CRISP: An Inpatient Pediatric Curriculum for Family Medicine Residents Using Clinical Reasoning and Illness Scripts

Introduction

Clinical reasoning enables safe patient care and is an important competency in medical education but can be challenging to teach. Illness scripts facilitate clinical reasoning but have not been used to create pediatric curricula.

Methods

We created CRISP (Clinical Reasoning with Illness Scripts in Pediatrics), a curriculum comprising four 1-hour learning sessions that deliberately incorporated clinical reasoning concepts and illness scripts to organize how four common chief complaints were taught to family medicine residents on inpatient pediatric rotations. We performed a multisite curriculum evaluation project over 6 months with family medicine residents at four institutions to assess whether the use of clinical reasoning concepts to structure CRISP was feasible and acceptable for learners and instructors and whether the use of illness scripts increased knowledge of four common pediatric chief complaints.

Results

For all learning sessions, family medicine residents and pediatric hospitalists agreed that CRISP's format was preferable to traditional didactic lectures. Pre-/posttest scores showed statistically significant increases in family medicine resident knowledge (respiratory distress [n = 42]: pretest, 72%, posttest, 92%; abdominal pain [n = 44]: pretest, 82%, posttest, 96%; acute febrile limp [n = 44]: pretest, 68%, posttest, 81%; well-appearing febrile infant [n = 42]: pretest, 58%, posttest, 73%; ps < .05).

Discussion

By using clinical reasoning concepts and illness script comparison to structure a pediatric curriculum, CRISP represents a novel instructional approach that can be used by pediatric hospitalists to increase family medicine resident knowledge about diagnoses associated with common pediatric chief complaints.

A Case Series of Potential Pediatric Cyanotoxin Exposures Associated with Harmful Algal Blooms in Northwest Ohio

Cyanobacterial harmful algal blooms (CyanoHABs) are increasing in prevalence and severity in the Great Lakes region, as well as both globally and locally. CyanoHABs have the potential to cause adverse effects on human health due to the production of cyanotoxins from cyanobacteria. Common routes of exposure include recreational exposure (swimming, skiing, and boating), ingestion, and aerosolization of contaminated water sources. Cyanotoxins have been shown to adversely affect several major organ systems contributing to hepatotoxicity, gastrointestinal distress, and pulmonary inflammation. We present three pediatric case reports that coincided with CyanoHABs exposure with a focus on presentation of illness, diagnostic work-up, and treatment of CyanoHAB-related illnesses. Potential cyanotoxin exposure occurred while swimming in the Maumee River and Maumee Bay of Lake Erie in Ohio during the summer months with confirmed CyanoHAB activity. Primary symptoms included generalized macular rash, fever, vomiting, diarrhea, and severe respiratory distress. Significant labs included leukocytosis and elevated C-reactive protein. All patients ultimately recovered with supportive care. Symptoms following potential cyanotoxin exposure coincide with multiple disease states representing an urgent need to develop specific diagnostic tests of exposure.

P2Y12 pre-treatment for NSTE-ACS in a tertiary hospital centre: real world compliance experience with ESC 2020 guidelines

Funding Acknowledgements

Type of funding sources: None.

Background

The 2020 ESC guidelines for managing NSTE-ACS recommend against routine pre-treatment with a P2Y12 receptor inhibitor if coronary anatomy is not known and an early (&lt;24h) invasive management is planned. With delayed (&gt;24h) invasive management, pre-treatment may be considered in selected cases.

Purpose

Evaluate antiplatelet pre-treatment practices for NSTE-ACS in a tertiary cardiology centre in Australia.

Methods

Retrospective analysis of NSTE-ACS cases from January to August 2021 were obtained from the cardiac laboratory database. Patients on a P2Y12 inhibitor prior to presentation were excluded. Clinical, demographic, angiographic and medication data were obtained from the electronic database.

Results

85 cases were included. Mean age was 62 ± 11.5 and 81% were male. The prevalence of hypertension, hypercholesterolaemia, type 2 diabetes and active smoking was 54.8%, 51.2%, 38.1% and 34.5% respectively. Mean time to angiography was 1.7 ± 1.4 days and the median peak pre-procedural troponin T was 191.5 (80 to 852). Access was predominantly radial (84.5%) with the remainder femoral (15.5%).

Angiographic findings included, obstructive disease amenable to percutaneous coronary intervention (50.0%), obstructive disease for surgical revascularisation (22.6%), and non-obstructive disease (27.4%). The mean time from angiography to surgical revascularisation was 6.4 ± 4.4 days. Three patients (3.6%) had bleeding [managed conservatively], specifically upper limb haematoma, groin haematoma, and haemoptysis.

The majority of patients (79.8%) received P2Y12 inhibitors (40.5% clopidogrel and 39.3% ticagrelor) prior to angiography. Of these, 49.3% had percutaneous angioplasty, 17.9% had surgical revascularisation and 32.8% had non-obstructive disease (managed with single antithrombotic agent). Of those who did not receive P2Y12 inhibitors [n = 17, 20.2%]. Of these, 53% had percutaneous angioplasty, 40% had surgical revascularisation, and 5% had non-obstructive disease.

Conclusions

Overall, pre-treatment with a P2Y12 inhibitor was still very common, risking delays to bypass surgery and increasing bleeding. Practice did not generally align with contemporary ESC 2020 guidelines. Understanding the reasons for guideline non-compliance would be important for optimising treatments. Education for emergency and cardiology staff as well as creation of local practice policies may help increase compliance with evidence-based guidelines.

Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Practical consensus recommendations regarding the management of sentinel lymph node issues in early breast cancer

Axillary lymph node involvement is a very important poor prognostic factor in the clinical staging and management of breast cancer patients. Traditionally, axillary lymph node dissection (ALND) has been used for determining the status of the axillary lymph nodes. More recently the sentinel lymph node biopsy (SLNB) procedure has gained wider acceptance as the standard of care, having the advantage of being less invasivewhile providing good accuracy. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of the two different procedures and other issues in patients with early breast cancer for the benefit of community oncologists.

Dexmedetomidine Infusion as a Novel Supportive Therapy for Fluphenazine-Induced Neuroleptic Malignant Syndrome in a 10-Year-Old Boy: A Case Report and Review of Literature

A 10-year-old male child patient developed symptoms of neuroleptic malignant syndrome (NMS) 1 month following initiation of fluphenazine for behavioral therapeutic management. Dexmedetomidine infusion was able to adequately control the symptoms of NMS with resolution of encephalopathy. This was the first report of novel dexmedetomidine utilization for the treatment of NMS. We suggest using dexmedetomidine as an adjunctive agent to control NMS symptomatology without attendant risk of respiratory depression.

The impact of cervical cytobrush sampling on cervico-vaginal immune parameters and microbiota relevant to HIV susceptibility

The immunology and microbiota of the female genital tract (FGT) are key determinants of HIV susceptibility. Cervical cytobrush sampling is a relatively non-invasive method permitting the longitudinal assessment of endocervical immune cells, but effects on FGT immunology are unknown. Blood, cervico-vaginal secretions and cervical cytobrushes were collected from sexually transmitted infection (STI)-free women at baseline and after either 6 hours or 48 hours. Endocervical immune cell subsets were assessed by flow cytometry, and pro-inflammatory cytokines by multiplex ELISA. The density of Lactobacillus species and key bacterial vaginosis-associated bacterial taxa were determined by qPCR. Paired changes were assessed before and after cytobrush sampling. After 6 hours there were significant increases in CD4 + T cell, antigen presenting cell (APC) and neutrophil numbers; APC elevations persisted at 48 hours, while neutrophil and CD4 + T cell numbers returned to baseline. In addition, pro-inflammatory cytokine levels were increased at 6 hours and returned to baseline by 48 hours. No significant changes were observed in the absolute abundance of Lactobacillus species or BV-associated bacteria at either time point. Overall, cytobrush sampling altered genital immune parameters at 6 hours, but only APC number increases persisted at 48 hours. This should be considered in longitudinal analyses of FGT immunology.

Toxicocladosporium aquimarinum sp. nov. and Toxicocladosporium qatarense sp. nov., isolated from marine waters of the Arabian Gulf surrounding Qatar

The Arabian Gulf surrounding Qatar is distinct from other marine ecosystems due to its high salinity (35-75 PSU) and extreme water temperature fluctuations (11-40 °C). Furthermore, in the last decade, Qatar has been witnessing an industrial boom as well as extensive infrastructure construction activities. Marine micro-organisms, including fungi, remain largely unexplored in the Arabian Gulf. During a 3 year study, we investigated the diversity of marine fungi in coastal waters around Qatar. As a result, two new Toxicocladosporium species were isolated from the Qatari marine environment. Molecular and phylogenetic analyses of rRNA gene sequences of five loci, namely the internal transcribed spacer 1 and 2 regions and the D1/D2 domains of the large subunit rRNA, actin, RNA polymerase second largest subunit and beta-tubulin genes, were used to confirm the identity of the novel species for which we propose the names Toxicocladosporium aquimarinum sp. nov. and Toxicocladosporium qatarense sp. nov.

Abstract P5-08-06: Differential effects of eribulin on key transcription factors snail and slug

Microtubule targeting agents (MTAs) are a mainstay in the treatment of breast cancer and a growing body of evidence demonstrates that they have non-mitotic effects that contribute to their anticancer actions. Even after decades of clinical use, there is much to still be learned about the mechanisms of action these drugs, and differences among them, for optimal utility. MTAs rapidly alter microtubule dynamics, often within minutes, leading to significant changes in oncogenic cellular signaling. We evaluated the early effects of eribulin on key oncogenic signaling pathways following a 2 h incubation using clinically relevant concentrations and compared the effects to those initiated by other MTAs. These studies led to the identification of novel mechanisms by which MTAs disrupt oncogenic signaling and contribute to the reversal of epithelial to mesenchymal transition (EMT), including unanticipated differences among drugs.

The TGF-β-mediated expression of the Snail transcription factor is a key driver pathway of EMT in breast cancer. The effects of eribulin and other MTAs on TGF-β-induced, Smad-dependent expression of Snail were evaluated. Our results show that eribulin and vinorelbine, but not paclitaxel or ixabepilone, inhibit the ability of TGF-β to promote the transcriptional induction of Snail by impeding the nuclear transport of Smad2/3 proteins in 4 triple-negative breast cancer cell lines. This study begins to explain how microtubule disruption might contribute to the eribulin-mediated EMT reversal observed in vitro, in vivo, and in patients.

Slug is another member of the Snail family of transcription factors that plays a central role in breast cancer EMT. Although Snail and Slug are often grouped together due to functional similarities, it is becoming increasingly clear that Slug has an independent role in regulating stemness and cancer cell survival during partial EMT. In contrast to our findings with Snail, eribulin and vinorelbine, but not paclitaxel or ixabepilone, induced Slug expression independent of TGF-β stimulation in a subset of triple-negative breast cancer cell lines. Studies are ongoing to identify the molecular pathways and consequences of eribulin and vinorelbine-induced Slug induction, which might begin to identify biomarkers of patient response to different MTAs. This work highlights the multifaceted nature of MTA-mediated effects on EMT-associated signaling pathways in breast cancer cells and prompts a reevaluation of their differential efficacy in tumors with distinct molecular profiles. These studies are supported by Eisai Inc.

Citation Format: Kaul R, Risinger AL, Mooberry SL. Differential effects of eribulin on key transcription factors snail and slug [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-08-06.

Association of HPV infection and clearance with cervicovaginal immunology and the vaginal microbiota

Cervical human papillomavirus (HPV) infection may increase HIV risk. Since other genital infections enhance HIV susceptibility by inducing inflammation, we assessed the impact of HPV infection and clearance on genital immunology and the cervico-vaginal microbiome. Genital samples were collected from 65 women for HPV testing, immune studies and microbiota assessment; repeat HPV testing was performed after 6 months. All participants were HIV-uninfected and free of bacterial STIs. Cytobrush-derived T cell and dendritic cell subsets were assessed by multiparameter flow cytometry. Undiluted cervico-vaginal secretions were used to determine cytokine levels by multiplex ELISA, and to assess bacterial community composition and structure by 16S rRNA gene sequence analysis. Neither HPV infection nor clearance were associated with broad differences in cervical T cell subsets or cytokines, although HPV clearance was associated with increased Langerhans cells and HPV infection with elevated IP-10 and MIG. Individuals with HPV more frequently had a high diversity cervico-vaginal microbiome (community state type IV) and were less likely to have an L. gasseri predominant microbiome. In summary, HPV infection and/or subsequent clearance was not associated with inflammation or altered cervical T cell subsets, but associations with increased Langerhans cells and the composition of the vaginal microbiome warrant further exploration.

Distinct Effects of the Cervicovaginal Microbiota and Herpes Simplex Type 2 Infection on Female Genital Tract Immunology

Background

Genital inflammation is a key determinant of human immunodeficiency virus (HIV) transmission, and may increase HIV-susceptible target cells and alter epithelial integrity. Several genital conditions that increase HIV risk are more prevalent in African, Caribbean, and other black (ACB) women, including bacterial vaginosis and herpes simplex virus type-2 (HSV-2) infection. Therefore, we assessed the impact of the genital microbiota on mucosal immunology in ACB women and microbiome-HSV-2 interactions.

Methods

Cervicovaginal secretions and endocervical cells were collected by cytobrush and Instead Softcup, respectively. T cells and dendritic cells were assessed by flow cytometry, cytokines by multiplex enzyme-linked immunosorbent assay (ELISA), and the microbiota by 16S ribosomal ribonucleic acid gene sequencing.

Results

The cervicovaginal microbiota of 51 participants were composed of community state types (CSTs) showing diversity (20/51; 39%) or predominated by Lactobacillus iners (22/51; 42%), L. crispatus (7/51; 14%), or L. gasseri (2/51; 4%). High-diversity CSTs and specific bacterial phyla (Gardnerella vaginalis and Prevotella bivia) were strongly associated with cervicovaginal inflammatory cytokines, but not with altered endocervical immune cells. However, cervical CD4+ T-cell number was associated with HSV-2 infection and a distinct cytokine profile.

Conclusions

This suggests that the genital microbiota and HSV-2 infection may influence HIV susceptibility through independent biological mechanisms.

Abstract P4-07-10: Epithelial mesenchymal transition associated with high miR-221 and integrin β6 leads to poor prognosis in hormone receptor positive HER2 negative breast cancers

Background: MicroRNA mediated molecular alterations are involved in the initiation and progression of cancer. Altered expression of multiple microRNAs is associated with endocrine resistance in hormone receptor positive HER2 negative (HR+/HER2-ve) cancer. The role of miR-221 in inducing epithelial to mesenchymal transition (EMT) is well documented especially in cell line model systems. However, the detailed mechanism of specific microRNAs in intrinsic and acquired resistance to endocrine therapy needs to be worked out. In addition, more needs to be done in the documentation of these mechanisms in human breast cancer specimens with complete clinical documentation and long-term follow-up. In this study, we have evaluated the clinical significance of miR-221 and its mechanistic role in EMT using human specimens and cell line models.

Materials and Methods: Formalin fixed paraffin embedded tumor from 129 HR+/HER2-ve breast cancer patients with a median follow up of 63 months were used for estimation of miR-221 by quantitative real time PCR. Expression levels of genes which are direct targets of miR-221 and related genes in EMT were analysed from these tumors. Survival between miR-221 high and low groups was compared by Kaplan Meier survival curves and prognostic relevance was estimated by Cox proportional hazard model.

Cell line experiments to investigate the role of miR-221 in inducing EMT through integrin β6 are underway in both wild type and tamoxifen resistant MCF-7 cell lines (A gift from Prof Ben Ho Park, Johns Hopkins University School of Medicine).

Results: A significant elevated level of miR-221 was observed in small proportion (14%) of HR+/HER2-ve tumors. miR-221 expression had an inverse correlation with both ER protein and ESR1 mRNA levels within HR+/HER2-ve tumors. Tumors with high levels of miR-221 showed significantly higher expression of integrin β6 which is a robust marker of EMT. Patients with high expression of miR-221 had a poorer survival in Kaplan Meier analysis.

Results of interrogation of EMT mediated through integrin related pathways involving miR-221 in cell line models will be presented.

Discussion: The association between miR-221 and integrin β6 in HR+/HER2-ve breast cancer with endocrine resistance suggests a potential link between an epigenetic regulator and a mediator of tumor-stromal interaction. The other mediators involved in this pathway are being investigated. miR-221 could be potentially used as a marker for identification of a poor prognostic subtype within HR+/HER2-ve breast cancers.

Citation Format: Prabhu JS, Kaul R, Korlimarla A, Desai K, Gangadharan C, Rajarajan S, Nair MG, Alexander A, Kaluve R, Manjunath S, Correa M, Prasad MSN, Patil S, Srinath BS, Sridhar TS. Epithelial mesenchymal transition associated with high miR-221 and integrin β6 leads to poor prognosis in hormone receptor positive HER2 negative breast cancers [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-07-10.

Abstract P4-04-04: Eribulin impairs TGF-β type I receptor localization and signaling in BT-549 cells

Microtubule targeting agents (MTAs) continue to be some of the most valuable drugs used to treat breast cancer. While decades of research have shown that these drugs cause mitotic arrest in cells by suppressing the dynamic instability of microtubules, recent evidence demonstrates that the ability of MTAs to disrupt microtubule-dependent transport of key signaling components, including proteins and microRNAs, in interphase cells likely contributes to their anticancer actions. TGF-β signaling is a driver of oncogenesis and epithelial-to-mesenchymal transition (EMT) that involves multiple protein trafficking and intracellular signaling events. Ligand mediated activation of the cell surface TGF-β receptors leads to downstream signaling in the canonical and the non-canonical pathways that collectively lead to the expression of proteins implicated in EMT, including Snail and Slug. Additionally, TGF-β type 1 receptor (TGF-βR1) undergoes constant cycling from the plasma membrane to the cytosol, a microtubule-dependent process. We tested the hypothesis that a short-term treatment of breast cancer cells with eribulin or 3 other clinically relevant MTAs would differentially disrupt interphase microtubules and alter the transport and downstream signaling of TGF-βR1. BT-549 cells were treated for 2 h with concentrations of MTAs that cause comparable disruption of the interphase microtubule network; 100 nM was used for the destabilizers, eribulin or vinorelbine and 1 µm was used for the stabilizers, paclitaxel or ixabepilone. The results show that TGF-βR1 was extensively localized along the stabilizer-induced microtubule bundles, a phenomenon not observed with destabilizer-treated cells. The downstream consequences were further assessed. The expression of Snail and Slug were evaluated in cells pretreated with MTAs followed by TGF-β stimulation. Eribulin and vinorelbine significantly inhibited the TGF-β-induced expression of Snail and Slug while stabilizers did not alter their expression levels. We hypothesize that eribulin and vinorelbine are inhibiting the non-canonical TGF-β signaling pathway since they had no effect on the localization and expression of Smad2/3, proteins involved in the canonical pathway. Eribulin induced inhibition of TGF-β signaling is consistent with previous studies that show that a 7 day treatment reversed TGF-β mediated EMT in breast cancer cells1. Data from patients shows that eribulin decreases the plasma concentration of TGF-β within 7 days of treatment initiation2. Our data suggest that eribulin rapidly inhibits non-canonical TGF-β signaling indicating that this is a potential mechanism for the eribulin-mediated EMT reversal. This information, together with previously published reports, suggest that eribulin has multiple effects leading to inhibition of TGF-β signaling. These studies begin to shed light into the diverse mechanisms of action of MTAs.

1. Yoshida T, et al., Brit J Cancer 110(6): 1497-505, 2014

2. Ueda S, et al., Brit J Cancer, 2016

This work is funded by Eisai Inc.

Citation Format: Kaul R, Risinger AL, Mooberry SL. Eribulin impairs TGF-β type I receptor localization and signaling in BT-549 cells [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-04-04.

Management of acute osteomyelitis: a ten-year experience

Osteomyelitis is an infection of the bone; proper management requires prolonged antibiotic treatment. Controversy exists as to when a patient should transition from intravenous to oral antibiotics. However, due to the high bioavailability of some oral antibiotics, optimal time to transition from high to low bioavailability antibiotics is a more valid consideration. Additionally, there are questions surrounding the efficacy of certain antibiotics, specifically trimethoprim-sulfamethoxazole (TMP-SMX), in treating osteomyelitis. After obtaining Institutional Review Board approval from both universities, a retrospective chart review was conducted, utilizing an author-created severity scale, on all patients seen by Pediatric Infectious Diseases at the Universities of Michigan and Toledo with an acute osteomyelitis diagnosis from 2002-2012. There were 133 patients, 106 treated successfully. Success was defined in this study specifically as treatment of <14 weeks without recurrence within 30 days of stopping antibiotics or permanent site disability. Seventeen patients were treated with TMP-SMX at comparable cure rates. Patients with pre-existing bone defects (noted in radiological reports), initial erythrocyte sedimentation rate (ESR)≥70, hematogenous osteomyelitis with soft tissue extension, and skull osteomyelitis were associated with increased failure rate. Switch to low bioavailability antibiotics occurred, on average, at 3.5 weeks; however, switching before then was not associated with decreased cure rate. As prevalence of methicillin-resistant Staphylococcus aureus (MRSA), especially clindamycin-resistant MRSA, increases, TMP-SMX appears to be an acceptable antibiotic. There does not appear to be a minimum length of high bioavailability treatment required for cure. Prior bone defect, extensive infection, ESR≥70, or skull osteomyelitis may be indications for more aggressive management.

Abstract P5-03-08: Eribulin impairs the transport of TGF-β type I receptor leading to inhibition of downstream non-canonical TGF-β signaling necessary for cancer metastasis and survival

Microtubule targeting agents (MTAs) continue to be some of the most valuable drugs used in the treatment of breast cancers. While decades of research have shown that these drugs cause mitotic arrest in cells by suppressing the dynamic instability of microtubules, recent evidence demonstrates that the ability of MTAs to disrupt microtubule-dependent transport of key signaling components, including proteins and microRNAs, in interphase cells likely contributes to their anticancer actions. TGF-β receptors are known to undergo constant cycling from the plasma membrane to intracellular portions of the cell, a process which is microtubule dependent. This microtubule-dependent trafficking has been shown to regulate the nuclear translocation of the TGF-β type I receptor, TGFβR1. Nuclear translocation of TGFβR1 activates the expression of genes including Snail and MMP2, which facilitate the invasiveness, motility and metastasis of cancer cells. We tested the hypothesis that a 2 h treatment of breast cancer cells with eribulin or 4 other clinically relevant MTAs, would differentially disrupt interphase microtubules and alter the internalization and trafficking of TGFβR1 to the nucleus; thereby impacting downstream signaling events. Cells were serum starved for 12 hours and then treated for 2 h with concentrations of MTAs that caused comparable disruption of the interphase microtubule network; 100 nM was used for the destabilizers, eribulin and vinorelbine and 1 μM was used for the stabilizers, paclitaxel, docetaxel and ixabepilone. Following the 2 h treatment, cells were stimulated with 10 ng/mL TGF-β1 for 30 min. The results show that there are distinct differences between the effects of microtubule stabilizers and destabilizers on TGFβR1 trafficking. Eribulin and vinorelbine decreased the nuclear localization of TGFβR1 in a panel of breast cancer cell lines with initial studies suggesting that eribulin impairs this trafficking to a greater extent. In contrast, the microtubule stabilizers, particularly ixabepilone, increased TGFβR1 localization in the nucleus. Additionally, TGFβR1 was extensively localized along stabilizer-induced microtubule bundles. Overall, our work suggests that eribulin is the most effective MTA at inhibiting TGFβR1 nuclear accumulation and subsequent phosphorylation of Smads 2 and 3. The downstream signaling effects of these MTAs on TGFβR1 induced transcription of Snail and MMP2 are also being investigated. Eribulin induced inhibition of non-canonical TGF-β signaling is consistent with previous studies that show that a 7 day treatment with eribulin reversed TGF-β-mediated EMT in breast cancer cells.1,2 Our data suggest that inhibition of the nuclear transport of TGFβR1 could be a potential mechanism for the eribulin-mediated EMT reversal. These studies begin to shed light into the diverse mechanisms of MTAs and lay the groundwork to identify patient populations that might respond optimally to different MTAs.

1. Yoshida T, et al., Brit J Cancer 110(6): 1497-505, 2014.

2. Dezso Z, et al., PloS One, 9(8): e106131, 2014.

This work is funded by Eisai Inc.

Citation Format: Rohena CC, Kaul R, Risinger AL, Mooberry SL. Eribulin impairs the transport of TGF-β type I receptor leading to inhibition of downstream non-canonical TGF-β signaling necessary for cancer metastasis and survival. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-03-08.

Identification of preferential CD4+ T-cell targets for HIV infection in the cervix

A better understanding of the cellular targets of HIV infection in the female genital tract may inform HIV prevention efforts. Proposed correlates of cellular susceptibility include the HIV co-receptor CCR5, peripheral homing integrins, and immune activation. We used a CCR5-tropic pseudovirus to quantify HIV entry into unstimulated endocervical CD4(+) T cells collected by cytobrush. Virus entry was threefold higher into cervix-derived CD4(+) T cells than blood, but was strongly correlated between these two compartments. Cervix-derived CD4(+) T cells expressing CD69, α(4)β(7), or α(4)β(1) were preferential HIV targets; this enhanced susceptibility was strongly correlated with increased CCR5 expression in α(4)β(7)(+) and CD69(+) CD4(+) T cells, and to a lesser extent in α(4)β(1)(+) CD4(+) T cells. Direct binding of gp140 to integrins was not observed, integrin inhibitors had no effect on virus entry, and pseudotypes with an env that preferentially binds α(4)β(7) still demonstrated enhanced entry into α(4)β(1)(+) cells. In summary, a rapid and sensitive HIV entry assay demonstrated enhanced susceptibility of activated endocervical CD4(+) T cells, and those expressing α(4)β(7) or α(4)β(1). This may relate to increased CCR5 expression by these cell subsets, but did not appear to be due to direct interaction of α(4)β(7) or α(4)β(1) with HIV envelope.

Oncolytic viruses in head and neck cancer: a new ray of hope in the management protocol

This paper intends to highlight the different types of oncolytic viruses (OVs), mechanism of tumor specificity, its safety, and various obstacles in the design of treatment and combination therapy utilizing oncotherapy. Search was conducted using the internet-based search engines and scholarly bibliographic databases with key words such as OVs, head and neck cancer, viruses, oral squamous cell carcinoma, and gene therapy. Revolutionary technologies in the field of cancer treatment have gone through a series changes leading to the development of innovative therapeutic strategies. Oncolytic virotherapy is one such therapeutic approach that has awaited phase III clinical trial validation. OVs are self-replicating, tumor selective and lyse cancer cells following viral infection. By modifying the viral genome, it is possible to direct their toxicity toward cancer cells. Viruses that are used for treatment of head and neck cancer are either naturally occurring or genetically modified. OVs are tumor selective and potential anticancer agents. Virotherapy may become the standard of care and part of combination therapy in the management of head and neck cancer in the future.

Abstract P4-07-09: An approach to the identification of tumors driven by HER2 using the integrated activity of oncomiR miR-21 along with HER2 enriched genes

Introduction: The initial identification of HER2 as a driver in a subset of breast cancers was at the level of DNA (amplification), and subsequently noted at the level of transcripts and protein as well. However, the clinical selection of patients for treatment with Trastuzumab, has been through either IHC (protein) or FISH (DNA amplification) and not through transcript abundance. Interestingly, in most studies that have estimated transcript abundance in primary tumors, the proportion of patients that demonstrate increased transcript levels (termed HER2 Enriched) have tended to be slightly larger than the clinical HER2+ category.

A more clinically useful measure might be proof of HER2 downstream activity that might help separate tumors being driven significantly by HER2 from ones where its role is supportive. One of the many consequences of HER2 over-expression is activation of the oncomiR, miR-21 via the MAPK pathway. miR-21 in turn is known to epigenetically regulate multiple targets including the tumor suppressors PTEN and PDCD4. While these molecular mechanisms have been demonstrated convincingly in breast cancer cell lines, clinical studies of these alterations in large numbers are yet to be reported. In this study we have examined the relationship between clinical HER2 positivity and miR-21 levels in 124 surgically excised breast cancer specimens.

Methods: We selected 124 surgically excised specimens of primary breast cancers from our cohort that by HER2 immunohistochemistry (IHC) comprised 42 positive, 62 negative and 20 equivocal. Relative abundance of miR-21 was assessed using a TaqMan qRT-PCR, with normalization by RNU48. Relative transcript abundance of a set of 6 genes (HER2, GRB7, MLN64 and 3 reference genes) were evaluated by SYBR Green real time qPCR.

Results: The majority of tumors that were clinically HER2+ over expressed miR-21. A concordance with an AUC of 96% at 100% sensitivity and 85% specificity was noted. There is a highly significant differential expression of miR-21 between HER2 positive, negative and equivocal samples (P &lt; 0.0001).

HER2 enriched score determined by using the expression levels of 3 genes (HER2, GRB7, MLN64) identified 35% (44/124) of the samples to be HER2 enriched. 72% of these (32/44) were also clinical HER2 positive by IHC. As expected, miR-21 was significantly over expressed in these tumors as well (P&lt;0.0001).

To identify all samples which might show HER2 downstream activity, a logistic regression model was built using expression of miR-21, HER2, MLN64 and GRB7 as the determinants of HER2 status. The best fitting model classified 91% (38/42) of HER2 +, 95% (59/62) of the HER2 negative accurately with 94% specificity and an AUC of 0.96. The model helped identify 10% of clinical HER2 negative samples (6/20 equivocal & 3/62 HER-2 negative) to have a high probability of being HER2+.

Conclusion: Identification of HER2+ tumors with evidence of downstream activity may help identify patients with tumors being driven significantly by HER2 from ones where its role is supportive. The possibility of targeting miR-21 raises the tantalizing prospect of effecting change by altering the epigenetic regulation of multiple targets including tumor-suppressors.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-07-09.

A role for mucosal IL-22 production and Th22 cells in HIV-associated mucosal immunopathogenesis

Interleukin-22 (IL-22) is a cytokine with epithelial reparative and regenerative properties that is produced by Th22 cells and by other immune cell subsets. Therefore, we explored the hypothesis that disruption of the gut barrier during HIV infection involves dysregulation of these cells in the gastrointestinal mucosa. Sigmoid IL-22-producing T cell and Th22 cells were dramatically depleted during chronic HIV infection, epithelial integrity was compromised, and microbial translocation was increased. These alterations were reversed after long-term antiretroviral therapy. While all mucosal IL-22-producing T-cell subsets were also depleted very early during HIV infection, at these early stages IL-22 production by non-T-cell populations (including NKp44+ cells) was increased and gut epithelial integrity was maintained. Circulating Th22 cells expressed a higher level of the HIV co-receptor/binding molecules CCR5 and α4β7 than CD4+ T-cell subsets in HIV-uninfected participants, but this was not the case after HIV infection. Finally, recombinant IL-22 was protective against HIV and tumor necrosis factor-α-induced gut epithelial damage in a validated in vitro gut epithelial system. We conclude that reduced IL-22 production and Th22 depletion in the gut mucosa are important factors in HIV mucosal immunopathogenesis.

Foreskin T-cell subsets differ substantially from blood with respect to HIV co-receptor expression, inflammatory profile, and memory status

The foreskin is the main site of heterosexual human immunodeficiency virus (HIV) acquisition in uncircumcised men, but functional data regarding T-cell subsets present at this site are lacking. Foreskin tissue and blood were obtained from Ugandan men undergoing elective adult circumcision. Tissue was treated by mechanical and enzymatic digestion followed by T-cell subset identification and assessment of cytokine production using flow cytometry. Foreskin CD4(+) T cells were predominantly an effector memory phenotype, and compared with blood they displayed a higher frequency of CCR5 expression (42.0% vs. 9.9%) and interleukin-17 production. There was no difference in T-regulatory cell frequency, but interferon-γ and tumor necrosis factor-α production were increased in foreskin CD8(+) T cells. These novel techniques demonstrate that the foreskin represents a proinflammatory milieu that is enriched for HIV-susceptible T-cell subsets. Further characterization of foreskin T-cell subsets may help to define the correlates of HIV susceptibility in the foreskin.

Inorganic mercury exposure in prairie voles (Microtus ochrogaster) alters the expression of toll-like receptor 4 and activates inflammatory pathways in the liver in a sex-specific manner

Environmental exposure to mercury can cause a number of adverse effects in humans including the disruption of endocrine function that may result in sex-specific effects. The present study was designed to characterize sex-specific effects of chronic inorganic mercury exposure on toll-like receptor (TLR) 2 and TLR4 and inflammatory signaling in the liver of prairie voles (Microtus ochrogaster). Following 10 weeks of exposure to mercury via drinking water, effects on protein expression levels of TLR2 and TLR4 and the downstream p38 mitogen-activated protein kinase (p38 MAPK) and nuclear factor-kappa (NF-κB) signaling pathways were assessed. Using immunoblot analysis, we found that mercury exposure significantly enhanced the expression of TLR4 and activated p38 MAPK and NF-κB pathways in vole livers. This is the first report indicating that TLR4 may serve as a sensor for chronic mercury exposure in the liver. Further, compared to females, mercury-treated male voles exhibited significant increases in activated p38 MAPK and a greater extent of liver damage. Together, these findings establish sex-specific liver immunomodulation and cellular signaling following chronic inorganic mercury exposure. Furthermore, this study also supports the use of voles as biomarkers of environmental mercury contamination and offers a promising in vivo tool to test various therapeutic strategies for mercury detoxification.

Defining the genital immune correlates of protection against HIV acquisition: co-infections and other potential confounders

The sexual transmission of HIV is very inefficient, presumably because mucosal immune defences prevent infection after most exposures. Since numerous genital immune factors have antiviral effects in vitro, their elucidation might greatly inform the microbicide and HIV prevention fields, particularly in the context of HIV-exposed but persistently seronegative (ESN) individuals. However, several important confounders must be considered in such research. First, sound epidemiological criteria are needed to define individuals as ESN. Then, since high-risk sexual activity is commonly one of these criteria, its potential impact on genital immunology must be carefully considered, both the direct effects of sex and the secondary immune effects of genital co-infections. This means that it may be very difficult to determine whether differences in genital immunology between ESN and control groups are responsible for HIV protection, or are a consequence of high-risk sexual activity. To overcome this confounding, the demographics and epidemiology of ESN cohorts must be described very carefully, thorough co-infection diagnostics must be performed and, if possible, prospective studies with an endpoint of HIV acquisition should be performed to define the direction of causality.

VRQ397 (CRAVKY): a novel noncompetitive V2 receptor antagonist

Vasopressin type 2 receptor (V2R) exhibits mostly important properties for hydroosmotic equilibrium and, to a lesser extent, on vasomotricity. Drugs currently acting on this receptor are analogs of the natural neuropeptide, arginine vasopressin (AVP), and hence are competitive ligands. Peptides that reproduce specific sequences of a given receptor have lately been reported to interfere with its action, and if such molecules arise from regions remote from the binding site they would be anticipated to exhibit noncompetitive antagonism, but this has yet to be shown for V2R. Six peptides reproducing juxtamembranous regions of V2R were designed and screened; the most effective peptide, cravky (labeled VRQ397), was characterized. VRQ397 was potent (IC(50) = 0.69 +/- 0.25 nM) and fully effective in inhibiting V2R-dependent physiological function, specifically desmopressin-L-desamino-8-arginine-vasopressin (DDAVP)-induced cremasteric vasorelaxation; this physiological functional assay was utilized to avoid overlooking interference of specific signaling events. A dose-response profile revealed a noncompetitive property of VRQ397; correspondingly, VRQ397 bound specifically to V2R-expressing cells could not displace its natural ligand, AVP, but modulated AVP binding kinetics (dissociation rate). Specificity of VRQ397 was further confirmed by its inability to bind to homologous V1 and oxytocin receptors and its inefficacy to alter responses to stimulation of these receptors. VRQ397 exhibited pharmacological permissiveness on V2R-induced signals, as it inhibited DDAVP-induced PGI(2) generation but not that of cAMP or recruitment of beta-arrestin2. Consistent with in vitro and ex vivo effects as a V2R antagonist, VRQ397 displayed anticipated in vivo aquaretic efficacy. We hereby describe the discovery of a first potent noncompetitive antagonist of V2R, which exhibits functional selectivity, in line with properties of a negative allosteric modulator.

Iron deficiency anaemia in sickle cell disorders in India

BACKGROUND & OBJECTIVE

Iron deficiency anaemia (IDA) is uncommon in individuals with sickle cell disease (SCD) because of availability of an adequate iron source potentially from increased red cell turnover and from blood transfusions. Also, iron deficiency anaemia can often go unnoticed because the sickle cell disease patients are already anaemic. Iron deficiency in sickle cell patients may result in lowering the intracellular haemoglobin concentration and this may ameliorate sickling. The present study was undertaken to determine the prevalence of iron deficiency anaemia and the response of iron supplementation in sickle cell disorders in tribal population of the four States viz. Maharashtra, Gujarat, Orissa and Tamil Nadu.

METHODS

A total of 8434 individuals (7105 AA, 1267 AS and 62 SS) were tested for zinc protoporphyrin/haem (ZPP/H) ratio and haemoglobin levels. Twenty two sickle cell anaemia (SS), 47 sickle cell trait (AS) and 150 normal control (AA) individuals who were iron deficient, were given iron therapy for a period of 12 wk and the laboratory investigations were repeated at the 13th wk.

RESULTS

Sixty seven per cent of subjects with sickle cell anaemia and 26 per cent with sickle cell trait had elevated ZPP/H ratios (>80 micromol/mol) as against 22.8 per cent of normal individuals. The elevated ZPP/H ratios is an indicator of microcytic anaemia of iron deficiency. Following iron therapy, an improvement in the Hb levels and ZPP/H ratios was observed in both sickle cell disorders and normal individual cases.

INTERPRETATION & CONCLUSION

This study suggests that iron deficiency anaemia is an important problem in Indian sickle cell anaemia patients and iron supplementation should be given only in proven cases of iron deficiency anaemia.

[Swimming for 12 hours leads to no reduction of adipose subcutaneous tissue--a case study]

In a 12-hour swimming event, an athlete with constant body weight lost 1.1 kg of muscle mass and 21 of total body fluids whereas fat mass remained stable. Based both on the urine's specific gravity and haematological parameters, the athlete did not suffer from dehydration. We assume that loss of skeletal muscle mass occurred due to degradation of intramyocellular lipids and muscle glycogen. In order to confirm these results obtained in a case study regarding the decrease of skeletal muscle mass with stable fat mass during prolonged swimming exercise, a larger number of athletes would have to be analyzed.

The genital tract immune milieu: an important determinant of HIV susceptibility and secondary transmission

HIV is generally sexually acquired across the genital or rectal mucosa after exposure to the genital secretions of an HIV-infected partner. Most exposures to HIV do not result in infection, likely due to protection afforded by an intact mucosal epithelium, as well as by innate and adaptive mucosal immune factors present in the genital tract. Another important mucosal determinant of transmission may be the number and activation status of potential HIV target cells, including CCR5/CD4+ T cells and DC-SIGN+ dendritic cells. The simultaneous presence of other genital infections, including classical sexually transmitted infections (STIs), can enhance HIV susceptibility either by breaching the epithelial barrier, recruiting HIV target cells to the genital tract, or by generating a pro-inflammatory local immune milieu. In HIV-infected individuals, genital co-infections increase HIV levels in the genital secretions, thereby increasing secondary sexual transmission. Co-infections that act as important HIV cofactors include human cytomegalovirus (CMV), Herpes simplex virus type 2 (HSV2), Neisseria gonorrhoeae and many others. Strategies focused on genital co-infections, such as vaccines, microbicides and suppressive therapy, are feasible in the short term and have the potential to curb the pandemic.

Sequence analysis of the haemagglutinin and fusion protein genes of peste-des-petits ruminants vaccine virus of Indian origin

The amino acid composition of the two surface proteins of peste-des-petits ruminants vaccine virus belonging to lineage four from India were deduced from the nucleotide sequence. The fusion (F) protein gene of PPRV Sungri/96 is 2405 nucleotides long and in relation to the length, it is 80 nucleotides longer than that of PPRV Nigeria/75/1 which are found to be present at the 5'UTR of this virus. The complete F gene alignment with other morbillivirus reveals a homology of 89% with PPRV/Nigeria/75/1 and 48-51% with other morbilliviruses. The F protein of PPRV Sungri/96 exhibited characteristics similarity to those of other morbillivirus F proteins. The overall amino acid similarity with its counterpart PPRV Nigeria/75/1 was 96%; with other morbilliviruses it is 65-74%. The PPRV Sungri/96 haemagglutinin (H) protein gene is 1954 nucleotides long and showed a sequence homology of 90.7% with PPRV/Nigeria/75/1 and with other morbilliviruses it ranged from 33% to 45%. At amino acids level, PPRV Sungri/96 showed a homology of 92.3% with PPRV/Nigeria/75/1 and 34-49% with other morbilliviruses. The phylogenetic tree constructed for F and H gene reveals four separate groups which is very similar to that found in other genes. To the best of our knowledge this is the first report describing the F and H genes of an Indian isolate.

Scan of human genome reveals no new Loci under ancient balancing selection

There has been much speculation as to what role balancing selection has played in evolution. In an attempt to identify regions, such as HLA, at which polymorphism has been maintained in the human population for millions of years, we scanned the human genome for regions of high SNP density. We found 16 regions that, outside of HLA and ABO, are the most highly polymorphic regions yet described; however, evidence for balancing selection at these sites is notably lacking--indeed, whole-genome simulations indicate that our findings are expected under neutrality. We propose that (i) because it is rarely stable, long-term balancing selection is an evolutionary oddity, and (ii) when a balanced polymorphism is ancient in origin, the requirements for detection by means of SNP data alone will rarely be met.

The DNA sequence and biological annotation of human chromosome 1

The reference sequence for each human chromosome provides the framework for understanding genome function, variation and evolution. Here we report the finished sequence and biological annotation of human chromosome 1. Chromosome 1 is gene-dense, with 3,141 genes and 991 pseudogenes, and many coding sequences overlap. Rearrangements and mutations of chromosome 1 are prevalent in cancer and many other diseases. Patterns of sequence variation reveal signals of recent selection in specific genes that may contribute to human fitness, and also in regions where no function is evident. Fine-scale recombination occurs in hotspots of varying intensity along the sequence, and is enriched near genes. These and other studies of human biology and disease encoded within chromosome 1 are made possible with the highly accurate annotated sequence, as part of the completed set of chromosome sequences that comprise the reference human genome.

A trial of education, prompts, and opinion leaders to improve prescription of lipid modifying therapy by primary care physicians for patients with ischemic heart disease

BACKGROUND

Recent clinical trials indicate that treatment with lipid modifying therapy improves outcomes in patients with ischemic heart disease (IHD) and low levels of high density lipoprotein (HDL) cholesterol. The results of these trials, however, have not been widely implemented in clinical practice.

OBJECTIVES

To develop and test an intervention designed to increase the rate of prescription of lipid modifying therapy and to determine the relative effectiveness of three different prompts (progress notes, patient letters, or computer chart reminders).

METHODS

The study was conducted in 11 US Department of Veterans Affairs Medical Centers. The effect of the intervention on the proportion of eligible patients receiving lipid modifying therapy was compared between five intervention sites and six matched control sites using a controlled before and after study design. Additionally, 92 providers within the intervention clinics were randomized to receive one of the three prompts. Data were analyzed using logistic regression modeling which incorporated terms to account for the clustered nature of the data.

RESULTS

At the intervention sites the prescription rate increased from 8.3% during the pre-intervention period to 39.1% during the intervention (OR = 6.5, 95% CI 5.2 to 8.2, p<0.0001) but remained unchanged at the control sites. The interaction between group (control v intervention) and time period was highly significant (p<0.0001). The adjusted odds of receiving a prescription during the intervention period was 3.1 times higher at the intervention sites than at the control sites (95% CI 2.1 to 4.7). Overall, there was no significant difference in prescription rates among the three prompt groups. However, there was a significant interaction between prompt group and site, indicating that the efficacy of the prompts differed by site.

CONCLUSION

An intervention for primary care providers consisting of an educational workshop, opinion leader influence, and prompts substantially increased the prescription rate of lipid modifying therapy.

Complete genome sequence of the genetically tractable hydrogenotrophic methanogen Methanococcus maripaludis

The genome sequence of the genetically tractable, mesophilic, hydrogenotrophic methanogen Methanococcus maripaludis contains 1,722 protein-coding genes in a single circular chromosome of 1,661,137 bp. Of the protein-coding genes (open reading frames [ORFs]), 44% were assigned a function, 48% were conserved but had unknown or uncertain functions, and 7.5% (129 ORFs) were unique to M. maripaludis. Of the unique ORFs, 27 were confirmed to encode proteins by the mass spectrometric identification of unique peptides. Genes for most known functions and pathways were identified. For example, a full complement of hydrogenases and methanogenesis enzymes was identified, including eight selenocysteine-containing proteins, with each being paralogous to a cysteine-containing counterpart. At least 59 proteins were predicted to contain iron-sulfur centers, including ferredoxins, polyferredoxins, and subunits of enzymes with various redox functions. Unusual features included the absence of a Cdc6 homolog, implying a variation in replication initiation, and the presence of a bacterial-like RNase HI as well as an RNase HII typical of the Archaea. The presence of alanine dehydrogenase and alanine racemase, which are uniquely present among the Archaea, explained the ability of the organism to use L- and D-alanine as nitrogen sources. Features that contrasted with the related organism Methanocaldococcus jannaschii included the absence of inteins, even though close homologs of most intein-containing proteins were encoded. Although two-thirds of the ORFs had their highest Blastp hits in Methanocaldococcus jannaschii, lateral gene transfer or gene loss has apparently resulted in genes, which are often clustered, with top Blastp hits in more distantly related groups.

Hypervariability, suppressed recombination and the genetics of individuality

We define 'genetic individuality' as intraspecies variation that has substantial heritability and involves traits that are sufficiently common that they can be observed in any modest-sized sampling of individuals. We propose that genetic individuality is largely shaped by the combinatory shuffling of a modest number of genes, each of which exists as a family of functionally and structurally diverged alleles. Unequivocal examples of such allele families are found at the O-antigen-biosynthetic locus in Pseudomonas aeruginosa and the human leucocyte antigen locus in humans. We examine characteristic features of these allele families and explore the possibility that genetic loci with similar characteristics can be recognized in a whole-genome scan of human genetic variation.