Vaccines targeting ESR1 activating mutations elicit anti-tumor immune responses and suppress estrogen signaling in therapy resistant ER+ breast cancer

ER+ breast cancers (BC) are characterized by the elevated expression and signaling of estrogen receptor alpha (ESR1), which renders them sensitive to anti-endocrine therapy. While these therapies are clinically effective, prolonged treatment inevitably results in therapeutic resistance, which can occur through the emergence of gain-of-function mutations in ESR1. The central importance of ESR1 and development of mutated forms of ESR1 suggest that vaccines targeting these proteins could potentially be effective in preventing or treating endocrine resistance. To explore the potential of this approach, we developed several recombinant vaccines encoding different mutant forms of ESR1 (ESR1mut) and validated their ability to elicit ESR1-specific T cell responses. We then developed novel ESR1mut-expressing murine mammary cancer models to test the anti-tumor potential of ESR1mut vaccines. We found that these vaccines could suppress tumor growth, ESR1mut expression and estrogen signaling in vivo. To illustrate the applicability of these findings, we utilize HPLC to demonstrate the presentation of ESR1 and ESR1mut peptides on human ER+ BC cell MHC complexes. We then show the presence of human T cells reactive to ESR1mut epitopes in an ER+ BC patient. These findings support the development of ESR1mut vaccines, which we are testing in a Phase I clinical trial.

Costs and health care resource utilization among Medicare beneficiaries diagnosed with chronic lymphocytic leukemia

BACKGROUND

Chronic lymphocytic leukemia (CLL) is the most common type of leukemia. However, published studies of CLL have either only focused on costs among individuals diagnosed with CLL without a non-CLL comparator group or focused on costs associated with specific CLL treatments. An examination of utilization and costs across different care settings provides a holistic view of utilization associated with CLL.

OBJECTIVE

To quantify the health care costs and resource utilization types attributable to CLL among Medicare beneficiaries and identify predictors associated with each of the economic outcomes among beneficiaries diagnosed with CLL.

METHODS

This retrospective study used a random 20% sample of the Medicare Chronic Conditions Data Warehouse (CCW) database covering the 2017-2019 period. The study population consisted of individuals with and without CLL. The CLL cohort and non-CLL cohort were matched using a 1:5 hard match based on baseline categorical variables. We characterized economic outcomes over 360 days across cost categories and places of services. We estimated average marginal effects using multivariable generalized linear regression models of total costs and across type of services. Total cost was compared between CLL and non-CLL cohorts using the matched sample. We used generalized linear models appropriate for the count or binary outcome to identify factors associated with various categories of health care resource utilization, such as inpatient admissions, emergency department (ED) visits, and oncologist/hematologist visits.

RESULTS

A total of 2,736 beneficiaries in the CLL cohort and 13,571 beneficiaries in the non-CLL matched cohort were identified. Compared with the non-CLL cohort, the annual cost for the CLL cohort was higher (CLL vs non-CLL, mean [SD]: $22,781 [$37,592] vs $13,901 [$24,725]), mainly driven by health care provider costs ($6,535 vs $3,915) and Part D prescription drug costs ($5,916 vs $2,556). The main categories of health care resource utilization were physician evaluation/management visits, oncologist/hematologist visits, and laboratory services. Compared with beneficiaries aged 65-74 years, beneficiaries aged 85 years or older had lower use and cost in maintenance services (ie, oncologist visits, hospital outpatient costs, and prescription drug cost) but higher use and cost in acute services (ie, ED). Compared with residency in a metropolitan area, living in a nonmetropolitan area was associated with fewer physician visits but higher ED visits and hospitalizations.

CONCLUSIONS

The cooccurrence of lower utilization of routine care services, along with higher utilization of acute care services among some individuals, has implications for patient burden and warrants further study.

Developing Social Enhancements for a Web-Based, Positive Emotion Intervention for Alzheimer Disease Caregivers: Qualitative Focus Group and Interview Study

BACKGROUND

Alzheimer disease is a degenerative neurological condition that requires long-term care. The cost of these responsibilities is often borne by informal caregivers, who experience an elevated risk of negative physical and psychological outcomes. Previously, we designed a positive emotion regulation intervention that was shown to improve well-being among dementia caregivers when delivered through one-on-one videoconferencing lessons with a trained facilitator. However, the format required significant resources in terms of logistics and facilitator time. To broaden the reach of the intervention, we aimed to develop the Social Augmentation of Self-Guided Electronic Delivery of the Life Enhancing Activities for Family Caregivers (SAGE LEAF) program, an iteration of the intervention in a self-guided, web-based format with enhanced opportunities for social connection.

OBJECTIVE

The aim of this study was to gather feedback to inform the design of social features for the SAGE LEAF intervention. In the absence of a facilitator, our goal with the self-guided SAGE LEAF intervention was to integrate various social features (eg, discussion board, automated support, and profiles) to maximize engagement among participants.

METHODS

Qualitative data were collected from 26 individuals through (1) interviews with participants who completed a previous version of the intervention via videoconferencing with a facilitator, (2) focus groups with dementia caregivers who had not previously experienced the intervention, and (3) focus groups with Alzheimer disease clinical care providers. We conducted a qualitative thematic analysis to identify which social features would be the most helpful and how they could be implemented in a way that would be best received by caregivers.

RESULTS

Interview and focus group feedback indicated that participants generally liked the potential features suggested, including the discussion boards, multimedia content, and informational support. They had valuable suggestions for optimal implementation. For example, participants liked the idea of a buddy system where they would be matched up with another caregiver for the duration of the study. However, they expressed concern about differing expectations among caregivers and the possibility of matched caregivers not getting along. Participants also expressed interest in giving caregivers access to a podcast on the skills, which would allow them to review additional content when they wished.

CONCLUSIONS

Taken together, the discussions with caregivers and providers offered unique insights into the types of social features that may be integrated into the SAGE LEAF intervention, as well as implementation suggestions to improve the acceptability of the features among caregivers. These insights will allow us to design social features for the intervention that are optimally engaging and helpful for caregivers.

Randomized controlled trial of a positive emotion regulation intervention to reduce stress in family caregivers of individuals with Alzheimer's disease: protocol and design for the LEAF 2.0 study

BACKGROUND

Caring for a loved one with Alzheimer's disease can be stressful, resulting in poorer emotional and physical health among family caregivers. Although supportive resources for caregivers are available, distance, caregiver health, and the daily demands of caregiving are barriers to access. Based on research demonstrating the importance of positive emotions in coping with stress, our previous trial showed that dementia caregivers who participated in facilitated, web-based delivery of a positive emotion regulation intervention called LEAF (Life Enhancing Activities for Family caregivers) experienced increased positive emotion and decreased depression and anxiety. Building on this evidence, the LEAF 2.0 study aims to test whether web-based, self-guided delivery can confer similar benefits for caregivers of individuals with Alzheimer's disease.

METHODS

This paper presents the design and methods for LEAF 2.0, a 3-arm web-based randomized controlled trial (N = 500) in which family caregivers of patients with Alzheimer's disease (AD) are randomized to (1) the LEAF intervention facilitated remotely via the web (N = 200), (2) the LEAF intervention self-guided online (N = 200), or (3) an emotion reporting control (N = 100), which then crosses over to the intervention after approximately 6 months, half to the facilitated arm and half to the self-guided arm. We aim to (1) compare the effect of the facilitated and self-guided LEAF positive emotion interventions to an emotion reporting control condition on AD caregiver well-being (positive emotion, depression, anxiety, and perceived stress) and secondary outcomes (caregiving burden, caregiving self-efficacy, positive aspects of caregiving, quality of care, and AD patient quality of life); (2) assess whether effects are mediated by improvements in positive emotion or other aspects of caregiver well-being; and (3) test whether caregiver age or gender or the care recipient's dementia severity moderates the effects of the intervention.

DISCUSSION

If demonstrated to be effective, LEAF can be widely disseminated and ultimately have a significant impact on the stress experienced by AD caregivers and the well-being of people living with Alzheimer's disease.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03610698.

Disparity in treatment patterns among Medicare beneficiaries diagnosed with chronic lymphocytic leukemia: an analysis of patient and contextual factors

This study characterizes the patterns and timing of CLL treatment and, to our knowledge, is the first to identify social vulnerability factors associated with CLL treatment receipt in the Medicare population. A total of 3508 Medicare beneficiaries diagnosed with CLL from 2017 to 2019 were identified. We reported the proportion of individuals who received CLL treatment and the time until the first CLL treatment receipt after the first observed claim with a CLL diagnosis. Logistic regression and time-to-event models provided adjusted odds ratios and hazard ratios associated with baseline individual-level and county-level factors. Sixteen percent of individuals received CLL treatment, and the median follow-up time was 540 d. The median time to receipt of CLL treatment was 61 d. Older age and residence in a county ranked high in social vulnerability (as defined by minority status and language) were negatively associated with treatment receipt and time to treatment receipt.

Donor noradrenaline use is associated with better allograft survival in recipients of pancreas transplantation

INTRODUCTION

Outcomes following pancreas transplantation are suboptimal and better donor selection is required to improve this. Vasoactive drugs (VaD) are commonly used to correct the abnormal haemodynamics of organ donors in intensive care units. VaDs can differentially affect insulin secretion positively (dobutamine) or negatively (noradrenaline). The hypothesis was that some VaDs might induce beta-cell stress or rest and therefore impact pancreas transplant outcomes. The aim of the study was to assess relationships between VaD use and pancreas transplant graft survival.

METHODS

Data from the UK Transplant Registry on all pancreas transplants performed between 2004 and 2016 with complete follow-up data were included. Univariable- and multivariable-adjusted Cox regression analyses determined risks of graft failure associated with VaD use.

RESULTS

In 2,183 pancreas transplants, VaDs were used in the following numbers of donors: dobutamine 76 (3.5%), dopamine 84 (3.8%), adrenaline 161 (7.4%), noradrenaline 1,589 (72.8%) and vasopressin 1,219 (55.8%). In multivariable models, adjusted for covariates and the co-administration of other VaDs, noradrenaline use (vs non-use) was a strong predictor of better graft survival (hazard ratio [95% confidence interval] 0.77 [0.64-0.94], p = 0.01).

CONCLUSIONS

Noradrenaline use was associated with better graft survival in models adjusted for donor and recipient variables - this may be related to inhibition of pancreatic insulin secretion initiating pancreatic beta-cell 'rest'. Further research is required to replicate these findings and establish whether relationships are causal. Identification of alternative methods of inducing beta-cell rest could be valuable in improving graft outcomes.

Enhanced optical conductivity and many-body effects in strongly-driven photo-excited semi-metallic graphite

The excitation of quasi-particles near the extrema of the electronic band structure is a gateway to electronic phase transitions in condensed matter. In a many-body system, quasi-particle dynamics are strongly influenced by the electronic single-particle structure and have been extensively studied in the weak optical excitation regime. Yet, under strong optical excitation, where light fields coherently drive carriers, the dynamics of many-body interactions that can lead to new quantum phases remain largely unresolved. Here, we induce such a highly non-equilibrium many-body state through strong optical excitation of charge carriers near the van Hove singularity in graphite. We investigate the system's evolution into a strongly-driven photo-excited state with attosecond soft X-ray core-level spectroscopy. We find an enhancement of the optical conductivity of nearly ten times the quantum conductivity and pinpoint it to carrier excitations in flat bands. This interaction regime is robust against carrier-carrier interaction with coherent optical phonons acting as an attractive force reminiscent of superconductivity. The strongly-driven non-equilibrium state is markedly different from the single-particle structure and macroscopic conductivity and is a consequence of the non-adiabatic many-body state.

Acceptability and Feasibility of a Socially Enhanced, Self-Guided, Positive Emotion Regulation Intervention for Caregivers of Individuals With Dementia: Pilot Intervention Study

BACKGROUND

The responsibilities of being a primary caregiver for a loved one with dementia can produce significant stress for the caregiver, leading to deleterious outcomes for the caregiver's physical and psychological health. Hence, researchers are developing eHealth interventions to provide support for caregivers. Members of our research team previously developed and tested a positive emotion regulation intervention that we delivered through videoconferencing, in which caregiver participants would meet one-on-one with a trained facilitator. Although proven effective, such delivery methods have limited scalability because they require significant resources in terms of cost and direct contact hours.

OBJECTIVE

This study aimed to conduct a pilot test of a socially enhanced, self-guided version of the positive emotion regulation intervention, Social Augmentation of Self-Guided Electronic Delivery of the Life Enhancing Activities for Family Caregivers (SAGE LEAF). Studies have shown that social presence or the perception of others in a virtual space is associated with enhanced learning and user satisfaction. Hence, the intervention leverages various social features (eg, discussion boards, podcasts, videos, user profiles, and social notifications) to foster a sense of social presence among participants and study team members.

METHODS

Usability, usefulness, feasibility, and acceptability data were collected from a pilot test in which participants (N=15) were given full access to the SAGE LEAF intervention over 6 weeks and completed preintervention and postintervention assessments (10/15, 67%). Preliminary outcome measures were also collected, with an understanding that no conclusions about efficacy could be made, because our pilot study did not have a control group and was not sufficiently powered.

RESULTS

The results suggest that SAGE LEAF is feasible, with participants viewing an average of 72% (SD 42%) of the total available intervention web pages. In addition, acceptability was found to be good, as demonstrated by participants' willingness to recommend the SAGE LEAF program to a friend or other caregiver. Applying Pearson correlational analyses, we found moderate, positive correlation between social presence scores and participants' willingness to recommend the program to others (r9=0.672; P=.03). We also found positive correlation between social presence scores and participants' perceptions about the overall usefulness of the intervention (r9=0.773; P=.009). This suggests that participants' sense of social presence may be important for the feasibility and acceptability of the program.

CONCLUSIONS

In this pilot study, the SAGE LEAF intervention demonstrates potential for broad dissemination for dementia caregivers. We aim to incorporate participant feedback about how the social features may be improved in future iterations to enhance usability and to further bolster a sense of social connection among participants and study staff members. Next steps include partnering with dementia clinics and other caregiver-serving organizations across the United States to conduct a randomized controlled trial to evaluate the effectiveness of the intervention.

A multicenter retrospective study evaluating the impact of desmopressin on hematoma expansion in patients with antiplatelet-associated intracranial hemorrhage

INTRODUCTION

Antiplatelet medications interfere with hemostasis which can contribute to increased risk of hematoma expansion and potentially worse outcomes in patients presenting with intracranial hemorrhages (ICH). Current Neurocritical Care Society guidelines recommend desmopressin (DDAVP) in patients with antiplatelet-associated ICH with evidence limited by small cohorts.

MATERIALS AND METHODS

Patients were included in our multi-center, retrospective study if they had computed tomographic (CT) scan confirmed ICH and were taking antiplatelet medications. Patients were excluded if hospital length of stay was <24 h, administered DDAVP dose was <0.3 μg/kg, no follow-up head CT scan was performed within the first 24 h after baseline, major neurosurgical intervention was performed in between CT scans, or the injury was an acute on chronic ICH. The primary outcome was incidence of hematoma expansion (defined as >20 % increase from baseline). Secondary outcomes were incidence of thrombotic complications within 7 days, largest absolute decrease in serum sodium within the first 24 h, and patient disposition.

RESULTS

Among the 209 patients included in the study, 118 patients received DDAVP while 91 did not. The frequency of hematoma expansion was similar between patients who received DDAVP and those who did not (16.1 % vs 17.6 %; P = 0.78). No difference in secondary outcomes was observed between the two groups.

CONCLUSIONS

These findings in conjunction with recently published literature may suggest minimal benefit or harm with DDAVP treatment. However, further study could elucidate any potential impact on long-term function outcomes.

A-06 Current Norms May Overestimate Rates of Neurocognitive Impairment among American Indian and Alaskan Native Adults

Objective

Currently available normative data subsume American Indian and Alaskan Native (AI/AN) populations within the non-Latinx white (NLW) ethnoracial group. The classification accuracy of such norms among AI/AN remains unknown. This cross-sectional study aims to identify whether disparities exist in the rates of neurocognitive impairment (NCI) between AI/AN and NLW adults. &lt; br&gt;&lt;br &gt; 

Method

Two hundred community-dwelling adults (50&#37; NLW; 50&#37; Male; M Age = 42 ± 14 years; M Education = 13 ± 3 years) completed comprehensive neurocognitive, quality of education (Wide Range Achievement Test- 4 [WRAT-4]), neuromedical, urine toxicology, and psychiatric/substance use evaluations. Average T-scores were calculated using widely used demographically corrected (age, gender, education) NLW norms to identify NCI (&gt; 1 SD; e.g., Heaton et al., 2004; Heaton & Marcotte, 2000). A comorbid condition propensity score (CCPS) identified the probability to which comorbid conditions (e.g., Heaton et al., 2010) informed ethnoracial identity. &lt;br&gt;&lt;br &gt; 

Results

After adjusting for WRAT-4 and CCPS, the results of a logistic regression analysis demonstrated a significant ethnoracial disparity in risk for NCI (X2(3) = 13.88, p&lt;.01, R2 = .07), such that the AI/AN group was at 2.52 times higher odds (32.3&#37; vs. 16.0, CI: 1.15–5.46, p = .01, Cohen’s d = .51) for NCI in comparison to the NLW group. &lt;br&gt;&lt;br &gt; 

Conclusions

Published norms for NLW adults may overestimate impairment in AI/AN adults. Thus, population-specific normative data are needed to clarify the classification accuracy of neurocognitive impairment and possible disparities in neurocognitive disorders (e.g., HIV-associated neurocognitive disorders) among AI/AN adults. Future work should replicate these findings among other diverse populations (e.g., Caribbean, Middle Eastern) lacking population-specific normative data.876199.

Kinetic implication of moving warm side-stream Anaerobic ammonium oxidizing bacteria to cold mainstream wastewater

Decreased activity of Anaerobic ammonia oxidation (Anammox) at low temperatures is widely reported and one of the key challenges to applying Anammox to mainstream wastewater treatment. In this work, we systematically measured Anammox across a range of temperatures for biomass taken from a side-stream (25-30 °C) Anammox system. Using the Cardinal temperature model with inflection (CTMI) and parameters T_min = 10 °C, T_opt = 31 °C, T_max = 40 °C, and µ_max = 0.29 d^-1, the data was accurately represented. Alternatively, the popularly used Arrhenius equation was not able to consistently capture the trend we observed. The CTMI was further used to compute the relative increase in retention time and/or biomass concentration to treat the same quantity of nitrogen at sub-optimal temperatures, requiring a two-fold increase at 21 °C and three-fold increase at 19 °C. We conclude that cold adapted cultures are necessary to evaluate the possibility of cold Anammox wastewater treatment.

The Transplant Surgeon: An Unlikely, Yet Suitably Qualified, Member of The Complex Neuro Endocrine Multi-Disciplinary Team

Curative surgery for retro-peritoneal tumours involving vascular structures is challenging and multi-visceral resection is often required to obtain clear resection margins. Abdominal transplant surgeons have considerable experience in all aspects of visceral, vascular and retro-peritoneal surgery. Application of these skills to resect tumours involving vascular structures, and re-implant organs to preserve function is unique. We present the case of a 15- year old girl with a complex retro-peritoneal tumour which was resected en-bloc with the kidneys and vena-cava followed by auto-transplantation of the left kidney. Seven years later, the patient represented with a recurrent tumour which was successfully excised in its entirety. We discuss how innovative surgical strategies can be performed safely on an individualized basis. We highlight the importance of balancing the benefits of the ‘technically possible procedure’ with its risks, along with consideration of the outcomes of treatment and non-treatment alike.

Establishment and characterization of an anoxia-tolerant cell line, PSU-AL-WS40NE, derived from an embryo of the annual killifish Austrofundulus limnaeus

Most animal cells rely on aerobic metabolism for survival and are damaged or die within minutes without oxygen. Embryos of the annual killifish Austrofundulus limnaeus, however, survive months without oxygen. Determining how their cells survive without oxygen has the potential to revolutionize our understanding of the cellular mechanisms supporting vertebrate anoxia tolerance and the evolution of such tolerance. Therefore, we aimed to establish and characterize an anoxia-tolerant cell line from A. limnaeus for investigating mechanisms of vertebrate anoxia tolerance. The PSU-AL-WS40NE cell line of neuroepithelial identity was established from embryonic tissue of A. limnaeus using a tissue explant. The cells can survive for at least 49 d without oxygen or replenishment of growth medium, compared to only 3 d of anoxic survival for two mammalian cell lines. PSU-AL-WS40NE cells accumulate lactate during anoxia, indicating use of common metabolic pathways for anaerobic metabolism. Additionally, they express many of the same small noncoding RNAs that are stress-responsive in whole embryos of A. limnaeus and mammalian cells, as well as anoxia-responsive small noncoding RNAs derived from the mitochondrial genome (mitosRNAs). The establishment of the cell line provides a unique tool for investigating cellular mechanisms of vertebrate anoxia tolerance, and has the potential to transform our understanding of the role of oxidative metabolism in cell biology.

Systematic review to assess the possibility of return of cerebral and cardiac activity after normothermic regional perfusion for donors after circulatory death

BACKGROUND

Normothermic regional perfusion (NRP) is a novel technique that aids organ recovery from donors after circulatory death (DCDs). However, ethical concerns exist regarding the potential return of spontaneous cerebral and cardiac activity (ROSCCA). This study aimed to determine the likelihood of ROSCCA in NRP-DCDs of abdominal organs.

METHODS

Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory out-of-hospital cardiac arrest (OOHCA) was identified as a comparator for NRP-DCDs and as a validation cohort. A systematic search identified all articles relating to NRP-DCDs and ECPR-OOHCA. Rates of ROSCCA and survival outcomes (ECPR-OOHCA only) were recorded and analysed according to the duration of no perfusion.

RESULTS

In NRP-DCDs, 12 of 410 articles identified by database searching were eligible for inclusion. There were no instances of ROSCCA recorded among 493 donors. In ECPR-OOHCA, eight of 947 screened articles were eligible for inclusion (254 patients). Where the absence of perfusion exceeded 5 min in ECPR-OOHCA, there were no survivors with a favourable neurological outcome.

CONCLUSION

ROSCCA is unlikely following commencement of NRP and has not occurred to date. Strict observance of the 5-min interval following asystole provides satisfactory assurance that ROSCCA will not occur following NRP.

Small Non-coding RNA Expression and Vertebrate Anoxia Tolerance

Background: Extreme anoxia tolerance requires a metabolic depression whose modulation could involve small non-coding RNAs (small ncRNAs), which are specific, rapid, and reversible regulators of gene expression. A previous study of small ncRNA expression in embryos of the annual killifish Austrofundulus limnaeus, the most anoxia-tolerant vertebrate known, revealed a specific expression pattern of small ncRNAs that could play important roles in anoxia tolerance. Here, we conduct a comparative study on the presence and expression of small ncRNAs in the most anoxia-tolerant representatives of several major vertebrate lineages, to investigate the evolution of and mechanisms supporting extreme anoxia tolerance. The epaulette shark (Hemiscyllium ocellatum), crucian carp (Carassius carassius), western painted turtle (Chrysemys picta bellii), and leopard frog (Rana pipiens) were exposed to anoxia and recovery, and small ncRNAs were sequenced from the brain (one of the most anoxia-sensitive tissues) prior to, during, and following exposure to anoxia. Results: Small ncRNA profiles were broadly conserved among species under normoxic conditions, and these expression patterns were largely conserved during exposure to anoxia. In contrast, differentially expressed genes are mostly unique to each species, suggesting that each species may have evolved distinct small ncRNA expression patterns in response to anoxia. Mitochondria-derived small ncRNAs (mitosRNAs) which have a robust response to anoxia in A. limnaeus embryos, were identified in the other anoxia tolerant vertebrates here but did not display a similarly robust response to anoxia. Conclusion: These findings support an overall stabilization of the small ncRNA transcriptome during exposure to anoxic insults, but also suggest that multiple small ncRNA expression pathways may support anoxia tolerance, as no conserved small ncRNA response was identified among the anoxia-tolerant vertebrates studied. This may reflect divergent strategies to achieve the same endpoint: anoxia tolerance. However, it may also indicate that there are multiple cellular pathways that can trigger the same cellular and physiological survival processes, including hypometabolism.

Renal Allograft Failure After Ipilimumab Therapy for Metastatic Melanoma: A Case Report and Review of the Literature

Transplant recipients are at an increased risk of malignant melanoma, a result of chronic immunosuppression. Ipilimumab is a newer biological agent targeting T lymphocytes to potentiate an immune response against melanoma, and the use of this agent results in a new adverse effect profile that the clinician must be aware of while a patient is on therapy. We report the case of a male renal transplant recipient who developed graft failure while treated with ipilimumab and minimal immunosuppressive therapy for metastatic ocular melanoma, with biopsy evidence of glomerulonephritis and acute rejection. We highlight the immunological side effects that can manifest from ipilimumab therapy and conclude that it did influence graft function in this patient. Our case illustrates the importance of weighing the risks and benefits to graft function and long-term survival as well as the importance of considering other treatment modalities in this specific group of melanoma patients.

Clinical practice guidelines--Nursing management for pediatric patients with small bowel or multivisceral transplant

PURPOSE

Small bowel or multivisceral transplant is a relatively new treatment for irreversible intestinal damage, and no published practice guidelines exist. The purpose of this article is to report evidence regarding the best plan of care to achieve adequate nutrition and appropriate development for children.

DESIGN AND METHODS

An integrative review was conducted with 54 articles related to management of this transplant population. A nine-member nursing team integrated the findings.

PRACTICE IMPLICATIONS

This resulting guideline represents the best research and best practices on which to base staff education and competency validations to manage this medically fragile patient population.

Precision and linearity targets for validation of an IFNgamma ELISPOT, cytokine flow cytometry, and tetramer assay using CMV peptides

BACKGROUND

Single-cell assays of immune function are increasingly used to monitor T cell responses in immunotherapy clinical trials. Standardization and validation of such assays are therefore important to interpretation of the clinical trial data. Here we assess the levels of intra-assay, inter-assay, and inter-operator precision, as well as linearity, of CD8+ T cell IFNgamma-based ELISPOT and cytokine flow cytometry (CFC), as well as tetramer assays.

RESULTS

Precision was measured in cryopreserved PBMC with a low, medium, or high response level to a CMV pp65 peptide or peptide mixture. Intra-assay precision was assessed using 6 replicates per assay; inter-assay precision was assessed by performing 8 assays on different days; and inter-operator precision was assessed using 3 different operators working on the same day. Percent CV values ranged from 4% to 133% depending upon the assay and response level. Linearity was measured by diluting PBMC from a high responder into PBMC from a non-responder, and yielded R2 values from 0.85 to 0.99 depending upon the assay and antigen.

CONCLUSION

These data provide target values for precision and linearity of single-cell assays for those wishing to validate these assays in their own laboratories. They also allow for comparison of the precision and linearity of ELISPOT, CFC, and tetramer across a range of response levels. There was a trend toward tetramer assays showing the highest precision, followed closely by CFC, and then ELISPOT; while all three assays had similar linearity. These findings are contingent upon the use of optimized protocols for each assay.

Impact of cryopreservation on tetramer, cytokine flow cytometry, and ELISPOT

Background

Cryopreservation of PBMC and/or overnight shipping of samples are required for many clinical trials, despite their potentially adverse effects upon immune monitoring assays such as MHC-peptide tetramer staining, cytokine flow cytometry (CFC), and ELISPOT. In this study, we compared the performance of these assays on leukapheresed PBMC shipped overnight in medium versus cryopreserved PBMC from matched donors.

Results

Using CMV pp65 peptide pool stimulation or pp65 HLA-A2 tetramer staining, there was significant correlation between shipped and cryopreserved samples for each assay (p ≤ 0.001). The differences in response magnitude between cryopreserved and shipped PBMC specimens were not significant for most antigens and assays. There was significant correlation between CFC and ELISPOT assay using pp65 peptide pool stimulation, in both shipped and cryopreserved samples (p ≤ 0.001). Strong correlation was observed between CFC (using HLA-A2-restricted pp65 peptide stimulation) and tetramer staining (p < 0.001). Roughly similar sensitivity and specificity were observed between the three assays and between shipped and cryopreserved samples for each assay.

Conclusion

We conclude that all three assays show concordant results on shipped versus cryopreserved specimens, when using a peptide-based readout. The assays are also concordant with each other in pair wise comparisons using equivalent antigen systems.

Predictive, pre-natal and diagnostic genetic testing for Huntington's disease: the experience in Canada from 1987 to 2000

Predictive and pre-natal testing for Huntington's Disease (HD) has been available since 1987. Initially this was offered by linkage analysis, which was surpassed by the advent of the direct mutation test for HD in 1993. Direct mutation analysis provided an accurate test that not only enhanced predictive and pre-natal testing, but also permitted the diagnostic testing of symptomatic individuals. The objective of this study was to investigate the uptake, utilization, and outcome of predictive, pre-natal and diagnostic testing in Canada from 1987 to April 1, 2000. A retrospective design was used; all Canadian medical genetics centres and their affiliated laboratories offering genetic testing for HD were invited to participate. A total of 15 of 22 centres (68.2%), currently offering or ever having offered genetic testing for HD, responded, providing data on test results, demographics, and clinical history. A total of 1061 predictive tests, 15 pre-natal tests, and 626 diagnostic tests were performed. The uptake for predictive testing was approximately 18% of the estimated at-risk Canadian population, ranging from 12.5% in the Maritimes to 20.7% in British Columbia. There appears to have been a decline in the rate of testing in recent years. Of the predictive tests, 45.0% of individuals were found to have an increased risk, and a preponderance of females (60.2%) sought testing. A greater proportion of those at < or = 25% risk sought predictive testing once direct CAG mutation analysis had become available (10.9% after mutation analysis vs 4.7% before mutation analysis, p = 0.0077). Very few pre-natal tests were requested. Of the 15 pre-natal tests, 12 had an increased risk, resulting in termination of pregnancy in all but one. Diagnostic testing identified 68.5% of individuals to be positive by mutation analysis, while 31.5% of those with HD-like symptoms were not found to have the HD mutation. The positive diagnostic tests included 24.5% of individuals with no known prior family history of HD.

The influence of applicator angle on dosimetry in vaginal vault brachytherapy

In vaginal vault brachytherapy, the critical normal tissues are bladder and rectum; doses to these tissues may be affected by the position of a single line applicator placed in the vagina. Dosimetry with the applicator lying at its "natural" angle in the vagina with the patient in the lithotomy position has been compared with the applicator held horizontal as defined by a spirit level in 30 consecutive patients. A mean change in angle of 19.7 degrees was found. This resulted in a mean decrease in ICRU (International Commission of Radiation Units and Measurements) rectal point dose when the applicator is horizontal of 12.9%, equivalent to a mean absolute dose reduction of 1.3 Gy for a prescription dose of 5.5 Gy at 5 mm depth. An increase in mean dose to the ICRU bladder point when the applicator is horizontal of 13.3%, equivalent to an absolute mean dose increase of 0.5 Gy per fraction for the same prescription dose, was also found. On the basis of these findings, it is recommended that vaginal vault brachytherapy is performed with a single line source held in the "corrected" horizontal position to reduce bowel dose as this is the most sensitive critical normal tissue.

A different start: midwifery in South Australia 1836-1920

It is the popular belief of many midwives and nurses in Australia that midwives of the nineteenth and early twentieth century in this country practiced completely independently of medicine, resorting to medical assistance only if the labor and delivery did not progress normally. There is also the opinion that only affluent childbirthing women had a medical man in attendance at the delivery and poorer women had a midwife. Indeed, much of the Australian historical literature supports these notions. However, evidence suggests that in South Australia this was not the case and that generally midwives practiced in collaboration with medical men. Apart from some exceptions, both midwives and medical men attended the deliveries of most childbirthing women from all strata of society. This paper will explore the provision of midwifery care in the early days of settlement in South Australia and show how the relationship between the community midwife and the general practitioner developed. In doing so, this paper will establish that the normal place of delivery in nineteenth-century South Australia was in the home with both a doctor and midwife in attendance as part of normal community life.

Transportation of maternal serum specimens for screening for chromosomal aneuploidies: effect of seasonal variations, distance, and freezing on the stability of the biological markers

OBJECTIVES

We studied the stability of maternal serum markers for screening for Down syndrome [alpha-fetoprotein (AFP), unconjugated estriol (uE3), total human chorionic gonadotropin (hCG), and free beta-human chorionic gonadotropin] following transportation.

DESIGN AND METHODS

For each gestational week between 14 and 18 weeks, we collected about 50 samples for each possible combination of three potential sources of variation during transportation: season (winter/summer), sample frozen/fresh (prior to analysis) and origin (local or referred in) for a total of 1845 specimens. Commercial assays were used (IMx, Abbott for AFP and total hCG; AutoDelfia and Wallac for free beta-hCG and AFP; and radioimmunoassay Ortho-Clinical Diagnostics, for uE3).

RESULTS

Results of both total and free beta-hCG were significantly higher when samples were collected during summer and when they were sent to the laboratory from extramural blood drawing sites (multifactorial ANOVA, p < 0. 007).

CONCLUSION

We conclude that both total and free beta-hCG can be adversely affected during transportation. The resulting higher concentrations of these markers may increase the false positive rate of prenatal screening programs for aneuploidies.

Lack of germline CDK6 mutations in familial melanoma

Germline mutations in genes encoding several components of the retinoblastoma pathway have been linked with inherited predisposition to melanoma. Most commonly, such mutations involve CDKN2A, a cyclin-dependent kinase inhibitor of two kinases, CDK4 and CDK6, which phosphorylate the retinoblastoma protein (pRB) and thereby promote passage through the G1/S cell-cycle restriction point. Less frequently, germline mutations in the CDK4 gene have also been linked with an increased risk of melanoma. Despite the sequence and functional homology between CDK4 and CDK6, the role of germline mutations in CDK6 in melanoma predisposition is unknown. We detected no CDK6 mutations within the p16 (CDKN2A) binding domain in index cases from 60 melanoma-prone kindreds that lacked germline mutations in the coding regions of either CDKN2A or within the entire CDK4 coding region. We conclude that germline mutations in CDK6 do not make a significant contribution to melanoma predisposition.

Surgical treatment of tracheomediastinal fistula from recurrent Hodgkin's lymphoma

The role of surgery in the management of Hodgkin's disease is usually diagnostic because chemotherapy and radiation are often curative. We report here the surgical treatment of a tracheomediastinal fistula from recurrent Hodgkin's lymphoma.

Mutation of the CDKN2A 5' UTR creates an aberrant initiation codon and predisposes to melanoma

Approximately 8-12% of melanoma is inherited in an autosomal dominant fashion with variable penetrance. A chromosome 9p21 locus has been linked to this disease in 50-80% of affected families. CDKN2A (also known as P16, INK4, p16INK4A and MTS1) is allelic to this locus and encodes a cdk4/cdk6 kinase inhibitor that constrains cells from progressing through the G1 restriction point. Although germline CDKN2A coding mutations cosegregate with melanoma in 25-60% of families predisposed to the disease, there remains a number of mutation-negative families that demonstrate linkage of inherited melanoma to 9p21 markers. We show here that a subset of these kindreds possess a G-->T transversion at base -34 of CDKN2A, designated G-34T. This mutation gives rise to a novel AUG translation initiation codon that decreases translation from the wild-type AUG. The G-34T mutation is not seen in controls, segregates with melanoma in families and, on the basis of haplotyping studies, probably arose from a common founder in the United Kingdom. Characterization of this and other CDKN2A non-coding mutations should have an impact on current efforts to identify susceptible melanoma-prone families and individuals.

Psychological outcomes following maternal serum screening: a cohort study

BACKGROUND

Maternal serum screening is used to assist in the prenatal detection of congenital anomalies. Its use is controversial, and one concern that has been expressed is its psychological effects on women. The authors examined whether this test leads to an increase in anxiety and depression among women who have a false-positive result as compared with those who have a true-negative result or do not undergo testing.

METHODS

A prospective cohort study with baseline assessment at 15 to 18 weeks' gestation and follow-up at 24 weeks' gestation was conducted. Pregnant women at 8 geographically diverse sites across Ontario were recruited. The main outcome measures were the state portion of the State--Trait Anxiety Inventory and the Center for Epidemiologic Studies Depression Scale.

RESULTS

Of the 2418 potential subjects 2020 (83.5%) were enrolled and eligible; 1741 (86.2%) completed the follow-up. A total of 1177 women (67.6%) underwent maternal serum screening. No overall adverse psychological effects as a result of testing were found at 24 weeks' gestation. Women with a false-positive result had a mean increase in anxiety score of 1.6 (95% confidence interval [CI] -1.7 to 4.9), whereas women with a true-negative result had a mean decrease of 1.1 (95% CI -1.8 to -0.3) and those not tested had a mean decrease of 0.4 (95% CI -1.3 to 0.5). The mean depression score increased by 0.5 (95% CI -0.9 to 2.0) in the false-positive group, was unchanged (95% CI -0.3 to 0.4) in the true-negative group and increased by 0.2 (95% CI -1.7 to 1.2) in the not tested group. Of the women who underwent testing, 87 (7.6%) were unsure of their result at the time of follow-up.

INTERPRETATION

The results suggest that maternal screening in Ontario is not causing serious psychological harm to women. Communication regarding test results could be improved, since a substantial proportion of women were unsure of their test result.

The lost voice of midwifery

The proposed review and amendments to the Nurses' Act in South Australia has caused intense debate in this state especially between nurses and midwives. On the one hand midwives claim that the new changes will affect their ability to deliver optimum care to the childbirthing woman and so affect their role as midwife. While on the other hand nurses counter claim that the proposed changes to the Act will not make any difference to midwifery care and cannot understand what all the fuss is about. Yet midwifery has never sat comfortably under the umbrella of nursing and this debate is not new. This paper takes a historical look at the professionalisation of nursing prior to the implementation of the original Nurses' Registration Act of South Australia in 1920. It explores the implications of this for the midwife of the time, highlighting the unresolved differences between these two professions that have contributed to the debate of today.

Role of the cyclin-dependent kinase inhibitor CDKN2A in familial melanoma

BACKGROUND

Approximately 8 to 12% of melanoma appears to be inherited in an autosomal dominant form. Although most early stage melanomas can be treated successfully by simple surgical excision, patients with advanced disease are rarely cured even with aggressive chemotherapy and/or immunotherapy.

OBJECTIVE

There is now compelling evidence that germline mutations of the CDKN2A gene on chromosome 9p21 predispose to melanoma in a subset of melanoma-prone families. In this article the evidence for the role of CDKN2A in the genesis of familial melanoma is reviewed and the implications of genetic testing in families with this disease are discussed.

CONCLUSION

The identification and subsequent surveillance of unaffected individuals who have a genetic predisposition to melanoma may lead to the detection of early (curable) melanomas and to a reduction in mortality.