothelial cell line from mesenteric adventitial tissue (SV-LEC) which is distinct from blood aortic (AEC) and venous (VEC) endothelial cells, based on expression of several lymphatic markers (e.g., Prox-1, LYVE-1, Flt-4). SV-LEC also expresses MAdCAM-1 in response to TNF-alpha, an effect seen in VEC, but not AEC.

METHODS AND RESULTS

Lymphatic endothelial cells (SV-LEC) were isolated from mesenteric adventitia from mice expressing temperature-sensitive SV40 large T ('Immortomouse', H-2K(b)tsA58) selected with hypoxia culture in D-valine-substituted MEM supplemented with VEGFC in a low oxygen atmosphere (0% O2, 5% CO2, and 95% N2) with 5 mM thioglycolate. Expression of lymphatic-specific markers (Flt-4, LYVE-1, Prox-1) and the tight junction proteins (ZO-1) were examined by RT-PCR, immunoblotting, and fluorescent microscopy. MAdCAM-1 (a high endothelial venular marker) expression was also examined in response to TNF-alpha IL-1beta and IFN-gamma.

RESULTS

Message for Flt-4 and LYVE-1 was detected on SV-LEC. Immunoblotting for LYVE-1 and Prox-1 showed strong expression on SV-LEC and VEC, but not AEC. Occludin expression was seen in all cell types, junctional ZO-1 was detected at SV-LEC and VEC junctions, not AEC.

CONCLUSION

SV-LEC expresses several lymphatic endothelial markers, some of which are shared with VEC, but not AEC, and may represent a useful system for modeling lymphatic function in vitro.

N-methyl-d-aspartate receptor activation in human cerebral endothelium promotes intracellular oxidant stress

Cerebral endothelial cells in the rat, pig, and, most recently, human have been shown to express several types of receptors specific for glutamate. High levels of glutamate disrupt the cerebral endothelial barrier via activation of N-methyl-d-aspartate (NMDA) receptors. We have previously suggested that this glutamate-induced barrier dysfunction was oxidant dependent. Here, we provide evidence that human cerebral endothelial cells respond to glutamate by generating an intracellular oxidant stress via NMDA receptor activation. Cerebral endothelial cells loaded with the oxidant-sensitive probe dihydrorhodamine were used to measure intracellular reactive oxygen species (ROS) formation in response to glutamate receptor agonists, antagonists, and second message blockers. Glutamate (1 mM) significantly increased ROS formation compared with sham controls (30 min). This ROS response was significantly reduced by 1) MK-801, a noncompetitive NMDA receptor antagonist; 2) 8-( N, N-diethylamino)- n-octyl-3,4,5-trimethoxybenzoate, an intracellular Ca2+antagonist; 3) LaCl3, an extracellular Ca2+channel blocker; 4) diphenyleiodonium, a heme-ferryl-containing protein inhibitor; 5) itraconazole, a cytochrome P-450 3A4 inhibitor; and 6) cyclosporine A, which prevents mitochondrial membrane pore transition required for mitochondrial-dependent ROS generation. Our results suggest that the cerebral endothelial barrier dysfunction seen in response to glutamate is Ca2+dependent and may require several intracellular signaling events mediated by oxidants derived from reduced nicotinamide adenine dinucleotide oxidase, cytochrome P-450, and the mitochondria.

Results of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial after completion of 5 years' adjuvant treatment for breast cancer

The standard adjuvant endocrine treatment for postmenopausal women with hormone-receptor-positive localised breast cancer is 5 years of tamoxifen, but recurrences and side-effects restrict its usefulness. The aromatase inhibitor anastrozole was compared with tamoxifen for 5 years in 9366 postmenopausal women with localised breast cancer. After a median follow-up of 68 months, anastrozole significantly prolonged disease-free survival (575 events with anastrozole vs 651 with tamoxifen, hazard ratio 0.87, 95% CI 0.78-0.97, p=0.01) and time-to-recurrence (402 vs 498, 0.79, 0.70-0.90, p=0.0005), and significantly reduced distant metastases (324 vs 375, 0.86, 0.74-0.99, p=0.04) and contralateral breast cancers (35 vs 59, 42% reduction, 12-62, p=0.01). Almost all patients have completed their scheduled treatment, and fewer withdrawals occurred with anastrozole than with tamoxifen. Anastrozole was also associated with fewer side-effects than tamoxifen, especially gynaecological problems and vascular events, but arthralgia and fractures were increased. Anastrozole should be the preferred initial treatment for postmenopausal women with localised hormone-receptor-positive breast cancer.

Late follow-up of a randomized trial of surgery plus tamoxifen versus tamoxifen alone in women aged over 70 years with operable breast cancer

BACKGROUND

Breast cancer has been considered a more indolent disease in the elderly, who are less tolerant of aggressive therapy. This trial tested the hypothesis that tamoxifen without surgery would provide adequate control of breast cancer for the remainder of life in elderly women, thereby sparing them surgery.

METHOD

Women aged over 70 years with operable, invasive breast cancer were randomized to receive either tamoxifen alone or surgery plus tamoxifen. Time to treatment failure (TTF), indicating initial primary treatment failure, was the primary endpoint. Overall mortality, and death from breast cancer were also compared between the two groups.

RESULTS

Between 1984 and 1991, 455 patients were included in the trial. The analysis was based on a median follow-up of 12.7 years. The TTF was significantly shorter in the tamoxifen alone group: hazard ratio (HR) 4.41 (95 per cent confidence interval (c.i.) 3.31 to 5.88). Ninety-three (40.4 per cent) of 230 patients randomized to tamoxifen alone underwent surgery for the management of their disease. Both overall mortality and mortality from breast cancer were significantly increased in the tamoxifen alone group, although the survival curves did not diverge for the first 3 three years: HR 1.29 (95 per cent c.i. 1.04 to 1.59) and 1.68 (95 per cent c.i. 1.15 to 2.47) respectively.

CONCLUSION

Omission of primary surgery in unselected elderly women with operable breast cancer who were fit for the procedure resulted in an increased rate of progression, therapeutic intervention and mortality.

Glutamate causes a loss in human cerebral endothelial barrier integrity through activation of NMDA receptor

l-Glutamate is a major excitatory neurotransmitter that binds ionotropic and metabotropic glutamate receptors. Cerebral endothelial cells from many species have been shown to express several forms of glutamate receptors; however, human cerebral endothelial cells have not been shown to express either the N-methyl-D-aspartate (NMDA) receptor message or protein. This study provides evidence that human cerebral endothelial cells express the message and protein for NMDA receptors. Human cerebral endothelial cell monolayer electrical resistance changes in response to glutamate receptor agonists, antagonists, and second message blockers were tested. RT-PCR and Western blot analysis were used to demonstrate the presence of the NMDA receptor. Glutamate and NMDA (1 mM) caused a significant decrease in electrical resistance compared with sham control at 2 h postexposure; this response could be blocked significantly by MK-801 (an NMDA antagonist), 8-(N,N-diethylamino)-n-octyl-3,4,5-trimethyoxybenzoate (an intracellular Ca2+ antagonist), and N-acetyl-L-cystein (an antioxidant). Trans(+/-)-1-amino-1,3-cyclopentanedicarboxylic acid, a metabotropic receptor agonist (1 mM), did not significantly decrease electrical resistance. Our results are consistent with a model where glutamate, at excitotoxic levels, may lead to a breakdown in the blood brain barrier via activation of NMDA receptors.

Human neuroepithelial cells express NMDA receptors

L-glutamate, an excitatory neurotransmitter, binds to both ionotropic and metabotropic glutamate receptors. In certain parts of the brain the BBB contains two normally impermeable barriers: 1) cerebral endothelial barrier and 2) cerebral epithelial barrier. Human cerebral endothelial cells express NMDA receptors; however, to date, human cerebral epithelial cells (neuroepithelial cells) have not been shown to express NMDA receptor message or protein. In this study, human hypothalamic sections were examined for NMDA receptors (NMDAR) expression via immunohistochemistry and murine neuroepithelial cell line (V1) were examined for NMDAR via RT-PCR and Western analysis. We found that human cerebral epithelium express protein and cultured mouse neuroepithelial cells express both mRNA and protein for the NMDA receptor. These findings may have important consequences for neuroepithelial responses during excitotoxicity and in disease.

Anastrozole alone or in combination with tamoxifen versus tamoxifen alone for adjuvant treatment of postmenopausal women with early-stage breast cancer: results of the ATAC (Arimidex, Tamoxifen Alone or in Combination) trial efficacy and safety update analyses

BACKGROUND

The first analysis of the ATAC (Arimidex, Tamoxifen Alone or in Combination) trial (median follow-up, 33 months) demonstrated that in adjuvant endocrine therapy for postmenopausal patients with early-stage breast cancer, anastrozole was superior to tamoxifen in terms of disease-free survival (DFS), time to recurrence (TTR), and incidence of contralateral breast cancer (CLBC). In the current article, the results of the first efficacy update, based on a median follow-up period of 47 months, are reported along with the results of an updated safety analysis, performed 7 months after the first analysis (median duration of treatment, 36.9 months).

METHODS

DFS, TTR, CLBC incidence, and safety were assessed in the same patient group as in the first analysis of the ATAC trial.

RESULTS

DFS estimates at 4 years remained significantly more favorable (86.9% vs. 84.5%, respectively) for patients receiving anastrozole compared with those receiving tamoxifen (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.76-0.99; P = 0.03). The benefit generated by anastrozole in terms of DFS was even greater in patients with hormone receptor-positive tumors (HR, 0.82; 95% CI, 0.70-0.96; P = 0.014). The HR for TTR also indicated a significant benefit for patients receiving anastrozole compared with those receiving tamoxifen (HR, 0.83; 95% CI, 0.71-0.96; P = 0.015), with additional benefit for patients with hormone receptor-positive tumors (HR, 0.78; 95% CI, 0.65-0.93; P = 0.007). CLBC incidence data also continued to favor anastrozole (odds ratio [OR], 0.62; 95% CI, 0.38-1.02; P = 0.062), and statistical significance was achieved in the hormone receptor-positive subgroup (OR, 0.56; 95% CI, 0.32-0.98; P = 0.042). The updated safety analysis also confirmed the findings of the first analysis, in that endometrial cancer (P = 0.007), vaginal bleeding and discharge (P < 0.001 for both), cerebrovascular events (P < 0.001), venous thromboembolic events (P < 0.001), and hot flashes (P < 0.001) all occurred less frequently in the anastrozole group, whereas musculoskeletal disorders and fractures (P < 0.001 for both) continued to occur less frequently in the tamoxifen group. These results indicated that the safety profile of anastrozole remained consistent.

CONCLUSIONS

After an additional follow-up period, anastrozole continues to show superior efficacy, which is most apparent in the clinically relevant hormone receptor-positive population. Furthermore, anastrozole has numerous noteworthy advantages in terms of tolerability compared with tamoxifen. These findings suggest that the benefits of anastrozole are likely to be maintained in the long term and provide further support for the status of anastrozole as a valid treatment option for postmenopausal women with hormone-sensitive early-stage breast cancer.

Malignancy-associated changes in lactiferous duct epithelium

OBJECTIVE

To determine whether cells from histologically normal appearing epithelium of the lactiferous duct from women with a remote ductal lesion in the breast provide any clues indicating the existence of such a lesion.

STUDY DESIGN

Tissue sections cut to 4 microns and stained with hematoxylin and eosin were prepared from duct tissue of 20 women with breast lesions and of 20 women free of any such lesion who had undergone mammoplastic procedures or resection for benign reasons. One hundred nuclei were measured from each case. Measures of nuclear deviation from normal were computed, discriminant functions were derived, and multivariate significance tests were conducted.

RESULTS

Nuclei from histologically normal appearing regions of lactiferous duct epithelium from women harboring distant lesions exhibited changes in the distribution pattern of their nuclear chromatin, indicating the presence of these lesions. The statistical significance of these changes was documented. The changes were clearly evident in all 20 subjects with lesions and were not observed in 19 of the 20 subjects without lesions.

CONCLUSION

The results suggest that studies aimed at detecting malignancy-associated changes in cells collected by ductal lavage might lead to a minimally invasive screening procedure for breast lesions.

Upper airway obstruction and acute lung injury associated with cocaine abuse

We describe the case of a 14-year-old boy who developed airway obstruction due to acute upper respiratory tract infection. Following emergency tracheostomy, he developed pulmonary oedema and required ventilation. The postoperative course was complicated by the development of adult respiratory distress syndrome, characterised by marked respiratory distress, diffuse pulmonary infiltrates on chest radiography, reduced pulmonary compliance and marked increase in alveolar-arterial oxygen difference. He also developed persistent high-grade pyrexia, renal failure and cardiac instability. A social history of substance abuse (crack cocaine, amphetamines, alcohol and cigarettes) was obtained three weeks post-admission and is thought to have made a significant contribution to the severity of his disease.

Trends in the incidence of childhood diabetes in south Asians and other children in Bradford, UK

AIMS

To investigate incidence rates and time trends, over 21 years, of Type 1 diabetes in a migrant population of south Asian children in Bradford, UK.

METHODS

Children (0-14 years) living in the city of Bradford and diagnosed with Type 1 diabetes were selected from a population-based region-wide register. Between 1978 and 1998, 289 new-onset cases were registered and classified as south Asian (Indian, Pakistani, Bangladeshi) or not, based on their full name using two different computer algorithms and visual inspection.

RESULTS

Sixty-six children (22.8%) were designated as south Asian with 223 (77.2%) remaining. The overall age-sex standardized incidence for south Asian and non-south Asian children was 13.0 per 100,000 person years (95% confidence interval 9.9-16.2) and 12.9 (11.2-14.6), respectively. Rates were similar for south Asians at all ages, whereas for the mainly Caucasian children incidence differed significantly by age group (P < 0.001). An average annual increase in incidence of 4.3% (P = 0.001) was seen for all children compared with 6.5% in south Asians (P = 0.002) and 2.4% (P = 0.128) in non-south Asians.

CONCLUSIONS

Children in south Asia have a low incidence of Type 1 diabetes but migrants to the UK have similar overall rates to the indigenous population. However, a more steeply rising incidence is seen in the south Asian population, and our data suggest that incidence in this group may eventually outstrip that of the non-south Asians. Genetic factors are unlikely to explain such a rapid change, implying an influence of environmental factors in disease aetiology. The similarity in rates by age group in the south Asian population is notable.