Clonal Hematopoiesis and Cardiovascular Disease in Patients With Multiple Myeloma Undergoing Hematopoietic Cell Transplant

Importance

There is a paucity of information on the association between clonal hematopoiesis of indeterminate potential (CHIP) and cardiovascular disease (CVD) in patients with cancer, including those with multiple myeloma (MM) undergoing hematopoietic cell transplant (HCT), a population at high risk of developing CVD after HCT.

Objective

To examine the association between CHIP and CVD in patients with MM and to describe modifiers of CVD risk among those with CHIP.

Design, Setting, and Participants

This was a retrospective cohort study of patients with MM who underwent HCT between 2010 and 2016 at City of Hope Comprehensive Cancer Center in Duarte, California, and had pre-HCT mobilized peripheral blood stem cell (PBSC) products cryopreserved and accessible for CHIP analyses. The study team performed targeted panel DNA sequencing to detect the presence of CHIP (variant allele frequency 2% or more).

Main Outcomes and Measures

The primary end point was the 5-year cumulative incidence and risk for developing de novo CVD (heart failure, coronary artery disease, or stroke) after HCT.

Results

Of 1036 consecutive patients with MM (580 male [56%]; median age, 60.0 years) who underwent a first autologous HCT, 201 patients had at least 1 CHIP variant (19.4%) and 35 patients had 2 or more variants (3.4%). The 5-year incidence of CVD was significantly higher in patients with CHIP (21.1% vs 8.4%; P < .001) compared with those without CHIP; the 5-year incidence among those with 2 or more variants was 25.6%. In the multivariable model, CHIP was associated with increased risk of CVD (hazard ratio [HR], 2.72; 95% CI, 1.70-4.39), as well as of individual outcomes of interest, including heart failure (HR, 4.02; 95% CI, 2.32-6.98), coronary artery disease (HR, 2.22; 95% CI, 1.06-4.63), and stroke (HR, 3.02; 95% CI, 1.07-8.52). Patients who had both CHIP and preexisting hypertension or dyslipidemia were at nearly 7-fold and 4-fold increased risk of CVD, respectively (reference: no CHIP, no hypertension, or dyslipidemia).

Conclusion and Relevance

CHIP was significantly and independently associated with risk of CVD in patients with MM undergoing HCT and may serve as a novel biologically plausible biomarker for CVD in this cohort. Patients with MM and both CHIP and cardiovascular risk factors had an exceptionally high risk of CVD. Additional studies are warranted to determine if cardiovascular preventive measures can reduce CHIP-associated CVD risk.

A multicenter analysis of the outcomes with venetoclax in patients with relapsed mantle cell lymphoma

To report the activity of venetoclax in patients with relapsed mantle cell lymphoma (MCL), we identified 81 patients treated with venetoclax monotherapy (n = 50, 62%) or in combination with a Bruton tyrosine kinase inhibitor (BTKi) (n = 16, 20%), an anti-CD20 monoclonal antibody (n = 11, 14%), or other active agents at 12 US academic medical centers. Patients had high-risk disease features including Ki67 >30% (61%), blastoid/pleomorphic histology (29%), complex karyotype (34%), and TP53 alterations (49%), and received a median of 3 prior treatments including BTKis in 91%. Venetoclax alone or in combination resulted in an overall response rate (ORR) of 40% and median progression-free (PFS) and overall survival (OS) of 3.7 and 12.5 months, respectively. The receipt of ≤3 prior treatments was associated with higher odds of response to venetoclax in a univariable analysis. In a multivariable analysis, having a high-risk Mantle Cell Lymphoma International Prognostic Index score before receiving venetoclax and disease relapse or progression within 24 months of diagnosis were associated with inferior OS whereas the use of venetoclax in combination was associated with superior OS. Although most patients (61%) had low risk for tumor lysis syndrome (TLS), 12.3% of patients developed TLS despite the implementation of several mitigation strategies. In conclusion, venetoclax resulted in good ORR but short PFS in patients with MCL who are at high risk, and may have a better role in earlier lines of treatment and/or in conation with other active agents. TLS remains an important risk in patients with MCL who initiate treatment with venetoclax.

Identifying monoclonal gammopathy of undetermined significance from electronic health records

BACKGROUND

Monoclonal gammopathy of undetermined significance (MGUS) precedes multiple myeloma (MM). Use of electronic health records may facilitate large-scale epidemiologic research to elucidate risk factors for the progression of MGUS to MM or other lymphoid malignancies.

AIMS

We evaluated the accuracy of an electronic health records-based approach for identifying clinically diagnosed MGUS cases for inclusion in studies of patient outcomes/ progression risk.

METHODS AND RESULTS

Data were retrieved from Kaiser Permanente Southern California's comprehensive electronic health records, which contain documentation of all outpatient and inpatient visits, laboratory tests, diagnosis codes and a cancer registry. We ascertained potential MGUS cases diagnosed between 2008 and 2014 using the presence of an MGUS ICD-9 diagnosis code (273.1). We initially excluded those diagnosed with MM within 6 months after MGUS diagnosis, then subsequently those with any lymphoid malignancy diagnosis from 2007 to 2014. We reviewed medical charts for 100 randomly selected potential cases for evidence of a physician diagnosis of MGUS, which served as our gold standard for case confirmation. To assess sensitivity, we also investigated the presence of the ICD-9 code in the records of 40 randomly selected and chart review-confirmed MGUS cases among patients with a laboratory report of elevated circulating monoclonal (M-) protein (a key test for MGUS diagnosis) and no subsequent lymphoid malignancy (as described above). The positive predictive value (PPV) for the ICD-9 code was 98%. All MGUS cases confirmed by chart review also had confirmatory laboratory test results. Of the confirmed cases first identified via M-protein test results, 88% also had the ICD-9 diagnosis code.

CONCLUSION

The diagnosis code-based approach has excellent PPV and likely high sensitivity for detecting clinically diagnosed MGUS. The generalizability of this approach outside an integrated healthcare system warrants further evaluation.

O-294 In-vitro maturation of oocytes from ovary tissue and ovarian longevity

Study question

Is it possible to accomplish simple and robust in-vitro maturation (IVM) of oocytes from human ovarian tissue using principles of in vitro gametogenesis?

Summary answer

Many mature oocytes can be obtained from ovary tissue with simple media and no need for ovarian stimulation.

What is known already

IVM from ovarian tissue has been difficult in the past. To mature primordial follicles in vitro has become possible in mice utilizing eight ‘core genes’. It has not yet been performed in humans, and will be complicated. However, culturing germinal vesicle oocytes that have already become meiotically competent by in-vivo IVD and IVG would not be expected to be difficult. In addition, it is far easier to obtain many germinal vesicle oocytes with cortical dissection rather than with a needle.

Study design, size, duration

After the ovarian cortex has been dissected from the medulla and divided into slices for cryopreservation, the ‘spent’ medium in which the dissection took place was examined for free, loose cumulus complexes, and cultured for 24 to 48 hours. A variety of different culture media and gonadotrophin concentrations were employed, based on previously published data from in vitro gametogenesis in mice.

Participants/materials, setting, methods

A total of 119 female patients between age 2 and 35 years old underwent ovary cryopreservation (as well as in-vitro maturation of oocytes and IVM in the last 13 individuals) over a 24 year period. Up to 22 years later, 17 returned to have their ovary tissue thawed and transplanted back.

Main results and the role of chance

Every woman had return of ovarian function 5 months after transplant, similar to previous observations. As observed before, AMH concentration rose as FSH fell 4 months later. The grafts continued to work up to 8 years. Of the 17, 13 (76%) became pregnant with intercourse at least once, resulting in 19 healthy live births, including six live births from three women who had leukemia. Of the harvested germinal vesicle oocytes, 35% developed with simple culture media into mature metaphase II oocytes. Maturation of germinal vesicle to MII oocytes was detected between 24 and 48 h of exposure to the HCG-containing media. For most participants, the number of mature oocytes was what would be obtained from ovarian stimulation. Surprisingly, the success of IVM was not related to the specific media or to the concentration of gonadotrophin in the media. A variety of media and concentrations were intentionally used in light of now-established mechanisms of in-vitro oogenesis, to see if this understanding could be used for a simplification of IVM.

Limitations, reasons for caution

This is an early pilot study only, but the results are strikingly consistent with our extensive work with IVG in mice.

Wider implications of the findings

This study and the results of in-vitro gametogenesis reveal the limited role of the ovulatory cycle and ovarian stimulation in oocyte development other than for the oocyte to exit the ovary. The normal ovulation cycle is not needed for meiotic competence. Ovarian stimulation is only required for easy oocyte retrieval.

Trial registration number

Not applicable

A cost-effectiveness evaluation of Dance to Health: a dance-based falls prevention exercise programme in England

OBJECTIVES

This study aimed to evaluate whether the falls prevention programme Dance to Health provides the health system with an effective and cost-effective means to address the issue of older people's falls.

STUDY DESIGN

This study used a pre-post design; that is, the same assessment measures were used both before and after the programme.

METHODS

Analysis and modelling were conducted using monitoring data (frequencies including session attendance, falls, general practitioner (GP) and hospital visits), comprehensive financial information (including all costs related to the delivery of Dance to Health), and the Public Health England economic model: 'A return on investment tool for falls prevention programmes in older people based in the community'.

RESULTS

Findings from the research show that under the suggested health intervention, there was a 58% reduction in the number of falls. Furthermore, the results also demonstrate that Dance to Health offers a potential cost saving of more than £196m over a 2-year period, of which £158m is a potential cost saving for the NHS.

CONCLUSIONS

The evidence outlines that Dance to Health offers the health system a cost-effective means to address the issue of older people's falls and most importantly a method that produces strong results in terms of falls prevention.

A single center retrospective study of daratumumab, pomalidomide, and dexamethasone as 2nd-line therapy in multiple myeloma

Daratumumab, pomalidomide, and dexamethasone (DPd) is an FDA-approved 3rd or later line of therapy for myeloma. However, as there are limited published data on the efficacy of 2nd-line DPd, we conducted a retrospective analysis (n = 33). Herein, we report our center's data for 2nd-line DPd. Our patient population had a high amount of high risk cytogenetics (45.5%). The overall response rate (ORR) was 84.9% with a 1-year Progression Free Survival (PFS) of 37.7%. In standard risk myeloma (n = 18), the ORR was 88.9% and 1-year PFS was 61.1% (95% CI 42.3-88.3%). In high risk myeloma (45.5%, n = 15), the ORR was 80% with a 1-year PFS of 7.3% (95% CI 1.1-47.9%). This suggests that the efficacy of 2nd-line DPd in myeloma with high risk cytogenetics should be further investigated.

Epidemiology of infections following haploidentical peripheral blood hematopoietic cell transplantation

BACKGROUND

The use of T-cell replete haploidentical hematopoietic cell transplant (haplo-HCT) has increased substantially since the introduction of post-transplant cyclophosphamide (PTCy) regimens. Limited data exist concerning infectious complications of haplo-HCT utilizing mobilized peripheral blood (PB) hematopoietic cells.

METHODS

This retrospective cohort study included all adult patients at our institution undergoing PB haplo-HCT with PTCy between June 2009 and June 2015. Infections were microbiologically confirmed. Invasive fungal infections (IFI) classified as "proven" or "probable" by standard definitions were included.

RESULTS

In total, 104 patients were identified. Median follow-up was 218 days (range: 6-1576). A total of 322 episodes of infection were recorded. Eighty-nine percent of patients experienced at least one infection. Median time to first infection was 22 days. Patients experiencing at least one bacterial, viral, and IFI were 62%, 72%, and 6%, respectively. The majority (69%) of bacterial infections were caused by enteric organisms. Seven cases of Staphylococcus aureus infection were recorded, with one bacteremia case. Cytomegalovirus (CMV) viremia occurred in 54/71 (76%) at-risk patients at a median time of 24 days. Sixteen (15%) patients developed CMV disease. Nineteen percent (20/104) of patients developed BK polyomavirus-associated cystitis. Six (6%) patients experienced a total of seven IFI. Infection was the primary cause of death for 12% (6/51) of patients and was a secondary cause for 41%.

CONCLUSION

In PB haplo-HCT patients, a high incidence of CMV viremia and disease was observed. Infections with enteric bacteria were common. Fungal and staphylococcal infections were uncommon. Further studies are needed to compare infectious complications in haplo-HCT with other transplant modalities.

Sarcoidosis manifesting as a pseudotumorous renal mass

A 53 year-old African American woman with a three-year history of pulmonary sarcoidosis had a follow-up computed tomographic scan to evaluate the status of her disease and response to treatment. On the scan, an abnormal, hypodense mass on the left renal superior pole, which was not present on previous scans, was incidentally discovered. The initial concern was of carcinoma, despite her lack of any urinary symptoms. She underwent further evaluation with magnetic resonance, and the enhancement pattern and the shape of the mass were more suggestive of lymphoma or infarction than a carcinoma. A review of literature revealed sparse case reports demonstrating sarcoidosis presenting as infiltrative granulomatous masses resembling tumors with nonspecific imaging qualities. This diagnosis was entertained and then proven by biopsy. Pseudotumorous renal sarcoid should be in the differential of renal masses, especially in patients with a history of sarcoidosis, as it alters clinical management.

Botulinum toxin assessment, intervention and aftercare for paediatric and adult niche indications including pain: international consensus statement

Evidence is emerging for the use of botulinum neurotoxin type-A (BoNT-A) for niche indications including pain independent of spasticity. Pain indications such as chronic nociceptive back pain, piriformis syndrome, chronic myofascial pain, pelvic pain, complex regional pain syndrome, facial pain and neuropathic pain are outlined in this paper. Of these, class I evidence is available for the treatment of chronic nociceptive low back pain, piriformis syndrome, myofascial pain, facial pain, neuropathic pain and plantar fasciitis. Peri-operative use of BoNT-A is emerging, with indications including planning for surgery and facilitating surgery, as well as healing and improving analgesia post-operatively. Evidence is limited, although there are some reports that clinicians are successfully using BoNT-A peri-operatively. There is class I evidence showing pre-operative use of BoNT-A has a beneficial effect on outcomes following adductor-release surgery. The use of BoNT for treatment of tremor, other than neck tremor in the setting of cervical dystonia, including evidence for upper limb tremor, cranial tremor and non-dystonic neck tremor is reviewed. The evidence is variable at this stage, and further study is required to develop definitive recommendations for the clinical utility of BoNT-A for these indications.

Magnetic resonance imaging in the diagnosis of occult dorsal wrist ganglions

Small occult dorsal wrist ganglia, which are not visible or palpable, may be painful. Clinically, there is tenderness over the scapholunate ligament and pain with hyperextension of the wrist with normal radiographs and an otherwise normal examination. We reviewed 20 patients with suspected occult ganglia who underwent an MRI scan and subsequently underwent surgical excision of the cyst. We compared the MRI diagnosis with the intra-operative findings and the histological evaluation of the surgical specimen to determine the accuracy of MRI in identifying an occult ganglion. When intra-operative determination of disease was used as a standard, the sensitivity of MRI scanning was 83%, the specificity was 50%, the positive predictive value was 94% and the accuracy 80%. Using histology as the standard, the sensitivity was 80%, the specificity 20%, and the positive predictive value 75%.

Optimizing Achilles tendon repair: effect of epitendinous suture augmentation on the strength of achilles tendon repairs

BACKGROUND

Epitendinous suture augmentation has been shown to increase gap resistance and overall strength in flexor tendon repairs of the hand. The purpose of this study was to evaluate the effect of various suture augmentation techniques in Achilles tendon repair.

MATERIALS AND METHODS

Eighteen fresh-frozen cadaveric Achilles tendons were transected and repaired with a 4-strand Krackow core stitch. Suture augmentation was performed with 3 figure-of-eight stitches in 6 specimens and a running cross-stitch weave in 6 specimens. The other 6 specimens were not augmented. Each tendon was loaded to failure on an MTS. Force to failure (defined as peak force or force at 5 mm gapping), gapping resistance, stiffness, and elongation were compared.

RESULTS

Force to failure (p < 0.001), stiffness (p < 0.01) and gapping resistance (p < 0.05) were increased by suture augmentation. Additionally failure force and gapping resistance for the cross-stitch augmentation was higher than the figure-of-eight augmentation (p < 0.05).

CONCLUSION

Cross-stitch augmentation of Achilles tendon repair yields a stronger and stiffer repair with greater resistance to gapping.

CLINICAL RELEVANCE

Achilles tendon repairs augmented with a cross stitch weave will be able to withstand substantially higher forces than non-augmented repairs.

The mosaic of brain glial hyperactivity during normal ageing and its attenuation by food restriction

Food restriction of adult rodents increases lifespan, with commensurate attenuation of age-related pathological lesions in many organs, as well as attenuation of normal ageing changes that are distinct from gross lesions. Previous work showed that chronic food restriction attenuated age-associated astrocyte and microglial hyperactivity in the hippocampal hilus, as measured by expression of glial fibrillary acidic protein and major histocompatibility complex II antigen (OX6). Here, we examined other markers of astrocyte and microglial activation in gray and white matter regions of ad libitum-fed (Brown Norway x Fischer 344) F1 male rats aged three and 24 months and chronic food-restricted rats aged 24 months. In situ hybridization and immunohistochemical techniques evaluated glial expression of glial fibrillary acidic protein, apolipoprotein E, apolipoprotein J (clusterin), heme oxygenase-1, complement 3 receptor (OX42), OX6 and transforming growth factor-beta1. All markers were elevated in the corpus callosum during ageing and were attenuated by food restriction, but other regions showed marked dissociation of the extent and direction of changes. Astrocytic activation, as measured with glial fibrillary acidic protein expression (coding and intron-containing RNA, immunoreactivity), increased with age in the corpus callosum, basal ganglia and hippocampus. Generally, food restriction attenuated the age-related increase in glial fibrillary acidic protein messenger RNA and immunoreactivity. Food restriction also reduced the age-related increase in apolipoprotein J and E messenger RNA and heme oxygenase-1 immunoreactivity in the basal ganglia and corpus callosum. However, astrocytes in the hilus of the hippocampus showed an age-related decrease in apolipoprotein J and E messenger RNA, which was further intensified by food restriction. The age-associated microglial activation measured by OX6 and OX42 immunoreactivity was reduced by food restriction in most subregions. The localized subsets of glial age changes and effects of food restriction comprise a mosaic of ageing consistent with the regional heterogeneity of ageing changes reported by others. In particular, age has a differential effect on astrocytic and microglial hyperactivity in gray versus white matter areas. The evident mosaic of glial ageing and responses to food restriction suggests that multiple mechanisms are at work during ageing.

Typical household vacuum cleaners: the collection efficiency and emissions characteristics for fine particles

The issue of fine particle (PM2.5) exposures and their potential health effects is a focus of scientific research because of the recently promulgated National Ambient Air Quality Standard for PM2.5. Before final implementation, the health and exposure basis for the standard will be reviewed by the U.S. Environmental Protection Agency within the next five years. As part of this process, it is necessary to understand total particle exposure issues and to determine the relative importance of the origin of PM2.5 exposure in various micro-environments. The results presented in this study examine emissions of fine particles from a previously uncharacterized indoor source: the residential vacuum cleaner. Eleven standard vacuum cleaners were tested for the emission rate of fine particles by their individual motors and for their efficiency in collecting laboratory-generated fine particles. An aerosol generator was used to introduce fine potassium chloride (KCl) particles into the vacuum cleaner inlet for the collection efficiency tests. Measurements of the motor emissions, which include carbon, and the KCl aerosol were made using a continuous HIAC/Royco 5130 A light-scattering particle detector. All tests were conducted in a metal chamber specifically designed to completely contain the vacuum cleaner and operate it in a stationary position. For the tested vacuum cleaners, fine particle motor emissions ranged from 9.6 x 10(4) to 3.34 x 10(8) particles/min, which were estimated to be 0.028 to 176 micrograms/min for mass emissions, respectively. The vast majority of particles released were in the range of 0.3-0.5 micron in diameter. The lowest particle emission rate was obtained for a vacuum cleaner that had a high efficiency (HEPA) filter placed after the vacuum cleaner bag and the motor within a sealed exhaust system. This vacuum cleaner removed the KCl particles that escaped the vacuum cleaner bag and the particles emitted by the motor. Results obtained for the KCl collection efficiency tests show > 99% of the fine particles were captured by the two vacuum cleaners that used a HEPA filter. A series of tests conducted on two vacuum cleaners found that the motors also emitted ultra-fine particles above 0.01 micron in diameter at rates of greater than 10(8) ultra-fine particles/CF of air. The model that had the best collection efficiency for fine particles also reduced the ultra-fine particle emissions by a factor of 1 x 10(3).

Efficacy of Nicardipine for Long-Term Therapy of Chronic Stable Angina

BACKGROUND: Although angina is a chronic disease, most clinical trials evaluating antianginal therapy are of a few weeks or months in duration. METHODS AND RESULTS: To evaluate the effects of nicardipine, a second-generation dihydro-pyridine calcium channel blocker, as long-term therapy, patients with chronic stable angina were treated for 1 year with open-label nicardipine. Anginal symptoms were controlled with 20 mg tid in 24%, 30 mg tid in 34%, and 40 mg tid in 42%. Of 72 patients completing the 1-year trial, only 14 (19%) had required the addition of long-acting nitrates for control of symptoms. The remaining 57 patients, who had anginal symptoms controlled with nicardipine alone, were continued into the 3-week, double-blind period and were randomized to continue their usual dose of nicardipine or placebo. Throughout the 1-year, open-label treatment period, the number of anginal episodes and exercise parameters of angina were significantly reduced with nicardipine. CONCLUSIONS: During the double-blind period, the patients who continued on nicardipine had significantly greater exercise time and time to onset of angina than patients who were randomized to placebo. The exercise parameters in the patients randomized to placebo were improved over baseline after 1 year of therapy; however, the improvement with nicardipine was significantly greater.

An atomic model of fimbrin binding to F-actin and its implications for filament crosslinking and regulation

Using a new procedure that combines electron-density correlation with biochemical information, we have fitted the crystal structure of the N-terminal actin-binding domain of human T-fimbrin to helical reconstructions of fimbrin-decorated actin filaments. The map locates the N-terminal calcium-binding domain and identifies actin-binding site residues on the two calponin-homology domains of fimbrin. Based on this map, we propose a model of a fimbrin crosslink in an actin bundle and its regulation by calcium.

A preliminary placebo-controlled crossover trial of fludrocortisone for chronic fatigue syndrome

OBJECTIVE

To provide a preliminary assessment of the efficacy and safety of fludrocortisone acetate treatment of chronic fatigue syndrome.

DESIGN

A placebo-controlled, double-blind, random-allocation crossover trial of 6 weeks of fludrocortisone.

SETTING

An outpatient clinical trials unit.

PATIENTS

Twenty-five participants with chronic fatigue syndrome (mean age, 40 years; 19 [76%] women; mean duration of illness, 7.0 years) were recruited from a research and clinic registry. Five patients withdrew from the trial.

INTERVENTIONS

All participants were scheduled to receive fludrocortisone acetate (0.1-0.2 mg) or a placebo for 6 weeks in each treatment.

MAIN OUTCOME MEASURES

Self-administered questionnaires were completed at the beginning and end of each treatment arm that asked patients to rate the severity of their symptoms on a visual analogue scale. The Medical Outcomes Study 36-Item Short-Form Health Survey, a reaction time test, and a treadmill exercise test were used to assess functional status. Blood pressure, heart rate, and plasma norepinephrine levels were obtained at baseline. Blood pressure and heart rate were recorded at the end of the exercise test and monitored at all subsequent visits.

RESULTS

At baseline, the study participants reported symptom severity greater than 5 for most symptoms, and all had evidence of marked functional impairments. No improvement was observed in the severity of any symptom or in any test of function for the 20 participants who completed both arms of the trial. Blood pressure and heart rate readings were unaffected by treatment, and plasma norepinephrine levels did not differ from those of a healthy control group. The incidence of adverse experiences was similar in the fludrocortisone and placebo arms of the trial.

CONCLUSION

Low-dose fludrocortisone does not provide sufficient benefit to be evident in a preliminary blinded trial of unselected patients with chronic fatigue syndrome.

Beta 4 integrin transfection of UM-UC-2 (human bladder carcinoma) cells: stable expression of a spontaneous cytoplasmic truncation mutant with rapid loss of clones expressing intact beta 4

The alpha 6 beta 4 integrin is a component of the hemidesmosome, the anchoring structure in the basal membrane of epithelial cells. alpha 6 beta 4 expression is frequently altered in neoplastic cells. It is sometimes lost and sometimes overexpressed, which suggests that disruption of normal function is involved in neoplastic transformation. To examine the effect of this integrin on the growth and behavior of malignant cells that have lost beta 4, we transfected a full-length beta 4 cDNA into the UM-UC-2 cell line that expresses alpha 6 but not beta 4. Although large numbers of clones were obtained when a control vector was used in the transfection, only 12 clones could be isolated that expressed beta 4. Of these, only two beta 4-positive clones, clones 8 and 11, persisted long enough for further study. Clone 8 cells initially expressed beta 4, but within 2 weeks, all positive cells were lost from the culture. Clone 11 persisted in culture and retained strong surface expression of alpha 6 beta 4. Biochemical analysis and Western blotting revealed that this clone contained a truncated form of beta 4 that had lost the distal cytoplasmic domain. We conclude that expression of wild-type beta 4 in UM-UC-2 inhibits cell growth, presumably by an integrin-mediated signaling pathway. Clone 11 escaped from normal signaling because the cytoplasmic domain, a region essential for basal polar localization, was lost. The alpha 6 beta 4 integrin appears to have tumor suppressor activity in epithelial tumors.

An interdisciplinary mental health consultation team in a nursing home

The Mental Health Consultation Team (MHCT) at the Portland Veterans Affairs Medical Center nursing home is an interdisciplinary group of mental health professionals and primary care providers established to triage mental health consultations, improve communication between consultants and primary care providers, help staff translate consultants' recommendations into patient care, and furnish education in the management of mental health problems. The MHCT has decreased the demands for formal psychiatry and psychology consultations while increasing mental health services through innovative use of existing staff.

Dopamine D2 receptors in the hippocampus and amygdala in Alzheimer's disease

Receptor autoradiography was used to quantify the number of dopamine D2 receptors labeled with [125I]epidepride in the medial temporal lobe of seven cases of Alzheimer's disease in comparison to eight cases of neurologically intact controls. The Alzheimer's disease cases showed the greatest losses of D2 receptors in the basolateral nucleus of the amygdala and molecular layer of the dentate gyrus and the smallest differences from controls in the perirhinal region and subiculum. The loss of D2 receptors in the hippocampus and amygdala of cases with Alzheimer's disease in concert with alterations in dopaminergic innervation could contribute to the clinical symptoms of this disorder.

Epizootiological investigation of an outbreak of pullorum disease in an integrated broiler operation

An integrated broiler company experienced a major outbreak of pullorum disease during 1990. The outbreak resulted in the distribution of Salmonella pullorum-infected birds to more than 150 roaster flocks in five states. Twenty-two parent (multiplier) breeder flocks became infected. An epizootiological investigation uncovered a grandparent male line breeder flock as the index flock supplying males to the affected parent flocks. Transmission apparently occurred vertically through the egg and horizontally by contact in the hatcheries and by placement of chicks on contaminated litter.

Equivalence of five forms of the Selective Reminding Test in young and elderly subjects

This study evaluated the equivalence of five forms of the Selective Reminding Test, a widely used measure of verbal learning, 45 normal young and 45 normal elderly subjects were randomly administered three of the five test forms on three separate sessions. The five forms generally correlated well with one another and were of comparable difficulty, suggesting adequate test equivalence. Four of the five forms were particularly well matched.

Strategic psychotherapy in psychiatric consultations

Inpatient psychiatric consultation work often involves the need to quickly bring about behavioral changes in distressed patients who are not interested in participating in psychotherapy. The behavior of such patients often impinges upon other individuals in the general hospital milieu and can be viewed within a systems framework. The strategic psychotherapeutic approach is summarized and two cases are described that illustrate the benefits that such an approach can have in effective consultations. Reframing, pacing and leading, and confusion techniques are among the specific tactics that are discussed.