Available but inaccessible: patient experiences during the first 2 years of a primary care-based medical cannabis program at an academic medical center

BACKGROUND

Medical cannabis use and public acceptance in the United States have increased over the past 25 years. However, access to medical cannabis remains limited, particularly for underserved populations. To understand how patients experience medical cannabis accessibility, we measured medical cannabis use and barriers to use after medical cannabis certification in an urban safety-net academic medical center.

METHODS

We conducted a retrospective cohort study among patients seen in Montefiore's Medical Cannabis Program (MMCP) from 2017 to 2019. Patient demographic and clinical characteristics, as well purchase history of medical cannabis, were extracted from electronic medical records. We also administered a phone questionnaire to a subset of patients to assess usage patterns, effectiveness, and barriers to medical cannabis use.

RESULTS

Among 562 patients who were newly certified for medical cannabis between 2017 and 2019, 45% purchased medical cannabis, while 55% did not. Patients who purchased medical cannabis were more likely to be white and have private insurance or Medicare. Unregulated cannabis use and current tobacco use were less common among those who purchased medical cannabis. In multivariable logistic regression analysis, unregulated cannabis use remained negatively associated with purchasing medical cannabis. Patients reported that affordability and dispensary accessibility were their main barriers to purchasing medical cannabis.

CONCLUSION

Among patients certified for medical cannabis use, fewer than half purchased medical cannabis after certification. Improving access to medical cannabis is crucial for ensuring equitable access to regulated cannabis, and to reducing unregulated cannabis use.

Plasma cytokine and growth factor response to acute psychosocial stress in major depressive disorder

BACKGROUND

Pro-inflammatory cytokines such as interleukin (IL)-6 and tumor necrosis factor (TNF)-α are elevated in response to psychosocial stress; however, less is known about other inflammatory markers.

METHODS

We explored response to the Trier Social Stress Test (TSST) of 16 cytokines and growth factors in patients with major depressive disorder (MDD, n = 12) vs. healthy volunteers (HV, n = 16). Outcomes were baseline and post-stress levels estimated by area under the curve (AUCi) and peak change over 3 timepoints. We also explored correlations between biomarkers and clinical characteristics.

RESULTS

Baseline concentrations were higher in MDD for platelet-derived growth factor (PDGF)-AB/BB (p = 0.037, d = 0.70), granulocyte-macrophage colony-stimulating factor (GM-CSF, p = 0.033, d = 0.52), and IL-8 (p = 0.046, d = 0.74). After TSST, AUCi was higher in MDD for GM-CSF (p = 0.003, d = 1.21), IL-5 (p = 0.014, d = 1.62), and IL-27 (p = 0.041, d = 0.74). In MDD, depression severity correlated positively with soluble CD40L (sCD40L) for AUCi (Spearman's ρ = 0.76, p = 0.004) and with baseline vascular endothelial growth factor A (VEGFA, r = 0.85, p < 0.001), but negatively with baseline monokine induced by gamma interferon (MIG, aka CXCL9; r = -0.77, p = 0.003).

CONCLUSIONS

Effect sizes were robust in this exploratory study, although interpretation of the results must be cautious, given small sample size and multiple comparisons. Differential study of stress-induced biomarkers may have important ramifications for MDD treatment.

Treatment of severe COVID-19 with convalescent plasma in Bronx, NYC

Convalescent plasma with severe acute respiratory disease coronavirus 2 (SARS-CoV-2) antibodies (CCP) may hold promise as a treatment for coronavirus disease 2019 (COVID-19). We compared the mortality and clinical outcome of patients with COVID-19 who received 200 mL of CCP with a spike protein IgG titer ≥ 1:2430 (median 1:47,385) within 72 hours of admission with propensity score-matched controls cared for at a medical center in the Bronx, between April 13 and May 4, 2020. Matching criteria for controls were age, sex, body mass index, race, ethnicity, comorbidities, week of admission, oxygen requirement, D-dimer, lymphocyte counts, corticosteroid use, and anticoagulation use. There was no difference in mortality or oxygenation between CCP recipients and controls at day 28. When stratified by age, compared with matched controls, CCP recipients less than 65 years had 4-fold lower risk of mortality and 4-fold lower risk of deterioration in oxygenation or mortality at day 28. For CCP recipients, pretransfusion spike protein IgG, IgM, and IgA titers were associated with mortality at day 28 in univariate analyses. No adverse effects of CCP were observed. Our results suggest CCP may be beneficial for hospitalized patients less than 65 years, but data from controlled trials are needed to validate this finding and establish the effect of aging on CCP efficacy.

Treatment of Severe COVID-19 with Convalescent Plasma in the Bronx, NYC

Convalescent plasma with severe acute respiratory disease coronavirus 2 (SARS-CoV-2) antibodies (CCP) may hold promise as treatment for Coronavirus Disease 2019 (COVID-19). We compared the mortality and clinical outcome of patients with COVID-19 who received 200mL of CCP with a Spike protein IgG titer ≥1:2,430 (median 1:47,385) within 72 hours of admission to propensity score-matched controls cared for at a medical center in the Bronx, between April 13 to May 4, 2020. Matching criteria for controls were age, sex, body mass index, race, ethnicity, comorbidities, week of admission, oxygen requirement, D-dimer, lymphocyte counts, corticosteroids, and anticoagulation use. There was no difference in mortality or oxygenation between CCP recipients and controls at day 28. When stratified by age, compared to matched controls, CCP recipients <65 years had 4-fold lower mortality and 4-fold lower deterioration in oxygenation or mortality at day 28. For CCP recipients, pre-transfusion Spike protein IgG, IgM and IgA titers were associated with mortality at day 28 in univariate analyses. No adverse effects of CCP were observed. Our results suggest CCP may be beneficial for hospitalized patients <65 years, but data from controlled trials is needed to validate this finding and establish the effect of ageing on CCP efficacy.

Abstract B48: A LIN28B-PDZ kinase axis promotes neuroblastoma metastasis

Background: Neuroblastoma, an aggressive cancer of the developing sympathetic nervous system, continues to cause significant morbidity and mortality, highlighting the need to identify novel therapeutic vulnerabilities. We previously demonstrated that the RNA binding protein (RBP) LIN28B is an oncogenic driver and induces neuroblastoma proliferation, in part by regulating a RAN GTPase-Aurora kinase A axis. LIN28B blocks the processing of the let-7 family of tumor suppressors and binds mRNAs directly. In addition to alterations in cell cycle/apoptosis, metastatic dissemination is a hallmark of cancer that is incompletely understood, and neuroblastoma exhibits a striking proclivity for widespread metastases. In these studies, we investigated how LIN28B shapes neuroblastoma metastasis.

Methods: We generated GFP-luciferase expressing neuroblastoma cell line models in which LIN28B levels were manipulated, injected these models into the tail veins of NSG mice, and tracked dissemination using an IVIS Spectrum system. We used gain- and loss-of-function approaches (siRNAs, shRNAs, microRNA mimetics) to manipulate transcripts of interest in neuroblastoma cells and measured effects on self-renewal, invasion, and downstream signaling. To discover LIN28B-associated pathways, we assessed clinically annotated mRNA expression datasets.

Results: Mice injected with LIN28B-depleted neuroblastoma cells exhibit a delayed onset of tumor metastasis, reduced tumor burden, and extended survival (103 days vs. 50 days, p&lt;0.0001), compared to mice bearing neuroblastoma cells expressing control scrambled shRNA. We next demonstrated that LIN28B promotes, and let-7 opposes, self-renewal and migration, two hallmarks of metastasis. As we discovered that Aurora kinase A is a novel LIN28B target, we speculated that LIN28B might positively regulate diverse oncogenic kinases to promote metastasis. We evaluated the TARGET dataset of neuroblastoma tumors and found LIN28B mRNA expression to be robustly correlated with PDZ-binding kinase mRNA expression (PBK; r=0.67; p=3.2 × 10-33), a kinase with roles in cell proliferation/survival, self-renewal, and metastasis, and is overexpressed in multiple malignancies. We demonstrated that LIN28B directly promotes, and let-7 opposes, the expression of PBK protein, and, indeed, that PBK is a novel and direct let-7 target. Moreover, we reveal that MYCN binds to the promoter of PBK and positively regulates PBK RNA and protein expression. Finally, PBK depletion mimics the effects of LIN28B depletion, with respect to self-renewal and invasion.

Conclusions: Taken together, our findings suggest that LIN28B/let-7 shapes neuroblastoma metastasis, in part through influencing PBK, a kinase not previously implicated in the pathogenesis of aggressive pediatric solid tumors. Current studies are defining whether PBK, a therapeutically tractable target for which clinically relevant inhibitors exist, represents a novel therapeutic vulnerability in metastatic neuroblastoma.

Citation Format: Dongdong Chen, Julie Cox, Jayabhargav Annam, Melanie Weingart, Grace Essien, Komal Rathi, Priya Khurana, Selma Cuya, Jo Lynne Harenza, Kristopher Bosse, Adeiye Pilgrim, John M. Maris, Robert W. Schnepp. A LIN28B-PDZ kinase axis promotes neuroblastoma metastasis [abstract]. In: Proceedings of the AACR Special Conference on the Advances in Pediatric Cancer Research; 2019 Sep 17-20; Montreal, QC, Canada. Philadelphia (PA): AACR; Cancer Res 2020;80(14 Suppl):Abstract nr B48.

LIN28B promotes neuroblastoma metastasis and regulates PDZ binding kinase

Neuroblastoma is an aggressive pediatric malignancy of the neural crest with suboptimal cure rates and a striking predilection for widespread metastases, underscoring the need to identify novel therapeutic vulnerabilities. We recently identified the RNA binding protein LIN28B as a driver in high-risk neuroblastoma and demonstrated it promotes oncogenic cell proliferation by coordinating a RAN-Aurora kinase A network. Here, we demonstrate that LIN28B influences another key hallmark of cancer, metastatic dissemination. Using a murine xenograft model of neuroblastoma dissemination, we show that LIN28B promotes metastasis. We demonstrate that this is in part due to the effects of LIN28B on self-renewal and migration, providing an understanding of how LIN28B shapes the metastatic phenotype. Our studies reveal that the let-7 family, which LIN28B inhibits, decreases self-renewal and migration. Next, we identify PDZ Binding Kinase (PBK) as a novel LIN28B target. PBK is a serine/threonine kinase that promotes the proliferation and self-renewal of neural stem cells and serves as an oncogenic driver in multiple aggressive malignancies. We demonstrate that PBK is both a novel direct target of let-7i and that MYCN regulates PBK expression, thus elucidating two oncogenic drivers that converge on PBK. Functionally, PBK promotes self-renewal and migration, phenocopying LIN28B. Taken together, our findings define a role for LIN28B in neuroblastoma metastasis and define the targetable kinase PBK as a potential novel vulnerability in metastatic neuroblastoma.

Abstract 3668: A LIN28B-PBK Axis promotes neuroblastoma dissemination and aggression

LIN28B is an RNA binding protein that plays key roles in normal development and, when deregulated, oncogenesis; mechanistically, it blocks the processing of the let-7 family of tumor suppressors and binds mRNAs directly. We previously demonstrated that LIN28B induces neuroblastoma proliferation, in part by regulating the expression of RAN GTPase and Aurora kinase A (AURKA). However, given the widespread metastases seen within neuroblastoma, we speculated that LIN28B might also influence neuroblastoma dissemination. We used gain and loss of function approaches to genetically manipulate transcripts of interest in neuroblastoma cells and measured effects on self-renewal, invasion, and downstream signaling. To examine the impact of LIN28B on dissemination, we generated GFP-luciferase expressing neuroblastoma cell line models in which LIN28B levels were manipulated, injected these lines into the tail veins of NSG mice, and tracked dissemination using an IVIS Spectrum system. Results show that depletion of LIN28B significantly delayed the onset of tumor metastasis, reduced tumor burden, and extended mouse survival (104 days versus 50 days, p&lt;0.0001) compared to control cells. While LIN28B did not impact anoikis resistance, it did increase both tumorsphere number and size, linking self-renewal to metastatic dissemination. Additionally, LIN28B promoted cellular invasion. These effects were largely opposed by let-7. We next sought to understand how LIN28B promotes aggression and metastasis, specifically focusing on novel networks that are currently therapeutically targetable. Given our discovery of AURKA as a novel LIN28B target, we speculated that LIN28B might promote the expression of additional oncogenic kinases, perhaps revealing novel therapeutic possibilities to target the LIN28B network. We evaluated the TARGET dataset of neuroblastoma tumors and, focusing on the top 10 kinases most significantly and positively correlated with high LIN28B expression, nominated PBK for further study (4/10 of top correlated kinases). PBK (PDZ-binding kinase) is a Ser/Thr protein kinase expressed in normal embryonic tissues and various tumor types that plays a role in both mitosis and metastasis. Depletion of PBK mimicked the effects of LIN28B depletion, with respect to self-renewal and invasion. Depletion of LIN28B and overexpression of let-7 both reduced PBK protein expression, suggesting that PBK is a direct or indirect let-7 target. Taken together, our findings suggest that LIN28B/let-7 shapes neuroblastoma aggression, in part through influencing PBK, a kinase not previously implicated in the pathogenesis of neuroblastoma or other aggressive pediatric solid tumors. Current studies are further dissecting the functional and molecular relationships among LIN28B, let-7, and PBK in neuroblastoma.

Citation Format: Dongdong Chen, Julie Cox, Jayabhargav Annam, Melanie Weingart, Grace Essien, Komal Rathi, Priya Khurana, Selma M. Cuya, Robert W. Schnepp. A LIN28B-PBK Axis promotes neuroblastoma dissemination and aggression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3668.