Improved Cardiomyopathy Risk Prediction Using Global Longitudinal Strain and N-Terminal-Pro-B-Type Natriuretic Peptide in Survivors of Childhood Cancer Exposed to Cardiotoxic Therapy

PURPOSE

To leverage baseline global longitudinal strain (GLS) and N-terminal-pro-B-type natriuretic peptide (NT-proBNP) to identify childhood cancer survivors with a normal left ventricular ejection fraction (LVEF) at highest risk of future treatment-related cardiomyopathy.

METHODS

St Jude Lifetime Cohort participants ≥5 years from diagnosis, at increased risk for cardiomyopathy per the International Guideline Harmonization Group (IGHG), with an LVEF ≥50% on baseline echocardiography (n = 1,483) underwent measurement of GLS (n = 1,483) and NT-proBNP (n = 1,052; 71%). Multivariable Cox regression models estimated hazard ratios (HRs) and 95% CIs for postbaseline cardiomyopathy (modified Common Terminology Criteria for Adverse Events ≥grade 2) incidence in association with echocardiogram-based GLS (≥-18) and/or NT-proBNP (>age-sex-specific 97.5th percentiles). Prediction performance was assessed using AUC in models with and without GLS and NT-proBNP and compared using DeLong's test for IGHG moderate- and high-risk individuals treated with anthracyclines.

RESULTS

Among survivors (median age, 37.6; range, 10.2-70.4 years), 162 (11.1%) developed ≥grade 2 cardiomyopathy 5.1 (0.7-10.0) years from baseline assessment. The 5-year cumulative incidence of cardiomyopathy for survivors with and without abnormal GLS was, respectively, 7.3% (95% CI, 4.7 to 9.9) versus 4.4% (95% CI, 3.0 to 5.7) and abnormal NT-proBNP was 9.9% (95% CI, 5.8 to 14.1) versus 4.7% (95% CI, 3.2 to 6.2). Among survivors with a normal LVEF, abnormal baseline GLS and NT-proBNP identified anthracycline-exposed, IGHG-defined moderate-/high-risk survivors at a four-fold increased hazard of postbaseline cardiomyopathy (HR, 4.39 [95% CI, 2.46 to 7.83]; P < .001), increasing to a HR of 14.16 (95% CI, 6.45 to 31.08; P < .001) among survivors who received ≥250 mg/m2 of anthracyclines. Six years after baseline, AUCs for individual risk prediction were 0.70 for models with and 0.63 for models without GLS and NT-proBNP (P = .022).

CONCLUSION

GLS and NT-proBNP should be considered for improved identification of survivors at high risk for future cardiomyopathy.

St. Jude Survivorship Portal: sharing and analyzing large clinical and genomic datasets from pediatric cancer survivors

Childhood cancer survivorship studies generate comprehensive datasets comprising demographic, diagnosis, treatment, outcome, and genomic data from survivors. To broadly share this data, we created the St. Jude Survivorship Portal (https://survivorship.stjude.cloud), the first data portal for sharing, analyzing, and visualizing pediatric cancer survivorship data. Over 1,600 phenotypic variables and 400 million genetic variants from over 7,700 childhood cancer survivors can be explored on this free, open-access portal. Summary statistics of variables are computed on-the-fly and visualized through interactive and customizable charts. Survivor cohorts can be customized and/or divided into groups for comparative analysis. Users can also seamlessly perform cumulative incidence and regression analyses on the stored survivorship data. Using the portal, we explored the ototoxic effects of platinum-based chemotherapy, uncovered a novel association between mental health, age, and limb amputation, and discovered a novel haplotype in MAGI3 strongly associated with cardiomyopathy specifically in survivors of African ancestry.

Health-Related quality of life and DNA Methylation-Based aging biomarkers among survivors of childhood cancer

BACKGROUND

Childhood cancer survivors are at high risk for morbidity and mortality and poor patient-reported outcomes, typically health-related-quality-of-life (HRQOL). However, associations between DNA methylation (DNAm)-based aging biomarkers and HRQOL have not been evaluated.

METHODS

DNAm was generated with Infinium EPIC BeadChip on blood-derived DNA (median[range] for age at blood draw = 34.5[18.5-66.6] years) and HRQOL was assessed with age at survey (32.3[18.4-64.5] years) from 2,206 survivors in the St Jude Lifetime Cohort. DNAm-based aging biomarkers, including epigenetic age using multiple clocks (eg, GrimAge) and others (eg, DNAmB2M beta-2-microglobulin; DNAmADM: adrenomedullin), were derived from the DNAm Age Calculator (https://dnamage.genetics.ucla.edu). HRQOL was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey to capture eight domains, and physical and mental component summaries (PCS and MCS). General linear models evaluated associations between HRQOL and epigenetic age acceleration (EAA, eg, EAA_GrimAge) or other age-adjusted DNAm-based biomarkers (eg, ageadj_DNAmB2M) after adjusting for age at blood draw, sex, cancer treatments, and DNAm-based surrogate for smoking pack-years. All P values were 2-sided.

RESULTS

Worse HRQOL was associated with greater EAA_GrimAge (PCS β[95%CI]=-0.18[-0.251,-0.11] years, P = 1.85 × 10-5; and four individual HRQOL domains), followed by ageadj_DNAmB2M (PCS: -0.08[-0.124,-0.037], P = .003; and three individual HRQOL domains), and ageadj_DNAmADM (PCS: -0.082[-0.125,-0.039], P = .002; and two HRQOL domains). EAA_Hannum (Hannum clock) was not associated with any HRQOL.

CONCLUSIONS

Overall and domain-specific measures of HRQOL are associated with DNAm measures of biological aging. Future longitudinal studies should test biological aging as a potential mechanism underlying the association between poor HRQOL and increased risk of clinically assessed adverse health outcomes.

Cancer germline predisposing variants and late mortality from subsequent malignant neoplasms among long-term childhood cancer survivors: a report from the St Jude Lifetime Cohort and the Childhood Cancer Survivor Study

BACKGROUND

Carriers of cancer predisposing variants are at an increased risk of developing subsequent malignant neoplasms among those who have survived childhood cancer. We aimed to investigate whether cancer predisposing variants contribute to the risk of subsequent malignant neoplasm-related late mortality (5 years or more after diagnosis).

METHODS

In this analysis, data were included from two retrospective cohort studies, St Jude Lifetime Cohort (SJLIFE) and the Childhood Cancer Survivor Study (CCSS), with prospective follow-up of patients who were alive for at least 5 years after diagnosis with childhood cancer (ie, long-term childhood cancer survivors) with corresponding germline whole genome or whole exome sequencing data. Cancer predisposing variants affecting 60 genes associated with well-established autosomal-dominant cancer-predisposition syndromes were characterised. Subsequent malignant neoplasms were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 4.03 with modifications. Cause-specific late mortality was based on linkage with the US National Death Index and systematic cohort follow up. Fine-Gray subdistribution hazard models were used to estimate subsequent malignant neoplasm-related late mortality starting from the first biospecimen collection, treating non-subsequent malignant neoplasm-related deaths as a competing risk, adjusting for genetic ancestry, sex, age at diagnosis, and cancer treatment exposures. SJLIFE (NCT00760656) and CCSS (NCT01120353) are registered with ClinicalTrials.gov.

FINDINGS

12 469 (6172 male and 6297 female) participants were included, 4402 from the SJLIFE cohort (median follow-up time since collection of the first biospecimen 7·4 years [IQR 3·1-9·4]) and 8067 from the CCSS cohort (median follow-up time since collection of the first biospecimen 12·6 years [2·2-16·6]). 641 (5·1%) of 12 469 participants carried cancer predisposing variants (294 [6·7%] in the SJLIFE cohort and 347 [4·3%] in the CCSS cohort), which were significantly associated with an increased severity of subsequent malignant neoplasms (CTCAE grade ≥4 vs grade <4: odds ratio 2·15, 95% CI 1·18-4·19, p=0·0085). 263 (2·1%) subsequent malignant neoplasm-related deaths (44 [1·0%] in the SJLIFE cohort; and 219 [2·7%] in the CCSS cohort) and 426 (3·4%) other-cause deaths (103 [2·3%] in SJLIFE; and 323 [4·0%] in CCSS) occurred. Cumulative subsequent malignant neoplasm-related mortality at 10 years after the first biospecimen collection in carriers of cancer predisposing variants was 3·7% (95% CI 1·2-8·5) in SJLIFE and 6·9% (4·1-10·7) in CCSS versus 1·5% (1·0-2·1) in SJLIFE and 2·1% (1·7-2·5) in CCSS in non-carriers. Carrying a cancer predisposing variant was associated with an increased risk of subsequent malignant neoplasm-related mortality (SJLIFE: subdistribution hazard ratio 3·40 [95% CI 1·37-8·43]; p=0·0082; CCSS: 3·58 [2·27-5·63]; p<0·0001).

INTERPRETATION

Identifying participants at increased risk of subsequent malignant neoplasms via genetic counselling and clinical genetic testing for cancer predisposing variants and implementing early personalised cancer surveillance and prevention strategies might reduce the substantial subsequent malignant neoplasm-related mortality burden.

FUNDING

American Lebanese Syrian Associated Charities and US National Institutes of Health.

Prevalence of Diastolic Dysfunction in Adult Survivors of Childhood Cancer: A Report From SJLIFE Cohort

Background

The prevalence of diastolic dysfunction has not been systematically evaluated in a large population of survivors of childhood cancer using established guidelines and standards.

Objectives

This study sought to assess the prevalence and progression of diastolic dysfunction in adult survivors of childhood cancer exposed to cardiotoxic therapy.

Methods

Comprehensive, longitudinal echocardiographic examinations of adult survivors of childhood cancer ≥18 years of age and ≥10 years from diagnosis in SJLIFE (St. Jude Lifetime Cohort Study) were performed. Diastolic dysfunction was defined based on 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines.

Results

Among 3,342 survivors, the median (25th-75th percentiles [quartile (Q)1-Q3]) age at diagnosis was 8.1 years (Q1-Q3: 3.6-13.7 years), 30.1 years (Q1-Q3: 24.4-37.0 years) at the baseline echocardiography evaluation (Echo 1), and 36.6 years (Q1-Q3: 30.8-43.6 years) at the last follow-up echocardiography evaluation (1,435 survivors) (Echo 2). The proportion of diastolic dysfunction was 15.2% (95% CI: 14.0%-16.4%) at Echo 1 and 15.7% (95% CI: 13.9%-17.7%) at Echo 2, largely attributable to concurrent systolic dysfunction. Less than 5% of survivors with preserved ejection fraction had diastolic dysfunction (2.2% at Echo 1, 3.7% at Echo 2). Using global longitudinal strain assessment in adult survivors with preserved ejection fraction (defined with a cutpoint worse than -15.9%), the proportion of diastolic dysfunction increased to 9.2% at baseline and 9.0% at follow-up.

Conclusions

The prevalence of isolated diastolic dysfunction is low among adults who received cardiotoxic therapies for childhood cancer. The inclusion of left ventricular global longitudinal strain significantly increased the identification of diastolic dysfunction.

Abstract 4513: St. Jude Survivorship Portal: A data portal for storing, analyzing, and sharing large and complex cancer survivorship datasets

Survivors of childhood cancer are at risk for developing various adverse health conditions as adults that are attributable to the cancer and treatments they were exposed to as children. Cancer survivorship research relies on large-scale, longitudinal studies that generate a wide range of demographic, clinical, and genetic data on cancer survivors at multiple time points. To maximize the utility of these comprehensive datasets, we must be able to store and share these datasets in a web-based environment that can be accessed by the broader survivorship research community. Furthermore, this environment should be integrated with analytical tools for performing statistical analyses on the stored data without needing to download the data and import it into third-party analytical software. To address this need, we have created the St. Jude Survivorship Portal (https://survivorship.stjude.cloud &gt; Clinical Data Browser), a web-based data portal for exploring, sharing, and analyzing data from survivors of pediatric cancer. The portal hosts data from two large cohorts of pediatric cancer survivors: the St. Jude Lifetime Cohort Study and the Childhood Cancer Survivor Study. The data stored on the portal consists of demographic data, clinical data, including cancer diagnosis, cancer treatment, clinical outcomes, and patient-reported data, and genetic data, including whole-genome-sequencing-derived genotypes and published polygenic risk scores computed for &gt;500 traits. This data is organized hierarchically in a data dictionary that can be easily explored by the user. Charts and plots of variables can be quickly created, customized, and stratified with other variables, all within the portal environment. Statistical analyses, including cumulative incidence analysis and regression analysis, may also be performed within the portal. In cumulative incidence analysis, users can analyze the incidence of a variety of CTCAE-graded adverse events (e.g., cardiovascular dysfunction, neurological disorders, subsequent neoplasms) in survivors and can also compare them across different survivor populations defined by other variables. In regression analysis, users have the option to perform either a linear, logistic, or cox regression analysis and may use any of the demographic, clinical, or genetic variables on the portal as outcome or explanatory variables in the analysis. In this way, users can assess any risk factor associations within a survivor cohort and generate predictive models for outcomes of interest. Lastly, we also provide the user with the option to download the data on the portal for use in any future analyses. The St. Jude Survivorship Portal provides a comprehensive, powerful, and easy-to-use interface for sharing and analyzing childhood cancer survivorship data that will serve as a valuable research tool for the broader survivorship research community.

Citation Format: Gavriel Matt, Edgar Sioson, Jaimin Patel, Jian Wang, Robin Paul, Colleen Reilly, Congyu Lu, Kyla Shelton, Qi Liu, Weiyu Qiu, Cindy Im, Zhaoming Wang, Carmen L. Wilson, Nickhill Bhakta, Kirsten Ness, Gregory T. Armstrong, Melissa M. Hudson, Leslie L. Robison, Jinghui Zhang, Yutaka Yasui, Xin Zhou. St. Jude Survivorship Portal: A data portal for storing, analyzing, and sharing large and complex cancer survivorship datasets. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4513.

Epigenetic Age in Peripheral Blood Among Children, Adolescent, and Adult Survivors of Childhood Cancer

Importance

Certain cancer therapies are risk factors for epigenetic age acceleration (EAA) among survivors of childhood cancer, and EAA is associated with chronic health conditions (CHCs). However, small numbers of younger survivors (aged <20 years) previously evaluated have limited the ability to calculate EAA among this age group.

Objective

To evaluate the change rate of epigenetic age (EA) and EAA in younger compared with older survivors and the possible association of EAA with early-onset obesity (aged <20 years), severity/burden of CHCs, and late mortality (>5 years from cancer diagnosis).

Design, Setting, and Participants

Study participants were from the St Jude Lifetime Cohort, initiated in 2007 with ongoing follow-up. The present study was conducted from April 17, 2022, to March 23, 2023. Survivors in this cohort of European ancestry with DNA methylation data were included. Cross-sectional annual changes in EA and EAA were compared across 5 different chronologic age groups: age 0 to 9 (children), 10 to 19 (adolescents), 20 to 34 (younger adults), 35 to 49 (middle-aged adults), and greater than or equal to 50 (older adults) years. Logistic regression evaluated the association between EAA and early-onset obesity or severity/burden of CHCs. Cox proportional hazards regression assessed the association between EAA and late mortality.

Main Outcomes and Measures

Early-onset obesity, severity/burden of CHCs (graded using the Common Terminology Criteria for Adverse Events (grade 1, mild; 2, moderate; 3, severe/disabling; 4, life-threatening) and were combined into high vs low severity/burden based on frequency and grade), and late mortality were the outcomes based on follow-up until April 2020. Expanded DNA methylation profiling increased the number of survivors younger than 20 years (n = 690). Epigenetic age was calculated primarily using the Levine clock, and EAA was derived from least squares regression of EA against chronologic age and was standardized to a z score (Levine EEA).

Results

Among 2846 participants (median age, 30.3 [IQR, 9.3-41.5] years; 53% males), the cross-sectional annual change in EA_Levine was higher in children (1.63 years) and adolescents (1.14 years), and the adjusted least-squares mean of Levine EEA was lower in children (-0.22 years) and older adults (-1.70 years). Each 1-SD increase in Levine EEA was associated with increased risk of developing early-onset obesity (odds ratio [OR], 1.46; 95% CI, 1.19-1.78), high severity/burden of CHCs (OR, 1.13; 95% CI, 1.03-1.24), and late mortality (hazard ratio, 1.75; 95% CI, 1.35-2.26).

Conclusions and Relevance

The findings of this study suggest that EAA measured in children and adolescent survivors of childhood cancer is associated with early-onset obesity, severity/burden of all CHCs, and late mortality. Evaluating EAA may help identify survivors of childhood cancer at increased risk for early-onset obesity, morbidity in general, and mortality.

Distinct DNA methylation signatures associated with blood lipids as exposures or outcomes among survivors of childhood cancer: a report from the St. Jude lifetime cohort

BACKGROUND

DNA methylation (DNAm) plays an important role in lipid metabolism, however, no epigenome-wide association study (EWAS) of lipid levels has been conducted among childhood cancer survivors. Here, we performed EWAS analysis with longitudinally collected blood lipid data from survivors in the St. Jude lifetime cohort study.

METHODS

Among 2052 childhood cancer survivors of European ancestry (EA) and 370 survivors of African ancestry (AA), four types of blood lipids, including high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol (TC), and triglycerides (TG), were measured during follow-up beyond 5-years from childhood cancer diagnosis. For the exposure EWAS (i.e., lipids measured before blood draw for DNAm), the DNAm level was an outcome variable and each of the blood lipid level was an exposure variable; vice versa for the outcome EWAS (i.e., lipids measured after blood draw for DNAm).

RESULTS

Among EA survivors, we identified 43 lipid-associated CpGs in the HDL (n = 7), TC (n = 3), and TG (n = 33) exposure EWAS, and 106 lipid-associated CpGs in the HDL (n = 5), LDL (n = 3), TC (n = 4), and TG (n = 94) outcome EWAS. Among AA survivors, we identified 15 lipid-associated CpGs in TG exposure (n = 6), HDL (n = 1), LDL (n = 1), TG (n = 5) and TC (n = 2) outcome EWAS with epigenome-wide significance (P < 9 × 10^-8). There were no overlapping lipids-associated CpGs between exposure and outcome EWAS among EA and AA survivors, suggesting that the DNAm changes of different CpGs could be the cause or consequence of blood lipid levels. In the meta-EWAS, 12 additional CpGs reached epigenome-wide significance. Notably, 32 out of 74 lipid-associated CpGs showed substantial heterogeneity (P_het < 0.1 or I² > 70%) between EA and AA survivors, highlighting differences in DNAm markers of blood lipids between populations with diverse genetic ancestry. Ten lipid-associated CpGs were cis-expression quantitative trait methylation with their DNAm levels associated with the expression of corresponding genes, out of which seven were negatively associated.

CONCLUSIONS

We identified distinct signatures of DNAm for blood lipids as exposures or outcomes and between EA and AA survivors, revealing additional genes involved in lipid metabolism and potential novel targets for controlling blood lipids in childhood cancer survivors.

Association of Modifiable Health Conditions and Social Determinants of Health With Late Mortality in Survivors of Childhood Cancer

IMPORTANCE

Associations between modifiable chronic health conditions (CHCs), social determinants of health, and late mortality (defined as death occurring ≥5 years after diagnosis) in childhood cancer survivors are unknown.

OBJECTIVE

To explore associations between modifiable CHCs and late mortality within the context of social determinants of health.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal cohort study used data from 9440 individuals who were eligible to participate in the St Jude Lifetime Cohort (SJLIFE), a retrospective cohort study with prospective clinical follow-up that was initiated in 2007 to characterize outcomes among childhood cancer survivors. Eligible individuals had survived 5 or more years after childhood cancer diagnosis, were diagnosed between 1962 and 2012, and received treatment at St Jude Children's Research Hospital were included in mortality estimates. A total of 3407 adult SJLIFE participants (aged ≥18 years) who completed an on-campus assessment were included in risk factor analyses. Vital status, date of death, and cause of death were obtained by linkage with the National Death Index (coverage from inception to December 31, 2016). Deaths occurring before inception of the National Death Index were obtained from the St Jude Children's Research Hospital Cancer Registry. Data were analyzed from June to December 2022.

EXPOSURES

Data on treatment exposures and causes of death were abstracted for individuals who were eligible to participate in the SJLIFE study. Information on modifiable CHCs (dyslipidemia, hypertension, diabetes, underweight or obesity, bone mineral deficiency, hypogonadism, hypothyroidism, and adrenal insufficiency, all graded by the modified Common Terminology Criteria for Adverse Events), healthy lifestyle index (smoking status, alcohol consumption, body mass index [calculated as weight in kilograms divided by height in meters squared], and physical activity), area deprivation index (ADI; which measures neighborhood-level socioeconomic disadvantage), and frailty (low lean muscle mass, exhaustion, low energy expenditure, slowness, and weakness) was obtained for participants.

MAIN OUTCOMES AND MEASURES

National Death Index causes of death were used to estimate late mortality using standardized mortality ratios (SMRs) and 95% CIs, which were calculated based on US mortality rates. For the risk factor analyses (among participants who completed on-campus assessment), multivariable piecewise exponential regression analysis was used to estimate rate ratios (RRs) and 95% CIs for all-cause and cause-specific late mortality.

RESULTS

Among 9440 childhood cancer survivors who were eligible to participate in the SJLIFE study, the median (range) age at assessment was 27.5 (5.3-71.9) years, and the median (range) duration of follow-up was 18.8 (5.0-58.0) years; 55.2% were male and 75.3% were non-Hispanic White. Survivors experienced increases in all-cause mortality (SMR, 7.6; 95% CI, 7.2-8.1) and health-related late mortality (SMR, 7.6; 95% CI, 7.0-8.2). Among 3407 adult SJLIFE participants who completed an on-campus assessment, the median (range) age at assessment was 35.4 (17.9-69.8) years, and the median (range) duration of follow-up was 27.3 (7.3-54.7) years; 52.5% were male and 81.7% were non-Hispanic White. Models adjusted for attained age, sex, race and ethnicity, age at diagnosis, treatment exposures, household income, employment status, and insurance status revealed that having 1 modifiable CHC of grade 2 or higher (RR, 2.2; 95% CI, 1.2-4.0; P = .01), 2 modifiable CHCs of grade 2 or higher (RR, 2.6; 95% CI, 1.4-4.9; P = .003), or 3 modifiable CHCs of grade 2 or higher (RR, 3.6; 95% CI, 1.8-7.1, P < .001); living in a US Census block with an ADI in the 51st to 80th percentile (RR, 5.5; 95% CI, 1.3-23.5; P = .02), an ADI in the 81st to 100th percentile (RR, 8.7; 95% CI, 2.0-37.6; P = .004), or an unassigned ADI (RR, 15.7; 95% CI, 3.5-70.3; P < .001); and having frailty (RR, 2.3; 95% CI, 1.3-3.9; P = .004) were associated with significant increases in the risk of late all-cause death. Similar associations were observed for the risk of late health-related death (1 modifiable CHC of grade ≥2: RR, 2.2 [95% CI, 1.1-4.4; P = .02]; 2 modifiable CHCs of grade ≥2: RR, 2.5 [95% CI, 1.2-5.2; P = .01]; 3 modifiable CHCs of grade ≥2: RR, 4.0 [95% CI, 1.9-8.4; P < .001]; ADI in 51st-80th percentile: RR, 9.2 [95% CI, 1.2-69.7; P = .03]; ADI in 81st-100th percentile: RR, 16.2 [95% CI, 2.1-123.7; P = .007], unassigned ADI: RR, 27.3 [95% CI, 3.5-213.6; P = .002]; and frailty: RR, 2.3 [95% CI, 1.2-4.1; P = .009]).

CONCLUSIONS AND RELEVANCE

In this cohort study of childhood cancer survivors, living in a Census block with a high ADI and having modifiable CHCs were independently associated with an increased risk of late death among survivors of childhood cancer. Future investigations seeking to mitigate these factors will be important to improving health outcomes and developing risk-stratification strategies to optimize care delivery to childhood cancer survivors.

A novel locus on 6p21.2 for cancer treatment-induced cardiac dysfunction among childhood cancer survivors

BACKGROUND

Adult survivors of childhood cancer are at increased risk of cardiac late effects.

METHODS

Using whole-genome sequencing data from 1,870 survivors of European ancestry in the St. Jude Lifetime Cohort (SJLIFE) study, genetic variants were examined for association with ejection fraction (EF) and clinically assessed cancer therapy-induced cardiac dysfunction (CCD). Significant findings were validated in 301 SJLIFE survivors of African ancestry and 4,020 survivors of European ancestry from the Childhood Cancer Survivor Study (CCSS). All statistical tests were 2-sided.

RESULTS

A variant near KCNK17 showed genome-wide significant association with EF (rs2815063-A: EF reduction = 1.6%; P = 2.1 × 10-8) in SJLIFE survivors of European ancestry, which replicated in SJLIFE survivors of African ancestry (EF reduction: 1.5%; P = .004). The rs2815063-A also showed a 1.80-fold (P = .008) risk of severe/disabling or life-threatening CCD and replicated in 4,020 CCSS survivors of European ancestry (OR = 1.40; P = .039). Notably, rs2815063-A was specifically associated among survivors exposed to doxorubicin only, with a stronger effect on EF (3.3% EF reduction) and CCD (2.97-fold). Whole blood DNA methylation data in 1,651 SJLIFE survivors of European ancestry showed significant correlation of rs2815063-A with dysregulation of KCNK17 enhancers (false discovery rate <5%), which replicated in 263 survivors of African ancestry. Consistently, the rs2815063-A was associated with KCNK17 downregulation based on RNA-sequencing of 75 survivors.

CONCLUSIONS

Leveraging the two largest cohorts of childhood cancer survivors in North America and survivor-specific polygenomic functional data, we identified a novel risk locus for CCD which showed specificity with doxorubicin-induced cardiac dysfunction and highlighted dysregulation of KCNK17 as the likely molecular mechanism underlying this genetic association.

Pathogenic Germline Mutations in DNA Repair Genes in Combination With Cancer Treatment Exposures and Risk of Subsequent Neoplasms Among Long-Term Survivors of Childhood Cancer

PURPOSE

To investigate cancer treatment plus pathogenic germline mutations (PGMs) in DNA repair genes (DRGs) for identification of childhood cancer survivors at increased risk of subsequent neoplasms (SNs).

METHODS

Whole-genome sequencing was performed on blood-derived DNA from survivors in the St Jude Lifetime Cohort. PGMs were evaluated in 127 genes from 6 major DNA repair pathways. Cumulative doses of chemotherapy and body region-specific radiotherapy (RT) were abstracted from medical records. Relative rates (RRs) and 95% CIs of SNs by mutation status were estimated using multivariable piecewise exponential models.

RESULTS

Of 4,402 survivors, 495 (11.2%) developed 1,269 SNs. We identified 538 PGMs in 98 DRGs (POLG, MUTYH, ERCC2, and BRCA2, among others) in 508 (11.5%) survivors. Mutations in homologous recombination (HR) genes were significantly associated with an increased rate of subsequent female breast cancer (RR, 3.7; 95% CI, 1.8 to 7.7), especially among survivors with chest RT ≥ 20 Gy (RR, 4.4; 95% CI, 1.6 to 12.4), or with a cumulative dose of anthracyclines in the second or third tertile (RR, 4.4; 95% CI, 1.7 to 11.4). Mutations in HR genes were also associated with an increased rate of subsequent sarcoma among those who received alkylating agent doses in the third tertile (RR, 14.9; 95% CI, 4.0 to 38.0). Mutations in nucleotide excision repair genes were associated with subsequent thyroid cancer for those treated with neck RT ≥ 30 Gy (RR, 12.9; 95% CI, 1.6 to 46.6) with marginal statistical significance.

CONCLUSION

Our study provides novel insights regarding the contribution of genetics, in combination with known treatment-related risks, for the development of SNs. These findings have the potential to facilitate identification of high-risk survivors who may benefit from genetic counseling and/or testing of DRGs, which may further inform personalized cancer surveillance and prevention strategies.

Abstract 1198: The St. Jude Survivorship Portal links whole-genome genetic data with clinical therapy and outcome phenotypes for 7302 pediatric cancer survivors

Clinical and basic research addressing the long-term outcomes of the increasing and high-risk population of pediatric cancer survivors requires large cohorts with high quality information. We have assembled the largest group of pediatric cancer survivors to date with comprehensive clinical characterization and germline whole-genome sequencing (WGS), and made these data available through the Survivorship Portal on St. Jude Cloud (https://survivorship.stjude.cloud).

The Portal contains data from 7302 survivors from two large studies, including 4402 from the St. Jude Lifetime Cohort Study (SJLIFE) with clinically-assessed outcome phenotypes, and 2900 from the Childhood Cancer Survivor Study (CCSS) with self-reported outcome phenotypes. High-quality germline variants and genotype calls from WGS were generated and curated by an in-house pipeline with corrected indel alleles and read counts. Germline variants of individual survivors are linked with standardized phenotypes described by &gt;300 variables, spanning cancer-related data including diagnosis, length of follow-up, treatment (cumulative doses of chemotherapy, region-specific radiation therapy doses, surgery), demographic characteristics, selected health behaviors, and long-term outcomes (severity-graded chronic health conditions including second cancers). In addition, clinically-relevant genetic variables including ancestry admixture, HLA alleles, leukocyte telomere length, and blood type have been computed from WGS. Both phenotypic and genetic variables are represented by the Dictionary Browser that allows to quickly identify variables of interest, view summary graphics, cross-tabulate variables by default or user-defined categories and test for association between categories. Using GenomePaint on the Portal, investigators can navigate to a locus of interest and explore the presence and frequencies of variants in the cohort, filter variants with multiple criteria including LD r2 values, and identify DNA binding motif change for non-coding variants. Combining GenomePaint with Dictionary Browser, the real-time association analysis allows to identify trait-associated variants at a locus, through the definition of traits, covariates, and inclusion/exclusion criteria using the Dictionary Browser. Future implementation includes supporting copy number and structural variations, characterization of pharmacogenetic diplotypes, gene-level rare variant analysis, polygenic scores, time-to-event survival analysis, and data download and session management enabled by user login. We envision this cohort with high quality phenotypic and genetic information, together with an enabling software platform co-developed with multidisciplinary principal investigators, will accelerate the discovery in both survivorship research and human genetics in general.

Citation Format: Xin Zhou, Nickhill Bhakta, Jian Wang, Edgar Sioson, Jaimin Patel, Kyla Shelton, Zhaoming Wang, Shaohua Lei, Alexander M. Gout, Carmen L. Wilson, Wendy Leisenring, Smita Bhatia, Yutaka Yasui, Melissa M. Hudson, Gregory T. Armstrong, Leslie L. Robison, Jinghui Zhang. The St. Jude Survivorship Portal links whole-genome genetic data with clinical therapy and outcome phenotypes for 7302 pediatric cancer survivors [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1198.

Molecular Mechanism of Telomere Length Dynamics and Its Prognostic Value in Pediatric Cancers

BACKGROUND

We aimed to systematically evaluate telomere dynamics across a spectrum of pediatric cancers, search for underlying molecular mechanisms, and assess potential prognostic value.

METHODS

The fraction of telomeric reads was determined from whole-genome sequencing data for paired tumor and normal samples from 653 patients with 23 cancer types from the Pediatric Cancer Genome Project. Telomere dynamics were characterized as the ratio of telomere fractions between tumor and normal samples. Somatic mutations were gathered, RNA sequencing data for 330 patients were analyzed for gene expression, and Cox regression was used to assess the telomere dynamics on patient survival.

RESULTS

Telomere lengthening was observed in 28.7% of solid tumors, 10.5% of brain tumors, and 4.3% of hematological cancers. Among 81 samples with telomere lengthening, 26 had somatic mutations in alpha thalassemia/mental retardation syndrome X-linked gene, corroborated by a low level of the gene expression in the subset of tumors with RNA sequencing. Telomerase reverse transcriptase gene amplification and/or activation was observed in 10 tumors with telomere lengthening, including two leukemias of the E2A-PBX1 subtype. Among hematological cancers, pathway analysis for genes with expressions most negatively correlated with telomere fractions suggests the implication of a gene ontology process of antigen presentation by Major histocompatibility complex class II. A higher ratio of telomere fractions was statistically significantly associated with poorer survival for patients with brain tumors (hazard ratio = 2.18, 95% confidence interval = 1.37 to 3.46).

CONCLUSION

Because telomerase inhibitors are currently being explored as potential agents to treat pediatric cancer, these data are valuable because they identify a subpopulation of patients with reactivation of telomerase who are most likely to benefit from this novel therapeutic option.

Whole-Genome Sequencing of Childhood Cancer Survivors Treated with Cranial Radiation Therapy Identifies 5p15.33 Locus for Stroke: A Report from the St. Jude Lifetime Cohort Study

PURPOSE

To identify genetic factors associated with risk of stroke among survivors of childhood cancer treated with cranial radiotherapy (CRT).

EXPERIMENTAL DESIGN

We analyzed whole-genome sequencing (36.8-fold) data of 686 childhood cancer survivors of European ancestry [median (range), 40.4 (12.4-64.7) years old; 54% male] from the St. Jude Lifetime Cohort study treated with CRT, of whom 116 (17%) had clinically diagnosed stroke. Association analyses (single-variant and Burden/SKAT tests) were performed, adjusting for demographic characteristics and childhood cancer treatment exposures.

RESULTS

We identified a genome-wide significant association between 5p15.33 locus and stroke [rs112896372: HR = 2.55; P = 1.42 × 10^-8], with a stronger association (HR = 3.68) among survivors treated with CRT dose 25-50 Gray (Gy) and weaker associations among those treated with CRT doses <20 or 20-25 or >50 Gy (HRs = 2.14, 2.40, and 2.28). The association was replicated in 90 CRT-exposed African survivors (HR = 3.05; P = 0.034). In CRT-exposed Europeans, rs112896372 significantly (P < 0.001) improved predictive ability (AUC = 0.717) for determining stroke risk than nongenetic factors alone (AUC = 0.663) at 30 years since diagnosis, with significant improvement among African survivors (P = 0.047). SNP rs112896372 was further evaluated in three independent datasets including 1,641 European (HR = 1.54; P = 0.055) and 316 African survivors (HR = 1.88; P = 0.283) not treated with CRT, and 166,988 males in the UK Biobank (OR = 1.0012; P = 0.042).

CONCLUSIONS

A novel locus 5p15.33 is associated with stroke risk among childhood cancer survivors, with a possible CRT dose-specific effect. The locus is of potential clinical utility in characterizing individuals who may benefit from surveillance and intervention strategies.

Abstract 4909: Whole-genome sequencing of childhood cancer survivors treated with cranial radiation therapy identifies 5p15.33 locus for stroke: A report from the St. Jude Lifetime Cohort (SJLIFE) study

Long-term survivors of childhood cancer are at increased risk of stroke, which is attributed to the well-established dose-response association with cranial radiation therapy (CRT) dose and risk. While radiation-induced vasculopathy is believed to be the likely mechanism underlying CRT-associated stroke, there is a variation in the dose-risk association, suggesting a potential contribution of genetic factors. We performed analyses of deep-coverage (36.8X) whole-genome sequencing data of 696 childhood cancer survivors of European descent [median (range): 40.4 (12.4-64.7) years old; 54% male] from the SJLIFE cohort treated with CRT, of whom 116 (17%) developed clinically-diagnosed stroke. Analyses of common variants [minor allele frequency (MAF)&gt;0.05] were performed using logistic regression, adjusting for age at cancer diagnosis, sex, age at follow-up, CRT dose and top principal components derived from genotypes. Rare/low-frequency variants (MAF≤0.05) were aggregated by different functional annotations and agnostic 4-kb sliding windows and tested jointly using Burden and SKAT Tests, adjusted for the same covariates. Results identified a genome-wide significant association between a common variant on 5p15.33 locus and CRT-associated stroke [rs112896372: MAFaffected=0.27; odds ratio (OR)=2.93; P=4.66×10-8]. Stratified analyses showed that rs112896372 had the strongest association (OR=4.81; P=4.16×10-4) among survivors treated with CRT dose 25-50 Gray (Gy); survivors treated with CRT dose &lt;25 Gy and those treated with CRT dose &gt;50 Gy had the weaker associations (OR=2.41; P=1.01×10-3, OR=3.01; P=4.91×10-3, respectively). We replicated the association between rs112896372 and stroke in two independent SJLIFE samples: (1) 20 with and 70 without stroke of African ancestry treated with CRT (MAFaffected=0.23; OR=6.47; P=8.99×10-3) and (2) 60 with and 1581 without stroke of European ancestry not treated with CRT (MAFaffected=0.25; OR=1.58; P=0.04). SNP rs112896372 maps to an intergenic region located approximately 155 kb downstream of IRX1 (iroquois homeobox 1), a member of IRX family of transcription factors with established roles in ventricular chamber, conducting system development and heterogeneity of ventricular repolarization. Overall, we identified and independently replicated a novel locus for CRT-associated stroke among survivors of childhood cancer, with a possible CRT dose-specific effect. Considering the large effect size and the relatively high MAF, the 5p15.33 locus may have potential clinical utility for identifying high-risk CRT exposed cancer survivors and guide intervention strategies.

Citation Format: Yadav Sapkota, Yin Ting Cheung, Wonjong Moon, Kyla Shelton, Carmen L. Wilson, Zhaoming Wang, Daniel A. Mulrooney, Jinghui Zhang, Gregory T. Armstrong, Melissa M. Hudson, Leslie L. Robison, Kevin R. Krull, Yutaka Yasui. Whole-genome sequencing of childhood cancer survivors treated with cranial radiation therapy identifies 5p15.33 locus for stroke: A report from the St. Jude Lifetime Cohort (SJLIFE) study [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 4909.

Genetic Risk for Subsequent Neoplasms Among Long-Term Survivors of Childhood Cancer

Purpose Childhood cancer survivors are at increased risk of subsequent neoplasms (SNs), but the germline genetic contribution is largely unknown. We assessed the contribution of pathogenic/likely pathogenic (P/LP) mutations in cancer predisposition genes to their SN risk. Patients and Methods Whole-genome sequencing (30-fold) was performed on samples from childhood cancer survivors who were ≥ 5 years since initial cancer diagnosis and participants in the St Jude Lifetime Cohort Study, a retrospective hospital-based study with prospective clinical follow-up. Germline mutations in 60 genes known to be associated with autosomal dominant cancer predisposition syndromes with moderate to high penetrance were classified by their pathogenicity according to the American College of Medical Genetics and Genomics guidelines. Relative rates (RRs) and 95% CIs of SN occurrence by mutation status were estimated using multivariable piecewise exponential regression stratified by radiation exposure. Results Participants were 3,006 survivors (53% male; median age, 35.8 years [range, 7.1 to 69.8 years]; 56% received radiotherapy), 1,120 SNs were diagnosed among 439 survivors (14.6%), and 175 P/LP mutations were identified in 5.8% (95% CI, 5.0% to 6.7%) of survivors. Mutations were associated with significantly increased rates of breast cancer (RR, 13.9; 95% CI, 6.0 to 32.2) and sarcoma (RR, 10.6; 95% CI, 4.3 to 26.3) among irradiated survivors and with increased rates of developing any SN (RR, 4.7; 95% CI, 2.4 to 9.3), breast cancer (RR, 7.7; 95% CI, 2.4 to 24.4), nonmelanoma skin cancer (RR, 11.0; 95% CI, 2.9 to 41.4), and two or more histologically distinct SNs (RR, 18.6; 95% CI, 3.5 to 99.3) among nonirradiated survivors. Conclusion The findings support referral of all survivors for genetic counseling for potential clinical genetic testing, which should be prioritized for nonirradiated survivors with any SN and for those with breast cancer or sarcoma in the field of prior irradiation.

Contemporary outcomes for ruptured abdominal aortic aneurysms using endovascular balloon control for hypotension

OBJECTIVE

Ruptured abdominal aortic aneurysm (rAAA) continues to portend significant mortality, despite ruptured endovascular aneurysm repair (rEVAR), enhanced perioperative care, and endovascular balloon control (EBC) for hypotension. We review our academic institution's experience using a protocol of EBC for all hypotensive patients, irrespective of type of repair.

METHODS

A retrospective review was conducted of 66 cases of rAAA treated at a single academic institution from 2007 to 2016 using EBC for hypotensive patients. Demographics, comorbidities, intraoperative parameters, and clinical outcomes were recorded. Patients were studied with respect to hemodynamic status, rEVAR, or ruptured open aortic repair in the setting of EBC for hypotension.

RESULTS

rEVAR was performed in 43 patients (65%) and ruptured open aortic repair in 23 patients (35%). rAAA was treated in 51 men (77%). Mean rAAA size was 7.6 mm, and mean age of the patients was 73 years. Perioperative survival was 82%. Overall survival at 30 days, 1 year, and 5 years was 71%, 65%, and 52%. Blood transfusion and severe hypotension were significant predictors of mortality at 30 days on multivariable analysis (odds ratio of 1.2 [P = .08] and 39 [P = .03], respectively). Severe hypotension was defined as a mean arterial blood pressure <65 mm Hg and vasopressor use and was present in 59% of the cohort. Normotension was defined as an absence of these conditions and was present in 12%, with 29% of patients exhibiting moderate hypotension. There was no difference in 30-day survival between normotensive and moderately hypotensive patients. The 30-day survival for severely hypotensive patients was 61% vs 85% for moderately hypotensive patients (P = .003), with a significant difference between groups that persisted at 1 year (85% vs 51%; P = .008) and 5 years (66% vs 51%; P = .017).

CONCLUSIONS

Good midterm outcomes for moderately hypotensive and normotensive patients can be obtained using an EBC protocol for hypotension with a regionalized transport system directly to the operating room. Severely hemodynamically unstable rAAA patients still pose a significant challenge despite mitigation of hypotension by EBC, suggesting that survival may be compromised by factors other than hypotension alone. We still advocate for the use of EBC for all hypotensive patients as part of a defined rAAA protocol before definitive repair.

The cumulative burden of surviving childhood cancer: an initial report from the St Jude Lifetime Cohort Study (SJLIFE)

BACKGROUND

Survivors of childhood cancer develop early and severe chronic health conditions (CHCs). A quantitative landscape of morbidity of survivors, however, has not been described. We aimed to describe the cumulative burden of curative cancer therapy in a clinically assessed ageing population of long-term survivors of childhood cancer.

METHODS

The St Jude Lifetime Cohort Study (SJLIFE) retrospectively collected data on CHCs in all patients treated for childhood cancer at the St Jude Children's Research Hospital who survived 10 years or longer from initial diagnosis and were 18 years or older as of June 30, 2015. Age-matched and sex-frequency-matched community controls were used for comparison. 21 treatment exposure variables were included in the analysis, with data abstracted from medical records. 168 CHCs for all participants were graded for severity using a modified Common Terminology Criteria of Adverse Events. Multiple imputation with predictive mean matching was used for missing occurrences and grades of CHCs in the survivors who were not clinically evaluable. Mean cumulative count was used for descriptive cumulative burden analysis and marked-point-process regression was used for inferential cumulative burden analysis.

FINDINGS

Of 5522 patients treated for childhood cancer at St Jude Children's Research Hospital who had complete records, survived 10 years or longer, and were 18 years or older at time of study, 3010 (54·5%) were alive, had enrolled, and had had prospective clinical assessment. 2512 (45·5%) of the 5522 patients were not clinically evaluable. The cumulative incidence of CHCs at age 50 years was 99·9% (95% CI 99·9-99·9) for grade 1-5 CHCs and 96·0% (95% CI 95·3-96·8%) for grade 3-5 CHCs. By age 50 years, a survivor had experienced, on average, 17·1 (95% CI 16·2-18·1) CHCs of any grade, of which 4·7 (4·6-4·9) were CHCs of grade 3-5. The cumulative burden in matched community controls of grade 1-5 CHCs was 9·2 (95% CI 7·9-10·6; p<0·0001 vs total study population) and of grade 3-5 CHCs was 2·3 (1·9-2·7, p<0·0001 vs total study population). Second neoplasms, spinal disorders, and pulmonary disease were major contributors to the excess total cumulative burden. Notable heterogeneity in the distribution of CHC burden in survivors with differing primary cancer diagnoses was observed. The cumulative burden of grade 1-5 CHCs at age 50 years was highest in survivors of CNS malignancies (24·2 [95% CI 20·9-27·5]) and lowest in survivors of germ cell tumours (14·0 [11·5-16·6]). Multivariable analyses showed that older age at diagnosis, treatment era, and higher doses of brain and chest radiation are significantly associated with a greater cumulative burden and severity of CHCs.

INTERPRETATION

The burden of CHCs in survivors of childhood cancer is substantial and highly variable. Our assessment of total cumulative burden in survivors of paediatric cancer, with detailed characterisation of long-term CHCs, provide data to better inform future clinical guidelines, research investigations, and health services planning for this vulnerable, medically complex population.

FUNDING

The US National Cancer Institute, St Baldrick's Foundation, and the American Lebanese Syrian Associated Charities.

Pulmonary Function after Treatment for Childhood Cancer. A Report from the St. Jude Lifetime Cohort Study (SJLIFE)

RATIONALE

The relationship between treatment-related impairment of pulmonary function in adult survivors of childhood cancer and subsequent physical function has not been studied.

OBJECTIVES

In this prospective evaluation of 606 adult survivors of childhood cancer, we sought to determine the risk factors for, as well as the functional impact of, clinically ascertained pulmonary function impairment.

METHODS

We measured FEV1, FVC, total lung capacity (TLC), and single-breath diffusing capacity of the lung for carbon monoxide corrected for hemoglobin (DlCOcorr), expressing the results as percent predicted and lower limit of normal (LLN) values, and we also assessed functional exercise capacity (6-minute-walk distance). Lung radiation exposure was expressed as the estimated percentage of lung tissue that received at least 10 Gy (V10). Associations of clinical and treatment factors with pulmonary function measures were assessed using log-binomial regression to calculate relative risks and 95% confidence intervals.

MEASUREMENTS AND MAIN RESULTS

The participants' median age at evaluation was 34.2 years, and the median elapsed time from diagnosis was 21.9 years. Among the sample population, 50.7% had an FEV1 percent predicted less than 80%, 47.2% had an FVC percent predicted less than 80%, 31.2% had a TLC percent predicted less than 75%, and 44.6% had DlCOcorr percent predicted less than 75%. Also, 49.0% had FEV1 less than the LLN on the basis of the Global Lung Function Initiative (GLI) criteria, and 45.4% had FVC less than LLN. Obstructive lung defects (FEV1/FVC, <0.7) were found in 0.8%, but none had obstructive lung defects on the basis of the GLI criterion of FEV1/FVC less than the LLN. Restrictive lung defects (TLC, <75%) were found in 31.2% of participants. V10 and elapsed time since diagnosis were associated with abnormal FEV1 and FVC based on the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03 criteria, and with abnormal FEV1 using the GLI criterion. Age at diagnosis was an additional risk factor for abnormal FVC based on the GLI criteria. Age at diagnosis and V10 were associated with abnormal TLC. Increased body mass index, V10, and elapsed time since diagnosis were risk factors for abnormal DlCOcorr. Abnormal pulmonary function tests were associated with decreased 6-minute walk distance.

CONCLUSIONS

Impaired pulmonary function in adult survivors of childhood cancer is associated with decreased physical function. These patients may benefit from interventions designed to preserve and/or improve pulmonary function.

Physiologic frailty as a sign of accelerated aging among adult survivors of childhood cancer: a report from the St Jude Lifetime cohort study

PURPOSE

Frailty, a phenotype reported among 9.9% of individuals 65 years old and older (9.6% of women; 5.2% of men), has not been assessed among adult childhood cancer survivors (CCS). We estimated the prevalence of frailty and examined associations with morbidity and mortality.

METHODS

Participants included 1,922 CCS at least 10 years from original cancer diagnosis (men, 50.3%; mean age, 33.6 ± 8.1 years) and a comparison population of 341 participants without cancer histories. Prefrailty and frailty were defined as two and ≥ three of the following conditions: low muscle mass, self-reported exhaustion, low energy expenditure, slow walking speed, and weakness. Morbidity was defined as grade 3 to 4 chronic conditions (Common Terminology Criteria for Adverse Events version 4.0). Fisher's exact tests were used to compare, by frailty status, percentages of those with morbidity. In a subset of 162 CCS who returned for a second visit, Poisson regression was used to evaluate associations between frailty and new onset morbidity. Cox proportional hazards regression was used to evaluate associations between frailty and death.

RESULTS

The prevalence of prefrailty and frailty were 31.5% and 13.1% among women and 12.9% and 2.7% among men, respectively, with prevalence increasing with age. Frail CCS were more likely than nonfrail survivors to have a chronic condition (82.1% v 73.8%). In models adjusted for existing chronic conditions, baseline frailty was associated with risk of death (hazard ratio, 2.6; 95% CI, 1.2 to 6.2) and chronic condition onset (relative risk, 2.2; 95% CI, 1.2 to 4.2).

CONCLUSION

The prevalence of frailty among young adult CCS is similar to that among adults 65 years old and older, suggesting accelerated aging.

A Comparison of Florida Medical Examiners’ Reports and Death Certificates for Specific Drug Related Overdose Deaths

Death certificates are a source of information on deaths caused by specific drugs. However, the completeness of such information has been questioned. This study compared counts in the Florida Medical Examiner Commission's drug related death reporting system (ME) with those from death certificates (DC) for overdose deaths involving selected drugs during 2005-2008 to assess the completeness of death certificate information. DC data indicated 2,401 deaths with benzodiazepines as a cause, 2,182 for cocaine, 2,055 for methadone, and 416 for heroin. The ratios of ME deaths to DC deaths were 1.19 (95% CI 1.13-1.26) for benzodiazepines, 1.38 (95% CI 1.31-1.46) for cocaine, 1.37 (95% CI 1.29-1.44) for methadone, and 0.96 (95% CI 0.83-1.09) for heroin. For each drug, ratios were similar for unintentional (accidental), suicide, and undetermined intent deaths. Ratios varied across the 24 ME districts, but few districts reported significantly fewer deaths in the ME system than in the DC system. Results suggest that surveillance based on death certificate data underestimates specific drug caused deaths as counted by medical examiners in a state with multiple, independent medical examiners. Death certificate data might therefore underestimate drug overdose mortality nationwide.

Isolation and characterization of the mouse cytosolic phosphoenolpyruvate carboxykinase (GTP) gene: evidence for tissue-specific hypersensitive sites

A 72 kilobase pair DNA fragment that contains the mouse phosphoenolpyruvate carboxykinase (PEPCK) gene locus, pck1, was isolated from a genomic bacterial artificial chromosome library. The region from approximately -5.5 to +6.6 kilobase pairs relative to the pck1 transcription start site was sequenced and exhibits a high degree of homology to the rat and human genes. Additionally, the chromatin structure of the PEPCK gene in mouse liver resembles that seen in rat. Backcross panel analysis of a microsatellite sequence confirms that the gene is located on chromosome 2. Hypersensitive site analysis was performed on nuclei isolated from the adipocyte cell line 3T3-F442A in the preadipose and adipose states. Several hypersensitive sites are present in the undifferentiated 3T3-F442A cells, before PEPCK mRNA is detected. The same sites are present after differentiation, however, the sensitivity of mHS 3 increases relative to the others. We conclude that the chromatin is open in 3T3-F442A cells and that factors are able to bind in the undifferentiated state but that something else is required for transcription.

Histologic effect of diode laser sclerostomy in human cadaver eyes

BACKGROUND AND OBJECTIVES

To study tissue effects and thresholds of efficacy in producing a full-thickness scleral fistula in human eyes obtained from cadavers. The effect of laser sclerostomies created with indocyanine green (ICG) was also evaluated.

MATERIALS AND METHODS

Ab externo laser sclerostomies were produced in 12 fresh human eyes obtained from cadavers using a 200-micron diameter fiber optic connected to a diode laser system. Power settings were 500, 750, 1000, 1250, 1500, and 2000 mW with a constant duration of 100 and 200 ms. The same diode laser settings were repeated in the tissues injected with ICG.

RESULTS

The laser sclerostomies were associated with heat coagulation damage adjacent to the burn margins, with disruption of stromal collagen. Tissue damage was greater at higher power and longer duration. Scleral injection of ICG prior to laser sclerostomy did not enhance laser penetration.

CONCLUSION

The diode laser can create a sclerostomy in human sclera with an optimum level of 1500 mW and 100 ms. ICG did not significantly enhance the ease of penetration or reduce the association thermal damage to the sclera.

Glaucomatocyclitic crisis in a child

PURPOSE

To report a case of glaucomatocyclitic crisis (Posner-Schlossman syndrome) in a child.

METHOD

Case report. A 13-year-old boy presented with decreased vision, photophobia, halos, and pain in the right eye.

RESULT

Findings in this child were consistent with a diagnosis of Posner-Schlossman syndrome.

CONCLUSION

Glaucomatocyclitic crisis can occur in a child and must be included in the differential diagnosis of uveitis and glaucoma in pediatric patients.

Epidermal growth factor-binding protein in Mycobacterium avium and Mycobacterium tuberculosis: a possible role in the mechanism of infection

Epidermal growth factor (EGF) is a potent mitogen for a variety of eukaryotic cells. EGF is found in a number of tissues and is prevalent in necrotic tissues and granulomata. The biological effect of EGF on mammalian cells is initiated by the binding to a specific receptor. Both Mycobacterium avium and Mycobacterium tuberculosis cause lung infections and localized or disseminated disease in both patients without AIDS and those with AIDS. Histopathologic studies show necrosis in the lung, liver, and splenic tissues of patients with disseminated mycobacterial infection. In the course of experiments to examine the effect of growth factors on macrophages, it was observed that M. avium and M. tuberculosis but not Mycobacterium smegmatis cultured in the presence of 5, 50, or 500 ng of EGF per ml grew significantly faster than mycobacteria cultured in the absence of EGF. 125I-EGF was found to bind to M. avium and M. tuberculosis, and the binding was competitively inhibited by unlabeled EGF. A receptor for EGF was identified on mycobacteria. Incubation of mycobacteria with EGF prior to infection of macrophage monolayers resulted in faster bacterial growth within macrophages compared with that of mycobacteria not incubated with EGF. EGF-binding protein was cloned and expressed in Escherichia coli, and subsequently the protein was purified and the N-terminal amino acids were sequenced. These results suggest that EGF is a growth factor for pathogenic mycobacteria in granulomatous tissues and within macrophages and might enhance growth rates of both intracellular and extracellular mycobacteria in the site of infection.

Comparison of the ability of Mycobacterium avium, M. smegmatis and M. tuberculosis to invade and replicate within HEp-2 epithelial cells

OBJECTIVE

Previous studies have demonstrated that mycobacteria can interact with epithelial cells, a property which can be important for establishing infection. In this study we investigated comparatively the ability of Mycobacterium avium, M. tuberculosis and M. smegmatis to invade and multiply within HEp-2 epithelial cells.

DESIGN

The ability to invade and to multiply intracellularly in HEp-2 cells was examined using a virulent strain of M. avium, a virulent (H37Rv) and an attenuated (H37Ra) strain of M. tuberculosis and a strain of M. smegmatis. The locus responsible for M. avium invasion was also cloned in Escherichia coli and M. smegmatis.

RESULTS

It was observed that M. avium invaded HEp-2 cells with greater efficiency than M. tuberculosis and M. smegmatis, while the H37Rv strain of M. tuberculosis was more efficient in invading HEp-2 than H37Ra and M. smegmatis. Both M. avium and M. tuberculosis were capable of multiplying within HEp-2 cells, while M. smegmatis was not. E. coli K12 and M. smegmatis were transformed with M. avium DNA. The invasive locus of M. avium provided E. coli K12 and M. smegmatis strains S5M101-1 and S5M101-2 with the ability to invade HEp-2 epithelial cells. Transformed M. smegmatis strains were able to grow intracellularly.

CONCLUSION

'Virulent' strains of M. avium and M. tuberculosis were shown to invade and to multiply within HEp-2 epithelial cells. This property was transferred to E. coli K12 and M. smegmatis by transformation with the invasive locus of M. avium. The ability of certain strains of mycobacteria to invade epithelial cells (bronchial, alveolar, intestinal) may represent an important phenotypic characteristic and could be directly related to pathogenicity.

Characterization of a cis-acting regulatory element which silences expression of the class II-A beta gene in epithelium

Class II major histocompatibility complex (MHC) genes encode for alpha/beta chain pairs that are constitutively expressed principally on mature B cells and dendritic cells in mice. These gene products are easily induced on macrophages with cytokines, and may also aberrantly appear on the surface of epithelium during immune injury. The appearance of class II determinants in parenchymal tissue potentially renders these somatic cells capable of antigen presentation to circulating CD4+ T lymphocytes, and their absence may be protective for normal tissues expressing self-antigens. The low surface class II expression observed on parenchymal cells generally correlates with low levels of mRNA, suggesting that transcription rate is a major element in class II regulation. To understand the transcriptional mechanism maintaining low basal surface expression of class II in somatic cells, we transiently transfected mini-gene reporter constructs to study the regulation of the murine A beta promoter in a cultured renal epithelial cell line. We describe here a negative cis-acting regulatory region located between -552 and -489 bp upstream of the A beta cap site that silences the transcriptional activity of the A beta promoter in epithelial cells in an orientation-dependent manner, and is also able to silence a heterologous promoter. This region is not active in class II-expressing B cells (BAL-17) in culture, but is functional in two other murine class II-negative cell lines, fibroblasts and thymoma T cells. Using competition electrophoretic mobility shift assays, we have localized the core protein binding site within this region to an 8-10-bp response element, designated A beta NRE, at -543 to -534 bp. A nuclear extract from BAL-17 cells does not bind to this element. Mutation of this site abrogates the transcriptional silencing activity of the region. We conclude that the transcription of class II-A beta in parenchymal cells, and some lymphocytes, can be actively repressed by an upstream silencing element.

New diagnosis: caregiver role strain

Caregiver role strain is a new diagnosis accepted by NANDA in 1992. The diagnosis is a well-described family phenomenon that can be measured and predicted. Sources of variance for the various defining characteristics have been identified. The diagnosis is also important to society. Nurses can play a significant part in reducing the role strain caregivers feel or preventing its occurrence.

Successful management of paraprotein-associated peripheral polyneuropathies by immunoadsorption of plasma with staphylococcal protein A

Two patients with paraprotein-associated peripheral polyneuropathy were treated successfully using immunoadsorption of patient's plasma with staphylococcal protein A. Both had previously been treated with immunosuppressive agents or plasma exchange, and were rapidly relapsing at the time of their protein A immunoadsorption therapy. One patient was treated "on-line" with a blood cell separator, and one was treated "off-line." Both responded well to therapy with minimal toxicity. Serum levels of circulating immune complexes were elevated in one patient and remained so during and after therapy. Immunoadsorption with protein A should be investigated as a therapeutic option for patients with paraprotein-associated peripheral polyneuropathy. The therapy is relatively easy to administer, particularly "off-line," and was well tolerated by our patients. More experience, including formal clinical trials, will be required to properly define the indications for, and mechanism of response to, this therapy.

Analysis of the cDNA sequence encoding MHC-A beta in tubular epithelium from mouse kidney

Class II gene products of the major histocompatibility complex (MHC) are not expressed usually in abundance on normal epithelium. The cell surface visibility of such proteins for the immune system is thought to be limited protectively in order to minimize inflammation consequent to the recognition of self-antigens in parenchymal structures by T lymphocytes. In the current experiments we investigated whether the previously recognized sparseness of A beta on the surface of tubular epithelial cells might be accounted for by a protein coding difference deduced from the primary structure of its transcript compared with sequence from lymphoid cells that normally express A beta in generous amounts. We demonstrate, however, using clones obtained from a cDNA library prepared from tubular epithelium harvested from H-2s (A beta/alpha+; E beta/alpha-) mice susceptible to autoimmune interstitial nephritis, that the nucleotide sequence encoding the class II A beta chain in cells from both compartments is essentially identical. Our findings suggest that there is no primary structural aberrancy in the coding region of parenchymal A beta that would contribute to its low expression. The protective tolerance afforded by reduced numbers of class II molecules in normal tissues is, therefore, more likely the result of repressive regulatory processes.

The use of the GnRH analogue buserelin for IVF--does it improve fertility?

OBJECTIVE

To determine the effect of a short course of the GnRH analogue buserelin and human menopausal gonadotrophin (hMG), for ovarian stimulation in our IVF programme, on reproductive endocrinology and pregnancy rates compared with conventional clomiphene citrate and hMG treatment.

DESIGN

Prospective randomized allocation to one of two ovulation stimulation regimens.

SETTING

Fertility clinic.

SUBJECTS

373 infertile couples with various factors associated with their subfertility. All the women were less than 46 years of age and had normal menstrual cycles.

INTERVENTION

The first group (n = 151) was given clomiphene citrate (CC) from days 2-6 of the menstrual cycle and hMG from day 5 onwards (CC/hMG). The second group (n = 222) was given buserelin from days 1-3 and hMG from day 2 (buserelin/hMG).

MAIN OUTCOME MEASURES

Concentration of plasma luteinizing hormone (LH), oestradiol (E2) and progesterone, number of ovulatory follicles induced and the occurrence of pregnancy.

RESULTS

Plasma LH, E2 and progesterone concentrations were reduced in the late follicular phase after buserelin/hMG compared with CC/hMG. Buserelin/hMG promoted the development of more follicles than CC/hMG. The overall pregnancy rate after buserelin/hMG was not significantly different from that following CC/hMG treatment.

CONCLUSION

The chance of pregnancy is not improved by the short-term use of buserelin with hMG, provided adequate follicular phase management is maintained.

Supersensitivity to the reinforcing effects of cocaine following 6-hydroxydopamine lesions to the medial prefrontal cortex in rats

The effects of neurotoxic lesions to the medial prefrontal cortex on both the acquisition and maintenance of intravenous cocaine self-administration were examined. In one experiment, acquisition of intravenous cocaine self-administration (0.25, 0.5 or 1.0 mg/kg/infusion) was measured in separate groups of rats 14 days following either a sham or 6-hydroxydopamine lesion to the medial prefrontal cortex. For sham rats, the 1.0 and 0.5 mg/kg dose supported reliable self-administration as indicated by discriminative responding. These rats reliably chose a lever that resulted in the delivery of these doses of cocaine over an inactive lever. Reinforced response rates were reduced when 0.25 mg/kg was the available dose and there was a loss of discriminative responding for some of the rats suggesting that it was close to threshold for self-administration. For rats that sustained a 70% depletion of dopamine in the medial prefrontal cortex, the dose-response curve was an inverse function across the entire dose range tested. In contrast to the data from the control rats, lesioned rats had a high rate of reinforced responses and demonstrated good discrimination for all doses including 0.25 mg/kg/infusion, suggesting a supersensitive response to the initial reward effect of cocaine. Another group of rats was first screened for reliable cocaine self-administration (0.5 mg/kg/infusion) and then subjected to either the prefrontal cortical 6-hydroxydopamine or sham lesion. Dose-response curves for cocaine self-administration were compared 14 days following the infusions. The lesioned rats responded reliably for low doses of cocaine that were unable to maintain responding in sham rats. These data support the hypothesis that the medial prefrontal cortex plays an important role in cocaine self-administration.

Establishing pregnancies after follicular stimulation for IVF with clomiphene citrate and human menopausal gonadotrophin only

Data are presented on establishing pregnancies by IVF during 1987 using only clomiphene citrate and human menopausal gonadotrophin for follicular stimulation. Of the 562 patients undergoing follicular stimulation, 80% reached oocyte recovery and 70% had at least one conceptus replaced. Patients having one or more (up to a maximum of four) conceptuses replaced demonstrated a significant increase in the establishment of pregnancies from one to two (14-29%: P = 0.035) and from two to three conceptuses (29-42%: P = 0.037). There was a significant decline in pregnancies when four conceptuses were replaced compared with three (P = 0.004). The data were also analysed according to the cause of infertility, specifically tubal, endometriosis, unexplained infertility and male factors only. After the replacement of conceptuses, the incidence of implantation and abortion was not significantly different. The incidence of pregnancy declined significantly after 35 years (26%) compared with women under 31 years (43%; P = 0.043). Of 129 women having three conceptuses replaced, in those greater than 35 years (63 patients) 23 (37%) became pregnant whereas in those less than 31 years (65 patients), 34 (52%; P = 0.05) became pregnant. Twenty-two per cent of stimulated cycles resulted in an endogenous LH surge and the incidence of patients having three conceptuses replaced in this group was lower than those in the HCG group (P = 0.007). Fertilization per oocyte was also significantly reduced (P less than 0.001) in patients with an LH surge. In total, 2824 oocytes were recovered and 57% fertilized with 54% of patients having three conceptuses replaced.(ABSTRACT TRUNCATED AT 250 WORDS)

Preexposure sensitizes rats to the rewarding effects of cocaine

During a preexposure period rats were injected once daily with either cocaine HCI (10 mg/kg, IP) or the saline vehicle for 12 consecutive days. Rats that were chronically exposed to cocaine during the pretreatment phase were more responsive to the motor activating effects of a subsequent injection of cocaine than were rats chronically treated with saline. In self-administration testing, saline-pretreated groups did not exhibit a significant preference for a lever producing a cocaine infusion relative to an inactive lever, suggesting that the doses tested (0.225 and 0.45 mg/kg/infusion) were subthreshold for cocaine reward. In contrast, subjects preexposed to cocaine had a higher rate of reinforced responses and exhibited a preference for a lever that resulted in a cocaine infusion. It was unlikely that the higher response rate was due to an elevation in nonspecific activity since inactive lever responding remained low and relatively invariant over the 9 days of testing. Thus the enhanced responding in the cocaine-preexposed rats suggests that the reinforcing effectiveness of the drug had increased. These data indicate that sensitivity to cocaine's behavioral effects can be enhanced and that predisposing factors to cocaine abuse can be manipulated.

Luteal inadequacy during the early luteal phase of subfertile cows

A study was made of early luteal function (up to Day 6) in cyclic and pregnant heifers and also in older, subfertile cows. There were no differences in vivo or in vitro between cyclic and pregnant heifers, indicating no luteotrophic effect of the embryo at this stage, but the increase in postovulatory peripheral progesterone concentrations was delayed (P less than 0.01) and occurred more slowly (P less than 0.001) in the subfertile cows than in the heifers. The corpora lutea of the subfertile cows were heavier (P less than 0.001) than those of the heifers on Day 6. Basal progesterone production by dispersed luteal cells was similar between heifers and subfertile cows, but there was a difference (P less than 0.001) in the pattern of response to exogenous LH and PGE-2. Cells from subfertile cows were less sensitive to the stimulatory effects of PGE-2 and although LH increased (P less than 0.001) progesterone production by all cells, this stimulation by a low dose of LH was inhibited by PGE-2 in luteal cells from subfertile cows. This effect did not occur in the luteal cells from heifers. These results indicate the possibility that luteal inadequacy, due to a diminished response to circulating luteotrophic hormones, may contribute to embryo mortality in subfertile cows.

Prostaglandin E-2 as a potential luteotrophic agent during early pregnancy in cattle

Heifers slaughtered on Day 18/19 of pregnancy had significantly higher (P less than 0.001) concentrations of PGE-2 (measured as its methyl oxime) in uterine flushings than did animals slaughtered on Days 6 or 12 of pregnancy, or on Days 6 or 12 of the oestrous cycle. In addition, concentrations were higher in the uterine horn ipsilateral to the corpus lueum on Days 12 (P less than 0.05) and 18/19 (P less than 0.01) than in the contralateral horn. Incubation of dispersed luteal cells for 3 h with LH (0.1 or 100 ng/ml) and/or PGE-2 (0.01-1000 ng/ml) in vitro showed no differences in basal progesterone production or in the responses to exogenous hormones between pregnant and non-pregnant cattle. However, low doses of PGE-2 (0.01-10 ng/ml) inhibited the stimulation of progesterone secretion by the lower dose of LH. These findings indicate that although PGE-2 can stimulate progesterone synthesis by luteal cells it may also have inhibitory effects, and therefore its role in pregnancy requires further definition.

Self-administration of phenylpropanolamine (PPA) by rats previously trained to self-administer amphetamine

Central nervous system stimulation, similar to that observed for amphetamine, has been attributed to phenylpropanolamine (PPA). However, formal tests, using evaluation of locomotion or of self-administration, fail to reveal that PPA is a stimulant. Self-administration studies have trained rats to self-administer cocaine and then have attempted to switch rats to PPA with no success of transfer. The present study further examined the reinforcing properties of PPA (0.08, 0.16, and 0.32 mg/infusion, IV) in rats that were initially trained to self-administer d-amphetamine (0.005-0.08 mg/infusion) in a two-lever paradigm. Self-administration of amphetamine was a function of dose with 0.01 mg/infusion producing reliably high responding on the active lever. The proportion of active/inactive lever presses remained constant (0.60-0.80) across the amphetamine dose range. PPA was dose-dependently self-administered during the first hour of each session with rats responding at approximately 70% on the active lever. In contrast, responding on the active lever dropped off to approximately 48% when saline was substituted for amphetamine. These data document that rats with prior exposure to amphetamine will self-administer PPA during the initial portion of a three-hour test.

Ovum retention in the human

Two cases of ovum retention occurring in postovulatory follicles are described. The ova were recovered at laparoscopy by aspiration of decompressed ovulatory follicles, one during a natural cycle and the other following a programmed clomiphene/human chorionic gonadotropin cycle. Each patient had a normal luteal phase with an increased progesterone level indicative of ovulation. The implications of these findings and their relevance to human fertility studies are discussed.

DNA content of microcells prepared from rat kangaroo and mouse cells

Enucleation of animal cells in which nuclear fragmentation (micronucleation) has been induced by treatment with mitotic inhibitors results in the formation of subdiploid microcells consisting of one or several micronuclei, some cytoplasm and surrounded by a plasma membrane. Microcells were prepared from rat kangaroo cells (12 chromosomes) and a polyoma virus transformed mouse cell line (61 chromosomes) and analysed for DNA content. Microspectrophotometric DNA measurements and the appearance of micronuclei at mitosis show that small micronuclei contain genetic information equivalent to single chromosomes. A large proportion of the micronuclei and the microcells, however, contains DNA corresponding to several chromosomes. Heterogeneous mixtures of microcells can be fractionated by a unit gravity sedimentation procedure so as to isolate the small microcells. These can afterwards be fused with intact normal or mutant cells.