Single-Cell Analysis Reveals a Subset of High IL-12p40-Secreting Dendritic Cells within Mouse Bone Marrow-Derived Macrophages Differentiated with M-CSF

Macrophages and dendritic cells (DCs), although ontogenetically distinct, have overlapping functions and exhibit substantial cell-to-cell heterogeneity that can complicate their identification and obscure innate immune function. In this study, we report that M-CSF-differentiated murine bone marrow-derived macrophages (BMDMs) exhibit extreme heterogeneity in the production of IL-12, a key proinflammatory cytokine linking innate and adaptive immunity. A microwell secretion assay revealed that a small fraction of BMDMs stimulated with LPS secrete most IL-12p40, and we confirmed that this is due to extremely high expression of Il12b, the gene encoding IL-12p40, in a subset of cells. Using an Il12b-YFP reporter mouse, we isolated cells with high LPS-induced Il12b expression and found that this subset was enriched for genes associated with the DC lineage. Single-cell RNA sequencing data confirmed a DC-like subset that differentiates within BMDM cultures that is transcriptionally distinct but could not be isolated by surface marker expression. Although not readily apparent in the resting state, upon LPS stimulation, this subset exhibited a typical DC-associated activation program that is distinct from LPS-induced stochastic BMDM cell-to-cell heterogeneity. Overall, our findings underscore the difficulty in distinguishing macrophages and DCs even in widely used in vitro murine BMDM cultures and could affect the interpretation of some studies that use BMDMs to explore acute inflammatory responses.

Apoptosis recognition receptors regulate skin tissue repair in mice

Apoptosis and clearance of apoptotic cells via efferocytosis are evolutionarily conserved processes that drive tissue repair. However, the mechanisms by which recognition and clearance of apoptotic cells regulate repair are not fully understood. Here, we use single-cell RNA sequencing to provide a map of the cellular dynamics during early inflammation in mouse skin wounds. We find that apoptotic pathways and efferocytosis receptors are elevated in fibroblasts and immune cells, including resident Lyve1+ macrophages, during inflammation. Interestingly, human diabetic foot wounds upregulate mRNAs for efferocytosis pathway genes and display altered efferocytosis signaling via the receptor Axl and its ligand Gas6. During early inflammation in mouse wounds, we detect upregulation of Axl in dendritic cells and fibroblasts via TLR3-independent mechanisms. Inhibition studies in vivo in mice reveal that Axl signaling is required for wound repair but is dispensable for efferocytosis. By contrast, inhibition of another efferocytosis receptor, Timd4, in mouse wounds decreases efferocytosis and abrogates wound repair. These data highlight the distinct mechanisms by which apoptotic cell detection coordinates tissue repair and provides potential therapeutic targets for chronic wounds in diabetic patients.

Combinatorial Immunotherapy with Agonistic CD40 Activates Dendritic Cells to Express IL12 and Overcomes PD-1 Resistance

Checkpoint inhibitors have revolutionized cancer treatment, but resistance remains a significant clinical challenge. Myeloid cells within the tumor microenvironment can modulate checkpoint resistance by either supporting or suppressing adaptive immune responses. Using an anti-PD-1-resistant mouse melanoma model, we show that targeting the myeloid compartment via CD40 activation and CSF1R blockade in combination with anti-PD-1 results in complete tumor regression in a majority of mice. This triple therapy combination was primarily CD40 agonist-driven in the first 24 hours after therapy and showed a similar systemic cytokine profile in human patients as was seen in mice. Functional single-cell cytokine secretion profiling of dendritic cells (DC) using a novel microwell assay identified a CCL22+CCL5+ IL12-secreting DC subset as important early-stage effectors of triple therapy. CD4+ and CD8+ T cells are both critical effectors of treatment, and systems analysis of single-cell RNA sequencing data supported a role for DC-secreted IL12 in priming T-cell activation and recruitment. Finally, we showed that treatment with a novel IL12 mRNA therapeutic alone was sufficient to overcome PD-1 resistance and cause tumor regression. Overall, we conclude that combining myeloid-based innate immune activation and enhancement of adaptive immunity is a viable strategy to overcome anti-PD-1 resistance.

Functionally and Metabolically Divergent Melanoma-Associated Macrophages Originate from Common Bone-Marrow Precursors

Tumor-associated macrophages (TAMs) can be widely heterogeneous, based on their ontogeny and function, and driven by the tissue-specific niche. TAMs are highly abundant in the melanoma tumor microenvironment (TME), usually correlating with worse prognoses. However, the understanding of their diversity may be harnessed for therapeutic purposes. Here, we used the clinically relevant YUMM1.7 model to study melanoma TAM origin and dynamics during tumor progression. In i.d. YUMM1.7 tumors, we identified distinct TAM subsets based on F4/80 expression, with the F4/80^high fraction increasing over time and displaying a tissue-resident-like phenotype. While skin-resident macrophages showed mixed ontogeny, F4/80⁺ TAM subsets in the melanoma TME originated almost exclusively from bone-marrow precursors. A multiparametric analysis of the macrophage phenotype showed a temporal divergence of the F4/80⁺ TAM subpopulations, which also differed from the skin-resident subsets and their monocytic precursors. Overall, the F4/80⁺ TAMs displayed co-expressions of M1- and M2-like canonical markers, while RNA sequencing showed differential immunosuppressive and metabolic profiles. Gene-set enrichment analysis (GSEA) revealed F4/80^high TAMs to rely on oxidative phosphorylation, with increased proliferation and protein secretion, while F4/80^low cells had high pro-inflammatory and intracellular signaling pathways, with lipid and polyamine metabolism. Overall, we provide an in-depth characterization of and compelling evidence for the BM-dependency of melanoma TAMs. Interestingly, the transcriptomic analysis of these BM-derived TAMs matched macrophage subsets with mixed ontogeny, which have been observed in other tumor models. Our findings may serve as a guide for identifying potential ways of targeting specific immunosuppressive TAMs in melanoma.

Functionally and metabolically divergent melanoma-associated macrophages originate from common bone-marrow precursors

Melanomas display high numbers of tumor-associated macrophages (TAMs), which correlate with worse prognosis. Harnessing macrophages for therapeutic purposes has been particularly challenging due to their heterogeneity, based on their ontogeny and function and driven by the tissue-specific niche. In the present study, we used the YUMM1.7 model to better understand melanoma TAM origin and dynamics during tumor progression, with potential therapeutic implications. We identified distinct TAM subsets based on F4/80 expression, with the F4/80 ^high fraction increasing over time and displaying tissue-resident-like phenotype. While skin-resident macrophages showed mixed on-togeny, F4/80 ⁺ TAM subsets in i.d. YUMM1.7 tumors originated almost exclusively from bone-marrow precursors. Mul-tiparametric analysis of macrophage phenotype showed a temporal divergence of F4/80 ⁺ TAM subpopulations, which also differed from skin-resident subsets, and from their monocytic precursors. Overall, F4/80 ⁺ TAMs displayed co-ex-pression of M1- and M2-like canonical markers, while RNA-seq and pathway analysis showed differential immunosup-pressive and metabolic profiles. GSEA showed F4/80 ^high TAMs to rely on oxidative phosphorylation, with increased proliferation and protein secretion while F4/80 ^low cells had high pro-inflammatory and intracellular signaling pathways, with lipid and polyamine metabolism. Overall, the present in-depth characterization provides further evidence of the ontogeny of the evolving melanoma TAMs, whose gene expression profiles matched recently-identified TAM clusters in other tumor models and human cancers. These findings provide evidence for potentially targeting specific immunosup-pressive TAMs in advanced tumor stages.

Apoptosis recognition receptors regulate skin tissue repair in mice

Apoptosis and clearance of apoptotic cells via efferocytosis are evolutionarily conserved processes that drive tissue repair. However, the mechanisms by which recognition and clearance of apoptotic cells regulate repair are not fully understood. Here, we use single-cell RNA sequencing to provide a map of the cellular dynamics during early inflammation in mouse skin wounds. We find that apoptotic pathways and efferocytosis receptors are elevated in fibroblasts and immune cells, including resident Lyve1 + macrophages, during inflammation. Interestingly, human diabetic foot wounds upregulate mRNAs for apoptotic genes and display increased and altered efferocytosis signaling via the receptor Axl. During early inflammation in mouse wounds, we detect upregulation of Axl in dendritic cells and fibroblasts via TLR3-independent mechanisms. Inhibition studies in vivo in mice reveal that Axl signaling is required for wound repair but is dispensable for efferocytosis. By contrast, inhibition of another efferocytosis receptor, Timd4, in mouse wounds decreases efferocytosis and abrogates wound repair. These data highlight the distinct mechanisms by which apoptotic cell detection coordinates tissue repair and provides potential therapeutic targets for chronic wounds in diabetic patients.

Langerhans cells are essential components of the angiogenic niche during murine skin repair

Angiogenesis, the growth of new blood vessels from pre-existing vessels, occurs during development, injury repair, and tumorigenesis to deliver oxygen, immune cells, and nutrients to tissues. Defects in angiogenesis occur in cardiovascular and inflammatory diseases, and chronic, non-healing wounds, yet treatment options are limited. Here, we provide a map of the early angiogenic niche by analyzing single-cell RNA sequencing of mouse skin wound healing. Our data implicate Langerhans cells (LCs), phagocytic, skin-resident immune cells, in driving angiogenesis during skin repair. Using lineage-driven reportersw, three-dimensional (3D) microscopy, and mouse genetics, we show that LCs are situated at the endothelial cell leading edge in mouse skin wounds and are necessary for angiogenesis during repair. These data provide additional future avenues for the control of angiogenesis to treat disease and chronic wounds and extend the function of LCs beyond their canonical role in antigen presentation and T cell immunity.

Abstract B48: CD40-agonist treatment can prime the inflammatory response of macrophages and reverse checkpoint inhibitor resistance in melanoma

Checkpoint inhibitors (CPIs) have revolutionized cancer treatment, but therapy resistance remains a significant clinical challenge. One strategy to restore anti-tumor activity is to target immunosuppressive tumor-associated macrophages (TAMs) and myeloid cells that suppress adaptive immune responses. Our previous results in the YUMMER mouse melanoma model demonstrated that agonistic CD40 antibody (CD40ag) and CSF1R blockade could overcome PD-1 resistance via functional activation of a specific CCL22+CCL5+ IL-12-secreting dendritic cell (DC) subset, but did not indicate a clear role for TAMs, when initiated at day 7 post-tumor injection (early treatment). We hypothesized that CD40ag-treatment efficacy is impacted by the stage of tumor growth, leading to differential responsive immune cell populations. To address this, we studied a different treatment scheme in which a single dose of CPIs anti-PD-1 and anti-CTLA4 induced complete tumor regression when applied early, but fail to be effective in delayed administration schemes (after day 10). Specifically, we added CD40ag to a single-dose CPI treatment initiated at different stages of tumor growth, in order to define key myeloid subpopulations and cell-cell interactions leading to successful TME reprogramming versus resistance. In immunocompetent mice, a Ly6Cint TAM subset exhibited a partial inflammatory response which appeared to be dependent on early tumor T-cell infiltration. Administration of early CD40ag treatment did not generate additional changes in inflammatory markers in the TAM population, despite the significant fraction of CD40+ TAMs. However, a delayed CD40ag treatment rapidly upregulated pro-inflammatory markers in a CD40+Ly6C+ TAM subset, with high iNOS, CCL3 and TNFa expression. This approach synergized with CPIs, inducing more than 90% overall survival, in contrast to the monotherapies, which showed initial tumor control but were ineffective on their own long-term. The efficay of a single-dose CPI+CD40ag decreased with treatment initiation delay. Furthermore, in Rag-/- mice, we did not detect the poorly-inflammatory TAM subset and early CD40ag treatment induced an immediate TAM response with multiple proinflammatory markers, but transient in the absence of T cells. By scRNA-seq, early treatment with CD40ag, and in combination with CPIs, increased expression of genes involved in T cell recruitment and activation, such as Il12b and Cxcl9/10, in responding subsets of DCs and TAMs, respectively. These findings supported the role of CD40ag and improved treatment schemes, priming the innate compartment and establishing an important link with adaptive immunity. Integrating scRNA-seq, flow cytometry and in vivo functional data, we determined changes in myeloid cells associated with successful immune responses as well as TAM subsets limiting immunotherapy. Future studies will focus on immune cell spatial distribution to build and refine relevant interaction networks within the TME to define successful, myeloid-driven therapeutic responses in melanoma.

Citation Format: Gabriela A Pizzurro, Kate Bridges, Susan Kaech, Marcus Bosenberg, Kathryn Miller-Jensen. CD40-agonist treatment can prime the inflammatory response of macrophages and reverse checkpoint inhibitor resistance in melanoma [abstract]. In: Proceedings of the AACR Special Conference: Tumor Immunology and Immunotherapy; 2022 Oct 21-24; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2022;10(12 Suppl):Abstract nr B48.

Mapping and Validation of scRNA-Seq-Derived Cell-Cell Communication Networks in the Tumor Microenvironment

Recent advances in single-cell technologies, particularly single-cell RNA-sequencing (scRNA-seq), have permitted high throughput transcriptional profiling of a wide variety of biological systems. As scRNA-seq supports inference of cell-cell communication, this technology has and continues to anchor groundbreaking studies into the efficacy and mechanism of novel immunotherapies for cancer treatment. In this review, we will highlight methods developed to infer inter- and intracellular signaling from scRNA-seq and discuss how they have contributed to studies of immunotherapeutic intervention in the tumor microenvironment (TME). However, a central challenge remains in validating the hypothesized cell-cell interactions. Therefore, this review will also cover strategies for integration of these scRNA-seq-derived interaction networks with existing experimental and computational approaches. Integration of these networks with imaging, protein secretion measurements, and network analysis and mathematical modeling tools addresses challenges that remain with scRNA-seq to enhance studies of immunosuppressive and immunotherapy-altered signaling in the TME.

The Critical Need to Recognize That Families Matter for Adult Health: A Systematic Review of the Literature

A systemic approach to researching families and health should capture the complex network within which family members are embedded, including multiple family relationships and larger systems of health care. However, much of the families and health research focused on adult family members has focused solely on intimate partnerships, usually the marital relationship. This neglects the remainder of the powerfully influencing family relationships adults retain, and may increasingly focus on as they age. We conducted a systematic review of the families and adult health literature, retaining 72 articles which were subsequently thematically coded to highlight main foci of this area of research. Results highlight six themes, which include family relationship quality, family composition, behavioral factors in health and health care, psychophysiological mediators, caregiving, and aging health. Findings support an underrepresentation of family members, other than the intimate partner, in research on adult health.

PedHITSS: A Screening Tool to Detect Childhood Abuse in Clinical Settings

BACKGROUND AND OBJECTIVES

Though child abuse is prevalent and detrimental, health care providers fail to screen for abuse at sufficient rates to detect or preempt events. Current child abuse screening tools lack brevity and usefulness in clinical settings. To validate the Pediatric Hurt-Insult-Threaten-Scream-Sex (PedHITSS) screening tool, a 5-item questionnaire designed to detect and prompt provider investigation into child abuse in clinical settings, the PedHITSS was compared to the Conflict Tactics Scale: Parent-Child Version (CTSPC) screening measure.

METHODS

Participants included 422 pediatric patients (n=242 nonabused; n=180 abused subsample) recruited from an ambulatory care setting, a medical center at-risk referral clinic, or homeless shelter clinic. Parents were asked to complete a cross-sectional survey, including PedHITSS and CTSPC questionnaires. Concurrent validity of PedHITSS was tested with 242 participants identified as nonabused. Construct validity was assessed with 180 participants previously identified as victims of child abuse.

RESULTS

Concurrent validity between the CTSPC and PedHITSS was strong, rs=.70 (P<.01). Sensitivity and specificity for correctly identifying abuse victims (≤12 years) was optimal at a cutpoint of one or greater. There was no significant difference in sensitivity and specificity of HITSS and CTSPC in correctly identifying victims of child abuse.

CONCLUSIONS

This study indicates that PedHITSS performs as well as CTSPC in identifying and differentiating victims and nonvictims of child abuse. PedHITSS allows health care providers to confidently screen and report suspected cases of child abuse and serves as a mechanism to confirm abuse status through validated means.

Erythropoiesis-stimulating agents in oncology: a study-level meta-analysis of survival and other safety outcomes

BACKGROUND: Cancer patients often develop the potentially debilitating condition of anaemia. Numerous controlled studies indicate that erythropoiesis-stimulating agents (ESAs) can raise haemoglobin levels and reduce transfusion requirements in anaemic cancer patients receiving chemotherapy. To evaluate recent safety concerns regarding ESAs, we carried out a meta-analysis of controlled ESA oncology trials to examine whether ESA use affects survival, disease progression and risk of venous-thromboembolic events.

METHODS: This meta-analysis included studies from the 2006 Cochrane meta-analysis, studies published/updated since the 2006 Cochrane report, and unpublished trial data from Amgen and Centocor Ortho Biotech. The 60 studies analysed (15 323 patients) were conducted in the settings of chemotherapy/radiochemotherapy, radiotherapy only treatment or anaemia of cancer. Data were summarised using odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS: Results indicated that ESA use did not significantly affect mortality (60 studies: OR=1.06; 95% CI: 0.97–1.15) or disease progression (26 studies: OR=1.01; 95% CI: 0.90–1.14), but increased the risk for venous-thromoboembolic events (44 studies: OR=1.48; 95% CI: 1.28–1.72).

CONCLUSION: Though this meta-analysis showed no significant effect of ESAs on survival or disease progression, prospectively designed, future randomised clinical trials will further examine the safety and efficacy of ESAs when used according to the revised labelling information.

Heparin use and venous thromboembolism (VTE) among cancer patients receiving chemotherapy with a prior history of VTE

6616

Background: Heparin is an effective treatment option for the prevention of venous thromboembolism (VTE) in cancer patients on chemotherapy. To date, information on the use of both low molecular weight heparin (LMWH) and non-LMWH in cancer patients receiving chemotherapy that have had a prior VTE is lacking. We evaluated heparin treatment patterns as well as the incidence of VTE in a cohort of cancer patients receiving chemotherapy, who have had a VTE prior to their cancer diagnosis. Methods: We conducted a retrospective cohort study using a large claims database representing the U.S. commercially-insured population. The cohort included all patients 18–64 years old from 2000 to 2007 who were diagnosed with cancer, were on chemotherapy, and who had a VTE occurring up to 12 months before cancer (n=331). We defined a diagnosis of cancer as two ICD-9 claims 30 days apart or more. A combination of ICD-9, HCPCS, and CPT codes were used to capture chemotherapy treatment after cancer. A VTE was identified by a single ICD-9 claim of 415.1, 451.2, 451.81, 451.9, 453.1, 453.2, 453.8, or 453.9. VTE claims occurring within 6 months of the index claim were considered part of the same VTE event. A patient was considered to have a VTE after cancer if they had a VTE claim that occurred both after the cancer diagnosis and at least 6 months beyond the most recent pre-cancer index VTE date. Results: Fifty-one percent of cancer patients with a history of VTE were prescribed an anticoagulant (n = 171). Fewer patients took LMWH compared to non-LMWH (6.7% versus 27.8%) while a portion took both (17.2%). A VTE after cancer was experienced by 49.1% of those on any kind of anticoagulant, 45.4% of those taking LMWH, 43.5% of those taking non-LMWH, and 59.6% of those who had taken both types. Fewer VTEs were reported among those taking no anticoagulants (29.4%). Conclusions: Approximately half of all cancer patients receiving chemotherapy were receiving heparin, with a smaller proportion using only LMWH. Even with prophylaxis, VTE recurs in half of cancer patients with a VTE history who receive chemotherapy. Recurrent VTE is a serious risk despite heparin or LMWH prophylaxis.

[Table: see text]

The use of a virtual three-dimensional model to evaluate the intraosseous space available for percutaneous screw fixation of acetabular fractures

We created virtual three-dimensional reconstruction models from computed tomography scans obtained from patients with acetabular fractures. Virtual cylindrical implants were placed intraosseously in the anterior column, the posterior column and across the dome of the acetabulum. The maximum diameter which was entirely contained within the bone was determined for each position of the screw. In the same model, the cross-sectional diameters of the columns were measured and compared to the maximum diameter of the corresponding virtual implant. We found that the mean maximum diameter of virtual implant accommodated by the anterior columns was 6.4 mm and that the smallest diameter of the columns was larger than the maximum diameter of the equivalent virtual implant. This study suggests that the size of the screw used for percutaneous fixation of acetabular fractures should not be based solely on the measurement of cross-sectional diameter and that virtual three-dimensional reconstructions might be useful in pre-operative planning.

Epstein-Barr virus-associated B cell lymphoproliferative disorder following mismatched related T cell-depleted bone marrow transplantation

Epstein-Barr virus (EBV) is closely associated with the progressive and often fatal lymphoproliferative disorders (LPD) in post bone marrow transplantation (BMT) and immunocompromised hosts. The incidence increases significantly when alternative donors or manipulation of marrow graft are used. A total of 318 consecutive BMT from partially mismatched related family donors (PMRD) were performed between February 1993 and June 1998. Known risk factors for the development of EBV-LPD were analyzed which included HLA mismatches, T cell depletion, antithymocyte globulin (ATG), and graft-versus-host disease (GVHD). Eighteen patients (5.7%) developed EBV-LPD at a median of 137 days post BMT (range 48-617). The estimated probability of developing EBV-LPD was 0.13 (95% CI 0.07-0.19) at 5 years. The incidence of grade II to IV GVHD was 19.2%, which translated into an increased trend of EBV-LPD. No correlation with other risk factors was observed. Treatment consisted of supportive antiviral agents, tapering of immunosuppressive regimens, donor leukocyte infusions and radiation. Three patients are alive and disease-free at a median follow-up of 69 months (range 36-71). We observed a lower than expected incidence of EBV-LPD despite existing multiple high-risk factors. We believe prevention and early control of GVHD may contribute to this finding.

In vitro generation of Epstein-Barr virus-specific cytotoxic T cells in patients receiving haplo-identical allogeneic stem cell transplantation

Use of a partially mismatched related donor (PMRD) is an option for patients who require allogeneic transplantation but do not have a matched sibling or unrelated donor. Epstein-Barr virus (EBV)-induced lymphoma is a major cause of mortality after PMRD transplantation. In this study, we present a clinical grade culture system for donor-derived EBV-specific cytotoxic T cells (CTLs) that do not recognize haplo-identical recipient cells. The EBV-specific CTLs were tested for cytolytic specificity and other functional properties, including ability to transgress into tissues, propensity for apoptosis, degree of clonality, stability of dominant T-cell clones, and Tc and Th phenotypes. The EBV-specific CTLs were routinely expanded to greater than 80 x 10(6) over a period of 5 weeks, which is sufficient for clinical application. A CD8+ phenotype predominated, and the CTLs were highly specific for donor lymphoblastoid cell lines (LCLs) without killing of recipient targets or K562. Vbeta spectratyping showed an oligoclonal population that was stable on prolonged culture. The EBV-specific CTLs were activated (D-related human leukocyte antigen [HLA-DR+], L-selectin+/-) and of memory phenotype (CD45RO+). Expression of the integrin VLA-4 suggested that these CTLs could adhere to endothelium and migrate into tissues. The Bcl-2 message was upregulated, which may protect the CTLs from the apoptosis. The first demonstration of overexpression of bcl-2 in human memory CTLs. In addition, we show that lymphoblastoid cell lines used to generate CTLs are readily genetically modified with recombinant lentivirus, indicating that genetically engineered antigen presentation is feasible.

Allogeneic bone marrow transplantation from partially mismatched related donors as therapy for primary induction failure acute myeloid leukemia

The outcome of acute myeloid leukemia patients with primary refractoriness to conventional chemotherapy is extremely poor. Allogeneic bone marrow transplants with matched sibling or matched unrelated donors provide 10-20% disease-free survival in this setting. We analyzed our transplant experience using readily available partially mismatched related donor (PMRD) in patients with primary induction failure (PIF) AML. Between March 1994 and December 1998, 13 patients with PIF AML were transplanted from 0-3 HLA antigen mismatched donors. All 12 evaluable patients engrafted at a median of day +16. Ten (77%) patients survived at least 100 days after transplant. Acute GVHD (grade II) was observed in one of 12 patients. Chronic GVHD was seen in one of 10 patients surviving beyond day 100. The major cause of failure was relapse of disease in six occurring 3-12 months after PMRD BMT. Three patients are alive without disease 14, 36 and 45 months post BMT with Karnofsky scores of 100%. The actuarial 3-year probabilities of relapse and disease-free survival were 0.54 and 0.19, respectively. We concluded that a PMRD graft is a viable option, comparable to the use of matched related or unrelated donors, in patients with PIF AML in whom time is of the essence.

Expression of CD134 (0X-40) on T cells during the first 100 days following allogeneic bone marrow transplantation as a marker for lymphocyte activation and therapy-resistant graft-versus-host disease

CD134 (OX-40) is an activation-associated antigen which functions as a costimulatory receptor for CD4+ T cells. In order to determine the expression of CD134 during immune recovery following allogeneic bone marrow transplantation (BMT), we measured its expression on T cells and T cell subsets during the first 100 days following BMT in 26 patients. CD4+CD134+ T could be seen approximately 14 days following BMT cells in patients who did not develop GvHD which required therapy (n = 20). The percentage of CD4+CD134+ cells continued to increase up to the fourth week following BMT to a maximum of 40-50% of CD4+ T cells (normal = 1-8%). Two patients who developed Grade I-II GvHD and who responded to treatment with pulsed high-dose methylprednisolone (MPD) showed a decline of approximately 40% in CD4+CD134+ T cells was seen within 48 hours of treatment. Four patients who developed GvHD that was not responsive to MPD and who later developed high IV GvHD showed increasing CD4+CD134+ T cells up to 85% of the CD4+ T cells. Additionally, rapid increases in CD134+ T cells following antibody-based T cell therapy were associated with GvHD recurrence. In no cases was the percentage of CD134+ CD4+ T cells predictive of clinical GvHD. In this exploratory study, we have shown that CD134, although not predictive of the initial onset of GvHD, may be a useful tool for monitoring the response to early GvHD therapy and identification of patients at risk for reemergence of GvHD who may benefit from anti-T cell therapy. Cytometry (Comm. Clin. Cytometry) 38: 238-243, 1999.

Anemia in hemodialysis patients: variables affecting this outcome predictor

Despite the prevalent use of recombinant human erythropoietin (rhEPO), anemia is a frequent finding in hemodialysis patients. The goal of this study was to evaluate the impact of anemia on patient survival and characterize the determinants of hematopoiesis that may be amenable to therapeutic manipulation to enhance rhEPO responsiveness and reduce death risk. Patient characteristics and laboratory data were collected for 21,899 patients receiving hemodialysis three times per week in dialysis centers throughout the United States in 1993. Hemoglobin concentrations (Hb) < or =80 g/L were associated with a twofold increase in the odds of death (odds ratio = 2.01; P = 0.001) when compared with Hb 100 to 110 g/L. No improvement in the odds of death was afforded for Hb >110 g/L. Using multiple linear regression, variables of rhEPO administration (rhEPO dose and percentage of treatments that rhEPO was administered), variables of iron status (serum iron, transferrin saturation, and ferritin), variables of nutritional status (serum albumin and creatinine concentration), and the dose of dialysis (urea reduction ratio) were found to be significantly associated with hemoglobin concentration (P < 0.001). Age, race, and gender were also found to be significantly associated with hemoglobin concentrations (P < 0.001). From this report, the following conclusions may be made. (1) Anemia may be predictive of an increased risk of mortality in some hemodialysis patients. (2) Hemoglobin concentrations > 110 g/L are not associated with further improvements in the odds of death. (3) Laboratory surrogates of iron stores, nutritional status, and the delivered dose of dialysis are predictive of hemoglobin concentration. Whether manipulation of the factors that improve anemia will also enhance the survival of patients on hemodialysis is unknown and should be evaluated by prospective, interventional studies.

The structure of common psychiatric symptoms: how many dimensions of neurosis?

In order to replicate and elaborate the two-dimensional model of depression and anxiety underlying the structure of common psychiatric symptoms proposed by Goldberg et al. (1987), we carried out latent trait analyses on PSE symptom data of the original Manchester study and two recent Dutch studies. We used the same analytical strategy as Goldberg et al. to facilitate comparison with the earlier work. It was found that a more comprehensive set of common psychiatric symptoms caused an extra, third dimension to emerge, so that the earlier anxiety dimension became split between a specific anxiety axis characterized by situational and phobic anxiety and avoidance, and a non-specific anxiety axis characterized by free-floating anxiety, various symptoms relating to tension, irritability and restlessness. It is argued that three dimensions are sufficient to account for the covariance between common psychiatric symptoms. A fairly consistent correlation between the non-specific anxiety and the depression dimension was found across sites, as well as independence of the specific anxiety dimension from the other two dimensions. Furthermore, the depression dimension was robust with similar symptom profiles across samples, but there appeared to be local differences in the structure of anxiety symptoms.

Changes in social support and quality of life: a case study of a man with an enduring psychotic illness

The Government's White Paper on community care has drawn attention to the importance of assessing changes in a person's well-being which occur as a consequence of clinical and social interventions. In the UK the evaluation of the quality of life of people with chronic mental illness is relatively new. This case study demonstrates the use of the 'Lancashire Quality of Life Profile' in routine clinical practice with reference to residential changes in the 'care programme' of a person with a long history of a severely disabling psychotic illness. The formulation and review of his care plan were determined by a network of agencies involved in his long term care.

Determinants of somatization in primary care

This study explores possible determinants of somatization in primary care. Hypotheses were tested on samples of 'somatizers', 'psychologizers' and controls recruited by epidemiological procedures. Although 'somatizers' were found to be similar to 'psychologizers' in many respects, they were (i) less depressed; (ii) reported lower levels of social dissatisfaction, social stress and less dependence on their relatives; (iii) more likely to have an unsympathetic attitude towards mental illness and less likely to consult a doctor about psychological symptoms, and (iv) more likely to have received medical in-patient care as an adult before they had consulted their doctor with their current illness. These findings are discussed in the context of previous research.

The influence of social factors on common mental disorders. Destabilisation and restitution

This study distinguishes between processes that cause individuals to experience symptoms--destabilisation--and those that are associated with loss of symptoms over time--restitution. It is shown that different clinical, social, and personality variables are associated with each of these processes. Where destabilisation is concerned, it is shown that different variables were associated with the development of symptoms of anxiety and those of depression. Different variables were associated with restitution, and they did not show the same relationship with the symptom dimensions of anxiety and depression as those which were associated with destabilisation.

The validity of diagnostic systems for common mental disorders: a comparison between the ID-CATEGO and the DSM-III systems

It is argued that latent trait analysis provides a way of examining the construct validity of diagnostic concepts which are used to categorize common mental illnesses. The present study adds two additional aspects of validity using multiple discriminant analysis applied to two widely used taxonomic systems. Scales of anxiety and depression derived from previous latent trait analyses are applied to individuals reaching criteria for 'caseness' on the ID-CATEGO system and the DSM-III system, both at initial diagnosis and six months later. The first multiple discriminant analysis is carried out on the initial scale scores, and the results are interpreted in terms of concurrent validity. The second analysis uses improvement scores on the two scales and relates to predictive validity. It is argued that the ID-CATEGO system provides a better classification for common mental illnesses than the DSM-III system, since it allows a better discrimination to be made between anxiety and depressive disorders.

Detecting anxiety and depression in general medical settings

To aid general practitioners and other non-psychiatrists in the better recognition of mental illness short scales measuring anxiety and depression were derived by latent trait analysis from a standardised psychiatric research interview. Designed to be used by non-psychiatrists, they provide dimensional measures of the severity of each disorder. The full set of nine questions need to be administered only if there are positive answers to the first four. When assessed against the full set of 60 questions contained in the psychiatric assessment schedule they had a specificity of 91% and a sensitivity of 86%. The scales would be used by non-psychiatrists in clinical investigations and possibly also by medical students to familiarise them with the common forms of psychiatric illness, which are often unrecognised in general medical settings.

Somatic presentations of psychiatric illness in primary care setting

We have tried to describe somatisation, not as a disease, but as a common and important human mechanism involving both doctor and patient. It is the single most common reason why psychiatric illness goes undetected in general medical settings, and it often occurs in conjunction with physical disease processes. The association with dysphoric affect has been recognised at least since George Cheyne 250 years ago, and the reason for this is that both anxiety and depression serve to amplify pains. However, it seems likely that somatisation can occur in the absence of dysphoria. Once it has been established, it is easy to see how it continues: it secures advantages from spouse, family and employers; and it tends to be encouraged by doctors--who differentially reward somatic symptoms. But why does it occur in the first place? We have argued that it seems to have three functions: First, it allows people who are unsympathetic to psychological illness, or who live in cultures where mental illness is stigmatised, to nonetheless occupy the sick-role while psychologically unwell. Second, it is blame-avoiding: instead of being responsible for the mayhem, one is cast in the role of the suffering victim. Finally, by reducing blame, it appears to save patients from being as depressed as they might otherwise have been.

The evaluation of a hostel ward. A controlled study using modified cost-benefit analysis

A controlled modified cost-benefit evaluation of a hostel ward caring for new long-stay patients is described and results are presented for the first two years. In some respects the residents of the hostel ward had fewer psychotic impairments than those remaining on the wards of the district general hospital, mainly because the latter seem to continue to acquire such defects, while the former have remained relatively unchanged. The hostel ward residents also develop superior domestic skills, use more facilities in the community, and are more likely to be engaged in constructive activities than controls. These advantages were not purchased at a price, since the cost of providing this form of care for these patients has cost less than care provided by the district general hospital.

The relationship between symptoms and diagnoses of minor psychiatric disorder in general practice

In an earlier paper (Goldberg et al. 1987) 36 common symptoms of minor psychiatric disorder in general practice were analysed using the technique of latent trait analysis. From this analysis two dimensions of illness emerged, corresponding to anxiety and depression. In the present paper, this symptom-based representation of minor psychiatric illness is used as a framework for comparing four diagnostic systems: General Practitioner (GP) diagnoses, the ID-CATEGO diagnostic system, the DSM-III system and the Bedford College diagnostic system. This analysis clarifies the reasons for disagreement among systems of diagnostic criteria and examines the practical effects of alternative diagnostic algorithms.

Dimensions of neuroses seen in primary-care settings

This study uses methods of latent trait analysis to examine the relationship between psychiatric symptoms that constitute the common psychiatric disorders encountered in primary-care setting. Two highly correlated symptom dimensions of anxiety and depression are shown to underlie these disorders. Neurovegetative symptoms of depression are shown to be on the same dimension as psychic symptoms of depression, but to represent a more severe manifestation of depression.

Screening for psychiatric illness in general practice: the general practitioner versus the screening questionnaire

This study compares the characteristics of general practitioners and a pen and paper test in the detection of psychiatric disorder in primary care settings. A psychiatrist interviewed a stratified sample of 283 patients drawn from 590 consecutive new illnesses seen in 15 general practices. Research diagnoses could be made in between one-quarter and one-third of the consecutive new illnesses. Two different research diagnostic systems agreed quite well with one another about who should be regarded as a psychiatric 'case' - although agreement between them for individual diagnoses was less impressive. Research diagnoses of psychiatric illnesses could be made in approximately 30% of new episodes of illnesses seen. If the DSM-3 system was used as a criterion of 'caseness', the specificity of the general health questionnaire was 75.4%, and the sensitivity was 87.1%. The general practitioners had fewer false positives than the questionnaire, but they were much more likely to miss psychiatric cases. Use of the general health questionnaire could increase their sensitivity from about 50% to 95%.

Douglas House: a new type of hostel ward for chronic psychotic patients

A new type of hostel ward is described in which domestic activities take the place of attendance at a day centre or industrial workshop. Residents no longer depend on the institution for meals, cleaning, or social activities. The programme is resident-orientated, and individual treatment plans are designed and effected using a points system. The emphasis of group activities is on communication and living skills. The hostel ward is able to care for our most disabled patients who are thought to need 24-hour nursing care.

Clonal separation of mature melanocytes from premelanocytes in a diploid human cell strain: spontaneous and induced pigmentation of premelanocytes

Strains of pigmented melanocytes can be derived reproducibly from normal human skin. Published procedures have been modified here to yield a strain, ‘Nohm-1’, comprising many unpigmented cells as well as cells with various degrees of pigmentation observable by light microscopy. The unpigmented cells contain early melanosomes (pigment organelles) and the specific enzyme tyrosinase. They are on average smaller and less dendritic than the pigmented cells. Nohm-1 cells show normal chromosomal banding patterns and normal proliferative behaviour, including senescence. They form no tumours in immunodeficient (nude) mice. Nohm-1 cells have been cloned and yield two distinct types of colony, depending on the progenitor cell. Well-pigmented melanocytes engender pure colonies of pigmented cells, but cells with little or no pigment can produce both unpigmented and pigmented progeny. Thus there is a separate cell type, or premelanocyte, which can differentiate spontaneously and stably in culture; this cell type includes both unpigmented and faintly pigmented cells. Usefully, most premelanocytes are viable after frozen storage, unlike well-pigmented melanocytes. Some components of the culture medium affect the proportion of pigmented cells in Nohm-1 cultures, and hence probably the ratio of mature melanocytes to premelanocytes. Rapid pigmentation can be induced artificially and simply, by using a medium with increased extracellular pH and tyrosine concentration.

Long-term efficacy of deferoxamine iron chelation therapy in adults with acquired transfusional iron overload

Transfusional iron overload in adult patients with acquired anemias may result in widespread organ dysfunction. Long-term deferoxamine mesylate therapy was administered by continuous subcutaneous infusion to six such patients, who have been followed up for up to 66 months of therapy while continuing to be transfusion-dependent. During deferoxamine therapy, liver density by computed tomographic scan decreased in four of five patients, liver iron content decreased in two of three patients, and liver function normalized in two patients. Plasma cortisol response to insulin-induced hypoglycemia improved in three of five patients receiving therapy. Pituitary growth hormone reserve normalized in two patients and remained normal in the other three tested. One patient, treated concurrently with ascorbic acid, died suddenly. The other five patients have had no cardiac deterioration by noninvasive testing. We conclude that long-term deferoxamine iron chelation therapy is effective not only in retarding but, in some cases, even reversing organ damage caused by transfusional iron overload.

Intracellular dissociation of receptor-bound asialoglycoproteins in cultured hepatocytes. A pH-mediated nonlysosomal event

The binding, internalization, and degradation of 125I-asialo-orosomucoid were studied in primary monolayer cultures of rat hepatocytes. Ligand entered the cell bound to the asialoglycoprotein receptor and subsequently dissociated from the receptor intracellularly. Rate coefficients for each of the transitions that constitute the endocytic pathway were computed. Subcellular fractionation on Percoll gradients revealed that prior to localization in lysosomes, 125I-asialo-orosomucoid resided in a fraction of slightly lower buoyant density than plasma membranes. Neither ammonium chloride (20 mM) nor leupeptin (0.1 mg/ml) affected ligand binding or internalization of prebound ligand. However, both reagents inhibited degradation of ligand by greater than 95%. Of the two, only ammonium chloride inhibited receptor-ligand dissociation. Ammonium chloride treatment resulted in the accumulation of ligand in the prelysosomal fraction. In contrast, exposure of cells to leupeptin led to accumulation of ligand within lysosomes. The results are interpreted in terms of pH-mediated dissociation of ligand-receptor complex within a nonlysosomal endocytic vesicle.

Fate of receptor and ligand during endocytosis of asialoglycoproteins by isolated hepatocytes

The endocytosis leading to degradation of 125I-labeled asialo-orosomucoid specifically bound to the surface of freshly isolated hepatocytes was monitored as a function of time at 37 degrees C. Experimental values were determined for the rates of internalization, dissociation of the receptor-ligand complex, and degradation of the labeled ligand. Compartmental analysis and computer modeling revealed that the data were compatible with dissociation of ligand from receptor preceding ligand degradation. The rate coefficient for internalization was calculated to be an order of magnitude greater than that for receptor--ligand dissociation. Ligand internalization did not result in concomitant depletion in the total number of cell surface receptors. Our data are taken to indicate that ligand remains associated with the receptor after internalization, that the complex is dissociated prior to degradation, and that new, unoccupied receptors are promptly returned to the cell surface from an internal pool.

Calcium regulates the commitment of murine erythroleukemia cells to terminal erythroid differentiation

An alteration in the rate of calcium transport appears to be the rate-limiting event for the commitment of murine erythroleukemia (MEL) cells to initiate a program of terminal erythroid differentiation. The dimethyl sulfoxide (DMSO)-induced commitment of MEL cells to erythroid differentiation can be inhibited by treatment of cells with the calcium-chelating agent EGTA. Upon removal of EGTA, cells initiate commitment without the 12-h lag normally observed after treatment with DMSO alone. Treatment of cells with DMSO in the presence of calcium ionophore A23187 causes cells to initiate commitment from time zero with no lag. These results suggest that the lag is the time required for DMSO to alter the calcium transport properties of the cell.

Reconstitution of the hepatic asialoglycoprotein receptor with phospholipid vesicles

A solubilized detergent-free preparation of the hepatic binding protein specific for asialoglycoproteins associates spontaneously with small unilamellar lipid vesicles. This process is independent of the phase transition of the lipid and effectively restores the specific binding activity of the receptor protein. The insensitivity of the resulting lipid-protein complex to ionic strength provides evidence for a hydrophobic interaction. There is a perturbation of the lipid phase transition concomitant with addition of the protein. Circular dichroism studies indicate that the protein undergoes a conformational change on association with lipid. Binding of specific ligand produces further physical changes in the receptor as indicated by alterations in the tryptophan fluorescence quenching pattern.