Prediction of Resistance to 177Lu-PSMA Therapy by Assessment of Baseline Circulating Tumor DNA Biomarkers

177Lu-PSMA-617 and 177Lu-PSMA I&T (collectively termed 177Lu-PSMA) are currently being used for the treatment of selected metastatic castration-resistant prostate cancer (mCRPC) patients with PSMA PET-positive disease, but biomarkers for these agents remain incompletely understood. Methods: Pretreatment circulating tumor DNA (ctDNA) samples were collected from 44 mCRPC patients receiving 177Lu-PSMA treatment. Prostate-specific antigen responders and nonresponders were assessed relative to the ctDNA findings at baseline. Results: The ctDNA findings indicated that nonresponders were more likely to have gene amplifications than were responders (75% vs. 39.2%, P = 0.03). In particular, amplifications in FGFR1 (25% vs. 0%, P = 0.01) and CCNE1 (31.2% vs. 0%, P = 0.001) were more likely to be present in nonresponders. CDK12 mutations were more likely to be present in nonresponders (25% vs. 3.6%, P = 0.05). Conclusion: Our analyses indicate that ctDNA assays may contain specific biomarkers predictive of response or resistance for 177Lu-PSMA-treated mCRPC patients. Additional confirmatory studies are required before clinicians can use these findings to make personalized treatment decisions.

Clinical and Molecular Determinants of PSA Response to Bipolar Androgen Therapy in Prostate Cancer

BACKGROUND

Bipolar Androgen Therapy (BAT) is a novel therapy known to be effective in a subset of men with metastatic castrate resistant prostate cancer (mCRPC). A better understanding of responders and non-responders to BAT would be useful to clinicians considering BAT therapy for patients. Herein we analyze clinical and genetic factors in responders/non-responders to better refine our understanding regarding which patients benefit from this innovative therapy.

METHODS

mCRPC patients were assessed for response or no response to BAT. Patients with PSA declines of greater than 50% from baseline after 2 or more doses of testosterone were considered to be responders. Whereas, Non-responders had no PSA decline after 2 doses of testosterone and subsequently manifest a PSA increase of >50%. Differences between these two groups of patients were analyzed using clinical and laboratory parameters. All patients underwent genomic testing using circulating tumor DNA (ctDNA) and germline testing pre-BAT.

RESULTS

Twenty five patients were non-responders and 16 were responders. Baseline characteristics between non-responders and responders varied. Responders were more likely to have had a radical prostatectomy as definitive therapy and were more likely to have been treated with an androgen receptor (AR) antagonist (enzalutamide or apalutamide) immediately prior to BAT (compared to abiraterone). Duration of prior enzalutamide therapy was longer in responders. Non-responders were more likely to have bone-only metastases and responders were more likely to have nodal metastases. Assays detected ctDNA AR amplifications more often in responding patients. Responders trended toward having the presence of more TP53 mutations at baseline.

CONCLUSIONS

BAT responders are distinct from non-responders in several ways however each of these distinctions are imperfect. Patterns of metastatic disease, prior therapies, duration of prior therapies, and genomics each contribute to an understanding of patients that will or will not respond. Additional studies are needed to refine the parameters that clinicians can utilize prior to choosing among the numerous treatment alternatives available for CRPC patients. This article is protected by copyright. All rights reserved.

Screening detects clinically significant hearing loss in patients with GU malignancies

e18624

Background: Four in 10 people aged 60-69 have hearing loss in frequencies that mediate speech comprehension. Untreated losses undermine medication adherence, increase risk for accidental injury, and generate higher total healthcare expenditures. Genitourinary (GU) malignancies are most frequently diagnosed in people over 60, and these patients are commonly exposed to ototoxic treatments like platinum-based chemotherapy. We hypothesized that a significant number of GU patients would fail hearing screenings at levels reflecting clinically significant hearing loss. Methods: This is a prospective, two-cohort pilot study conducted at Tulane Medical Center. Consecutive patients with active GU malignancies who did not use hearing aids were enrolled in cohort A. The primary objective of cohort A (screening) was to determine the prevalence of hearing loss among GU patients. Cohort B (interventional) will investigate the efficacy of a non-custom amplifier in improving communication for patients with hearing loss. The hearing screening consisted of a 9-item Self-Assessment of Communication (SAC) and a 25 decibel (dB) pure tone hearing screening at 1 kHz, 2 kHz, 4 kHz via an Earscan3 portable audiometer with headphones in a quiet exam room. The primary endpoint was the proportion of patients who failed the hearing screening (missed ≥ 2/6 tones). The SAC generates a global handicap score (none, slight, mild-to-moderate, severe). Surveys identifying any amount of handicap were considered positive. Patients who failed screenings were offered referrals to audiology. Here, we present results from cohort A. Results: From 8/21 to 1/22, 66 patients were invited to participate. Nine patients screen-failed (n = 8 hearing aids; n = 1 uninterested). Cohort A enrolled 57 patients [median age 68 (33-86); 91% men; 60% prostate, 24% kidney and 14% bladder cancer]. Most patients (82%) had evidence of metastatic disease and 12%, 19%, 36%, 21% of patients were receiving chemotherapy, immunotherapy, hormonal therapy, and no active therapy, respectively. Twenty (35%) patients had prior exposure to neurotoxic chemotherapy. Forty patients (70%) met the primary endpoint. Compared to the pure tone screening, the SAC had a specificity of 94%, and a sensitivity of 40%. The SAC asks patients for a situation where they want to hear better; 61% of patients who volunteered a scenario (17/28) identified a complex listening environment like an outpatient encounter. A minority of patients (n = 3) accepted audiology referrals after failing screenings. Cohort B is actively enrolling. Conclusions: Clinically significant hearing loss was prevalent among patients with GU malignancies. Patients reported struggling in listening situations with auditory demands like outpatient encounters but were unable to self-identify losses and did not pursue audiology referrals after failed screenings. Interventional studies addressing this unmet need are warranted.

Comparative ctDNA analyses of African-American and Caucasian patients with CRPC

24

Background: Somatic genetic analyses have indicated genetic distinctions in AA as compared to C patients. In the Mahal et al. study (1) evaluating a broad spectrum of pts with tissue based assays, FOXA1 mutations were more frequent in AA men and TP53 mutations were less frequent in AA men as compared to C men. In a separate analysis by Khashab et al. (2) conducted in prostate cancer pts receiving androgen deprivation therapy, using both tissue and ctDNA assays, the authors reported AR, TP53, SPOP, and BRCA2 were more frequently mutated in AA men as compared to C men. Herein we assessed the Guardant 360 platform in assessing ctDNA differences in AA and C men, all of whom had CRPC at the time assays were performed. Methods: Guardant 360 was used to analyze ctDNA with a cut-off of >0.5% for allelic fractions for ascertaining the presence or absence of pathogenic mutations and various amplifications. Lower allelic fractions were not analyzed given these may represent less relevant mutations. Depending on the timing of the assays (2015-2021), 70-83 genes were analyzed. All pts had CRPC and all patients were treated at Tulane Cancer Center. Chi Square analyses were used to determine statistical differences. AR, BRCA2, and TP53 were assessed but SPOP and FOXA1 were not assessable in the Guardant ctDNA assay. Both mutations and amplifications were evaluated. Results: Among men with CRPC, a total of 48 AA men and 179 C men were analyzed using ctDNA. Clear distinctions were found in the alteration reported in APC, TP53, and CDK12. TP53 was less frequently mutated and other genes were more frequently altered in the AA men. Conclusions: Using Guardant ctDNA assays in men with CRPC, clear distinctions were found in AA men as compared to C men. It is unclear why these results differ from that reported by others, however distinctions in both the assays and the populations are notable.[Table: see text]

Longitudinal ctDNA alterations in germline positive CRPC patients

275

Background: Circulating tumor-derived DNA (ctDNA) is an accessible method for characterizing somatic alterations. We report longitudinal ctDNA screenings of mCRPC patients (pts) who have had germline testing. Methods: Patients with both germline testing and ctDNA assessment were included. Germline testing was performed with a multi-gene cancer panel from Invitae (50-83 genes) and somatic alterations in ctDNA were identified by testing with Guardant 360 (70-83 genes). ctDNA alterations were characterized as deletions, frameshift, missense, nonsense, and other mutations. A total of 177 patients in various stages of therapy had both ctDNA and germline DNA tested. Results: From 2015-2021, 177 mCRPC patients were included and had an average of 3 ctDNA tests. 11.3% (20/177) had pathogenic or likely-pathogenic germline mutations. The common pathogenic germline mutations were in BRCA2 (25%; 5/20), ATM (10%; 2/20), and MSH2 (10%; 2/20). In ctDNA, missense mutations were the most prevalent type of gene alteration in germline negative (n = 539/790, 68%) and germline positive (n = 124/218, 57%) followed by frameshift mutations at 22% (n = 48/218) in germline positive and 10% (n = 80/790) in germline negative patients. Germline positive patients were more likely to have somatic frameshift mutations (OR = 2.09, 95% C.I. (1.3792, 3.1618), p = 0.001) and less likely to have missense mutations (OR = 0.61, 95% C.I. (0.4519, 0.8351), p = 0.002). Other alterations including deletions, nonsense, and other mutations were not significantly different. Of the germline positive pts, BRCA2 mutation was associated with the highest number of somatic alterations. Conclusions: Germline positive CRPC patients were more likely to have frameshift mutations and less likely to missense mutations compared to germline negative CRPC patients. Patients with germline mutations in BRCA2 and TP53 had the highest number of somatic alterations detected in ctDNA over the course of ctDNA evaluation.

Evaluation of ctDNA alterations in mCRPC patients with germline pathogenic mutations

177

Background: Germline alterations are found in approximately 12-17% of CRPC patients. Similarly, evaluating tumoral changes with circulating tumor DNA (ctDNA) has become an increasingly useful tool for understanding mechanisms underpinning disease progression. In this study, we evaluated both germline and somatic genetic changes in patients with mCRPC. Methods: Patients included had germline screening and ctDNA analyzed with the Guardant 360 assay. All patients were CRPC at the time of Guardant testing. Germline alterations were classified as pathogenic/likely-pathogenic or not pathogenic. Only ctDNA alterations with an alleleic fraction greater than 0.5% were included in analyses. Additional evaluation of CRPC status, treatment history, family history and other clinical covariates are ongoing. Chi-square and Fischer’s Exact tests were used for comparison of cohorts. Results: A total of 168 Caucasian CRPC patients had Guardant 360 testing at time of progression and germline testing between 2015-2021. 61% (n = 102/168) of patients have previously had treatment with abiraterone, 49% (n = 82/168) have had Enzalutamide and 40% (n = 68/168) have had treatment with taxanes. 12% (n = 20/168) of CRPC patients had a pathogenic/likely-pathogenic (P/LPv) germline alteration, 46% (n = 77/168) had a germline variant of unknown significance (VUS), 42% (n = 71/168) were germline negative. CRPC patients with pathogenic germline mutations were significantly more likely to have subsequent somatic alterations in BRCA2 (OR = 5.05, 95% C.I. (1.11, 23.01), p = 0.055), NF1 (OR = 7.89, 95% C.I. (2.15, 28.10), p = 0.004), and TP53 (OR = 3.52, 95% C.I. (1.28, 9.68), p = 0.015). In TP53, among germline positive patients, 45% (n = 9/20) had TP53 alterations compared to 30% (n = 45/148) of germline negative patients. Conclusions: Germline positive (P/LPv) CRPC patients were significantly more likely to have somatic alterations in BRCA2, NF1, and TP53. Understanding the totality of genetic changes, both germline and acquired somatic alterations is essential as the arsenal of targeted treatment for CRPC continues to expand. Additional studies including longitudinal assessment genetic changes and clinical correlates will be necessary to evaluate these findings in the context of treatment outcomes and disease progression.

68ga-PSMA-11 patients with newly diagnosed and recurrent prostate cancer (Firefly)

TPS189

Background: A primary challenge facing oncologists is the accurate identification of the source of the rising PSA in the recurrent disease setting and the failure of proper staging at the time of initial therapy. Current imaging modalities perform poorly in this regard. PSMA imaging is FDA approved but reimbursement remains a considerable issue for most patients. Methods: This is a phase II expanded access intermediate sized clinical trial using 68Ga-PSMA-11 (Telix Pharma cold kit) under our own Investigational New Drug (IND) with the FDA. Two cohorts are utilized, recurrent disease with a PSA > 0.2 or > 2.0 post-radiation, and newly diagnosed high risk localized disease and/or oligo-metastatic patients as assessed by conventional imaging. 300 patients will be allowed to enroll and 63 are enrolled to date. Patients will be injected with 1.8–2.2 MBq/kg body weight with 68Ga-PSMA-11 (per EANM guidelines). The lower and upper limits of the dose are set to 3 to 7 mCi respectively. Primary Objective(s): Utilize 68Ga-PSMA-11 PET images to define uptake location for localization of prostate cancer metastatic sites in patients prior to initial therapy and to utilize 68Ga-PSMA-11 PET images to define uptake location for localization of prostate cancer including both local recurrences and metastatic sites in patients with recurrent disease after initial therapy. Secondary Objectives: To assess the therapeutic consequences of 68Ga-PSMA-11 PET/CT imaging in prostate cancer patients with and without prior treatment. As such the planned therapies after the PSMA scan will be annotated and recorded. In addition, we aim to determine the number of patients with metastatic disease prior to initial therapy that was not diagnosed with conventional imaging and we aim to determine the locations of recurrent disease for those patients who have demonstrated PSA recurrence after curative therapy. Percentage of positive scans will be assessed for PSA values 0.2-0.5 ng/mL, > 0.5-1.0 ng/mL, > 1.0- > 2.0 ng/mL, and > 2 ng/mL. Results will be summarized descriptively with 95% confidence intervals. Localization of all lesions will be performed with regard to lymph nodes (pelvic versus non-pelvis), bones (by location), and other (by site). Treatment planning will be captured and quantified by radiation, surgery, hormonal therapy (type and duration), and/or observation at the time of the initial clinical visit after the PSMA scan and 6 months later. This trial is open and recruiting patients. Data analysis has not been performed. Clinical trial information: NCT04854369.

Circulating tumor DNA responses to high-dose testosterone injections in CRPC patients

173

Background: Some proportion of men with CRPC have favorable responses to high doses of testosterone (HDT) and some do not. Genomic determinants of these responders and non-responders are poorly understood. Herein ctDNA predictors of response are assessed using a responder/non-responder analysis. Methods: All men with CRPC had been pretreated with abiraterone, enzalutamide, or both. A ctDNA test was obtained prior to high doses of testosterone (administered as a dose of 400 mg IM testosterone cypionate every 3-4 weeks). Guardant 360 was used to analyze ctDNA (with an allelic fraction cut-off of > 0.5%) to ascertain the presence or absence of pathogenic mutations. Lower allelic fractions were not analyzed. Responders had a PSA decline of 50% or more (N = 16), non-responders received at least two doses of testosterone but never had any PSA decline at all (N = 20). All patients were treated at Tulane Cancer Center. Results: AR amplifications were more commonly detected (p = 0.036) pre-treatment in the ctDNA of responders (5/16) as compared to non-responders (1/20). No differences were found in those with common AR mutations; T878A was detected in 2/16 responders and 2/20 non-responders, L702H was detected in 1/16 responders and 2/20 non-responders. No differences were seen with regard to TP53 mutations, 6/20 non-responders and 7/16 responders. Non- AR/non- TP53 mutations were not distinct in the two groups but trended (P = 0.15) toward being more common in non-responders (5/16 in responders versus 11/20 non-responders). Pre- and post- ctDNA analyses were conducted in 5/6 patients for those with AR amplification at baseline. In all 5 of these patients, the degree of AR amplification diminished after testosterone injections. Conclusions: In this analysis of CRPC patients who were responders and non-responders to 400 mg testosterone cypionate q 3-4 weeks (post-abiraterone and/or enzalutamide), only AR amplifications in ctDNA were predictive of response. In all measured patients, the degree of AR amplification in the ctDNA diminished after testosterone injections.

POS1063 RHEUMATOLOGIST AND PATIENT PERSPECTIVES ON IMPLEMENTING CARDIOVASCULAR RISK PREVENTION IN THE MANAGEMENT OF PSORIASIS: A QUALITATIVE STUDY

Background:

Psoriatic arthritis (PsA) is an immune-mediated musculoskeletal disease associated with excess risk for cardiovascular disease (CVD). New US-based guidelines recognize psoriasis as a CVD risk enhancer; however, patients with PsA often do not have CVD risk factors identified nor managed.

Objectives:

This study examines strategies to improve CVD prevention care from the perspective of rheumatologists and patients with PsA.

Methods:

Semi-structured qualitative interviews were conducted using an interview guide based on the Consolidated Framework for Implementation Research to examine the perspectives of rheumatologists (N = 8) and patients with psoriatic arthritis managed by rheumatologists (N = 8) on barriers/facilitators to CVD prevention. Interviews were transcribed and coded using an integrated approach designed to enhance reliability and validity facilitated by NVivo software.

Results:

Most rheumatologists confirmed that they were not regularly engaging in CVD prevention care with psoriatic arthritis patients. Providers reported sometimes counseling and screening for CVD risk, but they were not regularly prescribing statins and not as willing to do so. Reasons included a lack of familiarity or comfort with guidelines, concern about working outside of their scope of practice, confusing boundaries between other clinicians, and time constraints. Most patients confirmed that it was uncommon for their rheumatologists to engage them in CVD prevention care but expressed desire for their rheumatologists inform them of the risk, and were open to CVD prevention care from them.

Conclusion:

We identified several potentially modifiable barriers to CVD screening and management. These findings will inform the design of a clinical trial comparing the effectiveness of rheumatologist implementation of CVD guideline-based counseling, screening and prescribing statins when appropriate in patients with PsA.

Figure 1.

Barriers to CVD screening and management among patients with PsA in a rheumatology practice setting and potential strategies to address those barriers. Abbreviations: CV = cardiovascular; SOC = standard of care.

Disclosure of Interests:

Alexis Ogdie Consultant of: Abbvie, Amgen, BMS, Celgene, Corrona, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB, Grant/research support from: Pfizer to Penn, Novartis to Penn, Amgen to Forward/NDB, Alix Gustafson: None declared, Adina Lieberman: None declared, Jennifer Mason: None declared, April Armstrong: None declared, Nehal Mehta Consultant of: Amgen, Eli Lilly, and Leo Pharma receiving grants/other payments, Grant/research support from: AbbVie, Celgene, Janssen Pharmaceuticals, Inc, and Novartis receiving grants and/or research funding and as a principal investigator for the National Institute of Health receiving grants and/or research funding., Employee of: NNM is a full-time US government employee, Rinad Beidas Consultant of: Camden Coalition of Healthcare Providers in the past 3 years. She currently is a consultant for United Behavioral Health. She serves on the Optum Behavioral Health Clinical and Scientific Advisory Council. Dr. Beidas receives royalties from Oxford University Press., Joel Gelfand Shareholder of: Dr Gelfand is a co-patent holder of resiquimod for treatment of cutaneous T-cell lymphoma, and he is a deputy editor for the Journal of Investigative Dermatology, receiving honoraria from the Society for Investigative Dermatology., Paid instructor for: CME work related to psoriasis that was supported indirectly by Eli Lilly and Company and Ortho Dermatologics, Consultant of: Bristol-Myers Squibb, Boehringer Ingelheim, GlaxoSmithKline, Janssen Biologics, Novartis Corp, UCB (Data Safety and Monitoring Board), Sanofi, and Pfizer Inc, Grant/research support from: research grants (to the Trustees of the University of Pennsylvania) from AbbVie, Janssen, Novartis Corp, Celgene, OrthoDermatologics, and Pfizer Inc.

H3K9 methyltransferases and demethylases control lung tumor-propagating cells and lung cancer progression

Epigenetic regulators are attractive anticancer targets, but the promise of therapeutic strategies inhibiting some of these factors has not been proven in vivo or taken into account tumor cell heterogeneity. Here we show that the histone methyltransferase G9a, reported to be a therapeutic target in many cancers, is a suppressor of aggressive lung tumor-propagating cells (TPCs). Inhibition of G9a drives lung adenocarcinoma cells towards the TPC phenotype by de-repressing genes which regulate the extracellular matrix. Depletion of G9a during tumorigenesis enriches tumors in TPCs and accelerates disease progression metastasis. Depleting histone demethylases represses G9a-regulated genes and TPC phenotypes. Demethylase inhibition impairs lung adenocarcinoma progression in vivo. Therefore, inhibition of G9a is dangerous in certain cancer contexts, and targeting the histone demethylases is a more suitable approach for lung cancer treatment. Understanding cellular context and specific tumor populations is critical when targeting epigenetic regulators in cancer for future therapeutic development.

Clinical Study of Fetal Mesencephalic Intracerebral Transplants for the Treatment of Parkinson's Disease

This study reports our findings from 22 patients (ages ranging from 42 to 73 yr; mean = 55.2) with recalcitrant idiopathic Parkinson's disease (PD) who received implants of fetal ventral mesencephalic tissue using an MRI-guided stereotactic procedure and who have been followed for at least 6 mo postoperatively, employing the guidelines established by the Core Assessment Program for Intracerebral Transplantations. Evaluations were videotaped and were performed both on and off levodopa medications. To date, we have seven patients with 24 mo, three with 18 mo, three with 12 mo, and nine with 6 mo of postsurgical assessments. Comparing surgical outcomes to levels prior to fetal transplants we found: 1) mean levodopa levels were reduced 46% at 6 mo, 12% at 12 mo, 20% at 18 mo, and 54% at 24 mo; 2) Unified Parkinson's Disease Rating Scale (UPDRS) scores with patients on levodopa were improved by an average of 38% (6 mo), 50.2% (12 mo), 69.3% (18 mo), and 73.9% (24 mo), while off medication scores showed reductions ranging from 24.7% at 6 mo to 55.1% at 24 mo. Other measures, including Hoehn-Yahr staging, Activities of Daily Living, and dyskinesia rating scales, were also significantly improved following fetal transplants. Timed motor tasks (finger dexterity, supination-pronation, foot tapping, and Stand-Walk-Sit) performance also demonstrated highly significant improvements. Patient's self-rating scores indicated that the patients typically perceived substantial improvements in their condition. However, substantial variability in the improvements following surgery still persists and range from nominal improvements in performance to significant changes that can be classified as altering the overall lifestyle of the patients. To date, 4 of the 22 subjects were considered by the physicians to be nonresponders; that is, there were no clinically relevant improvements in these patients' conditions.

Vaginal wet mounts on asymptomatic adolescent females; are they beneficial?

BACKGROUND

Wet mounts are commonly performed at the time of pelvic exam in some settings; however, there is a paucity of data on their usefulness in asymptomatic teen patients.

OBJECTIVE

To determine if wet mounts in asymptomatic teen women are useful in detecting gonorrhea or chlamydia, when compared with DNA amplification testing.

DESIGN AND METHODS

93 consecutive charts for asymptomatic adolescent female patients seen for a routine visit were retrospectively reviewed. Data was collected for vaginal pH, presence or absence of discharge on physical exam, appearance of cervix, wet mount results, and cervical testing results. Outcome measures were wet mount findings and result of DNA amplification test on cervical sample for gonorrhea and chlamydia

RESULTS

Wet mounts were abnormal in 29 (31.2%) patients. There was no significant relationship between abnormal wet mount and positive Neisseria gonorrhoeae and Chlamydia trachomatis cultures (P = 0.083). After excluding abnormal wet mounts due to Trichomonas vaginalis, BV or Candida, all remaining patients with positive N gonorrhoeae and C trachomatis had normal wet mounts. For N gonorrhoeae, the wet mount had a sensitivity of 0% and specificity of 92.6%. For C trachomatis, the wet mount had a sensitivity of 0% and specificity of 92.1%.

CONCLUSION

Wet mounts were not useful to detect N gonorrhoeae and C trachomatis in asymptomatic teen patients. The finding of T vaginalis and BV in these asymptomatic patients may justify continuing wet mount evaluation but this practice needs further study to determine if treatment in this population will result in clinically significant effects.

Soluble receptor for advanced glycation end products in multiple sclerosis: a potential marker of disease severity

OBJECTIVES

To compare serum levels of the receptor for advanced glycation end products (sRAGE) between multiple sclerosis (MS) patients and healthy control subjects, and to investigate whether serum sRAGE levels correlate with MS disease severity as indicated by the Kurtzke Expanded Disability Status Scale (EDSS).

METHOD

37 patients with clinical diagnosis of MS and 22 healthy control subjects were investigated in a cross-sectional study using enzyme-linked immunosorbent assays (ELISA).

RESULTS

Serum levels of sRAGE were found to be significantly lower in MS patients compared to levels in healthy controls (p = 0.005). A trend toward lower levels of serum sRAGE was observed in female MS patients compared to their male counterparts (p = 0.05). A relationship between sRAGE and EDSS, and sRAGE and rate of clinical relapse was observed (p = 0.012).

CONCLUSION

The significant reduction of sRAGE in MS patients relative to healthy controls supports the potential role for RAGE axis in MS clinical pathology. Lower levels of sRAGE may be associated with enhanced inflammatory responses. Based on these observations, further investigations into the role of sRAGE in MS clinical pathology is warranted.

Depression in Parkinson's disease -- a review

Major depression is present, at any given time, in 20-40% of Parkinson's disease (PD) patients, several times the prevalence in the general population. In addition, depression may precede the diagnosis of PD. These observations and reports of depression during deep brain stimulation of regions contiguous to the substantia nigra, as well as reports of dopamine agonist improving depression, suggest depression, rather than being mainly a psychological reaction to a debilitating disease, is part of PD. It is postulated that mesolimbic and mesocortical dopaminergic pathways that mediate affect, behavior, and cognition, contribute to depression in PD.

Can Alzheimer's type pathology influence the clinical phenotype of Parkinson's disease?

OBJECTIVES

Patients with clinical and pathological diagnosis of Parkinson's disease (PD) may, at death, also be found to have the pathological changes of Alzheimer's disease (AD). With this study we aim to determine the influence of AD pathology on the clinical phenotype of PD.

METHODS

We studied 64 patients who donated their brains to the University of Miami Brain Endowment Bank(TM) and fulfilled the clinical and pathological criteria for PD. For the evaluation of AD pathology we used the CERAD criteria. Dementia was diagnosed, in life, also using standard criteria. Case histories were abstracted and reviewed by one investigator (SP) who then made comparisons between patients.

RESULTS

Patients with AD pathology (PD-AD) were older both at the time of diagnosis and death. The presence of AD pathology did not seem to influence disease duration in our cohort of PD patients. As expected there was a clear relation between AD pathology and dementia but not all PD-AD patients were demented. Psychosis and depression were also found to be more prevalent in the PD-AD patients. In the comparison between demented and non-demented PD-AD patients dementia was more likely to appear in patients with PD and definite criteria for AD.

CONCLUSION

Apart from dementia AD pathology seems to be associated with a number of other clinical characteristics of PD.

Dementia in Parkinson's disease: a post-mortem study in a population of brain donors

OBJECTIVE

To identify factors associated with dementia in a cohort of Parkinson's disease (PD) brain donors and determine whether its presence may influence the clinical phenotype of the disease.

METHODS

We included 67 consecutive patients with a clinical and pathological diagnosis of PD, who while alive, consented to donate their brains to the University of Miami Brain Endowment Bank(TM). Dementia and psychiatric complications of PD were diagnosed according to established criteria. Case histories were abstracted and reviewed and comparisons between PD patients with (PD-D, n = 34) and without (PD, n = 33) dementia were made.

RESULTS

Age at death, age at disease onset and disease duration did not differ significantly between PD-D and PD patients. Other symptoms were similar in both groups. Visual hallucinations and bilateral symptoms at diagnosis were significantly higher in PD-D patients. No association between dementia and overall survival duration was found. Although the frequency of depression and psychosis was higher in the PD patients with dementia no statistical significance was reached. The overall lifetime prevalence of dementia in our group was 50.7%.

CONCLUSIONS

Visual hallucinations and bilateral symptoms were associated with dementia in our cohort of PD brain donors. No association between dementia and survival duration was found. Understanding the influence of dementia on the clinical phenotype of the disease and predicting its development is essential for the successful management of PD.

[Endoscopic management of chronic frontal sinusitis in the Negev population, Israel]

BACKGROUND

Chronic frontal sinusitis is a relatively common condition, yet one with potential for complications. The treatment of chronic frontal sinusitis has always been a challenge for the otolaryngologist, and it remains so even in the age of endoscopic sinus surgery. Successful treatment is evaluated by both subjective (patient history) and objective (radiologic and endoscopic) criteria.

PURPOSE

This article aims to present our experience in endoscopic surgery for chronic frontal sinusitis, with particular focus on the importance of the wide opening of the naso-frontal outflow tract, with maximal preservation of the mucosa in this area.

METHODS

During the period 1999 to 2001, 72 patients at the Soroka University Medical Center underwent endoscopic surgery for chronic frontal sinusitis. We reviewed the cases of fifty four patients of this group with a minimum six months follow-up. Patients who did not return for routine post-operative visits were excluded from this study. We evaluated and quantified subjective measurements including facial pain, nasal respiratory obstruction and hyposmia, and objective measurements, based on radiographic studies and endoscopic examination.

RESULTS

Most patients experienced improvement in all of the subjective categories, and particularly in the categories of facial pain/headache and nasal respiratory obstruction. Most patients who experienced this improvement had suffered from chronic pansinusitis.

CONCLUSIONS

The endoscopic management of chronic frontal sinus disease is an effective treatment, when principles of wide sinus drainage with maximal mucosal preservation are observed. Most patients undergoing this type of procedure experience significant clinical and radiologic improvement in their condition.

Application of consumer protection authority in preventing tobacco sales to minors

In the USA, the enforcement of state sales of tobacco products to minors laws has had only limited impact upon reducing youth access. The application of consumer protection authorities by state attorneys general to alter the sales and promotion practices of tobacco retailers provides a complementary and highly leveraged strategy to increase compliance with tobacco sales to minors laws.

Cloning and genomic organization of the mouse gene slc23a1 encoding a vitamin C transporter

Vitamin C is known to exist in particularly high concentrations in brain tissue, and its free radical scavenging function is thought to represent a major antioxidative defense system. We have cloned, sequenced and analyzed the genomic structure of a mouse sodium-dependent vitamin C transporter gene, Slc23a1 (also known as Svct2). The mouse Slc23a1 cDNA is 6.4 kb long and was cloned directly from a mouse brain RNA preparation. Hybridization screening of a mouse genomic BAC library identified BAC 53L21 which contains at least the entire coding sequence of the mouse Slc23a1 gene. Determination of the exon-intron structure of the gene revealed 17 exons ranging from 58 bp to 4407 bp extending over 50 kb of the mouse genome, with the translation start codon located in exon 3. Its 1944 nucleotide open reading frame encodes a polypeptide of 647 aa, which is highly similar to rat and human orthologs. The mouse gene was assigned to chromosome 2qG2 by fluorescence in situ hybridization analysis. Expression of this gene was demonstrated in a wide range of tissues, with especially high levels in brain. Neurodegenerative diseases with an established role for oxidative stress in the cytoplasm may therefore be conditions of SLC23A1 dysfunction. Key words: gene structure; Vitamin C; transporter; oxidative stress

Gene-toxin interaction as a putative risk factor for Parkinson's disease with dementia

We had previously examined environmental, sociodemographic and clinical variables as predictors for Parkinson's disease with dementia (PD + D) and found that lower educational attainment, greater motor impairment and advanced age at disease onset were more common in PD + D than in subjects with Parkinson's disease without dementia (PD-D). We now explore the hypothesis that genetic traits coupled with nongenetic factors may raise the risk of development of PD + D. The study cohort of 43 PD + D and 51 PD-D subjects was analyzed examining environmental, sociodemographic and clinical variables along with 3 candidate gene markers: poor debrisoquine metabolizer allele (CYP 2D6 29B+), monoamine oxidase B allele 1, and apolipoprotein E epsilon 4 allele. Variables were initially entered into a multivariate model singly. Again lower education, age at onset and motor impairment appeared as predictors of PD + D while other variables (including allele status) failed to emerge as significant individual risk factors for dementia. We then examined environmental and genetic variables analyzed in tandem to look for potential variable interactions. Subjects who had pesticide exposure and at least 1 copy of the CYP 2D6 29B+ allele had 83% predicted probability of PD + D (stepwise logistic regression model: p = 0.0491). This case-control study provides preliminary evidence that a gene-toxin interaction may play an etiological role in PD + D. Further assessment of the role of these putative risk factors in incident dementia in PD is indicated.

Outcomes and complications of fetal tissue transplantation in Parkinson's disease

This study was undertaken to investigate the outcomes, complication rates and risk factors of stereotactic intrastriatal neurotransplantation for Parkinson's disease (PD). Bilateral stereotactic neurotransplantation was performed (as previously described) in 60 patients with idiopathic PD. Clinical outcome was evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS). The incidence of complication was evaluated by retrospective analysis of the clinical outcomes of the transplanted patients. Patients demonstrated significant improvement in UPDRS scores 12 months after transplantation. Nine patients experienced adverse effects after neurotransplantation, 3 requiring surgical intervention. Patients showed a significant overall improvement and no greater incidence of risk than that of other intracranial procedures.

Androgen receptor mutation in Kennedy's disease

Kennedy's disease is an X-linked form of motor neuron disease caused by an expanded polyglutamine repeat in the androgen receptor. While the expansion mutation causes some loss of transcriptional activity by the androgen receptor, the predominant effect of expansion is probably a toxic gain of function, similar to the mechanism of other polyglutamine expansion diseases. Features of the neurodegenerative phenotype of Kennedy's disease have now been reproduced in transgenic animals and neuronal cell culture. Nuclear inclusions of mutant androgen receptor protein are found in these model systems and in autopsy samples from patients with Kennedy's disease.

A multicenter trial of ropinirole as adjunct treatment for Parkinson's disease. Ropinirole Study Group

OBJECTIVE

To evaluate the nonergot dopamine agonist ropinirole as an adjunct to L-dopa in a randomized, double-blind trial in PD patients with motor fluctuations.

BACKGROUND

L-dopa in the treatment of PD is associated with motor fluctuations, dyskinesia, and other adverse effects. The use of dopamine agonists in the treatment of PD delays recourse to L-dopa and thus delays the possibility of adverse effect onset.

METHODS

Ropinirole (n = 95) or placebo (n = 54) was added to L-dopa, and L-dopa was then reduced in a planned manner during the 6-month trial.

RESULTS

A significantly greater number of ropinirole patients were able to achieve a 20% or greater reduction in both L-dopa dose and in percent time spent "off" compared with placebo (35.0% versus 13.0%; p = 0.003). The mean daily L-dopa dose was reduced significantly with ropinirole treatment (242 mg versus 51 mg; p < 0.001) as was the percent awake time spent "off" (11.7% versus 5.1%; p = 0.039). There was no difference in the percent of patients who withdrew because of adverse effects (15.8% on ropinirole versus 16.7% on placebo).

CONCLUSIONS

Ropinirole permits a reduction in L-dopa dose with enhanced clinical benefit for PD patients with motor fluctuations.

Managing the neuropsychiatric symptoms of Parkinson's disease

Neuropsychiatric symptoms frequently complicate the treatment of Parkinson's disease (PD). Approximately 27% of PD patients are demented, and approximately 19% are cognitively impaired without being demented. These 46% of patients are prone to development of delirium when they take antiparkinsonian drugs. Approximately 40% of PD patients are depressed. The depression may be endogenous or exogenous, apathetic or agitated. Approximately 40% of PD patients are anxious or have panic attacks. The attacks may or may not be associated with depression. This article reviews the diagnosis of these symptoms and discusses their management.

Safety of intrastriatal neurotransplantation for Huntington's disease patients

Fetal neural transplantation has been shown to be a feasible, safe, and according to a number of recent reports, effective treatment for Parkinson's disease (PD). Fetal striatal transplantation may be as feasible, safe, and effective a treatment for Huntington's disease (HD), a disorder for which there is currently no effective treatment. This report describes our experience with fetal striatal transplantation to adult striatum in three HD patients. Three moderately advanced, nondemented HD patients received transplantation of fetal striatal tissue. The striatal precursor was selectively obtained from the lateral ganglionic eminence. Each patient received bilateral grafts from five to eight donors, placed into the caudate nucleus (one graft on each side) and the putamen (four grafts on each side). All three patients had HD as documented by family history, DNA heterozygosity (17-20 and 48-51 repeats), magnetic resonance imaging (MRI) revealing striatal atrophy, and 2-deoxyglucose positron emission tomography revealing striatal hypometabolism. All patients had been evaluated using the Unified Huntington's Disease Rating Scale and appropriate neuropsychological tests for at least 3 months prior to transplantation. One year following transplantation, MRI of all three patients revealed that the grafts survived and grew within the striatum without displacing the surrounding tissue. No patients demonstrated adverse effects of the surgery or the associated cyclosporin immunosuppression, nor did any patient exhibit deterioration following the procedure. The limited experience provided by these three patients indicates that fetal tissue transplantation can be performed in HD patients without unexpected complications.

Outcome following intrastriatal fetal mesencephalic grafts for Parkinson's patients is directly related to the volume of grafted tissue

The effect of varying the volume of grafted fetal mesencephalic tissue was studied in patients with idiopathic Parkinson's disease in a single-blinded study. Evaluations were performed according to the Core Assessment Program for Intracerebral Transplantation and videotaped both prior to transplantation and in 3-month intervals after transplantation. One group, low-volume grafts (six subjects; mean age, 57.2 years), received ventral mesencephalon grafts from one to two donors with an approximate volume up to 20 mm3, while the second group, high-volume grafts (seven subjects; mean age, 59.5 years), received ventral mesencephalon grafts from three or more donors with an approximate volume of 24 mm3. Both groups of patients demonstrated significant improvement over presurgical baseline scores on all major parameters. The high-volume group had significantly greater improvements on all the UPDRS scores and also better performance on a variety of motor performance tasks over that seen among low-volume patients. These results indicate that variations of fetal graft volume do have an impact on clinical outcome.

Clinical evaluation of pramipexole in advanced Parkinson's disease: results of a double-blind, placebo-controlled, parallel-group study

We compared the efficacy, safety, an tolerability of pramipexole, an aminobenzathiazol-derived dopamine agonist with novel properties, with those of placebo in advanced PD patients with motor fluctuations under levodopa treatment. Pramipexole improved motor function of patients during "on" and "off" periods, decreased the time spent in "off" periods, reduced the severity of "off" periods, decreased disability and PD severity during "on" and "off" periods, as assessed by the Unified Parkinson Disease Rating Scale, and permitted a reduction in levodopa dosage. Adverse effects related to the central nervous system were similar to those reported with other dopamine agonists, and the gastrointestinal and cardiovascular tolerability of the compound was satisfactory.

Microelectrode-guided posteroventral medial radiofrequency pallidotomy for Parkinson's disease

The outcome of radiofrequency-guided posteroventral medial pallidotomy was investigated in 29 patients with recalcitrant Parkinson's disease. Extracellular recordings were obtained in the target region to differentiate the internal from the external globus pallidus, and distinct waveforms were recorded in each region. Stimulation of the target site further verified the lesion location. Of the 29 patients treated during the course of 1 year, none showed any adverse side effects (such as hemianopsia or hemiparesis) from the procedure. Significant and immediate improvement in motor involvement (dyskinesia, rigidity, dystonia, freezing, and tremor) was observed as measured by the Unified Parkinson's Disease Rating Scale and the Hoehn and Yahr scale. Patients experienced improvements in their condition as measured on a self-rating scale, and their ability to perform the activities of daily living was also significantly improved. Although the onset and duration of the effect of a single dose of levodopa did not change, the number of hours in an "off" state of dyskinesia per day was significantly decreased. These results provide further evidence, in a large group of patients, that posteroventral medial pallidotomy results in significant control of the motor symptoms of Parkinson's disease with a minimum of undesirable side effects.

Recruiting and retaining low-income Latinos in psychotherapy research

This article offers suggestions for recruiting and retaining low-income Latinos in treatment studies. Because Latinos underuse traditional mental health services, places such as medical centers or churches with large Latino constituents are suggested as useful alternative sources. To keep Latinos in research protocols, providing culturally sensitive treatments are necessary. Culturally sensitive treatments should incorporate families as part of recruitment efforts, particularly older men in the family. In addition, showing respect is an important aspect of traditional Latino culture that includes using formal titles and taking time to listen carefully. Finally, traditional Latinos tend to like interactions with others that are more warm and personal than is generally part of a research atmosphere.

Branchial pouch sinus tract from the piriform fossa causing acute suppurative thyroiditis, neck abscess, or both: CT appearance and the use of air as a contrast agent

OBJECTIVE

Our objective was to describe the CT appearance of acute suppurative thyroiditis and neck abscess associated with a congenital sinus tract arising from the piriform fossa. In addition, we describe our observations on the use of air as a contrast agent during CT of the pharynx.

CONCLUSION

The thyroid is extremely resistant to acute bacterial infection; hence, when such an infection does occur, an underlying anomaly of the thyroid should be suspected, particularly when the infection is recurrent. In such a case, sonography or CT must be used to confirm the diagnosis of acute thyroiditis, neck abscess, or both. Then the sinus tract must be revealed by barium esophagography, CT scanning that use air as a contrast agent, or endoscopy.

Recruiting and retaining low-income Latinos in psychotherapy research

This article offers suggestions for recruiting and retaining low-income Latinos in treatment studies. Because Latinos underuse traditional mental health services, places such as medical centers or churches with large Latino constituents are suggested as useful alternative sources. To keep Latinos in research protocols, providing culturally sensitive treatments are necessary. Culturally sensitive treatments should incorporate families as part of recruitment efforts, particularly older men in the family. In addition, showing respect is an important aspect of traditional Latino culture that includes using formal titles and taking time to listen carefully. Finally, traditional Latinos tend to like interactions with others that are more warm and personal than is generally part of a research atmosphere.

Multicenter, placebo-controlled trial of cabergoline taken once daily in the treatment of Parkinson's disease

Cabergoline is a dopaminergic agonist relatively specific for the D2 receptor and much longer-acting than other dopamine agonists. We conducted a randomized, placebo-controlled, double-blind study of cabergoline in 188 levodopa/carbidopa-treated patients with suboptimally controlled Parkinson's disease (PD). The cabergoline patients had significantly better Activities of Daily Living (p = 0.032) and Motor Examination (p = 0.031) scores at the conclusion of the trial compared with the placebo group. The daily levodopa dose for the cabergoline patients decreased 18% compared with a 3% reduction for the placebo group (p < 0.001). The amount of time in the "on" state increased more in the cabergoline group (p = 0.022). The side-effect was similar to that seen with other dopamine agonists, and cabergoline was generally well tolerated. We conclude that cabergoline is an effective adjunct to levodopa for the treatment of PD.

Clinical study of fetal mesencephalic intracerebral transplants for the treatment of Parkinson's disease

This study reports our findings from 22 patients (ages ranging from 42 to 73 yr; mean = 55.2) with recalcitrant idiopathic Parkinson's disease (PD) who received implants of fetal ventral mesencephalic tissue using an MRI-guided stereotactic procedure and who have been followed for at least 6 mo postoperatively, employing the guidelines established by the Core Assessment Program for Intracerebral Transplantations. Evaluations were videotaped and were performed both on and off levodopa medications. To date, we have seven patients with 24 mo, three with 18 mo, three with 12 mo, and nine with 6 mo post-surgical assessments. Comparing surgical outcomes to levels prior to fetal transplants we found: 1) mean levodopa levels were reduced 46% at 6 mo, 12% at 12 mo, 20% at 18 mo, and 54% at 24 mo; 2) Unified Parkinson's Disease Rating Scale (UPDRS) scores with patients on levodopa were improved by an average of 38% (6 mo), 50.2% (12 mo), 69.3% (18 mo), and 73.9% (24 mo), while off medication scores showed reductions ranging from 24.7% at 6 mo to 55.1% at 24 mo. Other measures, including Hoehn-Yahr staging, Activities of Daily Living, and dyskinesia rating scales, were also significantly improved following fetal transplants. Timed motor tasks (finger dexterity, supination-pronation, foot tapping, and Stand-Walk-Sit) performance also demonstrated highly significant improvements. Patient's self-rating scores indicated that the patients typically perceived substantial improvements in their condition. However, substantial variability in the improvements following surgery still persists and range from nominal improvements in performance to significant changes that can be classified as altering the overall lifestyle of the patients. To date, 4 of the 22 subjects were considered by the physicians to be nonresponders; that is, there were no clinically relevant improvements in these patients' conditions.

Fluctuating Parkinson's disease. Treatment with the long-acting dopamine agonist cabergoline

OBJECTIVE

Assessment of the very long-acting dopamine agonist medication cabergoline in the control of motor fluctuations in Parkinson's disease.

DESIGN

Open-label trial (13 weeks).

SETTING

Referral centers (Mayo Clinic, Rochester, Minn, and Scottsdale, Ariz).

PATIENTS

Volunteer sample of 41 patients with idiopathic Parkinson's disease who were experiencing motor fluctuations while receiving stable doses of carbidopa and levodopa.

INTERVENTION

Adjunctive oral cabergoline was incrementally administered once daily with the maintenance dose determined by the clinical response (maximum dose, 5 mg/d).

MAIN OUTCOME MEASURES

Standardized serial motor examinations were performed, beginning anywhere from 30 minutes before and continuing to 6 hours after test doses of medications were administered. Scores during adjunctive cabergoline therapy were compared with the prestudy baseline scores during therapy with carbidopa and levodopa without cabergoline.

RESULTS

Adjunctive cabergoline therapy significantly improved mean motor scores at the time of each standardized serial examination, from 30 minutes to 6 hours after the administration of test doses of medications. Significant motor score improvement was also measured 24 hours after the last cabergoline dose was administered, suggesting a very long-acting antiparkinsonian effect. Mean dyskinesia scores were slightly but nonsignificantly elevated. Diary card "off-time" was improved by 42%, whereas the levodopa dosage was reduced by 18%. Only three patients dropped out (7% of the total), which contrasts with much higher dropout rates owing to adverse events in previous clinical trials of other antiparkinsonian dopamine agonists.

CONCLUSIONS

Cabergoline improved motor control in patients with Parkinson's disease who were experiencing clinical fluctuations. Possible advantages of this medication include an extended clinical response (persisting to 24 hours), tolerability, and ease of use (once per day administration).