A Pilot, First in Human Study of Autologous IFN-Gamma Stimulated Mesenchymal Stromal Cells for Treatment of Radiation-Induced Xerostomia

PURPOSE/OBJECTIVE(S)

There are no existing effective treatments for radiation-induced xerostomia (RIX), a common side effect of head and neck radiation. Mesenchymal stromal cells (MSCs) exhibit regenerative effects in multiple tissues and may represent an effective cell therapy for the treatment of RIX. Here we present the primary safety and secondary efficacy endpoints of a first-in-human pilot study of IFNγ-stimulated autologous bone marrow- derived MSCs [MSC(M)] for the treatment of RIX.

MATERIALS/METHODS

We conducted a single-center clinical trial investigating the safety and tolerability of autologous IFNγ-stimulated MSC(M). The study was conducted under an FDA-IND and approved by the local IRB. Patients underwent bone marrow aspiration, MSC(M) were then culture-expanded, stimulated with IFNγ, and cryopreserved. Banked IFNγ-stimulated MSC(M) were thawed, allowed to recover, and then 10 × 106 MSC(M) were injected transcutaneously via ultrasound guidance into one submandibular gland. The primary objective was safety and tolerability determined by dose-limiting toxicity (DLT) defined as submandibular pain > 5 on a standard 10-point pain scale or any serious adverse event (SAE) within one month after injection. Secondary objectives included analysis of efficacy as measured by salivary quantification and using 3 validated quality of life instruments. Quantitative results are reported as mean and standard deviation (SD).

RESULTS

Six radiation-induced xerostomia patients with head and neck cancer who had completed radiation at least 2 years earlier were enrolled. The median age was 71 (61-74) and 5 (83%) patients were male. Five patients (83%) were treated with chemoradiation and one patient (17%) with radiation alone. The average dose of radiation to the injected submandibular gland was 59.9 Gy. Three patients (50%) reported a pain score of 1 after submandibular gland injection, all pain resolved within 4 days. No patients reported pain 1 month after injection, with no SAEs or other DLTs reported 1 month after injection. The analysis of secondary endpoints demonstrated a trend of increased salivary production. The mean unstimulated saliva was 0.13 mL/min (SD 0.17) at baseline and increased to 0.14 mL/min (SD 0.12) at 1 month after injection and 0.19 mL/min (SD 0.21) at 3-months. Quality of life surveys also showed a trend towards improvement.

CONCLUSION

Injection of autologous IFNγ-stimulated MSC(M) into the submandibular gland of patients with RIX is safe and well tolerated. A trend towards an improvement in secondary endpoints of salivary quantity and quality of life was observed. This first-in-human pilot study provides support for further investigation into IFNγ-stimulated MSC(M) as an innovative, potentially curative, remedy to treat RIX. A phase I dose-escalation study injecting into bilateral submandibular glands is scheduled to begin accrual in the spring of 2023.

A comprehensive study of the incremental prognostic value of novel biomarkers in PARADIGM-HF (Bio-PREDICT-HF)

Background

Although multiple novel biomarkers have individually been shown to predict outcomes in patients with HFrEF, the value of these over and above conventional clinical and laboratory variables, plus natriuretic peptides, is uncertain.

Purpose

To test the incremental predictive value of 11 novel biomarkers added to a recent prognostic model 1 (PREDICT-HF) derived in PARADIGM-HF and validated in ATMOSPHERE and the Swedish heart failure registry. The PREDICT-HF model includes clinical variables, standard laboratory variables, and BNP or NT-proBNP.

Methods

1559 participants enrolled in PARADIGM-HF had all 11 biomarkers of interest measured. These reflected different pathophysiological pathways: (i) myocyte injury (high sensitivity cardiac troponin T), (ii) cardiac remodelling and inflammation (growth stimulation expressed gene 2, growth differentiation factor-15 and galectin-3), (iii) extracellular matrix remodelling (matrix metalloproteinase-2, matrix metalloproteinase-9, tissue inhibitor of metalloproteinase-1), (iv) neurohormonal pathways (aldosterone) and (v) renal dysfunction and injury (cystatin C, kidney injury molecule-1 and urinary albumin to creatinine ratio). The incremental prognostic value of these biomarkers was evaluated using Harrell's C statistic.

Results

The mean age of participants studied was 67.3 (SD 9.9) years, 1254 (80%) were men and 1103 (71%) were in NYHA class II. During a median follow-up of 31 months, 197 patients died and 300 experienced the primary composite outcome (cardiovascular death or heart failure hospitalization).

When each candidate biomarker (log unit) was added individually to the PREDICT-HF base model, GDF-15, ST2, TIMP1, cystatin C, hsTnT and UACR were independent predictors of all-cause mortality (Table 1). GDF-15, TIMP1, hs-TnT and cystatin C consistently increased the risk of both all-cause mortality and the primary outcome. Individuals who had all 4 biomarkers elevated (compared to none elevated) had the highest risk: HR for all-cause mortality 3.65 (2.01–6.64), p<0.0001. Adding these 4 biomarkers to the baseline PREDICT HF model improved the C statistic for all-cause mortality from 0.726 to 0.745.

Conclusion

Several novel biomarkers provide meaningful additional prognostic information in patients with HFrEF. A multimarker approach incorporating biomarkers reflecting different pathophysiological pathways added most information. This approach may be useful in refining risk and targeting treatment.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The PARADIGM-HF trial was funded by Novartis.J.J.V.M is supported by a British Heart Foundation Centre of Excellence Grant

Effects of intentional weight loss in patients with obesity and heart failure: a systematic review

OBJECTIVE

Obesity is an independent risk factor for the development of heart failure, and the two commonly co-exist. The European Society of Cardiology does not provide guidance regarding weight loss strategies in heart failure. The aim of this study was to systematically review the evidence for outcomes following intentional weight loss in patients with heart failure and obesity.

METHOD

A systematic review of English articles was undertaken using databases PubMed, Embase and CENTRAL. Randomized controlled trials and observational studies reporting outcomes following intentional weight loss by lifestyle, surgical or pharmacotherapy intervention in patients with obesity and heart failure were included.

RESULTS

Four randomized controlled trials and seven observational studies were identified. Two randomized controlled trials used diet and exercise as an intervention, one used diet alone and one used a pharmacological intervention (orlistat). All but one reported significant weight loss. Two reported improvement in exercise capacity and quality of life. One reported improvement in New York Heart Association functional class in heart failure with preserved ejection fraction. The observational studies, five of which reported on outcomes following bariatric surgery, despite being small, heterogeneous and high risk of bias, suggested a trend in improvement of left ventricular function, quality of life and exercise capacity following weight loss.

CONCLUSION

Weight loss is achievable with lifestyle intervention in those with heart failure and obesity and may result in improvements in New York Heart Association classification, quality of life and exercise capacity.

Informed decomposition of electroencephalographic data

BACKGROUND

Blind source separation techniques have become the de facto standard for decomposing electroencephalographic (EEG) data. These methods are poorly suited for incorporating prior information into the decomposition process. While alternative techniques to this problem, such as the use of constrained optimization techniques, have been proposed, these alternative techniques tend to only minimally satisfy the prior constraints. In addition, the experimenter must preset a number of parameters describing both this minimal limit as well as the size of the target subspaces.

NEW METHOD

We propose an informed decomposition approach that builds upon the constrained optimization approaches for independent components analysis to better model and separate distinct subspaces within EEG data. We use a likelihood function to adaptively determine the optimal model size for each target subspace.

RESULTS

Using our method we are able to produce ordered independent subspaces that exhibit less residual mixing than those obtained with other methods. The results show an improvement in modeling specific features of the EEG space, while also showing a simultaneous reduction in the number of components needed for each model.

COMPARISON WITH EXISTING METHOD(S)

We first compare our approach to common methods in the field of EEG decomposition, such as Infomax, FastICA, PCA, JADE, and SOBI for the task of modeling and removing both EOG and EMG artifacts. We then demonstrate the utility of our approach for the more complex problem of modeling neural activity.

CONCLUSIONS

By working in a one-size-fits-all fashion current EEG decomposition methods do not adapt to the specifics of each data set and are not well designed to incorporate additional information about the decomposition problem. However, by adding specific information about the problem to the decomposition task, we improve the identification and separation of distinct subspaces within the original data and show better preservation of the remaining data.

The psychometric properties of the Hospital Anxiety and Depressions Scale adapted for use with people with intellectual disabilities

BACKGROUND

There is increasing recognition of depression in people with intellectual disabilities (ID). There is a need to develop well-standardised self-report measures for both clinical and research purposes. This paper presents some psychometric properties of the Hospital Anxiety and Depression Scale (HADS) adapted for use with people with ID. The anhedonic emphasis in the depression scale of the HADS may be particularly useful for people with ID who present with high rates of physical co-morbidity.

METHOD

A total of 197 people with ID completed an adapted HADS; 32 participants also completed the Zung Depression Scale and 42 also completed the Glasgow Depression Scale.

RESULTS

The obtained factor structure is similar to the original form of the scale used with people without ID. However, the underlying question wording of the HADS, where most depression items are phrased positively and most anxiety items are phrased negatively, makes clear interpretation of the factor structure difficult. The HADS has an adequate internal reliability and correlates well with other self-report measures of depression.

CONCLUSIONS

The HADS may need further adaptation; however, the measurement of anhedonia is a useful addition to the self-report measures of depression available for people with ID.

Development of somatosensory-motor integration: an event-related analysis of infant posture in the first year of independent walking

The ability to integrate sensation with action is considered an important factor underlying the development of upright stance and locomotion. While many have studied sensory influences on posture, the nature of these influences and how they change with development have yet to be thoroughly characterized in infancy. Six infants were examined from 1 month prior to walk onset until 9 months of independent walking experience while standing quietly and touching either a static or a dynamic surface. Five adults were examined performing an analogous task. An event-related, time-frequency analysis was used to assess the relationship between postural sway and the motion of the somatosensory stimulus. Phase consistency between sway and stimulus was observed for both adults and infants, and with walking experience the infants increased their phase consistency rather than changing aspects of response amplitude. It is concluded that walking experience provides opportunities for an active tuning of sensorimotor relations for adequate estimation of body position in space and thus facilitates refined control over temporal aspects of postural sway.

The temporal organization of posture changes during the first year of independent walking

Although the development of upright posture has received considerable attention, the quiet stance of infants in their first months of learning this fundamental behavior has not been well studied. The purpose of the present study was to characterize the time evolutionary properties, or temporal organization, of these infants' unperturbed upright stance as well as to elucidate how somatosensory information influences that organization. Six healthy, full-term infants were tested monthly from walk onset until 9 months of independent walking experience while standing either independently or touching a static surface. The structure of sway was assessed through stabilogram-diffusion analysis using an exponential Ornstein-Uhlenbeck characterization. The results of this analysis revealed two new insights into postural development. First, the developmental changes in quiet stance involved a decreased rate at which sway decays to maximal variance, rather than an attenuation of the magnitude of that variance. Specifically, measures indexing amount of sway variance were significantly reduced when touching a static surface as compared with an independent stance condition, but revealed no change with increased walking experience. Further, a reduction in the average rate constant of decay indicated an increased influence of long time-scale sway corrections on the overall sway trajectory. Second, it was shown that, at early walk ages, the use of touch both reduced the amount of variance and shifted the rate constant of sway towards longer time-scale displacements. Taken in the context of previous research, these results support our conclusion that early postural development embodies the dual tasks of calibrating sensorimotor relations for estimation of self-motion as well as identification and tuning of control system properties.

Aging, physical activity, and cognitive processing: an examination of P300

Physical activity appears to attenuate the decline of cognitive function typically observed in older men and women. The P300 component of the event-related potential (ERP) is particularly affected by aging and allows for basic neurobiological assessment of cognitive function. Three aspects of the P300 component (i.e. latency, amplitude, and area under the curve (AUC)), elicited by an oddball task, were derived to assess cognitive function in young and older participants (N=73) who were further classified as high- and low-active. The low-active elderly participants exhibited larger AUC values than those observed in all other groups which were undifferentiated. That is, the high-active elderly and the young participants exhibited smaller AUC values than the low-active older group. In conclusion, higher levels of physical activity in the elderly may be associated with a reduction in the neural resources allocated in response to simple cognitive challenge. This interpretation is consistent with the concept of psychomotor efficiency proposed by Hatfield and Hillman [The psychophysiology of sport: a mechanistic understanding of the psychology of superior performance. In: Singer RN, Hausenbias HA, Janelle CM, editors. Handbook of sport psychology. 2nd ed. New York: Wiley; 2001, p. 362-88].

The role of the left temporal region under the cognitive motor demands of shooting in skilled marksmen

A number of investigators have reported elevated left temporal alpha power in marksmen during response preparation. This finding has been interpreted to indicate the suppression of irrelevant cognitive processes. However, lower-order motor processes have not been excluded as a possible explanation. Event-related alpha power (11-13 Hz) was examined at sites T3, T4, C3, and C4 in eight skilled marksmen during shooting and two control tasks varying in perceptual-motor complexity. Over an 8-s period preceding the trigger pull, the marksmen exhibited higher power and slope at T3 than at all other sites during shooting compared with the control conditions. No such difference between conditions was detected at C3 and C4. The relative synchrony of left temporal alpha power during shooting, in conjunction with the lack of change at central sites, is inconsistent with the explanation that the effect is accounted for by 'lower-order' motor processes exclusively involving the central region.

The U8 snoRNA gene family: identification and characterization of distinct, functional U8 genes in Xenopus

U8 snoRNA is the RNA component of a small nucleolar ribonucleoprotein (U8 snoRNP) required for accumulation of mature 5.8S and 28S rRNAs, components of the large ribosomal subunit. We have identified two putative U8 genes in Xenopus laevis. Sequence analysis of the coding regions of these two genes indicate that both differ at several positions from the previously characterized U8 RNA and that the two differ from each other. Functional analysis of these genes indicates that both are transcribed in vivo, produce stable U8 transcripts, and are capable of facilitating pre-rRNA processing in vivo. These data demonstrate that natural sequence variation exists among the U8 snoRNA genes in Xenopus. Alignment of these three Xenopus U8 sequences with the previously described mammalian U8 homologues in mouse, rat and human has provided information about evolutionarily conserved sequence and structural elements in U8 RNA. Identification and functional characterization of these naturally occurring variants in Xenopus has helped identify regions in U8 RNA that may be critical for function.

A phase II study of biochemotherapy for the treatment of metastatic malignant melanoma

The use of interleukin-2 (IL-2) and interferon-alpha (IFNalpha) in combination with chemotherapy for the treatment of advanced malignant melanoma has generated considerable interest. In particular, the relatively high number of durable complete responses has suggested this may be a significant advance in the treatment of malignant melanoma. We report our experience at the University of Colorado in 43 patients, including many with poor prognostic factors. Patients received cisplatin 20 mg/m2 on days 1-4, vinblastine 1.6 mg/m2 on days 1-4, dacarbazine 800 mg/m2 on day 1, IL-2 9 x 10(6) IU/m2 per day intravenously over 24h on days 1-4 and IFNalpha 5 x 10(6) IU/m2 per day subcutaneously on days 1-5 every 3 weeks. The median follow-up for all patients was 34 months. Responses were seen in 20 patients (47%, 95% confidence interval 31-62%) and comprised five complete responses (CRs) (12%) and 15 partial responses (PRs) (35%). Two patients achieving a CR remain disease free at 45 and 47 months follow-up. In addition three patients who obtained a surgical CR and another with only minor residual changes on computed tomography scan have not progressed at 27, 30, 40 and 27 months, respectively. Toxicity was manageable, but all patients had at least one grade 3 or 4 toxicity, predominantly hypotension and neutropenia. There were no treatment-related deaths. In conclusion, the response rate and duration is within the range previously reported for biochemotherapy. The results of ongoing randomized studies are awaited to better define the value of biochemotherapy in the treatment of advanced melanoma.

Wounds and pain management

Practice profiles are reflective pieces written by nurses in practice and based on continuing professional development articles. This week Karen McDowell discusses wound management and pain control. CPD article NS14, Gould D (1999) Wound management and pain control. Nursing Standard. 14, 6, 47-54.

Identification of a new aspartic proteinase expressed by the outer chorionic cell layer of the equine placenta

The pregnancy-associated glycoproteins (PAGs) are placental antigens that were initially characterized as pregnancy markers in the maternal circulation of domestic ruminant species. They are members of the aspartic proteinase gene family, having greatest sequence identity with pepsinogens. However, some are not capable of functioning as enzymes. The PAGs are associated with a large gene family within the Artiodactyla order (cattle, camels, pigs). So far, no members of this family have been characterized in species outside this order. This report describes the cloning and initial characterization of a PAG-like protein (equine PAG or ePAG) expressed in the placenta of the horse and zebra (order Perrisodactyla). Equine PAG is a proteinase capable of degrading 14C-hemoglobin and catalyzing the removal of its own pro-peptide. The ePAG mRNA is restricted to the chorion both prior to implantation and in the term placenta. Equine PAG is secreted from cultured placental tissue as both a processed (mature) and unprocessed (zymogen) form. Equine PAG shares similar identity with the PAGs and pepsinogens and probably arose from a pepsinogen-like precursor that gained the ability to be expressed in the placenta. The promoter of the ePAG gene shares sequence identity with the promoter from a bovine PAG gene but not with promoters of other aspartic proteinases. Therefore, we hypothesize that ePAG is a remnant of the pepsinogen-like progenitor gene that was expanded within the Artiodactyla to create the large and highly diverse PAG family.

The respiratory system in connective tissue diseases

Adolescents with connective tissue diseases (CTDs) are at risk for community-acquired and opportunistic respiratory tract infections; it is mandatory to consider an infectious etiology in the differential diagnosis. The authors highlight the respiratory manifestations of the more common CTDs seen in adolescence, and also discuss useful diagnostic tests and drug regimens.

Comparative modelling and analysis of amino acid substitutions suggests that the family of pregnancy-associated glycoproteins includes both active and inactive aspartic proteinases

The pregnancy-associated glycoproteins (PAGs) are secretory products synthesized by the outer epithelial cell layer (chorion) of the placentas of various ungulate species. The amino acid sequences of eight PAGs have been inferred from cloned cDNA of cattle and sheep, as well as of the non-ruminant pig and horse. We compare the PAG sequences and present results of the three-dimensional models of boPAG-1 and ovPAG-1 that were constructed on the basis of the crystal structures of homologous porcine pepsin and bovine chymosin using a rule-based comparative modelling approach. Further, we compare peptide binding subsites defined by interactions with pepstatin and a decapeptide inhibitor (CH-66) modelled on the basis of crystal structures of other aspartic proteinases. We have extended our analysis of the peptide binding subsites to the other PAG molecules of known sequence by aligning the PAG sequences to the structural template derived from the pepsin family and by making use of the three-dimensional models of the boPAG-1 and ovPAG-1. The residues that are likely to affect peptide binding in the boPAG-1, ovPAG-1 and other PAG molecules have been identified. Sequence comparisons reveal that all PAG molecules may have evolved from a pepsin-like progenitor molecule with the equine PAG most closely related to the pepsins. The presence of substitutions at the S1 and other subsites relative to pepsin make it unlikely that either bovine, ovine or the porcine PAG-1 have catalytic activity. Only two of the eight PAGs examined (porcine PAG-2 and equine PAG-1) retain features of active aspartic proteinases with pepsin-like activity. Our results indicate that in the PAGs so far characterized the peptide binding specificities differ significantly from each other and from pepsin, despite their high sequence identities. Analysis of the various peptide binding subsites demonstrates why both bovine and ovine PAG-1 are capable of binding pepstatin. The strong negative charge in the binding cleft of boPAG-1 and ovPAG-1 indicates a preference for lysine- or arginine-rich peptides. PAGs represent a family where the possible peptide binding function may be retained through their binding specificities, but where the catalytic activity may be lost in some cases, such as the boPAG-1, ovPAG-1 and the poPAG-1.

A retrospective study into the occurrence of cervical glandular atypia in cone biopsy specimens from 1977-1978 with clinical follow-up

Cervical glandular atypia (CGA) is now increasingly recognized in cone biopsy specimens removed for suspected cervical intra-epithelial neoplasia, although little is known of its natural history or pre-malignant potential. One hundred and eighty-three cone biopsy specimens received in our department during 1977 and 1978 from the City and Women's hospitals, Nottingham were reviewed and assessed for the presence of squamous CIN and CGA. One hundred and sixty-seven cone biopsies contained CIN and 28 of these also contained CGA. Ten cone biopsies contained high-grade CGA, the remaining 17 containing low-grade CGA. One cone biopsy contained high-grade CGA only. Twenty-one of the 28 cases of CGA had been followed up by annual pelvic examination and cervical cytology. None of these cases have developed abnormal cervical cytology or invasive cervical carcinoma after 13 years follow-up, even though 13 cone biopsies contained CGA which appeared to be incompletely excised. We concluded that if CGA is pre-malignant, the latent period for its progression to invasive carcinoma is in excess of 13 years. CGA of either grade is not, in itself, an indication for hysterectomy, allowing a conservative approach to management in the first instance.

Computerization of the Medical Quality Improvement program at a chronic care hospital

Utilizing micro computer technology and a relational data base manager we have successfully computerized the Peer Review functions of the Medical Quality Improvement program at Monroe Community Hospital, a Chronic Care Hospital. The developed computer programs enhance patient care by focusing on potential practitioner errors. The programs allow for trend analysis and identify the disciplines to whom problems have been referred. This effort has pointed to the need of a standardized lexicon to describe and catalogue potential practitioner errors.

Thoracoabdominal asynchrony in infants with airflow obstruction

Thoracoabdominal asynchrony (TAA) has long been thought clinically useful in the assessment of airflow obstruction (AO) in infants. To test the hypothesis that the measurement of TAA is useful in the assessment of lung mechanics in infants with AO, we have used respiratory inductive plethysmography (RIP) to quantity TAA. We compared changes in TAA to changes in lung mechanics before and after aerosolized bronchodilator (BD) administration in 13 infants. Abdominal wall (AB) and rib cage (RC) motion were displayed on an X-Y recorder in a Lissajous figure. Asynchrony between RC and AB motion was quantified by comparing the width m of the Lissajous figure (difference between AB inspiratory and expiratory positions) at mid-RC excursion with the total AB excursion at its extremes (s). Phase angle phi ws computed as sin phi = m/s (or phi = 180 degrees - mu, where sin mu = m/s for phase angles greater than 90 degrees) and was taken as a measure of TAA. Lung resistance RL and elastance EL were calculated from esophageal pressure (Pes), mouth pressure, tidal volume, and tidal flow. All infants displayed TAA at baseline. After BD administration, TAA decreased in those infants in whom RL decreased. The percentage decrease in the phase angle from baseline after BD administration was significantly correlated with the decrease in peak-to-peak Pes (delta Pes) and the percentage decrease in RL and EL. We conclude that AO in infants leads to TAA through altered pleural pressure swings acting on the compliant chest wall. Changes in lung mechanics induced by bronchodilators are reflected in changes in TAA.(ABSTRACT TRUNCATED AT 250 WORDS)

Sleep cyclicity in infants during the earliest postnatal weeks

Cyclicity within sleep was investigated in 20 fullterm infants who were monitored in the home for 24-hour periods when they were 2-5 weeks old. Using a pressure sensitive mattress in the crib, analog signals from the baby's respiration and body movements were computer scored for: Quiet Sleep, Active Sleep, Active-Quiet Transitional Sleep, Sleep-Wake Transition, and Wakefulness. Sleep episodes with at least four recurrences of Quiet Sleep were analyzed for cyclicity. Significant cyclicity of Quiet Sleep was found in 49 of the 55 sleep episodes analyzed. The mean Quiet Sleep recurrence period was 63.2 minutes. Eighteen of the 20 infants exhibited cyclicity on one or more weeks. Thus, sleep during the neonatal period is generally characterized by the presence of cyclicity. Cyclicity was not related to other parameters of the sleep cycle, but was correlated with stability of state patterning over weeks. The results provide new evidence for neurobehavioral competence of the neonate in terms of sleep organization.