Baseline levels of circulating galectin-1 associated with radiographic hand but not radiographic knee osteoarthritis at a two-year follow-up

Objective

We tested the potential of circulating galectin-1, interleukin (IL)-1 beta, IL-6, and tumour necrosis factor alpha (TNF alpha) levels at baseline in individuals with knee pain as biomarkers for development of radiographic knee and/or hand osteoarthritis (OA).

Design

This study comprised 212 individuals with knee pain from the Halland osteoarthritis cohort (HALLOA). Clinical characteristics and serum/plasma levels of galectin-1, IL-1 beta, IL-6, and TNF alpha were measured at baseline, and knee and hand radiographs were obtained at a two-year follow-up. The predictive value of circulating inflammatory markers and clinical variables at baseline was assessed using multinominal logistic regression for those who developed radiographic OA in knees only (n ​= ​25), in hands only (n ​= ​40), and in both knees and hands (n ​= ​43); the group who did not develop OA (n ​= ​104) was used as reference. Correlations were assessed using Spearman's correlation coefficients.

Results

As expected, age was identified as a risk factor for having radiographic knee and/or hand OA at the two-year follow-up. Baseline circulating galectin-1 levels did not associate with developing radiographic knee OA but associated with developing radiographic hand OA (odds ratio (OR) for a 20% increased risk: 1.14, 95% confidence interval (CI) 1.01-1.29) and both radiographic knee and hand OA (OR for a 20% increased risk: 1.18, 95% CI 1.05-1.30). However, baseline IL-1 beta, IL-6, and TNF alpha did not associate with developing radiographic knee and/or hand OA.

Conclusion

Non-age adjusted circulating galectin-1 is superior to IL-6, IL-1 beta, and TNF alpha in predicting radiographic hand but not knee OA.

Observation of Seven Astrophysical Tau Neutrino Candidates with IceCube

We report on a measurement of astrophysical tau neutrinos with 9.7 yr of IceCube data. Using convolutional neural networks trained on images derived from simulated events, seven candidate ν_{τ} events were found with visible energies ranging from roughly 20 TeV to 1 PeV and a median expected parent ν_{τ} energy of about 200 TeV. Considering backgrounds from astrophysical and atmospheric neutrinos, and muons from π^{±}/K^{±} decays in atmospheric air showers, we obtain a total estimated background of about 0.5 events, dominated by non-ν_{τ} astrophysical neutrinos. Thus, we rule out the absence of astrophysical ν_{τ} at the 5σ level. The measured astrophysical ν_{τ} flux is consistent with expectations based on previously published IceCube astrophysical neutrino flux measurements and neutrino oscillations.

Correlations Between Department and Training Program Online Presence and Women in Orthopedic Surgery Training

Background

Orthopedic residency programs increasingly use websites and social media to reach students. This accelerated during the COVID-19 pandemic, especially as away rotations became limited. Women remain a minority of orthopedic residents, and there are no data that indicate the correlation between department/program website content or social media presence on the gender diversity of residency classes.

Methods

Orthopedic department websites were assessed between June 2021 and January 2022 to identify program director's gender, as well as the gender composition of the faculty and residents. Instagram presence for the department and/or program was also identified.

Results

There was no correlation found between the residency program director's gender and the gender diversity of residents in a given program. The percentage of women faculty identified on a department website was significantly correlated with the percentage of women residents in the program, regardless of the program director's gender. While there was an increase in the percentage of women residents among programs with Instagram accounts for the class that started in 2021, this was negated when the percentage of women faculty was taken into account.

Conclusion

Efforts on multiple fronts will be needed to increase the number and percentage of women applying for and training in orthopedic surgery. Given the increasing use of digital media, we need a better understanding of what information, including faculty gender diversity, can be conveyed through this format that is useful for women medical students interested in orthopedic surgery to address their concerns about the field.

PDGFRβ promotes oncogenic progression via STAT3/STAT5 hyperactivation in anaplastic large cell lymphoma

BACKGROUND

Anaplastic large cell lymphoma (ALCL) is an aggressive non-Hodgkin T cell lymphoma commonly driven by NPM-ALK. AP-1 transcription factors, cJUN and JUNb, act as downstream effectors of NPM-ALK and transcriptionally regulate PDGFRβ. Blocking PDGFRβ kinase activity with imatinib effectively reduces tumor burden and prolongs survival, although the downstream molecular mechanisms remain elusive.

METHODS AND RESULTS

In a transgenic mouse model that mimics PDGFRβ-driven human ALCL in vivo, we identify PDGFRβ as a driver of aggressive tumor growth. Mechanistically, PDGFRβ induces the pro-survival factor Bcl-xL and the growth-enhancing cytokine IL-10 via STAT5 activation. CRISPR/Cas9 deletion of both STAT5 gene products, STAT5A and STAT5B, results in the significant impairment of cell viability compared to deletion of STAT5A, STAT5B or STAT3 alone. Moreover, combined blockade of STAT3/5 activity with a selective SH2 domain inhibitor, AC-4-130, effectively obstructs tumor development in vivo.

CONCLUSIONS

We therefore propose PDGFRβ as a novel biomarker and introduce PDGFRβ-STAT3/5 signaling as an important axis in aggressive ALCL. Furthermore, we suggest that inhibition of PDGFRβ or STAT3/5 improve existing therapies for both previously untreated and relapsed/refractory ALK+ ALCL patients.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

1115 Sleep Misperception, Anxiety, And Sleep Quality

Introduction

Sleep misperception is a phenomenon often identified in insomnia literature, in which individuals subjective reporting does not match objective measurements of their own sleep. Research indicates that anxiety symptoms may play a role in sleep misperception. This study assessed the relationship between sleep misperception, sleep quality, and anxiety in a young adult population with sub-clinical insomnia and anxiety symptoms. Linear regression models examined the relationships between sleep quality, anxiety symptoms, and sleep misperception.

Methods

This sample consisted of 130 young adults recruited from a University in the Bronx, NY. Anxiety was assessed using the Beck Anxiety Inventory (BAI), and sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Objective measures of sleep were collected via wrist-based actigraphy over a period of 7-14 days. Subjective sleep measures were collected via an online sleep diary. A misperception index was calculated to determine the discrepancy between subjective and objective sleep measures based on a formula established in previous research.

Results

Higher anxiety symptoms were associated with greater sleep disturbance. Higher sleep misperception was not associated with greater sleep disturbance. There was a significant, positive relationship between sleep misperception and anxiety symptoms (r=0.18, p=0.000). Gender emerged as an important covariate, with males exhibiting significantly higher sleep misperception and underestimating TST (M=-0.31, SD=0.22) compared to females (M=-0.18, SD=0.12).

Conclusion

Sleep misperception was not related to sleep quality, but was strongly related to anxiety symptoms in this population. In a sub-clinical young adult sample, sleep misperception is associated with anxiety but not sleep quality, and has significant gender differences. These findings contribute to sleep misperception literature with potential applications in diagnosis and treatment of insomnia and anxiety.

Support

n/a

Dental status in nursing home residents with domiciliary dental care in Sweden

OBJECTIVE

To describe the dental health status of elderly people in nursing homes receiving domiciliary dental care.

DESIGN

Case note review.

CLINICAL SETTING

Nursing homes in 8 Swedish counties.

PARTICIPANTS

Care dependent elderly people (≥65 years).

METHODS

Clinical data, including the number of remaining natural teeth, missing and decayed teeth (manifest dental caries) and root remnants, recorded by dentists according to standard practices. Medical and dental risk assessments were performed.

RESULTS

Data were available for 20,664 patients. Most were women (69.1%), with a mean age of 87.1 years (SD 7.42, range 65-109). The mean age for men was 83.5 years (SD 8.12, range 65-105). Two or more medical conditions were present in most of the population. A total of 16,210 individuals had existing teeth of whom 10,974 (67.7%) had manifest caries. The mean number of teeth with caries was 5.0 (SD 5.93) corresponding to 22.8% of existing teeth. One in four individuals were considered to have a very high risk in at least one professional dental risk assessment category.

CONCLUSIONS

Care dependent elderly in nursing homes have very poor oral health. There is a need to focus on the oral health-related quality of life for this group of frail elderly during their final period of life.

Lessons from a Broad-based ACA Outreach Effort: Promises and Pitfalls

The Marketplace Coverage Initiative (MCI) sought to expand awareness and ACA Marketplace enrollment in the greater Kansas City Area. The MCI was evaluated through interviews, surveys, and focus groups. Two main findings are particularly relevant for future Marketplace enrollment efforts. First, the link between contacting someone and actual enrollment is tenuous as follow-up is challenging. Outreach efforts that only track contacts, such as appointments and email addresses, lack information needed to assess enrollment. Linking outreach activities to enrollment outcomes leads us to a dramatically different conclusion about using big data and campaign-style tactics than evaluations of similar techniques such as that pioneered by Enroll America in 11 states. Second, there is a large chasm between the knowledge levels of the uninsured and the decisions they face on the Marketplace. Based on these findings, outreach efforts were redesigned for the 2014 open enrollment period to focus on smaller, community-driven projects.

Water-Soluble Coenzyme Q10 Reduces Rotenone-Induced Mitochondrial Fission

Parkinson's disease is a neurodegenerative disorder characterized by mitochondrial dysfunction and oxidative stress. It is usually accompanied by an imbalance in mitochondrial dynamics and changes in mitochondrial morphology that are associated with impaired function. The objectives of this study were to identify the effects of rotenone, a drug known to mimic the pathophysiology of Parkinson's disease, on mitochondrial dynamics. Additionally, this study explored the protective effects of water-soluble Coenzyme Q10 (CoQ10) against rotenone-induced cytotoxicity in murine neuronal HT22 cells. Our results demonstrate that rotenone elevates protein expression of mitochondrial fission markers, Drp1 and Fis1, and causes an increase in mitochondrial fragmentation as evidenced through mitochondrial staining and morphological analysis. Water-soluble CoQ10 prevented mitochondrial dynamic imbalance by reducing Drp1 and Fis1 protein expression to pre-rotenone levels, as well as reducing rotenone treatment-associated mitochondrial fragmentation. Hence, water-soluble CoQ10 may have therapeutic potential in treating patients with Parkinson's disease.

Complications and Their Resolution in Recipients of Deceased and Living Donor Liver Transplants: Findings From the A2ALL Cohort Study

The purpose of this study was to explore long-term complications in recipients of deceased donor liver transplant (DDLT) and living donor liver transplant (LDLT) in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). We analyzed 471 DDLTs and 565 LDLTs from 1998 to 2010 that were followed up to 10 years for 36 categories of complications. Probabilities of complications and their resolutions were estimated using the Kaplan-Meier method, and predictors were tested in Cox proportional hazards models. Median follow-up for DDLT and LDLT was 4.19 and 4.80 years, respectively. DDLT recipients were more likely to have hepatocellular carcinoma and higher disease severity, including Model for End-Stage Liver Disease score. Complications occurring with higher probability in LDLT included biliary-related complications and hepatic artery thrombosis. In DDLT, ascites, intra-abdominal bleeding, cardiac complications and pulmonary edema were significantly more probable. Development of chronic kidney disease stage 4 or 5 was less likely in LDLT recipients (hazard ratio [HR] 0.41, p = 0.02). DDLT and LDLT had similar risk of grade 4 complications (HR 0.89, p = 0.60), adjusted for other risk factors. Once a complication occurred, the time to resolution did not differ between LDLT and DDLT. Future efforts should be directed toward reducing the occurrence of complications after liver transplantation.

Patient safety in domiciliary dental care for elderly nursing home residents in Sweden

OBJECTIVE

To analyse patient safety in domiciliary dental care, with data from a quality registry.

DESIGN

Retrospective analysis.

CLINICAL SETTING

Domiciliary dental care, private caregiver, Sweden, 2012-2014.

METHODS

All reported events in the quality registry at a provider of domiciliary dental care, (2012-05-01 to 2014-06-30) were categorized into 14 domains, and for severity as 'minor', 'moderate', or 'serious' events. The reported events were also independently assessed by an experienced reviewer for national requirements of reporting patient safety related events.

RESULTS

The quality registry covered 724 (0.03%) reported events during 218,586 consecutive treatment sessions in domiciliary dental care, including 628,070 registered dental procedures. Fifty (6.9%) of the reported events were patient safety related, of which 11 (1.5%) events were reportedly of minor severity, 20 (2.8%) as moderate, and 19 (2.6%) as serious. For all degrees of severity, the most frequently reported events were related to problems with patient identity control (3.3%). None of the events required reporting to national authorities.

CONCLUSIONS

Domiciliary dental care has a low frequency of patient safety related events (0.03% of all treatments). Identity controls need to be emphasised in nursing homes or where individuals are dependent on the care of others.

Abstract PR05: IRF8 regulates GM-CSF expression in T cells and tumor cells to mediate myeloid-derived suppressor cell differentiation

Myeloid cells are a heterogenous and abundant population of haematopoietic cells that are virtually present in all mammalian tissues, where they monitor local microenvironment to maintain homeostasis. All myeloid cells originate from the pluripotent hematopoietic stem cells that undergo progressive restriction in their lineage potential to give rise to mature granulocytes and macrophages. Lineage restriction and differentiation are regulated by timely activation of specific set of lineage-specific transcription factors in concert with down-regulation of other set(s) of transcription factors that are important for alternative cell lineage potential. Altered expression of these lineage-specific transcription factors often leads to deregulation of myelopoiesis and resultant hematopoietic disorders. Therefore, lineage-specific transcription factors are essential for myeloid cell lineage differentiation and maturation. Mice with a null mutation of irf8, the gene that encodes IFN regulatory factor 8 (IRF8), exhibit massive accumulation of CD11b+Gr1+ immature myeloid cells (IMCs). Therefore, IRF8 is a myeloid cell lineage-specific transcription factor that plays an essential function in the regulation of myelopoiesis. Particularly, IRF8 may determine differentiation, lineage commitment, and immune function of monocytes versus granulocytes under physiological conditions.

A hallmark of cancer-bearing mice is the accumulation of CD11b+Gr1+ myeloid-derived suppressor cells (MDSCs). Interestingly, IRF8 is silenced in MDSCs from tumor-bearing mice. Therefore, IRF8 is apparently a key transcription factor that mediates MDSC differentiation. However, the molecular mechanism underlying IRF8 regulation of MDSCs is largely unknown. Because MDSCs is induced by inflammation, we therefore hypothesized that IRF8 may repress the expression of proinflammatory factors to mediate differentiation of MDSCs/IMCs under physiological and pathological conditions. To test this hypothesis, we made use of conventional IRF8 KO mice, mice with IRF8 deficiency only in myeloid cells, mice with IRF8 deficiency only in T cells, and tumor-bearing mouse models. Here we report an intriguing finding that although IRF8 conventional mice exhibit deregulated myeloid cell differentiation and resultant accumulation of CD11b+Gr1+ IMCs, surprisingly, mice with IRF8 deficiency only in myeloid cells exhibit normal myeloid cell lineage differentiation. Instead, mice with IRF8 deficiency only in T cells exhibited deregulated myeloid cell differentiation and IMC accumulation. We further demonstrated that IRF8-deficient T cells exhibit elevated GM-CSF expression and secretion. Treatment of mice with GM-CSF increased IMC accumulation, and adoptive transfer of IRF8-deficient T cells, but not GM-CSF-deficient T cells, increased IMC accumulation in the recipient chimera mice. Moreover, overexpression of IRF8 decreased GM-CSF expression in T cells. These data thus determine that IRF8 functions in T cells to repress GM-CSF expression to suppress IMCs. However, in tumor-bearing mice, IRF8 is silenced in MDSCs but not in T cells, suggesting a different mechanism of MDSC regulation by IRF8. We observed that silencing IRF8 using IRF8-specific siRNA dramatically increase GM-CSF expression in tumor cells. Therefore, IRF8 represses GM-CSF expression in tumor cells to mediate MDSC differentiation. In summary, we determine that IRF8 regulates GM-CSF expression in T cells and tumor cells, respectively, to mediate myelopoiesis under physiological and pathological conditions.

This abstract is also presented as Poster A84.

Citation Format: Amy Paschall, Ruihua Zhang, Kankana Bardhan, Chen-Feng Qi, Liang Peng, Geming Lu, Jianjun Yang, Miriam Merad, Mary Zimmerman, Tracy McGaha, Gang Zhou, Andrew Mellor, Scott I. Abrams, Herbert Morse, Keiko Ozato, Huabao Xiong, Kebin Liu. IRF8 regulates GM-CSF expression in T cells and tumor cells to mediate myeloid-derived suppressor cell differentiation. [abstract]. In: Proceedings of the AACR Special Conference: Tumor Immunology and Immunotherapy: A New Chapter; December 1-4, 2014; Orlando, FL. Philadelphia (PA): AACR; Cancer Immunol Res 2015;3(10 Suppl):Abstract nr PR05.

Abstract A84: IRF8 regulates GM-CSF expression in T cells and tumor cells to mediate myeloid-derived suppressor cell differentiation

This abstract is being presented as a short talk in the scientific program. A full abstract is printed in the Proffered Abstracts section (PR05) of the Conference Proceedings.

Citation Format: Amy Paschall, Ruihua Zhang, Kankana Bardhan, Chen-Feng Qi, Liang Peng, Geming Lu, Jianjun Yang, Miriam Merad, Mary Zimmerman, Tracy McGaha, Gang Zhou, Andrew Mellor, Scott I. Abrams, Herbert Morse, Keiko Ozato, Huabao Xiong, Kebin Liu. IRF8 regulates GM-CSF expression in T cells and tumor cells to mediate myeloid-derived suppressor cell differentiation. [abstract]. In: Proceedings of the AACR Special Conference: Tumor Immunology and Immunotherapy: A New Chapter; December 1-4, 2014; Orlando, FL. Philadelphia (PA): AACR; Cancer Immunol Res 2015;3(10 Suppl):Abstract nr A84.

Health economic analyses of domiciliary dental care and care at fixed clinics for elderly nursing home residents in Sweden

OBJECTIVES

Dental care for elderly nursing home residents is traditionally provided at fixed dental clinics, but domiciliary dental care is an emerging alternative. Longer life expectancy accompanied with increased morbidity, and hospitalisation or dependence on the care of others will contribute to a risk for rapid deterioration of oral health so alternative methods for delivering oral health care to vulnerable individuals for whom access to fixed dental clinics is an obstacle should be considered. The aim was to analyse health economic consequences of domiciliary dental care for elderly nursing home residents in Sweden, compared to dentistry at a fixed clinic.

METHODS

A review of relevant literature was undertaken complemented by interviews with nursing home staff, officials at county councils, and academic experts in geriatric dentistry. Domiciliary dental care and fixed clinic care were compared in cost analyses and cost-effectiveness analyses.

RESULTS

The mean societal cost of domiciliary dental care for elderly nursing home residents was lower than dental care at a fixed clinic, and it was also considered cost-effective. Lower cost of dental care at a fixed dental clinic was only achieved in a scenario where dental care could not be completed in a domiciliary setting.

CONCLUSIONS

Domiciliary dental care for elderly nursing home residents has a lower societal cost and is cost-effective compared to dental care at fixed clinics. To meet current and predicted need for oral health care in the ageing population alternative methods to deliver dental care should be available.

Abstract 2756: Ceramide analog targets xIAP and cIAP1 to sensitize metastatic colon carcinoma cells to apoptosis induction to suppress tumor progression

Sphingolipids are bioeffectors that mediate various cellular processes. We aimed to identify molecular targets of ceramide in the apoptosis pathway and to determine the efficacy of a ceramide analog in overcoming cancer cell resistance to apoptosis induction. We observed that exposure of human colon carcinoma cells to ceramide analog LCL85 results in apoptosis in a dose-dependent manner. Interestingly, a sublethal dose of LCL85 increased C16 ceramide content and overcame tumor cell resistance to FasL-induced apoptosis. Subsequently, treatment of tumor cells with exogenous C16 ceramide resulted in increased tumor cell sensitivity to FasL-induced apoptosis. LCL85 resembles Smac mimetic in sensitization of colon carcinoma cells to FasL-induced apoptosis by inducing proteasomal degradation of cIAP1 and xIAP proteins. Consistent with its apoptosis sensitization activity, LCL85 suppressed colon carcinoma cell metastatic potential in an experimental colon carcinoma lung metastasis mouse model. Taken together, we determined that a sublethal dose of LCL85 is effective as a sensitizer in overcoming apoptosis resistance of metastatic human colon carcinoma cells, and LCL85 is effective in suppressing tumor metastasis in vivo.

Citation Format: Amy Paschall, Mary Zimmerman, Christina Torres, Dafeng Yang, May Chen, Xia Li, Erhard Bieberich, Aiping Bai, Jacek Bielawski, Alicja Bielawska, Kebin Liu. Ceramide analog targets xIAP and cIAP1 to sensitize metastatic colon carcinoma cells to apoptosis induction to suppress tumor progression. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2756. doi:10.1158/1538-7445.AM2014-2756

Abstract 4888: Decitabine and vorinostat cooperate to sensitize metastatic human colon carcinoma cells to Fas-mediated apoptosis

The death receptor Fas and its physiological ligand, FasL, which is expressed on the surface of cytotoxic T-cells (CTLs), regulate apoptosis of cancerous cells. While normal colon epithelial cells express high levels of Fas, Fas expression is diminished in colon carcinomas. Metastatic colon cancers acquire an apopotosis-resistant phenotype often due to the loss of Fas expression and function. Previous studies have implicated Fas-mediated apoptosis as an important contributor of tumor regression. Therefore, targeting Fas resistance is of critical importance in treating colon cancer through Fas-based cancer therapy and immunotherapy. In this study, we explore whether epigenetic pharmacological agents can restore Fas expression and re-establish sensitivity to Fas-mediated apoptosis in metastatic human colon carcinoma cells. First we determined that the epigenetic drugs Decitabine, a DNA methyltransferase inhibitor, and Vorinostat, a HDAC inhibitor, each are capable of up-regulating Fas expression. When combined, these two inhibitors cooperate to increase Fas expression to an even greater extent than each agent alone. Pre-treatment with decitabine, vorinostat, or both drugs followed by incubation with FasL, was able to overcome resistance to FasL-induced apoptosis. Analysis of bisulfite-modified genomic DNA, isolated from human metastatic colon carcinoma cells revealed that the Fas promoter is sporadically methylated; therefore sensitization of Fas receptor expression on the cell surface by decitabine was unlikely through direct inhibition of Fas promoter meythlation. Although the Fas promoter was not heavily methylated, the promoters for BNIP3 and Bik, which are downstream of Fas signaling, were methylated. After treatment with these pharmacological epigenetic inhibitors, alone or in combination, protein levels of both BNIP3 and Bik were increased. Our data suggest that combined modalities of chemotherapy and Fas-based immunotherapy may be an effective approach for the suppression of colon cancer metastasis.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4888. doi:1538-7445.AM2012-4888

Decitabine and vorinostat cooperate to sensitize colon carcinoma cells to Fas ligand-induced apoptosis in vitro and tumor suppression in vivo

The death receptor Fas and its physiological ligand (FasL) regulate apoptosis of cancerous cells, thereby functioning as a critical component of the host cancer immunosurveillance system. To evade Fas-mediated apoptosis, cancer cells often downregulate Fas to acquire an apoptosis-resistant phenotype, which is a hallmark of metastatic human colorectal cancer. Therefore, targeting Fas resistance is of critical importance in Fas-based cancer therapy and immunotherapy. In this study, we demonstrated that epigenetic inhibitors decitabine and vorinostat cooperate to upregulate Fas expression in metastatic human colon carcinoma cells. Decitabine also upregulates BNIP3 and Bik expression, whereas vorinostat decreased Bcl-x(L) expression. Altered expression of Fas, BNIP3, Bik, and Bcl-x(L) resulted in effective sensitization of the metastatic human colon carcinoma cells to FasL-induced apoptosis. Using an experimental metastasis mouse model, we further demonstrated that decitabine and vorinostat cooperate to suppress colon carcinoma metastasis. Analysis of tumor-bearing lung tissues revealed that a large portion of tumor-infiltrating CD8(+) T cells are FasL(+), and decitabine and vorinostat-mediated tumor-suppression efficacy was significantly decreased in Fas(gld) mice compared with wild-type mice, suggesting a critical role for FasL in decitabine and vorinostat-mediated tumor suppression in vivo. Consistent with their function in apoptosis sensitization, decitabine and vorinostat significantly increased the efficacy of CTL adoptive transfer immunotherapy in an experimental metastasis mouse model. Thus, our data suggest that combined modalities of chemotherapy to sensitize the tumor cell to Fas-mediated apoptosis and CTL immunotherapy is an effective approach for the suppression of colon cancer metastasis.

Remote and rural: do mentors enhance the value of distance learning continuing medical education?

CONTEXT

Experts suggest that distance learning continuing medical education (CME) is only effective when there is the opportunity for two-way discussion and reflection. The value of on-line mentoring has been mainly studied in the West.

OBJECTIVES

We examined the benefits and practical implications of providing mentors for distance learning CME in a low technology setting.

METHODS

We conducted a randomized controlled trial with qualitative and quantitative analysis of the impact of mentoring on completion of CME and quality of reflective learning.

RESULTS

Twenty-six of 64 doctors completed all four CME modules. Non-completers were interviewed by telephone. Odds ratio analysis suggested that mentored doctors were three times more likely to complete their CME; however, this did not reach statistical significance (p = 0.07, 95% CI 0.89-10.57). Being in rural practice (p = 0.05) and younger in age (p = 0.005) were significantly associated with completion of CME. Mentored doctors seemed to show a higher quality of reflection on learning. Contact between mentors and mentees was difficult. Both mentors and mentees felt that optimal use of the system was not made.

DISCUSSION

Despite mentors' perceptions that they had little impact, mentored doctors did appear to be more likely to complete CME. Work is needed to increase the quality of interpersonal and educational interaction between mentors and mentees.

Cutting edge: IRF8 regulates Bax transcription in vivo in primary myeloid cells

A prominent phenotype of IRF8 knockout (KO) mice is the uncontrolled expansion of immature myeloid cells. The molecular mechanism underlying this myeloproliferative syndrome is still elusive. In this study, we observed that Bax expression level is low in bone marrow preginitor cells and increases dramatically in primary myeloid cells in wt mice. In contrast, Bax expression level remained at a low level in primarymyeloid cells in IRF8 KO mice. However, in vitro IRF8 KO bone marrow-differentiated myeloid cells expressed Bax at a level as high as that in wild type myeloid cells. Furthermore, we demonstrated that IRF8 specifically binds to the Bax promoter region in primary myeloid cells. Functional analysis indicated that IRF8 deficiency results in increased resistance of the primary myeloid cells to Fas-mediated apoptosis. Our findings show that IRF8 directly regulates Bax transcription in vivo, but not in vitro during myeloid cell lineage differentiation.

IRF8 regulates acid ceramidase expression to mediate apoptosis and suppresses myelogeneous leukemia

IFN regulatory factor 8 (IRF8) is a key transcription factor for myeloid cell differentiation and its expression is frequently lost in hematopoietic cells of human myeloid leukemia patients. IRF8-deficient mice exhibit uncontrolled clonal expansion of undifferentiated myeloid cells that can progress to a fatal blast crisis, thereby resembling human chronic myelogeneous leukemia (CML). Therefore, IRF8 is a myeloid leukemia suppressor. Whereas the understanding of IRF8 function in CML has recently improved, the molecular mechanisms underlying IRF8 function in CML are still largely unknown. In this study, we identified acid ceramidase (A-CDase) as a general transcription target of IRF8. We demonstrated that IRF8 expression is regulated by IRF8 promoter DNA methylation in myeloid leukemia cells. Restoration of IRF8 expression repressed A-CDase expression, resulting in C16 ceramide accumulation and increased sensitivity of CML cells to FasL-induced apoptosis. In myeloid cells derived from IRF8-deficient mice, A-CDase protein level was dramatically increased. Furthermore, we demonstrated that IRF8 directly binds to the A-CDase promoter. At the functional level, inhibition of A-CDase activity, silencing A-CDase expression, or application of exogenous C16 ceramide sensitized CML cells to FasL-induced apoptosis, whereas overexpression of A-CDase decreased CML cells' sensitivity to FasL-induced apoptosis. Consequently, restoration of IRF8 expression suppressed CML development in vivo at least partially through a Fas-dependent mechanism. In summary, our findings determine the mechanism of IRF8 downregulation in CML cells and they determine a primary pathway of resistance to Fas-mediated apoptosis and disease progression.

Experimental metastasis and CTL adoptive transfer immunotherapy mouse model

Experimental metastasis mouse model is a simple and yet physiologically relevant metastasis model. The tumor cells are injected intravenously (i.v) into mouse tail veins and colonize in the lungs, thereby, resembling the last steps of tumor cell spontaneous metastasis: survival in the circulation, extravasation and colonization in the distal organs. From a therapeutic point of view, the experimental metastasis model is the simplest and ideal model since the target of therapies is often the end point of metastasis: established metastatic tumor in the distal organ. In this model, tumor cells are injected i.v into mouse tail veins and allowed to colonize and grow in the lungs. Tumor-specific CTLs are then injected i.v into the metastases-bearing mouse. The number and size of the lung metastases can be controlled by the number of tumor cells to be injected and the time of tumor growth. Therefore, various stages of metastasis, from minimal metastasis to extensive metastasis, can be modeled. Lung metastases are analyzed by inflation with ink, thus allowing easier visual observation and quantification.

IFN-γ upregulates survivin and Ifi202 expression to induce survival and proliferation of tumor-specific T cells

BACKGROUND

A common procedure in human cytotoxic T lymphocyte (CTL) adoptive transfer immunotherapy is to expand tumor-specific CTLs ex vivo using CD3 mAb prior to transfer. One of the major obstacles of CTL adoptive immunotherapy is a lack of CTL persistence in the tumor-bearing host after transfer. The aim of this study is to elucidate the molecular mechanisms underlying the effects of stimulation conditions on proliferation and survival of tumor-specific CTLs.

METHODOLOGY/PRINCIPAL FINDINGS

Tumor-specific CTLs were stimulated with either CD3 mAb or cognate Ag and analyzed for their proliferation and survival ex vivo and persistence in tumor-bearing mice. Although both Ag and CD3 mAb effectively induced the cytotoxic effecter molecules of the CTLs, we observed that Ag stimulation is essential for sustained CTL proliferation and survival. Further analysis revealed that Ag stimulation leads to greater proliferation rates and less apoptosis than CD3 mAb stimulation. Re-stimulation of the CD3 mAb-stimulated CTLs with Ag resulted in restored CTL proliferative potential, suggesting that CD3 mAb-induced loss of proliferative potential is reversible. Using DNA microarray technology, we identified that survivin and ifi202, two genes with known functions in T cell apoptosis and proliferation, are differentially induced between Ag- and CD3 mAb-stimulated CTLs. Analysis of the IFN-γ signaling pathway activation revealed that Ag stimulation resulted in rapid phosphorylation of STAT1 (pSTAT1), whereas CD3 mAb stimulation failed to activate STAT1. Chromatin immunoprecipitation revealed that pSTAT1 is associated with the promoters of both survivin and ifi202 in T cells and electrophoresis mobility shift assay indicated that pSTAT1 directly binds to the gamma activation sequence element in the survivin and ifi202 promoters. Finally, silencing ifi202 expression significantly decreased T cell proliferation.

CONCLUSIONS/SIGNIFICANCE

Our findings delineate a new role of the IFN-γ signaling pathway in regulating T cell proliferation and apoptosis through upregulating survivin and ifi202 expression.

A simpler definition of major depressive disorder

BACKGROUND

The DSM-IV symptom criteria for major depressive disorder (MDD) are somewhat lengthy, with many studies showing that treatment providers have difficulty recalling all nine symptoms. Moreover, the criteria include somatic symptoms that are difficult to apply in patients with medical illnesses. In a previous report, we developed a briefer definition of MDD that was composed of the mood and cognitive symptoms of the DSM-IV criteria, and found high levels of agreement between the simplified and full DSM-IV definitions. The goal of the present study was to replicate these findings in another large sample of psychiatric out-patients and to extend the findings to other patient samples.

METHOD

We interviewed 1100 psychiatric out-patients and 210 pathological gamblers presenting for treatment and 1200 candidates for bariatric surgery. All patients were interviewed by a diagnostic rater who administered a semi-structured interview. We inquired about all symptoms of depression for all patients.

RESULTS

In all three samples high levels of agreement were found between the DSM-IV and the simpler definition of MDD. Summing across all 2510 patients, the level of agreement between the two definitions was 95.5% and the kappa coefficient was 0.87.

CONCLUSIONS

After eliminating the four somatic criteria from the DSM-IV definition of MDD, a high level of concordance was found between this simpler definition and the original DSM-IV classification. This new definition offers two advantages over the current DSM-IV definition--it is briefer and it is easier to apply with medically ill patients because it is free of somatic symptoms.

Task shifting and innovative medical education--moving outside the box to serve rural Nepal

Health care systems everywhere must tackle the problem of supplying quality health care workers to underserved areas. Except in countries that are both small and wealthy, the traditional methods of medical education and worker deployment have proven widely inadequate--and this is certainly the case in Nepal. We discuss here how alternative approaches to remedy the problem are being undertaken locally. First, we show how the concept of task-shifting to lower level staff has already begun to fill in gaps in the area of emergency obstetric care. In the short- and medium-term, task-shifting is a viable solution to the mal-distribution of health care workers. Second, we give three short case studies that illustrate a small, local organization, Nick Simons Institute, partnering with the government's National Health Training Center to pioneer 'outside the box' alternatives to medical education. These include the design and implementation of novel in-service courses, including CME.

Liver transplantation for primary biliary cirrhosis: results of aggressive corticosteroid withdrawal

INTRODUCTION

A subset of patients with primary biliary cirrhosis (PBC) may require long-term corticosteroid (CS) therapy following liver transplantation (OLT) due to concern over the possibility of recurrence. Our center has attempted to minimize CS use in all of our OLT recipients. In this study, we review our experience in this cohort to determine (1) patient outcome including PBC recurrence following transplantation and (2) the long-term requirement for CS use in PBC patients.

METHODS

From 1988 to 2006, 1102 OLTs were performed in 1032 adults at the University of Colorado, of which 70 patients (6.8%) with PBC received 74 allografts. Bivariate and multivariate analyses were used to evaluate predictors of CS withdrawal. Thirteen potential predictors of CS discontinuation were considered: age, gender, body mass index (BMI), race, type of graft (cadaveric or living donor [LD]), recurrence of PBC, warm ischemia time, and immunosuppressant.

RESULTS

Overall survival at 5 years was 85%. The 1-, 5-, and 10-year recurrence-free survivals were 90%, 72%, and 54%, respectively. PBC recurred in 18 patients (25.7%). Of these, none received a second transplant due to disease recurrence. At the time of last follow-up, 73% of recipients were steroid free. Independent predictors of CS discontinuation are age (>54; P = .0059) and LD graft type (P = .0008). Conversely, cyclosporine (P = .0007), female gender (P = .0216), and BMI > 31 (P = .0306) were negatively associated with CS withdraw. Importantly, steroid discontinuation did not influence PBC recurrence.

CONCLUSIONS

While long-term outcomes in PBC patients are favorable, disease recurrence can generally be managed medically without the need for a second transplant. Using an aggressive CS minimization approach, nearly three-quarters of the patients were CS free at the time of last follow-up. Increasing age and LD grafts were associated with successful CS withdraw. Conversely, cyclosporine use, female gender, and increasing BMI were associated with unsuccessful steroid discontinuation.

Accuracy of specific symptoms in the diagnosis of major depressive disorder in psychiatric out-patients: data from the MIDAS project

BACKGROUND

There is uncertainty about the diagnostic significance of specific symptoms of major depressive disorder (MDD). There is also interest in using one or two specific symptoms in the development of brief scales. Our aim was to elucidate the best possible specific symptoms that would assist in ruling in or ruling out a major depressive episode in a psychiatric out-patient setting.

METHOD

A total of 1523 psychiatric out-patients were evaluated in the Methods to Improve Diagnostic Assessment and Services (MIDAS) project. The accuracy and added value of specific symptoms from a comprehensive item bank were compared against the Structured Clinical Interview for DSM-IV (SCID).

RESULTS

The prevalence of depression in our sample was 54.4%. In this high prevalence setting the optimum specific symptoms for ruling in MDD were psychomotor retardation, diminished interest/pleasure and indecisiveness. The optimum specific symptoms for ruling out MDD were the absence of depressed mood, the absence of diminished drive and the absence of loss of energy. However, some discriminatory items were relatively uncommon. Correcting for frequency, the most clinically valuable rule-in items were depressed mood, diminished interest/pleasure and diminished drive. The most clinically valuable rule-out items were depressed mood, diminished interest/pleasure and poor concentration.

CONCLUSIONS

The study supports the use of the questions endorsed by the two-item Patient Health Questionnaire (PHQ-2) with the additional consideration of the item diminished drive as a rule-in test and poor concentration as a rule-out test. The accuracy of these questions may be different in primary care studies where prevalence differs and when they are combined into multi-question tests or algorithmic models.

The Paradox of Social Anxiety and Bipolar Disorder: Implications for Presentation and Treatment

Several reports have recently highlighted the close association between anxiety disorders and bipolar disorder. These reports have indicated a worse course for patients with such comorbidity, including more severe symptoms and poorer outcomes. Fewer studies, however, have closely looked at how social anxiety in particular impacts the clinical presentation and treatment-seeking behavior of people with bipolar disorder. The present report addresses this question using data from the Methods to Improve Diagnostic Assessment and Services (MIDAS) project, one of the largest ongoing clinical epidemiology studies in the United States with over 2,500 participants enrolled to date. Participants were outpatients seeking psychiatric treatment, all of whom underwent an extensive assessment via semi-structured interviews by highly trained diagnosticians. Patients with bipolar disorder and social anxiety (n = 85) were compared to patients with bipolar disorder alone (n = 150) on a series of clinical characteristics, including comorbidity, to determine how social anxiety impacts the clinical presentation of bipolar disorder. Results indicate that comorbid social anxiety is associated with a more severe clinical presentation. Follow-up analyses explored the extent to which this was due to social anxiety specifically versus comorbidity in general. Discussion focuses on how differences in presentation due to comorbid social anxiety and bipolar disorder are likely to impact treatment.

Diagnostic co-morbidity in 2300 psychiatric out-patients presenting for treatment evaluated with a semi-structured diagnostic interview

BACKGROUND

The largest clinical epidemiological surveys of psychiatric disorders have been based on unstructured clinical evaluations. However, several recent studies have questioned the accuracy and thoroughness of clinical diagnostic interviews; consequently, clinical epidemiological studies, like community-based studies, should be based on standardized evaluations. The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project is the largest clinical epidemiological study using semi-structured interviews assessing a wide range of psychiatric disorders conducted in a general clinical out-patient practice. In the present report we examined the frequency of DSM-IV Axis I diagnostic co-morbidity in psychiatric out-patients.

METHOD

A total of 2300 out-patients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) upon presentation for treatment.

RESULTS

The mean number of current and lifetime DSM-IV Axis I disorders in the 2300 patients was 1.9 (s.d.=1.5) and 3.0 (s.d.=1.8) respectively. The majority of patients were diagnosed with two or more current disorders, and more than one-third were diagnosed with three or more current disorders. Examination of the most frequent current disorders in the patients with the 12 most common principal diagnoses indicated that the pattern of co-morbidity differed among the disorders. The highest mean number of current co-morbid disorders was found for patients with a principal diagnosis of post-traumatic stress disorder and bipolar disorder.

CONCLUSIONS

Clinicians should assume that psychiatric patients presenting for treatment have more than one current diagnosis. The pattern of co-morbidity varies according to the principal diagnosis.

Relapsing polychondritis: a rare disease of multisystem involvement

Relapsing Polychondritis (RP) is a rare connective tissue disease of unclear pathogenesis and may present with multisystem involvement. In this report we describe a case of Relapsing Polychondritis, a rare autoimmune disease of varied presentation, course, and response to therapy.