De Novo Donor-Specific HLA Antibody Formation in Two Patients With Crigler-Najjar Syndrome Type I Following Human Hepatocyte Transplantation With Partial Hepatectomy Preconditioning

Clinical hepatocyte transplantation is hampered by low engraftment rates and gradual loss of function resulting in incomplete correction of the underlying disease. Preconditioning with partial hepatectomy improves engraftment in animal studies. Our aim was to study safety and efficacy of partial hepatectomy preconditioning in clinical hepatocyte transplantation. Two patients with Crigler-Najjar syndrome type I underwent liver resection followed by hepatocyte transplantation. A transient increase of hepatocyte growth factor was seen, suggesting that this procedure provides a regenerative stimulus. Serum bilirubin was decreased by 50%, and presence of bilirubin glucuronides in bile confirmed graft function in both cases; however, graft function was lost due to discontinuation of immunosuppressive therapy in one patient. In the other patient, serum bilirubin gradually increased to pretransplant concentrations after ≈600 days. In both cases, loss of graft function was temporally associated with emergence of human leukocyte antigen donor-specific antibodies (DSAs). In conclusion, partial hepatectomy in combination with hepatocyte transplantation was safe and induced a robust release of hepatocyte growth factor, but its efficacy on hepatocyte engraftment needs to be evaluated with additional studies. To our knowledge, this study provides the first description of de novo DSAs after hepatocyte transplantation associated with graft loss.

Incidence and prognostic impact of other cancers in a population of long-term survivors of chronic lymphocytic leukemia

BACKGROUND

Information on the impact of other cancers (OCs) in long-term survivors (LTSs) of chronic lymphocytic leukemia (CLL) is limited.

PATIENTS AND METHODS

Patients with CLL who survived >10 years were defined as LTSs of CLL. We calculated standardized incidence ratios (SIRs) to compare the incidence of OC in LTS of CLL versus the general population. A multivariable model was used to identify independent predictors of OC. Overall survival was analyzed as a function of the presence of OC.

RESULTS

Among 797 LTSs of CLL, the cumulative frequency of OC was 36%, similar between 570 patients (72%) who required treatment for CLL (TRT) and 227 (28%) who remained untreated (UT). The most common OC in both groups was non-melanoma skin cancer, followed by prostate cancer, breast cancer, melanoma, lung cancer, and leukemia in TRT patients, and by prostate cancer, breast cancer, melanoma, lung cancer, and gastrointestinal tumors in the UT group. The SIR for all OC was 1.2 (P = 0.034). It was higher in males (SIR 1.31; P = 0.013) and patients <60 years (SIR 1.27; P = 0.027). A higher SIR was shown for secondary leukemia, melanoma, and head-and-neck cancers, whereas a lower SIR was found for gastrointestinal and bladder cancers. Independent predictors of OC development were advanced age, male gender, and lower platelets. The survival of patients with OC was 16.2 months and that of patients without OC 22.9 years.

CONCLUSIONS

LTSs of CLL have an increased incidence of OC compared with the general population. CLL therapy is not a risk factor for OC in LTSs of CLL. The presence of an OC in these patients may be associated with shorter survival.

Targeted prostate cancer screening in men with mutations in BRCA1 and BRCA2 detects aggressive prostate cancer: preliminary analysis of the results of the IMPACT study

OBJECTIVE

To evaluate the role of targeted prostate cancer screening in men with BRCA1 or BRCA2 mutations, an international study, IMPACT (Identification of Men with a genetic predisposition to ProstAte Cancer: Targeted screening in BRCA1/2 mutation carriers and controls), was established. This is the first multicentre screening study targeted at men with a known genetic predisposition to prostate cancer. A preliminary analysis of the data is reported.

PATIENTS AND METHODS

Men aged 40-69 years from families with BRCA1 or BRCA2 mutations were offered annual prostate specific antigen (PSA) testing, and those with PSA > 3 ng/mL, were offered a prostate biopsy. Controls were men age-matched (± 5 years) who were negative for the familial mutation.

RESULTS

In total, 300 men were recruited (205 mutation carriers; 89 BRCA1, 116 BRCA2 and 95 controls) over 33 months. At the baseline screen (year 1), 7.0% (21/300) underwent a prostate biopsy. Prostate cancer was diagnosed in ten individuals, a prevalence of 3.3%. The positive predictive value of PSA screening in this cohort was 47·6% (10/21). One prostate cancer was diagnosed at year 2. Of the 11 prostate cancers diagnosed, nine were in mutation carriers, two in controls, and eight were clinically significant.

CONCLUSIONS

The present study shows that the positive predictive value of PSA screening in BRCA mutation carriers is high and that screening detects clinically significant prostate cancer. These results support the rationale for continued screening in such men.

ADME transcriptome in Hispanic versus White donor livers: Evidence of a globally enhanced NR1I3 (CAR, constitutive androstane receptor) gene signature in Hispanics

Previous studies have found that, compared with Whites, Hispanic donor livers had elevated expression of CYP2 enzymes, gene products regulated by the constitutive androstane receptor (CAR). The objectives of the current study were to determine (1) the CAR activation signature in human liver (2) whether other drug detoxification (absorption, distribution, metabolism and excretion (ADME)) genes were differentially expressed in Hispanic versus White livers, and (3) the extent of overlap in the CAR and Hispanic liver transcriptomes. The CAR transcriptome (ADME genes differentially expressed following phenobarbital versus vehicle treatment of human hepatocytes) and the Hispanic liver transcriptome (ADME genes differentially expressed in Hispanic versus White livers) were identified using Affymetrix oligonucleotide arrays. Quantitative real-time polymerase chain reaction (PCR) was used to verify candidate genes in a larger sample size. Comparison of the CAR and Hispanic liver ADME transcriptomes revealed a significant association between the gene changes. Sixty-four per cent of the ADME genes induced more than twofold by phenobarbital were also induced in Hispanics, and 14% of the ADME genes repressed more than twofold by phenobarbital were repressed in Hispanics. In conclusion, compared with Whites, Hispanic donor livers have increased expression of many genes that are transcriptionally regulated by CAR. This result has practical implications to the drug treatment of Hispanic patients.

Hyperglycemia and obesity in patients (pts) with acute lymphoblastic leukemia (ALL): Association with prevalence, response, and survival

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Increasing evidence suggests associations between obesity, diabetes and/or hyperglycemia (DM/HG) and solid tumors. Less is known about the relationship of these metabolic factors to the hematologic malignancies. To determine the prevalence of DM/HG and obesity in pts with ALL and whether these are predictors of response and survival, we conducted a retrospective chart review of 299 pts with newly diagnosed ALL, who were evaluated at our institution between November 1999 and May 2005 and received hyper-CVAD therapy: fractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone alternating with methotrexate and high-dose cytarabine. Median age was 43 yrs (range 15–83). Sixty-one percent of pts were male, and 39% female. Seventy-four percent had a diagnosis (dx) of precursor B cell ALL (22% Ph+), 18% Burkitt's ALL, 6% lymphoblastic lymphoma, 2% other. Prior to therapy, the overall prevalence of DM/HG (diabetes based on reported dx prior to ALL-dx, and hyperglycemia based on baseline serum glucose ≥200 mg/dL) was 16%. Pts with DM/HG were significantly older than those without DM/HG (median age 57 yrs vs. 40 yrs, p<0.001). Complete remission (CR) rate and the CR duration (CRD) were similar in the DM/HG vs. non-DM/HG group. However, the mean CRD was 80 wks in the HG separately group and 121 wks in the non-HG group (p=0.04). The mean CRD was 102 wks in the obese pts and 124 wks in the non-obese pts (p=.04). In univariate analysis, DM/HG, obesity, and older age were associated with shorter overall survival (OS). Mean OS of pts with DM/HG was 134 vs. 194 wks for pts without DM/HG, (p=0.2). Mean OS of obese pts was 136 vs. 199 wks for non-obese pts, (p=0.01). In a multivariable Cox regression model, the only factors that remained significant for survival were age, obesity, and white blood cell count (WBC). There was no significant difference in OS by leukemia diagnosis. In conclusion, the prevalence data suggests that DM/HG may be involved in the development of ALL. However, DM/HG has no impact on survival, probably because of its strong correlation with age. The association of obesity with shorter OS warrants further investigation.

No significant financial relationships to disclose.

Disrupted bile acid homeostasis reveals an unexpected interaction among nuclear hormone receptors, transporters, and cytochrome P450

Sister of P-glycoprotein (SPGP) is the major hepatic bile salt export pump (BSEP). BSEP/SPGP expression varies dramatically among human livers. The potency and hierarchy of bile acids as ligands for the farnesyl/bile acid receptor (FXR/BAR) paralleled their ability to induce BSEP in human hepatocyte cultures. FXR:RXR heterodimers bound to IR1 elements and enhanced bile acid transcriptional activation of the mouse and human BSEP/SPGP promoters. In FXR/BAR nullizygous mice, which have dramatically reduced BSEP/SPGP levels, hepatic CYP3A11 and CYP2B10 were strongly but unexpectedly induced. Notably, the rank order of bile acids as CYP3A4 inducers and activators of pregnane X receptor/steroid and xenobiotic receptor (PXR/SXR) closely paralleled each other but was markedly different from their hierarchy and potency as inducers of BSEP in human hepatocytes. Moreover, the hepatoprotective bile acid ursodeoxycholic acid, which reverses hydrophobic bile acid hepatotoxicity, activates PXR and efficaciously induces CYP3A4 (a bile-metabolizing enzyme) in primary human hepatocytes thus providing one mechanism for its hepatoprotection. Because serum and urinary bile acids increased in FXR/BAR -/- mice, we evaluated hepatic transporters for compensatory changes that might circumvent the profound decrease in BSEP/SPGP. We found weak MRP3 up-regulation. In contrast, MRP4 was substantially increased in the FXR/BAR nullizygous mice and was further elevated by cholic acid. Thus, enhanced hepatocellular concentrations of bile acids, due to the down-regulation of BSEP/SPGP-mediated efflux in FXR nullizygous mice, result in an alternate but apparent compensatory up-regulation of CYP3A, CYP2B, and some ABC transporters that is consistent with activation of PXR/SXR by bile acids.

The human pregnane X receptor: genomic structure and identification and functional characterization of natural allelic variants

The pregnane X receptor (PXR)/steroid and xenobiotic receptor (SXR) transcriptionally activates cytochrome P4503A4 (CYP3A4) when ligand activated by endobiotics and xenobiotics. We cloned the human PXR gene and analysed the sequence in DNAs of individuals whose CYP3A phenotype was known. The PXR gene spans 35 kb, contains nine exons, and mapped to chromosome 13q11-13. Thirty-eight single nucleotide polymorphisms (SNPs) were identified including six SNPs in the coding region. Three of the coding SNPs are non-synonymous creating new PXR alleles [PXR*2, P27S (79C to T); PXR*3, G36R (106G to A); and PXR*4, R122Q (4321G to A)]. The frequency of PXR*2 was 0.20 in African Americans and was never found in Caucasians. Hepatic expression of CYP3A4 protein was not significantly different between African Americans homozygous for PXR*1 compared to those with one PXR*2 allele. PXR*4 was a rare variant found in only one Caucasian person. Homology modelling suggested that R122Q, (PXR*4) is a direct DNA contact site variation in the third alpha-helix in the DNA binding domain. Compared with PXR*1, and variants PXR*2 and PXR*3, only the variant PXR*4 protein had significantly decreased affinity for the PXR binding sequence in electromobility shift assays and attenuated ligand activation of the CYP3A4 reporter plasmids in transient transfection assays. However, the person heterozygous for PXR*4 is normal for CYP3A4 metabolism phenotype. The relevance of each of the 38 PXR SNPs identified in DNA of individuals whose CYP3A basal and rifampin-inducible CYP3A4 expression was determined in vivo and/or in vitro was demonstrated by univariate statistical analysis. Because ligand activation of PXR and upregulation of a system of drug detoxification genes are major determinants of drug interactions, it will now be useful to extend this work to determine the association of these common PXR SNPs to human variation in induction of other drug detoxification gene targets.

Sequence diversity in CYP3A promoters and characterization of the genetic basis of polymorphic CYP3A5 expression

Variation in the CYP3A enzymes, which act in drug metabolism, influences circulating steroid levels and responses to half of all oxidatively metabolized drugs. CYP3A activity is the sum activity of the family of CYP3A genes, including CYP3A5, which is polymorphically expressed at high levels in a minority of Americans of European descent and Europeans (hereafter collectively referred to as 'Caucasians'). Only people with at least one CYP3A5*1 allele express large amounts of CYP3A5. Our findings show that single-nucleotide polymorphisms (SNPs) in CYP3A5*3 and CYP3A5*6 that cause alternative splicing and protein truncation result in the absence of CYP3A5 from tissues of some people. CYP3A5 was more frequently expressed in livers of African Americans (60%) than in those of Caucasians (33%). Because CYP3A5 represents at least 50% of the total hepatic CYP3A content in people polymorphically expressing CYP3A5, CYP3A5 may be the most important genetic contributor to interindividual and interracial differences in CYP3A-dependent drug clearance and in responses to many medicines.

Neonatal outcome of preimplantation genetic diagnosis by polar body removal: the first 109 infants

CONTEXT

Our center developed the technique of preimplantation genetic diagnosis (PGD) by sequential polar body removal (PBR) for the diagnosis of Mendelian disorders and aneuploidies. This study examines the obstetric and neonatal outcome of the first 109 live births after PGD by PBR.

OBJECTIVE

To determine if there were any observable effects of PGD by PBR on perinatal morbidity and mortality, birth defects, and growth parameters.

DESIGN

Data on perinatal outcome were gathered for the first 109 infants by parental reporting and confirmed by telephone interview and chart review when indicated. In infants >6 months old, a follow-up telephone interview was performed establishing the developmental milestones attained by the child.

SETTING

A research center conducting an institutional review board-approved research protocol in PGD.

PATIENTS

All patients who had PGD by PBR who had clinical pregnancies.

MAIN OUTCOME MEASURES

Gestational age, mode of delivery, perinatal mortality, birth weight, birth length, the presence of birth defects, and developmental milestones.

RESULTS

There was no significant decrease in birth length or weight, or the frequency of small for gestational age infants. No specific pattern of birth defects was observed.

CONCLUSION

Thus far, there are no observable detrimental effects of PGD by PBR on children born after the procedure.

Obstetric outcomes in 102 pregnancies after preimplantation genetic diagnosis

OBJECTIVE

We sought to determine whether preimplantation genetic diagnosis is associated with particular pregnancy or delivery complications.

STUDY DESIGN

A total of 102 consecutive pregnancies after preimplantation genetic diagnosis by polar body removal performed at Illinois Masonic Medical Center resulting in 114 live births were analyzed. All patients were given a delivery and newborn questionnaire, and attempts were made to contact and question them regarding any pregnancy complications and type of delivery. Permission was obtained to examine medical records and discuss the patient's pregnancy with her obstetrician when questions existed with respect to complications or indication for cesarean delivery.

RESULTS

Delivery and newborn questionnaires were completed or telephone contact was achieved for 100 of the 102 pregnancies. There were 85 singleton, 9 twin, and 7 triplet pregnancies. Of the 7 triplet gestations, 3 couples elected multifetal pregnancy reduction to twins and healthy triplets were born to 4 couples between 32 and 36 weeks by cesarean delivery. Of the 80 singleton deliveries, 60 (75%) progressed to term. Of these 60 term singleton deliveries, 34 were vaginal, 23 were cesarean (40%), and 3 delivery types were unknown. The incidence of small-for-gestational-age infants was 3% for neonates in the 60 term singleton deliveries and 7% in the entire cohort of 80 singleton deliveries. Only 3 pregnancy complications (other than premature delivery) were reported more than once. There were 3 instances each of gestational diabetes, intrauterine growth restriction, and pregnancy-induced hypertension. There was 1 case each of HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, congestive heart failure, mild oligohydramnios, and abruptio placentae. The indications for cesarean delivery were (in descending order) failure of labor to progress (n = 7), fetal distress (n = 4), placenta previa (n = 4), elective repeat cesarean delivery (n = 4), triplets (n = 3), uterine scarring (n = 3), 1 twin in the breech position (n = 3), failed forceps delivery (n = 2), and a variety of other indications that occurred in only 1 patient each. All preimplantation genetic diagnoses were confirmed by prenatal or postnatal testing. No diagnostic errors were made in this cohort of patients or in any patients undergoing preimplantation genetic diagnosis having polar body removal in our center.

CONCLUSIONS

Preimplantation genetic diagnosis is associated with a risk of multiple gestations, cesarean delivery, and placenta previa. Cesarean delivery rates and multiple gestation rates are comparable to those of patients undergoing in vitro fertilization in general. The preimplantation genetic diagnosis itself does not seem to cause an increased risk for any particular pregnancy complication, with the possible exception of placenta previa, which was seen in 4% of patients.

Defining hepatocellular chimerism in a liver failure patient bridged with hepatocyte infusion

BACKGROUND

A practical method of monitoring engraftment by transplanted hepatocytes for the purpose of bridging human liver failure to native regeneration is described.

METHODS

A previously healthy 37-year-old female with a 2-week history of a febrile illness presented with fulminant liver failure. Findings on admission included the following: illicit drug use, serum hepatitis B surface antigen positive, grade 1 encephalopathy, prothrombin time (pt) >100 sec, F7<1%, NH3 150 micromol/L, alanine aminotransferase 4079 U/L, total bilirubin level 11.4 mg/dl, and glucose 70 mg/dl (on IV D10). With immunosuppression, 8.8x10(8), 96% viable human hepatocytes were intraportally infused. Clinical chemistries, total sHLA class I, and ELISA to measure donor-specific sHLA-A1 and -B8 were recorded. Serial transjugular liver biopsies were performed and pooled for histological examination, DNA extraction, and HLA DNA typing.

RESULTS

The patient fully recovered. At months 3 and 4 with donor biopsy specimen class I HLA DNA no longer detectable, immunosuppression was tapered off. The patient is clinically normal, serum hepatitis B surface antigen negative at 10 months of follow-up.

CONCLUSIONS

Bridging liver failure with donor hepatocytes with HLA class I antigen disparate from recipients is clinically feasible, and allows for a marker, combined with serial graft histology, to safely wean immunosuppression when native liver regeneration succeeds.

Building a theory of grandparent development

A theory of grandparent development is described that includes the formulation of assumptions, goals for guiding instruction, curriculum design, and a measurement tool to assess learning needs and evaluate the effects of educational intervention. Cultural considerations are illustrated by a three generational study of African-American (n = 777), Caucasian (n = 1086), and Hispanic (n = 672) subjects who were administered the Grandparent Strengths and Needs Inventory. Perceptions of each generation about the attitudes and behaviors of grandparents were examined with multivariate analysis of variance and post-hoc comparisons to analyze the scores, confirm results, and facilitate interpretation of findings. Results showed significant differences between generations and within cultures. Each generation identified elements of grandparent success as well as issues that deserve consideration in building educational programs.

Current status of intestinal transplantation in children

PURPOSE

A clinical trial of intestinal transplantation (Itx) under tacrolimus and prednisone immunosuppression was initiated in June 1990 in children with irreversible intestinal failure and who were dependent on total parenteral nutrition (TPN).

METHODS

Fifty-five patients (28 girls, 27 boys) with a median age of 3.2 years (range, 0.5 to 18 years) received 58 intestinal transplants that included isolated small bowel (SB) (n = 17), liver SB (LSB) (n=33), and multivisceral (MV) (n=8) allografts. Nine patients also received bone marrow infusion, and there were 20 colonic allografts. Azathioprine, cyclophosphamide, or mycophenolate mofetil were used in different phases of the series. Indications for Itx included: gastroschisis (n=14), volvulus (n=13), necrotizing enterocolitis (n=6), intestinal atresia (n=8), chronic intestinal pseudoobstruction (n=5), Hirschsprung's disease (n=4), microvillus inclusion disease (n=3), multiple polyposis (n=1), and trauma [n=1).

RESULTS

Currently, 30 patients are alive (patient survival, 55%; graft survival, 52%). Twenty-nine children with functioning grafts are living at home and off TPN, with a mean follow-up of 962 (range, 75 to 2,424) days. Immunologic complications have included liver allograft rejection (n=18), intestinal allograft rejection (n=52), posttransplant lymphoproliferative disease (n=16), cytomegalovirus (n=16) and graft-versus-host disease (n=4). A combination of associated complications included intestinal perforation (n=4), biliary leak (n=3), bile duct stenosis (n=1), intestinal leak (n=6), dehiscence with evisceration (n=4), hepatic artery thrombosis (n=3), bleeding (n=9), portal vein stenosis (n=1), intraabdominal abscess (n=11), and chylous ascites (n=4). Graft loss occurred as a result of rejection (n=8), infection (n=12), technical complications (n=8), and complications of TPN after graft removal (n=3). There were four retransplants (SB, n=1; LSB n=3).

CONCLUSIONS

Intestinal transplantation is a valid therapeutic option for patients with intestinal failure suffering complications of TPN. The complex clinical and immunologic course of these patients is reflected in a higher complication rate as well as patient and graft loss than seen after heart, liver, and kidney transplantation, although better than after lung transplantation.

Long-term follow-up of patients with newly diagnosed acute myeloid leukemia treated at the University of Texas M.D. Anderson Cancer Center

BACKGROUND

Chemotherapy is known to cure a small minority of patients with acute myeloid leukemia (AML). Less is known about the risk of such patients developing subsequent cancers or about their ability to return to work.

METHODS

The authors analyzed outcomes among 1892 patients who received treatment for newly diagnosed AML at the University of Texas M. D. Anderson Cancer Center from 1965 to May 1995.

RESULTS

Because failure rates declined to relatively low levels after a first or later complete remission of > or = 3 years' duration, such patients comprised a "potentially cured" cohort. The criterion for entry into this cohort was fulfilled by 215 patients (10.7%; 203 in first complete remission and 12 in second remission). At a median of 6.2 years after entry into the cohort (i.e., 9.2 years from complete remission), 163 patients (76%) remain alive and in complete remission. Approximately 9% and 5% of the 1892 patients have been in complete remission for > 5 years and > 10 years, respectively. The pretreatment prognostic importance of cytogenetics is still apparent even after 5 years in complete remission. On average, members of the potentially cured cohort were not observed to be at increased risk of subsequent invasive malignancies compared with a normal population. Furthermore, two-thirds of those in the potentially cured cohort who were working full time before diagnosis of AML claimed to have returned to full-time work. Of those not working, only 10% cited physical limitation as the reason.

CONCLUSIONS

The major threat to the life and well-being of the patient with AML is clearly the disease and not its treatment.

Black grandparents: curriculum development

The performance of Black grandparents was examined to determine the most suitable content for an educational program intended to assist them in their role. A sample of 626 non-consanguineous subjects included 204 grandparents, 128 parents, and 294 grandchildren. Each generation group completed a separate version of the Grandparent Strengths and Needs Inventory to identify the favorable qualities of grandparents and aspects of their relationships in which further growth was necessary. A combination of multivariate analysis of variance procedures, univariate analysis of variance tests, and t-tests were used to analyze scores, confirm results, and assist with interpretation of data. All groups described aspects of grandparents success and made known specific realms of learning that grandparents should acquire in order to become more effective. Analysis of the responses revealed significant main effects for generation, gender of grandchild, age of grandchild, and amount of time that grandparent and grandchild spent together. Considerations were identified for improving grandparent influence and guiding the development of grandparent education programs.

Identification of a novel dexamethasone responsive enhancer in the human CYP3A5 gene and its activation in human and rat liver cells

The human liver cytochromes P450 3A (CYP3As), orthologous to the rat glucocorticoid inducible forms, are composed of at least four differentially expressed members. To begin the study of the molecular events in the glucocorticoid regulation of CYP3A5, we fused 5' sequences of CYP3A5 to the chloramphenicol acetyltransferase gene in a vector that contains the herpes simplex virus thymidine kinase promoter. In HepG2 cells, the largest 5' CYP3A5 gene fragment (1.4 kb) suppressed the TK promoter. However, suppression was overcome by addition of 10 microM dexamethasone. A series of unidirectional deletions revealed a unique 219-bp fragment (-891 to -1109 bp upstream from the transcriptional start site) that conferred dexamethasone responsiveness on the TK promoter regardless of either the distance or orientation from the promoter and thus appears to be an enhancer. Nucleotide sequence analysis of this CYP3A5 enhancer revealed no consensus 15-bp glucocorticoid responsive element (GRE) (GGTACANNNTGTTCT); however, two GRE "half-sites" (TGTTCT) were found separated by 160 bp. Although dexamethasone stimulated the CYP3A5 enhancer only 3-4-fold in HepG2 cells, the CYP3A5 enhancer was stimulated 7- and 12-fold in immortalized primary human hepatocytes and primary rat hepatocyte cultures, respectively. The glucocorticoid receptor (GCR) seems to be indispensable to this process because 1) dexamethasone induction can be blocked by the antiglucocorticoid RU-486, 2) dexamethasone-dependent transcriptional activation of the CYP3A5 enhancer in HepG2 cells required cotransfection of an expression vector containing the intact GCR, yet 3) cotransfection with a plasmid that contains a mutation in the ligand binding domain of the GCR does not activate the CYP3A5 enhancer in the presence of dexamethasone. To further localize the dexamethasone responsive region of the 219-bp CYP3A5 enhancer, it was subdivided and fused to the TKCAT expression vector. Transfection analysis in HepG2 cells demonstrated that neither GRE half-site can independently confer dexamethasone responsiveness on the TK promoter. Block mutations of either of the two GRE half-sites or point mutations at specific GCR binding sites eliminates dexamethasone inducibility, demonstrating the half-sites need to interact. Electromobility shift assays indicate that the CYP3A5 5'-GRE half-site 1) specifically binds purified GCR, 2) can displace binding of the GCR to a consensus GRE, and 3) shifts a protein in HepG2 nuclear extracts that is supershifted by GCR antibody, demonstrating that this enhancer is an authentic GRE. This is the first study to demonstrate that a member of the human CYP3A gene family contains an enhancer that binds the GCR and that this binding is critical to transcriptional activation by dexamethasone.

Grandparents in Taiwan: a three-generational study

Grandparents in the Republic of China want to remain influential, but social policy has not provided them with education to fulfill their changing role. The performance of grandparents was examined to determine suitable content for an intervention program. A sample of 751 non-consanguineous participants from urban and rural Taiwan included 234 grandparents, 241 parents, and 276 grandchildren. Each generation was administered a separate version of the Grandparent Strengths and Needs Inventory that was translated into Mandarin. Respondents identified favorable qualities of grandparents as well as aspects of their relationships in which growth was necessary. Multivariate analysis of variance, univariate analysis of variance, Scheffé and t-tests were used to analyze scores, confirm results, and facilitate interpretation. All three generations described aspects of grandparent success and specific realms of learning they should acquire to become more effective. Significant main effects that influenced responses about grandparent performance were generation, gender of grandchild, age of grandchild, frequency of grandchild care by grandparent, generations living together, and amount of time grandparent and grandchild spent together. Considerations were recommended to improve behavior of grandparents and guide the development of educational programs for them.

Grandparents in Japan: a three-generational study

Grandparents in Japan believe that their status in the family is eroding. They want to be influential but social policy has not included education for their changing role. The purpose of this study was to identify strengths and needs of Japanese grandparents as perceived by three generations. Each generation completed a separate version of the Grandparent Strengths and Needs Inventory. Multivariate analysis of variance procedures were used to compare perceptions of 239 grandparents, 266 parents, and 274 school-age grandchildren from cities and small towns. Grandparents reported more satisfaction, greater success, and more extensive involvement in teaching than was observed by parents and grandchildren. Grandparents experienced greater difficulty, more frustration, and felt less informed to carry out their role than was reported by parents and grandchildren. Significant main effects that influenced responses about grandparent performance were generation, gender of grandchild, age of grandchild, generations living together, frequency of grandchild care by grandparent, and amount of time they spent together. Considerations were identified to improve grandparent behavior and guide the development of educational programs for them.

Strengths and needs of black grandparents

This study was conducted to identify ethnic differences in grandparent performance and effectiveness so that an educational program called Becoming A Better Grandparent could be adapted to maximize its relevance for Black families. MANOVA procedures were used to compare perceptions of 204 Anglo grandparents and 204 Black grandparents as well as 175 Anglo and 295 Black grandchildren. Black grandparents perceived themselves more favorably than did Anglos on every subscale of the Grandparent Strengths and Needs Inventory. Black grandchildren assigned grandparents significantly more favorable ratings for teaching and overall success, whereas Anglo grandchildren assigned their grandparents higher scores for coping with difficulty, managing frustration, and meeting information needs. Analyses of grandparent responses revealed significant main effects for age of grandparent, age of grandchild, time spent together, and geographical proximity. Grandchildren responses yielded significant main effects for age of grandchild and time spent together. Findings showed interaction effects for ethnicity by age of grandparent, ethnicity by age of grandchild, and ethnicity by distance. Implications for modifying the program to fit Black grandparents were identified.

Segregation analysis of cancer in families of childhood soft-tissue-sarcoma patients

This paper presents the analysis of familial cancer data collected in a hospital-based study of 159 childhood soft-tissue-sarcoma patients. Two different statistical models detected excess aggregation of cancer, which could be explained by a rare dominant gene. For each kindred, we estimated the probability of the observed cancer distribution under the dominant-gene model and identified 12 families that are the most likely to be segregating the gene. Two of those families have confirmed germ-line mutations in the p53 tumor-suppressor gene. The relative risk of affection for children who are gene carriers was estimated to be 100 times the background rate. Females were found to have a slightly higher age-specific penetrance, but maternal and paternal lineages made equal contributions to the evidence in favor of the dominant gene. The proband's histology, ethnicity, and age at diagnosis were evaluated to determine whether any of these altered the probability of affection in family members. Only embryonal rhabdomyosarcoma was found to be a significant covariate under the dominant-gene model. While molecular genetic studies of familial cancer will eventually provide answers to the questions of genetic heterogeneity, age- and site-specific penetrance, mutation rates, and gene frequency, information from statistical models is useful for setting priorities and defining hypotheses.

Localization of epidermal growth factor receptor by immunohistochemical methods in human prostatic carcinoma, prostatic intraepithelial neoplasia, and benign hyperplasia

The epidermal growth factor receptor (EGFr) is a membrane-bound glycoprotein that is present in a wide variety of human normal and malignant tissues. In this study EGFr expression in frozen sections of prostate tissue obtained from 40 different surgical specimens was examined immunohistochemically with a well-characterized monoclonal antibody to EGFr, Ab-1 (Oncogene Science). Twenty cases of prostate adenocarcinoma and 20 cases of benign prostatic hyperplasia were studied. Six of the 20 cases of adenocarcinoma also contained prostatic intraepithelial neoplasia grade III (severe intraductal dysplasia). All of the cases containing benign glands showed strong immunostaining in a continuous or nearly continuous pattern, with staining restricted to the basal layer of the benign glands. Adenocarcinoma lacked immunostaining in 15 (75%) of 20 cases, while the remaining five cases (25%) showed diffuse cytoplasmic staining, which was weaker than that seen in the benign glands and that lacked basal accentuation. The six cases that contained prostatic intraepithelial neoplasia grade III showed a discontinuous basal pattern of staining, and the gaps in the staining appeared to correspond to areas of disruption of the basal cell layer. We conclude that the antigenic determinant recognized by this antibody to EGFr was detected preferentially in the basal layer in benign prostatic glands. In contrast, a minority of cases of adenocarcinoma expressed EGFr, as assessed by immunoreactivity with the Ab-1 monoclonal antibody. Prostatic intraepithelial neoplasia grade III expressed EGFr with a predominantly discontinuous basal pattern that corresponded to the disrupted basal cell layer typical of this process.

Interleukin-1 beta, human leukocyte antigen HLA-DR alpha, and transforming growth factor-beta expression in endometrium, placenta, and placental membranes

Maternal immune recognition of the fetal semiallograft appears to be necessary and beneficial for fetal survival and growth. Interleukin-1 beta and human leukocyte antigen HLA-DR are important for foreign antigen recognition by the immune system, whereas transforming growth factor-beta inhibits many of the immunostimulatory properties of interleukin-1 beta. In this study we found that first-trimester decidua and term placental membranes expressed significantly higher levels of interleukin-1 beta, interleukin-1 beta messenger ribonucleic acid, and human leukocyte antigen HLA-DR alpha messenger ribonucleic acid expression. All tissues found at the maternal-fetal interface, including first-trimester decidua, placenta, and placental membranes, contained transforming growth factor-beta and expressed transforming growth factor-beta 1 messenger ribonucleic acid. On the basis of these findings, we suggest that the increase in decidual interleukin-1 beta and human leukocyte antigen HLA-DR alpha during pregnancy may be involved in maternal recognition of the fetal semiallograft and that transforming growth factor-beta production may regulate the local maternal immune response and prevent rejection of the fetus.

Raising expectations for grandparents: a three generational study

Previous research resulted in the nation's first curriculum for grandparents. To determine the program benefits, 210 experimental subjects received instruction. Each of these persons chose one son or daughter and one grandchild to help evaluate changes in grandparent attitudes and behavior. All three generations completed separate versions of the Grandparent Strengths and Needs Inventory prior to the classes, at the end of intervention, and three months later. Posttesting of grandparents revealed significant improvement. These gains were corroborated by parents and grandchildren. Multivariate analyses identified the impact of eleven independent variables on grandparent performance. A control group of 185 subjects made no improvement.

Grandparents and learning

The educational needs of grandparents have been overlooked. They deserve access to a curriculum that can help them adjust to their changing role and illustrate how to build satisfying family relationships. In order to identify appropriate topics and instructional procedures for grandparent education, weekly meetings were held for a semester with 400 grandmothers and grandfathers. The resulting program includes experiences in sharing feelings and ideas with peers; listening to the views of younger people; studying lifespan growth and adjustment; acquiring intergenerational communication skills; and focusing self-evaluation. A fieldtest involving several hundred participants, equally divided into experimental and control groups, is underway to determine the worthwhileness of this approach to family development.

Epstein-Barr virus-associated lymphoproliferative disorder. Applications of immunoperoxidase and molecular biologic techniques

A 17-year-old boy with fever and cervical lymphadenopathy developed multiple-organ failure and died three weeks after hospital admission. A lymph node biopsy specimen demonstrated a florid immunoblastic infiltrate that was suspicious for a malignant lymphoma. By using immunoperoxidase and molecular biologic techniques, evidence was presented for an Epstein-Barr virus-associated lymphoproliferative disorder.

Cytotoxic studies in human newborns: lessened allogeneic cell-induced (augmented) cytotoxicity but strong lymphokine-activated cytotoxicity of cord mononuclear cells

Nonspecific cytotoxic responses such as natural killer activity can be increased in vitro by incubating effector cells with soluble factors or allogeneic cells. We sought to determine if newborn cells, known to be deficient in most cytotoxic responses, including resting NK activity, could develop enhanced cytotoxic responses following incubation with allogeneic cells (augmented cytotoxicity) or with lymphokines (lymphokine-activated cytotoxicity). Cord whole mononuclear cells (WMC) incubated with irradiated Raji cells for 5 days develop lower levels of cytotoxicity toward K562 targets at both a 20:1 effector:target (E:T) ratio (39 +/- 2.7% vs 49 +/- 3.6%) and a 10:1 E:T ratio (29 +/- 2.6% vs 40 +/- 3.6%) than do adult cells. Lessened specific cytotoxicity of cord cells developed toward the sensitizing Raji cells was also observed at both E:T ratios. Attempts to enhance the induced cytotoxicity by incubation with interferon or isoprinosine were unsuccessful. In contrast, lymphokine (i.e., interleukin 2)-activated killer (LAK) cytotoxicity is not deficient in cord WMC. Indeed, the level of LAK cytotoxicity is equivalent to that observed with similarly treated adult cells despite a lower baseline level of cytotoxicity toward the target cells. In the presence of purified IL-2 for 5 days, cord WMC cytotoxicity against K562 cells increased from 12 +/- 2.6 to 71 +/- 4.2% and against Raji cells increased from 9.6 +/- 2.5 to 48 +/- 6.7%. Similarly treated adult cells increased their killing against K562 from 23 +/- 4.2 to 61 +/- 4.5% and against Raji from 12 +/- 3.0 to 36 +/- 5.3%. This substantial lymphokine-activated cytotoxicity of newborn cells suggests the possibility of therapeutic intervention with purified lymphokines in neonatal infections or neoplasms.

Assessment of unscheduled and replicative DNA synthesis in hepatocytes treated in vivo and in vitro with unleaded gasoline or 2,2,4-trimethylpentane

In a recent chronic inhalation exposure study, unleaded gasoline (UG) produced kidney tumors in male rats and liver tumors in female mice, but did not increase the incidence of liver tumors in male mice or rats of either sex. To examine the possible basis for this pattern of hepatocarcinogenesis, unscheduled DNA synthesis (UDS) as an indicator of genotoxic activity and replicative DNA synthesis (RDS) as an indicator of cell proliferation were measured in rat and mouse hepatocytes following in vivo and in vitro exposures to UG and 2,2,4-trimethylpentane (TMP), a nephrotoxic component of UG. Primary hepatocyte cultures, prepared from cells isolated from Fischer-344 rats, B6C3F1 mice, or human surgical material, were incubated with [3H]thymidine and the test agent. UDS was measured by quantitative autoradiography as net nuclear grains (NG). By similar methods, UDS and RDS (S-phase cells) were measured in hepatocytes isolated from rats and mice treated by gavage with TMP (500 mg/kg) or UG (100 to 5,000 mg/kg). A dose-related increase in UDS activity was observed in rat hepatocytes treated in vitro with 0.05 to 0.10% (v/v) UG. These doses were, however, toxic in both mouse and human hepatocyte cultures. Weak UDS activity was observed in hepatocytes isolated from male and female mice treated 12 hr previously with UG. No UDS was induced in rat hepatocytes treated in vivo or in vitro with TMP. Twenty- and fourfold increases in the percentage of cells in S-phase were observed 24 hr after treatment with TMP in male and female mice, respectively, as compared to a fivefold increase in male rats. UG increased the percentage of S-phase cells in male mice by ninefold but failed to induce RDS in females. Thus, there appears to be genotoxic compounds in UG that can be detected in cultured hepatocytes and in the livers of exposed mice. The lack of UDS activity in rat liver was consistent with the reported lack of liver tumors in chronically exposed rats. However, neither the UDS nor the RDS responses in mice exposed by gavage correlated to the sex-specific pattern of liver tumors observed in the 2-year bioassay.

Lack of genotoxic activity of di(2-ethylhexyl)phthalate (DEHP) in rat and human hepatocytes

Di(2-ethylhexyl)phthalate (DEHP) is a widely used plasticizer which has been reported to induce a statistically significant increase in the incidence of hepatocellular carcinomas in female Fischer-344 rats (8/50) when administered in the diet at 12 000 p.p.m. for two years. Numerous studies with cells in culture have failed to show any genotoxic activity associated with DEHP. Because DEHP induces multiple changes in the liver, such as peroxisomal proliferation, it was possible that these alterations could result in genotoxic effects in the treated whole animal that would not be seen in cells in culture. Accordingly, the ability of DEHP to induce DNA damage or repair was examined in rat hepatocytes in vivo and in vitro and in human hepatocytes in vitro. Unscheduled DNA synthesis was measured by incorporation of [3H]thymidine into primary hepatocyte cultures immediately isolated from treated animals or hepatocyte cultures incubated directly with DEHP. DNA damage was measured by alkaline elution of cellular DNA from the same cultures. In vivo-in vitro treatment regimens were: (i) female rats, 12 000 p.p.m. DEHP in the diet for 30 days; (ii) female rats, 12 000 p.p.m. in the diet for 30 days, followed by 500 mg/kg DEHP by gavage 2 h before sacrifice; (iii) male rats, 500 mg/kg DEHP by gavage 2, 12, 24, or 48 h before sacrifice; and (iv) male rats, 150 mg/kg/day by gavage for 14 days. In vitro conditions were 0.1, 1.0 and 10.0 mM DEHP in the cultures for 18 h. Primary cultures of human hepatocytes were prepared from freshly discarded surgical material and exposed to the same concentration of DEHP. Concentrations up to 0.5 mM mono(2-ethylhexyl)phthalate, a principal metabolite of DEHP, were also examined in the human hepatocyte assay. No chemically induced DNA damage or repair was observed in vivo or in vitro in rat or human hepatocytes under any of the conditions employed. However, an increase in the percentage of cells in S-phase in the animals given DEHP was observed. These data indicate that DEHP does not exhibit direct genotoxic activity in the animals even with a treatment regimen which eventually produced tumors in a long term bioassay, and that both rat and human hepatocytes are similar in their lack of a genotoxic response to DEHP exposure in culture.

Induction of DNA repair in human and rat hepatocytes by 1,6-dinitropyrene

1,6-Dinitropyrene (DNP) was found to be an extremely potent genotoxicant in metabolically competent primary cultures of human and rat hepatocytes. Dose-dependent increases in DNA repair as measured by unscheduled DNA synthesis (UDS) were observed in the range from 0.05 to 5 microM 1,6-DNP for both species, indicating that the rat-hepatocyte assay is an appropriate model for assessing genotoxic potential in human hepatocytes for this class of compound. Unlike some nitroaromatic compounds, 1,6-DNP did not require gut flora for metabolic activation. No DNA repair was observed in hepatocytes isolated from rats treated with 50 mg/kg 1,6-DNP in corn oil by gavage 2, 12 or 24 h previously. The reason for the lack of a response in vivo is not known, but may relate to detoxification or distribution of the compound in the animal.

Mutagenesis and DNA binding of benzo(a)pyrene in cocultures of rat hepatocytes and human fibroblasts

The genotoxicity of benzo(a)pyrene (BP) was investigated in combined cultures of rat hepatocytes and human diploid fibroblasts. Freshly isolated rat hepatocytes were shown to activate BP to a species which bound to and damaged hepatocyte and fibroblast DNA. A significant increase in the hypoxanthine-guanine phosphoribosyltransferase mutation frequency was induced when 10 to 100 microM BP was added to the cocultures. A comparative analysis of the binding of BP metabolites to hepatocyte and fibroblast DNA revealed that approximately 4 times more [3H]BP metabolites were bound to the fibroblast DNA than were bound to the hepatocyte DNA (per microgram DNA). Activation of BP by the fibroblasts themselves was shown not to be the cause of the relatively greater binding of BP to fibroblast DNA than to the hepatocyte DNA. These results suggest that proximate and/or ultimately carcinogenic metabolites of BP are readily released from isolated hepatocytes and that the metabolites are sufficiently stable and long lived so as to bind to the DNA of an adjacent cell. The relative protection of the hepatocytic DNA from BP metabolites that generated in the cytoplasm of the hepatocyte may be significant in view of the observations that the liver is not under normal conditions a target of BP carcinogenicity in vivo.

Comparisons of the effects of chemical carcinogens in mixed cultures of rat hepatocytes and human fibroblasts

Unscheduled DNA synthesis (UDS) was measured simultaneously in rat hepatocytes and human fibroblasts when combined cultures of the 2 cell types were exposed to procarcinogens. Human fibroblasts were preincubated with 5-bromo-2'-deoxyuridine (BRdU) to substitute for thymidine in the DNA. Hepatocyte DNA was separated from the heavier BRdU-substituted fibroblast DNA by isopycnic centrifugations in neutral cesium chloride and the specific activities of the DNA's were determined. In the presence of hepatocytes, benzo - [a]pyrene (BP) induced more UDS in the fibroblasts than in the hepatocytes. BP induced no UDS in the fibroblasts in the absence of hepatocytes. Diethylnitrosamine (DEN) and 2-acetylaminofluorene (AAF) stimulated a significant amount of UDS only in the hepatocytes. Thus, the co-cultures of hepatocytes and fibroblasts responded with UDS to these chemical carcinogens in a manner that parallels the tissue specificity of the carcinogenicity of these chemicals in vivo. That is, the known hepatocarcinogens DEN and AAF, only stimulated significant UDS in the hepatocytes, whereas the non-hepatocarcinogen, BP, though activated in these cultures mainly by the hepatocytes, stimulated more UDS in the fibroblasts than in the hepatocytes. The amount of [3H]BP bound to DNA was investigated in the co-cultures and in cultures of fibroblasts alone. When co-cultures were exposed to [3H]BP the fibroblast DNA had approximately 3 times more BP bound to it (per microgram DNA) than did the hepatocyte DNA. The amount of [3H]BP bound to the DNA of cultures of fibroblasts alone was 29% of the amount bound to the DNA of the fibroblasts from the co-cultures. Thus, although the hepatocytes were mainly responsible for the activation of BP, more [3H]BP was bound to the fibroblast DNA. It is suggested that the intercellular distribution of carcinogenic metabolites may be a significant determinant of the carcinogenic effect.