Association between Liver Metastases and Treatment Response in Patients with Metastatic, Microsatellite Stable Colorectal Cancer Treated with Radiation Therapy and Dual Immune Checkpoint Blockade

PURPOSE/OBJECTIVE(S)

Most patients with metastatic colorectal cancer (CRC) have microsatellite stable (MSS) disease with a limited response to immune checkpoint inhibitors (ICIs). In our phase 2 trial (NCT03104439), 27 patients with metastatic MSS CRC received ipilimumab, nivolumab, and RT (24 Gy/3 fractions) on C2D1 with a disease control rate (DCR) of 37% (10/27) and overall response rate (ORR) of 15% (4/27). Our follow up phase 2 study with ipilimumab, nivolumab, and RT moved to C1D1 (NCT04361162) showed a DCR of 33% (10/30) and an ORR of 13% (4/30). Clinical and preclinical data suggest liver metastases are less responsive to systemic ICIs and complementary liver-directed RT can potentially overcome this effect. To address this, we investigated the association between liver metastases and response rates among patients treated with and without liver-directed RT in a pooled analysis of our phase 2 studies of nivolumab and ipilimumab with RT.

MATERIALS/METHODS

In this pooled secondary analysis of two open-label, single-arm, phase 2 studies, eligible patients had metastatic MSS CRC, ECOG PS 0-1, and progressed on at least one line of chemotherapy. Treatment consisted of ipilimumab 1 mg/kg q6weeks for 4 cycles, nivolumab 240 mg q2weeks on a 6-week cycle, and RT (24 Gy/3 fractions) on C1D1 or C2D1 to one site. Responses were defined outside of the RT field by RECIST 1.1 with centrally reviewed imaging q3months. ORR/DCR and PFS/OS were compared between patients with and without liver metastases with the Fisher's exact and log-rank tests, respectively. P-values are two-sided.

RESULTS

We treated 57 patients (median age 57 years [range, 26-85], 61% male, 88% white, 65% with liver metastases) from 07/2017 to 05/2022. Patients received a median of 3 (range, 1-10) prior lines of systemic therapy. The combined ORR was 14% (8/57; 95% CI, 6-26%) and DCR was 35% (20/57; 95% CI, 23-49%). The ORR was 30% (6/20; 95% CI, 12-54%) in patients without liver metastases and 5% (2/37; 95% CI, 1-18%) in patients with liver metastases (p = 0.017). The DCR was 55% (11/20; 95% CI, 32-77%) in patients without liver metastases and 24% (9/37; 94% CI, 12-41%) in patients with liver metastases (p = 0.040). 76% (28/37) of patients with liver metastases received liver-directed RT including 2/2 (100%) patients with a PR. The ORR was 0% in patients with liver metastases without liver-directed RT. The median PFS was 1.8 months (95% CI, 1.2-2.4 months) and OS was 9.8 months (95% CI, 6.8-12.8). OS was longer in patients without liver metastases (median 13.6 v 6.8 months, p = 0.010) and in patients treated with liver-directed RT among those with liver metastases (median 7.5 months v 4.5 months, p = 0.025).

CONCLUSION

Among patients with metastatic MSS CRC treated with ICIs and RT in two phase 2 studies, ORR, DCR, and OS are significantly higher in patients without liver metastases. Liver-directed RT may improve ICI efficacy and OS in patients with liver metastases. Further analysis of PFS and prospective study of ICIs with comprehensive liver-directed RT are warranted.

Die Fachklinik Bad Bentheim

Die Fachklinik Bad Bentheim mit ihrer mehr als 300-jährigen Geschichte basierte ursprünglich auf den natürlichen Heilquellen wie dem Schwefelmineralwasser und der Sole. Durch die Entwicklung der Balneofototherapie in den 70er- und 80er-Jahren entwickelte sich die Dermatologie zu einem besonders wichtigen Fachbereich. Heute stellt die Dermatologie mit der Akutklinik, der Klinik für Rehabilitation sowie der Ambulanz und Studienambulanz einen führenden Teilbereich der Klinik dar und bietet ihren Patienten modernste Medizin in historischem Ambiente. Dabei zeigen bspw. der Aufbau einer professionellen Studienambulanz, die Entwicklung eines spezifischen Rehabilitationskonzeptes für chronischen Pruritus sowie der Aufbau der dermato-onkologischen Rehabilitation die Anpassungsfähigkeit an die Erfordernisse der Zeit.

Quality of anticoagulation with unfractionated heparin plus phenprocoumon for the prevention of thromboembolic complications in cardioversion for non-valvular atrial fibrillation. Sub-analysis from the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial

INTRODUCTION

Anticoagulation in cardioversion for atrial fibrillation is performed using unfractionated heparin and oral anticoagulants. TEE-guided cardioversion, after achievement of therapeutic anticoagulation (1-3 days), may be an alternative to the traditional procedure (3-week anticoagulation followed by cardioversion). The quality of anticoagulation in atrial fibrillation has not been investigated in a randomised trial with TEE-guided cardioversion. We analysed respective data from the ACE trial on the quality of conventional anticoagulation, where most participating centres chose the TEE-guided approach.

MATERIALS AND METHODS

In a randomised, prospective, multicentre trial, we analysed the efficacy of unfractionated heparin plus phenprocoumon in 248 patients on an intention-to-treat basis. There were 2373 evaluable anticoagulation measurements (out of 2925 measurements) and 4 categories of anticoagulation quality (under-, target, over- and severe over-anticoagulation). Of patients with evaluable measurements, 88% received short-term anticoagulation (4 weeks) in TEE-guided cardioversion.

RESULTS

The median time to achieve therapeutic anticoagulation (aPTT> or =60 and <80 s or INR> or =2 and <3) was 3 days. Anticoagulation values were out of therapeutic range in 69.5% of measurements during 4- or 7-week follow-up, and never within therapeutic range in 10% of patients. Of the 15 primary endpoints observed (death, thromboembolism and major bleeding complications), only 3 were in patients with anticoagulation measurements within therapeutic range.

CONCLUSIONS

In this study setting, with predominance of 4 weeks anticoagulation in TEE-guided cardioversion for atrial fibrillation, therapeutic anticoagulation was reached within 3 days using conventional anticoagulation. Despite careful dose adjustments, anticoagulation was out of therapeutic range in almost 70% of total measurements and 80% of primary endpoints.

Efficient regeneration from cotyledon protoplasts in Arabidopsis thaliana

An efficient and fast regeneration system from cotyledon protoplasts was established for Arabidopsis thaliana accessions C24, Columbia, and Wassilewskija. Culture conditions and media compositions were optimised for the development of protoplasts embedded in thin alginate layers. Unexpectedly, the absence of cytokinins had a positive effect on cell development. Moreover, combined adjustment of alpha-naphthylacetic acid and dicamba concentrations resulted in high plating efficiencies of up to 30%, followed by shoot regeneration within only 19 days after protoplast isolation. The protocol is reproducible, efficient, extremely fast, and regenerated plants are fertile. Thus, this cotyledon-based system could prove useful for studying plant cell and molecular biology in A. thaliana.

Effects of selective inactivation of individual genes for low-molecular-mass subunits on the assembly of photosystem II, as revealed by chloroplast transformation: the psbEFLJoperon in Nicotiana tabacum

Photosystem (PSII) is a supramolecular polypeptide complex found in oxygenic photosynthetic membranes, which is capable of extracting electrons from water for the reduction of plastoquinone. An intriguing feature of this assembly is the fact that it includes more than a dozen low-mass polypeptides of generally unknown function. Using a transplastomic approach, we have individually disrupted the genes of the psbEFLJoperon in Nicotiana tabacum, which encode four such polypeptides, without impairing expression of downstream loci of the operon. All four mutants exhibited distinct phenotypes; none of them was capable of photoautotrophic growth. All mutants bleached rapidly in the light. Disruption of psbEand psbF, which code for the alpha and beta apoproteins of cytochrome b(559), abolished PSII activity, as expected; Delta psbL and Delta psbJ plants displayed residual PSII activity in young leaves. Controlled partial solubilisation of thylakoid membranes uncovered surprisingly severe impairment of PSII structure, with subunit and assembly patterns varying depending on the mutant considered. In the Delta psbL mutant PSII was assembled primarily in a monomeric form, the homodimeric form was preponderant in Delta psbJ, and, unlike the case in Delta psbZ, the thylakoids of both mutants released some PSII supercomplexes. On the other hand, Photosystem I (PSI), the cytochrome b(6)f complex, ATP synthase, LHCII, and CP24/CP26/CP29 antennae were present in near wild-type levels. The data are discussed in terms of their implications for structural, biogenetic and functional aspects of PSII.

Map positions of 69 Arabidopsis thaliana genes of all known nuclear encoded constituent polypeptides and various regulatory factors of the photosynthetic membrane: a case study

Landsberg erecta x Columbia F8 recombinant inbred lines of Arabidopsis thaliana, arrayed BAC clones covering most of the genome, and databank sequence information were used to map the positions of 69 genes in the genome of A. thaliana. These genes encode all known constituents of the photosynthetic thylakoid membrane, some regulatory factors involved in its biogenesis, and the RNA polymerases of nuclear origin that operate in chloroplasts and mitochondria. Designations of novel genes are proposed. The data of these three approaches are generally consistent, although ambiguities have been noted for some genome segments and with gene duplications. For thylakoid multi-subunit structures, no positional clustering of genes has been found, not even for genes encoding different subunits of the same membrane complex. The genes of the lhc superfamily encoding antenna apoproteins and their relatives are a particularly intriguing example. The lack of positional clustering is consistent with phylogenetically independent gene translocations from the plastid (endosymbiont) to the nucleus. This raises the basic question of how independently translocated genes which acquired different promoter sequences and transit peptides were functionally integrated into common signal transduction chains.

Deregulation of electron flow within photosystem II in the absence of the PsbJ protein

The photosystem II (PSII) complex of photosynthetic oxygen evolving membranes comprises a number of small proteins whose functions remain unknown. Here we report that the low molecular weight protein encoded by the psbJ gene is an intrinsic component of the PSII complex. Fluorescence kinetics, oxygen flash yield, and thermoluminescence measurements indicate that inactivation of the psbJ gene in Synechocystis 6803 cells and tobacco chloroplasts lowers PSII-mediated oxygen evolution activity and increases the lifetime of the reduced primary acceptor Q(A)(-) (more than a 100-fold in the tobacco DeltapsbJ mutant). The decay of the oxidized S(2,3) states of the oxygen-evolving complex is considerably accelerated, and the oscillations of the Q(B)(-)/S(2,3) recombination with the number of exciting flashes are damped. Thus, PSII can be assembled in the absence of PsbJ. However, the forward electron flow from Q(A)(-) to plastoquinone and back electron flow to the oxidized Mn cluster of the donor side are deregulated in the absence of PsbJ, thereby affecting the efficiency of PSII electron flow following the charge separation process.

The nucleus-encoded HCF107 gene of Arabidopsis provides a link between intercistronic RNA processing and the accumulation of translation-competent psbH transcripts in chloroplasts

To understand the functional significance of RNA processing for the expression of plastome-encoded photosynthesis genes, we investigated the nuclear mutation hcf107 of Arabidopsis. The mutation is represented by two alleles, both of which lead to a defective photosystem II (PSII). In vivo protein labeling, in vitro phosphorylation, and immunoblot experiments revealed that the psbB gene product (CP47) and an 8-kD phosphoprotein, the psbH gene product (PsbH), are absent in mutant plants. PsbH and PsbB are essential requirements for PSII assembly in photosynthetic eukaryotes, and their absence in hcf107 is consistent with the PSII-less mutant phenotype. RNA gel blot hybridizations showed that the hcf107 mutation specifically impairs the accumulation of some but not all oligocistronic psbH transcripts that are released from the pentacistronic psbB-psbT-psbH-petB-petD precursor RNA by intergenic endonucleolytic cleavage. In contrast, neither the levels nor the sizes of psbB-containing RNAs are affected. S1 nuclease protection analyses revealed that psbH RNAs are lacking only where psbH is the leading cistron and that they are processed at position -45 in the 5' leader segment of psbH. These data and additional experiments with the cytochrome b(6)f complex mutant hcf152, which is defective in 3' psbH processing, suggest that only those psbH-containing transcripts that are processed at their -45 5' ends can be translated. Secondary structure analysis of the 5' psbH leader predicted the formation of stable stem loops in the nonprocessed transcripts, which are unfolded by processing at the -45 site. We propose that this unfolding of the psbH leader segment as a result of RNA processing is essential for the translation of the psbH reading frame. We suggest further that HCF107 has dual functions: it is involved in intercistronic processing of the psbH 5' untranslated region or the stabilization of 5' processed psbH RNAs, and concomitantly, it is required for the synthesis of CP47.

Knock-out of the plastid ribosomal protein L11 in Arabidopsis: effects on mRNA translation and photosynthesis

The prpl11-1 mutant of Arabidopsis thaliana was identified among a collection of T-DNA tagged lines on the basis of a decrease in the effective quantum yield of photosystem II. The mutation responsible was localized to Prpl11, a single-copy nuclear gene that encodes PRPL11, a component of the large subunit of the plastid ribosome. The amino acid sequence of Arabidopsis PRPL11 is very similar to those of L11 proteins from spinach and prokaryotes. In the prpl11-1 mutant, photosensitivity and chlorophyll fluorescence parameters are significantly altered owing to changes in the levels of thylakoid protein complexes and stromal proteins. The abundance of most plastome transcripts examined, such as those of genes coding for the photosystem II core complex and RbcL, is not decreased. Plastid ribosomal RNA accumulates in wild-type amounts, and the assembly of plastid polysomes on the transcripts of the rbcL, psbA and psbE genes remains mainly unchanged in mutant plants, indicating that lack of PRPL11 affects neither the abundance of plastid ribosomes nor their assembly into polysomes. However, in vivo translation assays demonstrate that the rate of translation of the large subunit of Rubisco (RbcL) is significantly reduced in prpl11-1 plastids. Our data suggest a major role for PRPL11 in plastid ribosome activity per se, consistent with its location near the GTPase-binding centre of the chloroplast 50S ribosomal subunit. Additional effects of the mutation, including the pale green colour of the leaves and a drastic reduction in growth rate under greenhouse conditions, are compatible with reduced levels of protein synthesis in plastids.

Newborn hearing testing at Wisconsin hospitals: a review of the need for universal screening

Every year, an estimated 200 babies are born in Wisconsin with hearing impairment. Early identification of hearing loss is associated with better language development. This study describes the prevalence of newborn hearing screening at Wisconsin hospitals. Ninety-six percent of all 107 acute care hospitals with newborn delivery services responded to a mailed survey. In 1997, 10% of newborns in Wisconsin had hearing tested. In 1997 and 1998, two and then seven hospitals, respectively, established universal hearing screening programs. Nurses performed hearing tests on most newborns using automated auditory brainstem response equipment. Universal newborn hearing screening can be done by nurses or other personnel at community hospitals prior to discharge.

Disruption of the Arabidopsis photosystem I gene psaE1 affects photosynthesis and impairs growth

The psae1-1 mutant of Arabidopsis was identified on the basis of a decrease in the effective quantum yield of photosystem II, among a collection of plants subjected to transposon tagging with the Enhancer element. The steady-state redox level and the rate of re-oxidation of P700 are significantly altered in psae1-1 mutants. The responsible mutation was localised to psaE1, one of two Arabidopsis genes that encode subunit E of photosystem I. An additional mutant allele, psae1-2, was identified by reverse genetics. In wild-type plants, the psaE1 transcript is expressed at a higher level than psaE2 mRNA. In the mutants, however, the E1 transcript was barely detectable, and was expressed only in small groups of wild-type cells resulting from somatic reversions. As a consequence, the amount of PsaE protein present in the mutant is significantly reduced. Concomitantly, the levels of other stromal photosystem I subunits (PsaC and PsaD) are also affected. Mutant plants showed a marked increase in light sensitivity and photoinhibition. Additional effects of the psae1 mutation include light green pigmentation, an increase in chlorophyll fluorescence and a decrease of approximately 50% in growth rate under greenhouse conditions.

The assembly of the CAAT-box binding complex at a photosynthesis gene promoter is regulated by light, cytokinin, and the stage of the plastids

A functionally important region in the promoter of the spinach photosynthesis gene AtpC, which encodes the subunit gamma of the chloroplast ATP synthase, is located immediately upstream of the CAAT-box. A single nucleotide exchange in this region (AAAATTCAAT --> AAGATCAAT) uncouples the expression of an AtpC promoter::uidA gene fusion from the regulation by light, cytokinin, and functional plastids and results in a high constitutive expression of the reporter gene. By screening an Arabidopsis thaliana expression library with a double-stranded wild-type oligonucleotide from this promoter region, we have isolated cDNAs from Arabidopsis libraries that code for plant homologs of the CAAT-box binding factor (CBF)-C. Binding occurs only in the presence of nuclear extracts, consistent with reports from metazoa CBFs that the subunits A and B in addition to C are required for the formation of the CBF-DNA complex. At least eight genes with homologies to CBF-C are present in the Arabidopsis genome; one of them exhibits striking similarities to the gene for the human global transcriptional repressor Drap1. In gel mobility shift assays, low binding activity of CBF to the wild-type AtpC promoter sequence was observed with nuclear extracts from tissue with low AtpC expression levels, i.e. extracts from etiolated and photobleached seedlings, whereas high binding activity was detectable with extracts from tissues with high AtpC expression levels, i.e. extracts from light-grown seedlings and etiolated seedlings treated with cytokinin. Binding to the mutant sequence, which directs constitutive high level uidA expression in vivo, is significantly stronger than to the wild-type sequence. The data are consistent with the idea that the assembly of CBF at the AtpC promoter is regulated in response to light and cytokinin and that the low level of expression in etiolated and photobleached material is caused by an inhibitory effect. The structure/function relationships of the Arabidopsis CBFs are discussed in relation to their regulatory function in AtpC gene expression.

Characterization of the activity of a plastid-targeted green fluorescent protein in Arabidopsis

In Arabidopsis thaliana the PALE CRESS (PAC) gene product is required for both chloroplast and cell differentiation. Transgenic Arabidopsis plants expressing a translational fusion of the N-terminal part of the PAC protein harboring the complete plastid-targeting sequence and the green fluorescent protein (GFP) exhibit high GFP fluorescence. Detailed analyses based on confocal imaging of various tissues and cell types revealed that the PAC-GFP fusion protein accumulates in chloroplasts of mature stomatal guard cells. The GFP fluorescence within the guard cell chloroplasts is not evenly distributed and appears to be concentrated in suborganellar regions. GFP localization studies demonstrate that thin tubular projections emanating from chloroplasts and etioplasts often connect the organelles with each other. Furthermore, imaging of non-green and etiolated tissue further revealed that GFP fluorescence is present in proplastids, etioplasts, chromoplasts, and amyloplasts. Even photobleaching of carotenoid-free plastids does not affect PAC-GFP accumulation in the organelles of the guard cells indicating that the protein translocation machinery is functional in all types of plastids. The specific accumulation of GFP in guard cell chloroplasts, their tubular connections, the translocation of the precursor polypeptide into the different types of organelles, as well as the use of a plastid-targeted GFP protein as a versatile marker is discussed in the context of previously described observations.

A nuclear-encoded protein of prokaryotic origin is essential for the stability of photosystem II in Arabidopsis thaliana

To understand the regulatory mechanisms underlying the biogenesis of photosystem II (PSII) we have characterized the nuclear mutant hcf136 of Arabidopsis thaliana and isolated the affected gene. The mutant is devoid of any photosystem II activity, and none of the nuclear- and plastome-encoded subunits of this photosystem accumulate to significant levels. Protein labelling studies in the presence of cycloheximide showed that the plastome-encoded PSII subunits are synthesized but are not stable. The HCF136 gene was isolated by virtue of its T-DNA tag, and its identity was confirmed by complementation of homozygous hcf136 seedlings. Immunoblot analysis of fractionated chloroplasts showed that the HCF136 protein is a lumenal protein, found only in stromal thylakoid lamellae. The HCF136 protein is produced already in dark-grown seedlings and its levels do not increase dramatically during light-induced greening. This accumulation profile confirms the mutational data by showing that the HCF136 protein must be present when PSII complexes are made. HCF136 homologues are found in the cyanobacterium Synechocystis species PCC6803 (slr2034) and the cyanelle genome of Cyanophora paradoxa (ORF333), but are lacking in the plastomes of chlorophytes and metaphytes as well as from those of rhodo- and chromophytes. We conclude that HCF136 encodes a stability and/or assembly factor of PSII which dates back to the cyanobacterial-like endosymbiont that led to the plastids of the present photosynthetic eukaryotes.

The PAC protein affects the maturation of specific chloroplast mRNAs in Arabidopsis thaliana

The pale cress (pac) mutation arrests chloroplast development at an early stage in Arabidopsis thaliana and leads to a white phenotype. Chlorophyll fluorescence measurements demonstrated that the photosynthetic apparatus was impaired. The mutation did not reduce transcription of nuclear genes with photosynthetic function. However, distinct chloroplast-encoded transcripts were affected. The mutation mainly changed the maturation pattern, but the abundance of specific transcripts was also reduced. The defects observed imply a specific role for PAC in chloroplast mRNA maturation. PAC is encoded by a nuclear gene and is transported into the chloroplast. Therefore PAC may be one of the nucleus-encoded factors that function in plastid mRNA maturation and accumulation.

A nuclear mutant of Arabidopsis with impaired stability on distinct transcripts of the plastid psbB, psbD/C, ndhH, and ndhC operons

The high-chlorophyll fluorescence photosynthesis mutant hcf109 of Arabidopsis was characterized in detail to gain insights into the regulatory mechanism of RNA processing in higher plants. By using electron transport, chlorophyll fluorescence, and immunoblot studies, we assigned the mutational lesion to photosystems I and II and the plastid NAD(P)H dehydrogenase complex. The functional pleiotropy was reflected in RNA deficiencies. Although all nuclear-encoded photosynthetic RNAs analyzed revealed no difference in size or steady state level between mutant and wild type, the RNA patterns of the plastome-encoded psbB-psbT-psbH-petB-petD, psbD-psbC-ycf9, ndhC-ndhK-ndhJ, and ndhH-ndhA-ndhI-ndhG-ndhE-psaC-ndh D transcription units were severely disturbed. These operons encode subunits of photosystems I (psa) and II (psb), the cytochrome bGf complex (pet), the plastid NAD(P)H dehydrogenase (ndh), and the unidentified open reading frame ycf9. With the exception of the ndhC operon, the RNA deficiencies observed were specific and restricted to particular segments of the psbB, psbD/C, and ndhH operons, that is, the psbB-psbT, ycf9, and psaC regions. Run-on transcription studies with isolated chloroplasts showed that the failure of these transcripts to accumulate was due to RNA stability and not transcription. Other polycistronic transcription units analyzed were not affected by the mutation. This result indicates that the trans-regulatory factor encoded by the hcf109 gene is not a general RNA stability factor but that it specifically controls the stability of only these distinct transcripts. Because the hcf109 locus was mapped at a distance < 0.1 centimorgans from the phytochrome C gene, its molecular characterization by positional cloning is possible.

Isolation of high-chlorophyll-fluorescence mutants of Arabidopsis thaliana and their characterisation by spectroscopy, immunoblotting and northern hybridisation

Thirty-four recessive photosynthetic mutants of the high-chlorophyll-fluorescence (hcf) phenotype have been isolated by screening 7700 M2 progenies of ethyl methane sulfonate-treated seeds of Arabidopsis thaliana. Most of the mutants isolated were found to be seedling-lethal, but could be grown on sucrose-supplemented media. Chlorophyll (Chl) fluorescence induction, absorption changes in the reaction-centre chlorophyll of PS I (P700) at 830 nm and Chl a/Chl b ratios were recorded in order to probe the photosynthetic functions and to define the mutational lesion. These studies were complemented by immunoblot and Northern analyses which finally led to the classification of the mutants into six different groups. Four classes of mutants were affected in PS I, PS II (two different classes) or the intersystem electron-transport chain, respectively. A fifth mutant class was of pleiotropic nature and the sixth class comprised a Chl b-deficient mutant. Several of the mutants showed severe deficiencies in the levels of subunits of PS I, PS II or the cytochrome b6/f complex. Thus the mutational lesions could be located precisely. Only one mutant was defective in the transcript patterns of some plastid-encoded photosynthesis genes. Hence most of the mutants isolated appear to be affected in translational and post-translational regulatory processes of thylakoid membrane biogenesis or in structural genes encoding constituent subunits of the thylakoid protein complexes.

An exploratory study of health practices of American Catholic nuns

American Catholic nuns represent a distinct segment of American women, yet little is known about their health practices. Assessment of health-related activities of these women was conducted by means of a self-report survey which was completed by 345 nuns in the midwestern United States. Although 53% had a complete physical examination in the last year, 11% had not had one for more than seven years, and 44% had not had a recent breast or pelvic examination. Thirty-seven percent did monthly breast self-examination (BSE), 37% examined themselves rarely, and 26% never performed BSE. Nuns performing BSE were more likely to have been examined by a health care provider in the past year (p less than .05). Nuns reporting a more positive health status said they got an adequate amount of sleep and participated in regular exercise, yet reported themselves to be overweight (p less than .05). Stress was reported by 74%, and an inverse relationship between perceived relaxation time and perceived stress level was noted (p less than .05). Overall, data reflected certain health educational and behavioral deficits. Because nuns comprise a chronologically older cohort than their secular counterparts, efforts that enable adoption of wellness practices and facilitate improved health care among these women seem to be warranted.

Analysis of variables affecting perinatal mortality: St. Louis City Hospital, 1969-1975

A marked drop in perinatal mortality at St. Louis City Hospital No. 1 (SLCH) from 1974 to 1975 (39.7 vs 20.6 per 1000 births) prompted a detailed analysis of various factors which might have effected the change. Comparisons were also made between SLCH and St. Mary's Health Center (SMHC), a private hospital affiliated with St. Louis University. The significant drop in perinatal mortality at SLCH in 1975 seems to be due to a combination of various factors: 1) improvement in antepartum care, 2) increase use of cesarean sections, and 3) the influence of intrapartum fetal monitoring.