Overcoming AML T cell therapy barriers with engineered proteins

Leukemia is the most common pediatric cancer and the second leading cause of cancer deaths in children. Adoptive cell therapy (ACT) has been validated in pediatric B cell acute lymphoblastic leukemia, where engineered cancer-targeting T cells can effectively eradicate tumor and tumor recurrence, generally more safely than drug and radiation therapy. However, ACT is not approved for patients with pediatric AML, other leukemias or solid tumors. Of note, pediatric AML patients have a worse 5-year survival rate than ALL.

AML cells can severely diminish ACT efficacy by expressing ligands that activate T cell inhibitory receptors and by downregulating costimulatory ligand expression. To address these issues, we developed fusion proteins that combine the ectodomain of an inhibitory T cell receptor with an intracellular costimulatory signaling domain. We have shown that this effectively “replaces a brake with an accelerator” in CD8 T cells, and have now developed FPs with different costimulatory domains to confer different attributes to T cells. Despite improved outcomes with single FP T cell therapy, we hypothesized that combining differently costimulated T cells would provide a synergistically diverse T cell response and improve outcomes. We tested 1:1 pairwise combinations of differently costimulated T cells that are also transduced with a tumor-specific TCR in serial killing over-time (SKO) assays and in vivo persistence studies. In survival studies, dual T cell therapy resulted in enhanced survival. We propose that a synergistically diverse T cell therapy provides enhanced antitumor efficacy over a monogenic cell product.

A54 DIETARY COMPONENTS ARE ASSOCIATED WITH FECAL CALPROTECTIN IN ULCERATIVE COLITIS

Background

Ulcerative colitis (UC) is thought to arise from dysregulated immune responses due to intestinal dysbiosis and altered epithelial barrier function. Dietary components may affect the gut microbiome and contribute to either inflammation or its resolution. The relationship between diet and disease activity in UC warrants further investigation.

Aims

This prospective cohort study explored the relationship between dietary components, and markers of disease activity: fecal calprotectin (FCP) and partial Mayo score (PMS) in patients with UC.

Methods

40 participants were recruited from University of Calgary IBD clinics. Study staff obtained two 24-hour diet recalls using the validated automated self administered (ASA)-24 and captured PMS at baseline (T1) and follow-up at week 12 (T2). FCP samples were collected at T1 and T2. Diet variables included adjusted macro/micronutrients (n=44), food groups (n=36) and the validated Canadian healthy eating index-2009 (CHEI) where higher scores reflect healthier intake. CHEI captures intake of dark green and orange foods (DGO) and moderation scoring (MOD) of saturated fats (SF), sodium and added sugars. Higher CHEI scores result from increased intake of DGO and lower intake of SF, sodium and added sugars (higher MOD score). Associations with outcome variables were examined at T1 and T2 individually and across both timepoints (BT). Mixed effect logistic regression models identified relationships between dietary variables, FCP and PMS. Models were adjusted for age, sex, BMI, medications, probiotics, and for repeated measures in both timepoint analyses.

Results

A positive association was identified between FCP as a continuous variable and SF (T1:Coef=0.22, p_adj=0.02) and a negative association identified between FCP with citrus/melon/berries (BT:Coef=-1.01, p_adj =0.04), total sugars (BT:Coef=-0.06, p_adj=0.025) and HEI (BT:Coef=-0.13, p_adj =0.06 and T1 coef=-0.18, p_adj =7.0 e-5). FCP increased as SF (-0.30,p_adj=0.01), DGO (-0.60, p_adj=0.02), and MOD (-0.21, p_adj=0.02) scores decreased. The presence of inflammation (as a binary variable, FCP >250) was negatively associated with higher fiber intake (BT: Odds Ratio (OR)= 0.016, CI(0.001,0.40) p_adj=0.08). For PMS as a continuous variable, HEI had a negative association with PMS (T2: -0.05, p_adj=0.06). With PMS as a discrete score (remission=PMS<2) there was no significant association with any diet components.

Conclusions

This study suggests that a healthier diet, both in overall pattern and specific dietary components, was associated with lower FCP and PMS. Our findings related to SF, citrus/melons/berries, and DGO parallel the IOIBD dietary guidelines. Future research should explore through controlled intervention studies whether modifying dietary patterns and components independently reduces disease activity.

Funding Agencies

Crohn’s and Colitis Foundation

Reproducibility of FDG PET/CT image-based cancer staging and standardized uptake values with simulated reduction of injected FDG dose or acquisition time

¹⁸F-fluorodeoxyglucose (FDG) PET/CT is widely used for oncologic imaging. This study aimed to evaluate, using data simulation, if reduction of injected FDG dose or PET acquisition time could be technically feasible when utilizing a sensitive commercial PET/CT imaging system, without sacrificing image quality, image-based staging accuracy, or standardized uptake value (SUV) accuracy. De-identified, standard of care oncologic FDG PET/CT datasets from 83 adults with lymphoma, lung carcinoma or breast carcinoma were retrospectively analyzed. All images had been acquired using clinical standard dose and acquisition time on a single PET/CT system. The list mode datasets were retrospectively software reprocessed to achieve undersampling of counts, thus simulating the effect of shorter PET acquisition time or lower injected FDG dose. The simulated reduced-count images were reviewed and compared with full-count images to assess and compare qualitative (subjective image quality, stage stability) and semi-quantitative (image noise, SUVmax stability, signal-to-noise and contrast-to-noise ratios within index lesions driving cancer stage) parameters. While simulated reduced-count images had measurably greater noise, there appeared to be no significant loss of image-based staging accuracy nor SUVmax reproducibility down to simulated FDG dose of 0.05 mCi/kg at continuous bed motion rate of 1.1 mm/sec. This retrospective simulation study suggests that a modest reduction of either injected FDG dose or emission scan time might be feasible in this limited oncologic population scanned on a single PET/CT system. Verification of these results with prospectively acquired images using actual low injected FDG activity and/or short imaging time is recommended.

A18 DIETARY PREDICTORS OF BIOLOGICAL ACTIVITY IN CROHN’S DISEASE: A RETROSPECTIVE COHORT STUDY

Background

Patients with Crohn’s disease (CD) often seek advice on optimizing their diet to reduce gut inflammation. The relationship between dietary patterns, major food groups and individual nutrients, with disease activity in Crohn’s disease (CD) is incompletely understood and warrants further investigation.

Aims

1.To determine whether a diversified (DD) or nondiversified (NDD) dietary pattern is related to biological activity in CD (BACD) in long-term follow up.

2.To determine if specific foods or nutrients are associated with increased BACD.

Methods

In this retrospective cohort study, forty-six CD patients (52% male) in remission completed 3-day food records between 2015–2017 for a 3-month intervention study and were classified as DD or NDD. Remission was defined by a Harvey Bradshaw Index <5 and no endoscopic ulcerations within 6 months of baseline data collection. Patients were classified as NDD if dietary fibre was ≤15 g/day or total fruit/vegetable servings ≤3/week, and if they consumed ≥3 servings/week of red and processed meat. Patients were otherwise defined as DD. A retrospective chart review captured BACD data. BACD was defined as one of either fecal calprotectin (FCP) ≥250 ug/g, hospitalization for CD flare, bowel resection for active CD, biologic dose escalation/switch due to non-response (not therapeutic drug monitoring), corticosteroid use, endoscopic evidence of apthous or large ulcers, or active disease on contrast enhanced ultrasound or magnetic resonance enterography. Machine learning methods with random forest prediction models assessed if diet composition was associated with BACD followed by univariate Mann-Whitney tests to compare differences between high and low disease activity.

Results

Sixteen patients (35%) had BACD during the mean 42 month follow up (31–54 months,SD ± 6.6). See Table 1 for additional demographics. Based on the random forest prediction model, both vitamins and minerals, food groups and Mediterranean diet cut-points could predict disease activity responses (ROC-AUC = 0.68 and 0.75, respectively). For these models, baseline intake of vitamins E, D, B1, and C and leafy greens, and fruit intake were the most important predictors of BACD. For the univariate analysis, the high disease group had lower intakes of fiber, vitamin E, and C (p = 0.047, 0.066, and 0.09, respectively). A higher proportion of patients consumed a NDD with BACD compared to those without BACD (50% vs. 23.3%, p=0.07).

Conclusions

To our knowledge, this is the first study to assess if dietary patterns, foods and nutrients are able to predict disease activity over a mean 42 month follow up. Further research into the dietary determinants of BACD in CD is warranted. With higher baseline FCP observed in the BACD, multivariate analyses to assess the independent effect of diet to predict BACD is required.

Funding Agencies

Litwin IBD Pioneers Foundation, Alberta’s Collaboration of Excellence for Nutrition in Digestive Diseases (Ascend)

Abstract 2555: Engineering adoptive T cell therapy to co-opt Fas ligand-mediated death signaling in solid tumors

Over 20,000 women are diagnosed with ovarian cancer annually, and over half will die within 5 years. This rate has changed little in the last 20 years, highlighting the need for therapy innovation. A promising new strategy with the potential to control tumor growth without toxicity to healthy tissues employs immune T cells engineered to target proteins uniquely overexpressed in tumors. Mesothelin (MSLN) contributes to the malignant and invasive phenotype in ovarian cancer, and has limited expression in healthy cells, making it a candidate immunotherapy target in these tumors. Using patient-derived cell lines and the ID8 mouse cell line, we found that T cells engineered to express a human or mouse MSLN-specific high-affinity T cell receptor (TCRMSLN) can kill respectively human or murine ovarian tumor cells in vitro. In a disseminated ID8 tumor model, adoptively transferred TCRMSLN T cells preferentially accumulated within established tumors, delayed ovarian tumor growth, and significantly prolonged mouse survival. However, our data also revealed that elements in the tumor microenvironment (TME) limit engineered T cell persistence and ability to kill cancer cells.

To identify immunosuppressive features active in the ovarian TME in both human and murine disease, we performed gene expression analyses on whole tumor tissue (Thermo Fisher) or sorted cell populations (Nanostring). Deep transcriptome profiling confirmed the expression of similar gene signatures in human cancers and the preclinical ID8 model, including immunosuppressive pathways. RNA sequencing revealed consistently high expression of Fas ligand (FasL), notable because FasL signaling can play a significant role in the generation and persistence of tumors. Fas/FasL signaling can mediate T cell death, including activation-induced cell death, an apoptotic mechanism responsible for regulating T cell expansion, suggesting tumor cells may upregulate FasL for protection from tumor-infiltrating lymphocytes. By flow cytometry and immunohistochemistry, we and others previously detected FasL in the tumor vasculature and TME of human ovarian cancer. To overcome this potential T cell evasion mechanism, we generated a panel of immunomodulatory fusion proteins (IFP) containing the Fas receptor (Fas) extracellular binding domain fused to a CD28 or 4-1BB co-stimulatory domain rather than the natural death domain. Relative to T cells modified with only TCRMSLN, T cells engineered to express both TCRMSLN and a Fas IFP better infiltrate tumors, preferentially expand/persist, and retain function in the TME when transferred into tumor-bearing mice. Moreover, adoptive immunotherapy with IFP+ T cells significantly prolonged survival in tumor-bearing mice, relative to TCRMSLN T cells lacking an IFP. As many solid tumors overexpress FasL, the use of IFPs may provide an opportunity to enhance engineered adoptive T cell therapy in many other malignancies.

Citation Format: Kristin Anderson, Shannon Oda, Breanna Bates, Edison Chiu, Christopher Morse, Nicolas Garcia, Philip Greenberg. Engineering adoptive T cell therapy to co-opt Fas ligand-mediated death signaling in solid tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2555.

Abstract OT3-04-03: PARTNER randomised, phase II/III trial to evaluate the safety and efficacy of the addition of olaparib to platinum based neoadjuvant chemotherapy in triple negative and/or germline BRCA mutated breast cancer patients

Background: No specific targeted therapies are available for Triple Negative Breast Cancers (TNBC), an aggressive and diverse subgroup. The basal TNBC subgroup show some phenotypic and molecular similarities with germline BRCA (gBRCA). In gBRCA patients, and potentially other homologous recombination deficiencies, these already compromised pathways may allow drugs called PARP inhibitors (olaparib) to work more effectively.

Aims: To establish if the addition of olaparib to neoadjuvant platinum based chemotherapy for basal TNBC and/or gBRCA breast cancer is safe and improves efficacy (pathological complete response (pCR)).

Trial design: 3 stage open label randomised phase II/III trial of neoadjuvant paclitaxel and carboplatin +/olaparib, followed by clinicians' choice of anthracycline regimen.

Stage 1 and 2: Patients are randomised (1:1:1) to either control (3 weekly carboplatin AUC5/weekly paclitaxel 80mg/m2 for 4 cycles) or one of two research arms with the same chemotherapy regimen but with two different schedules of olaparib 150mg BD for 12 days.

Stage 3: Patients are randomised (1:1) to either control arm or to the research arm selected in stage 2.

Methods:

Stage 1 Safety: both research arms combined.

Stage 2 Schedule selection criteria: pCR rate and completion rate of olaparib protocol treatment. It is a “pickthewinner” design with 53 patients in each research arm. This allows a 90% power, 5% onesided significance level to test null hypothesis of pCR ≤35% versus an alternative hypothesis of pCR ≥55% in each of the research arms.

Stage 3 Efficacy:anticipated pCR ˜55-60% for all trial patients and ˜60-65% for gBRCA patients. The trial is powered to detect an absolute improvement of 15% (all patients) and 20% (gBRCA patients) by adding olaparib to chemotherapy (enriched design). TNBC patient recruitment will be capped, to ensure required gBRCA patients are enrolled. Enrichment design is applied with overall significance level 0.05(α) = 0.025(αall)+ 0.025(αgBRCA) and 80% power.

Target accrual: 527 [gBRCA 220] Current accrual: 56 Sites activated: 15 [expected number of sites 30-50].

Citation Format: Abraham J, Vallier A-L, Qian W, Grybowicz L, Thomas S, Machin A, Harvey C, Chiu E, McAdam K, Hughes-Davies L, Roylance R, Copson E, Armstrong A, Provenzano E, Tischkowitz M, McMurtry E, Earl H. PARTNER randomised, phase II/III trial to evaluate the safety and efficacy of the addition of olaparib to platinum based neoadjuvant chemotherapy in triple negative and/or germline BRCA mutated breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-04-03.

World psychiatric association section of old age psychiatry consensus statement on ethics and capacity in older people with mental disorders

The World Psychiatric Association (WPA) Section of Old Age Psychiatry, since 1997, has developed Consensus Statements relevant to the practice of Old Age Psychiatry. Since 2006 the Section has worked to develop a Consensus Statement on Ethics and Capacity in older people with mental disorders, which was completed in Prague, September 2008, prior to the World Congress in Psychiatry. This Consensus meets one of the goals of the WPA Action Plan 2008-2011, "to promote the highest ethical standards in psychiatric practice and advocate the rights of persons with mental disorders in all regions of the world". This Consensus Statement offers to mental health clinicians caring for older people with mental disorders, caregivers, other health professionals and the general public the setting out of and discourse in ethical principles which can often be complex and challenging, supported by practical guidance in meeting such ethical needs and standards, and to encouraged good clinical practice.

Standardized uptake value atlas: characterization of physiological 2-deoxy-2-[18F]fluoro-D-glucose uptake in normal tissues

PURPOSE

The purpose of this study was to map the distribution of 2-deoxy-2-[18F]fluoro-D-glucose (FDG) uptake in organs of patients with no known abnormalities in those tissues.

PROCEDURES

We measured maximum and mean standardized uptake values (SUV) from FDG-positron emission tomography (PET)/computed tomography (CT) obtained from 98 patients (48 males and 50 females).

RESULTS

Significant uptake (mean SUVmean>2.5) was visualized in the cerebellum (8.0+/-2.2), soft palate (2.92+/-0.86), palatine tonsils (3.45+/-1.4), lingual tonsils (3.08+/-1.05), sublingual glands (3.3+/-1.5), and testes (2.57+/-0.56). Negative correlation for FDG uptake versus age was observed for the palatine tonsils, sublingual glands, and lungs (P<0.001).

CONCLUSION

Better understanding of physiological uptake throughout the body is valuable for improved interpretive accuracy and should be useful for future semi-automated comparisons to a normal SUV database.

A comparison of the efficacy and safety of olanzapine and risperidone in the treatment of elderly patients with schizophrenia: an open study of six months duration

BACKGROUND

Following an earlier study in which elderly patients with schizophrenia had their typical antipsychotic medication changed to olanzapine or risperidone, the 61 patients were followed for up to a further six months to see if either treatment was superior in terms of efficacy or side effects.

AIMS

To determine whether either olanzapine or risperidone was superior in terms of efficacy or side effects when treating schizophrenia in late life.

METHODS

Psychiatric symptoms, side effects and quality of life were rated every six weeks for 24 weeks of open label comparative treatment using standard measures. Group differences were examined using analysis of covariance and within-group changes over time were assessed using paired t-tests.

RESULTS

There were 34 olanzapine and 32 risperidone patients who entered the study, but intention to treat data was only available for 61 of the 66 patients. There were no clinical or demographic differences between the groups. Parkinsonism, positive and negative symptoms of schizophrenia improved in both groups both from baseline switch to olanzapine or risperidone and during the six month follow-up after completion of crossover. No significant differences were seen between groups on most measures. However, patients treated with olanzapine showed a significantly greater improvement in quality of life from baseline compared to risperidone patients.

CONCLUSIONS

Both drugs were well tolerated and their use was associated with fewer symptoms of schizophrenia and less adverse effects than were seen when the patients were taking a typical antipsychotic at baseline. Olanzapine appears to have particular benefit with regard to quality of life.

Docosahexaenoic acid restores endothelial function in children with hyperlipidemia: results from the EARLY study

OBJECTIVE

The primary objective of this study was to determine whether the National Cholesterol Education Program Step II (NCEP-II) diet or supplementation with docosahexaenoic acid (DHA) with the diet, affects endothelial function in children with familial hypercholesterolemia (FH) or the phenotype of familial combined hyperlipidemia (FCH). As secondary endpoints, the influence of diet and DHA supplementation on lipid profiles as well as biomarkers for oxidative stress and inflammation, and asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, were all evaluated.

METHODS

In a double-blind, placebo-controlled, randomized, crossover study design, 20 children (ages 9-19 years) with FH (n = 12) and FCH (n = 8) received nutritional counseling based on the National Cholesterol Education Program Step II (NCEP-II) and food guide pyramid dietary guidelines for 6 weeks. They were then randomly assigned to supplementation with docosahexaenoic acid (DHA 1.2 g/d) or placebo for 6 weeks, followed by a washout phase of 6 weeks and crossover phase of 6 weeks while continuing the NCEP-II diet. Endothelium-dependent flow-mediated dilation (FMD) of the brachial artery was determined by high-resolution ultrasound. Plasma levels of total cholesterol, triglycerides and lipoprotein classes (LDL, HDL, VLDL) were measured by ultracentrifugation and enzymatic methods, plasma F2 isoprostanes by gas chromatography/mass spectrometry, urinary 8-OH-2' deoxyguanosine by liquid chromatography, high sensitivity C-reactive protein by immunonephelometry and ADMA by liquid chromatography.

RESULTS

FMD increased significantly after DHA supplementation compared to baseline (p < 0.001), diet alone (p < 0.002), placebo (p < 0.012) and washout (p < 0.001) phases of the study without affecting biomarkers for oxidative stress, inflammation or ADMA. DHA supplementation was associated with increased levels of total cholesterol (p < 0.01), LDL- and HDL cholesterol concentrations (p < 0.001) compared to the NCEP-II diet.

CONCLUSION

This study demonstrates that DHA supplementation restores endothelial-dependent FMD in hyperlipidemic children. The endothelium may thus be a therapeutic target for DHA. This is consistent with a hypothesis of increasing NO bioavailability, with the potential for preventing the progression of early coronary heart disease in high-risk children.

Response selection deficits in melancholic but not nonmelancholic unipolar major depression

One consistent functional imaging finding from patients with major depression has been abnormality of the anterior cingulate cortex (ACC). Hypoperfusion has been most commonly reported, but some studies suggest relative hyperperfusion is associated with response to somatic treatments. Despite these indications of the possible importance of the ACC in depression there have been relatively few cognitive studies ACC function in patients with major depression. The present study employed a series of reaction time (RT) tasks involving selection with melancholic and nonmelancholic depressed patients, as well as age-matched controls. Fifteen patients with unipolar major depression (7 melancholic, 8 nonmelancholic) and 8 healthy age-matched controls performed a series of response selection tasks (choice RT, spatial Stroop, spatial stimulus-response compatibility (SRC), and a combined Stroop + SRC condition). Reaction time and error data were collected. Melancholic patients were significantly slower than controls on all tasks but were slower than nonmelancholic patients only on the Stroop and Stroop + SRC conditions. Nonmelancholic patients did not differ from the control group on any task. The Stroop task seems crucial in differentiating the two depressive groups, they did not differ on the choice RT or SRC tasks. This may reflect differential task demands, the SRC involved symbolic manipulation that might engage the dorsal ACC and dorsolateral prefrontal cortex (DLPFC) to a greater extent than the, primarily inhibitory, Stroop task which may engage the ventral ACC and orbitofrontal cortex (OFC). This might suggest the melancholic group showed a greater ventral ACC-OFC deficit than the nonmelancholic group, while both groups showed similar dorsal ACC-DLPFC deficit.

Motor overflow in Huntington's disease

We investigated both motor overflow and ability to control voluntary movement in patients with Huntington's disease (HD). We hypothesised that, compared with controls, overflow would be significantly greater in HD participants and that they would exhibit poorer control of voluntary movement. In a finger flexion task, participants had to maintain target forces representing 25, 50, or 75% of the maximum strength capacity for whichever finger was performing the task; overflow was measured in the corresponding finger of the non-responding hand. HD participants exhibited significantly greater motor overflow than controls, and more difficulty controlling the target force with the active hand. In addition, the degree of overflow in HD participants positively correlated with overall UHDRS motor symptom severity. The presence of exacerbated motor overflow in HD, and its correlation with symptom severity, is an important finding worthy of further investigation.

Hypometric primary saccades and increased variability in visually-guided saccades in Huntington's disease

Eye movement abnormalities can be distinctive and suggestive of a specific pathophysiology. To further investigate the deficits in the control of saccades in patients with Huntington's disease (HD), we investigated the ability of 11 HD patients and 11 matched controls to perform visually-guided saccades. We adopted reflexive saccade tasks involving predictable and unpredictable sequences, at different amplitudes of target step (10 degrees, 20 degrees, 30 degrees, 40 degrees ), as well as voluntary self-paced saccades. Prolongation of initiation was observed in the HD group as the target amplitude of predictable saccades increased. During the self-paced saccade task, the HD patients had increased intersaccadic intervals, performed fewer saccades in the allocated time and displayed an increased temporal variability in comparison to the controls. Furthermore, hypometric primary saccades, and an increased number of corrective saccades, were observed during both reflexive and voluntary saccades in the HD group. The delayed initiation of large saccades, deficits in voluntary, self-paced saccades, impaired saccadic accuracy and increased corrective saccades in HD, were interpreted in light of other ocular motor and limb studies, and appear to be due to damage to the fronto-striatal loop, including the supplementary eye fields, as well as possible brainstem and cerebellar involvement.

The impact upon extra-pyramidal side effects, clinical symptoms and quality of life of a switch from conventional to atypical antipsychotics (risperidone or olanzapine) in elderly patients with schizophrenia

BACKGROUND

Atypical antipsychotics are commonly used in the management of schizophrenia in late life with evidence suggesting they induce lower rates of motor disturbance, but have similar efficacy to conventional antipsychotics. Trials in the elderly have been either retrospective, small, of short duration or of a single-arm design.

AIMS

To demonstrate the effects upon motor side-effects, efficacy, safety and quality of life (QOL) of switching elderly patients with schizophrenia from conventional antipsychotics to olanzapine or risperidone.

METHODS

Elderly patients with schizophrenia were randomly allocated to olanzapine or risperidone and followed through an open-label crossover period. Between and within group intention to treat analyses were conducted.

RESULTS

66 patients were randomised (mean age 69.6 [SD +/- 6.2]). Four (11.8%) patients on olanzapine and 8 (26.7%) patients on risperidone failed to complete the crossover because of treatment failure [Odds Ratio (OR) = 2.73[0.73-10.2] p = 0.14]. The mean doses upon completion of switching in each arm were 9.9 mg (SD = 4.2) and 1.7 mg (SD = 1.2) for olanzapine and risperidone respectively. In both arms there was improvement in Parkinsonism, though only olanzapine was associated with a reduction in dyskinetic symptoms. The Brief Psychiatric Rating Scale, Scale for the assessment of Negative Symptoms and Montgomery and Asberg Depression Rating Scale scores all improved through the crossover period in both arms with no between group differences. Treatment with olanzapine was associated with a better response over risperidone on the psychological domain of the World Health Organisation-Quality Of Life [Brief] (WHO-QOL-BREF) scale ( p = 0.02). Patients in the olanzapine arm also demonstrated improvement from baseline in the WHO-QOL-BREF physical, psychological and health satisfaction domains, but risperidone had no effect on any Quality of Life (QOL) measure.

CONCLUSIONS

After switching from a conventional antipsychotic, olanzapine and risperidone were associated with improvement in core symptoms of schizophrenia and motor side effects. Subjects switched to olanzapine were more likely to complete the switching process and show an improvement in psychological QOL.

"Clockness" in the detection of dementia: a semantic-conceptual effect

We studied aspects of clock cognition that might underlie the sensitivity of the CDT in screening for dementia of the Alzheimer type (DAT). Two groups, 15 patients with mild-moderate DAT and 15 controls, were assessed with the CDT and specially designed tests of clock-related cognition. Patients were impaired on the CDT, but they did not differ from controls in copying a clock face or selecting the correct representation of a given time. Patients were worse than controls at distinguishing between clock and nonclock objects, detecting anomalies in clocks, and in setting time irrespective of response format. These findings suggest that semantic-conceptual aspects of clock-related cognition are important in discriminating between patients with DAT and controls.

Mental rotation in unipolar major depression

Mental rotation (MR) performance may be used as an index of mental slowing or bradyphrenia, and may reflect, in particular, speed of motor preparation. MR was employed with a sample of both melancholic (n=8) and non-melancholic (n=9) unipolar depressed patients and healthy controls (n=10) to determine if motor slowing associated with depression might be reflected in slowed motor preparation (as reflected in slope of the MR function) independent of actual motor slowing (overall response time). Both melancholic and non-melancholic patients showed a generalised slowing relative to controls, perhaps reflecting bradykinesia and akinesia. This effect was significantly greater in the melancholic group than in the non-melancholic group. Relative to both the controls and the non-melancholic groups, the melancholic patients showed a progressive slowing with increasing angle of orientation indicating a specific slowing of MR. This deficit suggests a role of slowed motor planning in the psychomotor retardation of patients with melancholic depression.

A randomised, placebo-controlled, double blind study of treatment of Huntington's disease with unsaturated fatty acids

Huntington's Disease (HD) is a serious dominantly inherited neurodegenerative disorder for which there are no current treatments. Open label and animal studies have suggested that highly unsaturated fatty acids (HUFAs) may be beneficial. Seventeen patients with HD were entered into a randomised, placebo-controlled, double blind trial of HUFA therapy. Patients were assessed on the Rockland-Simpson Dyskinesia Rating Scale (RSDRS) and the Unified Huntington's Disease Rating Scale (UHDRS). On the RSDRS and the UHDRs motor scale patients on HUFA treatment improved while those on placebo deteriorated, with a significant difference between the two groups on the RSDRS. A similar trend was noted on the UHDRS functional performance scales. Little change was seen on the neuropsychology scales. There were no treatment-related adverse events. This is the first time that a significant improvement has been noted in a randomised trial in HD. The results are consistent with open label observations; a second placebo-controlled study in end-stage patients, and a study in a transgenic mouse model of HD.

Wavelet-based space-frequency compression of ultrasound images

This paper describes the compression of grayscale medical ultrasound images using a recent compression technique, i.e., space-frequency segmentation (SFS). This method finds the rate-distortion optimal representation of an image from a large set of possible space-frequency partitions and quantizer combinations and is especially effective when the images to code are statistically inhomogeneous, which is the case for medical ultrasound images. We implemented a compression application based on this method and tested the algorithm on representative ultrasound images. The result is an effective technique that performs better than a leading wavelet-transform coding algorithm, i.e., set partitioning in hierarchical trees (SPIHT), using standard objective distortion measures. To determine the subjective qualitative performance, an expert viewer study was run by presenting ultrasound radiologists with images compressed using both SFS and SPIHT. The results confirmed the objective performance rankings. Finally, the performance sensitivity of the space-frequency codec is shown with respect to several parameters, and the characteristic space-frequency partitions found for ultrasound images are discussed.

Movement-related potentials in Huntington's disease: movement preparation and execution

Movement-related potentials (MRPs) reflect increasing cortical activity related to the preparation and execution of voluntary movement. Execution and preparatory components may be separated by comparing MRPs recorded from actual and imagined movement. Imagined movement initiates preparatory processes, but not motor execution activity. MRPs are maximal over the supplementary motor area (SMA), an area of the cortex involved in the planning and preparation of movement. The SMA receives input from the basal ganglia, which are affected in Huntington's disease (HD), a hyperkinetic movement disorder. In order to further elucidate the effects of the disorder upon the cortical activity relating to movement, MRPs were recorded from ten HD patients, and ten age-matched controls, whilst they performed and imagined performing a sequential button-pressing task. HD patients produced MRPs of significantly reduced size both for performed and imagined movement. The component relating to movement execution was obtained by subtracting the MRP for imagined movement from the MRP for performed movement, and was found to be normal in HD. The movement preparation component was found by subtracting the MRP found for a control condition of watching the visual cues from the MRP for imagined movement. This preparation component in HD was reduced in early slope, peak amplitude, and post-peak slope. This study therefore reported abnormal MRPs in HD, particularly in terms of the components relating to movement preparation, and this finding may further explain the movement deficits reported in the disease.

Bimanual co-ordination in Huntington's disease

The ability of Huntington's disease patients to co-ordinate their two hands with and without external cueing was investigated. Twelve Huntington's disease patients and sex- and age-matched controls performed a bimanual cranking task at two speeds (0.5 Hz, 1.5 Hz) and phase relationships (in-phase, anti-phase), with and without an external metronome cue. Data were sampled at 200 Hz, and raw displacement data for each hand, mean and standard deviation measures of the relative positions of the two hands and their velocities were then calculated. All participants could perform the in-phase movement, at both speeds; however. the Huntington's disease patients were more variable and less accurate than the control participants, particularly at the fast speed. While controls could perform the anti-phase movement, in which rotation of the cranks differed by 180 degrees at both speeds, Huntington's disease patients were unable to do so at either speed, reverting to the in-phase movement at the slow speed. An external metronome cue did not improve the performance of the Huntington's disease patients, which differentiated this group from patients suffering from Parkinson's disease. The Huntington's disease patients' inability to perform the anti-phase movement may be due to damage to the basal ganglia and its output regions.

Reliance on external cues during serial sequential movement in major depression

Maintenance of motor set in patients with unipolar major depression was examined. Twelve melancholic and 12 non-melancholic depressed patients and 24 age matched controls performed a serial choice reaction time task while external cues aiding maintenance of a motor set were systematically removed. Melancholic patients were significantly slower than controls with no reduction in external cues and with a moderate reduction in external cues. At a high level of reduction in external cues, seven of 12 melancholic patients (but only three of 12 non-melancholic patients and controls) were unable to complete the task; suggesting a greater reliance on external cues, perhaps implicating a failure of motor planning ability in melancholic patients. This, in turn, may point to a prefrontal (premotor) deficit in melancholic depression, with possible commonalities with Parkinson's disease.

Motor imagery in Huntington's disease

We investigated the role of the basal ganglia (BG) in motor imagery in patients with Huntington's disease (HD). A visually guided pointing task assessed whether patients could predict actual movement time (MT) through motor imagery. Executed and imagined movements were performed when vision was constrained centrally, or was free to move. Participants completed a series of imagined and actual movements, with and without central fixation, between two target circles. Patients with HD and controls' imagined MTs were significantly faster than their executed MTs. In compliance with Fitt's law, both actual and imagined MTs increased as a function of increasing task difficulty. We conclude that motor imagery is relatively preserved in HD.

Characteristics of aggressive subjects in Australian (Melbourne) nursing homes

BACKGROUND

Aggressive behavior is common in nursing homes for the elderly. It causes distress to carers and can lead to hospitalization, overmedication, and physical restraint.

METHOD

A 6-month prospective study examining the characteristics of aggressive subjects in 11 nursing homes in Melbourne using validated, reliable instruments.

RESULTS

During the study, 121 and 143 subjects were rated aggressive on the Rating Scale for Aggressive Behavior in the Elderly and the Staff Observation Aggression Scale, respectively. Aggressive behavior was associated with younger age, men, subsequent mortality, and prescription of psychotropic drugs including neuroleptics, antidepressants, and benzodiazepines.

CONCLUSIONS

Educational programs in the use of psychotropic drugs directed at staff involved in the care of nursing home residents may be of value because these drugs have modest efficacy, have significant side effects, and may simply sedate the patient rather than treat aggressive behavior.

Parkinsonian motor characteristics in unipolar major depression

Clinical observation points to similarities between psychomotor retardation in major depression and bradykinesia in Parkinson's disease (PD). While common elements of neuropathology have been proposed to account for this, experimental investigations of this possible link have been few and inconclusive. The present study attempts to determine whether patients with depression display the characteristically Parkinsonian reliance on external cues; and if so, whether this is common to both melancholic and non-melancholic patients. Twenty three patients with unipolar major depression (11 melancholic and 12 non-melancholic) and 24 age-matched healthy controls performed a serial choice reaction time task known to be sensitive to Parkinsonian movement deficits. The melancholic patients showed a Parkinsonian pattern of impairment on the task, exhibiting a particular difficulty when initiating movements in the absence of external cues. This was largely alleviated when a moderate amount of external cueing was provided. At a high level of advance information, melancholic patients were again slow relative to controls. A base-line measure of bradykinesia and a derived measure of dependence upon external cues both correlated significantly with CORE (measure of psychomotor disturbance) ratings. The non-melancholic patients did not show any measurable motor impairment. This cue-dependent deficit may be due to an underlying basal ganglia dysfunction similar to that involved in PD, i.e. a failure of internal cueing. Difficulty with a high level of external cueing might reflect bradyphrenia or a prefrontal motor deficit of ability to plan multiple upcoming movements simultaneously. The results suggest that depression subtypes involve differing patterns of fronto-striatal impairment.

An open study of sertraline in patients with major depression who failed to respond to moclobemide

OBJECTIVES

The aim of this study is to evaluate the efficacy and tolerability of sertraline in patients with major depression who have failed to respond to an adequate trial of moclobemide.

METHOD

Sixty-three patients with major depression who had discontinued moclobemide within the last 6 weeks due to lack of efficacy were recruited from multiple psychiatric services in Victoria and Queensland. After a wash-out period, patients were treated with sertraline 50 mg once daily for 4 weeks. If there was an insufficient response, the dose was titrated upwards to a maximum of 200 mg/day, with 2 weeks at each dosage level. By the end of the study, patients had received a fixed dose of sertraline for 8 weeks. The main outcome measures were the 17-item Hamilton Rating Scale for Depression (HAMD) and Clinical Global Impression (CGI) scales. Secondary outcome measures included the Montgomery-Asberg Depression Rating Scale (MADRS) and Beck Depression Inventory (BDI).

RESULTS

Of the 62 intention-to-treat patients enrolled, 48 (77%) responded to sertraline (i.e. experienced > or =50% reduction in HAMD total score from baseline and had a final HAMD score of < or =17). Fifty-four (87%) patients were at least 'minimally improved' on the CGI scale. There were also significant improvements in mean total MADRS and BDI scores. Sertraline was well tolerated. Adverse events were reported by 84% of patients, but only 5% withdrew due to adverse events.

CONCLUSIONS

This study shows that patients with major depression who have failed to respond to moclobemide can generally be treated successfully with sertraline.

John Cade: the man

The personal aspects of John Cade's life are little known outside his family and close associates. This paper recounts some of the interesting anecdotes of his life to reveal a loyal, kind and curious person possessed of a quiet spirituality and a humanity that placed great value on his patients' individuality, the lives of his staff as people, and his family. This biographical sketch illuminates the curiosity and motivation in an uncommon man and provides a context in which to appreciate his discovery and application of lithium treatment in psychiatric practice.

Reboxetine versus imipramine in the treatment of elderly patients with depressive disorders: a double-blind randomised trial

BACKGROUND

Depression in older people is often unrecognised and untreated or under-treated. Antidepressant treatment may itself exacerbate a pre-existing illness, interact with concomitant medications or produce undesirable cognitive and sedative side effects. Newer antidepressants may offer advantages in terms of a lesser burden of adverse effects.

METHODS

The comparative tolerability of the unique selective noradrenaline reuptake inhibitor (selective NRI) reboxetine (4-6 mg/day; n = 176) and that of imipramine (50-100 mg/day; n = 171) was assessed in an elderly ( > 65 years) cohort of depressed or dysthymic patients in an 8-week, double-blind, multicentre trial. Comparative efficacy was also assessed.

RESULTS

Overall, 68% of patients in the reboxetine group experienced adverse events compared with 71% in the imipramine group. Reboxetine-treated patients were less likely to develop hypotension and related symptoms (7% vs. imipramine 16%) or cardiovascular disorders (12.5% vs. imipramine 21.1%), while those treated with imipramine were less likely to experience insomnia (6.3% vs. 2.9%). Adverse events were more often assessed as related to treatment (43%) and moderate to severe in intensity (73%) with imipramine than with reboxetine (33% and 65%, respectively). Furthermore, there were fewer serious adverse events in the reboxetine-treated group (P = 0.019). The reduction in the Hamilton Rating Scale for Depression (HAM-D) was comparable between the treatment groups in the total population. At the last assessment, the majority of patients in both treatment groups were assessed as normal to borderline or mildly ill using the Clinical Global Impression (CGI) scale. In a subanalysis of the dysthymic patients a modest but significant difference in favour of imipramine was observed for both HAM-D and CGI assessments. This may have been a reflection of a trend towards more severe depressive symptoms at baseline in the reboxetine group.

CONCLUSIONS

Reboxetine is as effective as imipramine in the treatment of depression in elderly patients but is at least as well tolerated with a lower risk of hypotension and related symptoms, fewer serious adverse events, adverse event-related withdrawals and treatment-related adverse events.

Asian Pacific cooperative study of allogeneic bone marrow transplantation

The first cooperative study of the Asian Pacific bone marrow transplantation group included 75 patients with early leukemia who received human leukocyte antigen-matched sibling bone marrow transplants and were randomized into granulocyte colony-stimulating factor and control groups. The selected patients were registered from 10 centers in six countries and areas within Asia (Beijing, Taipei, Hong Kong, Japan, Korea, and Malaysia). The incidence of grades II-IV acute graft-vs.-host disease was 22.2%, and the 2-year survival rate was 62.7%. The period of protective isolation (27.1-66.7 days), period of hospitalization (38.6-130.5 days), and medical costs for 4 months (US $10,300-US $80,803) varied considerably. Good cooperation, i.e., low rate of protocol violation or rapid and precise presentation of case reports, was obtained.

Up-regulation of vascular endothelial growth factor mRNA and angiogenesis after transmyocardial laser revascularization

BACKGROUND

Angiogenesis has been proposed as a potential mechanism whereby transmyocardial laser revascularization (TMLR) has provided clinical relief of angina. Experimental work has found histologic evidence supporting this, as well as an improved response when angiogenic growth factors have been added to TMLR. The purpose of this study was to demonstrate that the molecular response to TMLR was an increase in the production of endogenous vascular endothelial growth factor to promote angiogenesis.

METHODS

Ameroid constrictors were placed on the proximal circumflex artery in 12 domestic pigs. After a chronic ischemic zone was established the animals were randomly divided into two groups. In the TMLR group the ischemic zone was treated with carbon dioxide laser. In the control group the ischemic zone was untreated. Six weeks later the animals were sacrificed, and sections from the ischemic zone and the nonischemic zone were submitted for immunohistochemical, histologic, and molecular analysis. Messenger RNA was obtained from northern blot analysis after being probed with vascular endothelial growth factor.

RESULTS

There was a twofold increase in the vascular endothelial growth factor messenger RNA in the ischemic zone of the TMLR group compared with the control group. Additionally, there was a threefold increase in the number of new blood vessels in the ischemic zone of the TMLR group compared with the control group.

CONCLUSIONS

Transmyocardial laser revascularization promotes angiogenesis by upregulation of vascular endothelial growth factor. The resulting angiogenesis could be the principle mechanism for the clinical efficacy of TMLR.

Differential clinical and motor control function in a pair of monozygotic twins with Huntington's disease

We report a pair of monozygotic Huntington's disease (HD) twins who, although sharing identical CAG repeat lengths, not only present with marked differences in clinical symptoms but also behavioral abilities as measured by our experimental procedures. Both HD twins and two healthy control subjects were tested twice over 2 years. Patient A was generally more impaired at a motor level, whereas Patient B showed greater attentional impairment; Patient B, however, showed more progressive deterioration. The control subjects' performance remained consistent over the 2-year interval. Patient A clinically had the more hyperkinetic hypotonic variant of the disease, whereas Patient B, who was the more impaired, presented with a more hypokinetic hypertonic (rigid) variant. The influences of epigenetic pre- and postnatal environmental factors should not be ignored.

Allogeneic bone marrow transplantation for adult acute lymphoblastic leukemia: a single-centre experience

Between 1990 and 1997, we performed 29 allogeneic BMTs for acute lymphoblastic leukemia (ALL) patients with HLA-identical sibs. Their median age was 31 years (range 15 to 43); there were 15 males and 14 females. The conditioning protocol was Cy-TBI (n = 15), VP16-Cy-TBI(n = 12), CBV (n = 1) and Bu-Cy (n = 1). Cyclosporin and methotrexate were used for GVHD prophylaxis. The median disease-free survival (DFS) was 12 months (range 1 to 92) with an actuarial 4-years DFS of 42.3 per cent. Three patients died of transplant-related complications before 100 days. Relapse occurred in 11 cases at a median time of 5 months (range 3 to 14). All nine patients relapsing within one year died form resistant leukemia. Three patients died of late treatment-related complications. There were 13 survivors (median follow-up 38 months, range 12-98), with 12 in remission. Only four had limited cGVHD, and all had 100 per cent performance scores. One patient also cleared her chronic hepatitis B carrier status due to acquired immunity. The DFS rates amongst CR1 cases and R1/CR2 cases were comparable (p = 0.39). No long-term DFS is obtained from patients with resistant disease (n = 4). The survival results for BMT at CR1 were superior to those using intensive chemotherapy consolidation (p = 0.29), mainly due to poor late results in the chemotherapy arm. For young ALL patients with HLA-matched siblings, the option of BMT should be considered in light of local consolidation survival results.

Severe deep white matter lesions and outcome in elderly patients with major depressive disorder: follow up study

OBJECTIVE

To determine the difference in outcome among elderly people with major depression who do and do not have severe white matter lesions on magnetic resonance imaging.

DESIGN

Follow up study.

SETTING

Two psychiatric and two general hospitals in Melbourne, Australia.

SUBJECTS

60 depressed subjects aged over 55 referred to hospital psychiatric services with major depressive disorder meeting American Psychiatric Association (DSM-IIIR) criteria.

MAIN OUTCOME MEASURE

Proportion with good outcome as determined by full recovery from initial illness and no evidence of depressive relapse or cognitive decline during follow up among those with and without lesions.

RESULTS

Mean (SD) follow up was 31.9 (9.9) months. Survival analysis showed a significant effect of severe lesions on time to poor outcome (P=0.04), with median survival 136 days in those with severe lesions compared with 315 days in those without.

CONCLUSION

Severe white matter change on magnetic resonance imaging is associated with poor outcome in elderly depressed subjects.

A patient who changed my practice

An encounter with a patient with Huntington's Disease gave rise to the beginning of a holistic biopsychosocial approach to behavioural expressions of neurodegenerative diseases. Such an approach should be in the context of unconditional positive regard for patients.

A study of the quality of life of the severely mentally ill

As part of a larger study, the Lehman Quality of Life Interview (QOLI) was conducted a total of 85 times with 55 clients with serious mental illness. Results revealed widespread adverse objective circumstances (unemployment, poverty and social isolation) despite which most clients rated their satisfaction levels about average (about equally satisfied and dissatisfied). As expected, subjective quality of life indicators were generally better predictors of global well-being (GWB) (itself based on subjective ratings) than were objective indicators. Correlations between objective and subjective indicators were very low and insignificant. Moderate relationships were found between GWB and levels of personal functioning, and changes in levels of personal functioning, as rated by mental health workers. Retests showed that subjective quality of life was relatively stable over intervals of several months. The findings suggest that leisure and social relations would be suitable areas for interventions that might improve clients' quality of life.

Temporal lobe magnetic resonance imaging can differentiate Alzheimer's disease from normal ageing, depression, vascular dementia and other causes of cognitive impairment

BACKGROUND

Previous work suggests that temporal lobe magnetic resonance imaging (MRI) can distinguish those with dementia of the Alzheimer type (DAT) from healthy age-matched controls. However, its specificity with regard to conditions such as vascular dementia, depression and other disorders associated with cognitive impairment has not been determined.

METHODS

We studied 222 subjects using T1 weighted MRI with 5.1 mm coronal slices throughout the temporal lobe. Subjects included: healthy controls (N = 40); DSM-III-R major depression (N = 61); NINCDS/ADRDA DAT (N = 77) and OTHER (N = 44, comprising subjects with vascular dementia, Huntington's disease, schizophrenia, alcohol related cognitive impairment and a group of 'memory complainers'). Hippocampus, amygdala, entorhinal cortex, parahippocampal gyrus and cerebral cortex were rated visually on a 0-3 scale by two experienced neuroradiologists blind to clinical diagnosis.

RESULTS

Ratings of temporal lobe atrophy provided good separation between those with AD and all other groups. For example, anterior hippocampal atrophy had a sensitivity of 83% for detecting DAT, a specificity of 80% for controls, 87% for depressed subjects and 89% for OTHER. Other regions were less sensitive, but more specific for the diagnosis of DAT. In particular parahippocampal gyrus and entorhinal cortex had high specificity (97% for depressed subjects and 98% for OTHER). Because of an age-related increase in atrophy, sensitivity was highest for those over the age of 75, while specificity was highest for younger subjects. Significant correlations were observed between atrophy ratings of hippocampus, amygdala, entorhinal cortex and parahippocampal gyrus and CAMCOG memory score and length of history.

CONCLUSIONS

Temporal lobe MRI may have an important role in assisting with the clinical diagnosis of DAT, particularly its differentiation from depression and other disorders that may cause diagnostic difficulties in clinical practice.

The relationship between two scales measuring aggressive behaviour among elderly nursing home residents

Data from a large 6-month prospective study of aggressive behaviour in 11 nursing homes for the elderly are used to examine the relationship between two aggression scales (SOAS and RAGE). There was a strong and significant correlation between the SOAS and RAGE scales for the total and the subscale scores. Both these scales appear useful in measuring aggressive behaviour in nursing homes for the elderly and the nursing home staff can be trained in completing them effectively.