Gut bacteria-derived serotonin promotes immune tolerance in early life

The gut microbiota promotes immune system development in early life, but the interactions between the gut metabolome and immune cells in the neonatal gut remain largely undefined. Here, we demonstrate that the neonatal gut is uniquely enriched with neurotransmitters, including serotonin, and that specific gut bacteria directly produce serotonin while down-regulating monoamine oxidase A to limit serotonin breakdown. We found that serotonin directly signals to T cells to increase intracellular indole-3-acetaldehdye and inhibit mTOR activation, thereby promoting the differentiation of regulatory T cells, both ex vivo and in vivo in the neonatal intestine. Oral gavage of serotonin into neonatal mice resulted in long-term T cell-mediated antigen-specific immune tolerance toward both dietary antigens and commensal bacteria. Together, our study has uncovered an important role for specific gut bacteria to increase serotonin availability in the neonatal gut and identified a function of gut serotonin in shaping T cell response to dietary antigens and commensal bacteria to promote immune tolerance in early life.

Patient-derived tumor organoids with p53 mutations, and not wild-type p53, are sensitive to synergistic combination PARP inhibitor treatment

Poly (ADP-ribose) polymerase inhibitors (PARPi) are used for patients with BRCA1/2 mutations, but patients with other mutations may benefit from PARPi treatment. Another mutation that is present in more cancers than BRCA1/2 is mutation to the TP53 gene. In 2D breast cancer cell lines, mutant p53 (mtp53) proteins tightly associate with replicating DNA and Poly (ADP-ribose) polymerase (PARP) protein. Combination drug treatment with the alkylating agent temozolomide and the PARPi talazoparib kills mtp53 expressing 2D grown breast cancer cell lines. We evaluated the sensitivity to the combination of temozolomide plus PARPi talazoparib treatment to breast and lung cancer patient-derived tumor organoids (PDTOs). The combination of the two drugs was synergistic for a cytotoxic response in PDTOs with mtp53 but not for PDTOs with wtp53. The combination of talazoparib and temozolomide induced more DNA double-strand breaks in mtp53 expressing organoids than in wild-type p53 expressing organoids as shown by increased γ-H2AX protein expression. Moreover, breast cancer tissue microarrays (TMAs) showed a positive correlation between stable p53 and high PARP1 expression in sub-groups of breast cancers, which may indicate sub-classes of breast cancers sensitive to PARPi therapy. These results suggest that mtp53 could be a biomarker to predict response to the combination of PARPi talazoparib-temozolomide treatment.

A pancreatic cancer organoid platform identifies an inhibitor specific to mutant KRAS

KRAS mutations, mainly G12D and G12V, are found in more than 90% of pancreatic ductal adenocarcinoma (PDAC) cases. The success of drugs targeting KRASG12C suggests the potential for drugs specifically targeting these alternative PDAC-associated KRAS mutations. Here, we report a high-throughput drug-screening platform using a series of isogenic murine pancreatic organoids that are wild type (WT) or contain common PDAC driver mutations, representing both classical and basal PDAC phenotypes. We screened over 6,000 compounds and identified perhexiline maleate, which can inhibit the growth and induce cell death of pancreatic organoids carrying the KrasG12D mutation both in vitro and in vivo and primary human PDAC organoids. scRNA-seq analysis suggests that the cholesterol synthesis pathway is upregulated specifically in the KRAS mutant organoids, including the key cholesterol synthesis regulator SREBP2. Perhexiline maleate decreases SREBP2 expression levels and reverses the KRAS mutant-induced upregulation of the cholesterol synthesis pathway.

Deficiency of metabolic regulator PKM2 activates the pentose phosphate pathway and generates TCF1+ progenitor CD8+ T cells to improve checkpoint blockade

TCF1high progenitor CD8+ T cells mediate the efficacy of PD-1 blockade, however the mechanisms that govern their generation and maintenance are poorly understood. Here, we show that targeting glycolysis through deletion of pyruvate kinase muscle 2 (PKM2) results in elevated pentose phosphate pathway (PPP) activity, leading to enrichment of a TCF1high central memory-like phenotype and increased responsiveness to PD-1 blockade in vivo. PKM2KO CD8+ T cells showed reduced glycolytic flux, accumulation of glycolytic intermediates and PPP metabolites, and increased PPP cycling as determined by 1,2 13C glucose carbon tracing. Small molecule agonism of the PPP without acute glycolytic impairment skewed CD8+ T cells towards a TCF1high population, generated a unique transcriptional landscape, enhanced tumor control in mice in combination with PD-1 blockade, and promoted tumor killing in patient-derived tumor organoids. Our study demonstrates a new metabolic reprogramming that contributes to a progenitor-like T cell state amenable to checkpoint blockade.

Patient-derived tumor organoids with p53 mutations, and not wild-type p53, are sensitive to synergistic combination PARP inhibitor treatment

Poly (ADP-ribose) polymerase inhibitors (PARPi) are used for patients with BRCA1/2 mutations, but patients with other mutations may benefit from PARPi treatment. Another mutation that is present in more cancers than BRCA1/2 is mutation to the TP53 gene. In 2D breast cancer cell lines, mutant p53 (mtp53) proteins tightly associate with replicating DNA and Poly (ADP-ribose) polymerase (PARP) protein. Combination drug treatment with the alkylating agent temozolomide and the PARPi talazoparib kills mtp53 expressing 2D grown breast cancer cell lines. We evaluated the sensitivity to the combination of temozolomide plus PARPi talazoparib treatment to breast and lung cancer patient-derived tumor organoids (PDTOs). The combination of the two drugs was synergistic for a cytotoxic response in PDTOs with mtp53 but not for PDTOs with wtp53. The combination of talazoparib and temozolomide induced more DNA double-strand breaks in mtp53 expressing organoids than in wild-type p53 expressing organoids as shown by increased γ-H2AX protein expression. Moreover, breast cancer tissue microarrays (TMAs) showed a positive correlation between stable p53 and high PARP1 expression in sub-groups of breast cancers, which may indicate sub-classes of breast cancers sensitive to PARPi therapy. These results suggest that mtp53 could be a biomarker to predict response to the combination of PARPi talazoparib-temozolomide treatment.

Endocarditis caused by Neisseria bacilliformis: a case report and review of literature

A 58-years-old male with history of previous aortic prosthetic endocarditis caused by Enterococcus faecalis was admitted due to dyspnoea and fever. The two sets of blood cultures were positive for Neisseria bacilliformis. Transoesophageal echocardiography did not demonstrate endocarditis signs, but PET-CT scan showed active infection signs in the valvular aortic tube and possible infection in the aortic prosthetic valve. A six-week course of ampicillin was prescribed; gentamicin was added during the first two weeks. The patient continued a favourable clinical course. This is the 3rd described case of N. bacilliformis endocarditis and the first one in a prosthetic valve.

Abstract B55: Patient-Derived Organoids model time-dependent sensitivities to PARP inhibitors in patients with metastatic colorectal cancer

Background: Poly (ADP-ribose) polymerase inhibitors (PARPi) have been approved as monotherapy and combination therapy for BRCA-mutated breast, ovarian, and prostate cancer and it is proposed that they may be effective for other BRCA-mutated cancer as well. However, recent clinical trials show inconsistent efficacy of PARPi on BRCA-mutated cancers, partially due to imperfect biomarker definition and unknown resistance mechanism. BRCA status alone may not be a good indicator for PARPi responsiveness as many proteins are involved in the homologous recombination (HR) pathway, which is why this experiment raises the question of whether time plays a role in tumor drug sensitivity. Patient-derived tumor organoids (PDTOs) can be used to study the pharmacogenomics between PARPis and HR deficient cancer. PDTOs are emerging ex vivo cancer models used for precision medicine because they harbor the mutational landscape of primary tumors. The common pipeline for organoid preclinical research includes confirming mutation profile, performing drug screening, and proposing clinically relevant candidates. The goal of this experiment was to model if the responses of patient-derived colorectal cancer organoids with BRCA gene deletion and TP53, SMAD4, and KRAS gene mutations to the PARPi talazoparib and olaparib differ depending on time.Methods: Patient sample: Colorectal: rectal cancer with BRCA1 gene deletion. Mutations in ⦁ KRAS p.Gly12Val ⦁ TP53 p.Arg175His ⦁ SMAD4 p.Arg361Cys + control: Puromycin 2 ug/mL - control: DMSO PARPi: talazoparib and olaparib In a 96 well plate, 1500 cells per well were plated in 10uL of a media/matrigel mixture and 100 uL of additional media were added to each well. The plate was put in the incubator at 37 C for 48 hours. The PARPi talazoparib and olaparib were then added after a serial dilution at max 50 uM concentration. The plates with the drugs (additional 100uL media with 2X drugs) were put in the incubator at 37 C for 120 hours. The plate for timepoint 1 was then read using the viability assay called Cell Titer Glo 3D. The next timepoint was taken after 168 hours using the same method. In addition, cell viability was measured by high content imaging which is being developed at EIPM.Results: Patient-Derived organoids were sensitive to talazoparib at hour 120 and hour 168 (IC50 1.6 and 1.9 respectively). Patient-derived organoids were not sensitive to olaparib at any time point tested and did not yield a meaningful IC50.Conclusion: The sensitivity of patient-derived colorectal cancer organoids with BRCA gene deletion and TP53, SMAD4, and KRAS gene mutations to the PARPi talazoparib and olaparib did not significantly differ depending on time. However, organoids were more sensitive to talazoparib than to olaparib. These results can guide which PARPi should be used in similar ex vivo experiments to yield meaningful results to eventually lead to successful clinical treatments for patients.

Citation Format: Maria Mastropaolo, Helen Kuo, John Nguyen, Florencia Madorsky Rowdo, Jared Capuano, Jenna Moyer, M. Laura Martin, Julianne Hall, Olivier Elemento. Patient-Derived Organoids model time-dependent sensitivities to PARP inhibitors in patients with metastatic colorectal cancer [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 B55.

Next generation patient derived tumor organoids

Patient-derived tumor organoids (PDTOs) have emerged as exceptional pre-clinical models as they preserved, in most of the cases, the mutational landscape and tumor-clonal heterogeneity of the primary tumors. Despite being extensively used in disease modelling as well as in precision medicine for drug testing and discovery, they still have some limitations. The main limitation is that during their establishment they lose all components of the tumor microenvironment (TME) which are known modulators of tumor response to therapeutic treatment as well as disease progression. In this review we address the effects of different players of the TME such as immune cells, fibroblasts, endothelial cells and the extracellular matrix composition on tumor behavior and response to treatment as well as the different culture and co-culture strategies that could improve PDTOs value as pre-clinical models leading to the development of next generation PDTOs.

Abstract 6037: Kinome crispr cas9 screening in breast cancer organoids derived from Ghanaian patients

Breast cancer is a polygenic genetic disease caused by multifaceted factors which are often unique for each individual patient. In our prior studies we have demonstrated that west African ancestry is associated with more aggressive breast tumor phenotypes. Precision medicine approaches to cancer treatment exploit genetic differences to tailor therapy options that are specific to individual patients/groups. We hypothesize that shared genetic susceptibilities to cancer, which are harbored within populations of common ancestry, may translate to options for targeted therapies. Specifically, we will investigate whether genetic manipulation of kinases in Patient-Derived Tumor Organoids (PDTO) from West African breast cancer patients uncover novel drug targets in a genetic background that has not been investigated in this context to date. PDTO are three-dimensional cellular models grown in culture ex vivo from the tumor tissues obtained from patients retaining cell-cell and cell-matrix interactions. We established and characterized PDTO from Ghanaian patients and optimized the experimental conditions to perform a lentiviral-based CRISPR-Cas9 loss-of-function mutation screen targeting kinases in breast cancer organoids. We analyzed which kinases are essential for tumor viability or directly impact the response to current therapy/drugs. Tumor specimens were collected in Ghana from breast cancer patients and PDTO were stablished in Weill Cornell Medicine (USA). These PDTO were characterized by IHC, targeted panel sequencing and RNA-seq and biobanked. We established stable Cas9-expressing PDTO and we confirmed Cas9 expression by Western Blot and its activity by reporter-based assays, confirming that at least 80% of the cells present Cas9 activity. We performed a Kinome CRISPR Cas9 screen with 2 PDTO. The screening was performed in the presence of DMSO (vehicle to identify essential genes), a MEK inhibitor or an EGFR inhibitor. Preliminary analysis of the screening revealed efficient depletion of the positive controls as well as of previously proposed pan-cancer essential kinases, including CHEK1, ATR and AURKA. Additional analysis and validation of potential novel targets is currently ongoing. Conclusions: We successfully established the conditions to identify potential new therapeutic targets in PDTO derived from Ghanaian patients. Our Kinome Crispr Screen identified known as well as previously unknown essential kinases for breast cancer.

Citation Format: Florencia P. Madorsky Rowdo, Sarah Ackermann, Joseph K. Oppong, Ishmael Kyei, Colin Tang, Lisa Newman, Olivier Elemento, Lukas E. Dow, M. Laura Martin, Melissa B. Davis. Kinome crispr cas9 screening in breast cancer organoids derived from Ghanaian patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6037.

Abstract 1309: Patient-derived tumor organoids as a platform to study radiation-exposed neoantigens

Focal radiation therapy (RT) can increase tumor immunogenicity and T cell-mediated tumor rejection when combined with immune checkpoint blockade (ICB). Our prior findings in patients and in preclinical studies suggest that one mechanism whereby RT increases tumor immunogenicity is by enhancing the expression of neoantigens.1,2 In response to RT, cells rapidly transcribe and translate hundreds of genes associated with the DNA damage response (DDR), protein turnover and cellular stress. Genes in these pathways are frequently mutated in cancer. Thus, we hypothesized that the presence of immunogenic mutations in genes upregulated by radiation could help predict the benefits of RT used in combination with ICB. In order to develop such a predictor, we built an in vitro system to study the RT-induced transcriptional response of primary human tumors cultured as patient-derived tumor organoids (PDO). PDOs were established from 2 breast cancer (BC), 4 non-small cell lung cancer (NSCLC) and 3 colorectal cancer (CRC) patients. PDOs were irradiated with doses of 5 to 8 Gy daily for 3 days (n=4) or left untreated (UT, n=4) and cultured for 24h prior to RNA extraction. RNA sequencing was carried out using a NovaSeq6000 sequencer (Illumina) to a depth of 30 million reads. Differential expression analysis between RT and UT samples was performed using DESeq2 and significantly perturbed genes were defined as genes with fold change greater than 1.5 and adjusted p-value cutoff of 0.05. In total we detected an average of 15,000+/-800 protein coding genes per sample and the number of genes modulated by RT was found to vary with cancer type. This ranged from an average of 3.9+/-1.6% genes upregulated by RT in NSCLC to 12.1+/-2.5% in CRC organoids. There were 104 and 490 genes commonly upregulated by RT in NSCLC and CRC, respectively. One of the BC PDOs is a triple-negative BC and the other HR+ and despite this difference, we identified 24 commonly upregulated genes. Gene Set Enrichment Analysis (GSEA), revealed enrichments in DDR and pro-inflammatory signaling pathways among the upregulated genes. Whole exome sequencing and paired normal tissue was used to determine the variants and predicted neoantigens for these PDOs. In one of the EGFR mutated NSCLC PDOs we found that among the genes transcriptionally upregulated by RT, 18 carried somatic mutations predicted to be antigenic. The presentation of these neoantigens is being investigated by mass spectrometry analysis of the immunopeptidome eluted from surface MHC-I molecules. Similar investigations are being carried out in the other models. Overall, results support the feasibility of identifying a common signature of RT upregulated genes in PDOs. This will provide a system to predict RT- exposed neoantigens. [1] Formenti et al. Nat. Med. 2018;24(12):1845-1851, [2] Lhuillier et al. J. Clin. Invest. 2021;131(5):e138740

Citation Format: Samantha J. Van Nest, Jared Capuano, Bhavneet Bhinder, Martin G. Klatt, Tuo Zhang, M. Laura Martin, Silvia C. Formenti, Olivier Elemento, Nils-Petter Rudqvist, Sandra Demaria. Patient-derived tumor organoids as a platform to study radiation-exposed neoantigens [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1309.

The lactate-NAD+ axis activates cancer-associated fibroblasts by downregulating p62

Reduced p62 levels are associated with the induction of the cancer-associated fibroblast (CAF) phenotype, which promotes tumorigenesis in vitro and in vivo through inflammation and metabolic reprogramming. However, how p62 is downregulated in the stroma fibroblasts by tumor cells to drive CAF activation is an unresolved central issue in the field. Here we show that tumor-secreted lactate downregulates p62 transcriptionally through a mechanism involving reduction of the NAD⁺/NADH ratio, which impairs poly(ADP-ribose)-polymerase 1 (PARP-1) activity. PARP-1 inhibition blocks the poly(ADP-ribosyl)ation of the AP-1 transcription factors, c-FOS and c-JUN, which is an obligate step for p62 downregulation. Importantly, restoring p62 levels in CAFs by NAD⁺ renders CAFs less active. PARP inhibitors, such as olaparib, mimick lactate in the reduction of stromal p62 levels, as well as the subsequent stromal activation both in vitro and in vivo, which suggests that therapies using olaparib would benefit from strategies aimed at inhibiting CAF activity.

Gut microbiota-derived metabolites confer protection against SARS-CoV-2 infection

The gut microbiome is intricately coupled with immune regulation and metabolism, but its role in Coronavirus Disease 2019 (COVID-19) is not fully understood. Severe and fatal COVID-19 is characterized by poor anti-viral immunity and hypercoagulation, particularly in males. Here, we define multiple pathways by which the gut microbiome protects mammalian hosts from SARS-CoV-2 intranasal infection, both locally and systemically, via production of short-chain fatty acids (SCFAs). SCFAs reduced viral burdens in the airways and intestines by downregulating the SARS-CoV-2 entry receptor, angiotensin-converting enzyme 2 (ACE2), and enhancing adaptive immunity via GPR41 and 43 in male animals. We further identify a novel role for the gut microbiome in regulating systemic coagulation response by limiting megakaryocyte proliferation and platelet turnover via the Sh2b3-Mpl axis. Taken together, our findings have unraveled novel functions of SCFAs and fiber-fermenting gut bacteria to dampen viral entry and hypercoagulation and promote adaptive antiviral immunity.

Key aspects of statin intolerance leading to treatment discontinuation: a patient perspective

Background and aims

Statins are the standard of care for patients with dyslipidemia, but some patients develop intolerance to treatment. The experience of statin intolerant (SI) patients is poorly understood. The objective of this study was to identify key aspects of SI that may be associated with treatment discontinuation.

Methods

Using a previously created questionnaire, we conducted a pilot cross-sectional survey to identify items important for describing patient-centric aspects of SI. The study recruited adult (18+) patients with a history of statin-associated side effects from 9 clinics in 6 countries (France, Italy, Norway, Spain, Sweden, and the United Kingdom), who had received statin treatment within the previous two years.

Results

We surveyed 104 patients (mean age 61.5 SD=11.2 years, 63.5% men, 50% currently on statins). Patients most frequently reported muscle-related symptoms: pain (90.9%), cramps (63.7%), and stiffness (58.2%). Using a 0–10 point scale, significant differences were found between those continuing versus discontinuing their statins for being bothered by side effects (7.5 vs 9.2, p=0.001), for an inability to tolerate side effects (6.7 vs 9.0, p<0.001), and those having too much side effects interference with their daily life (5.7 vs 8.6, p<0.001; see figure). For patients whose doctors worked on adjusting statin regimen, 67% stayed on treatment; for those whose doctors did not, only 10% continued treatment.

Conclusions

Results of this pilot survey suggest patients who experience greater side effects severity and interference with daily activity, along with lower efforts by clinicians to work with adjusting their statin regimen, are at greater risk for discontinuing treatment. A wider survey and larger study population is needed to confirm the results of this pilot study.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was sponsored by Amgen Inc.

Single-cell DNA targeted sequencing (scDNA-seq) to test therapeutic vulnerabilities in urothelial cancer (UC) patient-derived organoids (PDO)

464

Background: Genomic alterations in FGFR3, PIK3CA, and CDKN2A are common actionable targets in urothelial cancer (UC). We aimed to determine the efficacy of alpelisib, a PIK3CA inhibitor, and abemaciclib, a CDK4/6 inhibitor in bladder cancer patient-derived organoid using single-cell targeted DNA sequencing. Methods: We established a patient-derived UC organoid (PDO) harboring the FGFR3 mutation (p.Y375C), the PIK3CA (p. E452K) mutation, and CDKN2A deletion, which we characterized using whole-genome sequencing. We generated dose-response curves of alpelisib, abemaciclib, and erdafitinib (an FGFR3 inhibitor) in PDO cells to determine the IC50 concentrations. The scDNA-seq (Tapsteri) platform was used to measure changes in the variant allele frequencies (VAF) and clonal fractions post-treatment. The Chi-square test for trend was used to test for linear trend across ordered categories. Results: scDNA-seq was performed after treating PDO cells with 3uM erdafitinib or DMSO. A total of 7000 single cells were obtained (4179 cells treated with erdafitinib vs. 2821 cells treated with DMSO). After removing variants mutated in <50% of cells, we identified 94 clonal variants. As expected, cells harboring FGFR3 Y375C have significantly decreased post erdafitinib treatment compared to DMSO-treated cells (66.05% vs. 82.36%, p<0.0001). We identified mutations in two genes ( RAB31 and SMAD4) that were associated with clonal expansion following FGFR3 inhibition (12% vs. 53% and 13% vs. 26%, respectively). We treated PDO cells with 3uM abemaciclib. We identified three genes harboring SNVs ( RB1, GNAQ, and SMAD4). The SNVs harboring cells were significantly decreased after abemaciclib compared to DMSO (p<0.0001). Then, we treated the cells with 1uM alpelisib for 72 hours alone or combined with abemaciclib (0.1uM). We identified that 100% of cells harbored the PIK3CA mutation E452K at pre-treatment, which limited our ability to detect significant changes in VAF post-treatment. Instead, we analyzed the effect on the FGFR3 Y375C clone. Using trend analysis, there was a significant reduction of FGFR3-mutant cells observed across the three conditions, abemaciclib + alpelisib vs. alpelisib alone vs. DMSO (74% vs. 85% vs. 92%, trend test p<0.0001), suggesting in vitro efficacy of alpelisib alone and significant synergism with the addition of abemaciclib. Conclusions: This study established the feasibility of using scDNA-seq as a promising tool to study the clonal evolution patterns in patient-derived UC organoids. Combined pharmacologic inhibition of CDK4/6 and PIK3CA showed more in vitro sensitivity than PIK3CA inhibition alone.

T cell-derived interferon-γ programs stem cell death in immune-mediated intestinal damage

Despite the importance of intestinal stem cells (ISCs) for epithelial maintenance, there is limited understanding of how immune-mediated damage affects ISCs and their niche. We found that stem cell compartment injury is a shared feature of both alloreactive and autoreactive intestinal immunopathology, reducing ISCs and impairing their recovery in T cell-mediated injury models. Although imaging revealed few T cells near the stem cell compartment in healthy mice, donor T cells infiltrating the intestinal mucosa after allogeneic bone marrow transplantation (BMT) primarily localized to the crypt region lamina propria. Further modeling with ex vivo epithelial cultures indicated ISC depletion and impaired human as well as murine organoid survival upon coculture with activated T cells, and screening of effector pathways identified interferon-γ (IFNγ) as a principal mediator of ISC compartment damage. IFNγ induced JAK1- and STAT1-dependent toxicity, initiating a proapoptotic gene expression program and stem cell death. BMT with IFNγ-deficient donor T cells, with recipients lacking the IFNγ receptor (IFNγR) specifically in the intestinal epithelium, and with pharmacologic inhibition of JAK signaling all resulted in protection of the stem cell compartment. In addition, epithelial cultures with Paneth cell-deficient organoids, IFNγR-deficient Paneth cells, IFNγR-deficient ISCs, and purified stem cell colonies all indicated direct targeting of the ISCs that was not dependent on injury to the Paneth cell niche. Dysregulated T cell activation and IFNγ production are thus potent mediators of ISC injury, and blockade of JAK/STAT signaling within target tissue stem cells can prevent this T cell-mediated pathology.

Abstract IA33: Precision medicine at Weill Cornell Medicine/New York Presbyterian: Breaking silos, integrating resources, being inclusive

Genomic testing with next-generation sequencing (NGS) has become a pillar of precision medicine, whose aim is to identify the genomic alterations of a patient’s tumor and provide guidelines to clinicians for optimal treatment. Clinical testing is typically performed with targeted panels interrogating a limited set of genes, selected based on our best scientific knowledge on their diagnostic or prognostic role. Despite more recent efforts to be more inclusive, most genomic databases have a limited representation of non-European populations, resulting in a biased selection of those genes, and the potential exclusion of under-represented groups from the benefit of precision medicine. At the Englander Institute for Precision Medicine (EIPM), we developed a whole-exome sequencing (WES) clinical test, EXaCT-1, which interrogates about 21,000 protein coding genes for single-nucleotide variants, indels, and copy number. EXaCT-1 enables an unbiased view of the genomic landscape of a patient’s tumor and allows for the collection of data to investigate genomic diversity. We also tackled one of the major barriers of precision medicine: the infrastructure to execute clinical sequencing. From ordering a test, collecting and processing samples, to the analysis and review of the data and generation of reports, several systems, procedures, and expertise are involved, and their effective coordination is a key component for the timely delivery of results. We have built a framework supporting the entire process of clinical genomic testing: a Laboratory Information Management System (LIMS) helps the clinical lab to receive orders, acquire and process specimens, and seamlessly communicate with the sequencers and the computational pipelines. Molecular pathologists use NGSReporter, a secure web application, to review the data and sign-out reports. NGSReporter integrates the results of a test with our Precision Medicine Knowledge Base (PMKB – https://pmkb.weill.cornell.edu), which classifies variants based on their relevance to clinical management and provides standardized interpretations. Reports are sent to the electronic health record (EHR) as PDFs as well as discrete entities, enabling queries such as: “Which Hispanic patients with KRAS mutations are diabetic?” Sharing de-identified data is also a key aspect of precision medicine. To this end, we provide our investigators and collaborators with a protected cBioPortal instance that, in addition to publicly available datasets, includes internal data, thus enabling the exploration of hypotheses about the role of alterations across different cohorts and clinical features. Being in the center of New York City has the added benefit of an ethnically diverse patient population. Finding the “right treatment for the right person and at the right time” requires a concerted effort of multiple partners. The EIPM infrastructure facilitates these efforts, with the goal of making precision medicine accessible to everyone.

Citation Format: Andrea Sboner, Cora Sternberg, Juan Miguel Mosquera, Wei Song, Michael Kluk, Wayne Tam, Hanna Rennert, David Pisapia, Jeffrey Catalano, Gloria Cheang, David Wilkes, Danielle Bulaon, M. Laura Martin, Alexandros Sigaras, Kenneth Eng, Rohan Bareja, Rob Kim, Massimo Loda, Olivier Elemento. Precision medicine at Weill Cornell Medicine/New York Presbyterian: Breaking silos, integrating resources, being inclusive [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr IA33.

Cell cycLe inhibitiON to target the EVolution of urOthelial cancer (CLONEVO): A single-arm, open-label window-of-opportunity trial of neoadjuvant abemaciclib in platinum-ineligible muscle invasive bladder cancer patients

TPS5096

Background: The standard of care for clinically localized muscle-invasive bladder cancer (MIBC) is neoadjuvant platinum-based combination chemotherapy followed by radical cystectomy (RC). Up to 40% of patients (pts) are ineligible to receive cisplatin and proceed to RC without any neoadjuvant therapy. We and others have demonstrated enrichment of molecular alterations in cell cycle genes in MIBC, including copy number losses of CDKN2A in 41% of pts. Abemaciclib is a unique CDK4/6 inhibitor with single agent activity and a target kinome distinct from other CDK4/6 inhibitors. We have demonstrated that CRISPR knockout of CDKN2A increases susceptibility to abemaciclib in bladder cancer cell lines. Beyond tumor-intrinsic effects, abemaciclib also modulates the tumor microenvironment (TME) via upregulating human endogenous retroviral elements and increasing T cell infiltration. Methods: Cell cycLe inhibitiON to target the EVolution of urOthelial cancer (CLONEVO) is a single arm, window-of-opportunity trial of neoadjuvant abemaciclib which will evaluate tumor cell and TME changes in response to abemaciclib. Enrolled pts must be ineligible for platinum-based neoadjuvant therapy for resectable MIBC. Pts receive abemaciclib (200 mg BID PO) for 4 weeks prior to RC. Tumor tissue collected via transurethral resection of bladder tumor (TURBT) and residual tumor at RC undergo single cell RNA sequencing and whole-exome sequencing. Patient-derived organoids and xenografts are generated for a co-clinical trial of abemaciclib alone or in combination. The primary endpoint is the measurement of changes in cell cycle dynamics. Secondary objectives are assessment of toxicity via NCI CTCAE v 5.0 and pathologic downstaging of MIBC. We will perform targeted sequencing of a panel of cell cycle genes in serial plasma and urine cell free DNA to evaluate changes in the variant allele fractions of somatic alterations. The novel design of this trial allows dynamic in vivo assessment of tumor changes and creates a new paradigm for studying tumor evolution in real time. Clinical trials information: NCT03837821. Clinical trial information: NCT03837821 .

Cell cycLe inhibitiON to target the EVolution of urOthelial cancer (CLONEVO): A single-arm, open-label window-of-opportunity trial of neoadjuvant abemaciclib in platinum-ineligible muscle invasive bladder cancer patients

TPS606

Background: The standard of care for clinically localized muscle-invasive bladder cancer (MIBC) is neoadjuvant platinum-based combination chemotherapy followed by radical cystectomy (RC). Up to 40% of patients (pts) are ineligible to receive cisplatin and proceed to RC without any neoadjuvant therapy. We and others have demonstrated enrichment of molecular alterations in cell cycle genes in MIBC, including copy number losses of CDKN2A in 41% of pts. Abemaciclib is a unique CDK4/6 inhibitor with single agent activity and a target kinome distinct from other CDK4/6 inhibitors. We have demonstrated that CRISPR knockout of CDKN2A increases susceptibility to abemaciclib in bladder cancer cell lines. Beyond tumor-intrinsic effects, abemaciclib also modulates the tumor microenvironment (TME) via upregulating human endogenous retroviral elements and increasing T cell infiltration. Methods: Cell cycLe inhibitiON to target the EVolution of urOthelial cancer (CLONEVO) is a single arm, window-of-opportunity trial of neoadjuvant abemaciclib which will evaluate tumor cell and TME changes in response to abemaciclib. Enrolled pts must be ineligible for platinum-based neoadjuvant therapy for resectable MIBC. Pts receive abemaciclib (200 mg BID PO) for 4 weeks prior to RC. Tumor tissue collected via transurethral resection of bladder tumor (TURBT) and residual tumor at RC undergo single cell RNA sequencing and whole-exome sequencing. Patient-derived organoids and xenografts are generated for a co-clinical trial of abemaciclib alone or in combination. The primary endpoint is the measurement of changes in cell cycle dynamics. Secondary objectives are assessment of toxicity via NCI CTCAE v 5.0 and pathologic downstaging of MIBC. We will perform targeted sequencing of a panel of cell cycle genes in serial plasma and urine cell free DNA to evaluate changes in the variant allele fractions of somatic alterations. The novel design of this trial allows dynamic in vivo assessment of tumor changes and creates a new paradigm for studying tumor evolution in real time. Clinical trial information: NCT03837821.

Orthohantavirus genotype Lechiguanas in Oligoryzomys nigripes (Rodentia: Cricetidae): New evidence of host-switching

To identify and predict situations of increased risk of orthohantavirus infection in humans, it is necessary to study the relationships between the virus and its rodent hosts. The present study investigated orthohantavirus infection in an assemblage of wild Sigmodontinae rodents of the Paraná Delta, Argentina, and providing new evidence of host-switching events. Rodents belonging to the species Oxymycterus rufus (n = 187), Akodon azarae (n = 82), Oligoryzomys flavescens (n = 80), Oligoryzomys nigripes (n = 47), Scapteromys aquaticus (n = 38), Deltamys kempi (n = 7) and Holochilus brasiliensis (n = 2) were captured at 4 sampling sites during 20 trapping sessions. Blood samples were analyzed by IgG ELISA and livers by a nested reverse transcription PCR for the diagnosis of orthohantavirus infection. The amplified products of the S and M orthohantavirus genomes were sequenced and analyzed to determine similarities with species of the Orthohantavirus genus. The species of the Oligoryzomys positive to the virus were confirmed by amplifying and sequencing the complete cyt b gene. Of the 443 serum samples analyzed by IgG ELISA, A. azarae presented the highest host-specific prevalence value (10/82, 12.2%) followed by Ol. nigripes (4/47, 8.5%) and Ox. rufus (1/187, 0.5%). All the sero-positive Ol. nigripes (n = 4) were positive to the amplification of the S and M segments of the Lechiguanas genotype (98% nucleotide identity for both segments). This is surprising given that Ol. nigripes has been previously associated with Juquitiba genotype, not Lechiguanas. The latter is generally associated with Ol. flavescens, which in our study were all sero-negative. In addition, the association Ox. rufus - Pergamino genotype found here is, to our knowledge, novel and another potential evidence of host-switching considering that Pergamino has been originally associated with A. azarae. These findings contribute to the building evidence that contradicts the one-genotype-one-reservoir species premise in the association between rodent reservoirs and orthohantaviruses, and supports the hypothesis that the community structure of sympatric host species may contribute to orthohantavirus dynamics.

Automated Integration of Multimodal MRI for the Probabilistic Detection of the Central Vein Sign in White Matter Lesions

BACKGROUND AND PURPOSE

The central vein sign is a promising MR imaging diagnostic biomarker for multiple sclerosis. Recent studies have demonstrated that patients with MS have higher proportions of white matter lesions with the central vein sign compared with those with diseases that mimic MS on MR imaging. However, the clinical application of the central vein sign as a biomarker is limited by interrater differences in the adjudication of the central vein sign as well as the time burden required for the determination of the central vein sign for each lesion in a patient's full MR imaging scan. In this study, we present an automated technique for the detection of the central vein sign in white matter lesions.

MATERIALS AND METHODS

Using multimodal MR imaging, the proposed method derives a central vein sign probability, π_ij, for each lesion, as well as a patient-level central vein sign biomarker, ψ_i. The method is probabilistic in nature, allows site-specific lesion segmentation methods, and is potentially robust to intersite variability. The proposed algorithm was tested on imaging acquired at the University of Vermont in 16 participants who have MS and 15 participants who do not.

RESULTS

By means of the proposed automated technique, participants with MS were found to have significantly higher values of ψ than those without MS (ψ_MS = 0.55 ± 0.18; ψ_non-MS = 0.31 ± 0.12; P < .001). The algorithm was also found to show strong discriminative ability between patients with and without MS, with an area under the curve of 0.88.

CONCLUSIONS

The current study presents the first fully automated method for detecting the central vein sign in white matter lesions and demonstrates promising performance in a sample of patients with and without MS.

Role of the C-terminal basic amino acids and the lipid anchor of the Gγ2 protein in membrane interactions and cell localization

Heterotrimeric G proteins are peripheral membrane proteins that frequently localize to the plasma membrane where their presence in molar excess over G protein coupled receptors permits signal amplification. Their distribution is regulated by protein-lipid interactions, which has a clear influence on their activity. Gβγ dimer drives the interaction between G protein heterotrimers with cell membranes. We focused our study on the role of the C-terminal region of the Gγ₂ protein in G protein interactions with cell membranes. The Gγ₂ subunit is modified at cysteine (Cys) 68 by the addition of an isoprenyl lipid, which is followed by the proteolytic removal of the last three residues that leaves an isoprenylated and carboxyl methylated Cys-68 as the terminal amino acid. The role of Cys isoprenylation of the CAAX box has been defined for other proteins, yet the importance of proteolysis and carboxyl methylation of isoprenylated proteins is less clear. Here, we showed that not only geranylgeranylation but also proteolysis and carboxyl methylation are essential for the correct localization of Gγ₂ in the plasma membrane. Moreover, we showed the importance of electrostatic interactions between the inner leaflet of the plasma membrane and the positively charged C-terminal domain of the Gγ₂ subunit (amino acids Arg-62, Lys-64 and Lys-65) as a second signal to reach the plasma membrane. Indeed, single or multiple point mutations at Gγ₂ C-terminal amino acids have a significant effect on Gγ₂ protein-plasma membrane interactions and its localization to charged Ld (liquid disordered) membrane microdomains. This article is part of a Special Issue entitled: Membrane Lipid Therapy: Drugs Targeting Biomembranes edited by Pablo V. Escribá.

Optimized Protocol To Analyze Changes in the Lipidome of Xenografts after Treatment with 2-Hydroxyoleic Acid

Xenografts are a popular model for the study of the action of new antitumor drugs. However, xenografts are highly heterogeneous structures, and therefore it is sometimes difficult to evaluate the effects of the compounds on tumor metabolism. In this context, imaging mass spectrometry (IMS) may yield the required information, due to its inherent characteristics of sensitivity and spatial resolution. To the best of our knowledge, there is still no clear analysis protocol to properly evaluate the changes between samples due to the treatment. Here we present a protocol for the evaluation of the effect of 2-hydroxyoleic acid (2-OHOA), an antitumor compound, on xenografts lipidome based on IMS. Direct treated/control comparison did not show conclusive results. As we will demonstrate, a more sophisticated protocol was required to evaluate these changes including the following: (1) identification of different areas in the xenograft, (2) classification of these areas (necrotic/viable) to compare similar types of tissues, (3) suppression of the effect of the variation of adduct formation between samples, and (4) normalization of the variables using the standard deviation to eliminate the excessive impact of the stronger peaks in the statistical analysis. In this way, the 36 lipid species that experienced the largest changes between treated and control were identified. Furthermore, incorporation of 2-hydroxyoleic acid to a sphinganine base was also confirmed by MS/MS. Comparison of the changes observed here with previous results obtained with different techniques demonstrates the validity of the protocol.

Recommendations for enhancing psychosocial support of NICU parents through staff education and support

Providing psychosocial support to parents whose infants are hospitalized in the neonatal intensive care unit (NICU) can improve parents' functioning as well as their relationships with their babies. Yet, few NICUs offer staff education that teaches optimal methods of communication with parents in distress. Limited staff education in how to best provide psychosocial support to families is one factor that may render those who work in the NICU at risk for burnout, compassion fatigue and secondary traumatic stress syndrome. Staff who develop burnout may have further reduced ability to provide effective support to parents and babies. Recommendations for providing NICU staff with education and support are discussed. The goal is to deliver care that exemplifies the belief that providing psychosocial care and support to the family is equal in importance to providing medical care and developmental support to the baby.

Content validity of the Benign Prostatic Hyperplasia Impact Index (BII); a measure of how urinary trouble and problems associated with BPH may impact the patient

AIMS

The objective of this qualitative interview study was to assess the content validity of the Benign Prostatic Hyperplasia Impact Index (BII) in a sample of men with signs and symptoms of Benign Prostatic Obstruction believed to be caused by benign prostatic hyperplasia (BPH lower urinary tract symptoms/BPH-LUTS) using concept elicitation (CE) and cognitive interviewing (CI) methods.

METHODS

Fifty men with BPH-LUTS participated in the study; 27 completed CE interviews and 23 completed cognitive interviews.

RESULTS

Patient's average age was 69 years with a mean duration of BPH-LUTS of 6.5 years. IPSS scores ranged from 8 to 33 (higher scores indicating greater symptom severity). Overall, the most frequent symptoms (prevalence of ≥ 75%) reported spontaneously or after further explanation were awakening from sleep, increased daytime voiding (frequency), urgent desire to void (urgency), slow stream, and feeling of incomplete bladder emptying. Symptoms primarily recognized in response to follow up probe questions with a prevalence of ≥ 40% included terminal dribble, splitting of urinary stream, intermittent stream, straining and post-micturition dribble. Especially bothersome [> 5 on the numerical rating scale (NRS) of 0-10] and frequent symptoms included urgency and awakening at night to void. Discomfort or pain while urinating and post-micturition dribble were equally bothersome though less frequent. Five BPH symptom-related impact themes were identified: coping, daily responsibilities, emotion, lifestyle and relationships, and sleep.

CONCLUSIONS

The BII was found to be easily understood, does capture clinically relevant BPH impacts related to urinary trouble and problems, and does capture most of the important symptom-related impacts as described by participants in this study.

Normalization of sphingomyelin levels by 2-hydroxyoleic acid induces autophagic cell death of SF767 cancer cells

The very high mortality rate of gliomas reflects the unmet therapeutic need associated with this type of brain tumor. We have discovered that the plasma membrane fulfills a critical role in the propagation of tumorigenic signals, whereby changes in membrane lipid content can either activate or silence relevant pathways. We have designed a synthetic fatty acid, 2-hydroxyoleic acid (2OHOA), that specifically activates sphingomyelin synthase (SGMS), thereby modifying the lipid content of cancer cell membranes and restoring lipid levels to those found in normal cells. In reverting, the structure of the membrane by activating SGMS, 2OHOA inhibits the RAS-MAPK pathway, which in turn fails to activate the CCND (Cyclin D)-CDK4/CDK6 and PI3K-AKT1 pathways. The overall result in SF767 cancer cells, a line that is resistant to apoptosis, is the sequential induction of cell cycle arrest, cell differentiation and autophagy. Such effects are not observed in normal cells (MRC-5) and thus, this specific activation of programmed cell death infers greater efficacy and lower toxicity to 2OHOA than that associated with temozolomide (TMZ), the reference drug for the treatment of glioma.

The role of flumazenil in outpatient transesophageal echocardiography

BACKGROUND

Benzodiazepines used for transesophageal echocardiography (TEE) sedation may be associated with postprocedural psychomotor effects that are undesirable.

HYPOTHESIS

We hypothesize that flumazenil can reverse cognitive and motor effects from benzodiazepine, promoting earlier return to baseline function.

METHODS

We prospectively evaluated the cognitive and motor function of patients who did or did not receive flumazenil following TEE. Patients' gait, level of drowsiness, and recall of items learned before and after benzodiazepine administration were evaluated before TEE, as well as immediately and 30 min after the procedure.

RESULTS

Of 207 patients (123 men and 84 women), 93 (45%) were given flumazenil 0.2 or 0.4 mg intravenously, and 113 (55%) were not. The baseline characteristics of the patients who received flumazenil were not significantly different from those who did not receive flumazenil, with the exception of a higher mean dosage of midazolam administered to the flumazenil group. In addition, patients in the flumazenil group appeared more drowsy immediately following TEE. When adjusted for age and midazolam dosage, there were no differences, at any time, between the two groups in gait or recall of items learned prior to sedation. however, at 30 min following TEE, the flumazenil group was able to recall a larger number of new items learned immediately after the procedure (1.92/3 vs. 1.61/3, p = 0.02) than did patients in the group not receiving flumazenil. No adverse effects were encountered in any patient.

CONCLUSION

Flumazenil appears safe and effective in reversing anterograde amnesic effects of benzodiazepine following TEE, but has no effects on retrograde amnesia and does not promote earlier return of motor function to baseline. It is useful in clinical situations where high dosages of benzodiazepine have been used and/or excessive drowsiness is evident following TEE. Routine use of the drug, however, is not necessary.

Expression of a lipid transfer protein in Escherichia coli and its phosphorylation by a membrane-bound calcium-dependent protein kinase

Ha-AP10 is a basic antifungal peptide from sunflower seeds (Helianthus annuus antifungal peptide of 10 kDa) belonging to the family of plant lipid transfer proteins. We report here its expression in E. coli [Glutathione S-transferase (GST) system] and its phosphorylation by endogenous membrane-bound calcium-dependent protein kinases.

Mineral metabolism influences pulse pressure increase provoked by chronic kidney disease

BACKGROUND

Pulse pressure (PP) increase has been associated with hypertension, ageing and chronic kidney disease. Although hyperparathyroidism and phosphate imbalance have been suspect in PP increase in hemodialysis patients, the link between these parameters and pulse pressure, in renal disease before dialysis, has not been established.

METHODS AND PATIENTS

1966 chronic kidney disease (CKD) patients.

STATISTICS

ANOVA, Student's t-and Chi-square, rank correlations (Spearman) and multivariate analysis, with PP as the dependent variable, while adjusting for other covariables.

RESULTS

There was an increase of pulse pressure parallel to renal function deterioration, and a significant influence of age, diabetes, hypertension, phosphate and PTH on pulse pressure in the whole population, as well as in patients with glomerular filtration rate < 60 ml/min. The impact of phosphate was particularly high after the age of 50.

CONCLUSION

PP increase present in renal disease patients might be primarily due to the underlying mineral metabolism disturbances.

Reported symptoms and quality-of-life impacts in patients having laser treatment for sight-threatening diabetic retinopathy

AIMS

To explore the patient experience of symptoms of eye disease related to diabetes and its treatment, including increase of symptoms over time and their relation to severity of the condition and the effect of multiple treatments and symptoms on quality of life.

METHODS

A qualitative interview study was implemented at four eye clinics in the UK. This study design was intended to yield 240 interviews in patients having their first laser treatment or first follow-up and in multi-treatment patients with a clinically documented loss of visual function in at least one eye (VA </= 6/12). The intention was to have an approximately equal number of patients with proliferative diabetic retinopathy (PDR) or macular oedema (MO).

RESULTS

A total of 227 interviews were completed (54% PDR and 46% MO). The most frequently reported symptom prior to initial treatment was blurred vision (55%). First-time-treatment patients reported fewer symptoms than the multi-treatment patients. After a pronounced reduction of quality-of-life impacts after the first laser treatment, results all demonstrate an increasing impact as patients move from first treatment to multiple treatments. The main responses regarding satisfaction with laser treatment were that, although patient expectations were basically met, the treatment had less of an impact than they hoped for, and they would have the treatment again if needed.

CONCLUSIONS

The current study provides a qualitative exploration of visual symptoms, levels of self-reported visual impairment, and general description of the areas of impact or restriction that patients experienced due to their eye disease, both pre- and post-laser treatment.

DEVELOPMENT OF A MULTIREGIONAL UNITED STATES SPANISH VERSION OF THE INTERNATIONAL PROSTATE SYMPTOM SCORE AND THE BENIGN PROSTATIC HYPERPLASIA IMPACT INDEX

PURPOSE

The International Prostate Symptom Score (I-PSS) and Benign Prostatic Hyperplasia Impact Index (BII) have gained widespread use in clinical practice and clinical trials. Although Spanish translations of the I-PSS are available, to our knowledge none was developed for the Spanish speaking population in the United States using a methodology to ensure appropriateness for the diverse United States Spanish speaking population. An existing translation intended for another Spanish speaking country, such as Mexico, or a translation developed without input from each language group may not be understood by those who immigrated from other Latin American regions. Hence, the development of a Spanish translation for the United States should involve input from translators from each region of Latin America.

MATERIALS AND METHODS

We reviewed and modified an existing United States Spanish translation of I-PSS using a multiregional reconciliation panel comprised of representatives from each of the major Spanish language groups in the United States. For BII full translation methodology was used to develop a translation for the United States, including 2 forward translations using translators from more than 1 region, a multiregional reconciliation panel meeting, a back translation evaluation, cognitive debriefing interviews with representatives from each language group, developer review, a final evaluation for consistency and proofreading.

RESULTS

The revised I-PSS better reflects common Spanish wording in the United States, while the BII translation was confirmed to be comprehended by Spanish speakers in the United States originating from multiple regions of Latin America.

CONCLUSIONS

United States Spanish translations of patient reported outcome measures should consider the diversity of the growing Spanish speaking population in the United States to ensure comprehension across the broad population originating from the multiple regions of Latin America.

Electronic versus paper questionnaires: a further comparison in persons with asthma

The use of electronic data capture (EDC) to assess health-related quality of life (HRQOL) using validated questionnaires is increasing; however, it must be determined how data collected electronically correlate with the original mode of administration used in validation. Our objective was to compare paper and electronic administration of the standardized Asthma Quality of Life Questionnaire (AQLQ(S)), Pediatric Asthma Quality of Life Questionnaire (PAQLQ(S)), and Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ). Using a crossover design, adults and children with asthma and caregivers of children with asthma were recruited from clinics. Subjects were asked to complete both forms of the appropriate HRQOL measures at enrollment and 24-48 hours later. In addition, 30 subjects from each group were asked to participate in a 1-week reproducibility assessment of the electronic versions of the three questionnaires. Psychometric properties were assessed for each of the EDC versions. Intraclass correlation coefficients (ICC) and Pearson correlations were calculated to compare EDC and paper versions. A total of 51 adults (mean age 37, 73% females), 52 children (mean age 13, 38% females), and 51 caregivers (mean age 43, 92% females) were evaluated. Internal consistency (Cronbach's alpha) for the overall score of each questionnaire was: 0.96 for the AQLQ(S) and the PAQLQ(S), and 0.92 for the PACQLQ. Overall ICCs comparing paper with EDC were: 0.96 for the AQLQ(S), 0.91 for the PAQLQ(S), and 0.82 for the PACQLQ. Pearson's correlations were identical. One-week reproducibility (ICC) of the EDC versions was: 0.88 for the AQLQ(S), 0.78 for the PAQLQ(S), and 0.85 for the PACQLQ. When asked which method subjects preferred, the electronic version was chosen by 69% of adults, 77% of children, and 73% of caregivers. Additionally, 14% of adults, 14% of children, and 18% of caregivers reported no difference in preference. As in previous studies comparing electronic with paper questionnaires, this study revealed statistical evidence to support the use of EDC of the AQLQ(S), PAQLQ(S), and PACQLQ for populations with asthma.

Longitudinal investigation of depression outcomes in primary care in six countries: the LIDO study. Functional status, health service use and treatment of people with depressive symptoms

BACKGROUND

Screening surveys of depressive symptoms were conducted among primary care patients at six sites in different countries. The LIDO Study was designed to assess quality of life and economic correlates of depression and its treatment in culturally diverse primary health care settings. This paper describes: (1) the association between depressive symptoms and functional status, global health-related quality of life (QoL), and use of general health services across different cultural settings; and (2) among subjects with depressive symptoms, the factors associated with recent treatment for depression.

METHODS

Subjects aged 18 to 75 were recruited from participating primary care facilities in Be'er Sheva (Israel), Porto Alegre (Brazil), Melbourne (Australia), Barcelona (Spain), St Petersburg (Russian Federation) and Seattle (USA). Depressive symptoms were measured using the CES-D. Also administered were the SF-12, global questions on QoL, selected demographic and social measures, and questions on recent treatment for depression, use of health care services, and lost workdays.

RESULTS

A total of 18,489 patients were screened, of whom 37% overall (range 24-55%) scored > or = 16 on the CES-D and 28% (range 17-42%) scored > or = 20. Overall, 13% reported current treatment for depression (range 4 to 23%). Patients with higher depressive symptom scores had worse health, functional status, QoL, and greater use of health services across all sites. Among those with a CES-D score > or = 16, subjects reporting treatment for depression were more likely than those reporting no treatment to be dissatisfied with their health (except in St Petersburg), and to have higher depressive symptom scores.

CONCLUSIONS

Higher depressive symptom scores in primary care patients were consistently associated with poorer health, functional status and QoL, and increased health care use, but not with demographic variables. The likelihood of treatment for depression was associated with perceptions of health, as well as severity of the depression.

Activities of daily living in the Spanish elderly. Association with mortality

The ability to manage basic activities of daily living (ADL) is a significant predictor for being housebound, placement in a nursing home and death. The aim of the study was to assess the capacity to perform activities of daily living in the Spanish sample (30 men and 49 women aged 80-85 y) from SENECA's Finale study (1999) and changes respect to the same sample ten years ago. The total ADL score (assessed by 16 questions) and the partials (mobility ADLm and self-care ADLc) show that the total ADL average in 1999 has been 23.9+/-10.2 (p<0.05) and 25.3+/-9.6 (p<0.001), being in 1989, 18.8+/-4.4 and 19.9+/-4.8 for men and women respectively. The ADL score from deceased subjects participating in 1989 was significantly worse (p<0.01 in men and p<0.001 in women) than ADL score from survivor subjects. Activities of daily living as a measurement of functionality decline with increasing age and in our study a better ADL score was found as survival factor.

Bone strength and related traits in HcB/Dem recombinant congenic mice

Fracture susceptibility depends jointly on bone mineral content (BMC), gross bone anatomy, and bone microarchitecture and quality. Overall, it has been estimated that 50-70% of bone strength is determined genetically. Because of the difficulty of performing studies of the genetics of bone strength in humans, we have used the HcB/Dem series of recombinant congenic (RC) mice to investigate this phenotype. We performed a comprehensive phenotypic analysis of the HcB/Dem strains including morphological analysis of long bones, measurement of ash percentage, and biomechanical testing. Body mass, ash percentage, and moment of inertia each correlated moderately but imperfectly with biomechanical performance. Several chromosome regions, on chromosomes 1, 2, 8, 10, 11, and 12, show sufficient evidence of linkage to warrant closer examination in further crosses. These studies support the view that mineral content, diaphyseal diameter, and additional nonmineral material properties contributing to overall bone strength are controlled by distinct sets of genes. Moreover, the mapping data are consistent with the existence of pleiotropic loci for bone strength-related phenotypes. These findings show the importance of factors other than mineral content in determining skeletal performance and that these factors can be dissected genetically.

Treatment of type II endoleaks with Onyx

Endoleaks are defined as persistent perfusion of an abdominal aortic aneurysm (AAA) after endovascular stent-graft deployment. The authors describe their experience treating six endoleaks with the liquid embolic agent Onyx (ethylene-vinyl-alcohol copolymer). Complete endoleak occlusion was achieved in five of six cases. Follow-up imaging has demonstrated decreased aneurysm diameter in all patients 7-29 weeks (mean = 19.2 weeks) after treatment.

Cause of ST segment abnormality in ED chest pain patients

The objective of this study was to determine the electrocardiographic diagnoses of chest pain patients with ST segment elevation (STE) on the 12-lead electrocardiogram (ECG). This study was a retrospective ECG review of adult chest pain patients in a university hospital emergency department (ED) over a 3-month period (January 1, 1996 to March 31, 1996). STE was determined if the ST segment was elevated >/=1 mm in the limb leads and >/=2 mm in the precordial leads in at least two anatomically contiguous leads. Results showed 902 patients who met entry criteria and of whom 202 (22.4%) had STE. Thirty-one (15%) patients had STE acute myocardial infarction (AMI) as the final hospital diagnosis which caused the STE; 171 (85%) patients with STE had non-AMI diagnosis responsible for the ST segment elevation, including left ventricular hypertrophy (LVH) 51 (25%), left bundle branch block (LBBB) 31 (15%), benign early repolarization (BER) 25 (12%), right bundle branch block 10 (5%), nonspecific bundle branch block 10 (5%), left ventricular aneurysm 5 (3%), acute pericarditis 2 (1%), ventricular paced rhythm 2 (1%), and undefined ST segment elevation 35 (17%). Forty-four patients had AMI as the final diagnosis of whom 31 showed STE on presentation to the ED. In 2 of 31 (6%) cases of STE AMI, the ST segment waveform was atypical for acute infarction. We concluded that AMI is not the most common cause of STE in ED chest pain patients. LVH is most often responsible for electrocardiographic STE followed by AMI and LBBB which occur at equal frequencies.

A comparison of 12- and 15-lead ECGS in ED chest pain patients: impact on diagnosis, therapy, and disposition

The objective of this study was to investigate the diagnostic and therapeutic impact of the 15-lead electrocardiogram (15ECG) on the emergency department (ED) management of chest pain (CP) patients. The design was prospective use of 15ECG with real-time physician survey and retrospective comparison to 12-lead ECG (12ECG). The study took place in a University hospital ED. Adult CP patients participated. During the 15ECG period (June 1996 to July 1996), 595 patients (92% of CP patients) had 15ECG analysis. Diagnoses of acute coronary ischemic syndromes (ACIS) were as follows: 13 acute myocardial infarction (AMI, 7 anterior [ANT], 5 inferior [INF], 1 lateral [LAT], 2 posterior [POST], 1 right ventricular [RV]) and 136 unstable angina (USA) with 47% exhibiting ECG abnormality; the 2 POST and 1 RV AMI occurred in the setting of coexisting INF AMI. The following management strategies were used: 6 fibrinolytic therapy (TT), 4 primary angioplasty (PTCA), 67 rule-out myocardial infarction (ROMI), and 144 admission to critical care unit (CCU). During the 12ECG period (June 1995 to July 1995), 599 patients were encountered. The diagnoses of ACIS were as follows: 11 AMI (5 ANT, 4 INF, 2 LAT) and 146 USA with 51% exhibiting ECG abnormality (P = NS for diagnostic comparisons to 15ECG). The following management strategies were used: 5 TT, 5 PTCA, 59 ROMI, and 137 admission to CCU (P = NS for all treatment comparisons to 15ECG). Of 15ECG cases 81% had completed real-time physician survey, showing that the diagnosis and management ACIS were not altered by the 15ECG; physicians felt, however, that the 15ECG provided a more complete anatomic picture of the ACIS. No false-positive cases of additional lead STE were noted in this investigation except in cases involving abnormal intraventricular conduction such as the bundle branch block scenario. The 15ECG provided a more complete description of myocardial injury without altering the ED diagnosis, ED-based therapy, or hospital disposition in adult CP patients. Further study is required to identify patient subset(s) which may benefit from the 15ECG.

A global inventory of hospitals using powder-free gloves: a search for principled medical leadership

Scientific experimental and clinical studies have demonstrated that cornstarch on surgical and examination gloves promotes disease by acting as a reactive foreign body in tissue and serving as a vector for latex allergy. Consequently, hospitals have selected an innovative glove selection program utilizing only powder-free gloves. Healthcare workers in emergency medical systems are now wearing powder-free, latex-free gloves to care for the growing number of patients sensitized to latex. A global Internet search has now identified 70 hospitals in the United States and three hospitals in Europe that use only powder-free gloves.

Cultural adaptation of a quality-of-life measure for urinary incontinence

OBJECTIVES

To translate and validate a urinary incontinence-specific measure of quality of life (I-QOL) in French, Spanish, Swedish, and German and provide translations only into seven other languages and variants of these languages.

METHODS

Quality of life and linguistic experts prepared two forward translations from American English to their native languages and helped to harmonize these translations at a meeting. In the four European countries, the adapted versions of the I-QOL were administered to 259 women with stress, urge, and mixed incontinence. Principal component analyses were used to confirm the proposed measurement model suggested by patient interviews. Psychometric testing was conducted using standardized procedures.

RESULTS

Translation procedures resulted in a change in the original instrument's Likert response scale from 4 to 5 points. Principal component analyses confirmed three patient-derived subscales and higher-order factor analysis confirmed a total summary score. In all countries, the internal consistency (alpha) and reproducibility (ICC) were high (alpha ranged between 0.87 and 0.93); (ICC ranged between 0.92 and 0.95). In all countries, I-QOL scores were significantly worse (p < 0.001) as perceived severity of incontinence, use of services, and number of incontinent episodes increased.

CONCLUSIONS

The I-QOL has been adapted successfully into eleven languages and six variants of these languages. The cross-sectional psychometric properties of the US version were confirmed in four European countries. The I-QOL fills the need for a valid, international quality-of-life instrument for incorporation in clinical trials covering patients with varying types and severity of urinary incontinence.

Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues

The Wolff-Parkinson-White syndrome (WPW), estimated to occur in approximately 0.1% to 3% of the general population, is a form of ventricular preexcitation involving an accessory conduction pathway. The definition of WPW relies on the following electrocardiographic features: (1) a PR interval less than 0.12 seconds (2) with a slurring of the initial segment of the QRS complex, known as a delta wave, (3) a QRS complex widening with a total duration greater than 0.12 seconds, and (4) secondary repolarization changes reflected in ST segment-T wave changes that are generally directed opposite (discordant) to the major delta wave and QRS complex changes. The accessory pathway bypasses the atrioventricular (AV) node, creating a direct electrical connection between the atria and ventricles. The majority of patients with preexcitation syndromes remain asymptomatic throughout their lives. When symptoms do occur they are usually secondary to tachyarrhythmias; the importance of recognizing this syndrome is that these patients may be at risk to develop a variety of supraventricular tachyarrhythmias which cause disabling symptoms and, in the extreme, sudden cardiac death. The tachyarrhythmias encountered in the WPW patient include paroxysmal supraventricular tachycardia (both the narrow QRS and wide QRS complex varieties), atrial fibrillation, atrial flutter, and ventricular fibrillation. Diagnostic and urgent, initial therapeutic issues based on initial electrocardiographic information are presented via 5 illustrative cases.